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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
19,060
| 104,539
|
16846
|
Discharge summary
|
report
|
Admission Date: [**2162-1-18**] Discharge Date: [**2162-1-23**]
Date of Birth: [**2083-2-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
ischemic heel ulcer with toe gangrene and rest pain
Major Surgical or Invasive Procedure:
1. Right femoral and profunda endarterectomy, and Dacron
patch profundoplasty.
2. Exploration of above-the-knee popliteal artery.
History of Present Illness:
Mr. [**Known lastname 47487**] is a 78-year-old male, who is
status post an aortobifemoral bypass graft and a failed
femoral to dorsalis pedis bypass graft performed 6 months
ago. The patient now presents with an ischemic heel ulcer as
well as toe gangrene with rest pain. A diagnostic arteriogram
demonstrated extensive SFA disease with a calcified popliteal
artery but yet a patent peroneal and anterior tibial. For
that reason, he was admitted to undergo a femoropopliteal
bypass.
Past Medical History:
Stress Test ([**2157-1-24**] - stress MIBI normal,LVEF 58%.)
Echo (Post CABG echo - LVEF 30%)
Congestive Heart Failure
Dyslipidemia
Hypertension
Ischemic Heart Disease
Hx of Myocardial Infarction
Hx of CABG (x1 [**3-/2161**] at [**Hospital3 2358**])
Peripheral Vascular/Arterial Disease (s/p
aortobifem in [**2157**])
Pulmonary Chronic Obstructive Pulmonary Disease
DM 2 (with retinopathy,neuropathy)
hypothyroidism
Gastrointestinal Reflux
Chronic Renal Insufficiency(Baseline Cr= 1.5)
prostate CA s/p seed implantation
polycythemia [**Doctor First Name **] s/p phlebotomy
s/p Aorta bifemoral bypass graft ([**2156**])
s/p Cholecystectomy
s/p left Carotid Endarterectomy([**7-16**])
Social History:
Nonsmoker/No EtOH
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAM:
General: no acute distress,Awake,Alert,& Oriented x 3
HEENT: neck supple, PERRLA,EOMI
Heart: regular rate and rhythm, without murmurs, rubs, or
gallops
Lungs: clear to auscultation bilaterally,
Abdomen: soft, nontender, nondistended, +bowel sounds
Extremities: no clubbing, cyanosis, or edema, capillary refill<
2 seconds,sensation intact to light touch
Pulses: fem [**Doctor Last Name **] PT DP
R palp palp dop dop
L palp palp dop dop
Pertinent Results:
[**2162-1-18**] 08:20PM GLUCOSE-50* UREA N-27* CREAT-1.6* SODIUM-138
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-31 ANION GAP-13
[**2162-1-18**] 08:20PM estGFR-Using this
[**2162-1-18**] 08:20PM ALT(SGPT)-17 AST(SGOT)-21 ALK PHOS-138* TOT
BILI-0.7
[**2162-1-18**] 08:20PM CALCIUM-8.7 PHOSPHATE-3.7 MAGNESIUM-2.5
[**2162-1-18**] 08:20PM %HbA1c-6.7*
[**2162-1-18**] 08:20PM WBC-5.7# RBC-3.10* HGB-11.4* HCT-34.7*
MCV-112*# MCH-36.9*# MCHC-32.9 RDW-16.9*
[**2162-1-18**] 08:20PM TSH-0.39
[**2162-1-18**] 08:20PM PLT COUNT-606*
[**2162-1-18**] 08:20PM PT-13.5* PTT-27.3 INR(PT)-1.2*
[**2162-1-19**] 6:17:04 Cardiology Report ECG:
Sinus rhythm. Left atrial abnormality. Intraventricular
conduction delay - may
be incomplete left bundle-branch block. Consider left
ventricular hypertrophy
and possible biventricular hypertrophy. ST-T wave abnormalities
with probable
prolonged QTc interval, although is difficult to measure - are
non-specific but
could be due to intraventricular conduction delay, left
ventricular
hypertrophy, drug/electrolyte,metabolic effect or possible
ischemia. Clinical
correlation is suggested. Since the previous tracing of [**2161-7-22**]
the rate is
slower and ST-T wave changes are less prominent
[**2162-1-19**] 12:39 AMCHEST (PRE-OP PA & LAT) Study Date of:Stable
cardiomegaly. Small left pleural effusion. No evidence
of pneumonia or CHF.
[**2162-1-22**] ECHOCARDIOGRAM:The left atrium is mildly dilated. No
spontaneous echo contrast is seen in the left atrial appendage.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. There is
severe mitral annular calcification. Moderate (2+) mitral
regurgitation is seen. Left ventricular function is depressed EF
20-25%. Septal a nd inferior walls are hypokinetic.There is no
pericardial effusion.
Brief Hospital Course:
1.ISCHEMIC HEEL ULCER WITH TOE GANGRENE & REST PAIN
[**2162-1-18**]
-Admit to Dr.[**Name (NI) 1392**] service (Vascular Surgery)
-Preop'ed patient for OR (consent,type/screen,)
[**2162-1-19**]
- a.m. labs
-CXR
-EKG
-To OR for Right femoral and profunda endarterectomy,and Dacron
patch profundoplasty.
-Pulmonary Artery(Swanz-Ganzth)Catheter placed
-Foley placed
-pain control
[**2162-1-20**]
-ruled out an MI with 3 sets of cardiac enzymes
-advance diet as tolerated
-out of bed to a chair
[**2162-1-21**]
-Pulmonary Artery(Swanz-Ganzth)Catheter Removed
[**2162-1-22**]
-Physical Therapy Consult
[**2162-1-23**]
-Discharged home today
Medications on Admission:
Acetylcysteine (Mucomyst, Mucosil)
Albuterol Aerosol
ASA (Aspirin)
Atorvastatin [Lipitor]
Carvedilol [Coreg]
Cipro (Ciprofloxacin)
Flagyl (Metronidazole)
Folic acid (Folvite)
Heparin (SC TID)
Insulin (Humulin, Novolin, Lente Iletin,
Semilente Iletin, Velosulin, Ultralente (70/30
and sliding scale)
Lasix (Furosemide)
Lisinopril [Prinivil, Zestril]
Percocet (Oxycodone/Acetaminophen) (prn)
Plavix (Clopidogrel)
Protonix
Vancocin (Vancomycin)
Other (hydroxyurea, montelukast
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO 1X/WEEK
([**Doctor First Name **]).
3. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
PRN for 30 days.
Disp:*60 Capsule(s)* Refills:*0*
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Right foot gangrene with ischemic rest pain.
2. Urinary retention
Discharge Condition:
good
pain controlled w/ oxycodone
d/c'ed with a foley catheter in place
Discharge Instructions:
Please call your physician or go to the emergency room if you
develop chest pain, shortness of breath,fever greater than
101.5, foul smelling or colorful drainage from your incisions,
redness or swelling, severe abdominal pain or
distention,persistent nausea or vomiting, inability to eat or
drink, or any other symptoms which are concerning to you.
Please do not get your incisions wet until your follow-up
appointment. If there is clear drainage from your incisions,
cover with a dry dressing. Please leave staples in until your
follow-up appointment.
Activity: You may resume activity as tolerated
Medications: Resume your home medications. You have been
prescribed an antibiotic called Bactrim,please take as directed.
You have also been given a pain medication called oxycodone
(prescription in OMR). This is a narcotic pain medication,so
please use with caution. Please do not drive while taking
oxycodone. You will also be given a stool softener, as oxycodone
can cause constipation.
You are being sent home with a foley catheter in place and leg
bag training. Please at the [**Hospital 159**] Clinic (([**Telephone/Fax (1) 10797**]) to be
evaluated and to have the foley catheter removed.
Followup Instructions:
Please follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**], M.D. in 2 weeks. Please
call his office at ([**Telephone/Fax (1) 4852**] to make an appointment
2. Please call the [**Hospital 159**] Clinic @([**Telephone/Fax (1) 10797**] on Monday [**1-25**]
for an appointment to be evaluated and have the foley catheter
removed
Please follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 28612**]
in 1 week.
Completed by:[**2162-7-30**]
|
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"V15.82",
"428.0",
"585.9",
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"414.00",
"440.24",
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"V58.67",
"438.89",
"414.8",
"707.14",
"496",
"289.0",
"250.80",
"728.87",
"412",
"428.30",
"440.30",
"790.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.18",
"00.41",
"38.08",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6606, 6612
|
4301, 4943
|
366, 502
|
6725, 6799
|
2302, 4278
|
8051, 8590
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1773, 1790
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5467, 6583
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6633, 6704
|
4969, 5444
|
6823, 8028
|
1821, 2283
|
275, 328
|
530, 1016
|
1038, 1722
|
1738, 1757
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,581
| 188,031
|
54453
|
Discharge summary
|
report
|
Admission Date: [**2175-9-6**] Discharge Date: [**2175-9-11**]
Date of Birth: [**2131-7-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
SOB, SSCP
Major Surgical or Invasive Procedure:
None
History of Present Illness:
44yo M w/ AIDS (VL 43,700 and CD4 11 on [**2175-7-25**]) and [**Date Range 1074**]
gastritis/colitis and [**Female First Name (un) **] esophagitis, recent MICU admission
for asthma, found to have MAC, presented to the ER from his
PCP's office for evaluation of his SOB. Pt states that for the
last 3 days, he has had increasing SOB and DOE. He denies having
any f/c/night sweats. 40# wt loss over last 6 weeks (but was
"water weight", treated w/ lasix). Has been told by his RN at
home that "the bottom of his lungs aren't working right", so
went to his PCP's office tonight for regular f/u and, given his
h/o of PCP and MAC, was sent to the ER by his PCP. [**Name10 (NameIs) **] EMS
arrival, he was found to be awake and alert, seated in a WC, on
4L by nc (his home regimen). His RR was 36 and his lung exam was
noted to have rhonchi and wheezing bilaterally. No O2 sat was
recorded, but the patient was placed on 15L by [**Name10 (NameIs) 597**]. O2 sats in
ED triage, back on 4L nc, were 93% -> improved to 100% on [**Name10 (NameIs) 597**].
.
In the ER, the patient was given respiratory treatments
(alb/ipratroprium nebs) and, once improved, was switched back to
4L nc with sats of 98%. Was able to eat dinner w/o difficulty.
Did note some pleuritic CP w/ movement from bed to stretcher. He
was given acyclovir 450mg IV x1 for zoster, bactrim 225mg IV x1
for ? PCP, [**Name10 (NameIs) **] percocet for pain. He was also transfused 1u pRBC
for a Hct of 16.5. Cultures were drawn (blood and urine) and are
pending. UA negative. ABG x2 were performed. First ABG was
7.5/27/161, second ABG was 7.43/35/78. It is unclear what
settings he was on ([**Name (NI) 597**] vs. nc) for the ABGs, but there is no
documentation of a change in status between the ABGs. He had a
CT of his chest performed and then was transferred to the MICU
for further care.
.
Of note, patient has been admitted to [**Hospital1 18**] twice over the past
summer, from [**6-26**] -> [**6-30**] (MICU admission for dyspnea, treated
for PCP pna and CAP despite neg cx, sputum eventually grew MAC,
does not appear to have been treated for MAC) and [**7-11**] -> [**7-30**]
(for diarrhea, dysphagia, and neutropenia; had prolonged hosp
course for w/u of diarrhea - cx neg, but ? [**Month/Day (4) 1074**] colitis - and
eventual BM bx which was negative for infxn or malignancy). He
was in rehab at [**Hospital1 **] til 2 weeks ago and was taking lasix
for diuresis of his "water weight". Upon hospital d/c, he states
he weighed 140# and is now down to 106# with lasix. He notes
that he was doing well at home until the last 3 days when he
went downhill "fast". His baseline functional status is that he
can do his ADLs, but uses a wheelchair to get around and is
chronically on 4L nc at home. He is moving in with his mother
soon as he can no longer manage on his own. Pt states that his
main reason for him coming to the hospital tonight is pain on
his buttocks and that the intervention that made the most
improvement in his symptoms was percocet. He does admit that the
nebulizers helped, but feels that his breathing is comfortable
currently.
.
ROS:
denies fevers, chills, night sweats, though notes evening hot
flashes
+ recent URI sx (sinus congestion, runny nose)
+ chronic cough - productive of thin, clear fluid
+ dysphagia
+ intermittent heartburn
+ SOB/DOE, but no audible wheezing
+ chest tightness with deep inspiration or movement -> never
associated w/ diaphoresis, neck or arm pain, nausea, vomiting
denies lightheadedness or dizziness
denies abd pain, n/v
diarrhea 4 episodes yesterday, 2 today - "explosive" in nature
denies BRBPR, hematochezia, hematemesis, melena
denies dysuria, hematuria, but + frequency
denies LE edema
+ zoster rash on R buttock x 3 days
Past Medical History:
# AIDS
- CD4 11, VL 43,700 on [**2175-7-25**]
- multiple OIs including [**Date Range 1074**] gastritis/colitis (though recent cx
negative) treated w/ ganciclovir, [**Female First Name (un) **] esophagitis, MAC,
shingles, h/o disseminated toxo, PCP pneumonia
[**Name Initial (PRE) **] on HAART as outpatient but w/ ? compliance
- AIDS anorexia -> on megace
# COPD/asthma
- last CTA showed emphysema
- no PFTs on file here
# Dysthymia
Social History:
MSM. Lives alone, but plans to move in with mother soon. [**Name2 (NI) **]
VNA. Unemployed, used to work as a word processing/graphic
design supervisor at an architectural firm. + tobacco use in
past (2ppd x ~20 yrs), now quit for 3 months. occ EtOH use
("social" - 4 drinks/yr), + marijuana use (usually daily).
Family History:
Mother A+W, h/o sarcoid. Father estranged. [**Name2 (NI) **] several
half-siblings and adopted brothers/sisters, all healthy. No fam
hx of CAD, heart disease, stroke, HTN, DM or lung disease.
Physical Exam:
.
VS - T 97.2, BP 112/61, HR 99-105, RR 21-28, sats 97-100% on 3L
nc
wt 43kgs
Gen: Cachectic appearing middle aged male in NAD.
HEENT: Sclera anicteric, PERRL, EOMI. OP + extensive thrush. MM
dry. JVP flat. Conjunctiva, skin pale.
CV: Tachy, reg, normal S1, S2. No m/r/g.
Lungs: CTA anteriorly, + scattered exp wheezing posteriorly,
poor air movement at bases bilaterally, dry crackles at L lung
base.
Abd: Soft, NTND. + BS. No masses. Liver edge palpable on
expiration 2 fingerbreadths below RCM.
Ext: 2+ PT, radial pulses bilaterally. No edema. No rashes.
Skin: Large, ~3-5cm lesion on medial aspect of R buttock,
erythematous and raised border, with scattered vesicles and
pustules, as well as some crusting/excoriations.
Neuro: AAOx3. CN II-XII grossly intact.
.
Pertinent Results:
.
MICRO:
[**2175-9-5**] - blood cx NGTD
.
[**2175-9-6**] - urine cx NO GROWTH, legionella negative
.
[**2175-9-6**] -
GRAM STAIN: 4+ GPRs, 4+ GPC in pairs and chains, 3+ GRNs, 2+
Budding yeast;
.
[**2175-9-7**] - [**Month/Day/Year 1074**] VL pending
[**2175-9-7**] - induced sputum PCP [**Name Initial (PRE) **]
[**2175-9-7**] - blood cx pending
.
IMAGING:
[**2175-9-5**] CXR: There has been near-complete interval resolution
of a left lower lobe opacity, with minimal residual
atelectasis/scarring. The cardiac silhouette, mediastinal and
hilar contours are normal. There is no pneumothorax. The
pulmonary vasculature is normal. The right lung is clear. The
surrounding soft tissue and osseous structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process. Near-complete
interval resolution of left lung base opacity
.
[**2175-9-6**] CTA:
1. Lingular consolidation and more diffuse tree-in-[**Male First Name (un) 239**] opacities
consistent with pneumonia
2. Resolution of left pleural effusion.
3. Emphysematous lungs, no PE.
.
[**2175-9-8**]
CXR PA and LAT: Left basilar atelectasis versus scarring.
.
[**2175-9-9**]
CXR: Left basilar atelectasis versus scarring.
.
[**2175-9-11**]
Thoracic spondylosis without listhesis or fracture. Unremarkable
radiographs of the lumbar spine
.
.
LABS on admission:
[**2175-9-5**] 07:20PM BLOOD WBC-6.9 RBC-1.40*# Hgb-5.0*# Hct-16.5*
MCV-118*# MCH-35.8* MCHC-30.4* RDW-22.2* Plt Ct-831*#
[**2175-9-5**] 07:20PM BLOOD Neuts-79* Bands-2 Lymphs-5* Monos-11
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-1* NRBC-6*
[**2175-9-5**] 07:20PM BLOOD PT-11.1 PTT-19.2* INR(PT)-0.9
[**2175-9-5**] 07:20PM BLOOD Ret Man-12.4*
[**2175-9-5**] 07:20PM BLOOD Glucose-93 UreaN-20 Creat-0.7 Na-141
K-3.4 Cl-110* HCO3-21* AnGap-13
[**2175-9-5**] 07:20PM BLOOD CK(CPK)-24* TotBili-0.4
[**2175-9-5**] 07:20PM BLOOD CK-MB-2 cTropnT-0.02*
[**2175-9-6**] 04:03AM BLOOD ALT-45* AST-28 LD(LDH)-224 CK(CPK)-23*
AlkPhos-61 TotBili-0.3
[**2175-9-6**] 04:03AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2175-9-5**] 07:20PM BLOOD Iron-106
[**2175-9-5**] 07:20PM BLOOD calTIBC-251* VitB12-216* Folate-16.2
Hapto-106 Ferritn-747* TRF-193*
[**2175-9-5**] 09:07PM BLOOD Type-ART pO2-161* pCO2-27* pH-7.50*
calTCO2-22 Base XS-0
[**2175-9-5**] 09:54PM BLOOD Lactate-1.1
.
Additional labs:
.
[**2175-9-6**] 04:03AM WBC-5.1 RBC-1.54* HGB-5.6* HCT-16.4*
MCV-106*# MCH-36.1* MCHC-33.9# RDW-25.7*
[**2175-9-6**] 04:03AM FERRITIN-638*
[**2175-9-6**] 04:03AM CK-MB-NotDone cTropnT-<0.01
[**2175-9-6**] 04:03AM ALT(SGPT)-45* AST(SGOT)-28 LD(LDH)-224
CK(CPK)-23* ALK PHOS-61 TOT BILI-0.3
[**2175-9-6**] 03:15PM HCT-21.1*#
.
[**2175-9-5**] 10:27PM BLOOD Type-ART pO2-78* pCO2-35 pH-7.43
calTCO2-24 Base XS-0 Comment-ROOM AIR
[**2175-9-11**] 06:30AM BLOOD Glucose-113* UreaN-16 Creat-0.5 Na-136
K-5.1 Cl-105 HCO3-27 AnGap-9
[**2175-9-11**] 06:30AM BLOOD Plt Ct-480*
[**2175-9-11**] 06:30AM BLOOD WBC-4.1 RBC-2.81*# Hgb-9.6*# Hct-29.2*#
MCV-104*# MCH-34.2* MCHC-32.9 RDW-26.1* Plt Ct-480*
.
.
Brief Hospital Course:
A/P: 44M with AIDS (VL=43K and CD4=[**2175-7-7**]) complicated by
multiple opportunistic infections transferred from MICU. Patient
has a history of MAC, PCP, [**Name10 (NameIs) 1074**] gastritis/colitis, and [**Female First Name (un) **]
esophagitis. He reported having diarrhea prior to admission. He
was found to have a hct of 16.5 on arrival.
.
# SOB:
The patient has been admitted and seen by a doctor multiple
times in the past year for increasing SOB. It is unclear what
the true etiology is but is likely multifactorial given his
history of COPD/emphysema by previous CTA, as well as + AFB in
sputum in [**6-1**] which grew MAC. His initial CT was negative for
PE but showed a lingular infiltrate as well which was concern
for pneumonia. Patient was placed on ceftriaxone and
clarithromycin for a possible CAP or MAC. He was subsequently
switched to azithromycin and discharged on PO augmentin to
complete a 10-day course of abx. He received alb/ipratroprium
nebs and salmeterol INH. ID continued to follow until patient
was discharged. A repeat CXR showed left basilar
atelectasis/scarring with no pleural effusion. Patient's room
air oxygen saturation was 97% on discharge.
.
# SSCP:
This issue seems to be chronic for the patient although he
reports that the pain has been worse lately. It is the same type
of pain he usually experiences at home. The pain seems to
migrate throughout his upper body (chest and abdomen) from one
day to another. The pain did not radiate anywhere and was not
associated with diaphoresis, or changes in RR, HR, or BP. It was
occasionally associated with movement or coughing. We thought
the etiology was likely musculoskeletal. However, given its
substernal nature, the patient was worked up for possible
cardiopulmonary causes.
EKG unchanged from prior, CTA negative for PE, and cardiac
enzymes on admission were negative. A thoracic/lumbar spine film
showed thoracic spondylosis without listhesis or fracture with
an unremarkable lumbar spine. The patient's pain was controlled
with percocet which helped alleviate it.
.
# ANEMIA:
The patient's hematocrit was 16 on admission. His anemia was
consistent with anemia of chronic disease with possible
underlying iron deficiency anemia. Iron studies were: fe 106,
calc TIBC 251, folate 16.2 nl, hapto 106 nl, ferritin 747, TRF
193. He had a bone marrow biospsy in [**7-2**] which was
negative negative for malignancy, infection or infiltrative
process. He received pRBCs throughout his stay for a goal hct
>21. He was discharged with a hematocrit of 29. He also received
vitamin B12, thiamine, and folate during his stay. Smear on
admission showed schistocytes raising concern for intravascular
hemolysis but tbili was low
.
# AIDS:
The patient has advanced HIV AIDS. He was continued on his
outpatient HAART regimen. He continued to receive the following
prophylactic meds: azithromycin, Bactrim DS, Diflucan, nystatin
s/sw, and Acyclovir (which was later switched to
valganciclovir). Infectious Disease continued to follow
throughout the hospitalization. He continued to receive
megestrol for AIDS anorexia
.
# DIARRHEA:
The patient's diarrhea was thought to be due to [**Month (only) 1074**] colitis
during a previous admission. His [**Month (only) 1074**] viral load was 5970 so this
bout of diarrhea was likely due to [**Month (only) 1074**] colitis as well. He did
not experience diarrhea since admission and had 2 instances of
formed stool prior to discharge. An email was sent to his PCP
asking him to repeat the patient's [**Month (only) 1074**] viral load as an
outpatient. He was discharged on lifelong prophylactic
valganciclovir.
.
# ZOSTER:
This is a chronic issue for this patient who has had multiple
bouts w/ zoster infection on his right buttock. This was likely
another outbreak. He was initially treated with acyclovir and
subsequently switched to valganciclovir. ID continued to follow.
The lesion was almost completely resolved prior to discharge.
.
# DYSTHYMIA:
Patient was kept on his home dose of mirtazapine and clonazepam.
.
# FEN:
Patient was maintained on a regular diet which he tolerated
well. His electrolytes were monitored daily and replenished as
needed
.
# PPX: hep SC, ranitidine QHS, fluconazole, nystatin
Other than his HIV-AIDS related prophylactic meds, patient was
on SC heparin during his stay
.
# CODE:
Patient remained a full code throughout his hospitalization
.
# DISPO:
The patient was discharged home with services. He was in stable
condition. His SOB had improved and his O2 sat was 97% on room
air. His diarrhea had resolved and his hematocrit on discharge
was 29.2
.
Medications on Admission:
MEDS: (per PCP's office note [**2175-9-5**])
Lamivudine 300mg PO QD *
Ritonavir 100mg PO QD *
Tenofovir 300mg PO QD *
Atazanavir 300mg PO QD *
Abacavir 600mg PO QD *
Mirtazapine 30mg PO QHS *
Salmeterol 50mcg/dose [**Hospital1 **] *
Budesonide 0.25mg/2mL neb INH [**Hospital1 **] *
Senna 2 tabs PO QHS *
Alb nebs Q6 prn + INH prn *
Ipratroprium INH Q6 prn *
Loperamide 2mg PO QID prn
Diphenoxylate-Atropine 2.5-0.025 mg PO Q6H prn *
Nystatin sw/sw PO TID *
Dapsone 100mg PO QD *
Megesterol 400mg PO BID *
Lasix 40mg PO BID *
Simethicone 80mg PO QID prn *
Thiamine 100mg PO DAILY *
Folic Acid 1mg PO DAILY *
Tylenol prn *
MVI 1 tab PO QD *
Colace 100mg PO BID *
Azithromycin 1200mg PO 1X/WEEK *
Testosterone injections Q 2 wks - done in clinic
Cyanocobalamin 1000mcg IM Q month
Roxicet 325/5 per 5mL PO x1 before meals up to QID
Clonazepam 0m5mg PO QHS prn sleep
.
Discharge Medications:
1. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Atazanavir 100 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
3. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
8. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
12. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation twice a day.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
16. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
17. Budesonide 0.25 mg/2 mL Solution for Nebulization Sig: One
(1) Inhalation twice a day.
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
19. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
20. Megestrol 40 mg/mL Suspension Sig: One (1) PO BID (2 times
a day).
21. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
22. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q4-6H (every 4 to 6 hours) as needed.
23. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
24. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
25. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO Q 24H
(Every 24 Hours).
Disp:*60 Tablet(s)* Refills:*2*
26. Augmentin XR 1,000-62.5 mg Tablet Sustained Release 12HR
Sig: One (1) Tablet Sustained Release 12HR PO twice a day for 6
days.
Disp:*12 Tablet Sustained Release 12HR(s)* Refills:*0*
27. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO once a
week.
Disp:*60 Tablet(s)* Refills:*2*
28. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO four times a day as needed for bloating.
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
[**Hospital1 1074**] colitis
Pneumonia (CAP)
HIV AIDS
Discharge Condition:
stable, afebrile, no diarrhea, no shortness of breath, room air
oxygen saturation 95%
Discharge Instructions:
Please take medications as prescribed.
Please keep your follow-up appointment(s).
We have added valganciclovir and the Amoxicillin to your home
medications. We stopped you lasix. Your PCP should decide
whether to restart it or not.
If you have any increasing nausea/vomitting, fevers/chills,
severe diarrhea or other worrying symptoms, please call your
primary care physician or return to the emergency room.
Followup Instructions:
Please follow up with your primary care physician. [**Name10 (NameIs) 357**] call
the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 2393**] to make an
appointment to be seen 3-4 days after discharge.
Dr [**Last Name (STitle) **] needs to follow up your pending blood culture and
sputum culture. He also needs to repeat a [**Last Name (STitle) 1074**] viral load.
|
[
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icd9cm
|
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[
[]
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,094
| 156,972
|
45435
|
Discharge summary
|
report
|
Admission Date: [**2113-7-26**] Discharge Date: [**2113-7-29**]
Date of Birth: [**2039-8-6**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Hydralazine / Ace Inhibitors / Diovan
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Placement of right IJ central catheter.
History of Present Illness:
HPI: Patient is a 73-year old female nursing-home resident with
MMP including ESRD on HD, CAD (s/p cath [**11-26**] showing 3VD, 2
stents to RCA, c/b contrast nephropathy leading to ESRD), hx of
MRSA osteomyelitis (completed 3 month course of Vancomycin on
[**7-14**]), DM, Afib who presents to the ED from HD with mental
status changes. Patient was reportedly in her USOH at dialysis
when she was noted to have a change in mental status and
responded inappropriately to questions; futher details
unavilable. Patient was taken to the ED where she was found to
be hypotensive to 70s and Temp of 100.6. She was alert and
oriented x 2. Her pressure initially responded to fluid boluses
but patient became hypotensive again. She was started on
Morphine 2mg IV x 1, Tylenol 650 mg POR x 1, Vancomycin 1g IV x
1, Levaquin 500mg IV x 1, and Flagyl 500mg IV x 1. Patient
received a head CT in the ED, wet read was negative for acute
bleed or infarction. She was transferred to the [**Hospital Unit Name 153**] for further
management. CXR showed bibasilar atelectasis and small pleural
effusions, no infiltrates were noted. UA was positive for
leukocyte esterase and 50 WBCs. Patient denied any chest pain,
headache, nausea, or vomiting. Denied urinary complaints.
Past Medical History:
hypercholesterolemia
IDDM
HTN
CAD - cath [**11-26**] with 3VD, s/p cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to RCA.
pulmonary HTN
CHF (Ef 30% improved to 60% after catheterization)
ESRD from contrast nephropathy post cardiac catheterization
[**11-26**] on HD since [**12-28**] (baseline creatinine [**2-24**])
Severe lumbar spondylosis and spinal stenosis s/p laminectomy
in [**2110**]
Osteomyelitis T5-T6 on suppressive vancomycin for 3 months
([**2113-4-13**] was day 1)
MRSA bacteremia from HD line infection
recent admit for mild-to-moderate cord compression [**Date range (1) 3046**]/05.
evaluated by neurosurgery felt mild and did not put patient at
risk for cauda equina syndrome.
Atrial fibrillation
Mitral Regurgiation 1+ TEE [**1-28**]
Social History:
Long hx of smoking until [**11-26**]. Social drinker. Has been
bedridden since [**Month (only) 1096**]. Prior to that ambulates with walking
assist device which she has required since "being dropped by
EMT's" prior to her surgical repair for spinal stenosis. Also
uses an electronic wheetchair. Has daughter and son that live in
area. Currently resident at nursing home.
Family History:
Fhx: Father died of CVA at 64yo. Mother died of MI @ 86yo.
Brother had CAD.
Brief Hospital Course:
A/P 73 year-old female MMP including CAD, DM, ESRD on HD p/w
fever and hypotension, impression is sepsis, patient would like
comfort care only, competent to make decision at time of
discussion -
.
1. Hypotension
Given fever and + UA appeared that UTI induced sepsis was high
on the differential but a urine culture was negative for
infection. Sepsis protocol initiated initially but hypotension
quickly resolved after hemodialysis stopped and fluid boluses
given. No EKG changes noted. Patient denied any chest pain. A
head CT was negative for any acute process. Two sets of blood
cultures from [**2113-7-26**] are negative to date. Initially treated for
UTI w/ Levoquin as admission u/a w/ moderate leukocyte esterase
and > 50 bacteria. Urine cx negative except for yeast so stopped
anitbiotics after short course. Given hx of MRSA sepsis,
initially covered with broad spectrum antibiotics, Vancomycin
for gram positive coverage, Levofloxacin for gram negative
coverage. Has been afebrile with normal wbc during admission.
It appears that hypotension secondary to UTI or potentially
hemodialysis. Blood pressure was stable since time of admission
to the ICU. Metoprolol had been held in setting of hypotension
on admission. Would recommend that PCP restart if patient
tolerates hemodialysis on day of discharge.
.
2. Mental Status change: Patient now A0 x 3. CT Head after
acute event was negative for acute bleed or infarction. UTI in
elderly common cause of change in mental status, combined with
dehydration, appears to be likely etiology as patient had been
started on no new medications and had no focal deficits on
neurologic [**Month/Day/Year **]. Patient had no subsequent changes in mental
status during her admission and was at her baseline as per her
family and PCP.
.
3. CAD: No chest pain or EKG changes from baseline suggestive of
cardiac source of her symptoms. Continue Aspirin, Plavix,
Lipitor. As noted above, her beta blocker was initally held but
would restart if patient tolerates HD on day of discharge.
.
4. ESRD: The renal service followed the patient during her
admission. Plan to do dialysis on [**2113-7-29**]. CaCO3 TID per
outpatient regimen. Patient initially refused to continue HD and
requested to be CMO. Later changed mind and will continue HD at
least temporarily. Renal aware.
.
5. DM: Patient had been refusing fingersticks so RISS held were
held for one day. Patient should be restarted on QID
fingersticks with regular insulin sliding scale in place.
.
6. Depression: Continued Citalopram 20mg [**Hospital1 **] during admission
and should be continued on discharge.
.
7. Back Pain: Acetaminophen 650mg PO q4-6h PRN pain given during
admission. Lidocaine Patch continued as outpatient. Had been on
morphine gtt when temporarily made CMO with good effect.
Continue with MS Contin prior to hemodialysis as had been
getting prior to admission.
.
8. PPx: Heparin 5000 SC TID, Protonix, and Folic Acid 1 mg PO qd
as inpatient.
.
9. F/E/N: Patient was on renal, low fat diet with 2g salt
restriction. Poor po intake during admission but had been
improving prior to discharge. Repleted electrolytes as needed.
.
10. CODE: DNR/DNI Patient had temporarily been made CMO on
[**2113-7-28**] because she no longer wanted to continue HD and felt her
quality of life was not worth prolonging her suffering. Ethics
committee consulted and discussions had with PCP. [**Name10 (NameIs) **] that
it was reasonable for patient to be CMO. However, after talking
with her family patient changed her mind and opted to continue
HD at least for now. Will continue DNR/DNI.
.
11. Communication: Daughter
.
12. Disposition: Will return to [**Hospital **] nursing home on [**2113-7-29**]
following dialysis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Hypotension likely in setting of hemodialysis
Osteomyelitis of thoracic spine
Spondylisthesis L5-S1
Urinary tract infection
Type 2 Diabetes
Hypertension
Coronary artery disease
End stage renal failure dependent on dialysis
Discharge Condition:
Improved
Discharge Instructions:
You will continue to have hemodialysis on your regularly
scheduled days.
Followup Instructions:
You will follow up with your primary care doctor at your
extended care facility.
Completed by:[**2113-7-29**]
|
[
"416.8",
"414.01",
"403.91",
"599.0",
"250.00",
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"V45.82",
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"730.28",
"427.31",
"428.0",
"424.0",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6721, 6815
|
2946, 6698
|
318, 359
|
7082, 7092
|
7213, 7325
|
2846, 2923
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6836, 7061
|
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|
267, 280
|
387, 1645
|
1667, 2441
|
2457, 2830
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,956
| 147,281
|
1179+55264
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-4-21**] Discharge Date: [**2107-5-4**]
Date of Birth: [**2025-8-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
afib with RVR, hypernatremia, respiratory distress
Major Surgical or Invasive Procedure:
Endotracheal intubation
Aterial line placement
Central venous line placement
History of Present Illness:
This is an 81 yo M with history of lung cancer s/p wedge
resection, prostate ca s/p radiation and chemotherapy, new
pancreatic mass likely IPMN, and recent admission for ruptured
appendix treated medically who is admitted with hypernatremia,
afib with RVR and respiratory distress.
.
The patient was admitted from [**3-29**] to [**4-13**] for RLQ pain found to
be a ruptured appendicitis. He was treated with medical
management and has been on Cipro/Flagyl for antibiotic therapy
since then. Of note, CT showed possible early abscess which was
unchanged to slightly improved on repeat CT. He was also found
to have a R subclavian vein thrombosis at the site of a prior
PICC line. He has been on anticoagulation since that time. He
additionally had a tachycardia thought to most likely be
MAT/sinus tach wtih APBs which was treated with IV and PO
lopressor.
.
He had been doing well at [**Hospital 100**] Rehab, receiving IV
Cipro/flagyl and was afebrile until [**4-19**]. At that time, he
began to develop hypernatremia and hyperkalemia with worsening
renal dysfunction. He was then given decreased Na in his TPN
and decreased his daily K supplement from 40 to 20 mEq daily.
He was given Lovenox for his RUE DVT and coumadin was initiated
on [**4-19**]. Per report, as his Na was increasing and his HR had
increased with rates in the 140s with SBPs in the 80s, he was
transferred to the ED for further management.
.
In the ED, initial VS were 98.8 140/102 114 92% on 4L NC. BP
decreased to 90s/40s up to 119/36 with IVF. He was given Vanc
1gm IV x1, Zosyn 4.5 mg IV x1, Dilt 10 mg IVx1 with minimal rate
improvement, heparin gtt started without bolus as well as dilt
gtt. He rec'd a total of 3L of IVF. He was intubated due to
increased work of breathing and started on fentanyl and versed
boluses for sedation. He was transferred to the floor for
further management.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, 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:
1. COPD
2. HTN
3. CHF EF 35% on stress ECHO [**4-10**] - inferior scar and LVEF 43%
on [**2103**] MIBI
4. PAF
5. Depression
6. Hip Fx
7. Hyperlipidemia
8. Osteoporosis
9. Stage III CKD (baseline Cr 1.3-1.5)
10. Mild Cognitive Impairment
11. Lung Cancer T1 Adenocarcinoma - wedge resection [**2105**]
12. s/p RUL wedge resection [**7-10**] ([**Doctor Last Name 952**]) - unable to perform
complete lobar resection [**3-7**] poor respiratory reserve. c/b
persistent mediastinal lymph node followed by yearly CT
13. Prostate CA - high grade, s/p Lupron tx, XRT - in [**12-11**]
14. s/p left intertrochanteric nail '[**97**]
15. pancreatic head mass -- likely IPMT
16. Ruptured apendicitis s/p medical therapy as not found to be
appropriate surgical candidate, [**4-11**]
Social History:
He lived alone in [**Location (un) **] apartment, but has been at [**Hospital 100**]
Rehab since discharge on [**4-13**]. He was divorced 25 yrs ago. (+)
tobacco 69 pack yrs quit 3 yrs ago. Has been drinking since his
divorce 25 yrs ago 1/2-1 liter wine qd. No hard liquor.
Family History:
noncontributory
Physical Exam:
General: Sedated and intubated
HEENT: Sclera anicteric, dry MM, ETT in place
Neck: supple, JVP not elevated
Lungs: Bilateral rhonchi Clear to auscultation bilaterally, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2107-4-21**] 01:05PM BLOOD WBC-9.4 RBC-3.36* Hgb-10.5* Hct-31.4*
MCV-93 MCH-31.3 MCHC-33.5 RDW-16.4* Plt Ct-372
[**2107-4-21**] 01:05PM BLOOD Neuts-77.8* Lymphs-15.4* Monos-4.9
Eos-1.2 Baso-0.7
[**2107-4-21**] 01:05PM BLOOD PT-18.1* PTT-49.6* INR(PT)-1.7*
[**2107-4-21**] 01:05PM BLOOD Glucose-120* UreaN-78* Creat-1.8* Na-150*
K-4.2 Cl-123* HCO3-18* AnGap-13
[**2107-4-21**] 01:05PM BLOOD cTropnT-0.06*
[**2107-4-21**] 01:05PM BLOOD CK(CPK)-32*
[**2107-4-21**] 09:27PM BLOOD Calcium-8.4 Phos-4.4 Mg-2.0
[**2107-4-21**] 01:05PM BLOOD calTIBC-151* Ferritn-647* TRF-116*
[**2107-4-21**] 05:04PM BLOOD Type-ART pO2-48* pCO2-56* pH-7.16*
calTCO2-21
.
CHEST (PORTABLE AP):
IMPRESSION: No evidence of consolidation. Decreased left pleural
effusion
compared to prior. Stable right sided pleural effusion.
.
CT ABDOMEN W/O CONTRAST:
IMPRESSION:
1. No evidence of fluid collection adjacent to the pancreas or
appendix.
2. Moderate bilateral pleural effusions.
3. Cholelithiasis without evidence of cholecystitis.
.
RENAL U.S. PORT
FINDINGS: There is no evidence of hydronephrosis or obstruction.
The right
kidney measures 11 cm in length. The left kidney measures 10.7
cm in length. There is a small anechoic cyst in the left kidney,
measuring 1.3 x 0.7 x 1.6 cm. The bladder is only minimally
distended and cannot be assessed.
IMPRESSION: No evidence for hydronephrosis.
.
EKG:
Atrial fibrillation with rapid ventricular response and one
premature
ventricular beat. Low limb lead voltage. Possible prior inferior
wall
myocardial infarction, age indeterminate. Compared to the
previous tracing of [**2107-4-4**] the ventricular response is faster.
The findings are otherwise
similar.
.
2D Echo:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with a basal inferior aneurysm. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). The right ventricular cavity is mildly dilated
with normal free wall contractility. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. There is at least mild
pulmonary artery systolic hypertension. There is moderate to
severe tricuspid regurgitation. There is no pericardial
effusion.
.
Compared with the prior study (images reviewed) of [**2106-4-12**],
mitral regurgitation is now less prominent. The basal inferior
aneurysm appears similar. Moderate to severe tricuspid
regurgitation is now detected.
Brief Hospital Course:
Mr. [**Known lastname 7509**] is an 81 year old male with history of lung cancer
s/p resection, prostate ca s/p hormonal therapy and XRT as well
as COPD, SVT, CHF and ruptured appendix on medical therapy who
was admitted with respiratory failure and atrial fibrillation
with RVR.
.
# Respiratory failure: Patient required intubation in the ED on
[**4-21**] for hypoxia and respiratory distress. Etiology felt likely
combination of IVF resuscitation in the setting of CHF, afib
with RVR, likely PE and profound metabolic acidosis that the
patient was attempting to compensate for (initial pH on arrival
to the ICU 7.16). The patient was gradually weaned to pressure
support and successfully extubated on [**4-30**]. On the floor the
patient was weaned to room air on [**5-4**]. His 02 sat was 92-94% on
2L.
.
#Hypotension: Likely secondary to sepsis and A-fib with RVR.
The patient mounted an appropriate response to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test
(14.6->28.5). TSH and FT4 were within normal limits. Patient
required levophed for several days which was eventually weaned
off when he was receiving ABX and rate control.
.
# Atrial Fibrillation with RVR: The patient presented in atrial
fibrillation with RVR, most likely a result of sepsis. He has a
history of afib with RVR in the setting of acute illness in the
past. Mixed venous O2 Sat was high, suggesting distributive
shock. Although the patient may have had a component of
cardiogenic shock, he did not much benefit from a diltiazem gtt
or metoprolol PO/IV. The patient was initially rate controlled
on a diltiazem drip. His home metoprolol was held in the
setting of hypotension while requiring levophed for blood
pressure support. He was transfused 2 u pRBCs on [**4-26**] per
Cardiology who felt the patient was intravascularly volume
depleted, and started on amiodarone. His heart rate came down
from 110s-130s to low 100s. After his blood pressure
stabilized, he was restarted on metoprolol which was uptitrated
from 12.5 TID to 50 TID. His heart rate was atrial fibrillation
with rate 80s-100 on the day of discharge. The rehab center
should continue to titrate metoprolol as his blood pressure will
tolerate for a goal rate of 70s. He was discharged on
amiodarone 200 [**Hospital1 **], and follow up with cardiology was arranged.
.
# Fever: Patient had been on cipro/flagyl for medical management
of a ruptured appendicitis with course to end on [**4-22**]. Initial
fever on presentation may have represented worsening of this
process vs. aspiration pneumonitis from intubation vs. other
occult infectious process. Notably, the patient did not have an
elevated WBC count. He may not have been able to mount a robust
inflammatory response due to older age and a generally
chronically ill state. CT abdomen-pelvis was negative for any
drainable abscesses and showed improvement of his ruptured
appendix. B-glucan returned floridly positive (>500) which was
not surprising given the patient's prolonged antibiotic
courses, frequent hospital stays and history of TPN. He did
have yeast in both urine and sputum cultures. His MRSA screen
was also positive. He was C. diff negative x 2. The patient
was started on vancomycin and zosyn on [**4-22**] for his initial
decompensation. He should complete a total of a 10 day course
(last dose 3/29). He was started on fluconazole for his
positive beta-glucan on [**4-27**]. Noteably, he improved markedly
after starting the latter medication. He completed a 7 day
course of this medication. He remained afebrile for >72 hours.
Follow up cultures were negative. His fever may have also been
due to his PE.
.
# Abdominal pain: The patient intermittently had abdominal
discomfort on exam. Although this was difficult to assess while
he was intubated, it was concerning given his history of a
medically managed ruptured appendicitis. Throughout his ICU
course he was stooling well (1-3 times a day). He was C.diff
neg x 2, and had no residuals with tube feeds that were
initiated per surgery recommendations. KUB was negative for
ileus or obstruction. LFTs, amylase, lipase all WNL. The
patient denied any abdominal pain after he was extubated.
Surgery did not feel his h/o appendicitis was still and issue.
.
# Hypernatremia: Likely secondary to free water deficit as
patient intermittently required D5W. On the 3 days prior to
discharge, the patient's sodium was 150, he received 500cc bolus
of D5W, then sodium was down to 146 the next morning. That
evening he was back up to 150 and received another 500 cc bolus
of d5W. His sodium remained at 150 the following morning. He
was slightly more anasarcic, but encouraged PO water and given
one more d5W bolus. Renal did not feel that lasix was indicated
and felt that the patient's sodium should be managed with free
water. His sodium levels will continue to be monitored at
[**Hospital1 7510**] MACU and D%W should be given as needed.
.
# Acute on chronic renal failure: Slowly resolved over the
course of the patient's hospitalization. Initially likely
pre-renal then with a component of ATN. At the time of transfer
to the floor the patient had an excellent urine output off all
diuretics and his creatinine had improved markedly. On the
floor his creatinine stabilized at 1.2-1.3, his urine output was
40-60cc/hr.
.
# Anemia: Baseline appears to be around 37. Admitted with HCT
in the high 20s, stable after 2 u pRBCs on [**4-26**]. B12, folate,
& iron within normal limits (though ferritin may be elevated as
an acute phase reactant and should be rechecked once pt recovers
from acute illness). [**Month (only) 116**] be partially related to CKD. Also
having low grade hematuria (pink urine) off and on (with
anticoagulation/INR 2.2). On the floor the patient's HCT was
stable between 27 and 29. He had no signs of bleeding and he
was stool guiaic negative.
.
# Right subclavian vein thrombosis/Presumed PE: Significant
erythema and edema of RUE on admission. Upper extremity ECHO
showed a clot. PAtient's TTE showed signs of likely pumonary
embolism, but given the patient's creatinine CTA was not
possible. He was anticoagulated and treated for presumed PE.
Patient stabilized and bridged to coumadin, initially on 2.0.
Warfarin was increased to 2.5 daily but the patient then became
supratherapeutic (3.6 to 4.8 to 4.0 on the day of discharge).
Warfarin has been held since Monday [**5-2**]. At [**Hospital 100**] rehab they
will continue to monitor INR, and restart warfarin as indicated.
Patient will require lifelong anticoagulation.
.
# Pancreatic mass: Followed as an outpatient and appears to have
been stable on repeat imaging. Plan is for utpatient follow up.
.
#Hematuria: Felt to be secondary to foley trauma, resolved by
discharge.
.
#Dysphagia: Speech and swallow saw the patient and recommended
-PO Diet: soft solids and thin liquids with chin tuck,
aspiration precautions
-PO Meds: Crushed in puree
.
#Code Status: full code
Medications on Admission:
Metoprolol Tartrate 75 mg PO TID
Simvastatin 20 mg QHS
Tiotropium Bromide 18 mcg daily
Trazodone 75 mg PO HS
Aspirin 81 mg daily
Vitamin D 1000 units daily
Docusate Sodium 100 mg PO BID
Levalbuterol HCl 0.63 mg/3 mL Solution Q6H prn
Lovenox 80 mg [**Hospital1 **]
Ferrous Sulfate 325 mg PO daily
Omeprazole 40 mg daily
Fluticasone 110 mcg/Actuation 2 puffs [**Hospital1 **]
Metronidazole 500 mg IV Q8H to be completed on [**4-22**]
Ciprofloxacin 250 mg PO BID
Regular insulin SS
Bicitra 15 mL QACHS
TPN
Coumadin 2.5 mg daily started [**4-18**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation Q4H (every 4 hours) as needed.
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED): see attached sliding scale.
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1)
PO DAILY (Daily).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours) as needed for wheezes.
8. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): please hold for SBP <100 or HR <60. Tablet(s)
13. Sodium Citrate-Citric Acid 500-300 mg/5 mL Solution Sig:
Fifteen (15) ML PO qACHS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Atrial Fibrillation with RVR
Sepsis
Right Subclavian Vein Clot
Pulmonary Embolism
Hypernatremia
Hypertension
Secondary Diagnosis:
COPD
CHF EF 35% on stress ECHO [**4-10**] - inferior scar and LVEF 43%
on [**2103**] MIBI
Depression
Hyperlipidemia
Osteoporosis
Stage III CKD (baseline Cr 1.3-1.5)
Mild Cognitive Impairment
Lung Cancer T1 Adenocarcinoma complete lobar resection [**3-7**] poor
respiratory reserve.
persistent mediastinal lymph node followed by yearly CT
Prostate CA - high grade, s/p Lupron tx, XRT - in [**12-11**]
s/p left intertrochanteric nail '[**97**]
pancreatic head mass -- likely IPMT
Ruptured apendicitis s/p medical therapy
Discharge Condition:
Pain free, no 02 requirement, sodium 150, creatinine 2.8, upper
extremity and lower extremity 2+ pitting edema.
Discharge Instructions:
You came to the hospital with a severe infection, had atrial
fibrillation with a fast heart rate, and a blod clot in your
lung. We treated you with antibiotics, blood thinner and
assistance with breathing in the ICU, and when you became stable
we transferred you to the floor.
.
We made the following changes to your medications:
Amiodarone 200 mg po BID
Metoprolol 50 mg po TID
.
[**Last Name (un) 6267**] follow up with your primary care doctor and your other
doctors as below.
.
If you have fevers, chills, worsening shortness of breath, chest
pain, abdominal pain, nausea, vomiting or any other symptoms
that are concerning to you please call your doctor or come to
the emergency room.
Followup Instructions:
Monday [**1128-5-8**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
.
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2107-6-3**] 1:10
.
Provider: [**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2107-6-13**]
2:30
.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD,PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2107-6-23**] 9:30
.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Name: [**Known lastname 952**],[**Known firstname **] Unit No: [**Numeric Identifier 953**]
Admission Date: [**2107-4-21**] Discharge Date: [**2107-5-4**]
Date of Birth: [**2025-8-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 954**]
Addendum:
ADDENDUM TO ABOVE:
For Afib:
-would continue amiodaron 200mg po BID for [**2-5**] more weeks
(patient has received 7days here) and then consider decreasing
to 200po daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 955**]
Completed by:[**2107-5-4**]
|
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"577.9",
"995.92",
"909.2",
"285.9",
"427.31",
"276.2",
"038.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.10",
"99.15",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
18915, 19146
|
7106, 14099
|
364, 442
|
16752, 16866
|
4352, 4352
|
17604, 18892
|
3851, 3868
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16050, 16050
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16890, 17191
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3883, 4333
|
17220, 17581
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274, 326
|
2369, 2749
|
470, 2351
|
16210, 16731
|
4368, 7083
|
16069, 16189
|
2771, 3542
|
3558, 3835
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,197
| 140,448
|
14309
|
Discharge summary
|
report
|
Admission Date: [**2173-6-10**] Discharge Date: [**2173-6-15**]
Date of Birth: [**2107-6-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Gadolinium-Containing Agents / lisinopril / Statins-Hmg-Coa
Reductase Inhibitors / Penicillins / Flecainide
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional chest discomfort
Major Surgical or Invasive Procedure:
Coronary Artery Bypass x 4 (LIMA-LAD, SVG-Diag, SVG-OM,
SVG-PDA), Ascending [**First Name3 (LF) **] Replacement with 32mm Gelweave, Maze
[**2173-6-11**]
History of Present Illness:
This is a 65yo male with known aortic
aneurysm and atrial fibrillation. He recently noted worsening
chest pressure on exertion, such as after 5-10 minutes of lawn
mowing or after climbing [**2-21**] flights of stairs. He denies
associated shortness of breath, chest pain at rest,
claudication,
edema, orthopnea, PND, and lightheadedness. Subsequent stress
test was abnormal and he was referred for cardiac
catheterization
which revealed multivessel coronary artery disease. He is now
referred for surgical revascularization. Of note, he is
currently
on Pradaxa for treatment of his atrial fibrillation.
Past Medical History:
- Aortic Insufficiency/Mitral Regurgitation
- Dilated aortic root/Ascending aortic aneurysm
- Hypercholesterolemia
- History of Rheumatic fever
- Paroxysmal atrial fibrillation,s/p multiple DCCV - mostly
recently in [**2173-3-21**]
- ? Lymes disease
- Hypertension
- Asbestosis involving right lung
- Mild right carotid artery disease
- Bilateral thyroid nodules
Past Surgical History:
s/p removal of a bladder tumor in [**2157**]
s/p arthroscopic knee surgery
s/p bilateral knee replacements
s/p inguinal hernia repair
s/p Nasal surgery for cyst and deviated septum
Social History:
Lives with: Wife in [**Name2 (NI) 17927**]
Occupation: Retired
Cigarettes: Denies
ETOH: < 1 drink/week [] [**1-26**] drinks/week [X] >8 drinks/week []
Illicit drug use: Denies
Family History:
No known premature coronary artery disease or
arrhythmias. Father died of asbestosis in his 40s
Physical Exam:
Pulse: 50 Resp: 16 O2 sat: 97% room air
B/P Right: 139/84 Left: 135/89
General: WDWN male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] soft diastolic murmur
noted
Abd: Soft [x] non-distended [x] non-tender [x] bowel sounds [x]
Extremities: Warm [x], well-perfused [x] Edema: None
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left: 2
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit: none
Pertinent Results:
[**2173-6-11**] TEE
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%). with mild global free wall hypokinesis.
The ascending [**Month/Day/Year 5236**] is mildly dilated at 4.0 cm.
The sino-tubular junctions are present, but mildly effaced. The
STJ diameter is 4.0. The diameter across the sinuses is 4.8.
There is no aortic valve stenosis. Mild to moderate ([**12-21**]+)
aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is in SR, on no inotropes.
Unchanged biventricular systolic fxn.
There is a prosthetic ascending aortic tube graft.
The native aortic valve now shows trace AI.
Trace MR. [**First Name (Titles) 42464**] [**Last Name (Titles) 5236**] intact.
Brief Hospital Course:
The patient was brought to the Operating Room on [**2173-6-11**] where
the patient underwent CABG x 4, Ascending [**Date Range **] Replacement,
Maze with Dr. [**Last 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.
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.
Coumadin and amiodarone were started for h/o AFib and s/p Maze.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD #4 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to home in good condition with
appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Atenolol 25 mg PO DAILY
2. Cholestyramine 4 gm PO BID
3. Dabigatran Etexilate 150 mg PO BID
4. Losartan Potassium 25 mg PO HS
5. Aspirin 81 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 Tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
2. Cholestyramine 4 gm PO BID
3. Vitamin D 400 UNIT PO DAILY
4. Acetaminophen 650 mg PO Q4H:PRN fever, pain
5. Clonazepam 1 mg PO QHS sleep
6. Metoprolol Tartrate 25 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 Tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
7. Milk of Magnesia 30 ml PO HS:PRN constipation
8. Oxycodone-Acetaminophen (5mg-325mg) [**12-21**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**12-21**] Tablet(s) by mouth
every four (4) hours Disp #*65 Tablet Refills:*0
9. Warfarin MD to order daily dose PO DAILY afib
goal INR 2.0-3.0
dose to be determined by Dr. [**Last Name (STitle) 131**]
RX *Coumadin 1 mg as directed Tablet(s) by mouth once a day Disp
#*90 Tablet Refills:*1
10. Potassium Chloride 20 mEq PO DAILY Duration: 7 Doses
Hold for K+ > 4.5
RX *potassium chloride 10 mEq 2 tablets by mouth once a day Disp
#*7 Tablet Refills:*0
11. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 Tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
12. Docusate Sodium 100 mg PO BID
13. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 Tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
- Aortic Insufficiency/Mitral Regurgitation
- Dilated aortic root/Ascending aortic aneurysm
- Hypercholesterolemia
- History of Rheumatic fever
- Paroxysmal atrial fibrillation,s/p multiple DCCV - mostly
recently in [**2173-3-21**]
- ? Lymes disease
- Hypertension
- Asbestosis involving right lung
- Mild right carotid artery disease
- Bilateral thyroid nodules
Past Surgical History:
s/p removal of a bladder tumor in [**2157**]
s/p arthroscopic knee surgery
s/p bilateral knee replacements
s/p inguinal hernia repair
s/p Nasal surgery for cyst and deviated septum
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema, scant serosang
drainage from distal aspect
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**]
Date/Time:[**2173-6-24**] 10:30 in the [**Hospital **] medical office building,
[**Doctor First Name **] [**Hospital Unit Name **]
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2173-7-14**] 02:30pm in the [**Hospital **]
medical office building, [**Doctor First Name **] [**Hospital Unit Name **]
Provider [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2173-7-7**] 12:20
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 132**] C. [**Telephone/Fax (1) 133**] in [**3-25**] 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
Coumadin for AFib
Goal INR [**1-22**]
First draw [**2173-6-16**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 131**]
Results to phone [**Telephone/Fax (1) 133**]
Completed by:[**2173-6-15**]
|
[
"V10.51",
"241.0",
"501",
"287.5",
"401.9",
"346.80",
"441.2",
"272.4",
"427.31",
"414.01",
"413.9",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"37.99",
"37.33",
"38.45",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6584, 6635
|
3687, 4864
|
403, 558
|
7246, 7434
|
2766, 3664
|
8222, 9405
|
1994, 2092
|
5197, 6561
|
6656, 7019
|
4890, 5174
|
7458, 8199
|
7042, 7225
|
2107, 2747
|
335, 365
|
586, 1192
|
1214, 1577
|
1799, 1978
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,005
| 197,496
|
20048
|
Discharge summary
|
report
|
Admission Date: [**2145-12-15**] Discharge Date: [**2145-12-28**]
Date of Birth: [**2084-8-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
from ED for sepsis
Major Surgical or Invasive Procedure:
placement of biliary drains
History of Present Illness:
The pt. is a 61 year-old male with h/o pancreatic cancer who
presented with fevers to the ED on [**12-15**]. He is s/p Whipple and
gemcitabine treatment for pancreatice cancer. In [**11-1**] prior to
a trip to [**Country 11150**], he was found to be jaundiced. At that time. Dr.
[**First Name (STitle) **] [**Name (STitle) **] attempted to place a stent by ERCP on [**11-17**].
However, he was unable to reach the major papilla for endoscopic
intervention. The paitent was placed on levaquin and he
proceeded on his trip to [**Country 11150**]. He then he underwent a
percutaneous biliary drain placement on [**12-10**]. He was monitored
in house for 2 days while the drain was draining. He then went
home with the drain capped on [**12-12**]. Yesterday, he called Dr.
[**Last Name (STitle) **] saying he had a fever and he was restarted on
Levaquin. Today, his fever was to 103 and he as told to come
into the ED by Dr. [**Last Name (STitle) 53982**].
.
In the ED, his initial vital signs were T 100.7, HR 123, BP
88/59, RR 17, sat 96% RA. Initial lactate was 6.7. Sepsis
protocol was initiated. A RIJ was placed. Initial CVP was 7. He
was recusistated with 7 L NS and BP improved. He recieved
Unasyn, ibuprofen, tylenol, vancomycin and oxycodone for pain at
the drain site. Drain was uncapped. Surgery was consulted, who
said to continue current management. CT of abd did not show any
acute process (per report from ED)
.
On review of systems, the pt. complains of pain at the drain
site and some moderate back pain he gets when lying down. he
also feels feverish. Had some nausea over the last few days. Has
had recent fever and chills. Denied headache, sinus tenderness,
rhinorrhea or congestion. Denied cough, shortness of breath.
Denied chest pain or tightness, palpitations. Denied vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
1. Pancreatic cancer with hepatic and pulmonary metastasis:
from OMR: In the summer of [**2142**], he develped DM II and
steatorrheas very quickly, CT scan showed a mass in the head of
his pancreas. In [**2142**], he underwent a resection and Whipple by
Dr. [**Last Name (STitle) 468**]. Pathology demonstrated a moderate to poorly
differentiated adenocarcinoma at the head of the pancreas with
positive margins at the SMA and with positive lymph nodes, eight
out of eight. he then underwent a right VATS for lund nodules
which showed pancreatic adneocarcinoma. He was initially
treated with infusional Gemcitabine and responded well. He
received his last dose of infusional Gemcitabine on [**11-18**],[**2143**]. A CAT scan done on [**11-26**] showed some progression
of the target lesions in his lungs so he was removed from
protocol. He received no treatment since infusional Gemcitabine
until his CAT scan showed new multiple hepatic metastases. He
was being treated on the Xelox protocol but developed severe
diarrhea (grade 2), hand foot syndrome (grade 2) and
dehydration. His feet were very
painful and he was having difficulty walking. The Xeloda was
discontinued and he was removoved from protocol. He then
expressed the wish to discontinue treatment at this time. He was
planning a trip for his entire family to [**Country 11150**] over the
[**Holiday **] vacation.
2. GERD
3. Hyperlipidimea
Social History:
He is a scientist and invented the PDS suture at Ethicon.
Born in [**Country **]. Married with 3 children. Occasional EtOH,
smoked tobacco pipe occasionally.
Family History:
father died of MI, no cancer in the family
Physical Exam:
Vitals: T: 100.7 P: 123 R: 17 BP: 88/59 SaO2: 96% RA
General: Awake, alert, NAD. Jaundiced. appears to be splinting
in pain
HEENT: NC/AT, PERRL, EOMI without nystagmus, + scleral icterus
noted, MMM, + subuncal icterus
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs with bibasilar crackles.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. drain site with dressing soaked. pain on
palpation of his left lateral side
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. CN II-XII intact
Pertinent Results:
Admission Labs:
[**2145-12-15**] 02:20PM BLOOD WBC-9.6 RBC-4.52* Hgb-12.1* Hct-35.1*
MCV-78* MCH-26.8* MCHC-34.5 RDW-17.8* Plt Ct-166#
[**2145-12-15**] 02:20PM BLOOD Neuts-55 Bands-20* Lymphs-8* Monos-11
Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-0 Other-2*
[**2145-12-15**] 02:20PM BLOOD Fibrino-677* D-Dimer-4382*
[**2145-12-15**] 02:20PM BLOOD Glucose-253* UreaN-35* Creat-1.2 Na-130*
K-4.3 Cl-91* HCO3-18* AnGap-25*
[**2145-12-15**] 02:20PM BLOOD ALT-87* AST-125* AlkPhos-413* Amylase-14
TotBili-17.4*
[**2145-12-15**] 02:20PM BLOOD Calcium-8.2* Phos-2.3* Mg-1.6
[**2145-12-15**] 04:15PM BLOOD Hapto-220*
[**2145-12-15**] 11:42PM BLOOD Cortsol-35.6*
[**2145-12-16**] 12:25AM BLOOD Cortsol-45.0*
[**2145-12-16**] 01:00AM BLOOD Cortsol-48.1*
[**2145-12-21**] 01:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES- negative
.
Micro:
[**12-15**] and [**12-16**] Bld cx and bile - grew E. coli
SENSITIVITIES: MIC expressed in
MCG/ML
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Imaging:
[**12-15**] CT Ab/Pelvis
1. Interval progression of pulmonary metastases.
2. Persistent intrahepatic biliary ductal dilatation throughout
most of the liver.
3. Similar appearance of multiple hepatic metastases.
4. New percutaneous biliary drain.
5. Status post Whipple surgery.
6. Non-specific stranding in the right upper quadrant.
.
[**12-20**] Cholangiogram
Nondilated right-sided biliary ducts were opacified. The common
bile duct close to the biliary-enteric anastomosis as well as
the anastomosis appear moderately narrowed, even though there is
free flow of contrast into the small bowel. No opacification of
the left-sided bile ducts was achieved with contrast injection.
A new 8-French internal/external biliary drainage catheter was
advanced over the wire and connected to a bag for drainage. The
catheter was secured with 0-Proelene sutures and a dressing was
applied.
.
Brief Hospital Course:
61 y.o. male with metastatic pancreatic cancer s/p percutaneous
biliary drain placement who returned with septic shock.
.
# Sepsis with e. coli bacteremia: Patient was admitted to the
intensive care unit in septic shock with a bandemia, elevated
lactate, hypotension, and fever. He was aggressively hydrated
and started on zosyn IV and vancomycin. His blood cultures and
biliary fluid subsequently grew e. coli and the vancomycin was
discontinued. He was transferred to the floor where he
remained hemodynamically stable but continued to spike fevers,
his WBC count and TB continued to rise. IR was reconsulted, the
cholangiogram showed obstruction of the left sided bile duct and
a second biliary drain was placed to improve drainage.
Surveillance blood cultures remained negative. Patients fever
curve declined overall, although he continued to have low grade
fevers. His WBC count declined, but his TB remained markedly
elevated. Continued biliary obstruction was attributed to the
progression of his metastatic pancreatic cancer. He completed
14 days of zosyn, and was discharged with an additional 5 days
of PO ciprofloxacin.
.
# Metastatic pancreatic cancer: Patient was made aware of his CT
scan results which showed progression of his cancer. He met
with Dr. [**Last Name (STitle) **] regarding further possible treatments and it
was ultimately decided that he would go to home hospice.
.
# Anemia: Patient's hematocrit was slowly down trending
throughout this hospitalization which was attributed to frequent
blood cultures and labs as well as hemodilution. He received a
total of 4 units of PRBCs during this hospitalization to
maintain a hct>27.
.
# Coagulopathy: Patient was coagulopathic on admission and
received a dose of vitamin K after which his coagulopathy
resolved.
.
# Low back pain: Chronic condition worsened by prolonged bed
rest. Patient was started on oxycontin [**Hospital1 **] with oxycodone PRN.
.
# Thrombocytopenia: Patient had thrombocytopenia initially which
resolved without intervention and was attributed to
sepsis/consumption. HIT negative.
.
# Hyponatremia: The patient had a mild hyponatremia which did
not respond to hydration. Sodium remained around 127-130.
Strict fluid restriction was not done given the goals of care
and the plan for the patient to go to hospice.
.
# DM: Diet controlled, continued on FS QID with ISS
# Pancreatic insufficiency: Continued patient on Creon 20 with
meals.
# h/o HTN: Lisinopril was held due to hypotension
# Hyperlipidemia: Held lipitor in setting of liver dysfunction
Medications on Admission:
1. protonix
2. compazine
3. celexa
4. lisinopril
5. Creon
6. Insulin
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO QIDWMHS (4 times a day
(with meals and at bedtime)).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Phenazopyridine 100 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 2 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD (): patch should
be put on for 12 hours, then off for 12 hours each day.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
12. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED): Please continue your usual home
regimen of insulin.
13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnoses:
Pancreatic cancer with hepatic and pulmonary metastases
E. coli bacteremia and sepsis
hyponatremia, likely due to SIADH
thrombocytopenia, likely due to sepsis
Secondary Diagnoses:
diabetes, secondary to pancreatic cancer
pancreatic insufficiency
hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
If you experience worsening fevers, chills, abdominal pain, or
other concerning symptoms, please call your doctor or return to
the emergency room for evaluation.
.
Please take all medications as prescribed.
We have been holding your lisinopril due to low blood pressure.
We have been holding your lipitor due to abnormalities in your
liver function tests. Please talk to your doctor about whether
these medications should be restarted.
.
Please attend all followup appointments.
Followup Instructions:
You have the following appointment already scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2146-1-5**] 9:30
.
You should also contact Interventional Radiology to have your
drains evaluated and/or changed. Their number is [**Telephone/Fax (1) 53983**].
This should be done in about 1 month. Contact them sooner if
there are any problems with the drains.
|
[
"197.0",
"995.92",
"287.5",
"V10.09",
"576.2",
"286.7",
"251.8",
"785.52",
"253.6",
"196.2",
"724.2",
"038.42",
"197.7",
"576.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.54",
"51.98",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11626, 11675
|
7135, 9695
|
335, 365
|
11999, 12008
|
4697, 4697
|
12536, 12988
|
3947, 3991
|
9814, 11603
|
11696, 11874
|
9721, 9791
|
12032, 12513
|
4006, 4678
|
11895, 11978
|
277, 297
|
393, 2325
|
4714, 7112
|
2347, 3753
|
3769, 3931
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,664
| 168,131
|
31414
|
Discharge summary
|
report
|
Admission Date: [**2107-7-16**] Discharge Date: [**2107-8-2**]
Date of Birth: [**2072-11-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Multiple fractures secondary to high speed trauma (see below)
Major Surgical or Invasive Procedure:
1. Arteriogram, pelvic embolization left pudendal and bilateral
obturator branches embolized with gelfoam.
2. Closed reduction of left glenohumeral joint
3. Closed reduction of left supracondylar elbow fracture
4. Closed reduction of left hip dislocation
5. Closed treatment of left [**Doctor Last Name 24991**] fracture
6. Placement of a femoral traction pin
7. Irrigation and debridement to bone of extensive grade [**3-6**]
open left foot wound.
8. Open reduction of left fifth metatarsal fracture
9. Open tracheostomy.
10. Percutaneous enteral gastrostomy feeding tube.
11. Percutaneous insertion of Bard G2 inferior vena cava filter
12. Open reduction, internal fixation of bilateral maxillary
fracture through subtarsal, intra-oral, and buccal incisions
13. Open reduction, internal fixation bilateral Le [**Location 56204**]
fracture
14. Open reduction, internal fixation bilateral Le Fort I
fracture
15. Open reduction, internal fixation of left orbital rim
fracture
16. Open reduction, internal fixation of split palatal fracture
with intra-oral palatal approach
17. Local advancement flap for the intra-oral palatal approach
18. Closed reduction nasal fracture.
19. Closed reduction nasal septal fracture
20. Open reduction, internal fixation of bilateral
dento-alveolar fracture
21. Open reduction, internal fixation of left femoral head
22. Open reduction, internal fixation of left medial ankle
23. Open reduction, internal fixation of right sacroiliac joint
24. Closed reduction and external fixation of anterior pelvic
ring fracture
25. Open reduction and internal fixation left humeral shaft
fracture
26. Lumbar drain placement and removal
History of Present Illness:
35y M w/ polytrauma; motorcycle vs truck at a high rate of
speed, probable LOC, GCS 14. Patient with visible deformities
and
multiple facial injuries transferred to [**Hospital1 18**] for management.
On arrival patient stabilized in ED. Injuries include multiple
pelvic fractures, femur dislocation, left humoral fracture.
Head/facial injuries include: L-frontal anterior and posterior
table fracture with minimal pneumocephalus, LeFort II comminuted
fractures with multiple bone fragments, superior and lateral
orbital wall fractures bilaterally, sagittal hard palate
fracture, avulsion of anterior dentition.
Patient taken to OR for intubation and distraction/stabilization
of hip.
Past Medical History:
None
Social History:
Works as autobody painter, non-smoker, married.
Family History:
Non-contributory
Physical Exam:
On admission:
PE: vitals: temp 97.7 HR:123 BP: 110/65 RR 30 O2Sat 100 NRB
HEENT: large ecchymosis/hematoma over left scalp/forehead.
Deformity of nasal bridge. Significant periorbital edema and
ecchymoses. Nares with heme. Septum without hematoma. Obvious
zygomatic deformity bilaterally. Maxilla with intraoral
laceration/avulsion of anterior dentition. 2 cm laceration over
central lower lip involving vermilion.
Chest: CTA bilateral
Abd: Soft/ND/NT
Extremities: wwp,
Left arm with gross deformity
Hip with obvious left deformity (internally rotated).
Left foot with macerated tissue, open fracture and exposed bone.
Pertinent Results:
Negative for c-difficil on [**2107-8-2**]
Brief Hospital Course:
Patient is a 35 year old male with polytrauma from a motorcycle
vs truck at a high rate of speed and was brought to the [**Hospital1 18**] on
[**7-9**]. In the ED he was stable but with numerous
fracture injuires. These included:
.
As demonstrated on [**2107-7-16**] maxillofacial CT scan: 1. Left
frontal nondisplaced fracture extending through the anterior and
posterior walls of the left frontal sinus with minimal
pneumocephalus. 2. Multiple comminuted fractures of the orbital
walls. Right superior orbital wall fracture fragment is
displaced inferiorly and compresses upon the superior rectus
muscle. 3. Comminuted nasal bone fracture involving the nasal
septum and nasal spine. 4. Comminuted fractures of the maxillary
sinuses and ethmoid air cells. 5. Comminuted maxillary fracture.
6. Fracture through the right anterior zygomatic arch. 7. There
is fracture through the pterygoid plates. The impression
included Bilateral Le Fort I, Le [**Location 56204**] fractures
.
[**2107-7-16**] CT of C-spine: negative for fracture
[**2107-7-16**] CT head: Subtle hypoattenuation left frontal lobe
inferiorly of contusion
[**2107-7-16**] CT of chest/abdomen/pelvis: 1. Tiny bilateral anterior
medial pneumothoraces. 2.Right lung contusion. 3.Anterior
dislocation of the left shoulder with [**Doctor Last Name **]-[**Doctor Last Name 3450**] deformity.
4.Fracture dislocation of the left femoral head, which is
shattered. 5.Bilateral superior and inferior pubic rami
fractures. 6.Pubic symphysis diastasis. 7.Hemorrhage within
the pelvis anterolateral to the bladder likely secondary to
pelvic fractures. Single focus of active extravasation at the
level of the pubic symphysis.
[**2107-7-16**] AP xray of femur/foot: Intra-articular fracture of the
medial malleolus, as well as fracture of the talus and fourth
metatarsal shaft. Partial avulsion of the 4th and 5th
phalangeal [**Hospital1 **].
.
Due to these injuries, the patient underwent a number of
surgical corrective procedures:
[**2107-7-16**]:
1. Closed reduction of left glenohumeral joint.
2. Closed reduction of left supracondylar elbow fracture.
3. Closed reduction of left hip dislocation.
4. Closed treatment of left [**Doctor Last Name 24991**] fracture.
5. Placement of a femoral traction pin.
6. Irrigation and debridement to bone of extensive grade [**3-6**]
open left foot wound.
7. Open reduction of left fifth metatarsal fracture.
.
PROCEDURES: [**2107-7-19**]
1. Open tracheostomy.
2. Percutaneous enteral gastrostomy feeding tube.
3. Percutaneous insertion of Bard G2 inferior vena cava
filter.
.
PROCEDURES PERFORMED: [**2107-7-23**]
1. Open reduction, internal fixation of bilateral maxillary
fracture through subtarsal, intra-oral, and buccal
incisions.
2. Open reduction, internal fixation bilateral Le [**Location 56204**]
fracture.
3. Open reduction, internal fixation bilateral Le Fort I
fracture.
4. Open reduction, internal fixation of left orbital rim
fracture.
5. Open reduction, internal fixation of split palatal
fracture with intra-oral palatal approach.
6. Local advancement flap for the intra-oral palatal approach.
7. Closed reduction nasal fracture.
8. Closed reduction nasal septal fracture.
9. Open reduction, internal fixation of bilateral
dento-alveolar fracture.
.
PROCEDURE: [**2107-7-25**]
1. Open reduction, internal fixation of left femoral head.
2. Open reduction, internal fixation of left medial ankle.
3. Open reduction, internal fixation of right sacroiliac
joint with 7.3 mm sacroiliac screw.
4. Closed reduction and external fixation of anterior pelvic
ring fracture.
.
Procedure: [**2107-7-28**]
Open reduction and internal fixation left humeral shaft fracture
.
On hospital day 13 ([**2107-7-18**]), the patient was noted to have
erythema around the insertion site of one of the ex-fix bars.
He was started on vancomycin for this cellulitis. Vanco levels
were checked while in house and we recommend that levels
continue to be monitored at the rehab facility.
.
The [**Hospital 228**] hospital course included time in the ICU of which
he remained hemodynamically stable throughout and was
transferred from the ICU to a step down unit, and then to the
general surgical floor without problems.
.
On [**2107-8-1**], the patient's tracheostomy tube was removed. His
airway was protected and he was able to phonate with mild volume
attenuation.
.
The patient was discharged on IV vancomycin to treat resolving
cellulitis in his left thigh. The plan was to send vancomycin
levels to the orthopaedics service. The patient was discharged
on Subcutaneous heparin for anticoagulation purposes.
.
The patient was discharged on [**2107-8-2**] in stable condition to a
rehabilitation facility with plans for follow-up with plastics,
neurosurgery, orthopaedics, and trauma surgery.
Medications on Admission:
None
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-4**]
Drops Ophthalmic PRN (as needed).
2. Vancomycin 1000 mg IV Q 12H
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO BID prn.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO bid prn.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection three times a day: Sub-cutaneous heparin injections
three times per day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Multiple injuries:
1. Left glenohumeral (shoulder) dislocation
2. Left distal humerus fracture (extraarticular supracondylar)
3. Left hip dislocation
4. Left acetabular fracture
5. Pelvic fracture
6. Medial malleolus fracture on the left
7. [**Location (un) **] neck fracture on the left
8. Grade 3 open left foot wound
9. Open left fifth metatarsal fracture
10. Bilateral Le Fort I facial fracture
11. Bilateral Le [**Location 56204**] fracture
12. Split palatal fracture
13. Left femoral head Pipken 1 fracture
14. Left ankle fracture, medial malleolus
15. Pelvic ring anterior-posterior injury with right sacroiliac
diastasis and pubic diastasis and anterior ring fractures
16. Left humeral shaft fracture
17. Cerebral spinal fluid leak
Discharge Condition:
Stable to rehabilitation facility
Discharge Instructions:
Please return to the hospital if you experience fevers greater
then 101.4, chills, or other signs of infection, especially if
the redness on your left thigh gets worse. Also return to the
hospital if you experience chest pain, shortness of breath,
increased redness, swelling, or purulent discharge from the
incision site. Return if you experience worsening pain or any
other concerning symptoms.
Certain pain medications may have side effects such as
drowsiness. Do not operate heavy machinery while on these
medications.
Certain pain medications such as percocet or codeine can cause
constipation. If needed you can take a stool softner such as
Colace (one capsule) or gentle laxative (such as Milk of
Magnesia) once per day.
Please modify your activity according to instructions by your
orthopaedic surgeons and physical therapists.
.
Please resume previous medications as prior to your surgery.
Please take pain medications and stool softener as prescribed.
.
Please follow-up as directed with orthopaedic surgery, and
Plastic Reconstructive Surgery, as well as Oral and maxillo
facial surgery and Dr. [**Last Name (STitle) **] in Trauma surgery.
.
You were discharged still taking Vancomycin, this is an
antibiotic. Your blood level of Vancomycin needs to be checked
frequently and your value needs to be reported to the
orthopaedic service with [**Doctor Last Name **] at [**Telephone/Fax (1) 10522**](fax); please
have the rehab or skilled nursing facility fax these values.
.
Your left arm does not need a splint, please have the physical
therapist provide range of motion exercises as tolerated.
Elevate it as tolerated when lying in bed. You have been
instructed to stay non-weight bearing on both of your legs.
Please continue this until you follow-up with orthopaedic
surgery.
.
Your left small toe is undergoing vascular necrosis. It will
need to be followed up and possibly debrided. It is not ready
yet to be debrided. Please have a general surgeon evaluate this
after 1 week.
.
Because of your facial fractures, the Plastic surgeonss
recommend that you only take in a blenderized diet for 3 more
weeks (for a total of 4 weeks).
Followup Instructions:
1) Plastic and reconstructive surgery, please call to make an
appointment ([**Telephone/Fax (1) 4652**])
2) Orthopaedic Trauma - follow-up in 2 weeks, please call to
make an appointment ([**Telephone/Fax (1) 1228**])
3) Neurosurgery - please call to make an appointment
[**Telephone/Fax (1) 1669**]
4) [as desired]-Oral and maxillofacial surgery ([**Telephone/Fax (1) 274**] -
clinics are every Friday from 1-4pm, please call to make an
appointment if you would like)
5) Trauma Surgery with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 6439**]) please call to
make an appointment
|
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icd9cm
|
[
[
[]
]
] |
[
"79.27",
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"31.1",
"99.04",
"88.49",
"38.7",
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icd9pcs
|
[
[
[]
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] |
9020, 9067
|
3611, 4660
|
376, 2048
|
9851, 9887
|
3545, 3588
|
12083, 12673
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2871, 2889
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|
9088, 9830
|
8470, 8476
|
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2904, 2904
|
275, 338
|
2076, 2762
|
4669, 8444
|
2918, 3526
|
2784, 2790
|
2806, 2855
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,534
| 137,816
|
20025
|
Discharge summary
|
report
|
Admission Date: [**2163-8-26**] Discharge Date: [**2163-9-11**]
Date of Birth: [**2086-6-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Intubation
R IJ
Dobhoff
Bronchoscopy
History of Present Illness:
(HPI obtained from [**Location (un) 1131**] notes from OSH as pt not able to give
history) 77yo F w/ a PMH of HTN, dementia, CRI, and recent
pacemaker placement who presented from [**Hospital1 1501**] with SOB and cough.
She was sent to rehab several days PTA after a week-long
hospitalization during which she had her pacemaker placed. She
had cough and SOB x few days prior to presentation. Per admit
note, she denied pleuritic pain, CP, palpitations, LE edema, or
hemoptysis. She did note a cough, but it was unclear if it was
productive or not. ROS was otherwise negative. Temperature on
admit was 97.9, BP 100/60, HR 90, RR 25, sats 100% on RA (?).
Initial exam was notable for moderate respiratory distress with
scattered wheezes and crackles at BLL. Initial CXR showed a
multilobar pneumonia. ABG was 7.29/44/53 with bicarb of 21. BNP
was 18,541. She was admitted to the ICU and treated with
rocephin (CTX), vanco, and azithromycin for pneumonia; lasix for
CHF; and solumedrol and nebulizers for COPD. Pulmonary was
consulted for help in management of her complicated respiratory
status. She had intermittent difficulty w/ SOB, with O2
requirements rising up to 6L nc. Labs and cultures were
initially unrevealing. She had an ECHO performed on [**2163-8-22**]
which showed global LV hypokinesis with an EF 30% and akinesis
of anterior wall, septum, and apex of LV. Estimated PCWP was 18.
There was also evidence of pulmonary artery hypertension. This
was felt to prove that CHF was part of her symptomatology, but
it was unclear why she had suffered such a problem with her
systolic function.
.
During her admission, her labs stayed relatively stable (other
than a slowly rising creatinine). She had two episodes of
stridor that resolved with solumedrol, racemic epinephrine, and
duonebs. ENT evaluated her looking for the etiology to her
stridor. She underwent a fiberoptic bronchscopy which showed
minimal blood in piriform sinuses, an excellent airway w/o
obstruction, and dry secretions in hypopharynx. It was felt that
the patient likely had secretions leading to a transient
obstruction and it was suggested that the patient have
aggressive humidification via face mask. On [**8-24**], because of the
lack of improvement in her symptoms, the patient was changed
from CTX to ceftazidime to cover pseudomonas. Cardiology was
consulted and recommended consideration of PE as a cause of her
hypoxia. Given her ARF, a CTA was not done but bilateral LENIs
were performed and were negative.
.
She was noted to go into respiratory distress on [**8-24**] w/
paradoxical breathing. ABG at that time was 7.34/34/61/18.
Concern was for PE so heparin gtt was started empirically. She
was soon after intubated due to her increased work of breathing
on [**8-24**]. She then had a R IJ placemed, during which the pt
developed a 10% apical PTX on the right. Serial CXR showed no
progression of the PTX over the remainder of her hospital stay.
Goal of ventilation was to keep her PEEP low and to increase the
FiO2. Surgery was consulted and felt that there was no need for
a chest tube given her clinical stability. On [**8-25**], the
patient's AM labs showed an INR >10 (with elev PTT) while on
heparin. She then had FFP infused to reverse her anticoagulation
(in addition to IM vitamin K). Heparin and coumadin were d/c.
There was an attempted diuresis of 500cc negative but her Cr
continued to rise. Her amiodarone was discontinued over concern
of it contributing to her pulmonary dysfunction. On [**8-26**], her
BP were elevated (SBPs in 170s) so a nitro gtt was added for
preload reduction. Pulmonary had been considering a bronch for
diagnostic purposes. The patient then began having bloody
secretions in her ETT which was felt to be due to her
coagulopathy and hemoptysis. Given ongoing complexity of her
multiple medical issues, pt was transferred to [**Hospital1 18**] for further
evaluation and care.
.
Of note, Ms. [**Known lastname 7749**] had a recent hospital admission from [**8-11**] -
[**8-19**] for LH, dizziness -> found to have AV block, underwent dual
chamber pacemaker placement. There was also a concern for
pneumonia on admission CXR and she was treated with
vancomycin/zosyn for 7days (last dose on [**8-19**]).
Past Medical History:
# Asthma
# HTN
# Dementia
# CRI
# Paroxysmal afib - on amiodarone, coumadin (? off recently due
to PM)
- tachy-brady syndrome w/ 2:1 AV block
- s/p dual chamber [**Month/Day (4) **] on [**2163-8-16**]
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse, drinks wine
occasionally.
Family History:
Family history of premature coronary artery disease or sudden
death was not elicited at this time.
Physical Exam:
VS - Tm 98.5, Tc 94.0, BP 143/62 (92-146/50-64), HR 60s (AV
paced), RR 16-24, sats 95% on AC 400x20, PEEP 10, FiO2 80%, peak
28, plat 25
Gen: WDWN elderly female in NAD.
HEENT: Sclera anicteric, pupils pinpoint but reactive to light.
OP not visualized due to ETT/OGT. JVP not able to be assessed.
CV: RR, normal S1, S2. No m/r/g.
Lungs: CTA anteriorly and bilaterally. Wheezes,
Abd: Soft, NTND. Multiple ecchymoses. Hyperactive BS. No masses.
Ext: 1+ pitting edema to mid shin bilaterally. Cool. No
cyanosis. 2+ DP pulses bilaterally.
Neuro: Opens eyes to voice. Pupils pinpoint but reactive.
Withdraws/grimaces to painful stimuli. MAFE spontaneously.
Pertinent Results:
proBNP 18,541 on [**8-22**] -> 70,560 on [**8-25**]
trop T 0.029 on [**8-22**] -> 0.208 -> 0.120 on [**8-23**]
vanco trough 36.9 on [**8-24**]
Cr 1.8 on [**8-26**]
INR 5.6 on [**8-26**]
Hct 22.6 on [**8-26**]
WBC of 12.1
.
MICRO: (from [**Location (un) 620**])
[**2163-8-22**] blood cx x2 NGTD
[**2163-8-22**] urine cx no growth
[**2163-8-23**] stool cx (Cdiff A+B) negative
[**2163-8-24**] pleural fluid cx:
gram stain - [**10-6**] PMNs, no org seen
cx - prelim no growth
[**2163-8-25**] sputum cx:
gram stain: <10 PMNs, no orgs, many RBC
sputum cx: prelim rare growth [**Female First Name (un) **] albicans
.
ECHO [**2163-8-12**] (from previous hospitalization):
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). There is a mild resting left ventricular outflow tract
obstruction. There was no change in the left ventricular outflow
tract gradient with Valsalva maneuver. A mid-cavitary gradient
is identified. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. There
are three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. No masses or vegetations are seen on the
aortic valve. There is mild aortic valve stenosis (area
1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Moderate (2+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion. If clinically suggested, the
absence of a vegetation by 2D echocardiography does not exclude
endocarditis.
.
IMAGING: (at [**Location (un) 620**])
[**2163-8-22**] CXR: There are new patchy opacities noted within the
right upper, right lower, left upper and left retrocardiac
region. There is new perihilar fullness associated with
indistinct bronchopulmonary vasculature likely reflects
underlying edema. The cardiac silhouette is grossly stable.
There are calcifications of the aorta present. There is a new
ICD device in place with intact leads terminating within the
expected region of the right atrium and right ventricle.
.
[**2163-8-22**] ECHO: The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is moderate to severe global left
ventricular hypokinesis (LVEF = 30 %). There is akinesis of the
anterior wall, anterior septum and apex of the left ventricle.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque. 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. Moderate (2+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension.
.
[**2163-8-24**] CXR: The patient's ET tube, NG tube, pacemaker wires and
right subclavian line all appear in similar position. The
patient's pneumothorax has not increased in size but a trace of
a residual right apical pneumothorax is probably still
visualized. The diffuse pulmonary consolidation has not
appreciably changed when compared to before. There is probably
increased left lower lobe atelectasis. Mild blunting of the
right hemidiaphragm is again appreciated.
IMPRESSION: LITTLE CHANGE FROM BEFORE. RIGHT APICAL
PNEUMOTHORAX NOT AS PRONOUNCED.
.
[**2163-8-25**] BILATERAL LENI: There is normal 2D [**Doctor Last Name 352**] scale and color
Doppler appearance of bilateral common femoral, superficial
femoral, popliteal, and superior portion of the greater
saphenous veins with normal compression and augmentation. No DVT
within either lower extremity.
.
[**2163-8-25**] CT CHEST: Diffuse ground glass changes are atypical for
pneumonia. Alveolitis/Pneumonitis is considered including acute
interstitial pneumonitis, chemical(aspiration) pneumonitis or
pulmonary edema.
.
[**2163-8-26**] CXR: Endotracheal tube, NG tube, right jugular central
venous catheter, and pacemaker electrodes are in the expected
and unaltered positions. As before, there is diffuse bilateral
air-space and interstitial disease consistent with pulmonary
edema/ARDS, unchanged. Likely right pleural effusion is not
definitely changed. No evidence for pneumothorax.
.
TTE ([**8-29**]):
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with apical
hypokinesis. No masses or thrombi are seen in the left
ventricle. No mid-cavitary gradient is identified. There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated. Right ventricular systolic function is normal.
The aortic valve leaflets are moderately thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**12-14**]+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension.
Compared with the prior study (images reviewed) of [**2163-8-12**],
the LV function is no longer hyperdynamic (the patient is no
longer tachycardiac) and there is no longer LVOT
obstruction/intra-cavitary gradient. Foocal apical hypokinesis
is now appreciated. Valvular regurgitation appears less.
IMPRESSION: Regional wall motion abnormality c/w CAD. Preserved
LVEF.
.
CT CHEST W/O CONTRAST [**2163-8-30**] 2:05 PM
FINDINGS: Patient is intubated. The tip of the ET tube is 2.5 cm
above the carina. Transvenous pacemaker leads terminate in
standard position in the right atrium and right ventricle.
Cardiac size is normal. There is no pericardial effusion.
Moderate calcifications are in the LAD, left circumflex and
aortic annulus. The aorta is normal in caliber. There is no
mediastinal lymphadenopathy. The NG tube tip is in the stomach.
There is a small hiatal hernia. Moderate-to-large bilateral
pleural effusions are non- hemorrhagic.
Diffuse lung abnormalities consistent with ground-glass opacity
and thickening of the interlobular septae are associated with
focal areas of more dense consolidations in the upper lobes,
greater in the right side.
There are no bone findings of malignancy.
In the upper abdomen aside from a soft tissue density lesion in
the upper pole of the left kidney measuring 30 x 36 mm the upper
abdomen is unremarkable.
IMPRESSION: Diffuse lung abnormality corresponds with the
clinical history of hemorrhage. Difficult to assess how much
component of pulmonary edema is present. No focal CT findings
that explain source of pulmonary hemorrhage.
Bilateral pleural effusions.
Soft tissue density lesion in the left kidney warrants further
evaluation with ultrasound.
.
CT HEAD W/O CONTRAST [**2163-8-30**] 2:04 PM
HISTORY: Left ventricular dysfunction, baseline dementia but
minimal responsiveness and change in mental status.
There are no comparison studies.
There is no acute hemorrhage or acute transcortical infarction.
There is a calcified extra-axial lesion in the right parietal
region which could represent a calcified meningioma or a dural
plaque.
There is intracranial vascular calcification.
Bilateral subinsular lacunes are seen.
IMPRESSION:
No acute abnormality
.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2163-9-5**] 10:54 AM
CT OF THE PARANASAL SINUSES WITHOUT CONTRAST: A left nasal
trumpet is in place. There is partial opacification of left
ethmoid air cells, with a couple of fluid levels noted in the
ethmoids on the left only. There is mild mucosal thickening
within the left maxillary sinus and within the frontal sinus. A
small mucus retention cyst is seen in the left lateral frontal
sinus, similar to that seen on prior head scan. A small fluid
level is seen in the left side of the sphenoid sinus. Coronal
reformatted images demonstrate opacification of the left OMU.
The right OMU is aerated.
The nasal septum mildly deviates toward the left. The left
cribriform plate is 1-2 mm superior to the right. The lamina
papyracea are intact bilaterally. The orbits are unremarkable.
IMPRESSION: Partial opacification of left ethmoids including
left ethmoid air-fluid levels likely relate to the presence of
the left nasal trumpet. Acute sinusitis cannot be entirely
excluded.
.
CHEST (PORTABLE AP) [**2163-9-8**] 5:26 AM
The Dobbhoff tube is coiled with its leads coiled in the stomach
with its tip in the proximal part of the stomach. There is no
change in the cardiomediastinal silhouette. There is also no
change in the lung volumes, but there is overall increase in
parenchymal opacities, especially in the right lower lobe. These
findings may represent either bilateral multifocal pneumonia
and/or edema. There is no change in bilateral pleural effusions.
IMPRESSION:
1. Slight worsening of the parenchymal infiltrative process.
2. The Dobbhoff tube tip is in proximal stomach.
.
<b>Other Labs:</b>
WBC-19.6, Hct-22, Plt-145, Na-142, K-3.6, Cl-104, HCO3-27,
BUN-29, Cr-2.2, Gluc-131, proBNP-23,497
Brief Hospital Course:
A/P: 77yo F w/ hypoxic respiratory failure, likely
multifactorial in origin, transferred here for further
management.
.
# RESPIRATORY FAILURE/MRSA Pneumonia: The patient was admitted
to the intensive care unit. She underwent bronchoscopy which
showed large amounts of blood concerning for alveolar
hemorrhage. The imaging of her lungs on CT scan showed likely
multifactorial etiology, with elements of pneumonia, COPD, CHF.
She was initially mechanically ventilated and then weaned. She
was treated with diuresis, solumedrol 60mg IV which was tapered,
freq nebululizer treatments and singulair. She was treated with
broad spectrum antibiotics including cefepime and vancomycin.
She had some clinical improvement onced off of mechanical
ventilation, then worsened. Her antibiotics were changed to
linezolid briefly, then only sputum cx came back with MRSA and
she was switched back to vancomycin (no clinical improvement
with linezolid). As a result of continued respiratory failure
despite antibiotics, meropenem was added for gram negative
coverage. She was treated aggressively with IV Lasix, given
continued findings of pulm. edema on CXR, as well as frequent
nebulizer treatments. She was kept on high flow oxygen mask and
treated symptomatically with low doses of IV morphine.
.
# Acute on chronic systolic CHF: The patient was found to have
new LV systolic dysfunction (as prior ECHO in [**12-19**] showed normal
EF and no WMA). It was unclear when and in what context the
patient has suffered this insult as her ECHO [**2163-8-12**] was
hyperdynamic and showed no WMA; 2+ TR and MR were seen (which is
new from ECHO in [**12-19**]), however she did have a mild elevation in
cardiac enzymes. Pt was treated with ASA, bblocker, and
increasing requirement for Lasix up to 100mg IV bid. Her ACE
inhibitor was held due to renal failure.
.
# ARF: No acute cause was found for worsening renal function,
though this may have been as a result of aggressive diuresis vs.
heart failure. All meds were renally dosed and nephrotoxic
agents were held.
.
# PTX: Pt developed a 10% apical PTX on [**2163-8-24**] in attempt at R
IJ placement (drew back serous yellow fluid). Monitored
clinically as pt's resp status had not changed. Surgery was
consulted at OSH, felt no need for chest tube placement. By
radiology here, felt that there is no evidence of PTX but that
instead there is pleural effusion (which makes more sense w/ her
BNP and current clinical picture). This subsequently showed
improvement on repeat CXRs.
.
# COAGULOPATHY: Likely multifactorial, with poor nutrition
compounding aggressive anticoagulation with heparin IV and
coumadin, in the setting of new antibiotics and daily
amiodarone. Pt received 2u FFP on [**8-25**] and 2u FFP on [**8-26**] for
INR >10. Also given IM vitamin K x2 doses. Coumadin was held.
.
# AFIB/TACHY-BRADY SYNDROME: Pt received dual chamber (RA, RV)
[**Company 1543**] Sigma DR [**Last Name (STitle) **] in L pectoral area on [**2163-8-16**] for
tachy-brady syndrome and 2:1 AV block. She was A-V paced at a
rate in the 60s. Amiodarone was continued. Her pacemaker was
interrogated by EP and shown to be functioning properly.
.
# ACCESS: The patient initially had a R IJ which was removed due
to the complications previously mentioned. Multiple attempts
were made to establish a new central line, but after placement
showed likely anomalous anatomy and discontinued.
.
Despite numerous efforts to treat the patient for her hypoxic
respiratory failure she did not improve. Discussions were held
with the patient's daughter, [**Name (NI) 14880**], and the decision was
made to make the patient CMO. She was subsequently transferred
to the medical floor on a morphine drip. She passed away the
following day.
Medications on Admission:
MEDS: (on d/c [**2163-8-19**])
Aspirin 81 mg PO DAILY
Ferrous Sulfate 325mg PO DAILY
Montelukast 10mg PO once a day
Fluticasone 110 mcg 2 puffs INH [**Hospital1 **]
Memantine 10mg PO BID
Donepezil 10mg PO QHS
Enalapril 20mg PO QDAILY
Pantoprazole 40mg PO Q24H
Metoprolol 25 mg PO BID
Fluticasone-Salmeterol 100-50 mcg Disk 1 INH [**Hospital1 **]
Amiodarone 200mg PO QDAILY
.
(on transfer)
ISS
ASA 81mg PO QDAILY
FeSO4 325mg PO QDAILY
Singulair 10mg PO QDAILY
Amiodarone 200mg PO QDAILY - last dose on [**8-24**]
Donepezil 10mg PO QDAILY
Azithromycin 250mg PO QDAILY (for 4 days, [**8-26**] = day 4)
Memantine 10mg PO QDAILY
Duoneb IH Q2 prn
Solumedrol 60mg IV Q6 - started on [**8-22**]
Advair 1 inh [**Hospital1 **]
Nexium 40mg IV QDAILY
Metoprolol 25mg PO BID
Coumadin 5mg PO QHS (last dose on [**8-24**])
Ceftazidime 1gm IV QDAILY - started [**8-24**], received dose on [**8-26**]
CTX 1gm IV QD from [**2167-8-22**]
Versed gtt
Fentanyl gtt
Nitroglycerin gtt (started [**8-26**])
Vancomycin 1gm IV Q48 - started [**8-22**], changed to Q48 on [**8-26**]
Vit K 5mg IM x2 days
Lasix 80mg IV BID (? if pt received it at this dose)
Morphine 1-2mg IV Q2h prn
Haldol 1-2mg PO/IV Q4h prn agitation
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypoxic Respiratory failure (multi-factorial)
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"584.9",
"403.90",
"V45.01",
"518.81",
"428.0",
"428.33",
"008.45",
"512.8",
"486",
"286.9",
"585.9",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"96.72",
"96.07",
"96.6",
"38.93",
"96.04",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
20414, 20423
|
15391, 19142
|
317, 355
|
20512, 20521
|
5801, 15251
|
20574, 20581
|
5012, 5112
|
20385, 20391
|
20444, 20491
|
19168, 20362
|
20545, 20551
|
5127, 5782
|
274, 279
|
383, 4619
|
4641, 4844
|
4860, 4996
|
15262, 15368
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,953
| 170,617
|
10162
|
Discharge summary
|
report
|
Admission Date: [**2160-4-17**] Discharge Date: [**2160-4-23**]
Date of Birth: [**2112-11-21**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: This is a 47-year-old male with
a past medical history of alcohol abuse, CHF with ejection
fraction of 30 percent from presumed alcoholic
cardiomyopathy, hypertension, chronic pancreatitis, who comes
in with chief complaint of nausea, vomiting, abdominal pain,
and alcohol withdrawal. The patient states that the
abdominal pain began after drinking 1-1/2 of a gallon of
vodka on the night before admission. The pain was a diffuse
abdominal pain with some associated nausea and vomiting. No
blood, no coffee-grounds, no fevers, chills, or anorexia. He
said that this was similar to his previous episodes of
pancreatitis.
He is also complaining of feeling tremulous at this time. He
is not having any visual or auditory hallucinations. No
seizures. He had his last drink the night prior to admission
as stated above. He denies any fevers, chills, chest pain,
shortness of breath.
Review of systems was negative for dyspnea on exertion,
palpitations, PND, or orthopnea. No recent weight loss. No
neurologic complaints.
PAST MEDICAL HISTORY:
1. There is a questionable history of HIV diagnosed with a
partially positive Western blot in the [**2135**], his previous
CD4 on [**2160-1-23**] was 283, which is stable from
previous measurements.
2. Hypertension.
3. Cardiomyopathy with an EF of about 30 percent, presumed
alcoholic cardiomyopathy.
4. Remote history of rheumatic heart disease.
5. Generalized anxiety disorder.
6. Chronic pancreatitis.
7. Macrocytic anemia.
8. Fatty liver.
9. Status post cholecystectomy.
10. Alcohol abuse.
11. Has had previous episodes of gastritis and GI bleed.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Risperidone 1 mg p.o. q.d.
2. Effexor XR 150 p.o. q.d.
3. Propanolol 80 mg p.o. b.i.d.
4. Klonopin 1 mg p.o. t.i.d.
5. Zestril 10 mg p.o. q.d.
6. Multivitamin.
7. Thiamine.
8. Folate.
9. Protonix 40 q.d.
10. Trazodone 25 p.o. q.h.s.
SOCIAL HISTORY: He lives in an assisted-living facility for
people with HIV. He has a significant alcohol history. He
normally drinks about 1 liter of hard liquor a night, which
he has done so for several years. He has tried detox and
rehab facilities in the past, but says that do not work
because he does not believe in the 12-step philosophy.
Tobacco history: He smoked two packs per day since he was a
teenager. He has about 80 pack years. Sexual history: He
is a male, who sleeps with males, but is not currently
sexually active. He is not employed and he is a college
graduate from [**University/College 33918**].
FAMILY HISTORY: Noncontributory.
Vital signs on admission: He was 98.0, blood pressure was
150/88, heart rate was 120, and respiratory rate was 20. He
was 98 percent on room air. In general, the patient was foul
smelling, [**Name (NI) 33919**] male. He was somewhat somnolent, but
tremulous when he was awake. HEENT: Pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements are intact. Sclerae were anicteric. His mucous
membranes were dry. Neck was supple. There were no masses
or lymphadenopathy. There was no JVD. Lungs are clear to
auscultation bilaterally. There were no rhonchi, wheezes, or
rales. Cardiovascular: He had a regular, rate, and rhythm.
He was tachycardic. He had a normal S1, S2. He had no
murmurs, rubs, or gallops. Abdomen was soft. He had diffuse
epigastric tenderness to light palpation. There was no
rebound or guarding. There was no CVA tenderness. No flank
discoloration. Extremities: There was no clubbing,
cyanosis, or edema.
LABORATORIES ON ADMISSION: His hematocrit was 40.5. His
Chem-7 was sodium of 137, potassium of 4.0, chloride is 96,
bicarb of 16, BUN of 8, creatinine of 0.9, glucose of 86.
His anion gap was about 15. His LFTs were elevated. His ALT
was 124, AST was 241, his alkaline phosphatase was 329. His
amylase was 138, lipase 38, T bilirubin 1.3. His tox screen
was negative. His alcohol level was 255. A urinalysis was
positive for ketones.
He had a right upper quadrant ultrasound done in the
Emergency Room, which showed he had a dilated common bile
duct. There were no stones present. His pancreatic head and
distal ducts were visualized. This study was unchanged from
previous right upper quadrant ultrasounds.
He had a KUB done, which showed no dilated loops of large or
small bowel. There was no free air seen.
He had a chest x-ray done, which showed two old rib
fractures, but otherwise there was no cardiopulmonary
disease.
The patient was admitted to Medicine for pancreatitis and
alcohol withdrawal.
HOSPITAL COURSE:
1. Alcohol withdrawal: The patient was monitored on the CIWA
scale. He was given 5-10 mg of Valium prn CIWA greater
than 10. On the evening of admission shortly after
arrival to the floor, the patient did have a seizure,
which was presumably from alcohol withdrawal. Shortly
after the seizure, the patient went into V-fib arrest and
was intubated for airway protection.
He was then transferred to the Intensive Care Unit. During
the Intensive Care Unit course, he was on an Ativan drip for
withdrawal. He was then transitioned over to prn standing
and prn Valium and kept on a CIWA scale. He was continued on
folate, thiamine, and multivitamin, and once he was extubated
alert and oriented, he did meet with [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 2412**] from the
Addiction Services. He again declined all 12-step programs,
but said that he would continue to followup with his SMART
program.
1. Cardiovascular: He had a V-fib arrest. He was
defibrillated. His cardiac enzymes were monitored until
they peaked and trended down. He had serial EKGs done.
His blood pressure regimen was changed slightly while he
was in the Intensive Care Unit. He was on metoprolol
instead of his propanolol. Continued on his ACE
inhibitor. He was monitored on telemetry for about one
week with no significant events, no further episodes of
ventricular fibrillation or tachycardia.
1. Pancreatitis: The patient was kept NPO for his
pancreatitis once he was awake and extubated and his
abdominal pain has cleared. His diet was advanced as
tolerated.
1. Alcoholic cardiomyopathy with an EF of 30 percent: The
patient's I's and O's were monitored throughout his
hospital course and he was euvolemic at the time of
discharge.
1. Hepatitis: The patient's liver function tests, AST was
greater than ALT, this was consistent with his history of
alcoholic hepatitis. There was no evidence of gallstones
on his right upper quadrant ultrasound. His LFTs were
followed until they began to trend down towards normal.
1. HIV: The patient has a questionable history of HIV. He
refused followup HIV testing.
1. Anxiety: The patient was continued on his propanolol and
was restarted on his Klonopin once he was extubated for
anxiety control.
1. Pulmonary: The patient was intubated for airway
protection. After the alcohol withdrawal seizure, he was
extubated without events after two days.
1. Neurologic: The patient's seizure was likely from alcohol
withdrawal. He did have a MRI done to further evaluate
for any structural cause of seizures, but the MRI was
within normal limits except for some hippocampal atrophy.
The patient refused a LP.
The patient was discharged to home on [**2160-4-24**].
DISCHARGE INSTRUCTIONS:
1. You are not to drink.
2. Take all medications as instructed.
FINAL DIAGNOSES:
1. Alcohol abuse.
2. Alcohol withdrawal seizure.
3. Ventricular fibrillation arrest.
4. Human immunodeficiency virus ?
5. Cardiomyopathy.
RECOMMENDED FOLLOWUP: He is to followup with Dr. [**First Name (STitle) 4702**] next
Tuesday at 10 a.m. He is to followup with Dr. [**Last Name (STitle) 4300**], his
psychiatrist on [**5-3**].
MAJOR SURGICAL OR INVASIVE PROCEDURES: He was defibrillated
and he was intubated.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Multivitamin.
2. Thiamine.
3. Folic acid.
4. Protonix 40 mg p.o. q.d.
5. Risperidone one tablet p.o. q.d.
6. Effexor 150 mg p.o. q.d.
7. Trazodone 50 mg p.o. q.h.s. prn.
8. Klonopin 1 mg p.o. t.i.d.
9. Percocet 1-2 tablets p.o. q.[**3-18**] prn rib pain.
10.
Lisinopril 5 mg p.o. q.d.
11. Propanolol 80 mg p.o. b.i.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 33920**]
Dictated By:[**Location (un) 5618**]
MEDQUIST36
D: [**2160-4-25**] 10:00:41
T: [**2160-4-26**] 08:38:50
Job#: [**Job Number **]
cc:[**Last Name (NamePattern1) 33921**]
|
[
"303.91",
"291.81",
"577.1",
"577.0",
"425.5",
"427.41",
"428.0",
"780.39",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.07",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8145, 8154
|
2733, 2763
|
8177, 8800
|
4767, 7596
|
7620, 7686
|
7703, 8123
|
166, 1195
|
3758, 4750
|
1217, 2086
|
2103, 2716
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,410
| 150,571
|
51951
|
Discharge summary
|
report
|
Admission Date: [**2159-9-18**] Discharge Date: [**2159-9-20**]
Date of Birth: [**2084-12-10**] Sex: M
Service: MEDICINE
Allergies:
Enalapril
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
s/p right carotid angiography and stenting
Major Surgical or Invasive Procedure:
Right carotid angiography and stenting
History of Present Illness:
74M hx of L ICA stenosis (s/p CEA [**2159-6-26**]), 80% R ICA stenosis,
CAD s/p CABG ([**2154**], anatomy unavailable), EF 60%, prior CVA (no
residual deficits), PAF (On Coumadin), HTN, HL, DMII, Moderate
to Severe PVD, that presents to CCU following right carotid
angiography and stenting.
.
The pt was referred to Dr. [**Last Name (STitle) **] on [**2159-4-28**] for evaluation of
PVD. The pt subsequently underwent stress nuclear perfusion (no
anginal symptoms or ischemic EKG changes). Non-Invasive vascular
studies revealed non-compressible vessels and moderate to
moderately severe peripheral vascular disease at rest based on
Doppler waveforms and PVR??????s. ABI??????s invalid due to non
compressibility of vessels. Given the pts known carotid bruits,
the pt underwent Carotid U/S that showed significant bilateral
carotid stenosis, L>R. Angiography ([**2159-6-25**]) revealed an 80%
stenosis of the [**Country **] (which supplies the left ACA) and a 99%
[**Doctor First Name 3098**] stenosis. Cerebral angiography further revealed patent
right ACA and MCA and patent left ACA and left MCA. He did have
a recent event when he was unable to move his left leg for a
couple of days, but slowly regained function.
.
Thus the pt underwent L CEA on [**2159-6-26**]. Of note during the
admission for ([**2159-6-25**] thru [**2159-6-28**]) the pt tolerated the
procedure well. On POD 1 he experienced a severe headache that
did resolve and was consistent with symptoms of reperfusion
postop. The pt was kept in the VICU overnight for observation.
The pt also experienced increased neck stiffness at that time.
The pt also had LE swelling US without DVT. Subsequent Carotid
U/S ([**2159-7-19**]) revealed stable R ICA stensosis 70-79%
(unchanged). Left side without residual stenosis at CEA site.
.
Upon further review of symptoms the pt reports + Occasional
dizziness, no prior syncope, occasional HA, Denies CP/SOB. No
sensory or motor defects. The pt also noted a history of "ill
defined feeling" in both legs with exercise that occasionaly
occurs with rest. The pt previously attributed this to prior SVG
harvest. He recalls that he might have had a stroke 10-15 years
ago (unclear) without any residual deficit. Prior to CABG, he
only had diaphoresis.
.
Further review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
.
In general, the patient tolerated the procedure well. He had a
vagal reaction during the procedure which required atropine.
His SBP then went up to the 200s requiring a nitro drip. Access
was first attempted in the right arm, but was unsuccessful.
Therefore a right femoral approach as used. He was transferred
to the CCU with an SBP of 100 off of the nitro drip for close
monitoring of his blood pressures with a goal SBP between 90 and
120. He had a headache after the procedure which resolved by
the time he was transferred to the CCU.
Past Medical History:
Paroxysmal atrial fibrillation
CAD s/p CABG in [**2154**] ([**Hospital1 112**])
Prior CVA
Bilateral carotid artery disease
Anemia
PVD
Hypertension
Diabetes c/b retinopathy and peripheral neuropathy
Cataracts s/p surgery
Thyroid nodule
Colon polyps s/p resection
Intermittent Lower back pain
Proteinuria
s/p right elbow fracture as a child
Arthritis
Social History:
Patient is married with two children
Lives with: Wife
Occupation: previously worked as a printer
ETOH: none
Family History:
No family history of premature CAD
Physical Exam:
VS: T=36.4 BP=91/44 HR=51 RR=14 O2 sat=100% RA
GENERAL: pleasant male in NAD. Alert and oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: 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. Left> right crackles at
the bases. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. RUE bandage is c/d/i.
RLE has some oozing at the cath site, no hematoma.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Warm
and well perfused with normal capillary refill time. 1+ Left
and trace right lower leg edema.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP, PT [**Name (NI) **]
[**Name (NI) 2325**]: Carotid 2+ Femoral 2+ Popliteal 1+ DP, PT [**Name (NI) **]
Pertinent Results:
Cardiac Cath ([**9-18**])-
1. Access was initially obtained at the right brachial artery.
Due to
anatomic tortuosity, we changed our approach and obtained access
from
the right femoral artery.
2. Selective angiography of the right carotid artery showed an
80%
stenosis at the bifurcation of the ICA and ECA extending
distally into
the proximal segment of the ICA.
3. Successful PTA and placement of an 8.0x29mm self-expanding
Carotid
Wallstent were performed. The stent was post-dilated using a
5.0mm
balloon. (See PTA comments.)
4. The right common femoral arteriotomy was successfully closed
using a
Perclose Proglide device.
.
FINAL DIAGNOSIS:
1. Right carotid artery disease.
2. Successful placement of a stent in the CCA-ICA.
3. The primary operator for this procedure was Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **].
The primary assistant was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
[**2159-9-19**] 06:40AM BLOOD WBC-8.1 RBC-2.95* Hgb-8.2* Hct-25.5*
MCV-87 MCH-27.7 MCHC-32.0 RDW-15.0 Plt Ct-220
[**2159-9-19**] 02:05PM BLOOD WBC-8.0 RBC-2.81* Hgb-8.0* Hct-24.5*
MCV-87 MCH-28.4 MCHC-32.5 RDW-14.3 Plt Ct-185
[**2159-9-18**] 09:00AM BLOOD PT-14.1* PTT-33.6 INR(PT)-1.2*
[**2159-9-19**] 06:40AM BLOOD PT-13.4 PTT-31.1 INR(PT)-1.1
[**2159-9-19**] 06:40AM BLOOD Glucose-58* UreaN-32* Creat-2.0* Na-134
K-4.3 Cl-100 HCO3-24 AnGap-14
[**2159-9-19**] 02:05PM BLOOD Glucose-215* UreaN-32* Creat-2.1* Na-130*
K-4.5 Cl-98 HCO3-23 AnGap-14
[**2159-9-19**] 02:05PM BLOOD Calcium-8.7 Phos-3.8 Mg-1.9
Brief Hospital Course:
74 y/o male with severe PVD, CABG in [**2154**], CVA with no residual
effect, and bilateral carotid artery disease s/p left CEA [**7-3**]
presenting for right carotid stenting.
.
# s/p RCA Stenting: Pt enrolled in [**Last Name (un) 81078**] study, underwent RCA
stenting. Patient had a vagal reaction during the procedure
which required atropine. His SBP then went up to the 200s
requiring a nitro drip. Otherwise he tolerated the procedure
well and was transferred to the CCU with an SBP of 100 off the
nitro drip. While in the CCU, our goal remained SBP 90-120.
Patient stayed in the 100s-120s. Neuro exam performed q1h for 2
hours, q2h for 2 checks, and then q6h after the procedure - all
were within normal limits. Post-cath check at 2:30PM showed
some R femoral oozing, but no hematoma or bruit. Patient's heart
rate was 40s-50s s/p procedure, asymptomatic. His beta blocker
was held in this setting; resumption will be addressed by his
PCP. [**Name10 (NameIs) **] will go home on [**Doctor Last Name **] of Hearts monitor to
continually monitor heart rate for 2 weeks. Patient's home dose
of ASA 325mg and Plavix 75mg continued after procedure.
Coumadin 5mg resumed after the procedure and lovenox
administered twice daily dosing until INR became therapeutic.
Patient will go home with 5 days of lovenox as bridge. INR will
be checked on [**9-24**].
.
# CORONARIES: previous CABG. Last stress-MIBI without concerning
ECG changes. Continued home ASA, Plavix, Statin, Beta-Blocker,
[**Last Name (un) **]. Patient denied any chest pain while in hospital. No EKG
changes noted.
.
# PUMP: Last EF 60%. Initially had elevated BP's post-procedure.
Trended down to SBP 100s-120s. Switched home atenolol 150mg
daily to metoprolol 75mg [**Hospital1 **] for rate control given slightly
increased creatinine. Upon discharge, BP was 110s-120s and HR
was 50s, 60s with ambulation. Patient stable.
.
# RHYTHM: Pt with hx of PAF, currently bradycardic sinus rhythm.
Continued to stay in bradycardic rhythm at HR 45-50s.
Discharged on [**Doctor Last Name **] of Hearts monitor for 2 weeks, as noted
above. Will transmit 2-3 times daily.
.
# DMII: Patient not on insulin as outpatient. HbA1C 7.3 ([**4-2**]).
Gave home dose of glipizide and then covered to Humalog SS while
in house. Held home metformin while in-hospital. Restarted
upon discharge.
.
# Anemia: Unclear etiology. There is a longstanding history
from prior records. Previous ferritin was normal. No
microcytosis. Mildly elevated creatinine. Hemoglobin
Electropheresis WNL (+FM hx for anemia). Hct baseline ranges
from 25-30. Ranged between 24.5-31.5 while in hospital.
Consider outpatient work-up.
.
Medications on Admission:
Aspirin 325mg daily
Plavix 75mg daily
Simvastatin 40mg Daily
Atenolol 150mg PO Daily
Irbesartan 300mg daily
Coumadin 2mg daily, 2 tablets as directed, last dose [**2159-9-13**]
Lovenox b.i.d. on [**2159-9-16**] and [**2159-9-17**]
Furosemide 40mg daily
Glipizide 10mg twice a day
Metformin 850mg three times a day
Iron-Docusate Sodium 150mg-100mg one tablet twice a day
Milk of Magnesia PRN
Foltx one tablet daily
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Metformin 850 mg Tablet Sig: One (1) Tablet PO three times a
day.
9. Iron with Stool Softener 150 (50)-100 mg Tablet Sustained
Release Sig: One (1) Tablet Sustained Release PO twice a day.
10. Foltx 2.5-25-2 mg Tablet Sig: One (1) Tablet PO once a day.
11. Enoxaparin 100 mg/mL Syringe Sig: One (1) injection
Subcutaneous Q24H (every 24 hours) for 5 doses.
Disp:*5 syringes* Refills:*0*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM for 5 doses.
Disp:*5 Tablet(s)* Refills:*0*
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
start once your INR is between [**2-27**]. Tablet(s)
Discharge Disposition:
Home
Discharge Diagnosis:
right sided carotid stenosis s/p stent placement
.
Secondary diagnoses:
- s/p CABG
- HTN
- dyslipidemia
- PAF (On Coumadin)
- Prior CVA [**60**]-15 years ago (No residual defects)
- Bilateral carotid artery disease s/p left CEA [**2159-6-26**]
- Anemia (Unknown Etiology)
- PVD
- DMII c/b retinopathy and peripheral neuropathy
- Cataracts s/p surgery
- Thyroid nodule
- Colon polyps s/p resection
- Intermittent Lower Back Pain
- Proteinuria
- s/p right elbow fracture as a child
- Arthritis
Discharge Condition:
Good, vital signs stable, ambulatory
Discharge Instructions:
You were admitted to the hospital to undergo a carotid stent
placement to relieve a blockage in your carotid vessel. The
procedure went well however you developed a low heart rate
afterwards. Because of this you were admitted to the CCU for
close monitoring. While you were in the CCU, your heart rate
remained stable and you were asymptomatic. You will go home
with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to continually monitor your heart
rate at home.
.
The following medication changes were made:
1. Stop your beta-blocker (atenolol 150mg).
2. Take lovenox 100mg daily for 5 days (day 1- [**9-20**]) or at least
until your Coumadin level (INR) is between [**2-27**].
3. Take Coumadin 5mg daily for 5 doses or until your INR is
between [**2-27**] and then you can go back to your home dose of
Coumadin 2mg daily.
4. You need to get your INR levels checked on [**9-22**] to monitor
your blood thinning levels.
.
Please follow-up with all of your outpatient medical
appointments listed below.
.
Please seek medical care if you experience any concerning
symptoms such as headache, dizziness, lightheadedness, decreased
muscle strength, chest pain, or increased shortness of breath.
Followup Instructions:
Please follow-up with all of your outpatient medical
appointments listed below.
1. Follow-up with your [**Hospital 263**] clinic ([**Hospital1 **]-[**Location (un) **]) for INR check on
Saturday, [**9-22**] (If your INR is between [**2-27**] then you can stop
Lovenox, if it is below 2, continue with Lovenox).
2. Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**]
Date/Time:[**2159-10-2**] 10:10
3. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2159-10-19**] 2:20
4. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1142**]
Date/Time:[**2159-11-7**] 11:15
Completed by:[**2159-9-20**]
|
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"V45.81",
"401.9",
"357.2",
"362.01",
"780.2",
"V70.7",
"250.50",
"272.4",
"250.60",
"440.22",
"427.31",
"433.30",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"00.40",
"00.44",
"00.45",
"00.61",
"00.63"
] |
icd9pcs
|
[
[
[]
]
] |
10926, 10932
|
6626, 9301
|
313, 353
|
11468, 11507
|
5047, 5679
|
12782, 13628
|
3871, 3907
|
9765, 10903
|
10953, 11004
|
9327, 9742
|
5696, 6603
|
11531, 12759
|
3922, 5028
|
11025, 11447
|
231, 275
|
381, 3356
|
3378, 3729
|
3745, 3855
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,087
| 123,540
|
46119+46120
|
Discharge summary
|
report+report
|
Admission Date: [**2171-3-28**] Discharge Date: [**2171-3-31**]
Date of Birth: [**2094-5-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7202**]
Chief Complaint:
presented to the OSH with progressive SOB and angina; tranferred
to [**Hospital1 18**] for cardiac catheterization
Major Surgical or Invasive Procedure:
Cardiac catheterization and placement of two drug eluting
stents, [**2171-3-28**].
Cardiac catheterization
History of Present Illness:
76 y.o. female with PMH significant for known CAD (cath in [**2165**],
severe COPD (FEV1 <1, on home O2), HTN who presented to [**Hospital **] on [**2171-3-26**] with symptoms of cough productive of
yellow/greenish sputum, runny nose. Over the past two months,
the patient has also been having progressive SOB (both at rest
and with exertion) and associated left sided chest tightness.
The patient could walk 20 feet at baseline without having to
stop and over the last couple of months she noticed that she
cannot walk 20 feet w/o having to stop because of SOB. She
denies associated nausea, vomiting, lightheadedness. Denies PND,
orthopnea. No fever/chills. + waxing and [**Doctor Last Name 688**] LE edema.
Chronic Prednisone therapy at home.
She was admitted to [**Location (un) **] on [**2171-3-26**]. Ruled out for AMI. No
acute EKG changes. She was treated for COPD exacerbatoin with
ceftaz 1gm q8hrs and levaquin 500mg po daily and solumedrol. CXR
showed opacity c/w early infiltrate vs. atelectasis.
Cath [**2165**] that showed moderate 3VD: 70% in distal LAD, 70% in
LCX, 40% at origin of RCA and 50% mid-distal. No intervention
done.
Past Medical History:
osteoporosis
osteoarthritis
bladder ca
s/p oophrectomy
cad
Gallstones pancreatitis
Copd, on home 1L O2
s/p appendectomy
anemia
h/o MRSA
HTN
son[**Name (NI) **] pneumothorax x 2
h/o Aspergillosis pneumonitis
GERD
Social History:
Lives with husband. children live in the area. Quit smoking in
[**2161**]. Denies EtOH use.
Family History:
NC
Physical Exam:
VS: afebrile, 137/71 90 18 99% at 2L
General: alert and oriented, pleasant, NAD.
Neck: JVP not elevated
HEENT: NC, AT, clera non-icteric, PERRL, EOM intact, MM sl dry
CV: regular, distant S1S2, no m/g/r
Pulm: bilateral crackles
Extr: 1+LE edema
Pertinent Results:
Labs on admission:
[**2171-3-29**] 04:55AM BLOOD WBC-11.8* RBC-3.18* Hgb-9.9* Hct-29.3*
MCV-92 MCH-31.3# MCHC-34.0 RDW-16.1* Plt Ct-337
[**2171-3-29**] 04:55AM BLOOD Glucose-100 UreaN-19 Creat-0.7 Na-141
K-3.4 Cl-96 HCO3-37* AnGap-11
[**2171-3-29**] 04:55AM BLOOD Calcium-9.4 Phos-4.9* Mg-1.8
[**2171-3-28**] 03:47PM BLOOD Type-ART O2 Flow-2 pO2-92 pCO2-56*
pH-7.46* calHCO3-41* Base XS-13 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
Labs on discharge:
[**2171-3-31**] 05:50AM BLOOD WBC-11.7* RBC-3.33* Hgb-10.4* Hct-30.0*
MCV-90 MCH-31.4 MCHC-34.9 RDW-16.1* Plt Ct-268
[**2171-3-31**] 05:50AM BLOOD Glucose-71 UreaN-19 Creat-0.7 Na-144
K-4.4 Cl-100 HCO3-36* AnGap-12
[**2171-3-31**] 05:50AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.0
Other lab results:
[**2171-3-30**] 05:20AM BLOOD Cholest-172 Triglyc-190* HDL-69
CHOL/HD-2.5 LDLcalc-65
[**2171-3-28**] 03:30PM BLOOD CK(CPK)-30
[**2171-3-28**] 11:24PM BLOOD CK(CPK)-109
[**2171-3-29**] 04:55AM BLOOD CK(CPK)-152*
[**2171-3-29**] 09:40AM BLOOD CK(CPK)-178*
[**2171-3-29**] 09:31PM BLOOD CK(CPK)-98
[**2171-3-30**] 05:20AM BLOOD ALT-14 AST-28 CK(CPK)-58
[**2171-3-28**] 03:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2171-3-28**] 11:24PM BLOOD CK-MB-22* MB Indx-20.2*
[**2171-3-29**] 04:55AM BLOOD CK-MB-27* MB Indx-17.8* cTropnT-0.58*
[**2171-3-29**] 09:40AM BLOOD CK-MB-26* MB Indx-14.6* cTropnT-0.54*
[**2171-3-29**] 09:31PM BLOOD CK-MB-NotDone cTropnT-0.46*
[**2171-3-30**] 05:20AM BLOOD CK-MB-NotDone cTropnT-0.35*
Cardiac catheterization [**2171-3-28**]:
1. Selective coronary angiography of this right dominant system
revealed
diffusely calcified two vessel coronary artery disease. The LMCA
had no angiographically apparent disease. The LAD gave off three
small-caliber diagonal branches, and had diffuse disease after
the third diagonal branch up to 50%. The LCx had a 90% stenosis
at the origin of the second obtuse marginal branch, and a 50%
stenosis at the origin of OM3. The right coronary artery was
heavily calcified and had an 80% ostial stenosis and a 50%
distal stenosis before the bifurcation of the PDA and the PLB.
2. Resting hemodynamics revealed normal right sided filling
pressures,
mildly elevated pulmonary artery systolic pressure (35 mm Hg),
normal left sided filling pressures (PCWP mean of 8 mm Hg), and
mildly elevated systemic arterial pressure (149/71, mean 103 mm
Hg). Cardiac index was
low-normal at 2.2 L/min/m2, when calculated by the Fick equation
(using an assumed oxygen consumption).
3. Successful Rotational Atherectomy of the OM1 followed by
stenting with a 2.5x12mm TAxus DES at 14 atms (See PTCA
comments).
4. Successful Rotational Atherectomy of the ostial RCA followed
by stenting with a 3.5x13mm Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] with a 3.75mm
NC Ranger
at 22 (See PTCA comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Mild pulmonary artery systolic hypertension, mild systemic
arterial
hypertension, low-normal cardiac index.
3. Successful Rotational Atherectomy and Stenting of the OM with
a Drug
Eluting Stent.
4. Successful Rotational Atherectomy and stenting of the ostial
RCA with
a Drug Eluting Stent.
ECHO [**2171-3-29**]:
A 4x3cm heterogeneous echogenic mass is seen in close
proximity/congruent with the the anterior free wall of the right
atrium. This "mass" appears to be somewhat contiguous with
epicardial fat and does not appear to originate outside of the
pericardial space or from the IVC. There is also no evidence of
obstruction to RV inflow. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function(LVEF>55%). Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. A mild (25mmHg
peak) mid-cavitary gradient is identified. Right ventricular
chamber size and free wall motion are normal. The right
ventricular free wall is hypertrophied. The aortic valve is not
well seen. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is an anterior space which most likely represents a fat
pad.
IMPERSSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Right atrial
mass as described above. Mild mid-left ventricular dynamic
gradient. If clinically indicated, a TEE, chest CT or cardiac MR
may be able to better define the right atrial abnormality.
Chest CTA [**2171-3-29**]:
1) Soft tissue thickening around the right coronary artery,
probably in the epicardial space, measuring up to 1 cm on the
myocardial side and 2 cm on the pericardial side, which is
somewhat hyperdense on the precontrast images. Given recent
cardiac catheterization, appearances are most concering for
epicardial hematoma. If clinically indicated confirmation and
further characterization could be performed using cardiac MRI.
2) Well-circumscribed low-density region of the superior most
aspect of the IVC, without definite corresponding findings on
the precontrast examination. This probably represents artifact
from reflux of contrast through the IVC mixing with nonopacified
contrast from the abdomen. This could be further evaluated if
indicated in conjunction with cardiac MR, or alternatively
abdominal ultrasound could further assess flow within the IVC.
3) Severe COPD.
4) Multifocal vertebral body compression fractures.
Initial findings were discussed with Dr. [**Last Name (STitle) 1299**] at 4:15 p.m.,
[**2171-3-29**].
ADDENDUM:
Additional literature review shows that epicardial hematoma is a
rare entity which can be associated with regional myocardial
infarction due to risk of avulsion of RCA perforators. Clinical
correlation is required. Additional comment was discussed with
Dr. [**Last Name (STitle) **] 23:00 [**2171-3-29**].
CXR [**2171-3-29**]:
Early congestive heart failure. No evidence for pneumonia.
Cardiac catheterization [**2171-3-30**]:
Selective coronary arteriography revealed no significant
coronary
artery disease. The previosuly noticed perforation in the RCA is
no
longer present.
US left groin [**2171-3-31**]:
No evidence of AV fistula, pseudoaneurysm, or hematoma within
the left groin.
Brief Hospital Course:
1. Coronary artery disease. The patient had a known 3 vessel
disease by catheterization report in [**2165**]. She ruled out for AMI
at the OSH. The patient underwent cardiac catheterization on
[**2171-3-28**] which revealed tight stenoses in the OM1 and RCA.
The lesions were treated with rotational atherectomy and stented
with Taxus and Cypher stents. The procedure was complicated by a
localized small wire perforation of the RV marginal branch that
appeared stable without visible hemodynamic sequelae during the
procedure. The patient then had an echo performed which revealed
an incidental finding of an abnormality in the anterior free
wall of the right atrium. This was further investigated by chest
CTA and was characterized as an epicardial hematoma. The patient
continued to be asymptomatic, however, the decision was to have
her undergo a re look catheterization which she had on [**2171-3-30**].
Repeat cath showed no significant coronary artery disease. The
previously noticed perforation in the RCA was no longer present.
The [**Hospital 228**] medical regimen included aspirin, Statin (normal
LFTs), Plavix, ACE inhibitor (started during this admission).
Norvasc was stopped to optimize anti-ischemic regimen.
Beta-blocker was not added because the patient has severe COPD.
She was continued on calcium channel blocker. The patient was
discharged home on HD #4. On the day of discharge, a new groin
bruit was noted. Left femoral US was negative for pseudoaneurysm
or hematoma. She was discharged with outpatient follow up.
2. CHF, preserved EF. The patient appeared euvolemic on exam.
Cath report revealed normal left sided filling pressures. The
patient was continued on Lasix per outpatient dose.
3. SOB. Differential diagnosis included cardiac etiology/demand
ischemia, COPD exacerbation, CHF, infectious causes particularly
because the patient was on chronic prednisone therapy, PE. The
patient was afebrile. Leukocytosis was attributed to prednisone
therapy. She patient was transferred from the OSH on Ceftazidime
and Levaquin which were started empirically to cover for
pneumonia given a question of infiltrate on CXR. Ceftazidime was
discontinued and she was continued on Levaquin for empiric
treatment of CAP. The had no evidence of decompensated CHF on
exam or by cath report. The patient was treated for COPD
exacerbation with slow steroid taper (started [**3-29**] prednisone at
60 mg), Levaquin, and she was continued on her nebulizers and
inhalers. On the day of discharge she reported her breathing
being at baseline on her outpatient level of oxygen at 2 liters
per minute.
4. Osteoporosis. The patient was a former smoker and also is on
chronic steroids for her COPD. The patient was continued on
Fosamax and calcium supplements.
5. Chronic steroids. She was continued on a PPI. Bactrim and
folate were added for PCP [**Name Initial (PRE) 1102**]. Her finger sticks were
monitored and covered with ISS.
Medications on Admission:
Outpatient meds:
Prednisone 20 mg daily
Aleve one [**Hospital1 **]
Lasix 60 mg daily
KCl 20 mEq [**Hospital1 **]
Norvasc 2.5 mg daily
Mucinex
Meds at transfer:
Protonix 40mg daily, mucinex 1200mg [**Hospital1 **], norvasc 2.5mg daily,
kcl 20meq [**Hospital1 **], lasix 60mg daily, aleve 200 [**Hospital1 **], solumedrol 40
[**Hospital1 **], fosamax 70mg qweek, colace 100 [**Hospital1 **], caltrate 600, Ceftaz
1gm q8 hrs, Levaquin 500 mg daily, flovent [**Hospital1 **], duo nebs,
verapamil 300mg daily, ecotrin 325, lescol, NTG patch 0.6mg,
flordil inhaler [**Hospital1 **].
Discharge Medications:
1. 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*
2. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QWEEK
().
Disp:*20 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO DAILY (Daily).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. 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*
12. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-20**]
Puffs Inhalation Q6H (every 6 hours).
Disp:*1 inhaler* Refills:*2*
13. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO bid () as needed for cough.
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
treatment Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
16. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
18. Verapamil HCl 300 mg Cap, 24HR Sust Release Pellets Sig: One
(1) Cap, 24HR Sust Release Pellets PO Q24H (every 24 hours).
Disp:*30 Cap, 24HR Sust Release Pellets(s)* Refills:*2*
19. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*15 Tablet, Sublingual(s)* Refills:*0*
20. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
22. Prednisone 10 mg Tablet Sig: Tapered dose as below: PO once
a day for 16 days: Take 4 tabs x 4days,
then 3 tabs x 4days,
then 2 tabs x 4days,
then 1 tab x 4days,
then off.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Primary diagnoses:
1. Coronary artery disease
2. Intramyocardial hematoma
3. Chronic obstructive pulmonary disease exacerbation
4. Osteoporosis
5. Chronic steroid use
6. Hyperlipidemia
Secondary diagnoses:
1. Osteoarthritis
2. Gastroesophageal reflux disease
Discharge Condition:
Shortness of breath at baseline on 2L of oxygen. Vital signs and
labs are stable.
Discharge Instructions:
Please return to care immediately if you develop chest pain,
worsening shortness of breath, nausea, dizziness, pain or
numbness in groin or leg or other concerning symptoms.
Please take all medications as prescribed below and follow up
with Dr. [**Last Name (STitle) 11493**]. Please note that we made several changes in your
medications. Below is the updated list. Do not stop taking
Plavix until you are told to stop taking it by your
cardiologist.
Please resume your usual activities gradually. Do not exert
yourself. Avoid lifting more than 5 pounds or other strenous
activity in the next 1-2 weeks.
Followup Instructions:
Please call [**Telephone/Fax (1) 11650**] to schedule a follow up appointment
with Dr. [**Last Name (STitle) 11493**] within 3-4 days after discharge from the
hospital.
Please call [**Telephone/Fax (1) 902**] to schedule a follow up appointment
with Dr. [**Last Name (STitle) 1911**] in one month.
Completed by:[**2171-4-25**] Admission Date: [**2171-4-1**] Discharge Date: [**2171-4-15**]
Date of Birth: [**2094-5-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76 yo s/p recent OM1, RCA stent [**2171-3-28**], d/c'd from [**Hospital1 18**] 1 day
ago, p/w epigastric pain to [**Hospital3 **]. Concern for instent
stenosis but quality of abd pain changes (diffuse then localized
to RLQ) D/C hep gave morphine and transfered to [**Hospital1 18**]. On
admission, afebrile,WBC 26, diffuse abd tenderness. Normal
non-contrast CT abd: no free air or RP bleed. In the ED, c/o
epigastic abd pain increased with decline in her SBP and
elevated HR. Intubated electively for MRA. Became hypotensive
and went into AF/RVR following intubation and was cardioverted
with 200 joules. NSR was established and aggressive IVF was
initiated. To avoid contrast nephropathy (had gotten 2 dye load
already) underwent MRA to evaluate for mesenteric ischemia -->
patent vessels; FOS. In addition, patient presents with
leukocytosis (26) that rose to 42 with left shift. Surgery
evaluated pt and asked for contrast CT.
During prior admission, patient undewent 2nd angio for ? of R
atrial mass to r/o perforation. This was negative. During that
admission she was d/c'd on a steroid taper for presumed COPD.
Past Medical History:
*Pancreatits
*Cholelithiasis
*choledocholithiasis [**2170**]
*severe COPD, (no PFT's documented here but follow by Pulm
Marukus at [**Hospital1 **] Nab) On chronic Pred per daughters (lowest ever
5mg (now on 20mg) [**2151**]-Intubated
*CAD with recent DES as above, [**2165**] which showed 70% distal
LAD, 70% OM1 ostial, 40% origin, and 50% mid-distal RCA stenoses
with IAPB and intubation during this admission.
*HTN
*GERD
*spont PTX x 2
*Bladder cancer treated with cystoscopy washing; Cystoscopy 2
weeks ago that was normal
*"anemia", (but no recent Fe Studies)
*History of Aspergillosis pneumonitis status post 12 month
course of voiroconazole anti-fungal [**Doctor Last Name 360**] in [**2169**]
*Hypercholesterolemia
*diastolic CHF
*[**2165**]-transfusion reactive with hemolysis.
PSH: appy, rt. oophorectomy, cystoscopy
Social History:
Approximately 20 pack year smoking history.; daughters live in
the area.
Family History:
NC
Physical Exam:
Tc, m 98.0, 140/54 (on admission)---96/63 at intubation. 112/56,
98 (88-142 in AF), 100% AC 550x14x5 100%.
Intubated, alert to voice; follows compands; NAD
PERRLA,EOMI, Nonicteric, JVP not assessed due to laying flat.
RR at 90, No MRG
Clear anterior fields;
diffuse abd distension with grimace with deep palp. + rebound
and guarding, no focal mass, no HSM, no stigmata of liver dz
Old right fem. access sites. no bruits at either side
Eccyhmosis at R arm
no c/c/e
Pertinent Results:
[**2171-3-31**] 05:50AM PLT COUNT-268
[**2171-3-31**] 05:50AM WBC-11.7* RBC-3.33* HGB-10.4* HCT-30.0*
MCV-90 MCH-31.4 MCHC-34.9 RDW-16.1*
[**2171-3-31**] 05:50AM CALCIUM-9.5 PHOSPHATE-4.1 MAGNESIUM-2.0
[**2171-3-31**] 05:50AM GLUCOSE-71 UREA N-19 CREAT-0.7 SODIUM-144
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-36* ANION GAP-12
[**2171-4-1**] 02:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0
LEUK-NEG
[**2171-4-1**] 02:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2171-4-1**] 02:00AM PLT SMR-NORMAL PLT COUNT-357
[**2171-4-1**] 02:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2171-4-1**] 02:00AM NEUTS-89* BANDS-0 LYMPHS-2* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-1*
[**2171-4-1**] 02:00AM WBC-26.3*# RBC-3.46* HGB-11.0* HCT-31.3*
MCV-90 MCH-31.7 MCHC-35.0 RDW-16.5*
[**2171-4-1**] 02:00AM CK-MB-4 cTropnT-0.48*
[**2171-4-1**] 02:00AM LIPASE-20
[**2171-4-1**] 02:00AM ALT(SGPT)-14 AST(SGOT)-22 CK(CPK)-34 ALK
PHOS-73 AMYLASE-147* TOT BILI-0.6
[**2171-4-1**] 02:00AM GLUCOSE-150* UREA N-38* CREAT-1.5* SODIUM-136
POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-31* ANION GAP-14
[**2171-4-1**] 02:04AM LACTATE-1.1
[**2171-4-1**] 02:04AM COMMENTS-GREEN TOP
[**2171-4-1**] 07:50AM PLT SMR-NORMAL PLT COUNT-424
[**2171-4-1**] 07:50AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+
[**2171-4-1**] 07:50AM NEUTS-90* BANDS-2 LYMPHS-2* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2171-4-1**] 07:50AM WBC-36.9* RBC-3.78* HGB-11.8* HCT-34.5*
MCV-91 MCH-31.1 MCHC-34.0 RDW-16.5*
[**2171-4-1**] 09:01AM LACTATE-1.7
[**2171-4-1**] 09:17AM RET AUT-2.8
[**2171-4-1**] 09:17AM PT-12.9 PTT-20.1* INR(PT)-1.1
[**2171-4-1**] 09:17AM PLT SMR-NORMAL PLT COUNT-430
[**2171-4-1**] 09:17AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+
[**2171-4-1**] 09:17AM NEUTS-86* BANDS-7* LYMPHS-0 MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2171-4-1**] 09:17AM WBC-41.7* RBC-3.76* HGB-11.8* HCT-33.6*
MCV-89 MCH-31.4 MCHC-35.2* RDW-16.5*
[**2171-4-1**] 09:17AM calTIBC-299 FERRITIN-219* TRF-230
[**2171-4-1**] 09:17AM ALBUMIN-3.8
[**2171-4-1**] 09:17AM IRON-21*
[**2171-4-1**] 09:17AM CK-MB-NotDone cTropnT-0.51*
[**2171-4-1**] 09:17AM LIPASE-16
[**2171-4-1**] 09:17AM LIPASE-16
[**2171-4-1**] 09:17AM GLUCOSE-171* UREA N-34* CREAT-1.3* SODIUM-142
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-32* ANION GAP-14
[**2171-4-1**] 10:29AM TYPE-ART PO2-386* PCO2-46* PH-7.38 TOTAL
CO2-28 BASE XS-1
[**2171-4-1**] 06:25PM PLT COUNT-325
[**2171-4-1**] 06:25PM WBC-35.2* RBC-3.29* HGB-10.5* HCT-29.7*
MCV-91 MCH-31.9 MCHC-35.3* RDW-16.3*
[**2171-4-1**] 06:25PM CK-MB-NotDone cTropnT-0.40*
[**2171-4-1**] 06:25PM CK(CPK)-31
[**2171-4-1**] 06:25PM GLUCOSE-142* UREA N-28* CREAT-1.0 SODIUM-145
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-29 ANION GAP-14
[**2171-4-1**]: FEMORAL VASCULAR ULTRASOUND: Grayscale, color, and
Doppler son[**Name (NI) 1417**] of the left groin were performed. The left
common femoral artery and left common femoral vein appeared
normal without evidence of pseudoaneurysm or fistulous
connection. Normal arterial and venous waveforms are
demonstrated along with normal color flow within both of these
vessels.
IMPRESSION: No evidence of AV fistula, pseudoaneurysm, or
hematoma within the left groin.
[**2171-4-1**]: RIGHT UPPER QUADRANT ULTRASOUND: Within the gallbladder
are two shadowing gallstones, the larger of which measures 1 cm
in diameter. The gallbladder is otherwise unremarkable without
evidence of significant distention, gallbladder wall edema, or
pericholecystic fluid. There is no intra- or extra-hepatic
biliary ductal dilatation, and the common bile duct measures 5
mm. A son[**Name (NI) 493**] [**Name (NI) **] sign was not elicited.
IMPRESSION: Cholelithiasis without evidence of cholecystitis.
[**2171-4-1**]: MRA of abdomen to rule out mesenteric ischemia:
FINDINGS: Celiac artery and superior mesenteric artery are
widely patent at their origins and throughout their courses. The
most proximal first few cm of the [**Female First Name (un) 899**] are patent; however, more
distally, the [**Female First Name (un) 899**] is not well visualized.
No bowel wall thickening. There is a large amount of stool
within the colon; however, there is no evidence of obstruction.
The liver, adrenals, spleen, and pancreas are unremarkable. A
few subcentimeter gallstones are noted. Renal cysts are
identified. Kidneys are otherwise unremarkable. Right renal
artery is widely patent; however, there is focal high-grade
stenosis of the origin of the left renal artery.
There is trace ascites.
Atelectasis is noted at the right lung base.
Note is made of multilevel compression fractures within the
lower thoracic spine, probably chronic.
IMPRESSION:
1) Widely patent superior mesenteric and celiac arteries.
Proximal [**Female First Name (un) 899**] is patent, however, is not well visualized more
distally.
2) No bowel wall thickening or edema to suggest ischemia.
[**2171-4-1**]: CT exam of the abdomen and pelvis
The appearance of the right epicardial space is unchanged from
the prior exam. Coronary artery calcifications again noted. The
right lower lobe pulmonary nodule is unchanged. There has been
interval development of small bilateral pleural effusions. The
liver, spleen, adrenal glands, stomach, gallbladder and pancreas
are unchanged. There is a small amount of ascites fluid anterior
to the liver. A single gallstone within the gallbladder is again
noted. Punctate calcifications of the pancreas are again noted.
A simple cyst is again seen within the right kidney, and another
hypodensity of the lower pole of the left kidney likely
consistent with cyst. An NG tube remains within the stomach.
There is no evidence of bowel obstruction. There has been
interval development of wall thickening at the splenic flexure
and there is enhancement of the mucosa. The wall thickening
likely extends proximally into the distal transverse colon.
There is no free air. The mesentery appears relatively [**Name2 (NI) 38068**]
throughout, and there may be some fat stranding adjacent to the
splenic flexure. The aorta is of normal caliber. There are
calcifications at the origin of the celiac, SMA, and [**Female First Name (un) 899**], and
there may be stenoses at these locales. The proximal branches of
the aorta appear patent however.
There is some enhancement of the mucosa within the rectum, and
there is a small amount of free fluid adjacent to the rectum.
There is a Foley catheter within the bladder. The uterus is
within normal limits. No pelvic or inguinal adenopathy
demonstrated.
No suspicious osteolytic or sclerotic lesions.
IMPRESSION:
1. Interval development of wall thickening at the splenic
flexure and distal transverse colon in addition to enhancing
mucosa and vague fat stranding at this locale. There is also
enhancing mucosa within the rectum. The differential diagnosis
for these new findings include inflammatory, infectious or
ischemic etiologies. Ischemia is definitely a consideration
given that the watershed area of the splenic flexure is
affected. Pseudomembranous colitis is also within the
differential diagnosis. There is no evidence of obstruction, and
no free air.
Severe calcifications and stenoses noted at the origin of the
celiac, superior mesenteric and inferior mesenteric arteries.
2. Interval development of small bilateral effusions.
3. Numerous other findings are unchanged compared to yesterday.
Brief Hospital Course:
[**2171-4-1**]: Admited to MICU given that family has refused surgical
intervention for possible ischemic bowel as cause of
pain/symptoms.
[**2171-4-2**]: No clear source of abd pain given neg studies. Renal
insufficiency resolving. Increasing abdominal pain. Vanco
started. Increasing NG tube drainage w/still no stool after
multiple interventions. WBC continues trending upward to 26.
Increasing lopressor secondary to poor rate control w/afib.
[**2171-4-3**]: Repeat CT of abdomen w/o free air or obstruction.
A-line placed. Neg Cdiff to date. Afibb refractory to
cardioversion (lopressor/dilt/amiodarone). Start GoLytely via OG
tube.
[**2171-4-4**]: Worsening abdominal distention/exquisitely tender. WBC
up to 32. Thought to be developing ischemic bowel. Unable to
ween from vent secondary to abdominal distention. Family
meeting, considering CMO.
[**2171-4-5**]: Decreasing urine output w/increasing creatinine, not
responding to fluids. Minimal stool output. Bladder pressure of
10. WBC down to 24. Hct slowly drifting down, now 27.
Hypernatremia ? secondary to free H2O depletion. Guaic pos
stools, will transfuse. Constipation not responding to aggresive
bowel regimen, starting erythromyocin 250 TID.
[**2171-4-6**]: Cardioverted x2. TPN started.
[**2171-4-7**]: Creatinine trending towards baseline, now 2.2 (from
2.7). Placed back on AC after PS trial secondary to fatigue.
[**2171-4-8**]: Increased respiratory secretions, failed PS trial
again. Crackles after transfusion x1u PRBCs for Hct of 27. GI
contact[**Name (NI) **] for possible colonoscopy for abd decompression given
no response to GI regimen, but GI felt patient at to high a risk
for perforation given CT findings of ? ischemic colitis, recs
for golytely and reglan implemented.
[**2171-4-9**]: Large bowel movement, approx 1 liter/guaic pos. Failed
repeat PS trial w/AM RSBI of 62. Flagyl/Ceftaz d/c secondary to
Neg CDiff studies and no clear infectious process. Increased
confusion/? ICU psychosis. Patient extubated after good SBT, but
re-intubated secondary to respiratory distress and failed CPAP
trial w/acidosis on blood gas.
[**2171-4-10**]: Diuresis for hopeful improvement on future extubation
attempts. Increasing stool output, w/improved abd exam.
[**2171-4-11**]: Repeat CT of abdomen w/o evidence of sbo obstruction
but w/diffusely dilated large intestine and ? air/fluid levels
in rectum. Tube feeds resumed.
[**2171-4-12**]: Temp spike 103, Vanco/Zosyn started, Aline d/c, ngt
changed to ogt. Increased secretions. Decreasing urine output,
got lasix. Abd exam markedly improved. Sputum cx neg to date.
[**2171-4-13**]: Right subclavian placed after removal of left
subclavian. Blood Cx from [**4-11**] grew out GPC x3/4 bottles.
Increasing tachycardia not responsive to fluid boluses,
?aflutter, lopressor increased w/amio gtt resumed.
[**2171-4-14**]: Increased confusion. Crackles in lung fields. OGT
pulled by patient. CX showing staph coag +. Per family and
patient's wishes, will perform PS trials today w/goal of d/c ETT
tomorrow with no reintubation if failing extubation. Infection
thought to be secondary to lines w/temp and WBC trending down
following line removal and abx initiation.
[**2171-4-15**]: CXR w/evid of mild chf. Sputum growing staph aureues
coag +. Hct trending down. OG tube pulled out again. Lasix given
for improved diuresis and better extubation attempt. Patient
pretreated w/lasxi and nebs prior to extubation. Patient
developed progressive respiratory distress. Per patient and
family wishes, patient was made comfortable and died at 1935hrs.
Dr [**Last Name (STitle) 14495**] pronouncing death w/family at bedside during entire
interval from extubation to death.
Medications on Admission:
Lisinopril 2.5, prednisone 40, protonix,lasix60, plavix75,folic
acid, tums, asa, Lescol 80, kcl,MDI, NEbs, 1L NC at home.
Discharge Medications:
None / Patient deceased.
Discharge Disposition:
Expired
Facility:
MICU
Discharge Diagnosis:
Death secondary to respiratory and cardiovascular failure.
Discharge Condition:
Expired while in MICU
Discharge Instructions:
None
Followup Instructions:
None
|
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18,219
| 162,480
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6085+55730
|
Discharge summary
|
report+addendum
|
Admission Date: [**2142-7-15**] Discharge Date: [**2142-8-9**]
Service: OMED
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
woman with renal cell carcinoma, metastatic to the lungs, who
presented to the Emergency Room with hemoptysis. The patient
was in her usual state of health until the morning of
admission when without warning she began having a
not associated with emesis.
Per the patient report, blood filled the toilet bowel and was
significantly more than one cup. The patient coughed for 1-2
min each time bringing up small amounts of bright red blood.
The patient denied any antecedent fevers, chills, cough,
upper respiratory infection symptoms, sinus symptoms, nausea,
history of hemoptysis.
On arrival to the Emergency Room, the patient's temperature
was 95.6, pulse 73, blood pressure 94/48, oxygen saturation
94% on room air at rest, with activity the patient
desaturated to 89% on room air, and the patient was
transferred to the floor.
PAST MEDICAL HISTORY: 1. Renal cell carcinoma diagnosed in
[**2137**]. The patient is status post right nephrectomy in
[**2138-10-20**]. The patient was observed until [**2140-6-19**] at
which time she began low-dose IL2, tolerating all 14 cycles.
No other therapy to date. 2. Abnormal mammogram in [**2140**].
The patient had focal atypical ductal hyperplasia and
atypical lobular hyperplasia, lobular carcinoma in situ,
multiple foci. 3. Hypothyroidism. 4. Atypical chest pain.
In [**2140-5-19**], Persantine MIBI showed no electrocardiogram
changes, no ejection fraction, no perfusion defects. 5.
Venostasis ulcers by chart. Cellulitis per the patient. The
patient has q.d. VNA for dressing changes. 6. Life-long
left facial droop.
MEDICATIONS ON ADMISSION: Synthroid 100 mcg p.o. q.d.
ALLERGIES: SULFA CAUSES A RASH. INTRAVENOUS CONTRAST CAUSES
RASH.
SOCIAL HISTORY: The patient lives with her husband in
[**Name (NI) 1468**]. She has no children. No tobacco or alcohol use.
She worked until [**2138**] doing office work for [**Last Name (un) 8320**] [**Doctor Last Name 11586**].
PHYSICAL EXAMINATION: Vital signs: On admission temperature
was 97.2??????, heart rate 76, blood pressure 110/55, respirations
34, initially 22 when more calm, oxygen saturation 96% on
room air. HEENT: Anicteric sclerae. Moist mucous
membranes. No sinus tenderness. Erythema and slight
swelling at the left corner of the mouth. Neck: Supple.
Cardiovascular: Regular rhythm with no gallops. Pulmonary:
Poor air movement without localizing features. No stridor or
wheezes. Abdomen: Soft, nontender, nondistended with normal
bowel sounds. Extremities: Bilateral lower extremity
wrapped in Kerlix with skin changes consistent with chronic
venous insufficiency. Neurological: The patient was alert
and oriented times four. Left facial droop with corner of
the mouth turned slightly down, and eye lid did not elevate
as much as the right. Cranial nerves II-VI and VIII-XII were
functionally intact. Strength 5 out of 5 and symmetric in
all major groups. Sensation intact to light touch. Deep
tendon reflexes normal and symmetric.
LABORATORY DATA: On admission white blood cell count 4.8,
hematocrit 41, platelet count 175,000; sodium 133, chloride
99.
CT angiogram on [**2142-7-15**], showed no evidence of
pulmonary embolus, marked progression of bilateral infrahilar
lung mass and subcarinal and bilateral hilar lobe
lymphadenopathy. There was resulting compression of the
mainstem bronchi bilaterally and severe compression of the
bronchus intermediate.
Head MRI showed large intracellular soft tissue mass lesion
with suprasellar extension, invasion of the cavernous
sinuses, superior displacement and compression of the optic
chiasm and homogenous enhancement, most likely representing a
large pituitary macroadenoma, possibility of meningioma, no
mass affect on the brain parenchyma.
HOSPITAL COURSE: On admission to the floor, the patient was
hemodynamically stable. CT angiogram showed no evidence of
pulmonary embolism. Marked compression of bilateral
infrahilar lung masses and subcarinal bilateral hilar
lymphadenopathy were seen with resultant compression of the
mainstem bronchi bilaterally and severe compression of the
bronchus intermediate.
Etiology of the hemoptysis was likely tumor. On hospital day
#3, the patient's oxygen saturation dropped to 88% on 10 L
nasal cannula with stable blood pressure. The patient was
transferred to the MICU and intubated for hypoxemia with
hemoptysis. The patient subsequently underwent bronchoscopy
with stenting of the bronchus intermediate and left mainstem
bronchus with Argon coagulation of right lower lobe tumor.
The patient tolerated the procedure well and was extubated on
hospital day #4.
Shortly after extubation, the patient became hypotensive with
systolic blood pressure in the 90s associated with decreased
urine output of an average of 40 cc/hr. The patient was
bolused with normal saline with good response. The patient
subsequently became hypotensive again with decreasing oxygen
saturation and increasing congestion with question of
aspiration pneumonia versus postobstructive pneumonia. The
patient was reintubated for airway protection. The patient's
hypotension was not responsive to 2.5 L normal saline fluid
boluses, and the patient was started on Dopamine for blood
pressure support.
The patient was started on intravenous Vancomycin,
Ceftriaxone, and Flagyl for suspected postobstructive
pneumonia versus aspiration pneumonia. The patient's sputum
had grown MRSA. The patient was continued on intravenous
antibiotics for a 10-day course.
On hospital day #8, the patient was not able to be weaned off
Dopamine, and cortical stimulation test was sent which was
positive suggesting adrenal insufficiency as the cause of
hypotension. An Endocrine consult was obtained. The patient
had an MRI of the brain which showed a large intracellular
soft tissue mass lesion with suprasellar extension, invasion
of the cavernous sinuses, superior displacement and
compression of the optic chiasm, likely representing a large
pituitary microadenoma versus meningioma. Laboratory studies
indicated low somatomedin (IgF -1), low ACTH, low FSH and LH
with a normal prolactin, and low free T4.
On review of the MRI, the patient's panhypopituitarism was
likely secondary to meningioma versus renal cell metastasis
to the pituitary. The patient was started on steroids for
adrenal insufficiency, and the patient's Synthroid dose was
increased for central secondary hypothyroidism.
The patient subsequently developed hypernatremia with sodium
of 152. The patient was started on DDAVP for presumed
diagnosis of diabetes insipidus. The patient's serum sodium
subsequently decreased to 142 in two days, and DDAVP was
discontinued. On hospital day #11, Dopamine was weaned off,
and the patient was extubated and transferred to the floor.
1. Oncology: Neuro-Oncology was consulted regarding
recommended treatment for brain mass noted on MRI. Brain
mass was likely a non-secreting pituitary adenoma versus
renal cell carcinoma metastasis. Recommended surgical
removal if prognosis was greater than one year, as radiation
induced retinopathy or cranial neuropathy would appear at one
year. The patient was subsequently evaluated by
Neurosurgery. As the patient's prognosis was poor and the
patient was without visual symptoms at this time, they did
recommend surgery. The patient was evaluated by Radiation
Oncology and subsequently underwent five days of radiation
treatment to right lung mass.
2. GI: The patient had an NG tube with tube feeds on
arrival to the floor. The patient underwent video
oropharyngeal swallow study which showed aspiration of thin
liquids with spontaneous coughing. The patient's NG tube was
replaced with an NJ tube for comfort. The patient's speech
and swallow was repeated five days later. Swallowing repeat
study showed aspiration with paste and thin liquids. The
patient went for placement of a JG tube.
3. Hyponatremia: The patient developed hyponatremia with a
sodium of 126. The patient is with an element of SIADH with
urine osmolality of 342 and urine sodium of 94. It was
uncertain if hyponatremia was from insufficient
glucocorticoids or from her lung tumor. The patient's
Prednisone was increased from 7.5 mg to 10 mg q.d., and the
patient was placed on a free water restriction with Sodium
Chloride tablets 3 g q.d. The patient's serum sodium
subsequently increased to 132.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to
rehabilitation.
DISCHARGE DIAGNOSIS:
1. Metastatic renal cell carcinoma to the lungs.
2. Adrenal insufficiency.
3. Hypothyroidism.
4. Hyponatremia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1736**]
Dictated By:[**Last Name (NamePattern1) 1297**]
MEDQUIST36
D: [**2142-8-9**] 12:29
T: [**2142-8-9**] 12:41
JOB#: [**Job Number 23855**]
Name: [**Known lastname 3862**], [**Known firstname 3863**] Unit No: [**Numeric Identifier 4080**]
Admission Date: [**2142-7-15**] Discharge Date: [**2142-8-14**]
Date of Birth: [**2065-1-28**] Sex: F
Service: O-MED
ADDENDUM: HOSPITAL COURSE:
#1. ONCOLOGY: The patient began palliative radiation
treatment on [**2142-8-3**], receiving five rounds of radiation
treatment.
#2. PULMONARY: The patient's O2 saturations remained stable
on two liters nasal cannula oxygen.
#3. ENDOCRINE: The patient was diagnosed with
panhypopituitarism. The patient was maintained on Prednisone
10 mg p.o.q.d. and Synthroid. In addition, hospital course
was complicated by hyponatremia. The patient's sodium
corrected with free-water restriction and sodium chloride
tablets. The sodium chloride tablets were discontinued prior
to discharge.
#4. NUTRITION: The patient had a JG-tube placed for
recurrent aspirations, prior to discharge.
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 4081**], M.D. [**MD Number(1) 4082**]
Dictated By:[**Last Name (NamePattern1) 1638**]
MEDQUIST36
D: [**2142-11-23**] 09:20
T: [**2142-11-23**] 09:38
JOB#: [**Job Number 4083**]
|
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"255.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.39",
"96.71",
"96.05",
"33.23",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8649, 9306
|
1759, 1857
|
9323, 10292
|
2114, 3903
|
117, 981
|
1004, 1732
|
1874, 2091
|
8553, 8628
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,679
| 167,467
|
2216
|
Discharge summary
|
report
|
Admission Date: [**2127-9-30**] Discharge Date: [**2127-10-3**]
Date of Birth: [**2048-7-9**] Sex: M
Service: NEUROLOGY
Allergies:
Ace Inhibitors
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
right arm and leg weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 11782**] is a 79 year-old right handed [**Location 7972**] man with a
history including left parieto-occipital hemorrhage ([**2120**]) with
residual right homonymous hemianopia and aphasia
(expressive>receptive), hypertension, hyperlipidemia, and
seizures who presents with a acute right-sided weakness for whom
a code stroke was called.
.
According to the patient and his family, he was in his usual
state of health until 12:30 pm on the day of evaluation. It is
unclear what he was doing at that time; his son denies preceding
sexual activity, agitation, and head trauma. However, at that
time, Mr. [**Known lastname 11782**] did notice the sudden onset of right upper
extremity weakness. He sought help from his wife and sat down.
Within 10 minutes, he developed right leg weakness. The
weakness might have been associated with sensory change in the
right extremities. The family called for help and he was
brought
to the [**Hospital1 18**] ED for evaluation. By the time of his arrival, he
was noted to have a right facial droop. Although he has a
baseline aphasia in which he has slightly limited comprehension
with word-finding difficulties and non-fluent speech, his speech
production seemed to be increasingly impaired. A fingerstick
was
112. A code stroke was called at 1:20 pm.
.
A non-contrast CT of the head was already in progress two
minutes
later at the time of the consult. The initial NIHSS score was
17
(2 loc questions, 2 right homonymous hemianopia, 2 right facial
palsy, 8 complete right hemiplegia, 1 decreased sensation to
pinprick in right extremities, 1 aphasia, 1 dysarthria),
although
baseline is estimated to be an NIHSS score of 5. The
non-contrast CT of the head revealed a left predominantly
frontal
hemorrhage. He was not considered a tPA candidate due to the
intraparenchymal hemorrhage.
Past Medical History:
1. L parieto-occipital hemorrhage (thought possibly related to
AVM; residual baseline motor>sensory aphasia and field cut)
2. Seizure disorder (complex partial)
3. HTN
4. High cholesterol
5. Depression
6. GERD
7. OA
8. h/o rotator cuff injury
9. CLBP with DJD at mult levels (recent MRI showed: disc at L2-3
on L impinging L3; spinal stenosis at L4-5 moderate, L3-4 mild;
L5-S1 disc with both nerve roots affected)
Social History:
He lives with his wife. [**Name (NI) **] contact with children. No
smoking, no significant alcohol. Worked as a teacher, then a
carpenter.
Family History:
No strokes or seizures.
Physical Exam:
At Admission:
NIH STROKE SCALE score: 17
1a. Level of Consciousness: 0
1b. LOC Question: 2 (baseline)
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 2 (baseline)
4. Facial palsy: 2
5a. Motor arm, left: 0
5b. Motor arm, right: 4
6a. Motor leg, left: 0
6b. Motor leg, right: 4
7. Limb Ataxia: 0
8. Sensory: 1 (decraesed pinprick sensation in right limbs)
9. Best Language: 1 (baseline)
10. Dysarthria: 1
11. Extinction and Neglect: 0
PHYSICAL EXAMINATION:
Vitals: T: not yet recorded P: 58 R: 20 BP: 173/55 SaO2: 98%
RA
General: Awake, cooperative, NAD. Dysarthric.
HEENT: Normocepahlic, atruamatic, no scleral icterus noted.
Mucus
membranes moist, no lesions noted in oropharynx
Neck: Supple. No carotid bruits appreciated.
Cardiac: Brady rate, normal S1 and S2.
Pulmonary: Lungs clear to auscultation bilaterally anteriorly.
Abdomen: Round. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: Alert.
* Orientation: oriented to year of birth ([**2048**]). Identifies
location as "[**Location (un) 86**]." He is unable to provide the present date,
month, year, or details of his home address (baseline per son)
* Attention: Attentive to exam but recitation exercises (eg days
of week backwards) limited by language barrier and aphasia at
this time.
* Memory: Able to correctly identify year of birthdate.
* Language: Language is non-fluent, and he becomes frustrated
with an inability to communicate. Repetition is intact ("today
is a sunny day."). Comprehension appears largely intact; pt
able
to correctly follow basic midline and appendicular commands. He
has difficulty following directions to "point to the door"
(unclear if this is due to a language or comprehension problem).
Pt able to name high frequency object (thumb). He is unable to
name any of the other stroke card items - although he tells his
son he recognizes them. His son says he does not read or write
English at baseline.
* Calculation: Pt is unable to calculate number of quarters in
$1.50 and subtract seven from 100.
* Neglect: difficult to test in setting of sensory disturbances
.
Cranial Nerves:
* I: Olfaction not evaluated.
* II: PERRL 3 to 2mm and brisk. Right homonymous hemianoia.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
* III, IV, VI: EOMI without nystagmus.
* V: Facial sensation intact to light touch in the V1, V2, V3
distributions.
* VII: right facial droop at rest with decreased excursion of
the
right face with voluntary showing of teeth; resolves with
spontaneous/emotional smile. Eyebrow raise and furrowing is
also
decreased on the right relative to the left.
* VIII: Hearing intact to finger-rub bilaterally.
* IX, X: Palate elevates symmetrically.
* [**Doctor First Name 81**]: 5/5 strength in trapezii on left, 0/5 on right.
* XII: Tongue protrudes in midline.
Motor:
* Tone: increased versus paratonia in left limbs, increased in
right lower extremity; normal to low in RUE.
* Adventitious Movements: low amplitude resting tremor of left
thumb and forefinger, left lower lip
Strength:
* Left Upper Extremity: 5 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Right Upper Extremity: plegic with no withdrawal to noxious
.
* Left Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
* Right Lower Extremity: plegic with no withdrawal to noxious
.
Reflexes:
* difficult to obtain in left limbs as he is constantly
moving/tightening limbs, 1+ at R biceps, brisk at R patella,
difficult to obtain at achilles bilat
* Babinski: extensor (R>>L) bilaterally
Sensation:
* Pinprick: decreased in RUE, RLE; otherwise intact in left
lower
extremity, upper extremity, trunk, face
Coordination
* Finger-to-nose: intact on left
* Heel-to-shin: intact on left as performed with LLE suspended
above shin
.
Gait:
* deferred
At discharge:
Neuro exam: R homon hemi, aphasia (exp>receptive; worse than
previous baseline), R facial droop, R hemiparesis (new), bilat
upgoing toes R>L, resting tremor L hand, L mouth
Pertinent Results:
[**2127-9-30**] 01:15PM WBC-5.1 RBC-4.09* HGB-12.8* HCT-33.9* MCV-83
MCH-31.2 MCHC-37.7* RDW-12.7
[**2127-9-30**] 01:15PM PT-11.9 PTT-21.9* INR(PT)-1.0
[**2127-9-30**] 01:15PM PLT COUNT-140*
[**2127-9-30**] 01:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2127-9-30**] 01:15PM LIPASE-44
[**2127-9-30**] 01:15PM GLUCOSE-106* UREA N-11 CREAT-1.1 SODIUM-140
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
[**2127-9-30**] 02:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2127-9-30**] 04:36PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
lipid panel - TG 79 HDL: 45 LDLcalc: 77
hgba1c -6
[**9-30**]: ECG
Sinus bradycardia. Normal tracing. Compared to the previous
tracing
of [**2122-1-8**] there is no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
56 170 96 [**Telephone/Fax (2) 11783**]2
NCHCT [**9-30**]
IMPRESSION:
1. Large left intraparenchymal hematoma without shift of midline
structures and small amount of subarachnoid extension.
Diagnostic considerations favor amyloid angiopathy.
2. Occipital encephalomalacia with ex vacuo dilatation of the
occipital [**Doctor Last Name 534**] of the left lateral ventricle and overlying
craniotomy changes of the left occipital bone.
[**9-30**] CTA Head and neck:
IMPRESSION:
1. Mild atherosclerotic changes of the anterior and posterior
circulation with no evidence of hemodynamically significant
stenosis, aneurysm or vascular malformation.
2. Judged by the contrast-enhanced images, there is no relevant
interval
change with regard to the left frontal hemorrhage.
[**9-30**] CXR PA and lat:
FINDINGS: AP upright and lateral views of the chest were
obtained. Low lung volumes limit evaluation. There is no focal
consolidation, effusion, or pneumothorax. No signs of CHF.
Cardiomediastinal silhouette normal. Osseous structures appear
intact. Degenerative changes in the imaged portion of the
thoracolumbar spine noted. No free air below the right
hemidiaphragm on this AP upright exam.
IMPRESSION: No acute findings on this limited exam.
[**10-1**] MRI head with and without contrast:
IMPRESSION:
1. Acute left parietal hemorrhage with overlying subarachnoid
hemorrhage.
and no associated enhancement. No abnormal vascular structures.
There is
enhancement of the superficial vasculature in the area of the
subarachnoid
hemorrhage most likely related to slow flow.
2. Stable left occipital encephalomalacia and chronic
hemorrhage.
3. No enhancing masses or new areas of infarct. Diffuse small
vessel disease seen throughout the white matter.
[**10-2**] CXR Portable:
Cardiomediastinal contours are unchanged with cardiac size top
normal. There are low lung volumes. There is no pneumothorax or
pleural effusion.
Faint opacities in the left lower lobe could be due to
atelectasis but
aspiration/pneumonia cannot be excluded.
[**10-2**] NCHCT:
IMPRESSION: No significant interval change since MR examination
from
[**2127-10-1**] in a large left parietal intraparenchymal hemorrhage
and associated subarachnoid extension and layering
intraventricular hemorrhage within the occipital horns.
[**10-3**] CXR PA and lateral:
Prelim read: no left lower lobe opacities. Overall no
infiltrates or opacities throughout.
Brief Hospital Course:
79yoRHM ([**Location 7972**]) h/o L parieto-occipital IPH (with
residual R homonymous hemianopia and nonfluent aphasia), HTN,
HL, tobacco use, and seizures p/w acute onset R arm and leg
weakness and worsening apahsia.
[] Intraparenchymal Hemorrhage - He was admitted overnight to
the Neuro ICU for close monitoring and BP management. His BP
remained at goal, and he had no change in neurologic status. He
does have a tremor in his left hand, which is a chronic process,
confirmed with his outpatient neurologist. He received an MRI
Brain which
redemonstrates the intraparenchymal and intraventricular
hemorrhage as well a few scattered microbleeds on GRE. It is
presumed at this point that the patient has amyloid angiopathy
and that this is likely the etiology of his hemorrhages. The
patient has remained clinically stable with right hemiplegia and
a nonfluent aphasia. The patient's lipid panel shows good
cholesterol control. Given the concern for statins having a role
in bleeding, we have stopped his previous home medicine
simvastatin. We ask that his PCP [**Name Initial (PRE) **]/or neurologist rechecks a
fasting lipid panel in 3 months ([**2127-12-9**]) and at this
point, if his lipids worsen, consider restarting simvastatin
40mg at that point. He has already been started on subcutaneous
heparin for DVT prophylaxis, but we ask that his aspirin 81mg
continue to be held until [**2127-10-7**] (7 days post-bleed), at which
point it can be resumed.
[] Low grade fevers - The patient has had fevers of 100-100.6
during his stay. He has no symptoms or signs of infection
otheriwse. His chest Xrays have been clear, his urine is clean,
and he has no leukocytosis. Blood and urine cultures have been
sent are are no growth to date. We therefore presume that his
fevers are related to the hemorrhage. If he starts to have high
grade fevers or develops any signs of infection, we ask that his
rehab facility evaluates further.
[] Thrombocytopenia - The patient's platelets were 140 at
admission. He received 6 units of platelets initially when he
was admitted. The pack of platelets were given to reverse
potential platelet disfunction since he had been taking daily
aspirin. Since the transfusion, his platelets have been
170-180s. This has been approximately his baseline for the past
2 years. No active issues.
Medications on Admission:
- asa 81 mg po daily
- seroquel 12.5 mg po qhs
- citalopram 20 mg po daily
- simvastatin 40 mg po qhs
- metoprolol 50 mg po bid
- omeprazole 20 mg po daily
- triamcinolone cream 1% app to affected areas [**Hospital1 **]
- levetaracetam 750 mg po bid
- naproxen 550 mg po q12 hr prn pain
Discharge Medications:
1. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO Q 12H
(Every 12 Hours).
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: Please do not
start until [**2127-10-7**]. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
intraparenchymal hemorrhage
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neuro exam: R homon hemi, aphasia (exp>receptive; acute
worsening of previous aphasia), R facial droop, R hemiparesis
(new), bilat upgoing toes R>L, resting tremor L hand, L mouth
Discharge Instructions:
It was a pleasure caring for you during your stay. You were
admitted to the hospital for evaluation of your right side
weakness and language trouble. You were found to have a bleed on
the left side of your brain. The cause of your bleeding is most
likely amyloid angiopathy that predisposes the blood vessels in
your brain to bleed.
-Given that your cholesterol is currently well controlled, we
have stopped your simvastatin. We ask that your cholesterol is
rechecked in 3 months ([**2127-12-9**]) and at that time your
cholesterol has significantly increased, the simvastatin can be
restarted.
-Currently we are holding your aspirin 81mg. Please restart this
medicine on [**2127-10-7**] (7 days after your bleed).
-During your stay you have had low grade fevers of 100-100.6.
Otherwise you have no other signs or symptoms of infection.
Multiple tests looking at your chest, urine, and blood have been
negative. We believe this is most likely due to a reaction to
the blood in your brain. We expect this to improve over time.
Followup Instructions:
Please see your neurologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6817**] in clinic on
[**12-24**] at 9:30am. Please call [**Telephone/Fax (1) 1690**] if you need to
reschedule this appointment.
Please also see your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in clinic on [**12-2**] at
10am. Please call [**Telephone/Fax (1) 250**] if you need to reschedule this
appointment.
Please attend your previously scheduled appointments:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2127-10-9**] 3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2128-4-21**] 1:00
|
[
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"345.40",
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"438.11",
"277.39",
"780.61",
"438.7",
"431",
"368.46",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14058, 14155
|
10406, 12731
|
310, 316
|
14227, 14227
|
7044, 10383
|
15637, 16398
|
2811, 2836
|
13068, 14035
|
14176, 14206
|
12757, 13045
|
14587, 15614
|
2851, 3293
|
3315, 3848
|
6851, 7025
|
244, 272
|
344, 2199
|
5098, 6837
|
14242, 14563
|
3873, 3873
|
2221, 2637
|
2653, 2795
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,408
| 116,100
|
31756
|
Discharge summary
|
report
|
Admission Date: [**2102-3-13**] Discharge Date: [**2102-3-13**]
Date of Birth: [**2029-12-18**] Sex: F
Service: MEDICINE
Allergies:
Crestor
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 yo female with afib, CHF (EF 30-35%), and metastatic colon
cancer undergoing palliative chemotherapy transferred from BIDN
for hypoxia in the context of bilateral multifocal pneumonia
seen on CXR. Patient c/o productive cough, SOB, subjective fever
(T to 100.1 at NH) for the past several days, given augmentin
500mg TID (D1=[**2102-3-11**]) at nursing home and brought to BIDN were
she was found to be hypoxic to the 70s on RA, 80% on 5L NC. VS
at BIDN: 93/50, 91, 25, 93% on nonrebreather. Labs at BIDN
included: WBC 11.0 (83.6% N), K 3.0, lactate 1.7, AST 82, AP
204, alb 2.6. CXR reportedly showed bilateral multifocal PNA.
Patient was given 2L NS, potassium supplementation (20meq),
duonebs, as well as vancomycin 1gm IV and zosyn 3.375gm IV at
10:15pm and transferred to [**Hospital1 18**] for an ICU bed given hypoxia.
Denies chest pain, nausea/vomiting, abdominal pain. She is
DNR/DNI, confirmed with patient, but is okay with pressors.
.
In the ED inital vitals were T 97, HR 97, BP 112/61, RR 24, O2
sat 83% on 15L nonrebreather. Patient is reportedly confused,
not understanding she has a foley in. Patient received 700 cc
IVFs in ED. UA showed small leuks, 25 WBCs. Per nursing home,
patient has a history of ESBL in urine. Vital signs on transfer
were HR 108, BP 107/52, RR 28, sat 95% on 15L nonrebreather,
however drops to 70s on RA.
.
On arrival to the ICU, VS T 98.6, HR 99, BP 107/61. RR 29, Sat
95% on 4L 100% nonrebreather, but desatted to the 70s with
attempting to get out of bed to go to the bathroom. At rest,
feels comfortable, without complaints except for cough
exacerbated with speaking.
Past Medical History:
- colorectal cancer (dx 08) s/p low anterior resection and
transverse
colostomy [**12-21**] and is status post 14 cycles of Capox which she
started in [**2099-2-12**] and completed in [**2100-8-12**]. She was
then started on irinotecan in [**2100-9-12**] with the last dose
being on [**12-24**] when she was hospitalized with abdominal pain and
nausea. CT scan of the abdomen at that time showed progressive
disease and new pulmonary metastases. She was subsequently sent
to rehab since then and has not been on any further
chemotherapy.
- atrial fibrillation
- CHF, EF 30-35%
- coronary artery disease s/p CABG in [**2087**] at the [**Hospital1 24300**] Hospital; the patient has been followed by Dr. [**First Name4 (NamePattern1) 122**]
[**Last Name (NamePattern1) **]; echocardiogram on [**2098-11-12**] showed inferior apical
left ventricular aneurysm and ejection fraction of 30%-35%
- htn
- hyperlipidemia
- hypothyroidism
- UTI with ESBL
- schizoaffective disorder
- depression
- anxiety
- arthritis, knees
- alcoholism
- cataracts
Social History:
Lives at [**Location 931**] House Nursing Center at baseline is alert,
oriented and follows instructions. Ambulates with assistance.
Ms. [**Known lastname **] is single and has no children; she previously worked
as a housekeeper and companion. She has a 75-pack-year history
of cigarette smoking.
Family History:
Father died at age 58 from myocardial infarction and her mother
died from complications of diabetes at age 78; a brother had
lung cancer and a sister had breast cancer at age 74; a maternal
uncle died of cancer; there is no family history of colon
cancer.
Physical Exam:
ADMISSION EXAM
Vitals: T 98.6, HR 99, BP 107/61. RR 29, Sat 95% on 4L 100%
nonrebreather
General: Alert, oriented, working to breathe
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: nonrebreather on, using abdominal muscles to breathe,
rales throughout lungs bilaterally with minimal end-expiratory
wheezes, no rhonchi
CV: Tachycardic rate and reg rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, calves nontender and symmetric.
Pertinent Results:
[**2102-3-13**] 04:38AM BLOOD Glucose-115* UreaN-11 Creat-0.5 Na-142
K-3.5 Cl-108 HCO3-23 AnGap-15
[**2102-3-13**] 04:38AM BLOOD ALT-26 AST-79* LD(LDH)-509* AlkPhos-168*
TotBili-0.9
[**2102-3-13**] 04:38AM BLOOD Albumin-3.3* Calcium-8.3* Phos-3.7 Mg-1.8
CXR [**2102-3-13**]
There are extensive bilateral upper zone opacities
with air bronchograms suggestive of pneumonia, previously
diagnosed at an
outside hospital. Outside hospital imaging was not available for
direct
comparison. Left hemidiaphragm is not visualized and suggests
left lower
field atelectasis and/or pleural effusion.
Brief Hospital Course:
72 yo female with afib, CHF (EF 30-35%), and metastatic colon
cancer undergoing palliative chemotherapy transferred from BIDN
for hypoxia in the context of bilateral multifocal pneumonia
seen on CXR.
She was initially started on vancomycin, levaquin and cefepime
for HCAP. Overnight she became progressively dyspneic and
hypoxic. In the morning, she was started on BiPAP to assist with
breathing. Around 11am, she was found to have right sided
hemiplegia and dysphasia, with a constricted right pupil,
suggesting that she had had a large hemispheric CVA. This
information was explained to her health care proxy, [**Name (NI) **] [**Name (NI) **].
The decision was made to pursue Comfort Measures Only and all
treatment was stopped. She was taken off the BiPAP and given a
morphine drip and ativan for comfort. She expired at 13:31. The
medical examiner was notified as she died within 24 hours of
admission. An autopsy was waved and also declined by next of
[**Doctor First Name **], her sister [**Name (NI) 43726**] [**Name (NI) 74569**].
Medications on Admission:
zyprexa 20 mg daily
colace 100mg [**Hospital1 **]
Senna 1 tab Qday
Magnesium oxide 400mg [**Hospital1 **]
Synthroid 75mcg daily
Melatonin 3mg Qhs
sertraline 100 mg daily
MV 1 tab daily
Trazodone 50mg Qhs
Ativan 0.5mg q4h prn anxiety
Morphine 2mg SL q4h prn pain
lidoderm patch 5%, 12hrs on, 12hrs off
Motrin 600mg Q6hrs prn pain
Acidophilus 2 tabs TID for 21 days (started [**3-9**])
Augmentin 500mg TID (started [**3-11**])
Started [**3-13**]: Saline nasal spray, duonebs, robitussin
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Colon cancer
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"799.02",
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"V45.72",
"366.9",
"401.9",
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"197.0",
"272.4",
"427.31",
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"434.91",
"311",
"V15.82",
"716.95",
"342.90",
"486",
"414.00",
"300.00",
"305.03",
"244.9",
"295.70",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6522, 6531
|
4917, 5959
|
276, 282
|
6597, 6606
|
4303, 4894
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|
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|
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|
6552, 6576
|
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|
6630, 6634
|
3601, 4284
|
229, 238
|
310, 1931
|
1953, 2996
|
3012, 3312
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,915
| 188,421
|
12019
|
Discharge summary
|
report
|
Admission Date: [**2149-1-14**] Discharge Date: [**2149-1-16**]
Date of Birth: [**2077-11-14**] Sex: F
CHIEF COMPLAINT: Transferred to the [**Hospital1 190**] for planned left anterior descending artery
intervention.
female with a history of coronary artery disease,
hypertension, and hypercholesterolemia. She underwent
stenting of the left circumflex one year ago after presenting
with symptoms of shortness of breath and fatigue.
She has been her usual state of health since then until last
Friday when she experienced significant back pain upon waking
accompanied by shortness of breath and mild nausea. The
patient took two [**Hospital1 37736**] nitroglycerin tablets with
minimal effect and then called Emergency Medical Service.
The paramedics gave Ms. [**Known lastname 18531**] [**Last Name (Titles) 37736**] nitroglycerin
spray which made her pain free.
Upon admission to [**Hospital3 1280**] Hospital, the patient ruled out
for a myocardial infarction by enzymes. She then underwent
an exercise treadmill test in which she seven minutes on the
[**Doctor First Name **] protocol and developed minor symptoms and 1-mm ST
depressions inferiorly. The patient was started on a
nitroglycerin drip and admitted to the Coronary Care Unit
where she remained pain free over the weekend awaiting
cardiac catheterization.
On the day prior to admission at [**Hospital1 190**], the patient had a catheterization at the
outside hospital which demonstrated a left main 20%
stenosis, and a right coronary artery 40% stenosis, a
proximal left anterior descending artery 80% stenosis, and a
first diagonal 70% stenosis, and a 50% stenosis of the first
obtuse marginal branch. The previously placed left circumflex
stent was patent.
She was then transferred to [**Hospital1 188**] for further intervention.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. History of transient ischemic attack in the past.
4. Bilateral carotid stenosis; 100% on the left and 50% on
the right (according to previous ultrasound reports).
5. Coronary artery disease; with a left circumflex stent in
[**2147**].
PAST SURGICAL HISTORY: None except for possible intervention
on the right carotid, which is uncertain at this point.
MEDICATIONS ON ADMISSION: (Home medications included the
following)
1. Nadolol 40 mg p.o. q.d.
2. Aspirin 325 mg p.o. q.d.
3 Lipitor 40 mg p.o. q.d.
4. Altace 2.5 mg p.o. q.d.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Father and brother with myocardial
infarctions in their 60s. Mother with angina.
SOCIAL HISTORY: The patient is a massage therapist. She has
three children; a daughter is a registered nurse at
[**Hospital3 1810**]. She is very physically active. She
smoked two packs of cigarettes per day for 20 years. She
quit 25 years ago. The patient also has a history of alcohol
abuse in the past; however, she has not had a drink for 25
years.
REVIEW OF SYSTEMS: On review of systems, the patient
complained of dyspnea on exertion over the past year. She
gets out of breath after two flights of stairs, but she is
able to walk one and a half miles on a level surface. No
orthopnea and no paroxysmal nocturnal dyspnea.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
upon admission to the Coronary Care Unit, the patient had the
following vital signs: Temperature was 97.8, blood pressure
was 112/43, heart rate was 60, oxygen saturation was 99% on
room air. In general, she was a pleasant woman who appeared
younger than her stated age, lying in bed, in no acute
distress. Head, eyes, ears, nose, and throat examination
revealed normocephalic and atraumatic. Pupils were equal,
round, and reactive to light. The oropharynx was clear and
moist. The neck was supple with no lymphadenopathy. No
jugular venous distention. She had radiation of a murmur to
both carotids and delayed upstrokes bilaterally.
Cardiovascular examination revealed a regular rate and
rhythm. Normal first heart sound and second heart sound. A
soft 2/6 systolic murmur at the left upper sternal border and
the right upper sternal border radiating to the carotids.
Lungs were clear to auscultation bilaterally. The abdomen
was soft, nontender, and nondistended. Normal active bowel
sounds. Extremities were warm and without edema. She had a
small hematoma in the right groin, but no bruits and good
distal pulses bilaterally. There was no hematoma in the left
groin. There was also no hematoma there and no bruit there.
Neurologically, alert and oriented times three. Cranial
nerves II through XII were grossly intact. She was moving
all extremities symmetrically.
PERTINENT LABORATORY VALUES ON PRESENTATION: She had a
creatine kinase drawn at the outside hospital which was 75.
PERTINENT LABORATORY VALUES ON DISCHARGE: On the day of
discharge, the patient had the following laboratory values:
She had a white blood cell count of 7.3 and hematocrit was
37. Chemistry-7 was as follows: Sodium was 143, potassium
was 4.4, chloride was 104, bicarbonate was 27, blood urea
nitrogen was 13, creatinine was 0.7, and blood glucose was
90. Calcium was 8.4, magnesium was 2.1, phosphate was 3.7.
Her creatine kinases here in the hospital were 130 to 140
with MB fractions from 10 down to 7. She had a troponin of
12.4. Her iron was 57, ferritin was 56, total iron-binding
capacity was 330, and a transferrin was 254.
RADIOLOGY/IMAGING: Pertinent laboratories and studies
revealed the patient had a cardiac catheterization at the
outside hospital which had the findings as mentioned
previously.
She had an electrocardiogram done in the Coronary Care Unit
during an episode of [**11-7**] chest pain after her cardiac
intervention at [**Hospital1 69**] which
showed a normal sinus rhythm at 51 with no ST-T wave changes.
She had a cardiac catheterization here at [**Hospital1 346**] for intervention on the left
anterior descending artery lesion with the following
findings: She had a baseline systolic blood pressure of 154,
a diastolic pressure of 50, mean pressure was 67, heart rate
was 53. She had a normal left main coronary artery. The
left anterior descending artery was a slightly calcified
vessel, 80% hazy eccentric stenosis proximally involving a
moderately sized diagonal branch which itself had an 80%
stenosis proximally, followed by several centimeters of a
diffusely diseased vessel with up to 60% stenosis. The left
circumflex stents were widely patent.
HOSPITAL COURSE:
1. CARDIOVASCULAR SYSTEM: The patient underwent cardiac
catheterization with intervention to the left anterior
descending artery lesion. During the procedure, the lesion
in the left anterior descending artery was stented;
whereupon, with increased flow, the disease in the more
distal left anterior descending artery appeared significantly
worse and did not improve with intravenous nitroglycerin.
Two more stents were then placed distally to the first stent,
but during these subsequent stenting, the moderately sized
first diagonal branch was severely compromised due to the
initial stenting in the proximal left anterior descending
artery. This diagonal was then rescued with percutaneous
transluminal coronary angioplasty using a 2-mm balloon. This
opened up the diseased portion of the diagonal branch but led
to a significant dissection of that diagonal branch. The
dissection later compromised flow down the diagonal branch
leading to severe reproduction of the patient's symptoms. A
percutaneous transluminal coronary angioplasty performed with
tacking up of the dissection with restoration of TIMI flow.
Thereafter, the patient's pain improved, and she was
transferred to the floor. On the floor she again
developed severe chest pain felt to be secondary to the
diagonal dissection. Futher intervention on the diagonal was
felt unlikely to help, and she was transferred to the Coronary
Care Unit where it was expected she would complete a diagonal
territory infarct.
In the Coronary Care Unit, the patient had intermittent back
and chest pain; despite the nitroglycerin drip. During her
night in the Coronary Care Unit, she received a total of 6 mg
of intravenous morphine for pain relief. CKs and troponins were
mildly elevated as above. ECGs were unremarkable.
She was transferred to the floor the next day, where she remained
chest pain free for the subsequent 24 hours without requiring
anymore morphine or other pain relief and did not have recurrence
of her chest pain.
Her blood pressure was mildly evaluated on the floor; in the
range of 141 to 154. It was thought prudent to discharge her on
her home regimen unchanged, however, she was to follow up with
her cardiologist in two days, at which point, he could make
additional changes in her medications to address this
slightly elevated blood pressure; likely by increasing her
dose of her ACE inhibitor. She was also started on Plavix to
be taken at 75 mg p.o. q.d. (for nine months). Her blood
pressure was treated in house with nadolol 40 mg p.o. q.d.
and lisinopril 10 mg p.o. q.d.
2. HEMATOLOGIC SYSTEM: On the day following the cardiac
catheterization, while in the Coronary Care Unit, the patient
was noted to have a hematocrit drop to 25. The value taken
at the outside hospital was 31. She had no evidence of
active bleeding, and the drop was most likely blood loss
during the catheterization and to hemodilution. She was
transfused 2 units of packed red blood cells, and her
hematocrit rose to 37 on the day of discharge without any
evidence of active bleeding.
3. GASTROINTESTINAL SYSTEM: The patient was guaiaced and
was found to be guaiac-negative. However, during the rectal
examination, there was found to a be a wedge in the rectal
vault; this was likely just her anatomy or an internal
hemorrhoid. This finding was communicated to the patient and
was recommended to follow up with her primary care physician
for [**Name Initial (PRE) **] repeat rectal examination. Incidentally, the patient
stated she had a colonoscopy one year ago which was negative.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post multiple stents to the left anterior
descending artery and diagonal branch with a dissection of
the diagonal branch during cardiac catheterization.
3. Hypertension.
4. Blood loss anemia.
5. Hypercholesterolemia.
MEDICATIONS ON DISCHARGE: (The patient was discharged on the
following medications).
1. Plavix 75 mg p.o. q.d. (times nine months).
2. Lipitor 40 mg p.o. q.d.
3. Enteric-coated aspirin 325 mg p.o. q.d.
4. Lisinopril 10 mg p.o. q.d.
5. Nadolol 40 mg p.o. q.d.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to call her cardiologist for a follow- up
appointment within two to three days; and she indicated that
she would do so.
2. The patient should have a scheduled stress test with Dr.
[**Last Name (STitle) 17234**] at [**Location (un) 47**] in two weeks.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2149-1-16**] 14:17
T: [**2149-1-21**] 06:12
JOB#: [**Job Number 37737**]
|
[
"413.9",
"V15.82",
"414.01",
"724.5",
"272.0",
"401.9",
"V17.3",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.05",
"36.06",
"99.20",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
2492, 2575
|
10193, 10454
|
10481, 10720
|
2280, 2474
|
6494, 10073
|
10753, 11310
|
2158, 2253
|
10088, 10172
|
4822, 6476
|
2956, 4807
|
137, 1826
|
1848, 2134
|
2592, 2935
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,402
| 167,574
|
3772
|
Discharge summary
|
report
|
Admission Date: [**2157-12-4**] Discharge Date: [**2157-12-14**]
Date of Birth: [**2096-3-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Decreased Right Eye visual acuity, gait disturbance
Major Surgical or Invasive Procedure:
[**2157-12-5**]: Right Stereotactic Brain Biopsy
[**2157-12-9**]: High-dose IV Methotrexate
History of Present Illness:
61 year old right handed engineer who presents today with
decreased visual acuity in right eye and history of difficulty
with balance while ambulating since [**2157-8-17**]. He has had 3
falls since [**Month (only) 205**] due to his difficulty with balance, the
last fall was this week. He has noticed his balance becoming
worse over the past week and has not gone to work for the past
week. Significant medical history includes left testicular mass
removal in [**2145**] that was diagnosed as malignant lymphoma, large
B cell. He has been followed by the hemotology/oncology team
routinely every 6 months for this.
Past Medical History:
HTN, CAD, s/p MI [**5-/2156**], lymphoma since [**2145**]-testicular mass
orchiectomy (Malignant lymphoma, predominantly large cell type
of
B-cell lineage)Blepharitis,inguinal hernia
repair,Hyperlipidemia,
STEMI LAD drug eluting stent,leukocytosis (leukocyte counts
between 11.3-18.5) kappa restricted B-cell
lymphoproliferative disorder
.
# Dyslipidemia - the patient refuses lipid-lowering therapy.
# Hypertension
# Emphysema (per CT on [**4-19**])
# ?Interstitial lung disease (per CT on [**4-19**])
# CLL/SLL
# s/p orchiectomy of L testes with atypical cellular infiltrate
initially though large B cell lymphoma but may have been
[**Doctor Last Name 6261**] transformation
# Blepharitis
# Status post inguinal hernia repair
Social History:
Lives with wife of 57 years - wife very involved. Has dedicated
daughter involved with her fathers care. [**Name2 (NI) **] currently
works full time as engineer. [**Name (NI) **] (wife)[**Telephone/Fax (1) 16950**]. Daughter
[**Name (NI) 16951**] cell [**Telephone/Fax (1) 16952**]. He drinks [**2-18**] alcoholic beverages [**3-22**]
nights per week.
Family History:
The patient's mother died at age 45 from malignant melanoma.
His father died at age 89 with a history of Parkinson disease.
He has no siblings. His maternal uncle died of possible lung
cancer, history unclear. There is no family history of premature
coronary artery disease or sudden death.
Physical Exam:
PHYSICAL EXAM:
GEN: NAD, Pleasant, Incision Right Forhead C/D/I
NECK: No LAD, Without neck stiffness
CV:RRR, No M/R/G
PULM: Rhonchi, Rales left lower lobe, No wheezes
ABD: Soft, Non Tender, Non Distended, +Bowel Sounds
SKIN: No bruising, jaundice. Some irritation
EXT:Multiple soft tissue swelling (present since childhood)
right upper extremity,
NEURO: AOx3, Normal sensation to light touch in the upper and
lower extremity, 5/5 strength deltoids, biceps, interosseous,
illiopsoas, quadriceps. Reflexes 2+ biceps, paltellar. Down
going toes.
Cerebellar: Normal tandem gait, Rapid Alt Movements, Heel to
shin
Cranial Nerves:
I: Not tested
II: Visual acuity diminished on right- able to make out two
fingers within one foot in front of face and able to see
movements. Left eye with 20/30 vision based on eye chart. PERRL
3 to 2 mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: EOMI Bilaterally
V, VII: Facial strength/sensation intact and symmetric.
VIII: Hearing intact.
IX, X: Palate Elevation symmetric
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Pertinent Results:
Labs on Admission:
[**2157-12-4**] 12:45PM BLOOD WBC-13.4* RBC-4.73 Hgb-15.4 Hct-41.4
MCV-88 MCH-32.7* MCHC-37.3* RDW-14.7 Plt Ct-272
[**2157-12-4**] 12:45PM BLOOD Neuts-61.0 Lymphs-32.9 Monos-4.4 Eos-0.8
Baso-0.8
[**2157-12-4**] 12:45PM BLOOD PT-13.1 PTT-21.0* INR(PT)-1.1
[**2157-12-4**] 12:45PM BLOOD Glucose-105 UreaN-15 Creat-0.8 Na-135
K-4.4 Cl-101 HCO3-25 AnGap-13
[**2157-12-5**] 03:54AM BLOOD Albumin-3.9 Calcium-8.9 Phos-2.9 Mg-1.8
[**2157-12-5**] 03:54AM BLOOD Phenyto-10.7
.
Labs on Transfer to Heme/onc Service:
[**2157-12-6**] 03:39AM BLOOD WBC-11.2* RBC-4.23* Hgb-13.9* Hct-38.0*
MCV-90 MCH-32.9* MCHC-36.6* RDW-13.6 Plt Ct-263
[**2157-12-6**] 03:39AM BLOOD PT-13.4 PTT-19.5* INR(PT)-1.1
[**2157-12-6**] 03:39AM BLOOD Glucose-140* UreaN-13 Creat-0.8 Na-139
K-4.3 Cl-105 HCO3-26 AnGap-12
[**2157-12-6**] 03:39AM BLOOD Calcium-9.3 Phos-2.5* Mg-1.9
[**2157-12-6**] 03:39AM BLOOD Phenyto-12.5
.
Pertinent Imaging:
MRI Head [**12-4**]: Apprx 6.7cmX6.8cm right frontal lobe mass, with
surrounding mass effect. Approximatley 8mm of leftward
subfalcine herniation.
.
Post-Biopsy CT of Head [**12-5**]: Expected postsurgical changes s/p
stereotactic biopsy
.
Bone marrow cytogenetics: report pending
.
Bone marrow biopsy:
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
MILDLY HYPERCELLULAR MARROW WITH MATURING TRILINEAGE
HEMATOPOIESIS AND PERSISTENT INVOLVEMENT BY CHRONIC LYMPHOCYTIC
LEUKEMIA/SMALL LYMPHOCYTIC LYMPHOMA.
Note: The extent of infiltration by chronic lymphocytic leukemia
appears decreased in comparison with the most recent biopsy.
Concurrent flow cytometry demonstrates a population of
lymphocytes with an immunophenotype consistent with chronic
lymphocytic leukemia.
.
Labs on discharge:
[**2157-12-14**] WBC-12.1* RBC-4.11* Hgb-13.3* Hct-36.5* MCV-89
MCH-32.3* MCHC-36.5* RDW-12.8 Plt Ct-230
[**2157-12-14**] Glucose-129* UreaN-19 Creat-1.0 Na-140 K-3.8 Cl-103
HCO3-27 AnGap-14
[**2157-12-14**] ALT-68* AST-37 LD(LDH)-199 AlkPhos-92 TotBili-0.6
[**2157-12-14**] Calcium-8.7 Phos-3.4 Mg-2.1
[**2157-12-14**] mthotrx-0.03
Brief Hospital Course:
Neurosurgery:
The patient was admitted to the ICU for Q1 hour neuro checks on
[**2157-12-4**]. He was found to have a very large right frontal mass
and due to his history of lymphoma he was not placed on
steroids. This was to ensure that we would have an accurate
biopsy. The patient was taken off his aspirin and plavix in
anticipation of surgery and was given a 6-pack of platelets
prior to going to the OR.
He had a right steriotactic brain biopsy on [**2157-12-5**]. The
preliminary pathology was consistent with lymphoma and he was
started on dexamethasone intra-operatively. The procedure went
well with no complications. The post-op head CT showed no
hemorrhage. The patient was kept in the ICU overnight for Q 1
hour neuro checks. His exam remained unchanged. He continued to
have very poor vision in the right eye but otherwise he was
neurologically intact. The patient was changed to Q4 hour neuro
checks on [**2157-12-6**]. Since the patient was neurologically stable
and there was no further neurosurgery that could be offered the
patient was transferred to the [**Hospital Ward Name 516**] on the oncology
service for urgent treatment for brain lymphoma.
Transfer - Medicine [**2157-12-6**]:
Pt is a 61 yo male with hx of large B cell lymphoma of the
testis and CLL/SLL by BM biopsy who presents with decreased
visual acuity and difficulty with balance since [**Month (only) 205**] of this
year. MRI with 7x7cm mass in right frontal lobe s/p stereotatic
brain biopsy. Preliminary pathology -lymphoma.
.
#Right Frontal Lobe Brain Mass/Lymphoma: On transfer to medicine
patient was continued on Dexamethasone 4mg Q6hrs, Dilantin 100mg
TID, and Q4hour neurologic exams. On transfer the patient's only
neurologic deficit was decreased visual acuity in the right eye.
Patient underwent BM biopsy and CT Torso to stage disease. Pt
then started on IV HD Methotrexate. Patient tolerated the
methotrexate well. During this time the patient's ASA/Plavix was
held. Patient's neurologic exam throughout hospitalization
remained unchanged - with the only deficit being decreased
visual acuity in the right eye. The patient was re-started on
ASA (but at lower dose of 81mg daily instead of 325mg daily) but
the plavix continued to be held (given concern for decreasing
platelets in the setting of MTX therapy), as per the
neurosurgical note and email discussion with the patient's
primary cardiologist at [**Hospital1 18**]. Once the MTX level had decreased
substantially in the patient, he was discharged, with close
oncologic follow-up. Patient was switched from dilantin to
keppra (keppra to be titrated up over 2 week intervals) d/t
dilantin's interaction with MTX. Patient tolerated keppra well.
Patient had hiccups, treated with thorazine. Due to concern with
patient's balance, PT walked patient and felt that he could be
discharged home safely without rehab. Pt with Neurosurgery
appointment as outpatient for suture removal.
.
#CAD: Initially ASA/Plavix held. Patient continued on Lisinopril
& Metoprolol. Patient had no chest pain while hospitalized. ASA
restarted, plavix continued to be held, as per above.
.
#HTN: Patient continued on Lisinopril 20 mg Daily. Hydralazine
was provided to maintain SBP<150 post operatively. Hydralazine
was stopped on post operative day 3. Blood pressure was well
controlled during hospitalization with metoprolol and
lisinopril.
.
#Hyperlipidemia: Patient continued on Atorvastatin.
Medications on Admission:
Atorvastatin [Lipitor] 80 mg Tablet 1 Tablet(s) by mouth once a
day
Clopidogrel [Plavix] 75 mg Tablet 1 Tablet(s) by mouth once a
day
Lisinopril 20 mg Tablet 1 Tablet(s) by mouth once a day
Metoprolol Succinate [Toprol XL]
Nitroglycerin [NitroQuick] 0.3 mg Tablet, Sublingual 1 Tablet(s)
sublingual every 5 minutes as needed for chest pain
Aspirin 325 mg Tablet 1 Tablet(s) by mouth once a day
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
4. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*14 Tablet(s)* Refills:*1*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*20 Capsule(s)* Refills:*1*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*20 Tablet(s)* Refills:*1*
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*28 Tablet(s)* Refills:*1*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*1*
9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
10. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days: After completing the 10 days of the 500mg twice
a day dose of this medication, start with this prescription for
1000mg twice a day dose.
Disp:*28 Tablet(s)* Refills:*0*
11. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO twice a
day: After 500mg twice a day for 10 days, and then 1000mg twice
a day for 14 days, then start this dose of 1500mg twice a day
and continue to take this.
Disp:*84 Tablet(s)* Refills:*1*
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily) as
needed for htn.
13. Leucovorin Calcium 5 mg Tablet Sig: Eight (8) Tablet PO
every six (6) hours for 3 days: Please discuss with Dr. [**Last Name (STitle) 410**]
on Friday ([**12-16**]) at your appointment with him, whether to
continue this medication, based upon your Methotrexate level at
that appointment.
Disp:*96 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right Frontal Lobe Brain Mass
B-cell lymphoma
CLL
Hypertension
Coronary artery disease
Discharge Condition:
Neurologically stable. Afebrile. Ambulating.
Discharge Instructions:
Changes to your medications include:
-Keppra (LeVETiracetam) (to prevent seizures); dose to be
increased as follows: 500mg twice a day for 10 days, then 1000mg
twice a day for the following 14 days, then 1500mg twice a day
after that.
-Leucovorin (to prevent toxicity from the chemotherapy); to take
at least until you see Dr. [**Last Name (STitle) 410**] on Friday [**12-16**], and then
based upon your Methotrexate level you should discuss with him
whether to continue this medication.
-Do NOT take your plavix for now (the chemotherapy can affect
your platelet number and so taking plavix could put you at an
increased risk of bleeding); after the chemotherapy,
consideration could be given to restarting plavix - that should
be discussed with your oncologist and your cardiologist
-Dexamethasone (steroid) (to be discussed with Dr. [**Last Name (STitle) 410**] how to
taper this dose down, do not stop it suddenly without a taper as
instructed by Dr. [**Last Name (STitle) 410**]
-Famotidine (to protect your stomach while taking the steroid)
-Colace, Senna (to prevent constipation, take them if needed)
-Aspirin dose decreased from 325mg daily to 81mg daily
.
You have sutures in your scalp from a biopsy done by
neurosurgery. You have an appointment tomorrow to have the
sutures removed. Until then, please keep your incision clean and
dry.Do NOT apply any lotions, ointments, shampoo or other
products to your incision. DO NOT DRIVE until after you have
been seen at the appointment. Do not lift objects over 10 pounds
until approved by your physician. [**Name10 (NameIs) 16953**] directed by your
doctor, do not take any anti-inflammatory medicines such as
Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase
your chances of bleeding.
.
After the biopsy:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel lightheaded or fatigued after increasing activity,
rest, decrease the amount of activity that you do, and begin
building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
.
Please avoid vitamin C (ascorbic acid) in your diet, as this
interacts with the chemotherapy you took.
.
If you developed fever, chills, chest pain, difficulty
breathing, abdominal pain, change in vision, change in balance,
confusion, or other symptoms that concern you, please call your
doctor or return to the hospital.
.
Your oncologist is Dr. [**Last Name (STitle) 410**] and his clinic's phone # is
[**Telephone/Fax (1) **] or [**Telephone/Fax (1) 3241**].
Followup Instructions:
??????You have an appointment for suture removal TOMORROW on [**2157-12-15**] in Dr.[**Name (NI) 9034**] office which is located in the [**Hospital Unit Name 3269**], [**Hospital Unit Name 12193**]. Please call [**Telephone/Fax (1) 2731**] if you need to
change this appointment.
.
You have an appointment with your oncologist, Dr. [**Last Name (STitle) 410**], MD:
FRIDAY [**12-16**] at 9AM. [**Telephone/Fax (1) **] or [**Telephone/Fax (1) 3241**]. He
will check your methotrexate level, your blood counts, your
platelets (especially given that you are taking aspirin), and
your liver function tests during this appointment. He should
also consider how to taper down the steroids that you are on.
.
The Radiation Oncologists (Dr. [**Last Name (STitle) 776**] and her team) will call
you to set-up an appointment for FRIDAY, [**12-16**]. Their
contact info is: [**Telephone/Fax (1) 9710**].
.
You are scheduled to come into the hospital on Friday [**12-23**], to [**Hospital Ward Name 1950**] Building, [**Location (un) 436**], for another round of
Methotrexate chemotherapy treatment, with Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD.
[**Telephone/Fax (1) 1844**].
.
You have a Brain [**Hospital 341**] Clinic follow-up appointment with Dr.
[**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2158-1-2**] 9:30 am.
This is on [**Hospital Ward Name 23**] 8 on the [**Hospital Ward Name 516**].
Completed by:[**2157-12-17**]
|
[
"348.4",
"401.9",
"515",
"412",
"492.8",
"272.4",
"204.10",
"202.80",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.31",
"99.25",
"01.13"
] |
icd9pcs
|
[
[
[]
]
] |
11661, 11719
|
5815, 9245
|
368, 462
|
11850, 11897
|
3733, 3738
|
16995, 18527
|
2250, 2543
|
9689, 11638
|
11740, 11829
|
9271, 9666
|
11921, 14673
|
2573, 3167
|
14700, 16972
|
277, 330
|
5458, 5792
|
490, 1110
|
3183, 3714
|
3752, 5439
|
1132, 1861
|
1877, 2233
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
690
| 133,648
|
5776
|
Discharge summary
|
report
|
Admission Date: [**2188-8-16**] Discharge Date: [**2188-9-4**]
Date of Birth: [**2109-9-24**] Sex: M
Service: SURGERY
Allergies:
Morphine / Codeine / Chocolate Flavor
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Fever, hypotension
Major Surgical or Invasive Procedure:
1. Debridement of the left foot
2. Hemodialysis
3. Central venous catheter
History of Present Illness:
This is a 78 yo M with a past medical history significant for
ESRD, DM2, PVD, CAD s/p CABG who presents to the ED after having
fevers to 105, 1 episode of nonbloody/nonbilious emesis, and
tachycardia upon arriving to HD today but was able to complete
dialysis for a total of -3.8L. He was given a dose of vanco
there. When EMS arrived, he was found also to be hypotensive to
the 70's, but he was still mentating clearly.
.
In the ED, he was volume resuscitated with 3+L, had a right
subclavian CVL placed, and after blood cx were drawn, received
doses of levo/flagyl. A UA was sent which was unremarkable. A
CXR was unremarkable for infiltrate, except for known left sided
pleural effusion, which, if anything, looked improved, and some
right sided basal atelectasis. Because he did not really respond
to IVF resuscitation, he was started on levophed. Labs were
notable for for a lactate of 1.9, a VBG of 7.43/50/59 and a
leukocytosis to 17,000 with a left shift. After going for
abdominal CT, he will be sent to the [**Hospital Unit Name 153**] for further management
of sepsis.
.
On arrival to the [**Hospital Unit Name 153**], the patient admitted that he has been
feeling unwell for the past several weeks. He describes having
vague abdominal discomfort as if "he was going to come down with
something" but it never blossoms into anything. He notes that he
has become more constipated in the last 2-3 weeks and his stool
has become darker. He has also had a productive cough on a daily
basis bringing up grey/yellow/white sputum. He denies fevers,
nausea/vomiting until today. He denies sore throat, headache,
ear pain, or dysuria. He also denies sick contacts or recent
travel. He has a new ulcer on his right foot, and is s/p left
3rd toe amputation secondary to gangrene but was just at the
podiatric surgeon the day pta and had both areas debrided. He
has not noted any change in the area of his AVF.
Past Medical History:
ESRD
Type 2 diabetes mellitus ('[**76**])
PVD, s/p R [**Doctor Last Name **]-dp BPG
Neuropathy
HTN
Hypercholesterolemia
Chronic anemia
Hiatal hernia
CAD, s/p CABG lima-lad, SVG RCA, OM [**3-27**]
Lower back pain s/p surgery for ?disk herniation
[**2-3**]- admission for herpes encephalitis and zoster
s/p AV graft thrombectomy [**6-2**]
recent L 3rd toe amputation [**7-3**]
Social History:
The patient lives at [**Location 38**] Manor. His wife is his
primary caregiver and HCP. [**Name (NI) **] is an ex-smoker (approx 40yrs),
quit 22 years ago. Used to drink socially, no longer drinks.
Family History:
The patient's mother died of MI at 89, father had DM, ?heart dz
died at 79, paternal GM had DM. He reports other family members
with heart disease.
Physical Exam:
Vitals: T 100.1 P 92 BP 133/69 R 17 Sat 100% NC 3L
General: pale 78 yo M, appears fatigued, but NAD
HEENT: AT/NC, EOMI, PERRL (reduced visual acuity in right eye),
anicteric sclerae. MM dry, OP clear. Fair dentition.
neck: No cervical, supraclavicular LAD. supple. JVP at 7cm
Chest: RRR harsh III/VI SEM heard best at the LUSB radiating to
the neck as well as across the precordium. No rubs.
Lungs: Decrease BS at the left base, minimal dry rales at the
right base. Otherwise, no rhonchi/wheezes.
Abd: soft, NT/ND +BS, no HSM
Ext: feet are wrapped in dressings s/p debridement yesterday,
legs are warm until distal leg/proximal ankle, then slightly
cooler. Venous stasis changes present to mid-calf. trace to 1+
radial pulses.
Neuro: A&Ox3. Reduced visual acuity in R eye. Reduced sensation
to LT at ankles. CN III-XII in tact.
Skin: Warm, no jaundice, no unusual lesions or rashes.
Access: RSC, slightly tender to palpation.
Pertinent Results:
Admission labs:
[**2188-8-16**] 12:33PM WBC-17.3*# RBC-4.56* HGB-14.9 HCT-45.4
MCV-100* MCH-32.7* MCHC-32.8 RDW-16.2*
[**2188-8-16**] 12:33PM NEUTS-84* BANDS-0 LYMPHS-10* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2188-8-16**] 12:33PM GLUCOSE-128* UREA N-17 CREAT-2.6*# SODIUM-137
POTASSIUM-4.9 CHLORIDE-91* TOTAL CO2-34* ANION GAP-17
[**2188-8-16**] 12:33PM CALCIUM-9.7 PHOSPHATE-2.9# MAGNESIUM-2.1
[**2188-8-16**] 03:10PM ALT(SGPT)-9 AST(SGOT)-17 CK(CPK)-20* ALK
PHOS-79 TOT BILI-0.4
[**2188-8-16**] 03:10PM LIPASE-55
[**2188-8-16**] 03:10PM PT-13.3* PTT-32.6 INR(PT)-1.2*
[**2188-8-16**] 12:48PM LACTATE-1.9
[**2188-8-16**] 03:10PM CK-MB-2 cTropnT-0.30*
.
Imaging:
CT ABDOMEN W/CONTRAST [**2188-8-16**] 3:31 PM
1. Small simple (by Hounsfield units) left pleural effusion with
enhancing pleural rim is suggestive of empyema. Would suggest
diagnostic thoracentesis for evaluation. Adjacent area of
consolidation is most reflective of atelectasis, however there
is not vivid enhancement, so early underlying pneumonia cannot
be completely excluded.
2. Cholelithiasis with a slightly distended gallbladder lumen
measuring up to 4 cm. No inflammatory changes to suggest acute
cholecystitis. Please correlate with clinical exam. If
indicated, further evaluation with HIDA scan recommended.
3. Hypoattenuating splenic lesion, too small to definitively
characterize but likely benign.
4. Extensive atherosclerotic disease.
5. Diverticulosis without evidence of acute diverticulitis.
.
CHEST (PORTABLE AP) [**2188-8-16**] 12:39 PM
Cardiac silhouette, mediastinal and hilar contours are
unchanged. The patient is status post CABG. Interval placement
of a right-sided subclavian approach central venous line with
its tip projecting at the mid SVC. Linear opacity in the right
lung base likely represent disc-like atelectasis. Mild interval
improvement in the left pleural effusion. No pneumothorax.
.
ECG Study Date of [**2188-8-16**] 12:26:36 PM
Sinus tachycardia. Left axis deviation with left anterior
fascicular block. Poor R wave progression - probably old
anteroseptal
myocardial infarction. Compared to tracing of [**2188-7-18**] there is
no significant diagnostic change.
.
ECHO Study Date of [**2188-8-18**]
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is low
normal (LVEF 50-55%). There is no ventricular septal defect. The
right ventricular cavity is mildly dilated. Right ventricular
systolic function is borderline normal. The aortic root is
mildly dilated at the sinus level. The aortic arch is mildly
dilated. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. No masses or vegetations are
seen on the aortic valve. There is mild aortic valve stenosis
(area 1.2-1.9cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. Mild to moderate ([**1-29**]+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2188-2-22**], mild AS is now detected and the
severity of mitral and tricuspid regurgitation has slightly
increased. If clinically indicated a TEE may better excluded a
small valvular vegetation.
.
FOOT AP,LAT & OBL BILAT PORT [**2188-8-18**] 9:01 PM PRELIM
1. Focal area of lucency along the lateral aspect of the fifth
proximal phalanx of the left foot, new compared with _____
previous study. In the correct clinical context, the possibility
of osteomyelitis must be considered.
2. Post-operative changes status post amputation of the left
third digit.
3. Chronic post-operative changes of the right foot.
4. Neuropathic changes of the feet bilaterally.
Brief Hospital Course:
A/P: 78 yo M with ESRD, DM2, CAD admittied from HD with fevers,
leukocytosis, and hypotension
1. Septic Shock, resolved: With fevers, leukocytosis,
hypotension and tachycardia and and the most likely source of
infection being possible introduction of bacteria by recent
debridement of foot ulcers and surgical site (pt has h/o MRSA
and enterococcus from wound) v. parapneumonic effusion/empyema
on CT, the patient had met criteria for septic. Peak lactate
was 1.9, now 0.6. He was given total of 4L NS (3.8 taken off at
HD) and required Levophed only overnight from day of admission.
He now is maintaining SBPs in 120s. Blood cxs from [**8-16**] grew
coag + Staph sensitive to Vanc. Pt is on vanc per HD protocol,
day 4. Podiatry evaluated the patient, took wound cultures of
his feet bilaterally. X-rays of bilateral feet were taken;
prelimin read suggests possible osteomyelitis along the lateral
aspect of the fifth proximal phalanx of the left foot. Podiatry
(attending Dr. [**Last Name (STitle) **] is following. Pt also had a
thoracentesis that removed 60 cc of serosanguinous fluid. This
has been a chronic effusion, seen on prior CXRs for months.
Pleural fluid analysis reveals exudative process with
predominance of lymphs. This is currently not thought to be the
source of infection given chronicity and initial fluid analysis.
Abdominal CT revealed no source of infection. He was
subsequently transferred to the floor without further incidents.
2. MRSA bacteremia. An extensive evaluation by Infectious
Diseases concluded that the most likely source of MRSA
bacteremia was from the foot. It was recommended to continue the
patient on vancomycin for a total of 6 weeks.
3. Osteomyelitis. Inconclusive evidence on plain film, and
unable to obtain a MRI given dialysis. Supportive test of ESR of
121 consistent with osteomyelitis. As in #2, ID recommended 6
weeks of antibiotic therapy.
4. Complex pleural effusion. Pulmonary was consulted and this
was thought to be from septic embolus. A CT scan was recommended
in 3 months time to assess for resolution.
5. ESRD: Patient is being followed by renal and his usual
dialysis days are Tues, Thurs, Sat. His medications were dosed
for his level of kidney function and he was maintained on
vancomycin regimen with dialysis.
6. Cardiac: The patient has a history of 3VD CAD s/p CABG. He
was maintained on his aspirin, metoprolol, and statin therapy.
7. Type 2 diabetes mellitus. The patient was maintained on
sliding scale insulin during hospitalization. On discharge, his
glipizide was resumed.
8. Hypercholesterolemia. Due to the risks of combination therapy
for dialysis patients, his gemfibrozil and niacin were held. He
was maintained on his simvastatin and ezetimibe. A follow up
fasting lipid panel is recommended in [**7-4**] weeks.
9. Peripheral artery disease / diabetic foot ulcer. Podiatry and
Vascular Surgery consults monitored the foot wounds and
recommended close outpatient follow up on discharge. Deep tissue
cultures demonstrated Pseudomonas and Staph colonization vs.
osteomyelitis.Patient transfered to Dr.[**Name (NI) 1392**] service for
Left TMA done on [**2188-9-1**].
[**2188-9-2**] POD#1 no overnight events. continued on Vancomycin but
cipro and flagyl discontinued. deit advanced. Physical thearphy
consulted for nonweight bearing left foot for toatal of four
weeks.Vanco will be continued for a total of 6 weeks which will
becompleted on [**9-28**]. CBC,elec and renal function should be
monitered while recieving antibitocs. He will followup with Dr.
[**First Name (STitle) 1075**] in [**Hospital **] clinic@ that time. (see appointments).
[**Date range (1) 19036**]/07 POD# [**3-1**] continued to progress. d/c to home with
services.
Medications on Admission:
1.Ezetimibe 10 mg qd,
2.glipiZIDE 1.25 mg [**Hospital1 **]
3.Gemfibrozil 600 mg [**Hospital1 **]
4.Pantoprazole 40 mg qd,
5.Simvastatin 40 mg qd
6.Hep SC 5000mg [**Hospital1 **]
7.Renagel 1600mg tid prior to meals,
8.colace 100mg qd,
9.flonase 0.05 each nose qd
10. niacin 500mg qd
Discharge Medications:
1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol).
Disp:*qs * Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 Tube* Refills:*2*
9. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Sorbitol 70 % Solution Sig: 30-150 MLs Miscellaneous [**Hospital1 **] (2
times a day) as needed for constipation.
12. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
14. Vancomycin 1000 mg IV DURING DIALYSIS ON [**9-4**]
To be dosed during Dialysis on [**2188-9-4**]
15. Outpatient Lab Work
cbc, bun/cr, electrolytes,weekly @ HD
16. Outpatient Lab Work
random vanco level 2x/week
17. Insulin Glargine 100 unit/mL Solution Sig: Seven (7) units
Subcutaneous at bedtime.
18. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
three times a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
1. Septic shock, resolved
2. MRSA bacteremia
3. Osteomyelitis of the foot
4. ESRD on hemodialysis
5. Type 2 diabetes mellitus with complications
6. Peripheral arterial disease history of right bypass
7. Coronary artery disease history of CABG
8. Hiatal hernia
9. Hyperlipidemia
Discharge Condition:
Improving, without fever or hypotension
Discharge Instructions:
1. Continue with hemodialysis as scheduled. You will receive a
total of 6 weeks of vancomycin given during hemodialysis.
2. Continue with wound care of your feet through home nursing
visits.
have cbc w diff and electrolytes and bun creatinine weekly while
on antibiotics call resultts to [**Hospital **] clinic Att:Dr.[**First Name (STitle) 1075**]
[**Telephone/Fax (1) 457**]
Followup Instructions:
1. Make an appointment with Podiatry within 1 week
2. Make an appointment with Vascular Surgery within 1 week
3. You have an appointment scheduled with Infectious Diseases,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**], [**Telephone/Fax (1) 457**] on [**2188-9-26**] 9:00a.
Completed by:[**2188-9-4**]
|
[
"511.9",
"403.91",
"272.0",
"250.80",
"276.51",
"731.8",
"276.3",
"707.07",
"285.21",
"V45.81",
"998.32",
"038.9",
"707.15",
"730.07",
"785.52",
"995.92",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"39.95",
"84.12",
"86.22",
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14111, 14162
|
8324, 12065
|
315, 392
|
14484, 14526
|
4079, 4079
|
14951, 15283
|
2962, 3113
|
12397, 14088
|
14183, 14463
|
12091, 12374
|
14550, 14928
|
3128, 4060
|
257, 277
|
420, 2330
|
4095, 8301
|
2352, 2728
|
2744, 2946
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,501
| 146,105
|
37177
|
Discharge summary
|
report
|
Admission Date: [**2183-11-20**] Discharge Date: [**2183-11-21**]
Date of Birth: [**2120-10-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
S/p PEA arrest
Major Surgical or Invasive Procedure:
L femoral A line placement
History of Present Illness:
63 yo M with h/o of multiple MVAs over the past 1 year and
subsequently residing in a nursing home found unresponsive in
vomitus and asystolic this morning. He was apenic and cyanotic,
and he had made some gasping efforts. He was seen 10 minutes
earlier and in no distress and at baseline. Apparently nursing
staff noted him to be apenic and placed an AED which advised "no
shock" and called EMS. By EMS he was noted to be in a PEA
arrest with a narroc complex tachycardia at a rate of around
100. He was given epi and atropine x 2 doses each. He never
regained a pulse during his transport. By the time he arrived
at [**Hospital3 **] he was again noted to be in PEA arrest with a
rate of 170-180 with occasional triplets of PVCs. He was given
1mg of epi, 1 amp of bicarb and 1g of magnesium (for the ectopy)
and he regained a pulse with a SBP of 100 at 9:08 am. His
perfusing rhythm was atrial fibrillation with a rate of 120 with
reportedly no ischemic changes on his EKG.
The patient had been intubated in the field and in the ER there
had been vomitus in the ET tube. The patient was initially
vented at AC 500 x 14 with a PEEP of 5 and FiO2 of 100%. His
ABG on this was 7.1 / 52 / 510. At this point his FiO2 was
decreased to 40%, a CXR revealed some scarring at the R base of
the patient's lung, also the ET tube was at the carina and was
pulled back 2 cm.
The patient was noted to have fixed pupils 4mm bilaterally and
was ordered for a CT scan of his chest and head but on the way
to the CT scan he was noted to be too unstable with a SBP
dropping to 70. A R femoral line was placed and levophed was
initiated, his SBP improved to 100 but given his instability the
imaging was not obtained.
Subsequently the patient's O2 sat was noted to be dropping in
the 80s, a repeat CXR was performed that was read was mild
bibasilar infiltrates vs. atelectasis. FiO2 was increased to
100% and O2 sat also improved to 100%. His repeat ABG was 7.22
/ 16 / 45 just prior to transport, given his good O2 sat this
was thought to be a VBG. Lactate was not sent given that this
is a sendout test at [**Hospital3 **]. He was transferred on
levophed.
Enroute from [**Hospital1 46**] the patient went back into PEA arrest at
12:08 pm. He received 2 additional rounds of epi was given CPR
and regained a pulse at 12:40 pm in Afib after the ambulance had
been deverted to [**Hospital3 **] medical center. At [**Hospital3 **] he
received fluids, solumedrol, [**Last Name (LF) **], [**First Name3 (LF) **] amp of bicarobante
and started on dopamine in addition to levophed. ABG on transfer
was 7.29/40/230/19.5.
The patient is intubated and unresponsive so history could not
be obtained from the patient.
According to the Lifecare nursing facility in [**Location (un) 3320**], MA the
patient is at baseline is usually slow to respond, oriented x 3,
has diffuse muscular atrophy and has difficulty holding his head
up and difficulty getting out of bed and is able to eat and hold
a conversation. He is wheelchair bound reportedly due to
orthopedic injuries but per nursing facility no spinal cord
injury.
Past Medical History:
Depression
?PVD
s/p 2 MVAs in past 1 year resulting in significant orthopedic
injuries and nursing home placement'
Neurodegenerative disease (unclear etiology)
Social History:
Lives at [**Location **] nursing facility in [**Location (un) 3320**] MA.
Family History:
not obtained
Physical Exam:
Vitals - T: 90.7 BP: 116/83 HR: 109 RR: 24 02 sat: 91% FiO2 100%
GENERAL: Intubated, sedated
HEENT: Pupils fixed and dilated, Sclerae anicteric
CARDIAC: RRR, no m/r/g
LUNG: CTA bilaterally
ABDOMEN: -Bs, soft, nt, nd
EXT: Cool, femoral pulses appreciated
NEURO: Does not withdrawl to painful stimuli
Pertinent Results:
(from [**Hospital3 3583**] [**2183-11-20**])
ABG 1 post intubation 7.1 / 52 / 500 on AC 14 x 500, FiO2 100%,
PEEP 5
ABG 2 prior to transport to [**Hospital1 18**] 7.22 / 16 / 45 (?VBG) on same
settings
CBC: WBC 5.8, Hct 48.1, Plt 198
Chem 7: Na 142, K 4.0, Cl 100, Bicarb 29, BUN 12, Cr 0.82,
Glucose 189, Ca 9.1
INR 1.1
LFTs reportedly unremarkable
Tn 0.06
MICROBIOLOGY: None
STUDIES:
EKG: Afib at rate 130 bpm, lateral STDs v4-6, no st elevations
CXR:
CXR 1 on [**2183-11-20**]: ([**Hospital 46**] hosp radiologist read) Scarring at R
base, ET tube at carina.
CXR 2 on [**2183-11-20**]: ([**Hospital 46**] hosp radiologist read) Bibasilar
infiltrates vs. atelectasis, ET tube in good position.
CXR ([**Hospital1 18**]) - per my read, Right effusion (new)
Bedside TTE - Focused study. The left ventricular cavity is
small. Regional left ventricular wall motion appears normal.
Overall left ventricular systolic function appears low normal
(LVEF 50-55%). Right ventricular chamber size is normal with
borderline normal free wall function (no evidence for RV strain
or pulmonary embolism). The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. There is an
anterior space which most likely represents a fat pad. No
pericardial effusion.
IMPRESSION: Preserved biventricular systolic function. No echo
evidence of pulmonary embolism
[**2183-11-21**] 04:37AM BLOOD WBC-8.0 RBC-5.10 Hgb-14.6 Hct-46.4 MCV-91
MCH-28.6 MCHC-31.5 RDW-14.0 Plt Ct-187
[**2183-11-20**] 02:12PM BLOOD WBC-11.2* RBC-5.89 Hgb-17.3 Hct-56.2*
MCV-96 MCH-29.3 MCHC-30.7* RDW-13.7 Plt Ct-280
[**2183-11-21**] 04:37AM BLOOD Neuts-81.5* Lymphs-8.9* Monos-8.5 Eos-0.8
Baso-0.2
[**2183-11-20**] 02:12PM BLOOD Neuts-77.9* Lymphs-15.4* Monos-5.1
Eos-1.2 Baso-0.4
[**2183-11-21**] 04:37AM BLOOD PT-14.9* PTT-35.3* INR(PT)-1.3*
[**2183-11-20**] 02:12PM BLOOD PT-15.2* PTT-31.6 INR(PT)-1.3*
[**2183-11-21**] 09:11AM BLOOD Glucose-138* UreaN-17 Creat-0.6 Na-140
K-3.6 Cl-115* HCO3-14* AnGap-15
[**2183-11-21**] 12:21AM BLOOD Glucose-147* UreaN-14 Creat-0.7 Na-141
K-4.1 Cl-116* HCO3-19* AnGap-10
[**2183-11-20**] 02:12PM BLOOD Glucose-335* UreaN-17 Creat-0.7 Na-143
K-3.6 Cl-109* HCO3-19* AnGap-19
[**2183-11-21**] 04:37AM BLOOD ALT-60* AST-81* LD(LDH)-391*
CK(CPK)-1053* AlkPhos-98 TotBili-0.5
[**2183-11-20**] 02:12PM BLOOD ALT-83* AST-109* CK(CPK)-270*
AlkPhos-183* Amylase-297* TotBili-0.8
[**2183-11-21**] 04:37AM BLOOD CK-MB-35* MB Indx-3.3 cTropnT-0.14*
[**2183-11-20**] 02:12PM BLOOD CK-MB-12* MB Indx-4.4 cTropnT-0.22*
[**2183-11-21**] 09:11AM BLOOD Calcium-7.8* Phos-1.7* Mg-2.0
[**2183-11-21**] 12:21AM BLOOD TSH-1.6
[**2183-11-21**] 12:21AM BLOOD Free T4-1.2
[**2183-11-21**] 10:15AM BLOOD Type-ART Rates-26/0 Tidal V-500 PEEP-10
FiO2-60 pO2-67* pCO2-24* pH-7.41 calTCO2-16* Base XS--6
Intubat-INTUBATED Vent-CONTROLLED
[**2183-11-20**] 02:25PM BLOOD Type-ART pO2-62* pCO2-51* pH-7.21*
calTCO2-21 Base XS--7
[**2183-11-21**] 10:15AM BLOOD Lactate-1.9
[**2183-11-20**] 02:25PM BLOOD Glucose-338* Lactate-3.6* Na-142 K-3.2*
Cl-107
[**2183-11-20**] 02:25PM BLOOD freeCa-1.02*
Brief Hospital Course:
63 yo M with pmhx mva x2, pvd, depression presents s/p pea
arrest.
PEA Arrest/Shock: unclear etiology. Possibly related to
aspiration as was very acute, patient found cyanotic after
breakfast. No significant cardiac ischemia, no PE, no
significant electrolyte abnormalities that could explain arrest.
Supported hemodynamically. He had at least 1 hour of CPR while
pulseless and unknown downtime. Prognosis was poor given fixed
and dilated pupils, comatose off sedation and prolonged
downtime. His family had decided to make the patient comfort
measures in compliance with his previous wishes. He was
pronounced dead at 4:20 p.m. on [**2183-11-21**]. Medical examiner
accepted the case, also the family requested an autopsy.
Medications on Admission:
Celexa 10mg daily
Colace
ASA 81mg daily
zocor 20mg daily
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
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109
| 161,950
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14800
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Discharge summary
|
report
|
Admission Date: [**2141-11-24**] Discharge Date: [**2141-12-1**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Headache, abdominal pain
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
24yo F w/PMHx of ESRD on HD, SLE, malignant HTN presents with
headache and abdominal pain beginning this morning, awakening
her from sleep. Had been previously discharged from [**Hospital1 **]
yesterday after being admitted for hypertension and abdominal
pain. Has had extensive work-up for abdominal pain including
ex-lap on [**2141-10-27**] which was negative. Upon discharge yesterday
she states her abdominal pain had subsided. She had HD
yesterday without complications. She awoke at 6am with a
headache and crampy, stabbing abdominal pain. Took 2mg PO
Dilaudid without relief and came to ED. No nausea/vomiting, no
changes in vision, no fevers, chills, night sweats. No chest
pain, SOB, diarrhea.
In the ED, initial vitals were T98.7, BP260/130, HR70, RR16.
Was initially given 10mg IV Labetalol X 2, 4mg Zofran for
nausea. No improvement in BP and started on Labetolol gtt. Got
1mg IV Dilaudid for pain.
Currently, patient continues to complain of headache and
abdominal pain, both [**7-17**]. No vision changes, chest pain or
shortness of breath. Has been feeling increased anxiety
recently and saw psychiatrist, was put on Celexa.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**] but refused it as of [**2140**], has
survived despite this
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] that resolved
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy: may be etiology of episodes of
worse hypertension given appears quite labile
.
PSHx:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**]
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
T98.2, BP176/135, HR94, RR 22, 100% RA
Gen: well-appearing african-american woman, lying comfortably
HEENT: anicteric, L eye prosthetic non-reactive, R pupil
reactive, MMM, neck supple with submanibular LAD
CV: RRR, II/VI SEM best heard at apex
Pulm: CTA b/l
Abd: hyperactive bowel sounds, midline scar well-healed, soft,
diffusely tender to palpation, +rebound, no guarding. PD
catheter in LLQ without erythema or purulent material draining.
+dullness on percusion with evidence of clinical ascites.
Ext: no edema, no clubbing, 2+ peripheral pulses DP and radial.
R femoral HD [**Last Name (un) **] in place without erythema, purulance
Neuro: A&O X 3, CN intact II-XII, [**5-15**] motor strength in upper
and lower extremities
Pertinent Results:
Admission labs:
CBC:
[**2141-11-26**] 05:21AM BLOOD WBC-3.5* RBC-3.07* Hgb-9.3* Hct-27.5*
MCV-90 MCH-30.1 MCHC-33.6 RDW-17.6* Plt Ct-180
CHEM 10:
[**2141-11-26**] 01:16PM BLOOD Glucose-87 UreaN-17 Creat-4.0* Na-136
K-5.2* Cl-106 HCO3-23 AnGap-12
[**2141-11-26**] 09:20PM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8
COAGS:
[**2141-11-26**] 01:16PM BLOOD PT-23.9* PTT-40.2* INR(PT)-2.3*
STUDIES:
1)Peritoneal fluid ([**11-26**]): negative for malignant cells.
Reactive mesothelial cells, macrophages, eosinophils and
lymphocytes.
2)BILAT UP EXT VEINS US ([**11-26**]): No evidence of deep vein
thrombosis of the right or left upper extremity.
3) MRI/MRA ([**11-30**]): FINDINGS: Examination is somewhat limited by
patient motion. T2/FLAIR sequences are unremarkable with
interval resolve of previously noted posterior abnormalities.
The major vessels appear patent proximally. There are stable
areas of low signal in the left frontal and right
occipetal/temporal lobes.
IMPRESSION:
1. Interval resolution of previously noted posterior white
matter
abnormalities.
2. Stable prior areas of hemorrhage within the left frontal and
right
occipital/temporal regions.
3. Very limited MRA as above.
Brief Hospital Course:
24yo F with SLE, ESRD on HD and malignant hypertension who
presented with abdominal pain and headache and was admitted for
hypertensive urgency.
[**Hospital Unit Name 153**] course:
The patient was admitted for blood pressure management and
evaluation of abd pain. An A-line was placed. EKG showed no
change from prior, and Abd x-ray showed a suggestion of RLL/R
diaphragm haziness. IV labetalol was started, and SBPS dropped
from 200s to 130s-160s. The patient had no symptoms of end-organ
damage. The renal team was consulted, and recommended no change
to home med regimen. The patient was found to be hypocalcemic,
and was started on calcium replacement therapy. When stable,
patient succesfully switched to PO meds and transferred to the
floor.
Upon transfer to the floor, the following was her course:
1. Hypertensive Urgency: Pt had had hemodialysis one day prior
to admission, so unlikely that she was volume overloaded.
Unclear what precipitated this episode of hypertensive urgency,
although suspect secondary to abdominal pain leading to an
anxiety which then precipitates hypertension. She may not have
been taking her medications secondary to pain. Negative serum
tox. On the floor, we continued hemodialysis Tu, Th, Sat. She
was initially continued on PO Labetolol 400mg TID, Hydralazine
100mg PO q8H, Nifedipine 90mg PO qday and clonidine; she
received hydralazine 10mg IV for goal BP < 180/100. Renal team
followed patient during this hospitalization. Per renal team
recs, labetalol was increased to 800mg TID due to poor blood
pressure control. Pt discharged on clonidine 0.3mg patch,
Hydralazine 100mg three times a day, Aliskiren 150mg twice a
day, Nifedipine 90mg daily and lobatalol 800mg TID. This
regimen worked well.
2. Abdominal Pain: Extensive prior workup unrevealing. Pt had
recent CT scan during prior admission which did not show source
of abdominal pain. On admission, LFTs were normal except for
slightly low albumin, lipase was slightly elevated and KUB was
negative for free air or evidence of SBO. Peritoneal fluid was
negative for malignant cells but showed reactive mesothelial
cells, macrophages, eosinophils and lymphocytes. Negative gram
stain or peritoneal fluid cultures, excluding SBP as a cause of
the abdominal pain. PD catheter was not removed. Pt was
continued on PO dilaudid 1-2mg Q6h and pain resolved. She denied
N/V/diarrhea or constipation.
3. ESRD: Pt on hemodialysis, on T/Th/Sat schedule. Renal
following patient closely throughout this hospitalization. Lytes
were checked frequently and kayexalate given prn.
4. Hx of SVC/brachiocephalic DVT: Pt was initially
subtherapeutic on coumadin. Unclear if she had not been taking
Coumadin although patient reported that she has been taking all
home meds. We started heparin gtt to bridge to Coumadin. Once
therapeutic, continued Coumadin 5mg PO qday.
5. Anxiety: Likely contributing to medical problems and could
have very well been the etiology of this admission. Although pt
stated she was taking her current medications, she did report
increased anxiety which can lead to medication non-compliance
and hypertension. Pt recently saw psychiatrist who started her
on Celexa. She was continued on celexa 20mg PO qday, ativan 1mg
PO q8hours PRN and psychiatry was re-consulted. Per psych recs,
started standing clonazepam. Pt refused psych VNA. Outpatient
PCP followup recommended.
6. Headache NOS: Pt complained of R-sided HA for several weeks,
radiating to R jaw where patient had previous tooth extraction.
Right upper extremity ultrasound was negative for DVT. She
did not have any focal neuro findings, no visual deficits. She
was initially treated with tylenol PRN Q6h; pt requested IV
dilaudid for HA, but use of this medication by IV route was
limited by team. It was felt by the pain service that her HA did
not fit migraine, tension type HA or rebound HA. They
recommended increasing dilaudid to 4-6mg Q6h PRN, continuing
tylenol and starting neurontin 300mg Qhs which was slowly
titrated to 300mg [**Hospital1 **] for better control. Per pain recs, a
neurology consult was also obtained during this admission.
MRI/MRA showed interval resolution of previously noted posterior
white matter abnormalities and stable prior areas of hemorrhage
within the left frontal and right occipital/temporal regions,
but very limited MRA as above. Per pain recs, dilaudid was
further increased to 4mg q4h for better control of her HA.
Neurology recommended outpt f/u and Pt scheduled with [**Hospital 878**]
clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**].
7. Anemia: Likely related to ESRD. No evidence of acute
bleeding. Hct remained stable during this hospitalization.
8. SLE: no acute issues. continued Prednisone 4mg PO qday
9. FEN: tolerated regular diet, repleted lytes PRN
9. Prophylaxis: Heparin gtt, then coumadin, bowel regigmen
Medications on Admission:
(from prior discharge summary)
Bisacodyl 10mg PO qday PRN
Prednisone 4mg PO qday
Aliskiren 150mg PO BID
Clonidine 0.3mg / 24 hr patch weekly qmonday
Labetalol 400mg PO TID
Warfarin 4mg PO qday
Nifedipine 90mg PO qday
Hydralazine 100mg PO q8H
Hydromorphone 2-4mg PO q4H PRN
Lorazepam 1mg PO q8H
Celexa 20mg PO qday
Prochlorperazine 10mg PO q6H
Colace 100mg PO BID
Hydralazine 25mg PO q30min PRN for HTN
Discharge Medications:
1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every [**Year (4 digits) 766**]).
3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QMONTH ().
4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
[**Year (4 digits) **]:*100 Tablet(s)* Refills:*2*
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Year (4 digits) **]:*90 Capsule(s)* Refills:*2*
9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for headache.
[**Year (4 digits) **]:*84 Tablet(s)* Refills:*0*
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
[**Year (4 digits) **]:*60 Tablet(s)* Refills:*0*
11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
[**Year (4 digits) **]:*60 Capsule(s)* Refills:*2*
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
[**Year (4 digits) **]:*60 Tablet(s)* Refills:*0*
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO every eight
(8) hours.
[**Year (4 digits) **]:*360 Tablet(s)* Refills:*2*
16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
[**Year (4 digits) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Hypertensive Emergency
2. SLE
3. Headache, NOS
4. Abdominal pain
Discharge Condition:
BP better controlled. Headache managed on oral meds
Discharge Instructions:
You were admitted with abdominal pain, high blood pressure, and
headache. Your abdominal pain resolved - no serious cause of
this pain was found. Your blood pressure medications were
continued, and with an increased in one medication, the
labetalol. Your blood pressure improved. You should continue
the clonidine 0.3mg patch changed on [**Year (4 digits) 766**], Hydralazine 100mg
three times a day, Aliskiren 150mg twice a day, and Nifedipine
90mg daily. The dose of Labetalol was increased to 800 mg three
times daily by you kidney doctor and you are given a new
prescription. Please take all medications as listed below.
For your headache, you had an MRI and MRA of the head, which did
not show a new or serious abnormality. You were seen by the
neurology and pain services. You should follow up at [**Hospital 878**]
clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**] at 6:30 PM (in
the evening). Your pain was managed by oral dilaudid, 4mg. You
should take this medication every 4 hours as needed. You were
also started on Gabapentin (also called Neurontin) for the
headache. The dose was slowly increased to twice a day. You
may not need as much dilaudid for your headache and should wean
this medication as tolerated, given it's potential for side
effects (constipation, lethargy, dependence). Finally, you will
likely need medications for constipation while you take
dilaudid. Take colace (a stool softener), senna (a laxative),
and bisacodyl (another laxative), as needed.
It is really important that you have a primary care doctor. You
are scheduled with Dr. [**Last Name (STitle) **] (see below) next Tuesday. You
will need your INR checked since you are on coumadin.
Call your doctor if you have worsened headache, chest pain,
confusion, or any other concerning symptom.
Followup Instructions:
Please make sure you attend the following doctor appointments:
1) Dr. [**Last Name (STitle) 4883**] (nephrologist) on Tuesday, [**2141-12-5**] at 10AM.
Phone number [**Telephone/Fax (1) 60**].
2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Location (un) **], [**Hospital Ward Name 23**] center, [**Location (un) **]. Phone:[**Telephone/Fax (1) 250**]. Date/Time:[**2141-12-5**] 3:20
3) Neurology: Dr. [**Last Name (STitle) 43502**] [**Name (STitle) **]. He is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2141-12-12**] 6:30 PM
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2141-12-2**]
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"710.0",
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"789.59",
"V45.78"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12686, 12692
|
5596, 10485
|
308, 323
|
12804, 12859
|
4389, 4389
|
14744, 15564
|
3501, 3625
|
10938, 12663
|
12713, 12783
|
10511, 10915
|
12883, 14721
|
3640, 4370
|
244, 270
|
351, 1504
|
4406, 5573
|
1526, 3273
|
3289, 3485
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,829
| 108,204
|
27218
|
Discharge summary
|
report
|
Admission Date: [**2187-12-7**] Discharge Date: [**2187-12-19**]
Date of Birth: [**2109-10-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Cough, hoarse voice
Major Surgical or Invasive Procedure:
G/J-tube placement per interventional radiology on [**12-14**].
Intubation
History of Present Illness:
Mr. [**Known lastname 66749**] is a 78 year-old man with a 3-year history of ALS,
for which he receives care at [**Hospital1 18**]. Over the past few months he
has had a progressive cough, but over the past 4 days it has
gotten much more severe, and last night he did not sleep at all
because he was coughing all night. His daughter stayed over at
his house and confirmed this history. He rarely brought up
yellowish-white sputum. He also described feeling a blockage in
his throat. Sometimes this is a little fluid that he has not
been able to swallow, but if he cannot cough up the sputum he
coughs so "you can hear [him] across the block". During these
coughing fits he feels very short of breath and dizzy, but he
describes no fevers or chills. In addition to the cough he has a
sore throat and feels that his voice has gotten more hoarse in
the past few weeks. He has significant dysarthria from his ALS,
but this is a change in the quality of his voice. He takes
guaifenesin to try to loosen his secretions, and recently his
daughter has brought a saline nebulizer home, which seemed to be
helping. According to his daughter, Mr. [**Known lastname 66749**] was recently
seen at the VA, where he was told that his VC was 1.3L. If it
goes down to 1L he will be a candidate for a tracheostomy. He is
on 3L of oxygen continuously at home, and is on a soft food and
thickened liquid diet.
.
In the ED his vitals were T 98.1, HR 77, BP 135/90, RR 20. O2
sat 96%3L, dropped down to 92% on 3L when talking. His NIF was
measured and found to be good at 38. His EKG showed NSR at 81,
RBBB, Q III/F, TWI III/F and V1-V4, with no prior to compare it
to. He recieved an ABG that was normal, a chest x-ray that
showed no signs of acute pulmonary process, V-Q scan was limited
but showed no signs of PE.
Past Medical History:
1. ALS: Mostly bulbar and respiratory troubles, but has been
dependent on a walker for past few months, has had 2 bad falls
in the last month.
2. HTN
3. Cervical stenosis
Social History:
Pt is a former boxer, was in the Navy and worked for the [**Location (un) 86**]
Fire Department for much of his life. He has 10 children and
about 30 grandchildren. He currently lives in his house with his
wife, who is ill with COPD. One of his daughters lives next door
and his a nurse, and she does most of the caretaking. His
granddaughters do the cooking, though Mr. [**Known lastname 66749**] still tries to
do some cleaning around the house.
He has never smoked, never drank, no illicit drugs.
Family History:
Father had lung cancer, does no know any other history of
cancer, diabetes or heart disease. No history of neurologic
disease.
Physical Exam:
Vitals: Tc:97.9 BP:190/98 HR:70 RR:20 O2:99% 3L, resting
General: Awake in bed, alert, no distress
HEENT: head NC/AT, PERRLA (pupils 2->1.5). EOMI, VF intact.
Neck: No palpable lymph nodes, no palpable thyroid
nodules/swelling
Card: nl S1S2, rrr, no m/r/g. PMI non-displaced
Lungs: Expiratory wheezes throughout, inspiratory squeeks in
lower lobes bilaterally, lung volumes decreased, no basilar
crackles.
Abd: +BS, distended, tympanic, non-tender, no masses
Ext: no cyanosis or edema, 2+ pedal pulses.
Neurologic:
Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Severe dysarthria. Language is
fluent with intact repetition and comprehension. There were no
paraphasic errors. Able to follow both midline and appendicular
commands. There was no evidence of neglect.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm OS and 1.5 to 1 mm OD and brisk.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric, though some
weakness of orbicularis oculi bilaterally
VIII: Hearing slightly diminished to finger-rub bilaterally.
IX, X: Palate elevates symmetrically but delayed gag reflex
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline; no fasciculations noted.
Motor: Severe wasting of UEs most notably in intrinsic hand
muscles bilaterally. Fasciculations present in L biceps and
triceps. Spasticity of all 4 ext. No tremor noted.
Delt Bic Tri WrE WrF FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 4+ 5 4+ 5 5- 5 0 2 4 5 5 5 5 4 4
R 4+ 5 4 5 5- 5 0 2 4 5 5 2 5 4 4
Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout.
DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 3 4
R 3 3 3 3 4
3 beats of clonus at bilateral ankles
Plantar response was flexor on the right, extensor on the left.
Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
Gait: Good initiation. Narrow-based, but short, shuffling
stride.
Pertinent Results:
Labs on admission:
ABG: pO2-100 pCO2-41 pH-7.42 calTCO2-28 Base XS-1
Glucose-106* UreaN-29* Creat-2.2* Na-143 K-4.4 Cl-107 HCO3-26
AnGap-14
Calcium-9.3 Phos-2.8 Mg-2.1
WBC-9.7 RBC-4.51* Hgb-13.2* Hct-39.4* MCV-87 MCH-29.3 MCHC-33.6
RDW-14.0 Plt Ct-275
Neuts-73.6* Lymphs-17.1* Monos-4.4 Eos-4.5* Baso-0.3
cTropnT-0.02* Lactate-0.9
[**2187-12-7**] Lung Scan - IMPRESSION: No evidence of interval
pulmonary embolism compared to study of [**2187-3-11**].
[**2187-12-9**] CT HEAD:
1. No acute intracranial hemorrhage.
2. Interval increase in right maxillary and right anterior
ethmoid sinus
mucosal thickening, likely representing chronic inflammatory
disease.
[**2187-12-10**] Video Oropharyngeal Swallow - IMPRESSION:
1. Moderate oral dysphagia.
2. Reflux from the esophagus into the pharynx with subsequent
penetration
into the airway seen.
Brief Hospital Course:
78 year-old man with a 3-year history of ALS who has recently
become more compromised in terms of mobility presents with 4
days of worsening minimally productive cough, sore throat and
hoarse voice without fever or leukocytosis.
#Cough: According to pts report he has had a cough for a few
months, but over the last 4 days it got progressively worse,
with minimal yellow-white sputum production. Pneumonia seemed
less likely in the setting of a normal chest x-ray and no focal
finding on lung exam, as well as lack of fever of leukocytosis.
Considered diagonoses were URI or continued aspiration,
overlying muscle weakness and difficulty clearing secretions.
His home O2 (3L) was continued, as well as his CPAP at night. He
was started on ipratroprium and albuterol nebulizers, as well as
dextromethorphan and codeine for cough suppression. We have IV
fluids, as his daughter reported that he has low PO intake, and
this may have been adding to his thick secretions. IV protonix
40 [**Hospital1 **] was started in case there was an element of
regurgitation. Speech and swallow consult was called to assess
whether he was aspirating more than he had previously.
#ALS: Pt appeared to have decompensated in the past several
months, and it was unclear if this presentation was just a
manifestation of and ALS "exacerbation". Home riluzole and
tizanidine were continued, as well as his previously prescribed
died of soft food and thickened liquidsa. PT consult was
ordered.
.
# CKD: Cr was 2.2 on admission.
.
# HTN: quite hypertensive on admission to floor, but down to 155
systolic after several hours. Continued to monitor BP and give
home metoprolol and terazosin.
.
# PPx: Pt was put on his some bowel regimen; started on a PPI,
and given heparin sc.
.
......
MICU course:
Mr. [**Known lastname 66749**] was transferred to the MICU as a result of
progressive metabolic acidosis and respiratory distress.
.
#ALS - The patient's increased dyspnea and acidosis on transfer
likely represent a progression of his underlying ALS. The
patient was intubated on [**12-18**] so that he could get his affairs
in order after a lengthy discussion with both the patient and
his daughter/HCP and reviewing his goals of care. Efforts to
minimize sedation were made so that the patient could be alert.
The patient self-extubated on the morning of [**12-20**] and
maintained his O2 sats alternating between a face tent and BiPAP
support. The palliative care team continued to follow the
patient and assist him in meeting his goals.
.
#Obstipation ?????? On transfer to the MICU the patient had severe
constipation. He was given an aggressive bowel regimen and
began stooling again. His tube feeds through his GJ tube were
subsequently resumed.
.
#Hypertension - prior to his MICU transfer the patient was
having significant episodes of HTN up to 190's-210, likely
secondary to respiratory distress and holding of his BP meds.
He was continued on hydralazine IV and his regular
antihypertensives were resumed via his GJ tube when his
obstipation resolved.
.
#Anion Gap Metabolic Acidosis ?????? On transfer the patient had an
anion gap acidosis, likely secondary to ketosis and progressive
respiratory muscle fatigue with progression of his ALS. He may
have also had a component of non gap acidosis from receiving NS
IVF. He was given IVF with D5 with 3 amps of sodium bicarbonate
for fluid repletion. His acidosis subsequently resolved.
Medications on Admission:
*Metoprolol Tartrate 25 mg PO twice a day
*MIRALAX PO once a day
*Riluzole 50 mg PO twice a day
*Terazosin 4mg HS
*Tizanidine 2 mg PO twice a day
*Aspirin 81 mg PO once a day
*Docusate Sodium [Colace] 100 mg Capsule PO twice a day
*Guaifenesin 400 mg PO four times a day
*Percocet 1 tab HS
Discharge Medications:
1. Fibersource Liquid Sig: 60 cc/hr PO 24 hours per day:
Please provide 30 day supply with 5 month refills - feed via G/J
tube.
Disp:*180 cans* Refills:*5*
2. Riluzole 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Terazosin 1 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
5. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours).
6. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q4H (every 4 hours) as needed.
Disp:*2 bottles* Refills:*5*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
Disp:*2 bottles* Refills:*5*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*2*
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*2*
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation: hold if having bowel
movements.
Disp:*1 bottle* Refills:*5*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
13. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One
(1) Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
Disp:*60 * Refills:*5*
14. Nebulizer & Compressor For Neb Device Sig: One (1)
Miscellaneous as directed.
Disp:*1 unit* Refills:*0*
15. Nebulizer Accessories Misc Sig: One (1) Miscellaneous
as directed.
Disp:*1 set* Refills:*0*
16. Humidified O2 Sig: One (1) as directed.
Disp:*1 * Refills:*5*
17. Suction equipment Sig: One (1) set Q2-6H as needed.
Disp:*1 set* Refills:*1*
18. face tent Sig: One (1) set as needed.
Disp:*1 set* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Amyotrophic lateral sclerosis
Hypertension
Discharge Condition:
Afebrile, requiring supplemental oxygen to maintain O2 sats.
Discharge Instructions:
You were admitted on [**2187-12-7**] with increased coughing,
difficulty swallowing hence interfering with your nutrition and
weakness. Initially, you were admitted to the medicine service
to rule other possible infection or blood clots that may be
causing your increased coughing but the evaluations were normal
hence you were transferred to neurology service for further
evaluation and treament of your ALS. You were eventually
transfered to the medical ICU service because of worsening
shortness of breath due to progression of your ALS.
After palliative consult and consultation with Dr. [**Last Name (STitle) 66750**]
[**Name (STitle) **], your neurologist at [**Hospital1 18**], you had G-tube placed per
interventional radiology with conscious sedation and without
complications.
You were also intubated briefly to allow you to settle some
legal matters.
Your tube feed has been recommended per nutrition consult and
you are discharged home with home hospice service. Please note
the changes that have been made with your medications.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) 1151**] [**Last Name (NamePattern1) 66751**] at the VA will be contacting you for follow-up.
He has been informed of your admission and plan of care.
Please follow-up with your primary care provider.
|
[
"335.20",
"403.90",
"723.0",
"276.2",
"518.81",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"44.32",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11962, 12019
|
6226, 9657
|
335, 412
|
12106, 12169
|
5356, 5361
|
13265, 13503
|
2963, 3091
|
9997, 11939
|
12040, 12085
|
9683, 9974
|
12193, 13242
|
3106, 3625
|
276, 297
|
440, 2236
|
3937, 5337
|
5835, 6203
|
5375, 5826
|
3640, 3921
|
2258, 2430
|
2446, 2947
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,135
| 112,953
|
25647
|
Discharge summary
|
report
|
Admission Date: [**2180-7-8**] Discharge Date: [**2180-7-28**]
Date of Birth: [**2106-8-10**] Sex: M
Service: PLASTIC
Allergies:
Morphine / Codeine
Attending:[**First Name3 (LF) 7733**]
Chief Complaint:
SOB, pleural effusion, sternal wound dihescience s/p sternectomy
and CABG
Major Surgical or Invasive Procedure:
thoracentesis
Sternal wound debridement and latissmus dorsi flap closure
History of Present Illness:
HPI: 73M male with h/o DMII, CAD s/p MI [**2167**] s/p 4-vessel CABG
complicated by fracture of sternal wires and wound dehiscence.
Recently was discharged from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] service here at [**Hospital1 18**]
on [**6-30**] after 10 day hospital stay. WAs discharged to [**Hospital 38**]
rehab with vac dressing over chest wound. Pt tx'ed to S. [**Hospital **]
Hosp on [**2180-7-5**] for SOB, fever to 101.9, HR 119, and found to
have large left pleural effusion s/p CT guided thoracentesis
with 1200 cc removed and pt's resp status is markedly improved
however his wound appears worrisome to them. Sating 93-96% on
RA.
.
Here prior hospitalization was notable for the following:
.
CAD/CHF. [**2180-5-1**] with chest and arm pain and found to have non-Q
MI. Transferred to Eastern [**State 1727**] MC on [**2180-5-2**] for cath, which
showed multi-vessel disease. On [**5-3**] he had a CABGx4. Post-op
course was complicated by respiratory failure and fluid
overload. He also had paroxysmal afib for which amiodarone and
coumadin were started. He later developed L hand weakness and
was felt to have had a R MCA ischemic stroke by neurology. Sx
improved, and he was admitted to acute rehab at EMMC on [**2180-5-11**].
.
Sternotomy Wound Dehiscence.
On [**5-13**] he was readmitted to medicine service after fracture of
his sternal wires and sternal incision dehiscence. He underwent
rewiring and debridement but continued to have serous drainage
from the mid-portion of his wound. On [**2180-5-19**] he underwent
sternal wound debridement and b/l pectoralis major flaps. On [**5-24**]
he was started on cefuroxime for L-sided infiltrate and
bronchospasm. On [**6-14**] he had another debridement and removal of
several sternal wires.
.
Stroke: On [**5-28**] he developed L hand weakness and L facial droop
was felt to have had a R MCA ischemic stroke by neurology (CT
negative at that time); started on aggrenox. Carotid U/S nl on
L, incomplete study on R. TEE with PFO with R to L shunting,
concentric LVH, mod TR. LE dopplers with no DVT.
.
Per D/C summary at [**Hospital1 34**], patient noted to be anemic and was
transfused 1 T PRBC, Cr 1.2-->2.0; due to changing Cr, lovenox
was switched to Hep gtts.
Past Medical History:
DM x15 years
h/o non-Q wave MI in [**2167**]; stents placed in [**2173**] and [**2174**];
CABGx4 vessel in [**2180-4-19**].
HTN
hyperlipidemia
chronic lower back pain; degenerative disk disease
R rotator cuff repair
umbilical hernia repair
L total knee arthroplasty
anal fissure repair [**2167**]
appendectomy
tonsillectomy
nephrolithiasis
mild renal insufficiency
Social History:
Lives in [**Location (un) 63982**], [**State 1727**] with wife and daughter. Quit
smoking in [**2147**]. No alcohol.
Family History:
Father died of heart disease age 78. Father also with DM.
Physical Exam:
Tc 97.3, 87, 180/100, 20, 98%
BSFS 122.
Looks comfortable
HEENT: PEERL, EOMI, mm moist
Neck: supple, no LAD
Chest: Mediastinal wound with minimal erythema on superior
acpect of wound near sternal notch. Lungs with decreased breath
sounds over left lower lobe.
Heart: RRR. No M/G/R
Abd: NABS, soft, NT, ND
Ext: Petichial hyperpigneted rash over lower legs. 1+ pitting
edema of feet and ankles.
Neuro: alert and oriented. Answers questions appropriately. .
Pertinent Results:
.
.
Labs:
Pleural Fluid at [**Hospital1 34**]: GS neg, Cx neg. WBC 63, alb 2.4, LDH 119
Cr 1.2 ([**7-5**])-->3.4 ([**7-7**]) --->2.9 ([**7-8**])
Labs [**7-8**] at [**Hospital1 34**]:
135 101 28
3.7 22 2.9
.
WBC 6.0, HCT 30.7, plt 304.
PTT 76.8 (hep 1250)
.
Rads at OSH: CT with Contrast: C/W SXternal Dehiscence with
surgical packing. no pneumomediastinum but 1.3cm of SQ gas at
prox edge. lg Left effusion.
.
ETT: [**5-23**]: in [**State 1727**]: EF 70%, concentric left vent hypertrophy.
.
[**7-10**] CXR: 1. Large midsternal lucency corresponding to known
open sternal wound in this patient with history of sternal
dehiscence.
2. Moderate-to-large left pleural effusion, probably slightly
increased in size in the interval. It is difficult to exclude
underlying pneumonia in the lingula or left lower lobe.
.
TTE: The left atrium is mildly dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF 60%). The right ventricular
free wall is hypertrophied. Right ventricular chamber size is
normal. Right ventricular systolic function appears depressed.
The aortic root is moderately dilated. The aortic arch is mildly
dilated. There are focal calcifications in the aortic arch. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are/present
but cannot be quantified. There is no pericardial effusion.
.
[**7-13**] CXR: 1. Residual small left pleural effusion, without
pneumothorax.
2. New small right pleural effusion.
[**2180-7-24**] 04:55AM BLOOD WBC-7.4 RBC-3.23* Hgb-9.3* Hct-28.9*
MCV-89 MCH-28.8 MCHC-32.2 RDW-16.1* Plt Ct-375
[**2180-7-23**] 11:24AM BLOOD WBC-7.7 RBC-3.14* Hgb-9.3* Hct-27.9*
MCV-89 MCH-29.6 MCHC-33.4 RDW-16.2* Plt Ct-359
[**2180-7-22**] 06:15AM BLOOD WBC-7.6 RBC-3.23* Hgb-9.3* Hct-28.8*
MCV-89 MCH-28.7 MCHC-32.2 RDW-16.5* Plt Ct-401
[**2180-7-21**] 07:57AM BLOOD WBC-10.1 RBC-3.20* Hgb-9.2* Hct-28.2*
MCV-88 MCH-28.8 MCHC-32.7 RDW-16.4* Plt Ct-370
[**2180-7-21**] 03:39AM BLOOD Hct-26.9*
[**2180-7-20**] 01:25PM BLOOD Hct-27.8*
[**2180-7-20**] 05:24AM BLOOD WBC-9.9 RBC-3.22* Hgb-9.0* Hct-28.2*
MCV-88 MCH-27.9 MCHC-31.8 RDW-16.2* Plt Ct-330
[**2180-7-19**] 10:44PM BLOOD Hct-26.0*
[**2180-7-19**] 09:25AM BLOOD Hct-25.4*
[**2180-7-18**] 03:00AM BLOOD WBC-17.2* RBC-3.25* Hgb-9.4* Hct-29.0*
MCV-89 MCH-28.9 MCHC-32.4 RDW-14.9 Plt Ct-386
[**2180-7-17**] 09:50PM BLOOD WBC-13.7*# RBC-3.44* Hgb-10.4* Hct-30.5*
MCV-89 MCH-30.2 MCHC-34.1 RDW-14.6 Plt Ct-400
[**2180-7-17**] 05:47AM BLOOD WBC-8.7 RBC-3.29* Hgb-9.4* Hct-29.6*
MCV-90 MCH-28.6 MCHC-31.9 RDW-14.9 Plt Ct-428
[**2180-7-16**] 02:45AM BLOOD WBC-9.8 RBC-3.26* Hgb-9.6* Hct-29.4*
MCV-90 MCH-29.4 MCHC-32.6 RDW-15.1 Plt Ct-434
[**2180-7-26**] 06:15AM BLOOD PT-12.6 PTT-25.8 INR(PT)-1.1
[**2180-7-17**] 09:50PM BLOOD PT-12.6 PTT-27.4 INR(PT)-1.1
[**2180-7-17**] 05:47AM BLOOD PT-12.2 PTT-29.1 INR(PT)-1.0
[**2180-7-16**] 02:45AM BLOOD PT-13.2 PTT-36.3* INR(PT)-1.1
[**2180-7-26**] 06:15AM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-136
K-4.2 Cl-98 HCO3-32 AnGap-10
[**2180-7-25**] 12:05PM BLOOD Glucose-168* UreaN-8 Creat-0.8 Na-135
K-4.4 Cl-99 HCO3-31 AnGap-9
[**2180-7-24**] 04:55AM BLOOD Glucose-120* UreaN-8 Creat-0.8 Na-136
K-3.7 Cl-97 HCO3-32 AnGap-11
[**2180-7-23**] 11:24AM BLOOD Glucose-226* UreaN-8 Creat-0.8 Na-135
K-4.0 Cl-98 HCO3-31 AnGap-10
[**2180-7-22**] 06:15AM BLOOD Glucose-133* UreaN-6 Creat-0.8 Na-139
K-3.6 Cl-99 HCO3-31 AnGap-13
[**2180-7-21**] 07:57AM BLOOD Glucose-169* UreaN-7 Creat-0.8 Na-138
K-3.5 Cl-101 HCO3-29 AnGap-12
[**2180-7-20**] 05:24AM BLOOD Glucose-85 UreaN-11 Creat-0.9 Na-139
K-4.1 Cl-103 HCO3-28 AnGap-12
[**2180-7-18**] 03:00AM BLOOD Glucose-180* UreaN-13 Creat-0.9 Na-137
K-4.7 Cl-101 HCO3-27 AnGap-14
[**2180-7-17**] 09:50PM BLOOD Glucose-136* UreaN-12 Creat-0.9 Na-137
K-4.2 Cl-101 HCO3-26 AnGap-14
[**2180-7-17**] 05:47AM BLOOD Glucose-176* UreaN-17 Creat-1.1 Na-138
K-4.0 Cl-99 HCO3-30 AnGap-13
[**2180-7-16**] 02:45AM BLOOD Glucose-139* UreaN-23* Creat-1.3* Na-137
K-3.6 Cl-98 HCO3-30 AnGap-13
[**2180-7-21**] 08:36PM BLOOD CK(CPK)-103
[**2180-7-21**] 10:57AM BLOOD CK(CPK)-121
[**2180-7-21**] 03:39AM BLOOD CK(CPK)-133
[**2180-7-14**] 05:12AM BLOOD LD(LDH)-174
[**2180-7-21**] 08:36PM BLOOD CK-MB-3 cTropnT-0.08*
[**2180-7-21**] 10:57AM BLOOD CK-MB-4 cTropnT-0.08*
[**2180-7-21**] 03:39AM BLOOD CK-MB-4 cTropnT-0.07*
[**2180-7-11**] 04:54AM BLOOD proBNP-4619*
[**2180-7-26**] 06:15AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.5*
[**2180-7-25**] 12:05PM BLOOD Calcium-7.8* Phos-3.8 Mg-1.6
[**2180-7-24**] 04:55AM BLOOD Mg-1.3*
[**2180-7-23**] 11:24AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.4*
[**2180-7-22**] 06:15AM BLOOD Calcium-7.8* Mg-1.8 Iron-16*
[**2180-7-21**] 05:40PM BLOOD Mg-1.9
[**2180-7-21**] 07:57AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.3*
[**2180-7-18**] 03:00AM BLOOD Calcium-8.1* Phos-4.6* Mg-1.9
[**2180-7-22**] 08:15PM BLOOD VitB12-1158* Folate-7.7 Ferritn-185
[**2180-7-22**] 06:15AM BLOOD calTIBC-230* Ferritn-206 TRF-177*
[**2180-7-22**] 08:15PM BLOOD TSH-48*
[**2180-7-22**] 06:15AM BLOOD TSH-41*
[**2180-7-8**] 09:19PM BLOOD TSH-55*
[**2180-7-8**] 09:19PM BLOOD Free T4-0.6*
[**2180-7-18**] 03:10AM BLOOD Type-ART pO2-113* pCO2-49* pH-7.40
calHCO3-31* Base XS-4
[**2180-7-17**] 10:08PM BLOOD Type-ART pO2-73* pCO2-47* pH-7.39
calHCO3-30 Base XS-2
[**2180-7-17**] 08:44PM BLOOD Type-ART pO2-237* pCO2-41 pH-7.43
calHCO3-28 Base XS-3
[**2180-7-17**] 07:11PM BLOOD Type-ART pO2-179* pCO2-40 pH-7.47*
calHCO3-30 Base XS-5
[**2180-7-17**] 05:52PM BLOOD Type-ART pO2-209* pCO2-38 pH-7.47*
calHCO3-28 Base XS-4 Intubat-INTUBATED
[**2180-7-17**] 03:58PM BLOOD Type-ART pO2-270* pCO2-34* pH-7.53*
calHCO3-29 Base XS-6
[**2180-7-18**] 03:10AM BLOOD freeCa-1.09*
[**2180-7-17**] 10:08PM BLOOD freeCa-1.12
[**2180-7-17**] 08:44PM BLOOD freeCa-1.09*
[**2180-7-17**] 07:11PM BLOOD freeCa-1.08*
[**2180-7-17**] 05:52PM BLOOD freeCa-1.12
[**2180-7-17**] 03:58PM BLOOD freeCa-1.08*
Brief Hospital Course:
Medicine part: [**Date range (1) 63984**]
A/P: 73M with CAD s/p CABGx4 with complication of wound
dehiscence.
.
# Sternal wound: Pt had CABG in [**4-23**] and has had wound
dehiscence s/p repeated debridement/revision with a pec flap
done at OSH. VAC dressing was placed during last admission to
[**Hospital1 18**], during which plastic surgery followed closely. On this
admission, plastic surgery evaluated the wound and was not
concerned for infection. Pt had been on keflex to cover skin
flora, and this was continued on admission. VAC was maintained
with high density sponge. When it became apparent that the
wound would not close quickly enough by secondary intention,
plan was for a latissimus flap to close the sternal wound with
both plastic surgery and CT surgery involved.
.
# CHF/pleural effustion: Pt appeared hypervolemic on exam, with
large L pl effusion on CXR. TTE was a limited study due to the
large, open sternal wound, but showed EF 60% and evidence of
diastolic dysfunction. Initially pt was diuresed with lasix
40mg IV BID with a goal of [**11-21**] L negative per 24h. I/O and
daily weights were strictly monitored; fluid restriction of
1500cc per 24h maintained. This improved his respiratory status
slightly. On [**7-13**] pt had a thoracentesis with 1200cc of fluid
removed. Pleural fluid had total proten 4.3 (serum 6.4), LDH
134 (174 serum), which was exudative.
.
# CAD s/p CABG: Pt had CABG [**5-3**] at OSH. Hospital course was
complicated by fluid overload and wound dehiscence. Continued
ASA, statin, BB (titrated to HR 60s). ACE was held initially
due to ARF, then restarted. Pt was medically cleared for
surgery: recent revascularization with CABG in [**4-23**].
Clinically, no CP or anginal symptoms. Perioperative BB
continued.
.
# Hematuria: Began when foley catheter was removed around the
time of transfer from OSH. When the patient began to pass clots
in his urine, a 3-way foley was placed with continuous bladder
irrigation. Heparin drip was stopped. Hematuria then resolved
and hct remained stable. Hematuria did not recur even when
lovenox was restarted for anticoagulation.
.
# Acute Renal Failure: This was likley due to contrast
andminstration at outside hospital and quickly resolved.
Initially lovenox was held and heparin started instead due to
ARF. Likewise ACE-inhibitor was held initially then restarted
when creatinine returned to baseline. Creatinine again bumped
up slightly, likely due to diuresis. Lasix and ACE-I were again
held...???
.
# Infection/?PNA: CXR on admission shows that the heart is
enlarged. There were no overt signs of failure. Considerable
opacification at the left base was present. This may have been
related to an effusion, extensive pleural thickening, or
consolidation or subsegmental atelectasis. Levofloxacin was
started, but discontinued because no clinical signs of infection
(no cough, fever, or elevated WBC count). Respiratory status
improved following thoracentesis.
.
# DM2: Continued lantus. Continued FS QID & ISS. [**Doctor First Name **] diet.
.
# HTN: stable, continued metoprolol. ACE was restarted when ARF
resolved.
.
# Hypothyroidism: Continued synthroid. TSH should be rechecked
in about 1 month.
.
# Paroxysmal Afib/Rhythm: Pt is higher risk due to PFO seen on
echo done at OSH. Heparin drip on admission (no lovenox
initially due to ARF). Anticoagulation was stopped due to
hematuria, then lovenox was restarted with no evidence of
bleeding. Pt has not been on coumadin so far due to the need
for surgical management of his wound.
# Anxiety/agitation: On last admission, this was an active
issue. Pt is less anxious currently. Trazodone was continued
for sleep. Neurontin helped with anxiety. Benzodiazepines were
avoided since they apparently made the patient
hallucinate/sundown on the last admission.
.
# R-IJ clot: Heparin drip was started on admission for
anticoagulation. Once acute renal failure resolved, switched
back to lovenox. Pt has not been on coumadin due to the need
for surgical management of his wound.
.
# FEN: [**Doctor First Name **]/cardiac diet. Monitored lytes and repleted as needed.
# PPX: pneumoboots, PPI, bowel regimen.
# Access: [**Name (NI) **], Pt has a RIJ clot visualized on chest CT on last
admission. Have avoided line placement in this vessel since
then.
PRS part [**2180-7-17**]
Underwent sternal wound debridement and latissmus dorsi flap
closure on [**2180-7-17**] without complications. He received one U
PRBC. Was tx to SICU. Post op pain and anixety were
controlled, B/P was elevated and treated with lopressor and
lisinopril. Was on atrovent nebs PRN. Electrolytes were folwed
and K and Mg were repleted as needed. lasix was given PRN. He
received periop Kefzol. urine output was adeq. Flap was warm
with good cap refill and no [**Last Name (un) **]. congestion, JPs were SS and
draining, and he had minimal edema. He was tx to the floor
[**7-18**]. Flap remained well perfused throughout hospital course
with good cap refill, it was warm, and never showed signs of
venous congestion. On the floor he amb with the help of PT.
His HCT remained stable and lytes were repleted as necess. On
[**2180-7-21**] c/o SOB and felt as if his lungs were filled with fluid.
Sympomatic relief when moved to chair. Had basilar crackles on
exam and CXR showed fluid in R lung field. EKG and enzymes were
negative and he was diuresed with Lasix ande he was placed on O2
NC (initally 5L) and titrated down. Medicine was consulted. O2
sats and symptoms improved with Lasix administration (goal was
500 negative per day) and his last Lasix dose was on [**2180-7-26**] (40
PO BID had been TID previous days) and it was stopped because
his O2 sat was stable off of O2. Wound Cx came back MRSA
positive and he was started on Vancomycin on [**2180-7-25**] for a total
of 14 days. On [**2180-7-26**] he was started on Lovenox (1 mg/kg [**Hospital1 **] =
110 mg [**Hospital1 **]) and coumadin 5 mg QHS for proph. On [**2180-7-28**] he is in
good condition for discharge to rehab.
Medications on Admission:
Meds on Transfer:
Hep wt based protocol 1250U /hr (PTT 76.8)
Zocor 20mg po qd
Protonix 40mg po qd
Levo 500mg IV qd
Zosyn 3.375mg IV q6 hours
Isordil--->Imdur 30mg qd
ASA 325mg po qd
Insulin gtts.
Discharge Medications:
1. 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*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*10 inhalation* Refills:*0*
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*30 inhalation* Refills:*0*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*0 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*0 Capsule(s)* Refills:*2*
7. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*0 Tablet(s)* Refills:*2*
8. Vancomycin HCl 1000 mg IV Q 12H
9. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
10. Enoxaparin Sodium 120 mg/0.8 mL Syringe Sig: One (1)
Subcutaneous [**Hospital1 **] (2 times a day).
Disp:*0 subq* Refills:*2*
11. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*0 Tablet(s)* Refills:*2*
12. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*0 Tablet Sustained Release 24HR(s)* Refills:*2*
13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
Disp:*0 Tablet(s)* Refills:*2*
14. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*0 Tablet Sustained Release 24HR(s)* Refills:*2*
15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*2*
16. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for anxiety.
Disp:*0 Capsule(s)* Refills:*0*
17. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*0 Tablet(s)* Refills:*2*
18. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Disp:*0 Tablet(s)* Refills:*0*
19. DM control
Regular insulin sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital 63985**] Health Center
Discharge Diagnosis:
sternal wound dehiscence
CAD, s/p CABG in [**4-23**]
CHF
DM type II
HTN
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc
Please take all medications as directed.
Please attend all follow up appointments.
If you have fever >101.5, severe pain, chest pain, shortness of
breath, if the flap changes color or in sensation, if you have
bleeding or discharge, or anything that causes you great
concern, please return or go to local hospital.
Followup Instructions:
Please followup with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3065**] [**Last Name (NamePattern1) 805**] within [**11-21**]
weeks after discharge from the hospital. Please call
[**Telephone/Fax (1) 63986**] for an appointment.
Recommend adjusting anti-coag and a TSH in 6 weeks.
Call Dr. [**Last Name (STitle) 5385**] for a follow up appt. ([**2179**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**]
|
[
"998.83",
"V45.81",
"244.9",
"401.9",
"412",
"427.31",
"584.9",
"511.9",
"745.5",
"428.30",
"V58.61",
"996.52",
"250.00",
"599.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"34.79",
"77.61",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
18569, 18630
|
9959, 16021
|
351, 426
|
18746, 18752
|
3812, 9936
|
19243, 19753
|
3257, 3318
|
16268, 18546
|
18651, 18725
|
16047, 16047
|
18776, 19220
|
3333, 3793
|
238, 313
|
454, 2716
|
2738, 3104
|
3120, 3241
|
16065, 16245
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,694
| 183,827
|
44166
|
Discharge summary
|
report
|
Admission Date: [**2143-7-15**] Discharge Date: [**2143-7-17**]
Date of Birth: [**2084-4-19**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 59-year-old
male, who was admitted to the CCU status post left carotid
artery stent placement. Patient has a history of transient
ischemic attack in the past that subsequently showed
bilateral carotid stenosis of 40%. Since then, the patient
has had two episodes of visual changes in the left eye that
patient described as "blind being drawn over the eye" that
was consistent with amaurosis fugax, as well as symptoms of
postural dizziness. The patient underwent carotid duplex
study on [**2143-6-25**] which showed 80% stenosis of left internal
carotid artery and 40% stenosis of right internal carotid
artery. Subsequently, patient was admitted for carotid
angiogram and percutaneous intervention by Dr. [**First Name8 (NamePattern2) 487**]
[**Last Name (NamePattern1) **].
PAST MEDICAL HISTORY:
1. Coronary artery disease. Patient has had numerous cardiac
catheterizations including cardiac catheterization in [**2140-10-23**] status post distal RCA stent placement, cardiac
catheterization [**7-/2140**] status post proximal OM-1 stent for
70% proximal stenosis, cardiac catheterization on [**10-23**] which
showed an ejection fraction of 68%, right dominant system.
RCA was 30% mid stenosis and distal RCA and obtuse marginal
stents patent. Since then, the patient has a normal exercise
stress test on [**11-24**].
2. Hypercholesterolemia.
3. Emphysema by pulmonary function tests on [**5-25**] showing
mild obstructive pattern of gas trapping.
4. Peripheral vascular disease, bilateral carotid stenosis.
5. Erectile dysfunction status post penile prosthesis.
6. Transient ischemic attack.
7. Arthritis.
PAST SURGICAL HISTORY:
1. Hernia repair.
2. Glaucoma surgery, laser surgery three years ago.
OUTPATIENT MEDICINES:
1. Aspirin 325 po q day.
2. Lipitor 40 mg po q hs.
3. Plavix 75 mg po q day.
4. Flovent.
5. Albuterol.
6. Nitroglycerin 0.4 mg po prn.
7. Atenolol 25 mg po q day.
8. Lisinopril 5 mg po q day.
9. Isosorbide mononitrate 120 mg po q day.
10. Norvasc 5 mg po q day.
11. Folic acid 800 mg po q day.
12. Serevent.
13. Flonase.
ALLERGIES: No known drug allergies. No known allergies to
shellfish or dye.
FAMILY HISTORY: Positive for coronary artery disease.
[**Name (NI) **] brother died at the age of 58 of myocardial
infarction. [**Name (NI) **] sister had CABG and died thereafter at
the age of 61.
SOCIAL HISTORY: Positive for smoking. Patient initially
quit in [**2127**], but recently restarted with four cigarettes a
day. Patient is married. His wife lives in [**Country 2559**]. Patient
has been going to [**Country 2559**] frequently to see his family.
On arrival to the CCU, the patient was afebrile with a blood
pressure of 170/78, pulse of 54, respirations 21, O2
saturation of 93% on room air. Physical examination showed a
nice gentleman in no apparent distress. HEENT: Pupils are
equal, round, and reactive to light and accommodation.
Patient's visual field examination was significant for left
visual field cut on his left eye. Patient's right visual
field examination was normal. Ophthalmoscopic examination
nondilated eyes revealed no gross abnormalities. Neck:
There was a right carotid bruit, no jugular venous
distention. No left carotid bruits were appreciated.
Pulmonary was clear to auscultation bilaterally.
Cardiovascular was regular, rate, and rhythm, normal S1, S2,
there were no murmurs, rubs, or gallops. Abdomen: Patient
has good bowel sounds. Abdomen was soft, nontender,
nondistended without organomegaly. Extremities: There was
no clubbing, cyanosis, or edema noted. Right groin: There
were no bruits or hematomas and normal peripheral pulses.
LABORATORY VALUES: Patient had normal white count,
hematocrit was stable at 43.9; the patient's platelets were
131. Patient's renal panel was normal with BUN and
creatinine of 13 and 1.0 respectively.
Patient's initial electrocardiogram was significant for sinus
bradycardia with a ventricular of 40-50 beats per minute.
Carotid angiogram: Left carotid angiogram showed 90% distal
occlusion of the common carotid artery and 90% occlusion of
internal carotid artery with ulceration, Percusurge wire was
used and two stents were placed in ACA and MCA. Ophthalmic artery
was visualized and was patent, but patient did develop blurry
vision after the stents were placed.
HOSPITAL COURSE: Patient was admitted for CCU for close
monitoring initially target systolic blood pressure was
140s-160s. Patient was started on Neo-Synephrine drip, with
which a target blood pressure goal was achieved.
Subsequently over the course of the night and the next day,
Neo-Synephrine was being weaned off. Over the course of the
night, patient did have an episode of asymptomatic
bradycardia with heart rate in the 30s to 40s. Patient was
given one dose of atropine with resulting heart rate
posttreatment in the 60s and systolic blood pressure at goal.
Over the course of the next day, Neo-Synephrine was titrated
off in order to maintain the goal systolic blood pressure of
140. The patient was given several boluses of normal saline
to 150 cc to maintain systolic blood pressure at goal.
Patient has remained asymptomatic. Was able to ambulate with
the help of Physical Therapy.
At the day of discharge, the patient's systolic blood
pressure was ranging from the 110-120s. The patient was seen
by Dr. [**First Name (STitle) **], and it was in agreement between the patient
and Dr. [**First Name (STitle) **] that the day following the discharge, the
patient was going to followup with Dr. [**First Name (STitle) **] for blood
pressure check.
2. Renal: Patient maintained stable creatinine and
electrolytes, and excellent urinary output.
3. Ophthal/Neuro: Patient had dilated ophthalmologic
examination by Ophthalmology service on the day of admission,
which did show a cholesterol embolus at one of the branches
of retinal artery and edema surrounding it, which was not
consistent with ischemia or optic neuropathy, but rather an
occlusion of a retinal artery branch with cholesterol
embolus. Patient was started on Alphagan as well as eyeball
massage.
Over the course of the next day, the patient's usual visual
field cut was resolved, and his visual field symptoms were
improving, although his vision out of the left eye did remain
somewhat blurry. The patient has been followed by
Ophthalmology daily. It was decided to followup in
[**Hospital 8183**] Clinic 1-2 weeks following discharge.
Neurologic: Since admission, the patient has been on close
neurochecks and exhibited no focal neurologic deficits. Of
note, left visual field changes were addressed as above.
4. Pulmonary: History of chronic obstructive pulmonary
disease. Patient maintained good oxygenation with home MDI
regimen.
5. Prophylaxis: SubQ Heparin was administered to the patient
while the patient was unable to ambulate being due to status
post carotid angiogram.
6. Disposition: Patient was discharged with a close followup
by Dr. [**First Name (STitle) **] the day following the discharge for vitals
check.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Carotid artery stenosis status post
right carotid artery stent placement.
DISCHARGE MEDICATIONS:
1. Atorvastatin 40 mg po q day.
2. Plavix 75 mg po q day.
3. Aspirin 325 mg po q day.
4. Alphagan as well as outpatient MDIs.
DISCHARGE INSTRUCTIONS: The patient was instructed to hold
and not to take his blood pressure medicines until discussed
with Dr. [**First Name (STitle) **] upon discharge.
FOLLOW-UP PLANS:
1. The patient is to followup with Dr. [**First Name (STitle) **] the day
following discharge for blood pressure check.
2. Follow up with Dr. [**First Name (STitle) **] in clinic 1-2 weeks.
3. [**Hospital 8183**] Clinic: The patient is to schedule followup
in [**1-24**] weeks after discharge. Patient in the meanwhile is to
still continue Alphagan and follow up with an ophthalmologist
sooner if visual changes persist and do not improve.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Name8 (MD) 4937**]
MEDQUIST36
D: [**2143-7-26**] 14:39
T: [**2143-7-30**] 10:20
JOB#: [**Job Number **]
cc:[**Last Name (NamePattern4) **]
|
[
"433.10",
"496",
"443.9",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
2343, 2527
|
7304, 7379
|
7402, 7529
|
4515, 7222
|
7554, 7703
|
1832, 2326
|
7720, 8458
|
161, 973
|
995, 1809
|
2544, 4497
|
7247, 7283
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,927
| 171,156
|
11427
|
Discharge summary
|
report
|
Admission Date: [**2188-11-6**] Discharge Date: [**2188-11-10**]
Date of Birth: [**2109-7-8**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old
male with a single episode of chest pain at rest and minimal
activity who went to the emergency department and was ruled
out for a myocardial infarction by enzymes. He followed up
with an exercise stress test and it was stopped secondary to
fatigue. It also showed ST-segment depression in multiple
leads. It also showed mild basilar hypokinesis of the
inferior wall and his EF was 60 percent. He was then
referred for a cardiac catheterization, which showed 80
percent stenosis of his LAD, 70 to 80 percent stenosis of his
OM1, his left circumflex showed no apparent CAD, and his
right coronary artery had approximately 80 percent stenosis
and 70 percent mid-stenosis. Echocardiogram revealed an EF
of 65 percent.
PAST MEDICAL HISTORY: Hypertension.
Hypercholesterolemia.
Chronic renal insufficiency.
PAST SURGICAL HISTORY: Status post repair of anal fissure.
Status post left inguinal hernia.
Appendectomy.
Kidney stone removal.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Aspirin 81 mg once a day.
2. Verapamil 180 mg once a day.
3. Lipitor 20 mg once a day.
4. Lisinopril 10 mg once a day.
5. Nitroglycerin sublingual p.r.n.
6. Multivitamin.
7. Colace b.i.d. p.r.n.
SOCIAL HISTORY: He is a nonsmoker. He drinks occasionally,
one drink three times a week.
FAMILY HISTORY: He does have a positive family history for
coronary artery disease. His father died at the age of 50 of
an MI. Multiple brothers have coronary artery disease.
PHYSICAL EXAMINATION: He is a 5 feet 5 inches male, 161
pounds. His vital signs were temperature 97.3 degrees, blood
pressure of 140/70, pulse of 73, respirations 18, and he was
94 percent on room air. He was alert and oriented x3, and
appropriately following commands. His lungs were clear to
auscultation bilaterally. His heart rate was regular rate
and rhythm. No murmurs, clicks, rubs, or gallops. His
carotids revealed no bruits. His abdomen was soft,
nontender, and nondistended. Positive bowel sounds. His
extremities were well perfused. No clubbing, cyanosis,
edema, or varicosities. His radial pulses bilaterally were 2
plus. His PT and DP distal pulses were 2 plus bilaterally.
LABORATORY DATA: On [**2188-10-24**], a chest x-ray showed no
cardiopulmonary abnormality; his UA was negative; his white
blood cell count was 7.2, hematocrit of 37, and platelets of
142,000. His sodium was 138, potassium 3.8, chloride 106,
bicarbonate 22. BUN 20, creatinine 1.1, glucose of 96. His
PT was 13.2, PTT 26.1, INR 1.1. ALT 21, AST 22, amylase 54,
total bilirubin 0.7, and albumin 3.9. His hemoglobin A1c was
5.6.
HOSPITAL COURSE: On [**2188-11-6**], the patient was taken to the
operating room and underwent coronary artery bypass graft
operation x4. The grafts were as follows: LIMA to LAD, vein
to RCA, vein to OM1, and vein to diagonal. Bypass time was
103 minutes, cross clamp time was 85 minutes. The operation
went well. The patient was in good condition and transferred
to the CSRU. His drips were as follows: Propofol at 30
mcg/kg/minute, Neo-Synephrine at 0.6 mcg/kg/minute. His
heart rate was 90 beats per minute, A paced. His mean
arterial pressure was 70, CVP of 7, PA diastolic of 8, and PA
mean of 15.
On postoperative day one, the patient was successfully
extubated. His blood gas revealed metabolic and respiratory
acidosis and patient received one unit of bicarbonate.
Physical examination revealed a patient in no acute distress
with a heart rate that was regular in rhythm with no murmurs.
His lungs were clear to auscultation. His vital signs were
as follows: 95 in sinus rhythm, blood pressure 129/59, he
was at 85 percent saturation. The patient was attempted to
receive BIPAP. His chest tubes put out 500. His JP in his
leg for the saphenectomy put out 50. His urine output was
300. The plan on postoperative day one was to discontinue
his Swan, give Lasix 20 mg b.i.d., start Lopressor at 12.5 mg
b.i.d., try to get the patient out of bed, and have Physical
Therapy see the patient.
On [**2188-11-8**], which was postoperative day two, the patient was
in stable condition with a T-max of 96.5 degrees, 110/60
blood pressure, and heart rate of 87. He was saturating at
94 percent on 2 liters of O2 via nasal cannula. His chest
tubes put out 310 and his JP was 50. The patient's physical
examination was unremarkable. His orders were to discontinue
his chest tubes. Also note, this day is the first day the
patient was on Far 2 regular telemetry floor. He was
transferred from CSRU on [**2188-11-7**] to Far 2.
On postoperative day three, which was [**2188-11-9**], the patient
was in stable condition. His physical examination was
unremarkable. His blood pressure was 115/64. He was 96
percent on 3 liters. The patient, overnight, went into
atrial fibrillation. He was started on amiodarone and his
Lopressor was increased. The patient's current heart rate is
in normal sinus on this day after the start of the
medication.
On postoperative day four, the patient received one unit of
packed red blood cells, late yesterday, [**2188-11-9**], for a
hematocrit of 24. He did not go back in any atrial
fibrillation rhythm. Since early yesterday, he was draining
some old blood from his saphenectomy in his right leg. Vital
signs were as follows: T-max 99.4 degrees, pulse 64 in sinus
rhythm, blood pressure of 130/70, input and output 1200 and
2100. The patient was alert and oriented x3. The rest of
his physical examination revealed clear lungs bilaterally;
regular rate and rhythm, no murmurs; bowel sounds were
positive; abdomen that was soft, nontender and nondistended.
His extremities were nonedematous. His sternum was clear,
dry, and intact; no erythema, no drainage. His right lower
extremity had some drainage of old blood from the JP drain.
The patient was discharged on [**2188-11-10**]. He was in stable
condition and discharged to home with services.
DISCHARGE DIAGNOSES: Coronary artery disease.
Hypertension.
Hypercholesterolemia.
Status post coronary artery bypass graft.
Chronic renal insufficiency.
FOLLOW-UP INSTRUCTIONS: The patient was recommended to
follow up with Dr. [**Last Name (STitle) 3142**] in one to two weeks, follow up
with Dr. [**Last Name (STitle) 5293**] in one to two weeks and follow up with Dr.
[**Last Name (STitle) **] in three to four weeks.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg 1 tablet p.o. q.d. x7 days.
2. Potassium chloride 10 mEq capsule 1 p.o. q.d. x7 days.
3. Colace 100 mg 1 capsule p.o. b.i.d.
4. Aspirin 325 mg 1 tablet p.o. q.d.
5. Pantoprazole sodium 40 mg 1 tablet p.o. q.24 h.
6. Atorvastatin 20 mg 1 tablet p.o. q.d.
7. Amiodarone 200 mg 2 tablets p.o. q.d. x1 month.
8. Lopressor 25 mg 3 tablets p.o. b.i.d.
9. Ferrous sulfate 325 mg 1 tablet p.o. q.d.
10.
Oxycodone/acetaminophen 5/325 one-to-two tablets p.o. q.4 h.
p.r.n. pain.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) 36534**]
MEDQUIST36
D: [**2188-11-10**] 14:32:00
T: [**2188-11-11**] 01:04:19
Job#: [**Job Number 36535**]
|
[
"413.9",
"414.01",
"427.31",
"997.1",
"272.0",
"593.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.72",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
1508, 1670
|
6143, 6280
|
6572, 7307
|
2823, 6121
|
1199, 1399
|
1030, 1178
|
1693, 2805
|
165, 915
|
6305, 6549
|
938, 1006
|
1416, 1491
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,359
| 141,249
|
33142
|
Discharge summary
|
report
|
Admission Date: [**2141-12-12**] Discharge Date: [**2142-1-4**]
Date of Birth: [**2086-1-5**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Tetanus
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
[**2141-12-12**]: Placement of high frontal ICP probe
[**2141-12-18**]: Removal of ICP bolt
[**2141-12-23**]: Tracheostomy
[**2141-12-27**]: [**Last Name (un) **] gastrostomy and Tru-Cut liver biopsy
[**2141-12-27**]: Bronchoscopy
[**2142-1-4**]: Video swallow
History of Present Illness:
55 year old male who presented to [**Hospital1 18**] ED as a transfer from a
referring hospital after a fall from approximately 2 stories.
By
report he was speaking but confused on arrival to that hospital
and was
moving all extremities. He was intubated and transferred to
[**Hospital1 18**] ED for futher evaluation. On arrival to the ED he was
moving all extremities. He had 3 chest tubes placed in the ED
for bilteral pneumothoracies and was evaluated by plastic
surgery for his facial fractures and neurosurgery for his head
injury.
Past Medical History:
Cirrhosis
ETOH
HTN
Hypothyroid
Social History:
Divorced, two children; up to 12 drinks/week per PCP [**Name Initial (PRE) 3726**]
Family History:
Noncontributory
Physical Exam:
Upon admission:
T: BP: 124/60 HR: 116 R 21 O2Sats 100% intubated
Gen: WD/WN, intubated
HEENT: L periorbital ecchymosis, Pupils: R 4 to 3mm, L 5 to
4.5mm
sluggish, laceration on L side of head
Neck: C-collar
Lungs: b/l chest tubes
Cardiac: RRR. S1/S2.
Extrem: Warm and well-perfused. multiple abrasions/lacs
shoulder,
hands
Neuro:
Mental status: did not open eyes to voice, moved toes and hand
grip b/l to voice command
Orientation, recall,language: unable to assess
Cranial Nerves:
I: Not tested
II: R 4 to 3mm brisk reactive, L 5mm to 4mm sluggish. Visual
fields: unable to assess.
III, IV, VI: unable to assess
V, VII: unable to assess
VIII: Hearing intact to voice.
IX-XII: unable to assess
Motor: moves all extremities spontaneously, unable to assess
full strength exam
Sensation: unable to assess
Coordination: unable to assess
Pertinent Results:
[**12-12**]: CT Head - R subdural hematoma, approx. 1cm in width. L
extraaxial hematoma overlying L frontal lobe, adjacent to site
of skull fracture, ?small epidural hematoma. SAH, with
hemorrhage in basal cisterns. Multiple facial fractures
[**12-12**]: CT C-spine - No cervical spine fracture
[**12-12**]: CT Chest - B PTX, B pulmonary contusions, and likely small
pulmonary lacs. Large amount of fluid in esophagus. Multiple
displaced rib fractures on left and right 1st rib fx.
[**12-12**]: CT A/P - No traumatic injury in abdomen or pelvis
[**12-13**]: [**Name (NI) 77037**] ptx, mult rib fx, bibasilar atelectasis, likely L
pulm contusion developing
[**12-13**]: ECHO: mild LVH, mild mitral regurg. EF >50%
1/23: CT Head-no significant change. ?can do CTA to r/o vasc
inj.
[**12-13**]: shoulder-Comminuted fracture distal left clavicle
[**12-13**]: R Hand: There is posterior dislocation of the third and
fourth PIPs.
[**12-13**]: R Hand (post redux): The dislocations have been reduced.
[**12-14**]: R Hand (post redux): ? capsular injury. There are no signs
for acute fractures.
[**12-14**]: CXR: decrease in bibasilar opacifications, no ptx
[**12-16**] CXR: no change post CT removal, no ptx
[**12-17**] CT Head: Persistent bilateral subdural hemorrhages, with
interval evolution of an area of contusion or infarction within
the right temporal lobe
[**12-18**]: CXR - worsening atelectasis w/mod L pleural effusion and
small R pleural effusion.
[**12-19**]: CTA - no PE. Small L apical and medial PTX. LLL
atelectasis, partial RLL atelectasis. Bilat upper lobes with
scattered ground-glass opacities - ?aspiration. Free fluid in R
subphrenic space.
[**12-19**]: CT head: ICH unchanged. Mild loss of [**Doctor Last Name 352**]-white
differentiation, suggesting diffuse cerebral edema.
[**12-21**]: CT head: New 1.9 cm right cerebellar hemorrhage with mild
surrounding edema, otherwise stable.
[**12-21**]: CT chest/abd/pelvis: . Extensive consolidation at the lung
bases, markedly increased on the left compared to the prior
exam, consistent with multifocal pneumonia. 2. Left chest tube
in place with small residual anterior pneumothorax. 3. Interval
development of ascites and anasarca. No intra-abdominal
infection identified.
[**12-22**]: CT head: no interval change
[**12-23**]: MRI Cspine: No evidence of ligamentous injury identified or
vertebral malalignment.
[**1-1**]:CT HEAD WITHOUT CONTRAST
IMPRESSION: Resolving subdural hematomas, right greater than
left with multiple old facial fractures as delineated in the
body of the report.
Cultures:
[**12-17**]: Cdiff - Neg
[**12-19**]: BAL: 2+PMN, no microorg, GNR ~6000, GNR #2 ~4000, unable
to r/o Haemophilus (overgrowth of Proteus species)
[**12-19**]: Urine: (prelim) 10-100,000 EColi
Brief Hospital Course:
He was admitted to the trauma ICU by the Trauma Surgery service
on [**2141-12-12**]. Because of his traumatic brain injury and the fact
that his GCS was less than 8, it was necessary to place an
intracranial bolt for monitoring of his intracranial pressures.
He tolerated this procedure well. He was loaded with Dilantin;
Mannitol and Nafcillin were initiated as well. The bolt was
eventually removed at bedside on [**2141-12-18**]. He also received
multiple units of packed RBCs, FFP and platelets. A PICC was
later placed for IV antibiotics; the PICC has been removed and
the antibiotics stopped.
He was followed by Plastic Surgery for his facial fractures
which were determined to be non-operative and also followed by
Plastics (Hand) for dislocation of middle and index fingers on
his right hand. These were relocated and he was splinted for
immobilization. Follow up with Plastic surgery is recommended in
2 weeks after discharge.
His care was continued in the ICU. He was seen by Ophthalmology
on [**12-15**] for evaluation due to his facial fractures and concern
for orbital injury. It was revealed that he had a traumatic
optic neuropathy in both eyes. He will require follow up with
Ophthalmology as an outpatient.
He later underwent an open tracheostomy and gastrostomy tube. He
was eventually weaned from the ventilator. Tube feedings had
been initiated early on via an OG tube; these were continued via
the gastrostomy tube. Eventually he was transferred to the
regular nursing unit.
His mental status has slowly improved over the course of his
stay. He has gone from being unresponsive during his initial ICU
stay to becoming awake. Currently he is much more alert and able
to respond to some questions with simple answers; follows simple
commands. A repeat head CT scan was performed on [**2142-1-1**] which
showed resolving subdural hematomas, right greater than left
with multiple old facial fractures.
He was evaluated by Speech & Swallow for Passy Muir valve, which
he was able to tolerate. A bedside swallow evaluation was also
done; it was recommended that he have a video swallow and so
this was ordered. He will require ongoing Speech therapy once at
rehab.
Physical and Occupational therapy were consulted early on; it
was determined that he would need an acute rehab stay follow his
hospitalization. Social work was also closely involved with
patient and family since early admission. Several family
meetings took place throughout his stay to discuss his course
and disposition.
Medications on Admission:
levothyroxine 50 mcg', thiamine 100 mg ', folic acid 1 mg'
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Date Range **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: Ten (10) ml PO BID (2
times a day).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Date Range **]: [**11-22**]
Drops Ophthalmic PRN (as needed).
5. Levetiracetam 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2
times a day).
6. Lactulose 10 gram/15 mL Syrup [**Month/Day (2) **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
7. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1) ml
Injection TID (3 times a day).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
12. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
13. Levothyroxine 100 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation Q6H (every 6 hours) as needed.
15. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
16. Ferrous Sulfate 300 mg/5 mL Liquid [**Last Name (STitle) **]: Five (5) ml PO DAILY
(Daily).
17. Haloperidol 0.5-1 mg IV TID:PRN increased agitation
Please notify team for increased sedation
18. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1) dose
Injection four times a day as needed for per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Fall
Traumatic brain injury
Subarachnoid hemorrhage
Subdural hematoma
Bilateral pneumothoracies and bilateral pulmonary contusions
Multiple facial fractures
Traumatic optic neuropathy (OU)
Multiple rib fractures
Comminuted fracture of distal left clavicle
Posterior dislocation 3rd and 4th PIPs
Discharge Condition:
Good
Followup Instructions:
Follow in Hand Clinic (Plastics) in 2 weeks for your finger
injuries call [**Telephone/Fax (1) 1228**] for an appointment. Please also
follow up with Dr. [**Last Name (STitle) 1005**] in 2 weeks, Orthopedic Surgery on
the same day as your hand appointment. You will need to let the
receptionist know that you need to have both of these
appointments on the same day as the clinics are in same
location.
Follow up with Dr. [**Last Name (STitle) **] in Neurosurgery in one month by
calling [**Telephone/Fax (1) 1669**] for an appointment. You need to have a CAT
scan of your head for this appointment so please inform the
office if this.
Please follow up with Dr. [**Last Name (STitle) **], Trauma Surgery in 2 weeks by
calling [**Telephone/Fax (1) 77038**] for an appointment.
Follow up with Ophthalmology in 4 weeks for the Optic Neuropathy
by calling [**Telephone/Fax (1) 253**] for an appointment.
Completed by:[**2142-1-24**]
|
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icd9cm
|
[
[
[]
]
] |
[
"96.72",
"43.19",
"96.6",
"34.04",
"01.18",
"31.1",
"38.93",
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"96.56",
"79.74",
"38.91",
"01.10",
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] |
icd9pcs
|
[
[
[]
]
] |
9630, 9700
|
4979, 7496
|
289, 555
|
10043, 10050
|
2195, 3408
|
10073, 11006
|
1295, 1312
|
7606, 9607
|
9721, 10022
|
7522, 7583
|
1327, 1329
|
241, 251
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583, 1125
|
1821, 2176
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4458, 4956
|
1343, 1668
|
1683, 1805
|
1147, 1179
|
1195, 1279
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,768
| 129,459
|
32232
|
Discharge summary
|
report
|
Admission Date: [**2103-2-22**] Discharge Date: [**2103-3-6**]
Date of Birth: [**2042-11-9**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Internal Jugular Central Line placement
History of Present Illness:
This is a 60yoF w NSCLC dx in [**12-14**] c/b brain mets s/p brain XRT
and has h/o recent admission for occipital stroke [**Date range (1) 75354**]/08. Pt
presented to outpt oncology clinic for regular scheduled
appointment for chemo when she was found to be weak and w/BP
69/49. In the office, she received 500cc IVF and BP increased to
91/55. Per pt, she had had steroid doses increased a few weeks
ago and since has been tapering doses. She notes that she's had
bilateral upper extremity weakness for ~3wks which she feels is
progressively worsening. She associates it w/steroid use. She
denies fever/chills/n/v, d/c/abdominal pain. Endorses fatigue
and her most bothersome complaint is blurry vision which was her
presenting complaint on her prior admission. She ntoes that
she's had some difficulty word-finding over the past month but
denies ha/dizzyness. Denies cp/palpitations/sob, but endorses
cough x 3d, nonproductive, no other URI sx associated.
.
In the [**Name (NI) **], pt was afebrile w/ BP 94/60 HR NSR 96-97% on 2L. She
was given Prednisone 20mg PO and Decadron 4mg IV for presumed
adrenal suppression. She also received CeftriaXONE 1g IV and
Levofloxacin 500mg IV. She was started on Norepinephrine for BP
support after receiving 4L NS and a LIJ was placed under sterile
conditions. CTA (-) for PE, and on echo in ED no significant
pericardial effusion was noted. U/A negative, and no changes
were noted on EKG.
.
Past Medical History:
Stage IV nonsmall cell lung cancer- c/b mets to brain, s/p
brain XRT
# bilateral posterior stroke with resultant blurry vision
# HTN
# Hyperlipidemia
# Anxiety
# Gerd
# Degenerative disc disease
Social History:
Lives in [**Location 8641**], NH with husband [**Name (NI) **].
1 daughter who has three children.
1 PPD for 37 years - quit at time of NSCLC dx.
Rare ETOH. No illicits.
Family History:
Mother passed away from complications related to heart valve
replacement. Father passed away at age 42 from heart disease.
Brother has HTN, Hypercholesterolemia.
Physical Exam:
VS: Temp: 9 BP: 113/60 HR: 66 RR: 20 O2sat98%4LNC
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: crackles in bases BL, o/w CTA w/o RRW
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: Alert, has word-finding difficulty says [**Hospital3 328**] to
place, [**2103**] to year, "[**Doctor Last Name **]" to president. Cn II-XII intact.
5/5 strength throughout. No sensory deficits to light touch
appreciated. No visual field defects noted.
.
Pertinent Results:
LABS ON ADMISSION
[**2103-2-22**] 01:20PM WBC-7.4 RBC-4.10* HGB-12.7 HCT-37.3 MCV-91
MCH-31.1 MCHC-34.1 RDW-13.3
[**2103-2-22**] 01:20PM PLT COUNT-281
[**2103-2-22**] 01:20PM GRAN CT-6880
[**2103-2-22**] 01:20PM ALT(SGPT)-98* AST(SGOT)-75* CK(CPK)-101 ALK
PHOS-95 TOT BILI-0.8
[**2103-2-22**] 01:20PM CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-2.3
[**2103-2-22**] 01:20PM UREA N-47* CREAT-1.5* SODIUM-133
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-26 ANION GAP-16
[**2103-2-22**] 04:45PM CK-MB-6 cTropnT-0.09*
[**2103-2-22**] 04:45PM CK(CPK)-101
[**2103-2-22**] 04:55PM LACTATE-1.2
[**2103-2-22**] 05:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2103-2-22**] 05:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0
LEUK-NEG
[**2103-2-22**] 05:25PM URINE RBC-[**4-11**]* WBC-3 BACTERIA-MOD YEAST-NONE
EPI-1 RENAL EPI-0-2
[**2103-2-22**] 05:25PM URINE GRANULAR-2*
IMAGING
CXR [**2-22**] - 1. No acute cardiopulmonary process.
2. Known left upper lobe spiculated mass concerning for
malignancy is not
clearly visualized. Please refer to the CT torso from [**2103-2-10**]
for additional details.
CTA chest [**2-22**] - 1. Linear filling defect within a subsegmental
branch of the superior segment of the right pulmonary artery
likely attributable to motion artifact. The finding represents
a true pulmonary embolus, the size and location of the filling
defect make it of doubtful clinical significance. No evidence
of aortic dissection.
2. 14-mm spiculated left upper lobe nodule with mediastinal and
left hilar lymphadenopathy consistent with history of
non-small-cell lung cancer.
CXR [**2-24**] - No significant interval change versus prior with no
evidence for acute cardiopulmonary disease.
MRI head [**2-27**] - Evolving lesions in bilateral occipital lobes
and centrum semiovale bilaterally, differential is unchanged and
includes PRES or embolic ischemia/vasculitis. No new lesions are
identified.
.
MRI spine [**3-2**]: results pending at time of discharge
.
DICHARGE LABS:
CBC:
WBC-7.2 RBC-3.02* Hgb-9.6* Hct-27.5* MCV-91 MCH-31.7 MCHC-34.8
RDW-14.1 Plt Ct-277
.
CHEM:
Glucose-82 UreaN-31* Creat-0.6 Na-136 K-3.9 Cl-99 HCO3-27
AnGap-14 Albumin-2.9* Calcium-8.5 Phos-4.0 Mg-1.9
Brief Hospital Course:
This is a 60 yo F with history of NSCLC complicated by brain
mets recently discharged after admission for stroke now
presenting with hypotension.
# Hypotension - The patient was initially bolused 4 L IVF in
the ED without much response in her BPs and was placed on
levophed gtt on arrival to the ICU. She was given 2 L of
additional IVF boluses with success in weaning her off levophed.
The differential diagnosis included dehydration [**3-10**] poor po
intake, infection, adrenal insufficiency, or possible PE. A
chest CTA was negative for PE. Cardiac ischemia was unlikely
given a EKG without ischemic changes. The patient did have
elevated troponins, but in the setting of flat CKs and renal
failure. Infection was unlikely given a negative CXR, negative
UA and lack of fevers. She was given stress doses of IV
dexamethasone for likely adrenal insufficiency (pt on steroids
at home due to brain mets, has not tolerated decreases in
steroid doses in past). At the time of transfer out of the ICU,
the patient had no longer required pressors for BP support for >
48 hours. On the oncology floor, the endocrinology service was
consulted and felt strongly that this was not adrenal
insufficiency since she was still taking large dose of steroids
at home. She was slowly weaned off of her steroids by 4 mg
weekly. There were no subsequent episodes of hypotension. All of
her antihypertensives were held during her stay and on
discharge.
# Elevated troponins - In setting of ARF, EKG w/o ischemic
changes. There were no episodes of chest pain during her stay.
# Confusion/word finding difficulty/blurry vision - Likely
residual from bilateral occipital strokes. Continued on
dipyridamole and full dose ASA. A repeat MRI brain showed
evolution of the lesions consistent with either stroke or
posterior reversible encephalopathy syndrome (PRES). Neurology
felt that patient exhibited signs of lower [**Last Name (un) 75355**] neuron weakness
consistent with possible steroid-induced myopathy. An MRI spine
was performed which was pending at time of discharge.
# ARF - On presentation, Cr 1.3, up from baseline Cr 0.8. This
resolved with IVFs.
# NSCLC - Stage IV c/b mets to brain, s/p brain whole brain
XRT. The patient was followed by her oncologist during ICU
admission. After her ICU stay, she was begun on chemotherapy
with her first round of carbplatin and gemcytabine on [**3-1**]. She
tolerated this well with no nausea or vomiting.
# Cough - No evidence of infection on imaging, afebrile.
Finished a 5 day course of azithromycin for presumed bronchitis.
Then started on cough suppressants prn.
.
# Hyperlipidemia: Continued outpt crestor and zetia
# HTN: Held home anti-hypertensives given hypotension.
# Code: pt confirmed DNR/DNI on this admission.
Medications on Admission:
ATACAND 16 mg daily
ATENOLOL 100 mg daily
DEXAMETHASONE 4 mg [**Hospital1 **]
PROTONIX 40 mg daily
Triamterene-Hydrochlorothiazid 37.5 mg-25 mg daily
ZETIA 10 mg daily
CRESTOR 40 mg daily
Dipyridamole-Aspirin 25 mg-200 mg one capsule twice per day
Discharge Medications:
1. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
2. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for nausea/anxiety.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
6. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**6-16**]
MLs PO Q6H (every 6 hours) as needed.
8. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
14. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): taper as follows:
4mg tid until [**3-8**], then 4mg [**Hospital1 **] for 7 days, then 4mg daily for
7 days, then off.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Hypotension NOS
.
Secondary:
# Stage IV nonsmall cell lung cancer- c/b mets to brain, s/p
brain XRT
# bilateral posterior stroke with resultant blurry vision
# HTN
# Hyperlipidemia
# Anxiety
# Gerd
# Degenerative disc disease
# Microhematuria
Discharge Condition:
stable, improved
Discharge Instructions:
You were admitted with weakness and low blood pressure. You were
very briefly on medicines to help keep your blood pressure up,
but these were quickly stopped. We checked for any sign of
infection to explain your low blood pressure, but there were
none. We stopped all of your anti-hypertensive mecidine and gave
you IV fluid to help supprt your blood pressure. We also put you
back on high dose steroids, which will be tapered down as
before.
.
While here you had an MRI of your head that showed stable,
largely resolved brain metastases, as well as what looks like
your old stroke. You were seen by our neurologists to assess
your stroke, and they recommended no changes in management.
.
Your oncology team felt that we should restart your chemotherapy
during your stay. You had your first dose on [**2103-3-1**].
.
Our physical therapists and occupational therapists all saw you
and recommended that you go to rhab in order to regain your
strength.
.
Please take all of your medicines as prescribed. Please keep all
of your outpatient appointments. If you experience any symptoms
which concern you, such as fevers/chills, shortness of breath,
or excessive nausea and vomiting, please call your doctor or go
to the ED.
Followup Instructions:
Please follow up with your oncology team:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 17488**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2103-3-8**] 2:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2103-3-8**]
2:00
Provider: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2103-3-8**] 3:00
.
Please call to make an appointment with our
Neuro-Ophthalmologist Dr. [**Last Name (STitle) **]: ([**Telephone/Fax (1) 5120**]
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
|
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"458.9",
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"198.3",
"041.19",
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"599.0",
"511.9",
"162.8",
"401.9",
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icd9cm
|
[
[
[]
]
] |
[
"99.25",
"38.93"
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icd9pcs
|
[
[
[]
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9942, 10021
|
5418, 8187
|
279, 321
|
10317, 10336
|
3114, 5395
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|
2207, 2371
|
8486, 9919
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10360, 11582
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2386, 3095
|
228, 241
|
349, 1784
|
1807, 2003
|
2019, 2191
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,578
| 110,184
|
3410
|
Discharge summary
|
report
|
Admission Date: [**2140-12-22**] Discharge Date: [**2141-1-5**]
Date of Birth: [**2060-11-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
hypoxemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 15676**] is a 80 year old Russian-speaking female with 45
admissions since [**2131**] and with a history of diastolic CHF, COPD
(5L home oxygen), HTN, pulmonary hypertension, A. Fib,
obstructive sleep apnea, renal insufficiency, bilateral lower
extremity discomfort, and an atrial septal defect. She is a poor
historian and information was obtained in part from her medical
record. Ms. [**Known lastname 15676**] was admitted on [**2140-12-22**] for hypoxia and
reported recent orthopnea and paroxysmal nocturia dyspnea, but
[**Date Range 15797**] fever/chills, N/V/D, chest pain or cough.
.
In the ED, Ms. [**Known lastname 15798**] initial vitals were: T: 98, P: 60,
BP: 145/60, R: 20, O2 Sat: 100% on NRB. A [**2140-12-22**] CXR indicated
unchanged cardiomegaly and low lung volumes as well as mild
pulmonary edema. Lasix (80 mg IV) was given which led to some
improvement in her symptoms. Ms. [**Known lastname 15676**] received IV Vanco,
but refused Bipap.
.
In the MICU, Ms. [**Known lastname 15676**] was given additional Lasix (80 mg
IVx2) which led to a diuresis of a 3.2 L. A [**2140-12-22**] ECG revealed
left axis deviation, non-specific intraventricular conduction
delay and non-specific ST-T wave changes -- findings considered
to be similiar to her [**2140-11-20**] ECG. A [**2140-12-23**] CXR indicated mild
edema, mostly in her right lung as well as a possible small
right pleural effusion. She received 6L of O2 as well as
morphine sulfate (2-4 mg) for her left lower extremity pain. She
weighed 103.7 kg (228.1 lbs) when she was transfered to [**Doctor Last Name **].
.
When she was transfered to [**Doctor Last Name **] on [**2140-12-23**], Ms. [**Known lastname 15798**]
vitals were: T96.9 BP 110/56 HR 65 RR 28 O2 86-88% on 6L. Her
heart rate was paced and her oxygen was weaned down to 5L, her
pre-admission level. Her [**2140-12-24**] CXR revealed findings consistent
with worsening CHF as well as an increased density at the right
base suggestive of pneumonia or pulmonary edema. While on
[**Doctor Last Name **], Ms. [**Known lastname 15676**] [**Last Name (Titles) 15797**] SOB, chest pain/tightness, and
mentated appropriately.
Past Medical History:
#HYPERTENSION
#DIASTOLIC CONGESTIVE HEART FAILURE
-estimated dry weight of 94kg
-last TTE [**4-/2140**]; LVEF >55%; 3+ tricuspid regurg
#ATRIAL FIBRILLATION
-s/p cardioversion x 2
-previously on amiodarone, discontinued due to paced rhythm
during hospitalization in [**2140-4-23**]
-not anticoagulated due to history of hemorrhagic CVA
#PULMONARY HYPERTENSION
-RSVP 75 in [**11/2139**]
-thought secondary to longstanding ASD
#COPD
-home O2 (5L NC)
-baseline saturation high 80's-low 90's on 5L O2
#OSA,
-nonadherent to CPAP therapy
Microcytic anemia
#CHRONIC RENAL INSUFFICIENCY
-baseline Cr 2-2.5
#GERD
#ATRIAL SEPTAL DEFECT
- s/p repair [**6-/2133**]
- complicated by sinus arrest
- with PPM placement. #Hypothyroidism
#Hx of hemorrhagic CVA on Coumadin
#Hx of Gallstone pancreatitis s/p ERCP, sphincterotomy
#Frequent hospitalizations
-admitted almost monthly since [**2132**]
#Surgeries
-s/p APPY
-s/p CHOLE ([**2133**])
-s/p TAH/BSO ([**2133**] for fibroids)
Social History:
Lives alone. Daughter-in-law visits frequently and helps out
around house and c groceries. VNA comes once a week to set
medications out in a pill box. No tob, EtOH, IVDU.
Family History:
NC
Physical Exam:
Vitals: T: 96.9 BP: 110/56 P: 65 R: 28 O2: 86-88% on 6L
General: NAD, alert and able to express simple commands
HEENT: Sclera anicteric, no conjunctivitis, poor dentition
Neck: Appropriate ROM, unable to assess JVP
Lungs: Bilateral crackles in lower 2/3rds of posterior lung
fields
Heart: Regular rhythm, 2/6 SEM at LUSB, no gallops or rubs
Ext: RLE/LLE: 2+ pitting edema, erythema and warmth; Erythema &
warmth greater in LLE than RLE.
Pertinent Results:
[**2140-12-22**] 01:01PM LACTATE-0.8
[**2140-12-22**] 01:03PM PT-13.9* PTT-28.3 INR(PT)-1.2*
[**2140-12-22**] 01:03PM PLT COUNT-154
[**2140-12-22**] 01:03PM NEUTS-74.0* LYMPHS-17.2* MONOS-6.3 EOS-2.2
BASOS-0.3
[**2140-12-22**] 01:03PM WBC-5.1 RBC-3.70* HGB-11.0* HCT-34.6* MCV-94
MCH-29.7 MCHC-31.7 RDW-16.0*
[**2140-12-22**] 01:03PM proBNP-3750*
[**2140-12-22**] 01:03PM estGFR-Using this
[**2140-12-22**] 01:03PM GLUCOSE-111* UREA N-60* CREAT-1.9* SODIUM-144
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-38* ANION GAP-11
[**2140-12-22**] 01:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2140-12-22**] 01:13PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2140-12-22**] 01:31PM O2 SAT-97
[**2140-12-22**] 01:31PM LACTATE-0.7 K+-4.1
[**2140-12-22**] 01:31PM TYPE-ART O2-96 PO2-109* PCO2-60* PH-7.36
TOTAL CO2-35* BASE XS-6 AADO2-537 REQ O2-87 COMMENTS-NRB
[**2140-12-22**] 04:18PM O2 SAT-91
[**2140-12-22**] 04:18PM TYPE-ART O2-90 O2 FLOW-4 PO2-65* PCO2-68*
PH-7.36 TOTAL CO2-40* BASE XS-9 AADO2-529 REQ O2-86
[**2140-12-22**] 10:25PM O2 SAT-18
[**2140-12-22**] 10:25PM LACTATE-1.3 TCO2-39*
[**2140-12-22**] 10:25PM TYPE-[**Last Name (un) **] PH-7.36
Brief Hospital Course:
1) Hypoxia: CHF exacerbation, likely a combination of medication
and fluid restriction non-compliance. The patient was afebrile
on admission making infection an unlikely etiology. Her CXR was
consistent with fluid overload. Also it may be the case that her
underlying pulmonary HTN/cor pulmonale is worse (she has not
been followed in pulmonary clinic as an outpatient for some
time). She also has COPD, however given absence of wheezing,
cough, or sputum production COPD exacerbation was not thought to
be the cause of her hypoxemia. In the ICU, IV lasix was started
and the patient diuresed 3.2L. She required oxygen via nasal
cannula, up to 6L to maintain O2 Sat between 84-91%. Once stable
she was transferred to the medical service. Combivent nebulizer
treatments, tiotropium were continued for her COPD. Her
metoprolol was increased and lasix was started on 80po daily and
IV as needed for further diuresis. She was maintained on O2
nasal cannula between 5-6L and did not use cpap at night. She
did well for 3 days on the medical service but began to be more
somnolent and again was hypoxic on exam and ABG. Pain medication
was held (percocet, fentanyl patch) but this did not improve her
mental status. She was transferred back to the ICU and further
diuresed 2L on lasix drip, acetazolamide (for metabolic
alkalosis) and bumex, and maintained on bipap (the patient
intermittently refused). She was also started on digoxin at
0.125mg qd for her RV disfunction. Her respiratory status
improved significantly. Once transferred back to the floor it
became clear that, once off bipap or cpap for an extended amount
of time she becomes sleepy. Bipap was ordered for use overnight.
The patient refused several times however once she would become
more tired and less alert she was amenable to using the mask.
This immediately improved her respiratory status, and in the
morning she would be able to tolerate nasal cannula with
improved saturation. During rehabilitation she would benefit
from cpap (or bipap if available) at night and nasal cannula
during the day.
.
2) Lower Extremity Erythema & Pain: Chronic [**Doctor First Name 15799**] statis issues
for several months. There were no open wounds concerning for
active infection. The patient remained afebrile. Her edema
improved with diuresis and compression stockings, topical
ointment and leg elevation. Her pain was treated with morphine
and percocet as needed, however given her somnolence from
hypoxia/hypercarbia this was switched to a fentanyl patch. A
wound care consult was called to ensure proper treatment of her
skin. Her pain improved and the fentanyl patch was discontinued,
also given her altering mental status at times. On discharge she
was not complaining of pain, however if this continues to be an
issue it would be reasonable to restart a fentanyl patch at low
dose.
.
3) Atrial fibrillation: Patient currently paced in the 60s. No
[**Doctor First Name **] due to prior hemmorhagic CVA on Coumadin. Her
pacemaker was interrogated and found to be functioning well
without recent episodes of arrhythmia. She was continued on
metoprolol and digoxin, and remained on telemetry during
admission.
.
4) Pulmonary Hypertension: It is likely that this is a large
contributor to her hypoxia and worsening pulmonary status. She
would benefit greatly from complying with her cpap while at
home. She was previously followed in pulmonary clinic but was
not compliant with treatment. She would benefit from a sleep
study once stable to establish her new NIPPV settings and
perhaps a more comfortable mask for home. In the future she
could potentially be started on sildenafil if appropriate.
.
5) Hypothyroidism: During her ICU stay TSH was 5.0. Her
synthroid was increased to 112mcg.
.
6) Nutrition: Continue cardiac heart healthy diet and fluid
restriction of 1200ml/day. She required potassium repletion
intermittently over the course of her admission.
.
7) Code: Full code.
.
8) Follow-up: appointment with Dr.[**Last Name (STitle) 3357**] on [**1-12**] 12:15pm. She
would benefit from pulmonary clinic follow-up for a sleep study
if agreeable.
.
Medications on Admission:
Metoprolol 12.5mg [**Hospital1 **]
Aspirin 81 mg daily
Paroxetine 10mg daily
Calcium Acetate 667 mg TID with meals
Ferrous Sulfate 325 mg daily
Senna 8.6 mg [**Hospital1 **]
Levothyroxine 100 mcg daily
Furosemide 80 mg [**Hospital1 **]
Tiotropium Bromide 18 mcg daily
Gabapentin 100 mg (3 tabs qam and 1 tab qpm)
.
Discharge Medications:
1. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
[**11-18**] Caps Inhalation DAILY (Daily).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-18**] Sprays Nasal
QID (4 times a day) as needed.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed.
12. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary: Acute exacerbation of chronic diastolic congestive
heart failure
Secondary: Chronic obstructive pulmonary disease, atrial
fibrillation, hypertension, pulmonary hypertension, chronic
renal insufficiency, obstructive sleep apnea, hypothyroidism
Discharge Condition:
Stable, with 5L Oxygen Requirement
Discharge Instructions:
You were admitted to the hospital because your heart failure was
worsening and you were having trouble breathing. Your condition
improved with medications to remove water from your body and
with oxygen. It is very important that you use your oxygen all
the time at
home. It is also very important that you take all of your
medications as prescribed.
It is important that you weigh yourself every morning and call
Dr. [**Last Name (STitle) 3357**] at ([**Telephone/Fax (1) 4606**]) if your weight increases by more
than 3 pounds.
You must also have a healthy diet and can not eat more than 2
grams of sodium each day. If you eat more salt than this, your
body will start storing up fluid and you may problems breathing,
requiring another admission to the hospital.
Because of your heart failure, it is important that you limit
the amount of liquids that you take, including ice. You should
not take more than 1.2 Liter of fluids each day.
Please return to the emergency room if you have worsening
trouble breathing or chest pain. You should seek medical
attention if you have fevers and chills or other symptoms that
are concerning
to you. The emergency room is open 24 hours every day.
Followup Instructions:
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 3357**]. Please call [**Telephone/Fax (1) 4606**] if
you need to change your appointment.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
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"403.90",
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"V45.01",
"428.0",
"244.9",
"585.9",
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icd9cm
|
[
[
[]
]
] |
[
"89.45"
] |
icd9pcs
|
[
[
[]
]
] |
11432, 11502
|
5504, 9622
|
325, 332
|
11801, 11838
|
4212, 5481
|
13107, 13342
|
3735, 3739
|
9988, 11409
|
11523, 11780
|
9648, 9965
|
11862, 13060
|
3754, 4193
|
276, 287
|
360, 2542
|
2564, 3530
|
3546, 3719
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,339
| 114,909
|
37410
|
Discharge summary
|
report
|
Admission Date: [**2194-12-24**] Discharge Date: [**2194-12-28**]
Date of Birth: [**2140-11-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
Patient is a 54 yo M with h/o hypertension and asthma who
presents with BRBPR after colonscopy with biposy yesterday. He
had a repeat colonscopy for the purpose of polypectomy
yesterday. He had a sessile 2 x 3.5 cm polyp in the cecum that
was biopsied. He woke up this morning with some lower abdominal
cramping that was somewhat relieved by passing gas. He had a
normal, brown bowel movement this morning. Then at 4PM, he
developed further abdominal cramping and when he went on the
toilet he noted fresh blood, no clots. Then while he was
driving, he had crampy abdominal pain, felt dizzy, and was
incontinent of blood clots.
.
He presented to Sturdy ED. HCT was 38.1. He was hemodynamically
stable. He was transferred to [**Hospital1 18**] given his procedure here.
.
In the [**Hospital1 18**] ED, initial VS were: 98.8, 98, 134/88, 14, 100% RA.
During his ED visit, he became diaphoretic, nauseous and BP fell
to 67/48. His SBP came up to 120s during a fluid bolus. Bloody
stool was noted on the pad. HCT was 35.9. Coags were normal. He
has received about 2L IVFs and 2 units PRBCs. GI has been
consulted and is requesting a prep (Golytely) for tomorrow. For
access, he has 2 18 and 1 16 PIVS. VS on transfer are: 86,
120/82, 17, 97%.
.
(+) Per HPI + urinary retention
(-) Denies fever, chills, headache, shortness of breath,
wheezing, chest pain, palpitations. Denies dysuria, frequency,
or urgency.
Past Medical History:
1. Hypertension
2. Asthma
3. H/o colonic polyps
Social History:
Patient is a truck driver. He denies any tobacco, etoh, and IVDA
Family History:
Colon cancer and polpys on both sides of the family
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
Orthostatics: supine 81, 152/80; sitting 94, 129/93
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, RLQ tender to palpation, no guarding, no rebound,
non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2194-12-24**] 09:43PM BLOOD WBC-15.4* RBC-4.23* Hgb-12.3* Hct-35.9*
MCV-85 MCH-29.0 MCHC-34.1 RDW-12.6 Plt Ct-285
[**2194-12-25**] 05:47AM BLOOD WBC-16.8* RBC-4.02* Hgb-12.0* Hct-34.0*
MCV-84 MCH-29.9 MCHC-35.4* RDW-12.7 Plt Ct-215
[**2194-12-26**] 04:07AM BLOOD WBC-11.8* RBC-4.02* Hgb-12.2* Hct-34.7*
MCV-86 MCH-30.3 MCHC-35.0 RDW-12.9 Plt Ct-179
[**2194-12-24**] 09:43PM BLOOD PT-12.9 PTT-22.1 INR(PT)-1.1
[**2194-12-24**] 09:43PM BLOOD Glucose-167* UreaN-15 Creat-0.8 Na-138
K-4.6 Cl-106 HCO3-23 AnGap-14
[**2194-12-25**] 05:47AM BLOOD Glucose-130* UreaN-17 Creat-0.7 Na-140
K-3.9 Cl-105 HCO3-23 AnGap-16
[**2194-12-26**] 04:07AM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-139
K-3.6 Cl-105 HCO3-24 AnGap-14
Colonoscopy:
Ulcer in the cecum at the site of previous polypectomy - three
endosocpic clips were applied for hemostasis. Blood in the whole
colon
Brief Hospital Course:
54 yo M who presents with BRBPR after colonoscopy with
polypectomy.
GI Bleed / Acute blood loss anemia.
He was initially admitted to the MICU. He was transfused four
units of pRBCs with stabilization of his hematocrit. GI was
consulted and performed colonoscopy on admission to the ICU; a
large ulcer was found at site of polypectomy with bright red
blood throughout the colon; the ulcer was clipped and hemostasis
was attained.
He had a fever and leukocytosis and this was likely in the
setting of stress but he was placed on emipiric antibiotics x 48
hours to cover GI organisms (amp, cipro, flagyl). These were
quickly peeled off as he defervesed. He was transferred to the
general medical [**Hospital1 **] on hospital day 3 where he remained stable
and his leukocytosis resolved.
HTN, benign: His lisinopril was resumed prior to discharge.
Asthma, without exacerbation: His advair was continued.
Medications on Admission:
Lisinopril 10 mg daily
Advair
Albuterol prn
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Outpatient Lab Work
[**2194-12-31**]: Please check CBC.
Results to: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 275**], [**Location (un) **],
[**Location (un) **],[**Numeric Identifier 6698**], [**Hospital1 **] HEALTHCARE -
[**Location (un) **] phone: [**Telephone/Fax (1) 6699**] Fax: [**Telephone/Fax (1) 84090**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: cecal ulcer secondary to post-polypectomy bleed
Secondary: asthma, benign hypertension
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted because you were bleeding from your rectum.
You had another colonoscopy and you had an ulcer where the polyp
was removed. This was clipped by the endoscopist. You required
blood transfusion due to the bleeding (4 units of red cells);
following the transfusion your counts remained stable.
Do not take any advil, aleve, aspirin or other NSAIDs for 72
hours. You may take Tylenol if needed.
Followup Instructions:
Follow up with your PCP this week. You need to have repeat
blood work at this visit.
Due to the large size of the polyp, you should have a repeat
colonoscopy with Dr. [**Last Name (STitle) **] in 6 months to make sure that there
is no residual polyp at the site where this large polyp was
removed. Please call ([**Telephone/Fax (1) 2306**] to schedule your repeat
colonoscopy with anesthesia.
|
[
"998.11",
"788.20",
"288.60",
"493.90",
"780.62",
"401.1",
"E878.8",
"285.1",
"780.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
5031, 5037
|
3446, 4352
|
324, 337
|
5177, 5177
|
2562, 3423
|
5786, 6185
|
1942, 1995
|
4447, 5008
|
5058, 5156
|
4378, 4424
|
5321, 5763
|
2010, 2543
|
279, 286
|
365, 1772
|
5191, 5297
|
1794, 1844
|
1860, 1926
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,441
| 159,470
|
27617
|
Discharge summary
|
report
|
Admission Date: [**2180-4-7**] Discharge Date: [**2180-4-11**]
Date of Birth: [**2147-6-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
Alcohol intoxication
Suicidal Ideation
Alcoholic ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
32M with hx ETOH BIBA after telling family he wanted to kill
himself. Per the pt his father noticed he was drinking too much
and had him call his PCP who called an ambulance. The patient
was hospitalized at the end of [**Month (only) 404**] at this hospital for ETOH
withdrawl. States that he has had episodes of withdrawl with
hallucinations before, but denies withdrawl seizures. Has been
in rehab several times, last 5 years ago, after which his
longest sober period was 98 days. Prior to entering rehab the pt
admitted to consuming isopropyl alcohol. He denies any recent
injestion of other alcholic beverages other than vodka. He has
been drinking 2 large bottles of vodka a day for the past two
weeks. Last drink was this am. He is unable to explain why he is
drinking more, does state that he is depressed and that he was
trying to drink himself to death. States that he took some of
his prescribed medications, notably tramadol, up to 3 at a time
over the past few days (per ED report took 120 pills over 3
days), also took 7 lunesta tabs the night before for insomnia.
He thinks the last thing he ate was [**First Name8 (NamePattern2) **] [**Location (un) 2452**] yesterday and is
unable to recall anything before that.
.
On ROS pt has a HA, nausea, abdominal pain, occasional
palpitations. Denies shortness of breath, shakes, chest pain,
vomiting, constipation. Has had diarrhea for the past 2 days, 3
times per day, doesn't know if there was melena or BPBPR. Had
one episode in the past of an UGIB ~ 2 years ago. Reports slight
dysuria with urination.
.
In ED VS100.6 134 120/110 22 94% RA
Given banana bag, MVI, thiamine, folate, ativan, magnesium. ETOH
level 327, urine methadone +. AG of 36.
Past Medical History:
Chronic Alcholism
ETOH cirrhosis
? fatty liver disease
Hypertension
Anxiety
Social History:
Lives in [**Location **] in an apartment with one roomate. Currently
employed as an administratory at BU. Denies smoking or illicit
drug use. No hx of IVDU. Drinks 2 bottles vodka per day.
Family History:
Uncle and Grandfather died of chronic alcoholism
Mother: Hx. MI, CAD. HTN. No DM or cancer.
Father: HTN, no DM, CAD or Cancers.
Physical Exam:
VS: Temp: BP:133/70 HR:119 RR:17 O2sat96% RA
GEN: Comfortable, flat affect, oriented
HEENT:pupils symmetric, dilated ~4cm, minimally responsive to
light. EOMI. MM dry. no scleral icterus
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g, tachycardia
ABD: mildly distended. Tender to palpation diffusely. + BS
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: Awake, alert and oriented. Flat affect. Pupils dilated
and minimally responsive.
Pertinent Results:
ADMISSION LABS
.
[**2180-4-7**] 04:10PM BLOOD WBC-6.3# RBC-4.69# Hgb-14.2 Hct-42.1
MCV-90 MCH-30.4 MCHC-33.8 RDW-14.2 Plt Ct-445*#
[**2180-4-7**] 04:10PM BLOOD Plt Ct-445*#
[**2180-4-7**] 04:10PM BLOOD Glucose-64* UreaN-14 Creat-1.1 Na-141
K-5.1 Cl-91* HCO3-19* AnGap-36*
[**2180-4-7**] 07:40PM BLOOD ALT-36 AST-58* LD(LDH)-186 AlkPhos-129*
Amylase-91 TotBili-0.4
[**2180-4-7**] 07:40PM BLOOD Lipase-40
[**2180-4-7**] 07:40PM BLOOD Albumin-4.5 Calcium-8.0* Phos-1.5*#
Mg-2.7*
[**2180-4-11**] 05:25AM BLOOD calTIBC-332 Ferritn-120 TRF-255
[**2180-4-7**] 04:10PM BLOOD Osmolal-376*
[**2180-4-7**] 04:10PM BLOOD ASA-NEG Ethanol-327* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2180-4-8**] 02:04AM BLOOD Type-[**Last Name (un) **] Temp-36.1 pO2-48* pCO2-35
pH-7.43 calTCO2-24 Base XS-0
[**2180-4-8**] 02:04AM BLOOD Lactate-3.8*
DISCHARGE LABS
.
[**2180-4-11**] 05:25AM BLOOD WBC-6.0 RBC-3.92* Hgb-11.8* Hct-35.4*
MCV-91 MCH-30.1 MCHC-33.3 RDW-14.2 Plt Ct-187
[**2180-4-11**] 05:25AM BLOOD Plt Ct-187
[**2180-4-11**] 05:25AM BLOOD Glucose-128* UreaN-10 Creat-0.8 Na-141
K-3.6 Cl-106 HCO3-26 AnGap-13
[**2180-4-11**] 05:25AM BLOOD Mg-1.7 Iron-28*
RADIOLOGY Final Report
.
CHEST (PA & LAT) [**2180-4-7**] 5:41
FINDINGS: Lung volumes are mildly diminished. No consolidation
or edema is evident. The mediastinum is unremarkable. The
cardiac silhouette is within normal limits for size. No effusion
or pneumothorax is evident. The visualized osseous structures
are unremarkable.
.
IMPRESSION: No acute pulmonary process.
Brief Hospital Course:
Patient is a 32 y/o male w/ alcohol abuse history who was
admitted to the MICU for alcohol intoxication, AG acidosis, and
CIWA measures. Pt has been to rehab multiple times in the past 5
years. Most recently in [**Month (only) 404**]. Prior to entering substance
abuse rehab in [**Name (NI) 404**], pt drank 2 bottles of isopropyl etoh.
Most recently pt has been drinking two bottles of vodka per day.
Patients story of whether or not he was trying to commit suicide
constantly changed. Pt adamantly denied suicide attempt or
ideation when coming out of the ICU. He did admit to being
depressed. Pt initially brought to hospital (per pt), because he
complained of feeling physically worse than usual to his father.
Father was concerned at patients increased etoh intake, called
physician who recommended calling ambulance.
.
In the ICU patients AG acidosis, closed, he was detoxed with
diazepam, and received IV hydration.
.
# Anion Gap Acidosis: Patient presented with alcoholic
ketoacidosis. He had an osmolar gap of 13 correcting for serum
ETOH. AG has been closing on hydration alone, had small ketones
in serum and urine. Other tox screens negative (ex for methadone
in urine), per tox unlikely to be other injestion causing AG
given that it closed with only IVF. Pt had normal anion gap at
discharge.
.
# Alcohol intoxication/Abuse disorder:
Patient denies prior withdrawal seizures, but admits to
hallucinations on prior detox attempts. Patient was placed on a
diazepam CIWA scale. Patient was weaned off of diazepam, prior
to discharge. CIWAs were zero prior to discharge. Pt received
supplemental MVI, thiamine, B12. He was seen by social work and
decided he wanted to try another addictions inpatient program.
Pt was discharged home for one day to a safe environment, his
parents house. The following day he was scheduled to enter a 30
day addictions program.
.
#Suicidal ideation: There were numerous account as to whether or
not this was a suicide attempt. Once sober patient continued to
deny that this was a suicide attempt. Psychiatry was consulted.
They felt that patient was not acutely suicidal. Pt continued to
deny SI or plans for attempt. Psych felt patient was safe for
discharge.
.
#Liver dz: Pt has a history of fatty liver. No signs of
fulminant failure. Pt was instructed to follow up with this
issue as an outpatient.
.
Patient was to follow up as is indicated in discharge paperwork.
Medications on Admission:
Medications:
Gabapentin 800mg TID
Tramadol 50mg tab Q4-6 hours
Duloxetine 20mg daily
alprazolam 0.5mg QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Alcohol intoxication
Cirrhosis
.
Secondary Diagnosis:
Peripheral neuropathy
cirrhosis from NASH
Depression
Anxiety
Anemia
Discharge Condition:
Stable for discharge.
Discharge Instructions:
You were admitted with alcohol intoxication. You were given
Valium to prevent alcohol withdrawal. Please follow up with
rehab and remain abstinent as further alcohol use may damage
your liver.
.
You are going to be entering an alcohol rehab program, as a
result of this you will not be able to take any benzodiazepines
like xanax.
.
We have added several medications to your regimen.
Seroquel 25mg nightly for insomnia at night
Thiamine HCl 100 mg Tablet daily
Cyanocobalamin 100 mcg Tablet daily
Folic Acid 1 mg Tablet daily
Hexavitamin 1 tab daily
.
If you develop seizures, worsening abdominal pain, fevers,
bloody stools, bloody vomiting, or any other concerning
symptoms, please contact your doctor or report to the nearest
ER.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 67474**] to schedule follow up
after you leave rehab. Please follow up with Dr. [**Last Name (STitle) **] in
regards to your depression and liver disease.
|
[
"291.81",
"300.00",
"571.2",
"276.2",
"V62.84",
"303.01",
"401.9",
"356.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
7324, 7330
|
4754, 7167
|
376, 382
|
7515, 7539
|
3210, 4731
|
8328, 8552
|
2439, 2571
|
7351, 7351
|
7193, 7301
|
7563, 8305
|
2586, 3191
|
275, 338
|
410, 2118
|
7424, 7494
|
7370, 7403
|
2140, 2217
|
2233, 2423
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,398
| 167,309
|
23295
|
Discharge summary
|
report
|
Admission Date: [**2107-9-18**] Discharge Date: [**2107-9-29**]
Date of Birth: [**2059-8-12**] Sex: F
Service: MEDICINE
Allergies:
Nicotine / Bactrim
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Change in MS
Major Surgical or Invasive Procedure:
PICC line placement
Right femoral line placement
Arterial line placement
History of Present Illness:
48yo F with h/o HIV, HCV, autoimmune hepatitis, and cirrhosis
admitted from NH with one day of changing mental status.
normally patient is A&Ox3, walks, talks and was to be d/c'd from
rehab to home [**2107-9-17**]. One day PTA patient was noted to be
lethargic and needed help with her ADLs which is not normal for
her. At the rehab a CXR was done that showed RLL atelectasis and
labs were drawn. Over the night her mental status continued to
decrease and she was sent to the ED [**2107-9-18**].
.
In the ED on initial assessment she was in a lot of pain but
could not localize it. Her vitals were: T99.6 HR 108 BO 86/40
RR16 O2sat 100% on 2L NC. She was given 2L normal saline and BPs
rose to 100s/50s which is her baseline per NH records. A CXR,
blood cultures, urine cultures were drawn and she was given
vanco 1gmX1, zosyn 4.5gm X1, ceftriaxone 2gmX1 and acyclovir
500mg X1. An abdominal u/s was performed and revealed no ascites
so a peritoneal tap was not done. A Head CT was negative for an
acute process. The ammonia level came back elevated to 111 and
in the setting of an increased INR an LP was not done in the ED.
.
On arrival to the floor patient was confused and unable to give
a full history. She did deny headache, photophobia, neck pain,
abdominal pain and difficulty breathing.
Past Medical History:
1) HIV. Dx in [**2087**]. [**11-30**] CD4 327, VL <50. CD4 nadir 12. No h/o
OIs or malignancies, but episode of shingles in [**2099**]. Since
[**2098**], she was on HAART with fully suppressed HIV VL. Received
Pneumovax 2-3 years ago. Hep B vaccinated. last PPD 4 years ago
non-reactive.
2) HCV - ?genotype I, dxd [**2098**], liver biopsy with HCV
+autoimmune
hepatitis. She is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14429**] (hepatology) at
[**Hospital1 2177**] but Dr. [**Last Name (STitle) 497**] has coordinated her TIPS, possible transplant
(not currently on tx list); last VL 501,000
3) Autoimmune hepatitis - [**Doctor First Name **] positive with markedly
elevated IgG; treated with steroids only, as she developed
hepatotoxicity associated with azathioprine.
4) s/p Ex-lap & small bowel resection ([**12-30**])
5) possible polypoid mass in distal jejunum seen on capsule
endoscopy ([**2104-9-9**] at [**Hospital1 2177**]), likely source of bleed
5) s/p TIPS in [**6-30**] placed because of frequent GIB.
6) Portal gastropathy
7) Severe esophagitis
8) Zoster, [**2099**] without recurrence
9) H/o IVDU. Has not used since HIV dx in [**2087**].
Social History:
Married. Lives at home with husband normally. Past history of
heavy etoh use and IVDU. No use since HIV diagnosis. Smokes 1
ppd X 35 years. Former silk screen printer. Now unemployed.
Family History:
Brother with a-1 anti-trypsin deficiency s/p OLT. Both of her
parents are carriers, but do not have lung or liver disease.
Physical Exam:
Physical Examination
GEN: Lying in bed in NAD
HEENT: NC/AT. Right eye conjunctive injected.
LUNGS: CTAB anteriorly
HEART: RRR S1/S2 4/6 systolic murmur heard best at apex/LUSB
ABD: Colostomy bag draining green-brown stool. Stoma pink. NT.
EXTREM: Edema of upper and lower extremities. 2+. Biceps
reflexes 2+ BL. LE strength symmetric and [**4-30**] BL. LUE full ROM.
RUE unable to passively abduct shoulder past 90 degrees. Not
particularly warm, no erythema over R shoulder. TTP deltoid on
right.
NEURO: Alert and oriented X3.
Pertinent Results:
[**2107-9-18**]
CT HEAD:
No evidence for edema, mass effect, or areas of abnormal
attenuation to indicate an underlying mass. Please note CT has
limited
sensitivity to the detection of intracranial masses for which
gadolinium-
enhanced MRI is most suited. No acute intracranial process was
noted.
TTE:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. No masses or vegetations are seen on the
aortic valve. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. There is small vegetation on
the mitral valve. Moderate (2+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: there is a small (<0.5cm) mobile echodensity on the
posterior leaflet of the mitral valve that is most likely a
vegetation. No other vegetations or abscess seen. Moderate
mitral and tricuspid regurgitation. Compared with the report of
the prior study (images unavailable for review) of [**2104-1-11**],
the mitral valve vegetation was not noted on the prior study.
The degrees of mitral and tricuspid regurgitation and pulmonary
hypertension have increased.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2107-9-23**] 07:40AM 10.2 2.75* 9.3* 28.4* 103* 33.8* 32.7
18.6* 85*
[**2107-9-22**] 01:03PM 10.4 2.64* 8.9* 27.2* 103* 33.9* 32.9
18.6* 74*
[**2107-9-21**] 02:20PM 11.8* 2.67* 9.0* 27.4* 103* 33.8* 32.9
18.1* 84*
[**2107-9-20**] 04:37AM 9.3 2.29* 7.8* 23.1* 101* 34.2* 33.9
18.9* 72*
[**2107-9-20**] 02:03AM 9.5 2.21* 7.6* 21.8* 99* 34.2* 34.6 18.7*
69*
[**2107-9-19**] 02:39AM 18.1* 2.80* 9.4* 27.5* 98 33.8* 34.4
18.8* 79*
[**2107-9-18**] 08:36PM 18.6* 3.00* 10.0* 29.4* 98 33.2* 34.0
18.8* 80*
[**2107-9-18**] 02:45PM 21.0*# 3.15* 10.7* 30.7* 98# 33.8* 34.7
18.9* 104*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2107-9-21**] 02:20PM 95.1* 2.4* 2.3 0.1 0.1
[**2107-9-18**] 02:45PM 97* 1 1* 1* 0 0 0 0 0
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Stipple Tear Dr
[**2107-9-18**] 02:45PM NORMAL 1+ 1+ 1+ NORMAL 1+ OCCASIONAL
OCCASIONAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2107-9-23**] 07:40AM 85*
[**2107-9-23**] 07:40AM 17.0*1 40.6* 1.5*
[**2107-9-22**] 01:03PM 74*
[**2107-9-22**] 01:03PM 19.6* 43.1* 1.8*
[**2107-9-21**] 02:20PM 84*
[**2107-9-21**] 02:20PM 16.0*2 40.8* 1.4*
[**2107-9-20**] 04:37AM 72*
[**2107-9-20**] 02:03AM 69*
[**2107-9-20**] 02:03AM 18.9* 64.6* 1.7*
[**2107-9-19**] 05:07AM 18.3*2 50.2* 1.7*
[**2107-9-19**] 02:39AM 79*
[**2107-9-19**] 02:39AM 18.8* 53.2* 1.7*
[**2107-9-18**] 08:36PM LOW 80*3
[**2107-9-18**] 02:45PM LOW 104*
[**2107-9-18**] 02:45PM 19.6*2 45.7* 1.8*
MISCELLANEOUS HEMATOLOGY ESR
[**2107-9-22**] 01:03PM 103*
T LYMPHOCYTE SUBSET WBC Lymph Abs [**Last Name (un) **] CD3% Abs CD3 CD4% Abs CD4
CD8% Abs CD8 CD4/CD8
[**2107-9-18**] 08:49PM 21.0* 1* 210 35 73* 8 16* 23 48* 0.3*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2107-9-23**] 07:40AM 98 38* 0.91 142 3.7 112* 19* 15
[**2107-9-22**] 01:03PM 134* 41* 1.6*1 140 3.8 112* 19* 13
[**2107-9-21**] 02:20PM 181* 43* 1.4*1 138 3.7 108 19* 15
LFT'S ADDED 1503 [**2107-9-21**];ICTERIC SPECIMEN
[**2107-9-20**] 02:03AM 102 46* 1.7* 140 3.2* 108 21* 14
[**2107-9-19**] 02:39AM 111* 48* 1.8* 135 4.12 107 18* 14
[**2107-9-18**] 08:36PM 119* 48* 1.9* 133 4.0 105 20* 12
[**2107-9-18**] 02:45PM 175* 51* 2.3*# 129* 7.1*3 100 19* 17
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2107-9-23**] 07:40AM 40 52* 388* 116 21.0*
[**2107-9-22**] 01:03PM 41* 51* 354* 106 20.7*
[**2107-9-21**] 02:20PM 46* 61* 368* 106 18.4* 9.3* 9.1
LFT'S ADDED 1503 [**2107-9-21**];ICTERIC SPECIMEN
[**2107-9-20**] 02:03AM 32 60* 213 65 9.3*
[**2107-9-19**] 02:39AM 46*1 87*1 382* 93 6.7* SLIGHTLY
HEMOLYSED
[**2107-9-18**] 02:45PM 59*1 210*2 105 6.8* GROSS
HEMOLYSIS
OTHER ENZYMES & BILIRUBINS Lipase
[**2107-9-18**] 02:45PM 32
GROSS HEMOLYSIS
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2107-9-23**] 07:40AM 2.8* 9.9 2.5* 2.2
[**2107-9-22**] 01:03PM 3.0* 9.8 2.3* 2.2
Source: Line-PICCICTERIC SAMPLE
[**2107-9-21**] 02:20PM 3.5 10.1 1.9* 2.2
[**2107-9-20**] 02:03AM 9.4 2.8 2.1
[**2107-9-19**] 02:39AM 2.1* 8.2* 3.5 2.01 SLIGHTLY
HEMOLYSED
[**2107-9-18**] 08:36PM 8.6 2.9 2.1
[**2107-9-18**] 02:45PM 2.4* GROSS HEMOLYSIS
OTHER CHEMISTRY Ammonia
[**2107-9-18**] 06:00PM 111*
IMMUNOLOGY CRP
[**2107-9-22**] 01:03PM 117.4*
ANTIBIOTICS Vanco
[**2107-9-23**] 07:40AM 36.0*
Source: Line-PICC
[**2107-9-20**] 02:03AM 10.9
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pH
Comment
[**2107-9-18**] 08:46PM [**Last Name (un) **] 7.30*
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate K
[**2107-9-19**] 05:17AM 2.2*
[**2107-9-18**] 08:46PM 2.4*
[**2107-9-18**] 04:21PM 4.1
[**2107-9-18**] 02:58PM 3.5*
CALCIUM freeCa
[**2107-9-18**] 08:46PM 1.20
**FINAL REPORT [**2107-9-19**]**
HIV-1 Viral Load/Ultrasensitive (Final [**2107-9-19**]):
679 copies/ml.
Performed by real-time PCR.
Detection range: 48 - 10,000,000 copies/ml.
[**2107-9-18**] 2:45 pm BLOOD CULTURE
**FINAL REPORT [**2107-9-21**]**
Blood Culture, Routine (Final [**2107-9-21**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2107-9-18**] 6:30 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2107-9-20**]**
URINE CULTURE (Final [**2107-9-20**]):
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2107-9-18**] 02:58PM BLOOD Lactate-3.5*
[**2107-9-18**] 10:07PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
[**2107-9-18**] 10:07PM URINE RBC-3* WBC-9* Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
[**2107-9-18**] 10:07PM URINE Hours-RANDOM Creat-34 Na-34 K-38
[**2107-9-18**] 10:07PM URINE Osmolal-286
[**2107-9-20**] 2:06 pm JOINT FLUID Source: shoulder.
**FINAL REPORT [**2107-9-23**]**
GRAM STAIN (Final [**2107-9-20**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2107-9-23**]): NO GROWTH.
[**2107-9-21**] 6:45 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 59815**] [**2107-9-18**].
Aerobic Bottle Gram Stain (Final [**2107-9-23**]):
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2107-9-23**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Brief Hospital Course:
This is a 48 y/o female with HIV on HAART (CD4 16, VL 679), Hep
C and alcoholic vs autoimmune cirrhosis, s/p ostomy for
perforated diverticulum in [**6-/2107**], admitted initially for
altered mental status from the ED to the MICU when she also
reportedly had a large "grossly bloody" bowel movement along
with a HCT drop from 36 to 28. She was also hypotensive and
admitted to the MICU. found to have native valve endocarditis
and MRSA bacteremia. Patient treated with Vanc, head CT done-neg
as above, hypotension responded to IVF, no pressors given,
started IV thiamine for ? wernicke's encephalopathy. Pt's mental
status improved, hypotension resolved, pt called out to floor in
stable condition. She was called out to floor on vanco and
stable until had acute onset of abdominal pain and hypotension
on day of transfer.
.
Overnight on [**2107-9-27**], patient suspicious for GIB as Hct went down
from 23 -> 21 despite transfusion of 1 unit PRBCs, and had new
abdominal pain that morning. Lactate was 5.1 suspicious for
ischemic bowel but not likely a good surgical candidate given
her chronic disease state. Newly guiac positive. Got 2 units
today, 1.5 L of fluid, hypotensive SBP 80s and tachycardic to
100-110s. Afebrile, but with increased WBC. Abx not broadened,
still just on vancomycin (1st neg BCx on [**9-23**]). Not taking any
PO meds, has had N/V. On standing zofran, not able to take
lactulose. Tbili 5.1. Of note, was admitted to [**Hospital1 2177**] in [**Month (only) **] with
perforated diverticulum s/p ostomy. Had meeting with partner,
HCP today regarding patient's goals of care, but husband did not
yet want patient to be CMO but wanted to continue aggressive
care. He did note that she was tired and kept saying that she
wanted to go home.
.
At 9:30pm on [**2107-9-28**], patient continued to be hypotensive with
SBP in 70-80s despite fluid boluses. Attempts made to place RIJ
central line were unsuccessful, so right femoral line placed.
Patient increasingly hypotensive and tachycardic after procedure
so pressor support with levophed was started with aggressive
fluid resuscitation. Addition of neo was not effective so
patient maintained on levophed with addition of vasopressin.
Venous lactate was increased to 6.5, patient with increased
respiratory distress and work of breathing (RR 30-40s although
maintaining good O2 sat on RA). Patient received 3.5L of fluid,
art line was placed showing ABG of pH 7.16/26/30/10. Patient
with BP 100-110s systolic with wide pulse pressure. Started
having profuse dark fluid output into ostomy, increased tense
abdomen. Spoke with husband regarding goals of care and current
situation, and decision at 12:30am of [**2107-9-29**] was made to make
patient comfort measures only due to poor prognosis of likely
mesenteric ischemia and septic shock. Pressure support withdrawn
at 12:35am, patient started on morphine drip for comfort, and
patient had quick decline to asystole and was pronounced dead at
12:45am [**2107-9-29**]. Partner, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 59816**] at bedside until
decision to make patient CMO and aware of patient's death.
Medications on Admission:
Lactulose - unknown
Dapsone 100 mg Monday, Wednesday and Friday
Kaletra 2 tab [**Hospital1 **]
magnesium oxide 500 mg per day
multivitamin 1 per day
tenofovir 300 mg per day
zinc 25 mg per day
calcium [**2099**] mg per day
Vicodin.
Cipro 500 mg [**Hospital1 **]
spironolactone 100 mg qday
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
|
[
"585.9",
"038.11",
"707.03",
"707.09",
"042",
"785.52",
"V09.0",
"070.44",
"557.0",
"599.0",
"285.9",
"578.9",
"995.92",
"584.9",
"421.0",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16252, 16261
|
12722, 15872
|
291, 365
|
16320, 16337
|
3821, 3837
|
16401, 16419
|
3124, 3248
|
16212, 16229
|
16282, 16299
|
15898, 16189
|
16361, 16378
|
3263, 3802
|
12364, 12699
|
239, 253
|
393, 1693
|
3846, 12320
|
1715, 2907
|
2923, 3108
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,037
| 144,768
|
44006
|
Discharge summary
|
report
|
Admission Date: [**2130-5-7**] Discharge Date: [**2130-6-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3513**]
Chief Complaint:
hypotension, decreased UOP
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History could not be obtained per pt. Per records:
Ms. [**Known lastname 5655**] is an 84 yo F with recently diagnosed metastatic
ovarian CA thought not to be a chemo candidate, with recent
admission [**Date range (1) 62824**] during which she was admitted for SOB, had 2
abdominal paracenteses, one of which showed adenocarcinoma via
peritoineal fluid culture c/w ovarian origin. She also had an
IVC filter placed for a VQ scan which was intermediate
probabillity for PE. Anticoagulation was not started [**3-2**] head
CT c/w possible metastatic disease and overall poor performance
status, however brain MRI showed no metastatic disease.
Palliative onc was consulted during that admission with the
patient and her son deciding that chemo that was aggressive
enough to shrink her tumor would not be tolerated by the pt
given her poor functional status and they thought palliative
care would be most appropriate. She was planned for a
peritoneal portacath, but this was not done [**3-2**] logistical
problems for the [**Name (NI) 2299**] [**Last Name (NamePattern1) **] (to which she was being
discharged).
.
Additionally she had ARF with Cr up to 2.8, which resolved with
fluid boluses, however there remains concern about possible
tumor infiltration into the bladder. MR urogram was not
revealing in this regard and was consistent with metastic
ovarian ca. She was discharged to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], however in
discharge summary it states that code status was attempted to be
discussed several times and the patient was unwilling to
discuss, rendering her full code on discharge to [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]
for hospice.
.
Today she was seen by her family and was not ready to be DNR.
She wanted other interventions, including peritoneal cath for
ascites. She was noted to be hypotensive to 73/37 at [**First Name4 (NamePattern1) 2299**]
[**Last Name (NamePattern1) **] and no urine output was noted since her arrival there on
[**5-5**]. Her foley was flushed and was patent. Her bladder scan was
negative, and her abdominal girth over 2 days grew two inches.
She was sent to the [**Hospital1 18**] ER for further evaluation.
.
In the ER she received 4L of NS and urinated 75cc. She was
given levo/flagyl and vanco and was started on peripheral dopa
until a RIJ could be placed, and then was started on levophed
drip and quickly weaned off dopamine. Initial temp was 99.2 and
BP was 89/45. Her family tried to convince her to be CMO per ED
documentation, however she wanted to be full code, thus she was
transferred to the ICU.
Past Medical History:
1) ovarian cancer, likely metastatic as above
2) D2M: Diagnosed [**2126**], last A1C 6.6. On glyburide 2.5mg PO
3) HTN: On metoprolol, amlodipine, valsartan, and HCTZ
Social History:
Originally from Barbados. Lives at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] but previously
lived with her son. [**Name (NI) **] report neg tobacco, neg EtOH. Pt has
never had pap smear, mammogram, or colonoscopy.
Family History:
No known family history of heart disease or cancer. Has son with
DM2.
Physical Exam:
Admission:
97.0, 120/59, 90, 12, 96% on 3LNC
Gen: lying in bed, poor eye contact, not talkative but can
converse after multiple prompts
HEENT: NCAT, anicteric
Cor: s1s2, RRR, no r/g/m
Pulm: CTAB anteriorly
Abd: soft, distended, +fluid wave, NT, +bs
Ext: trace edema BLE
Neuro: uncooperative with exam, oriented only to her name and
her birthday
Pertinent Results:
[**2130-5-7**] 05:50PM LACTATE-1.9
[**2130-5-7**] 05:37PM PT-13.7* PTT-28.8 INR(PT)-1.2*
[**2130-5-7**] 05:22PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.034
[**2130-5-7**] 05:22PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-MOD
[**2130-5-7**] 05:22PM URINE RBC-[**12-18**]* WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-[**7-8**]
[**2130-5-7**] 05:22PM URINE GRANULAR-0-2
[**2130-5-7**] 05:22PM URINE MUCOUS-FEW
[**2130-5-7**] 05:17PM GLUCOSE-71 UREA N-83* CREAT-4.9*# SODIUM-143
POTASSIUM-5.3* CHLORIDE-112* TOTAL CO2-14* ANION GAP-22*
[**2130-5-7**] 05:17PM WBC-19.3* RBC-3.64* HGB-9.3* HCT-31.2* MCV-86
MCH-25.6* MCHC-30.0* RDW-15.8*
[**2130-5-7**] 05:17PM NEUTS-88.1* BANDS-0 LYMPHS-8.1* MONOS-3.1
EOS-0.3 BASOS-0.4
[**2130-5-7**] 05:17PM HYPOCHROM-2+ ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL BURR-OCCASIONAL
[**2130-5-7**] 05:17PM PLT SMR-NORMAL PLT COUNT-223
*
[**2130-5-8**] Renal US:
FINDINGS: Left kidney measures 8.4 cm. The right kidney measures
8.9 cm. Again seen is a rounded hypoechoic structure within the
left kidney measuring approximately 1.3 cm in greatest
dimension. Allowing for technical differences, no significant
change is seen within the cyst compared to prior study. There is
no evidence of hydronephrosis or stones. Again noted is free
fluid within the abdomen.
IMPRESSION: No significant change from prior study. No evidence
of hydronephrosis or obstruction. Unchanged cyst within the left
kidney. Ascites.
*
[**2130-5-12**]
Chest AP
AP UPRIGHT PORTABLE CHEST: A right internal jugular central
catheter remains with tip at the level of the junction of the
SVC with right atrium. Heart size and cardiomediastinal contours
are not changed given differences in patient position. There is
prominence of the pulmonary vasculature consistent with volume
overload. There is atelectasis at the left base and a small
right pleural effusion. Surrounding osseous and soft tissue
structures are unchanged.
IMPRESSION: Volume overload. Left basilar atelectasis and small
right pleural effusion
*
ECG [**2130-5-12**]
Sinus tachycardia with frequent atrial ectopy. Technically
limited study.
Compared to the previous tracing of [**2130-5-10**] the rate has
increased and frequent
atrial ectopy has appeared. Possible prior inferior myocardial
infarction.
Brief Hospital Course:
84 yo woman with advanced metastatic ovarian CA who initially
presented on [**2130-5-7**] in septic shock, admitted to MICU for
hypotension/sepsis, transferred to the floor on [**2130-5-26**] with
acute renal failure.
.
Patient was admitted to [**Hospital Unit Name 153**] for hypotension and possible
sepsis. She was started on a ten day course of ceftriaxone and
was initially on Levophed but was weaned off of pressors. Renal
US was performed to evaluate oliguria and was negative for
hydronephrosis. She was stabilized overnight and transferred to
the floor the next day. Repeat paracentesis performed on [**5-17**]
demonstrated malignant cells, and given the advanced stage of
her ovarian cancer and her performance status, she was not a
candidate for palliative chemotherapy. While in the ICU, Dr.
[**First Name (STitle) **] of Palliative Care met with her, and tried to re-address
her goals of care and code status. Patient was full code when
transferred to the floor.
.
On the floor she continued to be followed by the palliative care
consult service. She continued to be oliguric. Urine
electrolytes were sent and were consistent with a prerenal
azotemia. She was hydrated initially with crystalloid, and
subsequently with blood, but with no response. Her creatinine
continued to rise. A urine sediment was significant for muddy
brown casts. Her worsening renal failure was thought more likely
to represent ATN from her presenting hypotension.
.
Her creatinine continued to rise and urine output remained low.
Concurrently the patient's anasarca, which was attributed to her
ovarian cancer and peritoneal seeding, worsened. Gentle diuresis
was attempted , however, given her renal failure and tenuous
blood pressure, the patient remained volume overloaded. When
transferred from the unit to the floor patient's mental status
was noted to be altered. Head MRI was negative for metastatic
disease. Her mental status changes were thought to be secondary
to toxic metabolic encephalopathy given uremia and recent
infections.
.
Given patient's underlying disease and the likelihood that she
would not recover renal function, code status was once again
addressed. As patient was no longer able to participate in her
health care decisions, her son (her designated HCP) agreed that
she should be comfort care only. Patient was given morphine for
pain control. She passed away on [**2130-6-3**].
Medications on Admission:
Milk Of Magnesia prn
dulcolax prn
fleets enema prn
tylenol prn
insulin slide scale
atrovent nebs prn
norvasc 5 qday
lipitor 10 qday
lopressor 50 [**Hospital1 **]
glyburide 2.5 qday
valsartan 160 qday
albuterol nebs
percocet tid
morphine prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary diagnoses
Metastatic ovarian cancer
Acute renal failure
.
Secondary diagnoses
HTN
DM
liver failure
anemia
Discharge Condition:
Patient expired.
Discharge Instructions:
Followup Instructions:
|
[
"567.29",
"599.0",
"038.9",
"183.0",
"250.00",
"276.52",
"486",
"428.0",
"427.31",
"198.3",
"570",
"584.5",
"349.82",
"995.92",
"785.52",
"285.1",
"197.6",
"403.91",
"286.7",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.07",
"00.17",
"54.91",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9002, 9075
|
6310, 8711
|
287, 293
|
9232, 9250
|
3880, 6287
|
9302, 9302
|
3422, 3495
|
9096, 9211
|
8737, 8979
|
9276, 9276
|
3510, 3861
|
221, 249
|
321, 2954
|
2976, 3145
|
3161, 3406
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,212
| 107,412
|
49609
|
Discharge summary
|
report
|
Admission Date: [**2132-8-19**] Discharge Date: [**2132-8-25**]
Date of Birth: [**2066-4-25**] Sex: M
Service: MEDICINE
Allergies:
Coumadin
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Left leg and scrotal swelling
Major Surgical or Invasive Procedure:
pericardial drain placement, [**2132-8-19**]
History of Present Illness:
66 initially presenting with left leg and scrotal swelling.
Referred in by PCP for concern for ARF vs IVC clot. Of note is
s/p LKR on [**2132-7-10**]. Has noted increased fluid retention over
the past few weeks with an approximately 13lb weight gain,
swelling in abd, scrotum and LE. Denies recent viral illness,
fevers, new medications, chest pain, foamy urine, rash. Does
have mild DOE, climbing a steep [**Doctor Last Name **] in front of his house
slightly more difficult that prior. No PND or orthopnea. No
confusion, blurred vision/double vision, numbness, tingling or
weakness. Had hyponatremia 120 on initial labs, normal cr.
States his wife thinks he drinks to much water, reports drinking
~1 gallon water per day.
Slight transaminitis noted on initial labs. CTV done to eval for
thrombosis, not ideal timing of contrast to establish presence
of IVC clot, incidentally a large pericardial effusion, free
fluid in abdomen and pleural effusions were found. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**]
concerned about tamponade, requesting ICU admission. Initial VS
in triage 96.5 100 132/93 20 100% RA. BP noted to be trending
down in ed to high 90s. Cards consulted in ED. TTE without
tamponade physiology, large RA/RV, raised ? of PE. Pt underwent
CTA which was negative for PE or aortic dissecction but showed
persistent pericardial effusion and b/l pleural effusions.
Given a total 1 1L NS in ED.
Past Medical History:
Benign lesion removed from his right breast [**2125**]
s/p 3 knee surgeries, LTR [**2132-7-20**]
Normal stress test in [**2127**]
HL (His LDL was over 150 before medication)
Pre-malignant skin lesions
Tendonitis (he is on disability from the
military due to the tendonitis)
HTN
Social History:
Retired IRS attorney. Now runs own business as CPA/tax lawyer.
Lives with wife. 2 grown children. [**Country 3992**] veteran. No h/o
incarceration or known TB exposures. No IVDU. Very distant
smoking history. 2 glasses wine/day.
Family History:
He has a strong family history of coronary artery disease.
Father d. fatal MI age 51.
Physical Exam:
Vitals: T:95.5 BP:128/99 P: 95 R: 13 SaO2: 99% Ra
General: Awake, alert, NAD, pleasant, appropriate, cooperative.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions
noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout. No nystagmus, dysarthria, intention or
action tremor. 2+ biceps, triceps, brachioradialis, patellar
reflexes and 2+ ankle jerks bilaterally. Plantar response was
flexor bilaterally.
Pertinent Results:
[**2132-8-18**] 03:00PM WBC-7.5 RBC-4.20* HGB-12.3* HCT-38.7* MCV-92
MCH-29.3 MCHC-31.8 RDW-14.1
[**2132-8-18**] 03:00PM NEUTS-72.1* LYMPHS-18.1 MONOS-9.0 EOS-0.3
BASOS-0.4
[**2132-8-18**] 03:00PM GLUCOSE-133* UREA N-24* CREAT-1.1 SODIUM-120*
POTASSIUM-4.6 CHLORIDE-83* TOTAL CO2-26 ANION GAP-16
[**2132-8-19**] 12:43PM TSH-1.4
[**2132-8-19**] 07:24AM ALT(SGPT)-136* AST(SGOT)-71* LD(LDH)-256*
CK(CPK)-96 ALK PHOS-174* TOT BILI-1.1
[**2132-8-19**] 07:24AM CK-MB-NotDone cTropnT-<0.01
[**2132-8-19**] 07:24AM [**Doctor First Name **]-POSITIVE TITER-1:40 [**Last Name (un) **]
[**2132-8-19**] 07:24AM NEUTS-67.0 LYMPHS-21.4 MONOS-9.7 EOS-1.6
BASOS-0.2
[**2132-8-19**] 07:24AM PT-16.1* PTT-29.2 INR(PT)-1.4*
.
CT ABDOMEN/PELVIS IMPRESSION: 1. Large pericardial effusion,
with apparent mass effect and tamponade on the heart. The
impaired venous return results in hepatic congestion and likely
affected the timing for IVC evaluation. 2. Anasarca, with
moderate-sized bilateral pleural effusions, large amount of free
fluid throughout the abdomen and pelvis, and edema within the
soft tissues. 3. Heterogeneous enhancement pattern of the liver,
likely reflecting congestion related to increased venous
pressures. 4. Assessment for IVC thrombosis is limited due to
suboptimal opacification of the venous system.
.
ECHO ON ADMISSION [**2132-8-19**]: The left atrium is normal in size.
The estimated right atrial pressure is 10-20mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular cavity is dilated with
normal free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. Tricuspid regurgitation is present but cannot be
quantified. There is a moderate sized pericardial effusion.
There are no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures.
.
CARDIAC CATH/Pericardiocentesis [**2132-8-19**]: 1. Resting hemodynamics
was measured at baseline and after pericardiocentesis. Right
sided filling pressures were elevated at baseline (RVEDP 19mmHg,
mean RA 21mmHg) and remained elevated post-pericardiocentesis
(RVEDP 22 mmHg). Left sided filling pressures were mildly
elevated with mean PCWP of 20mmHg at baseline and 19mmHg
post-procedure. Intrapericardial pressure was reduced from
13mmHg to -4mmHg post-pericardiocentesis. Calculated cardiac
index was 2.5 and 2.4 L/min/m2 pre- and post-pericardiocentesis.
There was inspiratory decline in systolic arterial pressure from
140 to 126mmHg pre-pericardiocentesis consistent with pulsus
paradoxus. This persisted after pericardiocentesis (141 to
126mmHg). 2 . Pericardiocentesis was performed via a subxiphoid
approach and 210 cc of serosanguinous fluid was removed and sent
for laboratory analyses. A pericardial drain was left in-situ. A
post-procedure transthoracic echocardiogram was performed and
demonstrated no residual pericardial effusion. FINAL DIAGNOSIS:
1. Pericardial effusion with mild hemodynamic compromise and
early
tamponade physiology. 2. Elevated left and right sided filling
pressures and pulsus paradoxus unchanged
post-pericardiocentesis.
.
CTA [**2132-8-19**]: 1. No evidence of pulmonary embolism. 2. Persistent
moderate-sized bilateral pleural effusions and large pericardial
effusion with possible mass effect on the heart. 3. Retained
contrast within the kidneys after prior IV contrast
administration - findings suggestive of ATN.
.
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) [**2132-8-19**]: No evidence of DVT in
bilateral lower extremity.
.
KNEE (2 VIEWS) LEFT [**2132-8-23**]: Comparison is made to the prior
study from [**2124-11-2**]. No more recent radiographs are
available here at this institution for comparison. The patient
is status post left total knee arthroplasty. There are no signs
for hardware-related complications or periprosthetic fracture.
There is a prominent knee joint effusion.
.
CXR [**2132-8-21**]: Increasing opacification at the left base
consistent with effusion and atelectasis.
.
ECHO ON DISCHARGE [**2132-8-25**]: The left atrium is mildly dilated.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The right ventricular
cavity is dilated There is abnormal septal motion/position. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). The pulmonary
artery systolic pressure could not be determined. There is a
small pericardial effusion. There are no echocardiographic signs
of tamponade. No right atrial diastolic collapse is seen. No
right ventricular diastolic collapse is seen. IMPRESSION: Small
pericardial effusion without evidence of tamponade. Dilated
right ventricle with depressed systolic function.
Brief Hospital Course:
66 year old with pericardial effusion, anasarca, and mildly
elevated LFTs. Hemmoragic pericardial effusion, s/p drainage on
[**2132-8-19**].
.
## Pericardial effusion/Anasarca: Later on the day of admission,
there was a concern that the patient might be developing early
tamponade physiology and consequently pericardiocentesis was
performed in the cath lab. Effusion was hemorrhagic, exudative
based only on LDHeff/LDHserum. Patient did not have recent chest
pain, therefore [**Last Name (un) 21160**]??????s unlikely. TB and lyme tests negative.
TSH WNL; PPD negative. [**First Name8 (NamePattern2) 6**] [**Doctor First Name **] showed a speckled patter at 1:40.
Gram stain of effusion was negative for microorganisms, however
one culture bottle grew coag negative staph. The pt was briefly
treated for this with a dose of vancomycin before it was
determined that this likely represented contaminant. Anaerobic
culture returned gram positive rods - consistent with
corynebacterium and propionibacterium. ID felt most likely
containment as these species do not cause pericarditis. No
history of recent viral illness. Concerned for malignancy. Lymph
nodes found on CT chest, no nodules/masses on CT chest or
abdomen with contrast. Colonoscopy in [**2129**] and [**2124**] with no
polyps. Had FNA breast in [**2128**]. Pathology report was abnormal,
however patient states mass was benign. No masses or enlarged
nodes on exam. Per primary care notes being treated for
pre-malignant skin lesions. Prostate screening up to date.
Unknown etiology of pericarditis. Following drainage, the pt's
urine output increased significantly and his edema was noted to
diminish. Was treated with Naproxen initially, discharged on
Mobic 7.5 mg [**Hospital1 **] for 10 days duration. Discharged on 20 mg po
Lasix for 3 days for diuresis. Pulsus 4 on discharge. ECHO on
discharge demonstrated resolved pericardial effusion, however
right ventricular cavity is dilated with abnormal septal
motion/position. Patient to have cardiac MR to investigate
constrictive cardiac pathology and follow-up with cardiology as
an outpatient.
.
## Hyponatremia: The pt has a low FeNA on urine lytes prior to
IVF, suggesting functional hypovolemic hyponatremia in setting
of poor cardiac output. With fluids and then tapping of his
pericardial effusion, his serum sodium slowly corrected. Patient
to have his Na checked in one week with follow-up.
.
## s/p LKR: The pt's surgery was done at NEBH. Dr. [**Last Name (STitle) 44068**] is the
surgeon. Several days into his hospital stay, the pt's left knee
was noted to be slightly warmer than his right. Both the [**Hospital1 18**]
Ortho Service and the pt's private orthopedist were consulted
and felt that this was normal post-operatively and unlikely to
represent infection.
.
## HTN: The pt's antihypertensives were held in the setting of
his effusion. At discharge, his HCTZ was not restarted given his
significant hyponatremia at admission. His Benicar was also held
until follow-up at his primary care appointment. SBP was stable
on the floor.
.
# Elevated LFTs: Trending down, most likely related to
congestion. ALT > AST. Hep B and C serologies pending.
Medications on Admission:
HCTZ 12.5mg daily
Benicar 40mg daily
Lipitor 10mg daily
Ferrous gluconate 325mg daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Mobic 7.5 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 14 days.
Disp:*14 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
5. Outpatient Lab Work
Please have a Chem-7 (Na, K, Cl, BiCarb, BUN, Creatinine) drawn
at your appointment with Dr. [**First Name (STitle) 679**] on [**9-3**] 9:30. We would
like to check your sodium level.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Hemorrhagic pericardial effusion
Secondary diagnoses:
- Anasarca
- Status-post left knee replacement
Discharge Condition:
Ambulating with stable vitals.
Discharge Instructions:
You were admitted for fluid surrounding your heart (pleural
effusion) and additional fluid in your stomach and legs. This
could be pericarditis related to a virus or unknown etiology. We
did some tests that can cause these symptoms - all were with in
normal limits. You were negative for lyme, TB, bacteria. You had
a procdure called a pericardiocentesis which drained the fluid
around your heart. Before discharge you had a follow up ECHO
which demonstrated only a small effusion remaining. We would
like to follow up with cardiology and your primary care doctor.
.
We have made the following changes to your medication:
1) We have stopped your blood pressure medications,
Hydrachlorothiazide (HCTZ) 12.5 mg and Benicar. Discuss with Dr.
[**First Name (STitle) 679**] whether this should be re-started.
2) Started Lasix 20 mg for 3 days duration
3) Started Mobic 7.5 mg twice a day for 10 days until follow-up
with Dr. [**First Name (STitle) 679**]
4) Please have your labs checked at your follow-up appointment
with Dr. [**First Name (STitle) 679**] on [**9-3**]. Your sodium was mildly decreased on
admission and we would like to check it.
Otherwise please take your medications as perscribed.
.
Please attend all your follow up appointments.
.
Return to the ER if your experience shortness of breath, chest
pain, worsening fluid accumalation, bleeding or other concerning
symptoms.
Followup Instructions:
Please attend the following appointments:
1) Cardiology: [**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2132-9-16**] 2:20 [**Hospital6 29**], [**Location (un) **]
2) Primary Care: Dr. [**First Name (STitle) 679**], Wednesday [**9-3**] at 9:30 am,
please come early and have your labs drawn. His office number is
([**Telephone/Fax (1) 103752**] if you need to contact him.
3) Schedule an ECHO in [**1-2**] weeks for follow-up. To schedule an
ECHO call [**Telephone/Fax (1) 62**]. Dr.[**Name (NI) 16937**] office can also schedule the
ECHO.
4) We are scheduling a Cardiac MR for you. They will contact you
with an appointment time. If you do not hear from them in a week
please call [**Telephone/Fax (1) 9559**].
Completed by:[**2132-8-27**]
|
[
"511.9",
"401.9",
"794.8",
"423.3",
"V43.65",
"276.52",
"276.1",
"420.90",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"37.21",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
12894, 12900
|
8902, 12079
|
307, 353
|
13066, 13099
|
3540, 6913
|
14534, 15333
|
2390, 2478
|
12215, 12871
|
12921, 12921
|
12105, 12192
|
6931, 8879
|
13123, 14511
|
2493, 3521
|
12996, 13045
|
238, 269
|
381, 1825
|
12940, 12975
|
1847, 2126
|
2142, 2374
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,881
| 168,893
|
51906+51907
|
Discharge summary
|
report+report
|
Admission Date: [**2168-1-20**] Discharge Date: [**2168-1-23**]
Date of Birth: [**2118-5-29**] Sex: F
Service: VASCULAR SURGERY
ADMITTING DIAGNOSIS: Nonhealing left great toe ulcer.
DISCHARGE DIAGNOSIS: Nonhealing left great toe ulcer.
PROCEDURES:
1. Left femoral AK popliteal bypass graft with saphenous
vein graft.
2. Left great toe amputation.
HISTORY OF PRESENT ILLNESS: The patient is a 49 year old
female with a twenty year history of insulin dependent
diabetes mellitus on pump with severe neuropathy in her
bilateral lower extremities as well as severe claudication,
greater in the left than the right.
She also has a past medical history significant for seizures
as well as coronary artery disease, inferior wall silent
myocardial infarction, history of congestive heart failure,
status post cardiac catheterization [**4-18**], with an ejection
fraction of 35%. She has chronic shortness of breath. She
is also hypothyroid and has glaucoma.
The patient is status post right superficial femoral
angioplasty and left external iliac artery angioplasty with
stenting in [**8-18**]. She has had minor improvement in the
claudication of her right leg following the angioplasty and
about four weeks prior to [**2167-12-28**], she began having redness
in the left great toe. She has had a previous right great
toe amputation which is well healed. She was hospitalized at
[**Hospital1 69**] and placed on
Ciprofloxacin 500 mg b.i.d. for her toe infection.
She presented to Dr.[**Name (NI) 27017**] office for further evaluation
and it was decided that the patient should undergo an
arterial reconstruction of the left leg and a left great toe
amputation at the proximal phalangeal level and this was
arranged for on an outpatient basis.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease, status post right
superficial femoral angioplasty and left external iliac
artery angioplasty with stenting in [**8-18**].
2. Insulin dependent diabetes mellitus times twenty years,
brittle, on insulin pump.
3. Chronic renal insufficiency with a creatinine of 1.8.
4. Neuropathy.
5. Seizures secondary to hypoglycemia.
6. Coronary artery disease with an inferior silent
myocardial infarction.
7. History of congestive heart failure with a cardiac
catheterization in [**4-18**], and an ejection fraction of 35%.
8. Obesity.
9. Increased cholesterol.
10. Hypothyroidism.
11, Glaucoma.
PAST SURGICAL HISTORY:
1. Amputation of right great toe [**5-18**].
2. Knee surgery [**10/2144**].
3. Plate and lumbar fusion L4, 5, 6, 7 in [**2163**].
4. Wrist, elbow and foot surgeries in [**2156**].
ALLERGIES No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Multivitamin.
2. Timolol.
3. Dilantin.
4. Ambien.
5. Nortriptyline.
6. Insulin pump.
7. Lasix 40 mg b.i.d.
8. Atenolol 25 mg.
9. Zestril.
10. Levoxyl.
11. Zoloft.
12. Ranitidine.
SOCIAL HISTORY: The patient quit smoking six months ago, 25
to 40 pack year history. ETOH denies and recreational drugs
denies.
PHYSICAL EXAMINATION: On physical examination, the patient
is awake, alert and oriented in no apparent distress. Her
blood pressure is 101/66. The heart is regular rate and
rhythm, S1 and S2. Her chest is clear to auscultation
bilaterally with distant air sounds. Extremities revealed 4+
femoral pulses bilaterally. On the left, no pulses palpable
below the femoral level, and on the right 3+ popliteal and
dorsalis pedis pulses, no posterior tibialis pulse on the
right.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2168-1-20**], and taken to the operating room for left femoral AK
popliteal bypass graft with saphenous vein graft as well as a
left great toe amputation. She tolerated the procedure well
and was transferred to the Post Anesthesia Care Unit in
stable condition.
In the Post Anesthesia Care Unit, she had a palpable left
dorsalis pedis and posterior tibialis pulse. From the Post
Anesthesia Care Unit, she was transferred to the unit in
stable condition. Her pulses continued to be palpable on the
left. She received one unit of packed red blood cells for a
hematocrit of 26.0.
The patient did have some flattened electrocardiographic
waves on her postoperative electrocardiogram and therefore,
formal rule out was done which was negative. She was seen by
[**Last Name (un) **] for management of her diabetes mellitus.
On postoperative day number one, the patient was doing well.
She had palpable dorsalis pedis and posterior tibialis
pulses. Left foot was warm. She did have some increased
blood pressure and was placed on Neo-Synephrine and given
another unit of packed red blood cells. Blood pressure
improved. Her hematocrit was 30.0 posttransfusion. Her
creatinine on [**2168-1-21**], was 0.9. Laboratories were otherwise
stable.
The patient continued to be monitored in the unit overnight.
Her diet was advanced. She was given Lasix 20 mg. Her
preoperative medications were restarted. Her dorsalis pedis
and posterior tibialis continued to be dopplerable.
She was transferred to the floor on postoperative day number
three. She continued to do well and she was afebrile and her
vital signs were stable. Her left thigh incision was clean,
dry and intact. Her left great toe amputation site was
clean, dry and intact as well, and her dorsalis pedis and
posterior tibialis were dopplerable bilaterally. Her
hematocrit was 26.5 which was stable. Her creatinine was
0.8.
On [**1-22**], the patient was noted to have blood pressure
in the 80's over 50's. She was given a 250 cc bolus of normal
saline and her Lopressor was decreased to 12.5 mg p.o. b.i.d.
She was asymptomatic. Her systolic pressures remained in the
90's overnight. Note that the patient chronically has low
blood pressure.
It was decided that the patient would be discharged to
rehabilitation in stable condition.
MEDICATIONS ON DISCHARGE:
1. Afrin 325 mg p.o. q.d.
2. Lopressor 12.5 mg p.o. b.i.d.
3. Insulin pump one unit per hour.
4. Regular insulin sliding scale 0-150 zero units, 151 to
200 three units, 201 to 250 five units, 251 to 300 seven
units, 301 to 350 ten units, 351 to 600 twelve units.
5. Nortriptyline 75 mg p.o. q.d.
6. Ambien 10 mg p.o. q.h.s.
7. Lasix 40 mg p.o. q.d.
8. Zoloft 100 mg p.o. q.d.
9. Zantac 300 mg p.o. b.i.d.
10. Percocet one to two tablets p.o. q3-4hours p.r.n.
11. Tylenol 650 mg p.o. q4-6hours p.r.n. pain.
The patient was told to be touch down weight bear for
transfer only and to continue to be nonweight-bearing for two
weeks. She should follow-up with Dr. [**Last Name (STitle) 1476**] in the office
in ten days. She needs dry dressing changes to her left
thigh and left foot q.d. p.r.n. The patient was also told to
follow-up with her cardiologist in four to six weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36
D: [**2168-1-23**] 11:37
T: [**2168-1-23**] 12:50
JOB#: [**Job Number 107454**]
Admission Date: [**2168-1-20**] Discharge Date: [**2168-1-23**]
Date of Birth: [**2118-5-29**] Sex: F
Service: VASCULAR SURGERY
ADMITTING DIAGNOSIS: Nonhealing left great toe ulcer.
DISCHARGE DIAGNOSIS: Nonhealing left great toe ulcer.
PROCEDURES:
1. Left femoral AK popliteal bypass graft with saphenous
vein graft.
2. Left great toe amputation.
HISTORY OF PRESENT ILLNESS: The patient is a 49 year old
female with a twenty year history of insulin dependent
diabetes mellitus on pump with severe neuropathy in her
bilateral lower extremities as well as severe claudication,
greater in the left than the right.
She also has a past medical history significant for seizures
as well as coronary artery disease, inferior wall silent
myocardial infarction, history of congestive heart failure,
status post cardiac catheterization [**4-18**], with an ejection
fraction of 35%. She has chronic shortness of breath. She
is also hypothyroid and has glaucoma.
The patient is status post right superficial femoral
angioplasty and left external iliac artery angioplasty with
stenting in [**8-18**]. She has had minor improvement in the
claudication of her right leg following the angioplasty and
about four weeks prior to [**2167-12-28**], she began having redness
in the left great toe. She has had a previous right great
toe amputation which is well healed. She was hospitalized at
[**Hospital1 69**] and placed on
Ciprofloxacin 500 mg b.i.d. for her toe infection.
She presented to Dr.[**Name (NI) 27017**] office for further evaluation
and it was decided that the patient should undergo an
arterial reconstruction of the left leg and a left great toe
amputation at the proximal phalangeal level and this was
arranged for on an outpatient basis.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease, status post right
superficial femoral angioplasty and left external iliac
artery angioplasty with stenting in [**8-18**].
2. Insulin dependent diabetes mellitus times twenty years,
brittle, on insulin pump.
3. Chronic renal insufficiency with a creatinine of 1.8.
4. Neuropathy.
5. Seizures secondary to hypoglycemia.
6. Coronary artery disease with an inferior silent
myocardial infarction.
7. History of congestive heart failure with a cardiac
catheterization in [**4-18**], and an ejection fraction of 35%.
8. Obesity.
9. Increased cholesterol.
10. Hypothyroidism.
11, Glaucoma.
PAST SURGICAL HISTORY:
1. Amputation of right great toe [**5-18**].
2. Knee surgery [**10/2144**].
3. Plate and lumbar fusion L4, 5, 6, 7 in [**2163**].
4. Wrist, elbow and foot surgeries in [**2156**].
ALLERGIES No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Multivitamin.
2. Timolol.
3. Dilantin.
4. Ambien.
5. Nortriptyline.
6. Insulin pump.
7. Lasix 40 mg b.i.d.
8. Atenolol 25 mg.
9. Zestril.
10. Levoxyl.
11. Zoloft.
12. Ranitidine.
SOCIAL HISTORY: The patient quit smoking six months ago, 25
to 40 pack year history. ETOH denies and recreational drugs
denies.
PHYSICAL EXAMINATION: On physical examination, the patient
is awake, alert and oriented in no apparent distress. Her
blood pressure is 101/66. The heart is regular rate and
rhythm, S1 and S2. Her chest is clear to auscultation
bilaterally with distant air sounds. Extremities revealed 4+
femoral pulses bilaterally. On the left, no pulses palpable
below the femoral level, and on the right 3+ popliteal and
dorsalis pedis pulses, no posterior tibialis pulse on the
right.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2168-1-20**], and taken to the operating room for left femoral AK
popliteal bypass graft with saphenous vein graft as well as a
left great toe amputation. She tolerated the procedure well
and was transferred to the Post Anesthesia Care Unit in
stable condition.
In the Post Anesthesia Care Unit, she had a palpable left
dorsalis pedis and posterior tibialis pulse. From the Post
Anesthesia Care Unit, she was transferred to the unit in
stable condition. Her pulses continued to be palpable on the
left. She received one unit of packed red blood cells for a
hematocrit of 26.0.
The patient did have some flattened electrocardiographic
waves on her postoperative electrocardiogram and therefore,
formal rule out was done which was negative. She was seen by
[**Last Name (un) **] for management of her diabetes mellitus.
On postoperative day number one, the patient was doing well.
She had palpable dorsalis pedis and posterior tibialis
pulses. Left foot was warm. She did have some increased
blood pressure and was placed on Neo-Synephrine and given
another unit of packed red blood cells. Blood pressure
improved. Her hematocrit was 30.0 posttransfusion. Her
creatinine on [**2168-1-21**], was 0.9. Laboratories were otherwise
stable.
The patient continued to be monitored in the unit overnight.
Her diet was advanced. She was given Lasix 20 mg. Her
preoperative medications were restarted. Her dorsalis pedis
and posterior tibialis continued to be dopplerable.
She was transferred to the floor on postoperative day number
three. She continued to do well and she was afebrile and her
vital signs were stable. Her left thigh incision was clean,
dry and intact. Her left great toe amputation site was
clean, dry and intact as well, and her dorsalis pedis and
posterior tibialis were dopplerable bilaterally. Her
hematocrit was 26.5 which was stable. Her creatinine was
0.8.
On [**1-22**], the patient was noted to have blood pressure
in the 80's over 50's. She was given a 250 cc bolus of normal
saline and her Lopressor was decreased to 12.5 mg p.o. b.i.d.
She was asymptomatic. Her systolic pressure remained in the
90's overnight. Note that the patient chronically has low
blood pressure.
It was decided that the patient would be discharged to
rehabilitation in stable condition.
MEDICATIONS ON DISCHARGE:
1. Afrin 325 mg p.o. q.d.
2. Lopressor 12.5 mg p.o. b.i.d.
3. Insulin pump one unit per hour.
4. Regular insulin sliding scale 0-150 zero units, 151 to
200 three units, 201 to 250 five units, 251 to 300 seven
units, 301 to 350 ten units, 351 to 600 twelve units.
5. Nortriptyline 75 mg p.o. q.d.
6. Ambien 10 mg p.o. q.h.s.
7. Lasix 40 mg p.o. q.d.
8. Zoloft 100 mg p.o. q.d.
9. Zantac 300 mg p.o. b.i.d.
10. Percocet one to two tablets p.o. q3-4hours p.r.n.
11. Tylenol 650 mg p.o. q4-6hours p.r.n. pain.
The patient was told to be touch down weight bear for
transfer only and to continue to be nonweight-bearing for two
weeks. She should follow-up with Dr. [**Last Name (STitle) 1476**] in the office
in ten days. She needs dry dressing changes to her left
thigh and left foot q.d. p.r.n. The patient was also told to
follow-up with her cardiologist in four to six weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36
D: [**2168-1-23**] 11:37
T: [**2168-1-23**] 12:50
JOB#: [**Job Number 107454**]
|
[
"357.2",
"443.9",
"707.15",
"780.39",
"250.61",
"414.01",
"250.71",
"428.0",
"440.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.11",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
7293, 7441
|
12961, 14129
|
9758, 9950
|
10578, 12935
|
9510, 9732
|
10104, 10560
|
7470, 8841
|
7237, 7271
|
8863, 9487
|
9967, 10081
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,302
| 179,677
|
31538
|
Discharge summary
|
report
|
Admission Date: [**2136-7-8**] Discharge Date: [**2136-7-14**]
Date of Birth: [**2074-3-9**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Multiple traumatic injuries from motorcycle crash
Major Surgical or Invasive Procedure:
1. Pelvic angiography with stenting of external iliac artery
2. Open reduction, internal fixation right posterior ring with
sacroiliac percutaneous screw.
3. Open reduction, internal fixation left posterior ring with
plates and screws.
4. Fixation anterior ring with anterior external fixators.
5. Open reduction, internal fixation of distal femur fracture
with [**Last Name (un) 101**], 5-hole plate.
History of Present Illness:
62-year-old gentleman involved in a motorcycle accident
Past Medical History:
1. s/p coronary artery bypass graft surgery
2. HTN
Social History:
Works as salesman, lives with wife. Non [**Name2 (NI) 1818**]
Family History:
Non-contributory
Physical Exam:
Gen: no acute distress
HEENT: PERRL, NC/AT, CNII-XII intact
Chest: CTAB
CV: RRR, no murmurs
Abd: soft/ND/NT
Ext: WWP, 2+ peripheral pulses, exfix in place, abrasions on
left arm
Large ecchymotic scrotal hematoma
Pertinent Results:
[**2136-7-8**] 11:54PM HCT-27.9*
[**2136-7-8**] 07:07PM WBC-10.8 RBC-2.79* HGB-8.7* HCT-24.9* MCV-89
MCH-31.3 MCHC-35.1* RDW-14.4
[**2136-7-8**] 07:07PM PT-14.8* PTT-32.6 INR(PT)-1.3*
[**2136-7-8**] 07:03PM GLUCOSE-185* UREA N-13 CREAT-0.7 SODIUM-140
POTASSIUM-4.2 CHLORIDE-112* TOTAL CO2-19* ANION GAP-13
[**2136-7-8**] 03:06PM GLUCOSE-128* LACTATE-2.6* NA+-139 K+-3.2*
CL--113* TCO2-22
[**2136-7-8**] 03:00PM UREA N-11 CREAT-0.6
[**2136-7-8**] 03:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2136-7-8**] 03:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Brief Hospital Course:
62-year-old gentleman who was involved in a motorcycle accident
resulting
in multiple injuries.
.
In the ED he was hemodynamically stable. He underwent a series
of radiologic studies which revealed the following.
Imaging:
[**7-8**] CT head: negative
[**7-8**] c-spine: negative
[**7-8**] chest: Right apical Pneumothorax, small right pulmonary
contusion, Rib frax Right-1,2,4 Left-1, Right clavicle fracture
[**7-8**] CT abdomen: +pelvic fractures: Comminuted fractures of
bilateral superior and inferior pubic rami. Fractures of
bilateral iliac wings, and right sacral ala.
Left distal femur fracture (supracondylar) described on CT as
obliquely oriented, minimally displaced fracture of the distal
femur extending from the lateral aspect of the distal femoral
shaft into the medial femoral condyle
.
Due to these injuries he underwent:
1. Open reduction, internal fixation right posterior ring with
sacroiliac percutaneous screw.
2. Open reduction, internal fixation left posterior ring with
plates and screws.
3. Fixation anterior ring with anterior external fixators.
4. Open reduction, internal fixation of distal femur fracture
with [**Last Name (un) 101**], 5-hole plate.
.
The patient initially underwent abdominal/pelvic arteriography
because of hemodynamic instability. This did not show active
bleeding but did find a dissecting flap in distal left external
iliac artery. This was stented.
.
The patient was initially managed in the T/SICU. Of note his
HCT dropped to a low of 21.6 from blood loss from his fractures.
He was transfused 4 units of packed red blood cells and
responded appropriately with a rise to 26.6. He was transferred
out of the ICU in stable condition on [**2136-7-9**] (hospital day 2).
Occupational and physical therapy evaluated and treated the
patient.
Also of note, the patient had one night of agitation and
confusion in the setting of high doses of benzodiazepines.
These medications were discontinued and the patient's agitation
and confusion completely resolved and patient mental status
returned to [**Location 213**].
.
On hospital day 7, the patient was discharged in stable
condition to rehab. He was alert and oriented with stable
hemodynamics.
Plans for follow-up were explained to patient.
Medications on Admission:
Ecotrin 81mg
Altace 5mg
Colpidogrel 75mg
Niacin 1000mg
Viagra
Restoril
Nasonex
Albuterol
Pseudoephedrine
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet 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.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 8641**] Healthcare, NH
Discharge Diagnosis:
1. Right clavicle fracture
2. Left supracondylar intraarticular femur fracture
3. Bilateral lateral compression type 2 pelvic fractures
(bilateral pubic rami and sacral alar fractures)
4. Right pneumothorax
5. Small right pulmonary contusion
6. Rib fractures Right-1,2,4 Left-1
7. Flap dissection at the distal left external iliac artery
8. Hypertension
Discharge Condition:
Stable to rehab
Discharge Instructions:
You will be non-weight bearing on both lower extremities due to
your fractures. You have an external fixator in place to
stabilize your pelvis. This will have to stay in place as
directed by the orthopaedic surgery team.
You also suffered from a right clavicle fracture and several rib
fractures. These were treated non-operatively and no further
work-up needs to be done.
You also suffered a small pneumothorax and small pulmonary
contusion. These resolved during your hospital stay.
Please return to the hospital if you experience fevers greater
then 101.4, chills, or other signs of infection. Also return to
the hospital if you experience chest pain, shortness of breath,
redness, swelling, or purulent discharge from the incision site.
Return if you experience worsening pain or any other concerning
symptoms.
Certain pain medications may have side effects such as
drowsiness. Do not operate heavy machinery while on these
medications.
Certain pain medications such as percocet or codeine can cause
constipation. If needed you can take a stool softner such as
Colace (one capsule) or gentle laxative (such as Milk of
Magnesia) once per day.
.
Please resume previous medications as prior to your surgery.
Please take pain medications and stool softener as prescribed.
.
Please follow-up as directed.
Followup Instructions:
Please follow-up with orthopaedic surgery. Please call to make
an appointment: ([**Telephone/Fax (1) 2007**]
|
[
"443.22",
"868.04",
"860.0",
"808.41",
"E825.2",
"807.09",
"821.23",
"810.00",
"401.9",
"V45.81",
"414.00",
"808.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"88.49",
"79.39",
"39.50",
"78.19",
"39.90",
"79.35",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
5106, 5167
|
1938, 2171
|
319, 723
|
5565, 5583
|
1242, 1915
|
6940, 7053
|
977, 995
|
4341, 5083
|
5188, 5544
|
4212, 4318
|
5607, 6917
|
1010, 1223
|
230, 281
|
751, 808
|
2180, 4186
|
830, 882
|
898, 961
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,680
| 116,338
|
47256
|
Discharge summary
|
report
|
Admission Date: [**2182-8-23**] Discharge Date: [**2182-8-27**]
Date of Birth: [**2112-9-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
bright reg blood per rectum
Major Surgical or Invasive Procedure:
upper endoscopy
colonoscopy
History of Present Illness:
69 F w/ DM, HTN, chronic back pain who presented to the ER with
c/o BRBPR. She reports that she had 3 seperate episodes of blood
associated with her bowel movement this am, present in toilet
bowl & not just covering stool. Denies any associated dizziness,
diaphoresis, abd. pain, N/V or palpitations. She also denies
melena or any hx of BRBPR. She was recently started on Naprosyn
2 months ago, and has been taking 2tabs twice daily for chronic
back, hip & ankle pain.
.
Past Medical History:
Diabetes II, oral [**Doctor Last Name 360**] controlled.
Hypertension
History of DVT in [**2170**]
TAH-BSO
Depression
Social History:
Lives in [**Location 686**]. 3 daughters, is primary caretaker for a
daughter with cerebral palsy. No EtOH, no tobacco, no illicits.
Originally from Mobile, [**State 9512**], married.
Family History:
Noncontributory.
Physical Exam:
Afebrile, mildly hypertensive but otherwise normal vitals signs
including sat greater than 90% on room air
Gen -- very pleasant black female in NAD
HEENT -- unremarkable
Heart -- regular
Lungs -- clear
Abd -- soft, nontender, nondistedend with appropriate bowel
sounds
Ext -- no edema, lesion or rash
Pertinent Results:
[**2182-8-27**] 06:40AM BLOOD WBC-6.3 RBC-3.76* Hgb-11.2* Hct-31.9*
MCV-85 MCH-29.9 MCHC-35.2* RDW-15.4 Plt Ct-188
[**2182-8-23**] 01:25PM BLOOD WBC-6.9 RBC-3.97* Hgb-11.5* Hct-32.4*
MCV-82 MCH-29.0 MCHC-35.5* RDW-15.2 Plt Ct-232
[**2182-8-27**] 06:40AM BLOOD Glucose-129* UreaN-5* Creat-0.6 Na-142
K-3.6 Cl-106 HCO3-26 AnGap-14
Brief Hospital Course:
1. bright red blood per rectum -- Admitted to [**Hospital Unit Name 153**], with
gastroenterology consultation. Hematocrit remained stable in
the low 30% range, although she had several heme positive stools
in the first 24 hours of admission. She had fluid resucitation
but was not hypotensive or orthostatic. She did not require
transfusion. She was transferred to the hospital medicine
service on 12 [**Hospital Ward Name 1827**], and underwent colonoscopy and endoscopy
Monday, [**8-26**]. Please see the procedure reports for details of
each. Briefly, endoscopy was normal throughout, and colonoscopy
showed diverticulosis with one diverticulum with some
inflammation and clot formation, likely the culprit of the
gastrointestinal bleed.
2. hypertension -- home medications were held until after
evaulation with endoscopy and colonoscopy. She remained mildly
hypertensive throughout her stay, which improved with
reinitiation of home medications.
2. diabetes mellitus II -- She was managed on sliding scale
insulin and scheduled accuchecks. Home medications were
reinitiated prior to discharge without difficulty.
3. chronic back pain -- Ms. [**Known lastname 13461**] is regularly followed by
an orthopedic surgeon for chronic lumbar back pain, and used
NSAIDs as well as Percocet prior to admission for GI bleed. She
was advised to discontinue use of NSAIDs, use Tylenol and
Percocet prn for pain.
Medications on Admission:
ASPIRIN 81MG--One by mouth every day
ATENOLOL 150 mg daily
GLUCOPHAGE 1000 mg qam, 500mg at noon, 1000mg qpm
GLYBURIDE 10MG twice a day
HYDROCHLOROTHIAZIDE 25 mg daily
MOEXIPRIL HCL 30 mg daily
MULTIVITAMINS
PERCOCET 5 mg-325 mg q 8 hours as needed for pain
RANITIDINE HCL 150 mg twice a day
.
Discharge Medications:
1. 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*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): **
this is a new medication, meant to replace ranitidine.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Atenolol 100 mg Tablet Sig: 150 mg Tablets PO once a day.
7. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
gastrointestinal bleeding, likely from a diverticulum
diabetes mellitus type II
hypertension
Discharge Condition:
stable, without continued bleeding, tolerating a full diet
Discharge Instructions:
You were hospitalized with gastrointestinal bleeding, most
likely from a diverticulum. You should continue to watch for
blood in your stool, and call your doctor or return to the
hospital if you experience more bleeding, have abdominal pain,
fever greater than 101, or any other concerns. Avoid NSAIDs
(including Motrin, aspirin, ibuprofen, naproxen or medications
including those names). You can continue to take Percocet and
tylenol, but do not exceed 4000 mg of acetaminophen (Tylenol) in
24 hours. You can resume taking your baby aspirin in 10 days.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2182-8-28**] 2:15
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2182-8-29**] 8:50
Provider: [**Name10 (NameIs) 13978**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2182-8-29**]
9:10
Provider: [**Name10 (NameIs) 100045**], [**Name11 (NameIs) 2048**] (primary care provider) [**Telephone/Fax (1) 250**]
on [**9-4**] at 8:30 AM.
|
[
"250.00",
"401.9",
"562.12",
"724.2",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
4548, 4554
|
1941, 3358
|
341, 371
|
4691, 4752
|
1588, 1918
|
5358, 5905
|
1234, 1252
|
3703, 4525
|
4575, 4670
|
3384, 3680
|
4776, 5335
|
1267, 1569
|
274, 303
|
399, 872
|
894, 1013
|
1029, 1218
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,582
| 139,129
|
38387
|
Discharge summary
|
report
|
Admission Date: [**2192-7-8**] Discharge Date: [**2192-7-21**]
Date of Birth: [**2133-5-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 18794**]
Chief Complaint:
anemia, thrombocytopenia, acute renal failure, ?TTP
Major Surgical or Invasive Procedure:
1. Intubation
2. Temporary HD line placement
3. Femoral Central Veinous Cannulation
4. Tunnelled HD Line Placement
5. Bone Marrow Biopsy
6. Arterial Line placement
History of Present Illness:
Mr. [**Known lastname 74316**] is a 58 year old man with h/o nephrolithiasis, HLD,
asthma, who is being transferred from [**Hospital3 **] Hospital with
concern for TTP.
.
The patient was evaluated 2 days prior to admission for back
pain. The patient noted a sudden onset of back pain while
playing golf. He was evaluated in the ED, determined to be
stable at that time, and was discharged home with pain
medications. Platelets were noted to have decreased from 189 in
[**5-26**] to 114 at that time. The following day, the patient
presented to his PCP's office with abdominal pain, nausea, and
vomiting. He was noted to be icteric and appeared generally
unwell and was referred back to the ED. The abdominal pain was
described as sharp and worst in the epigastric region, with
radiation to his back, shoulder, and the rest of his abdomen. He
had nausea and vomiting. He has also been coughing and has been
bringing up bloody sputum. No diarrhea or bloody bowel
movements. The patient notes a 10 pound weight loss in the past
week, poor appetite, and poor PO intake. He has had chills and
sweats, but no fevers. He has felt worse shortness of breath
over the last 2 days. Decreased urine output while he has been
hospitalized, but reports normal output prior to that time. He
recently traveled to [**Country **] in [**2192-5-17**]. He does not eat any
red meat or pork and has not had any undercooked meat recently.
.
The patient presented to the OSH [**2192-7-6**], where he was found to
have labs notable for WBC 15 (75% bands), Cr 4.5 (1.2 the day
prior to admission at the OSH), Tbili 23, Dbili 15, platelets
24. Peripheral smear was evaluated by Heme/Onc and showed e/o
schistocytes. UCx and BCx were drawn and are negative to date.
CT abdomen/pelvis was unremarkable. [**First Name8 (NamePattern2) 1356**] [**Last Name (NamePattern1) 10595**] from Heme/Onc
recommended treatment for possible TTP with pheresis, which [**Location (un) 21541**] Hospital is unable to offer. The patient was then
transferred to [**Hospital1 18**]. Prior to transfer, the patient was
hemodynamically stable, alert and oriented, and was only c/o a
mild headache.
.
On arrival to the ICU, the patient was conversant, AOx3. He
noted abdominal pain, which improved with Dilaudid. He was
coughing up blood-tinged frothy sputum during the interview. The
patient then became agitated and was noted to be requiring
increasing O2. He was electively intubated. The patient was
suctioned for a moderate amount of bloody secretions. He was
bronched at the bedside, which showed frothy bloody secretions.
.
Review of systems:
(+) Per HPI; +chills, night sweats, recent 10lb weight loss
(-) Denies fever. Denies headache, sinus tenderness, rhinorrhea
or congestion. Denies chest pain, chest pressure, palpitations,
or weakness. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
.
Past Medical History:
- Asthma
- Allergies
- Hypercholesterolemia
Social History:
Married and lives with his wife. [**Name (NI) **] retired from working as a
case manager. He denies chemical exposure. HIV negative in the
[**2162**], but has not been retested
- Tobacco: 25 pack year history, quit in [**2158**]
- Alcohol: rare
- Illicits: +marijuana use
Family History:
Throat cancer in mom and uncle.
Physical Exam:
Vitals: T: 99.8 BP: 193/105 P: 82 R: 28 O2: 94% on 4LNC
General: Alert, oriented, mild distress
HEENT: Sclera icteric, blood tinged mucous membranes
Neck: supple, no LAD
Lungs: coarse breath sounds, diffuse wheezing
CV: difficult to assess given loud breath sounds, Regular rate
and rhythm, normal S1 + S2, no murmurs, rubs, gallops
appreciated
Abdomen: soft, ttp epigastric and lower abdominal quadrants,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact, no focal deficits, AOx3
ON DISCHARGE
1. Tunnelled Right Subclavian
2. 1+ Pitting LE edema bilateral
Pertinent Results:
OSH Labs:
OSH Lab data [**2192-7-7**]:
Na 135 K 5.5 Cl 103 HCO3 22 BUN 70 Cr 6.8 Gluc 118
Ca 7.9 Mg 2.1 Phos 1.8
ALT 42 AST 198 AlkPhos 106 LDH 3900 Dbili 15 Ibili 7.9
Amylase 96 Lipase 69
Haptoglobin 14
Tylenol level WNL
WBC 12 HCT 35 Plt 24 Retic 1.4
Diff: Neut 17 Bands 73 Lymph 4 Mono 12 Eos 1 Baso 2
Morphology: 1+ spherocytes, acanthocytes, schistocytes
PTT 32.2 INR 1.4
Fibrinogen 260
Micro (OSH):
Babesia and Erlichia smears negative
Images:
[**7-6**] CXR (OSH): There is questionable minimal right lower lobe
infiltrate, not present on the prior chest x-ray of [**2191-3-8**].
No other abnormality is seen.
[**7-6**] Abdominal U/S (OSH): Negative for acute abnormality. There
is no explanation for abdominal pain. The right kidney shows
diffuse increase in the echogenicity of the cortex likely due to
diffuse parenchymal disease.
[**7-5**] CT abdomen/pelvis (OSH):
1. No evidence of obstructive uropathy or nephrolithiasis
2. Sequelae of granulomatous disease
3. Mildly enlarged prostate; correlate with PSA.
4. Bilateral hip osteoarthritis
EKG: NSR at 81, normal axis and intervals, TWI in aVL, no other
ST-Twave abnormalities, unchanged from prior EKG from OSH
[**2192-7-6**].
Heme Labs:
[**2192-7-12**] 02:07PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-2+
Macrocy-OCCASIONAL Microcy-1+ Polychr-2+ Spheroc-OCCASIONAL
Schisto-1+ Stipple-1+ Acantho-OCCASIONAL
[**2192-7-8**] 02:38PM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)
negative
Platelet Count: 24K on admission -> 124K on [**7-16**]
Haptoglobin: 14
Hct: 32.6 -> 18.5 -> 25.0
LDH: 3510 -> 271
Bilirubin: 30.3 -> 5.7
direct bili: 25.6 -> 13.8
Microbiology Data:
Blood cultures - [**7-8**], [**7-10**], [**7-13**] - no growth
CMV Ab - [**7-8**] - IgM negative, IgG positive
Catheter Tip - [**7-13**] - no growth
CMV Viral Load - negative
Leptospirosis - negative
Lyme serologies - negative
Sputum (OSH) - Pseudomanoas cultures, pan-sensitive to
Levofloxacin, Meropenem, Ceftriaxone, Ceftazidime, R to
Aztreonam
Stool cultures - negative for Salmonella, Shigella, Yersinia,
E. coli O157:H7 - negatve
B Glucan - negative
Galactomannan - negative
HIV - negative
Urine Gonorrhea/Chlamydia PCR - negative
Urine culture [**7-9**] - Enterococcus species (but contaminated
sample), [**7-17**] - Coag Negative Staph
Repeat urine cultures from [**7-12**], [**7-16**] negative
Hepatitis Titers:
Hep B sAb - negative
Hep B sAB - positive
Hep C Ab - negative
Hep A IgG - positive, IgM - negative
Parvovirus IgG positive, IgM negative
[**2192-7-12**] 02:07PM BLOOD Parst S-NEGATIVE
[**2192-7-11**] 07:31PM BLOOD HERPES SIMPLEX (HSV) 2, IGG- negative
[**2192-7-11**] 07:31PM BLOOD HERPES SIMPLEX (HSV) 1, IGG- postive
PPD normal from [**7-19**], read on [**7-21**]
Rheumatologic Work-up:
Anti-GBM Ab: negative
[**Doctor First Name **], ANCA - negative
Ceruloplasm - negative
[**2192-7-8**] 11:24AM BLOOD Lupus-NEG
[**2192-7-9**] 03:36AM BLOOD ACA IgG-4.1 ACA IgM-9.6
[**2192-7-8**] 11:23AM BLOOD ANCA-NEGATIVE B
[**2192-7-11**] 07:31PM BLOOD Smooth-NEGATIVE
[**2192-7-8**] 02:38PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2192-7-11**] 07:31PM BLOOD IgG-780 IgM-75
[**2192-7-10**] 04:39AM BLOOD C3-93 C4-13
Miscellaneous:
ADAMTS13 Activity and Inhibitor: 38%
[**2192-7-8**] 01:19AM BLOOD Fibrino-246
Serum Tox Screen:
[**2192-7-8**] 12:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-7-12**] 01:01AM BLOOD COPPER (SERUM)- normal
Hereditary Hemochromatosis: Negative
.
Imaging Studies:
Abd U/S:
1. Hepatomegaly.
2. Normal liver echotexture. A 1 cm hyperechoic lesion within
the right lobe is most likely a hemangioma.
3. Widely patent hepatic veins and main portal vein, with
appropriate flow
directions.
4. Trace ascites, and a small right pleural effusion.
5. Small amount of sludge within a normal appearing gallbladder.
6. Echogenic right kidney, may be compatible with known acute
renal failure.
7. The left kidney is not evaluated due to presence of overlying
bowel gas.
TTE: [**7-9**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF >55%).
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is borderline pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Borderline
pulmonary artery systolic hypertension.
Head CT:
1. No acute intracranial abnormality. Asymmetric size of the
lateral
ventricles is likely developmental/congenital in nature.
2. Severe pansinus inflammatory disease, with likely acute
component involving the sphenoid and maxillary sinuses.
CT Torso:
IMPRESSION:
1. Diffuse ground-glass opacities. Given patient's history of
hemoptysis,
these are most consistent with pulmonary hemorrhage. However,
underlying
infection/inflammation (Pneumocystis pneumonia, aspiration) and
atypical
pulmonary edema cannot be excluded.
2. Left lower lobe atelectasis or consolidation.
3. Anemia.
Scrotal U/S:
CONCLUSION: No evidence of epididymal orchitis. Slightly small
left testis, possibly as a result of prior orchitis or trauma.
Moderate left varicocele is noted, as well as a right epididymal
tail cyst.
Discharge Labs: (prior to HD)
HCT: 29.9
Plt: 238
Cr. 8.0
P 5.6
HCO3 16
bili 3.1
LDH 254
Brief Hospital Course:
SUMMARY
Mr. [**Known lastname 74316**] is a 58 year old man with h/o nephrolithiasis and
asthma transferred from [**Hospital3 **] Hospital with concern for TTP
and admitted to [**Hospital1 18**] for plasmapheresis. Pt with acute
hemolytic anemia, thrombocytopenia, acute renal failure,
hypertension, and elevated liver enzymes. He required 9
plasmapheresis sessions, HD (qd --> qod --> q3d), and high dose
steroids. Ultimately his platelets recovered, his HCT stabilized
(with low retic index) and he progressed from oliguria to
profuse UOP (3L/day) with stable [**Last Name (un) **] requiring HD by routine
(T/Th/Sat). He will follow up outpatient.
BY PROBLEM
1. TTP-HUS
-Acute Kidney Injury
-Thrombocytopoenia with spontaneous hemorrage (see resp
distress)
-Acute Hemolytic Anemia
-Steroid Induced Mood Disorder
Pt admitted with acutely new thrombocytopenia and anemia of
unclear etiology. Patient had consults from hematology, renal,
ID and transfusion medicine. No obvious medication effect or
infectious etiology was ever elicited. Likely diagnosis is
TTP/HUS, although pt did have abnormal coags at the OSH with an
INR 1.7 corrected with FFP. He had > 1% schistocytes on
peripheral blood smear. He was coomb's test positive for warm
auto-immune antibody and had positive hemolysis labs (low
haptoglobin, high LDH). ADAMTS13 activity was low (38%), but not
as low as with congenital loss of activity. No clear evidence of
an autoimmune process, as broad work-up was negative. With the
exception of the Coomb's test, rheumatologic work-up was
negative for any autoimmune process such as a lupus crisis
(negative [**Doctor First Name **], ANCA, complement levels, B2-glycoprotein-1).
Patient required occasional blood transfusions for Hct < 21 (8 U
total) and platelets (2 U total) for active bleeding, but all
transfusions were minimized in the setting of his TTP. He was
started on steroids (solumedrol) which was later transitioned to
dexamethasone and then prednisone when his bone marrow biopsy
returned with pathologic signs of HLH (but normal amount of
megakaryocytes, indicating a consumptive process). Final bone
marrow biopsy demonstrated subtle dyspoesis and
hemophagocytosis. Despite concern for HLH, No initiation of
cyclosporine due to lack of renal and liver reserve. Renal
recommended plasmapharesis for TTP treatment and HD when his
renal failure did not immediately improve. The patient underwent
9 days of plasmapheresis and his thrombocytopenia and anemia
improved (concomittant with steroids). His counts (platelets and
HCT) held steady as his bilirubin slowly fell and LDH remained
elevated. The patient developed labile moods and nightmares that
were swiftly controlled by olanzapine. He was discharged on 50
mg of prednisone with PPX (bactrim for pcp, [**Name10 (NameIs) **] for GIB and
olanzapine for mood disorder)
Follow Up:
1. Evaluate dose and course of steroids and appropropriate
prophylaxis regimen
2. Evaluate CBC, bilirubin, LDH, Haptoglobin and reticulocyte
index to account for degree of marrow recovery and hemolysis
2. Hypoxic Respiratory Distress
- New Hypertension with Hypertensive Emergency
- Spontaneous Pulmonary Hemorrhage (thrombocytopoenia)
On the day of admission, the patient became hypoxemic in the
setting of hemoptysis (platelet count of 24K) and flash
pulmonary edema secondary to hypertension from volume overload
due to his new acute on chronic renal failure. He was emergently
intubated for hypoxic rspiratory distress and airwayy
protection. Bronchoscopy s/p intubation showed frothy
blood-tinged secretions, consistent with flash pulmonary edema.
Patient may also have aspirated, as he had been coughing up
secretions and suctioning himself on arrival. His He was
oliguric and did not respond to lasix. CXR showed worsened
infiltrate in RLL that on Chest CT was concerning for
intrapulmonary hemorrhage. His OSH sputum cultures grew
Pseudomonas (pan-sensitive) and he was started on Levofloxacin
for a 14 day course. This was later discontinued as there was no
indication that he had invasive pseudomonal disease.
Respiratory status improved with nebulizers, and initial blood
pressure control with a labetol gtt, which was weaned once
patient was started on hemodialysis. TTE showed normal systolic
function with moderate pulmonary hypertension. He was eventually
extubated and his oxygen requirement was weaned to room air.
Work-up for autoimmune vasculitis such as Good-Pasteur's and
Wegener's granulomatosis was negative (negative ANCA, [**Doctor First Name **],
anti-GBM antibodies).
3. Acute oliguric renal failure
Pt with rapidly worsening Cr, from 1.2 several days prior to
admission to 8.0 (with peak at 9.0). Likely renal failure
associated with TTP. Urine sediment with acanthocytes, which can
be seen in microangiopathic hemolytic processes such as TTP
which cause small autoinfarcts in the glomerular filtration
system. Unlikely to be obstructive etiology, as renal imaging
from OSH has been negative. Patient was unresponsive to IV
lasix, so temporary HD line was placed and HD was initiated. HD
was initially daily, then qOD and finally he had HD on [**7-18**] and
[**7-21**]. He started making urine again on MICU Day #9. A tunnelled
HD line was placed on [**2192-7-18**] and by the day of discharge he was
producing 3L of urine daily. The marginal increase in creatinine
on non-HD days was progressively smaller such that it fell from
2.4-2.1-1.7-1.4. He was continued on HD T/Th/Sat on D/c with
phos binders and nephrocaps.
Follow up:
1. Evaluate chemistry labs and determine continued need for HD
2. Evaluate medication list (phos binders, nephrocaps) and
determine continued necessity
3. Evaluate BP and determine need for and appropriate dose of
anti-hypertensives
4. Arrange appropriate HD access - discontinue HD line or
arrange fistula access
4. Elevated Liver Enzymes
- Possible occult autoimmune hepatitis
Pt with elevated tbili, with predominant dbili, (given [**Last Name (un) **],
Dbili is excreted by the kidney). Normal AlkPhos and therefore
non-obstructive or infiltrative. Patient arrived with AST>ALT in
the setting of ARF/Hemolysis and was discharged with ALT>AST.
Workup was negative. Abdominal U/S with doppler gave no
evidence of Budd-Chiari/portal vein thrombosis, negative
hepatitis titers. Negative for tylenol toxicity (level neg at
OSH), [**Doctor First Name **], anti-SMA, ceruloplasmin, CMV viral load, EBV titers
and HHC gene. Iron studies showed elevated ferritin level >
[**2182**] which could be consistent with hemolysis or HLH (Ferritin >
500). Liver was consulted and agreed with diagnosis of secondary
HLH, but agreed with other studies to rule out a primary cause.
FOLLOW UP
1. Serial liver enzyme evaluation, consider biopsy if no
resolution
5. Asthma: continued advair, combivent nebulizer, and singulair.
6 Communication: Patient, wife [**Name (NI) 85481**] [**Telephone/Fax (3) 85482**] (h),
[**Telephone/Fax (1) 85483**] (w)
REVIEW OF FOLLOW UPS
1. Evaluate dose and course of steroids and appropropriate
prophylaxis regimen
2. Evaluate CBC, bilirubin, LDH, Haptoglobin and reticulocyte
index to account for degree of marrow recovery and hemolysis
3. Evaluate chemistry labs and determine continued need for HD
4. Evaluate medication list (phos binders, nephrocaps) and
determine continued necessity
5. Evaluate BP and determine need for and appropriate dose of
anti-hypertensives
6. Arrange appropriate HD access - discontinue HD line or
arrange fistula access
7. Serial liver enzyme evaluation, consider biopsy if no
resolution
Medications on Admission:
ASA 81mg PO daily
Advair 500/50 1puff [**Hospital1 **]
Albuterol 2puffs q4h prn
[**Doctor First Name **] D [**Hospital1 **]
Allergy shots 2/week
Singulair 10mg PO qhs
Mucinex prn
Ibuprofen prn
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Zyprexa 5 mg Tablet Sig: One (1) Tablet PO at bedtime: while
on steroids.
Disp:*30 Tablet(s)* Refills:*2*
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
Disp:*30 Tablet(s)* Refills:*2*
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 tablets* Refills:*2*
9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*120 Capsule(s)* Refills:*2*
10. Amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: TTP-HUS
Secondary: Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 74316**], it was a true pleasure to care for you. You were
admitted with a critical illness that caused severe kidney
damage, low platelets and low red blood cells. This was most
likely a condition called Thrombotic Thrombocytopenic
Purpura-Hemolytic Uremic Syndrome, or TTP-HUS.Your liver was
also inflamed. Despite requiring a tube in your lungs to help
you breathe, blood-exchange, blood transfusions, dialysis and
very high doses of steroids, you did well. You exceeded
expectations. Yet there is a lot of uncertainty. We do not know
what will happen with your kidney function, so you will need
dialysis and close follow up with kidney doctors. We do not know
how long you will have to be on steroids, so you will need close
follow up with blood doctors.
.
NEW MEDICATIONS
1. Prednisone - a steroid to keep your condition under control.
2. Protonix - an acid reducer to protect you while on steroids
3. Bactrim - an antibiotic to protect you while on steroids
4. Calcium Acetate - take with meals to protect you while your
kidneys are still damaged
5. Nephrocaps - a vitamin to support you while your kidneys are
damaged.
6. Olanzapine - a medication to keep you calm at night while on
steroids
7. Amlodipine - a blood pressure medicine to help while your
kidneys are recovering. You blood pressure will likely get
better as your kidneys improve. The dose of this medication
should be reviewed at every doctor's appointment.
8. Colace and Miralax are good over-the-counter medications to
help with constipation
STOP
1. Aspirin - consider restarting when your kidneys' status is
clear
Followup Instructions:
Dr. [**Last Name (STitle) 15170**] for [**Hospital3 **] Dialysis ([**Telephone/Fax (1) 33711**]) - Tuesday 6:00am
.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2192-7-26**] at 3:30 PM
With: [**First Name8 (NamePattern2) 25**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2192-7-26**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2192-7-22**]
|
[
"416.8",
"715.95",
"789.00",
"041.04",
"599.70",
"272.0",
"112.0",
"493.90",
"786.3",
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"518.4",
"482.1",
"518.81",
"608.9",
"584.9",
"599.0",
"446.6",
"585.9",
"276.6",
"283.9",
"283.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"33.23",
"41.31",
"99.71",
"38.95",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
19587, 19593
|
10397, 13263
|
335, 501
|
19672, 19672
|
4576, 8061
|
21458, 22254
|
3809, 3842
|
18246, 19564
|
19614, 19651
|
18028, 18223
|
19823, 21435
|
10300, 10374
|
3857, 4557
|
15951, 18002
|
3128, 3435
|
244, 297
|
529, 3109
|
9487, 10284
|
19687, 19799
|
3457, 3503
|
3519, 3793
|
8079, 9478
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,573
| 154,078
|
16342
|
Discharge summary
|
report
|
Admission Date: [**2154-10-31**] Discharge Date: [**2154-11-7**]
Date of Birth: [**2116-5-16**] Sex: M
Service: ENT
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 38 year-old male
with nasopharyngeal cancer status post radiation and
chemotherapy who had a past medical history notable for
angioedema and difficulty breathing who presented to [**Hospital1 1444**] on [**10-31**] for a neck
dissection for his metastatic nasopharyngeal cancer.
PAST MEDICAL HISTORY:
1. Lymphoepithelial nasopharyngeal cancer status post
radiation and chemotherapy.
2. Hepatitis B.
3. Hypertension.
4. Radiation pneumonitis. History of mild angioedema with
some difficulty breathing.
5. Hepatitis B.
MEDICATIONS ON ADMISSION:
1. Epivir 100 mg q day.
2. Roxicet.
ALLERGIES: Aspirin to which he gets a rash.
SOCIAL HISTORY: Denies the use of tobacco. Socially drinks
alcohol on occasion. He is married with two children. He is
from [**Country 3992**] and he is a computer engineer by profession.
PHYSICAL EXAMINATION: Vital signs temperature 97.6, blood
pressure 144/87, pulse 116, satting 98% on room air. The
patient appears well nourished Vietnamese gentleman in no
acute distress with a raspy voice. He had no difficulty
breathing. There was no [**Last Name (un) 15883**] noted on initial
presentation. Pupils are equal, round and reactive to light.
Extraocular movements intact. Face was symmetric. Tongue
was midline with full range of motion. The patient was able
to shrug his shoulders bilaterally. There was no palpable
cervical lymphadenopathy. Oropharynx was clear. His chest
was clear to auscultation bilaterally. Heart was regular
rate and rhythm. Abdomen soft, nontender, nondistended.
Bowel sounds present. G tube site was well healed.
LABORATORIES ON ADMISSION: White blood cell count 13.1,
hematocrit 34.9, platelets 268. Sodium 138, potassium 3.6,
chloride 103, bicarb 26, BUN 10, creatinine .7, glucose 86,
calcium 8.8, magnesium 1.8. [**Name (NI) 2591**], PT 12.9, PTT 26.6 and INR
of 1.1. His urinalysis was negative.
HOSPITAL COURSE: Mr. [**Known lastname **] is a 37 year-old gentleman with a
history of metastatic nasopharyngeal cancer status post
radiation and chemotherapy who presented to [**Hospital1 346**] for a neck dissection for which he
underwent on [**2154-10-31**]. The patient underwent a
right modified radical neck dissection with sparing of
cranial nerve [**Doctor First Name 81**]. His internal jugular vein was sacrificed
secondary to a neck mass, which was firm and fixed to the
sternocleidomastoid measuring about 3 cm and there was dense
scarring within the neck region. For further details please
refer to the operative note. The patient postoperatively was
transferred to the Intensive Care Unit for close monitoring.
He was kept intubated and sedated on Propofol. During the
surgery the surgeon had reported a blood loss
intraoperatively of 2 liters for which he required 3 units of
transfused packed red blood cells. He was noted to have
facial swelling more notable on the side of the operation,
however, he was noted to have chronic bilateral facial edema.
Neurological checks were performed. The patient was placed
on dexamethasone. Immediately postoperative the patient was
found to have some mild hyperkalemia. An electrocardiogram
was checked, which was normal and the patient was then given
some Kayexalate and it resolved appropriately. The patient
was placed on Ancef perioperatively. Postoperative days
following the surgery the patient was noted to have
improving edema. His hematocrit remained stable and he was
maintaining excellent urine output. The facial swelling was
felt most likely to be due to the resection of the right IJ
and underlying narrowing of the neck veins status post
radiation. He did undergo a left internal jugular
ultrasound, which revealed patent vessels with only some
narrowing, but normal flow. The patient was kept intubated
for airway protection. An nasogastric tube was placed for
nutritional purposes and tube feeds were started.
On postoperative day two the patient was noted to have a
slight leak around the cuff. Tracheoscopy and extubation was
performed. Around this time he was noted to have some right
facial edema with some mild right periorbital edema. His
extraocular movements intact. There was no diplopia.
However, he did haver some weakness of his right cranial
nerve XII and some left arm edema. The patient did well post
extubation. His left upper extremity edema improved.
Throughout this time he was placed on subcutaneous heparin.
Speech and swallow evaluation was performed. Their
recommendations including a po diet of puree solids and to
continue in the initial postoperative period of aspiration
precautions. Calorie counts were initiated. The patient did
well on a puree diet with supplemental shakes. On
postoperative day five his JP was removed. A few days later
a second JP as well as his clips were removed prior to
discharge. The patient eventually was transferred to the
floor where he remained stabile. His motility was improving
and his wound was clean and dry without any drainage. He was
taking adequate po. His pain was well controlled. It was
felt that the patient was stable for discharge on [**2154-11-7**] with follow up in clinic with Dr. [**First Name (STitle) **].
DISCHARGE STATUS: To home.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSIS:
Metastatic nasopharyngeal carcinoma.
SURGICAL PROCEDURE:
Status post modified right neck dissection.
DISCHARGE MEDICATIONS:
1. Roxicet 5 to 10 cc po q 3 to 4 hours prn pain.
2. Guaifenesin/codeine phosphate 5 to 10 cc po q 6 hours prn
cough for two weeks.
3. Levofloxacin 500 mg one tablet po q day for one week.
4. The patient was instructed to take pureed foods with
Boost supplements.
FOLLOW UP PLANS: The patient was instructed to follow up
with Dr. [**First Name (STitle) **] in one week. He is to call and schedule an
appointment at [**Telephone/Fax (1) 2349**].
Of note, although I was not directly involved in Mr. [**Known lastname **]
care, Dr. [**First Name (STitle) **] asked me to provide this discharge summary.
DR.[**First Name (STitle) 3880**],[**First Name3 (LF) **] 04-134
Dictated By:[**Last Name (NamePattern1) 12360**]
MEDQUIST36
D: [**2155-5-24**] 02:12
T: [**2155-5-28**] 07:50
JOB#: [**Job Number 46550**]
|
[
"998.11",
"070.32",
"E878.8",
"196.0",
"276.7",
"147.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"96.6",
"40.41"
] |
icd9pcs
|
[
[
[]
]
] |
5429, 5438
|
5585, 6433
|
5459, 5562
|
744, 829
|
2103, 5407
|
1045, 1805
|
162, 473
|
1820, 2085
|
495, 718
|
846, 1022
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,679
| 154,376
|
49101
|
Discharge summary
|
report
|
Admission Date: [**2126-3-26**] Discharge Date: [**2126-4-5**]
Date of Birth: [**2056-7-2**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: This is a 69-year-old male
with a long-standing history of poorly controlled
hypertension, type 2 diabetes, and hypercholesterolemia, who
presented to the [**Hospital6 256**] on
[**2126-3-26**] on referral from his primary care provider for
poorly controlled hypertension. The patient reportedly told
his primary care provider that he was suffering several
months worth of increased dyspnea on exertion associated with
throat constriction that occurred following walking for less
than two blocks. The patient denied any occurrence of
symptoms at rest. The patient was advised to undergo a
Persantine MIBI study at [**Hospital6 1597**]; however, the
scheduled study had to be cancelled secondary to the
patient's increased blood pressure.
The patient was subsequently referred to the [**Hospital6 1760**] for further evaluation and
was admitted to the Cardiac Medicine Service on [**2126-3-26**] for further evaluation and management.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Type 2 diabetes.
HOME MEDICATIONS:
1. Ecotrin.
2. Atenolol.
3. Allopurinol.
4. Glipizide.
5. Metformin.
6. Univasc.
7. Protonix.
8. Hydrochlorothiazide.
9. Norvasc.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient works as a stock broker. No
history of alcohol or drug abuse. Twenty-five pack year
history of smoking, however, the patient no longer smokes.
HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**]
Service on [**2126-3-26**] under the direction of Dr. [**Last Name (STitle) **].
The patient was initially managed with Captopril, Lopressor,
and aspirin; however, several episodes of spontaneously
increased blood pressure over the course of his two hospital
admission days resulted in the addition of nitroglycerin
paste for additional pressure control.
An echocardiogram obtained on [**2126-3-27**], demonstrated
evidence of inducible ischemia; subsequent cardiac
catheterization demonstrated three vessel coronary artery
disease with 90% occlusion of the proximal LAD, 80%
midsegment occlusion of the left circumflex, and 80-90%
occlusion of the right coronary artery. The cardiac
catheterization additionally demonstrated mild to moderate
diastolic biventricular dysfunction. The patient's ejection
fraction was noted to be approximately 51% with no evidence
of focal regional wall abnormalities.
Following extensive discussions with this patient and his
family regarding the risks and benefits of surgical
intervention, the patient was scheduled for an emergent
coronary artery bypass graft procedure on [**2126-3-28**].
The patient tolerated the procedure well with a CABG times
three with anastomosis from the LIMA to LAD, saphenous vein
graft to the PDA, and saphenous vein graft to the OM. Total
bypass time was 71 minutes; cross clamp time was 37 minutes.
The patient's pericardium was left open; intraoperative lines
placed included an arterial line and a Swan-Ganz catheter;
two ventricular wires and one atrial and one ground wire were
placed; both mediastinal and left pleural tubes were placed.
The patient was subsequently transferred from the Operating
Room to the Cardiac Surgery Recovery Unit, intubated for
further evaluation and management. On transfer, the
patient's mean arterial pressure was 74, CVP 10, PAD 19, [**Doctor First Name 1052**]
23. The patient was noted to be in atrially paced rhythm.
On transfer, the patient was on a propofol drip.
Shortly following arrival in the CSRU, the patient was
successfully weaned and extubated without complication. The
patient progressed well clinically in the CSRU through
postoperative day number three, at which point he was cleared
for transfer to the floor and was subsequently admitted to
the Cardiothoracic Service under the direction of Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**].
The patient was reviewed by Physical Therapy who deemed him
an appropriate discharge to home following completion of his
medical care. The patient's postoperative course was notable
for occasional incidents of elevated blood pressure with
systolics in the 160s and 170s, as well as significant
anxiety on the part of the patient.
On postoperative day number five, the patient was begun on
Norvasc to good effect and was thereafter noted to have
reasonable blood pressure control for the remainder of his
stay.
On postoperative day number three, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] diabetes consult
was also obtained to assist the patient in home training and
dietary control of his diabetes. The patient demonstrated a
reasonable understanding of his illness and was provided with
a Glucometer for home, fingerstick glucose monitoring.
On postoperative day number six, the patient complained of a
diffuse itching; physical examination demonstrated a mild
papular dry rash effecting the patient's trunk. The patient
was subsequently advised to refrain from ingestion of opiate
pain medications and demonstrated progressive relief from his
pruritic symptoms over the following days with therapy via
Benadryl and Sarna lotion. In addition, the patient
demonstrated intermittent episodes of respiratory wheezing
which were responsive to Albuterol nebulizer treatments. The
patient was subsequently trained in the use of an Albuterol
inhaler following clear x-ray studies demonstrating no
evidence of pulmonary infiltrate.
Following the removal of his Foley catheter, the patient
failed a voiding trial and required reinsertion of the
catheter with a postvoid residual noted of 925 cc. Urology
consult was obtained and advised the patient to maintain the
Foley in place for five to seven days following discharge
with a scheduled voiding trial follow-up with the Urology
Service on an outpatient basis.
At the request of the patient's primary care provider, [**Name10 (NameIs) **]
patient was also set up with an outpatient MRA to evaluate
his renal perfusion and assess for possible evidence of
renovascular hypertension.
By postoperative day number eight, the patient was noted to
be ambulatory and tolerating a full regular diet with
adequate pain control provided oral pain medications. The
patient was noted to have mild persistent respiratory
wheezing responsive to Albuterol inhaler treatment, as well
as steadily improving opioid related pruritus. The patient
was subsequently cleared for discharge to home with VNA
services on postoperative day number eight, [**2126-4-5**], with
instructions for follow-up.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Glipizide 5 mg p.o. q.d.
3. Metformin 500 mg p.o. q.d.
4. Atorvostatin 20 mg p.o. q.d.
5. Ibuprofen 600 mg p.o. q. eight hours p.r.n.
6. Benadryl 25 mg p.o. q. eight hours p.r.n.
7. Amlodipine 5 mg p.o. b.i.d.
8. Fluoxetine 20 mg p.o. q.h.s.
9. Tylenol #3 one to two tablets p.o. q. four hours p.r.n.
10. Lasix 20 mg p.o. b.i.d. times ten days.
11. Captopril 12.5 mg p.o. t.i.d.
12. Albuterol inhaler one to two puffs q. six hours p.r.n.
13. Lopressor 100 mg p.o. b.i.d.
14. Proscar 5 mg p.o. q.d.
DISCHARGE INSTRUCTIONS: The patient is to maintain his Foley
catheter in place until follow-up appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 365**] five to seven days following discharge for a voiding
trial. The patient is to maintain his sternal Steri-Strips
in place and keep incisions clean and dry at all times; the
patient should not remove his strips but let them fall off on
their own. The patient may shower but should pat dry
incisions afterwards; no bathing or swimming until further
notice. The patient may resume a regular diabetic diet. The
patient has been advised to limit physical activity; no heavy
exertion. No driving while taking prescription pain
medications.
FOLLOW-UP: The patient is to follow-up with his primary care
provider within one to two weeks following discharge for
potential outpatient MRA study to rule out renovascular
hypertension. The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 365**] five to seven days following discharge for a voiding
trial. The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]
six weeks following discharge for repeat evaluation; the
patient is to call [**Telephone/Fax (1) 170**] to schedule an appointment.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1053**]
MEDQUIST36
D: [**2126-4-7**] 01:43
T: [**2126-4-7**] 09:09
JOB#: [**Job Number 103025**]
|
[
"780.52",
"493.20",
"782.1",
"300.4",
"600.0",
"414.01",
"426.3",
"411.1",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"36.12",
"39.61",
"36.15",
"88.72",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
6753, 7293
|
1618, 6730
|
7318, 8916
|
1231, 1425
|
1147, 1213
|
1442, 1600
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,209
| 126,687
|
15515+15516
|
Discharge summary
|
report+report
|
Admission Date: [**2123-10-14**] Discharge Date:
Service: ACOVE
HISTORY OF PRESENT ILLNESS: The patient is an 83 year old male
with a history of Alzheimer's dementia, transferred from
[**Hospital3 4527**] for management of pancreatitis and possible
need for endoscopic retrograde cholangiopancreatography.
spoke with the patient's wife for history, who reported
unsteadiness and fever at home and she brought him to the
hospital for treatment of a supposed urinary tract infection,
which the patient chronically has. The patient had no abdominal
pain.
At [**Hospital3 4527**] Hospital, the patient was found to have a
lipase of 1,154, ALT 22, AST 12, total bilirubin 1.64, calcium
8.7, hematocrit 43.7 and a normal urinalysis. The patient
received Rocephin, Flagyl and Tylenol. He had temperature of
100.1, was given Zosyn as well as intravenous fluids and
transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for further
evaluation.
PAST MEDICAL HISTORY: 1. Alzheimer's dementia. 2. Chronic
urinary tract infections. 3. Chronic obstructive pulmonary
disease. 4. Hypercholesterolemia. 5. History of gallstones.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives at home with his wife. [**Name (NI) **]
has a 40 pack year history of tobacco, no alcohol use.
MEDICATIONS ON ADMISSION: Aricept 10 mg p.o.q.h.s.,
salmeterol two puffs inhaled b.i.d., albuterol two puffs
inhaled q.4h.p.r.n., simvastatin 20 mg p.o.q.d., ampicillin 2
gm i.v.q.8h., levofloxacin 500 mg p.o.q.d., Flagyl 500 mg
i.v.q.8h., pantoprazole 40 mg p.o.q.d., Tylenol p.r.n.
PHYSICAL EXAMINATION: On physical examination, the patient
had a temperature of 98, blood pressure 124/60, pulse 76, and
oxygen saturation 95% in room air. General: Elderly male,
pleasant, in no acute distress. Pulmonary: Dry crackles at
bilateral bases. Cardiovascular: No murmur, rub or gallop,
normal S1 and S2. Abdomen: Obese, soft, decreased bowel
sounds, nontender to palpation. Extremities: No edema,
warm. Neurologic examination: Alert and oriented times one,
extremely poor short term memory.
LABORATORY DATA: White blood cell count 8.2, hematocrit
39.2, platelet count 135,000, prothrombin time 14.6, INR 1.5,
sodium 139, potassium 3.9, chloride 103, bicarbonate 27, BUN
12, creatinine 0.9, glucose 91, ALT 6, AST 11, alkaline
phosphatase 60, amylase 69, lipase 255, total bilirubin 1.6,
albumin 3, calcium 8.1, phosphorous 2.8, magnesium 2, and
triglycerides 86.
RADIOLOGIC DATA: Right upper quadrant ultrasound showed
gallstones without gallbladder dilatation, question of
gallbladder wall edema.
HOSPITAL COURSE: The patient is an 83 year old man with a
history of Alzheimer's dementia, hypercholesterolemia,
gallstone pancreatitis diagnosed at outside hospital,
transferred here for treatment.
1. Gastrointestinal: The patient received a surgery evaluation
for a possible cholecystectomy. The patient received a
preoperative chest x-ray and electrocardiogram which showed no
consolidation and were within normal limits. The patient had
liver function tests rechecked, which showed an amylase of 26 and
lipase 33. The patient's white blood cell count was 6.3 on
recheck, hematocrit stayed between 35 and 37.
The patient was given aggressive fluid hydration and kept on
nothing by mouth. The patient was given Quick Mix for nutrition.
The patient received an endoscopic retrograde
cholangiopancreatography consultation and an MRCP, which showed
multiple small stones in the common bile duct and cystic duct.
The patient is to have an endoscopic retrograde
cholangiopancreatography in the hospital for removal of stones.
He will need to schedule an outpatient cholecystectomy.
2. Pulmonary: The patient has chronic obstructive pulmonary
disease and was stable throughout his hospital course, with
regular home therapy.
The rest of this dictation is to be dictated as an addendum
in the future.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAD
Dictated By:[**Name8 (MD) 8279**]
MEDQUIST36
D: [**2123-10-17**] 16:33
T: [**2123-10-20**] 14:16
JOB#: [**Job Number 44967**]
Admission Date: [**2123-10-14**] Discharge Date: [**2123-10-29**]
Service:
ADDENDUM: Mr. [**Known lastname **] [**Last Name (Titles) 1834**] endoscopic retrograde
cholangiopancreatography for gallstone removal on [**2123-10-18**]. A bilious sphincterectomy was performed in the 12
o'clock position using the sphincterotomy over an existing
guidewire. Two stones were extracted successfully using a
spiral basket and bone catheter. The patient did well
overnight, however, the next morning he woke up to go to the
bathroom and had shortness of breath and tachycardia. He had
nausea with emesis times two. The nurse was called. He was
found to be diaphoretic with blood pressure 70/45, heart rate
142, and oxygen saturations 92% on room air.
Electrocardiogram showed new right bundle branch block with
RV straining pattern. _________ was suspected and he was
transferred to the Intensive Care Unit. CTA was done and
showed massive bilateral pulmonary embolus. Endoscopic
retrograde cholangiopancreatography fellow was consulted and
the patient was started on heparin drip. He remained
hemodynamically stable overnight and was transferred back to
the floor the next day.
On the floor the patient remained on a weight based Coumadin
over the next five days and then Coumadin was restarted until
his INR became therapeutic on [**10-28**]. He was discharged
to rehab facility on [**10-29**] with therapeutic INR. His
cholelithiasis at this time resolved. There was no evidence
of myocardial damage.
DISCHARGE MEDICATIONS: Coumadin 5 mg po for two days and
then INR was to be rechecked and Coumadin adjusted
accordingly. Aricept 10 mg po q.d., Serevent two puffs MDI
b.i.d., Zocor 20 mg po q.d., Senna one to two tabs po 8 prn,
Nystatin powder to decubitus ulcer b.i.d. prn, Tylenol 650 po
q 6 prn.
He was discharged on a regular diet. No limitations on
physical activity. A follow up appointment was to be
scheduled with the patient's primary care physician by rehab
staff.
DISCHARGE DIAGNOSES:
1. Cholelithiasis.
2. Pulmonary embolism.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 18207**], M.D. [**MD Number(1) **]
Dictated By:[**Doctor Last Name 44968**]
MEDQUIST36
D: [**2123-10-29**] 11:27
T: [**2123-10-29**] 12:16
JOB#: [**Job Number 44969**]
|
[
"518.0",
"260",
"496",
"577.0",
"276.2",
"599.0",
"415.11",
"574.91",
"501"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"51.88",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
6275, 6596
|
5797, 6254
|
1435, 1694
|
2740, 5773
|
1717, 2121
|
101, 1034
|
2146, 2722
|
1057, 1276
|
1293, 1408
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,310
| 193,828
|
36429
|
Discharge summary
|
report
|
Admission Date: [**2162-5-4**] Discharge Date: [**2162-5-9**]
Date of Birth: [**2097-5-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
increasing exertional angina
Major Surgical or Invasive Procedure:
[**2162-5-4**] Coronary artery bypass grafting x4.
1. Left internal mammary artery grafted to the left
anterior descending artery.
2. Reverse saphenous vein graft to the diagonal branch of
the left anterior descending artery.
3. Reverse saphenous vein graft to the first obtuse
marginal branch of the circumflex.
4. Reverse saphenous vein graft to the second obtuse
marginal branch of the circumflex coronary artery
History of Present Illness:
64 yo male who noticed chest pain radiating to his left arm and
SOB for about 6 months. Prior ETT in [**7-21**] was negative for
schemia, but increasing symptoms recently prompted cath. This
showed severe 2VD. Referred for CABG.
Past Medical History:
? sarcoidosis
coronary artery disease
dilated ascenfding aorta
osteoarthritis right shoulder
syncope [**2158**]
splenectomy
anterior mediastinotomy?
left shoulder [**Doctor First Name **].
R. Ing. herniorrhaphy
removal bullet left anterior thigh
Social History:
works as a machinist
lives with wife
never used tobacco
no ETOH use
Family History:
father died of MI at 69
sister with CAD
mother died of MI at 52
Physical Exam:
68" 182#
well-nourished
skin unremarkable
slight shift of lips to right; PERRLA; EOMI;anicteric sclera;OP
unremarkable
neck supple;full ROM;no JVD or carotid bruits appreciated
CTAB
well-healed scar at sternal notch
RRR S1 S2 no m/r/g
soft, NT, ND +BS;well-helaed left flank scar, no hepatomegaly
warm,well-perfused; no peripheral edema or varicosities noted
well-healed left shoulder scar
MAE [**5-18**] strengths; nonfocal exam
2+ bil. fem/DP/radials
1+ bil. PTs
Pertinent Results:
Conclusions
PRE-CPB:1. The left atrium is normal in size. No spontaneous
echo contrast is seen in the left atrial appendage. No thrombus
is seen in the left atrial appendage.
2. No thrombus is seen in the right atrial appendage No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses and cavity size are normal.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal.
4. Right ventricular chamber size and free wall motion are
normal.
5. The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened (?#). Trace aortic regurgitation
is seen.
7. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
8. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB:
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2162-5-7**] 11:37
?????? [**2156**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Admitted [**5-4**] and underwent surgery with Dr. [**Last Name (STitle) **].
Transferred to CVICU in stable condition on titrated
phenylephrine and propofol drips.Extubated late that evening.
Developed A Fib and was treated with amiodarone.Transferred to
the floor on POD #2 to begin increasing his activity level.
Chest tubes and pacing wires removed per protocol.Coumadin
anticoagulation started on on POD #5. Target INR 2.0-2.5. Will
be followed by [**Hospital 197**] Clinic at [**Hospital1 **]( Dr. [**Last Name (STitle) 6254**].
First blood draw/INR on Tues. [**5-11**] Cleared for discharge to home
with VNA on POD #5.
Medications on Admission:
ASA 325 mg daily
metoprolol ER 25 mg daily
lipitor 80 mg daily
lisinopril 2.5 mg daily
isosorbide MN 30 mg daily
SL NTG 0.4 mg prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400mg twice a day then [**5-12**] decrease to 400
mg once a day until [**5-20**] then 200mg daily until follow up with Dr
[**Last Name (STitle) 6254**].
Disp:*60 Tablet(s)* Refills:*0*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): your dose has been decreased due to amiodarone please
follow up with Dr [**Last Name (STitle) 6254**] .
Disp:*30 Tablet(s)* Refills:*0*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing for 1 months.
Disp:*qs qs* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
please take 2mg on [**5-10**], lab to be drawn [**5-11**] for further dosing
of coumadin - results to [**Hospital1 **] coumadin clinic .
Disp:*60 Tablet(s)* Refills:*0*
11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day for 5 days.
Disp:*5 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**State 2748**]
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft
postop atrial fibrillation
Dilated ascending aorta
Osteoarthritis
Syncope [**2158**]
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:
Please call to schedule appointments
Dr [**Last Name (STitle) **] in [**2-16**] weeks at [**Hospital1 **] heart center
([**Telephone/Fax (2) 6256**])
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37063**] in 1 week ([**Telephone/Fax (1) 37064**]) please call for
appointment
Dr [**Last Name (STitle) 6254**] in [**2-16**] weeks ([**Telephone/Fax (1) 6256**]) please call for
appointment
***
Labs: PT/INR for coumadin dosing - atrial fibrillation goal INR
2.0-2.5 with result to [**Hospital1 **] coumadin clinic [**Telephone/Fax (1) 6256**]
first draw Tuesday [**5-11**] then twice weekly until on stable dose
Completed by:[**2162-5-10**]
|
[
"998.11",
"427.31",
"414.01",
"413.9",
"E878.2",
"135"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.13",
"39.63",
"99.05",
"99.07",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5946, 6000
|
3319, 3945
|
347, 781
|
6186, 6193
|
1976, 3296
|
6704, 7364
|
1409, 1474
|
4126, 5923
|
6021, 6165
|
3971, 4103
|
6217, 6681
|
1489, 1957
|
279, 309
|
809, 1039
|
1061, 1308
|
1324, 1393
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,076
| 121,471
|
2261
|
Discharge summary
|
report
|
Admission Date: [**2190-8-12**] Discharge Date: [**2190-8-14**]
Date of Birth: [**2104-11-4**] Sex: M
Service: MEDICINE
Allergies:
Librium / Aureomycin / Codeine / Benzocaine
Attending:[**Doctor Last Name 1857**]
Chief Complaint:
Increasing angina with exertion
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stenting of the right
coronary artery
History of Present Illness:
85 yo man with H/O angina, hypertension, hyperlipidemia, CKD
(baseline Cr 1.7-2.1), CAD s/p NSTEMI (s/p rotational
atherectomy RCA [**2173**], [**Year (4 digits) **] PCI [**2174**], [**Name (NI) 11919**] PTCA and proximal RCA
PCI [**2179**]) moderate-severe mitral regurgitation, who presented
with one week of intermittent chest pain. Per patient report,
the first episode occurred on Saturday, described as Left
shoulder pain into his back, [**5-20**], nonexertional, but associated
with mild diaphoresis; no shortness of breath, palpitations, or
nausea. Pain lasted less than 20 minutes and resolved with SLNTG
x1. Since then, he reportedly had mildly elevated BPs at home,
intermittent similar episodes of chest pain (about 1 episode per
day) each responding well to SLNTG. On Thursday, patient reports
he was using his lawn mower when had increased pain, more than
previously, feeling more similar to prior anginal pain,
resolving after 2 SLNTG. He called his cardiologist, Dr.
[**Last Name (STitle) 2201**], who felt the patient should be directly admitted for
cardiac catheterization after receiving pre-procedure hydration
overnight on the [**Hospital1 1516**] service.
On the day of transfer to the CCU, patient underwent cardiac
catheterization which showed 3-vessel disease, severe left
ventricular diastolic failure with moderately elevated wedge
with prominent V waves consistent with significant mitral
regurgitation. Patient was found to have significant RCA
disease. A bare metal stent was placed in the proximal RCA
complicated by wire induced dissection in the RCA managed with
two additional BMS. This was further complicated by plaque shift
and embolization into a major RV branch with transient inferior
ST elevation, nausea, heaves, bradycardia, and chest pain. He
was given atropine, which resolved the bradycardia. Patient
reports he continued to have retrosternal chest pain after the
procedure that lasted 20 minutes.
Currently on the floor, patient denies any chest pain, shortness
of breath, lightheadedness, nausea/vomiting, diaphoresis,
orthopnea, PND.
Past Medical History:
1. CAD RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS:
- s/p rotablator of RCA in [**2173**]
- s/p [**Name (NI) **] PTCA in [**2174**]
- s/p PTCA of [**Year (4 digits) 11919**] and stent in proximal RCA in [**2179**]
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- 3 Vessel CAD s/p NSTEMI [**2174**], [**2187**]
- Moderate-Severe mitral regurgitation
- Mild aortic stenosis and regurgitation
- bilateral carotid artery stenoses now s/p left carotid
endarterectomy
- Renal insufficiency (Cr over last three years 1.7-2.1)
- Chronic cough attributed to allergy/asthma
- Glaucoma
- Basal Cell Carcinoma
- Childhood polio
Social History:
-Tobacco history: quit 30 years ago. Smoked 1 PPD for 30 years.
-EtOH: [**1-11**] glasses of wine per night
-Illicit drugs: none
Family History:
Father died in sleep in late 60's possibly from an MI. No other
family history of heart disease.
Physical Exam:
Admission Physical Exam:
GENERAL: Elderly Caucasian man, appearing younger than stated
age, sitting up in bed
VITALS: T 98.1 BP 162/59 HR 55 RR 18 SaO2 99% on RA
HEENT: PERRL, EOMI, OP clear
NECK: supple, 6 cm JVD, no carotid bruits bilaterally
LUNGS: CTA bilaterally without crackles, wheezes, rales, rhonchi
HEART: regular, bradycardic; normal S1 S2, low pitched systolic
murmur @ apex
ABDOMEN: Soft, non-tender, normoactive bowel sounds, no
organomegaly
EXTREMITIES: 1+ DP/PT/radial pulses equal bilaterally, venous
stasis changes, 1+ edema to ankles, no cyanosis or clubbing
NEUROLOGIC: A&Ox3, CN II-XII wnl, moving all extremities, gait
normal
CCU Physical Exam:
GENERAL: WDWN NAD. Oriented x3. Mood, affect appropriate.
VS: T= afebrile BP= 150s/70 HR= 60s O2 sat= 96%on RA
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple; unable to assess JVP given big neck.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**3-16**] crescendo-decrendo murmur at LUSB,
[**3-16**] holosystolic murmur at apical area with radiation to the
axilla. 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 clubbing, cyanosis or edema. 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:
Admission Labs:
[**2190-8-13**] 01:20AM BLOOD WBC-7.1 RBC-4.23* Hgb-13.5* Hct-40.9
MCV-97 MCH-31.9 MCHC-33.0 RDW-15.0 Plt Ct-167
[**2190-8-13**] 01:20AM BLOOD PT-10.9 PTT-29.9 INR(PT)-1.0
[**2190-8-13**] 01:20AM BLOOD Glucose-92 UreaN-48* Creat-2.5* Na-138
K-4.5 Cl-107 HCO3-24 AnGap-12
[**2190-8-13**] 01:20AM BLOOD Calcium-8.2* Phos-4.1 Mg-2.6
[**2190-8-13**] 01:20AM BLOOD CK-MB-2 cTropnT-0.01
[**2190-8-13**] 08:00AM BLOOD CK-MB-3 cTropnT-0.02*
[**2190-8-13**] 09:00PM BLOOD CK-MB-3
[**2190-8-14**] 06:16AM BLOOD CK-MB-5
Discharge Labs:
[**2190-8-14**] 06:16AM BLOOD WBC-6.5 RBC-4.13* Hgb-13.2* Hct-39.8*
MCV-96 MCH-31.8 MCHC-33.1 RDW-15.0 Plt Ct-148*
[**2190-8-14**] 06:16AM BLOOD Glucose-150* UreaN-38* Creat-2.2* Na-137
K-3.8 Cl-103 HCO3-25 AnGap-13
[**2190-8-14**] 06:16AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.2
ECG [**2190-8-12**] 9:32:32 PM
Sinus bradycardia. Left ventricular hypertrophy. QS deflection
in lead V1 and Q wave in lead V2 with delayed R wave transition
consistent with prior anteroseptal myocardial infarction. These
findings are new as compared with previous tracing of [**2187-11-26**].
Followup and clinical correlation are suggested.
Cardiac catheterization [**8-13**]
1. Coronary angiography in this right dominant system
demonstrated three vessel disease. The LMCA was short and had no
angiographcally apparent disease. The LAD had proximal diffuse
disease to 40% just before D1. There was diffuse plaquing in D1
to 45% proximally. The mid LAD drug-eluting stents began just
after D1 and extended past the jailed D2 and contained mild
in-stent restenosis to 30%; the jailed D2 had an origin 60%
lesion. The distal LAD wrapped around the apex. The [**Month/Year (2) 8714**] had a
near-ostial bifurcation lesion involving the high OM1 to 65% in
the [**Month/Year (2) **] and 70% at the origin of OM1; OM1 itself had diffuse
disease to 65%. OM2 had diffuse disease to 50% proximally. The
[**Month/Year (2) 8714**] also supplied patent OM3/LPL1 and a modest LPL2. The RCA had
a patent near-ostial stent. There was a proximal 70% just beyond
the proximal RCA stent with diffuse disease thereafter down past
the major AM; the AM had an origin 70% stenosis with TIMI 2 slow
flow. There was TIMI 2 fast flow in the RCA proper. There was
diffuse disease in the mid-distal RCA before and after the long
[**Month/Year (2) 11919**]. The [**Month/Year (2) 11919**] had an origin 40% lesion. There was a patent,
modest caliber long RPL1 and a large RPL2 with diffuse plaquing
to 35% proximally. The RPL2 had small distal lateral branch that
was subtotally occluded.The distal AV groove RCA was 60%
diseased just after RPL2 leading into RPL3 which itself had a
proximal 40% lesion.
2. Resting hemodynamics revealed elevated left-sided filling
pressures. There was mild pulmonary arterial hypetension with
PASP of 40 mmHg. The PCWP was moderately elevated to 21 mmHg
with occasional prominent V waves consistent with significant
mitral regurgitation (ranging from 25 to 45 mmHg). The mean
transaortic gradient was 19 mmHg. The calculated aortic valve
area (using assumed oxygen consumption with a cardiac index of
3.2 L/min/m2) was 1.2 cm2, but this underestimates the true [**Location (un) 109**]
in the presence of known moderate-severe aortic regurgitation.
3. Successful direct stenting of proximal RCA with 3.0x15 mm
Integrity bare metal stent postdilated with a 3.25x12 mm NC
balloon, complicated by dissection requiring additional 3.0x15
mm Integrity bare metal stent to the mid RCA (most distal of the
stents) and 3.0x12 mm Integrity bare metal stent in mid RCA
jailing diseased AM (with ultimate TIMI 1 flow in the AM). Final
angiography showed a 10% residual stenosis in the stent in the
proximal RCA, no residual stenosis in the other 2 stents, no
apparent dissection, and essentially TIMI 3 flow in the RCA
proper (see PTCA Comments).
4. Bradycardia after IC diltiazem was treated with atropine.
5. Successful hemostasis of right radial arteriotomy was
achieved with a TR band.
6. Post-procedure, the patient's CK-MB remained normal.
Brief Hospital Course:
85 yo man with H/O CAD s/p NSTEMIx2 s/p PCIs, mod-severe mitral
regurgitation, known mild aortic stenosis and regurgitatino, who
presented with one week of intermittent chest pain concerning
for unstable angina admitted directly for precath hydration.
# CAD/Chest Pain: Patient with known 3 vessel CAD S/P prior PCIs
was admitted for a repeat cardiac catheterization in the setting
of accelerating intermittent chest pains similar to prior
angina, worsening in frequency over last week. He received pre-
and post-catheterization hydration. His CK-MB remained normal,
with a single troponin-T of 0.02 that could be attributed to
delayed clearance from his stage 4 chronic kidney disease. His
right and left heart catheterization demonstrated extensive 3
vessel disease, severe left ventricular diastolic failure with
moderately elevated wedge pressures and prominent V waves
consistent with significant mitral regurgitation. Mr [**Known lastname 1968**] was
found to have significant RCA disease, and a bare metal stent
was placed in the proximal RCA. Stenting was complicated by wire
induced dissection in the RCA managed with two additional BMS.
The procedure was further complicated by plaque shift and
embolization into major RV branch with transient inferior ST
elevation, nausea, heaves, bradycardia, and chest pain. He
received atropine which resolved the symptoms. He also had
transient chest pain (~20 minutes) directly after the procedure,
and the decision was made to monitor him overnight in the CCU.
During this brief CCU stay, he had couple episodes of nausea
relived with Zofran without any significant EKG changes. His
CKMB remained normal. He was continued on ASA, Plavix,
metoprolol and switched to atorvastatin 80 mg daily.
# Pump: Known moderate-severe aortic regurgitation with mild
aortic stenosis. Although the patient appeared euvolemic without
any shortness of breath, orthopnea, or PND with clear lungs, his
PCW was elevated at 21 mm Hg with LVEDP 28 mm Hg, indicative of
severe left ventricular diastolic heart failure. His Lasix was
held in the setting of receiving 250 cc of contrast during the
angiographic procedure.
# CKD: Patient is at increased risk of kidney damage (contrast
induced nephropathy) in the setting of having received 250 cc of
contrast during his procedure (required to treat the
unanticipated RCA dissections). He received 1 L of fluids prior
to angiography and 2 L additional NS fluid in the CCU. His
valsartan and Lasix were held. His creatinine remained at
baseline level of 2.2 on post-procedure day 1. He was asked to
restart his Lasix and valsartan on [**2190-8-16**].
# Hypertension: Blood pressure well controlled this admission
with new BP regimen. Patient was continued on his home dose of
isosorbide mononitrate extended release. Metoprolol was changed
to 37.5 mg [**Hospital1 **]. Hydralazine was discontinued and instead he was
started on 10 mg of amlodipine daily for his unrevascularized
CAD.
# Glaucoma: Continued Timolol Maleate, travoprost, Alphagan
# GERD: Continued ranitidine
# Allergies: Continued fluticasone, prednisone
# CODE STATUS: Full (confirmed)
# EMERGENCY CONTACT: Wife [**Name (NI) 382**] [**Name (NI) **] [**Name (NI) 1968**] [**Telephone/Fax (1) 11920**]
Transition of care:
- Patient will follow up with PCP and [**Name9 (PRE) 11921**] for further
management of his CAD.
- Patient will have chemistries drawn on Monday and results will
be faxed to PCP's office.
- Patient will restart his Lasix which he will take daily and
also restart his valsartan on Monday [**2190-8-16**].
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. HydrALAzine 25 mg PO HS
2. Metoprolol Tartrate 12.5 mg PO QAM
3. Metoprolol Tartrate 12.5 mg PO NOON
4. Metoprolol Tartrate 25 mg PO HS
5. Valsartan 20 mg PO BID
6. Simvastatin 40 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 15 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Timolol Maleate 0.5% 2 DROP BOTH EYES [**Hospital1 **]
11. travoprost *NF* 0.004 % OU daily
12. FoLIC Acid 1 mg PO DAILY
13. Pyridoxine 100 mg PO DAILY
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Furosemide 20 mg PO DAYS (TU,TH,SA)
16. Ranitidine 75 mg PO DAILY
17. Vitamin D 400 UNIT PO DAILY
18. Fluticasone Propionate NASAL 1 SPRY NU DAILY
19. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
20. PredniSONE 2.5 mg PO DAILY
21. Nitroglycerin SL Dose is Unknown SL PRN angina
22. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
3. Clopidogrel 75 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 15 mg PO BID
8. Metoprolol Tartrate 37.5 mg PO BID
RX *metoprolol tartrate 25 mg 1.5 tablet(s) by mouth Twice a day
Disp #*90 Tablet Refills:*0
9. Multivitamins W/minerals 1 TAB PO DAILY
10. PredniSONE 2.5 mg PO DAILY
11. Timolol Maleate 0.5% 2 DROP BOTH EYES [**Hospital1 **]
12. Ranitidine 75 mg PO DAILY
13. travoprost *NF* 0.004 % OU daily
14. Vitamin D 400 UNIT PO DAILY
15. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth Every Day Disp #*30
Tablet Refills:*0
16. Pyridoxine 100 mg PO DAILY
17. Atorvastatin 80 mg PO DAILY
RX *Lipitor 80 mg 1 tablet(s) by mouth Every Day Disp #*30
Tablet Refills:*0
18. Nitroglycerin SL 0.3 mg SL PRN angina
19. Outpatient Lab Work
Please check chemistries (Na, K, Cl, HCO3, BUN, Cr, Mg) and fax
results of patient PCP [**Telephone/Fax (1) 11922**].
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease
Marker negative unstable angina
Distal embolization and plaque shift into a right ventricular
branch
Guidewire induced coronary artery dissection
Stage 4 chronic kidney disease
Severe chronic left ventricular diastolic heart failure
Aortic stenosis and regurgitation
Mitral regurgitation
Hypertension
Dyslipidemia
Glaucoma
Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 1968**] it was a pleasure taking care of you.
You were admitted to [**Hospital1 18**] for cardiac catherization during
which several stents were placed. You were monitored in the CCU
after the procedure without event.
Several changes were made to your medication:
STOP your hydralizane.
HOLD your lasix and valsartan until Monday, [**8-16**]. After which
begin taking 20mg of lasix daily and resume your regular
valsartan dosing.
INCREASE your Metoprolol to 37.5mg tablets twice daily.
--Take one 37.5mg tablet in the morning and one in the evening.
CHANGE your simvastatin to atorvastatin. Take 80mg atorvastatin
daily
START Amlodpine 10mg tablets. Take one 10mg tablet daily
** DO NOT STOP TAKING ASPIRIN OR PLAVIX UNLESS INSTRUCTED BY
YOUR CARDIOLOGIST **
Also please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes
up more than 3 lbs.
Followup Instructions:
Please follow-up with outpatient Cardiologist, Dr. [**Last Name (STitle) 2201**] next
week. Please call for an appointment [**Telephone/Fax (1) 62**].
Department: DERMATOLOGY
When: WEDNESDAY [**2190-8-25**] at 1:15 PM
With: [**Doctor Last Name 3833**] [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2190-10-11**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], M.D. [**Telephone/Fax (1) 541**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: FRIDAY [**2190-10-22**] at 3:00 PM
With: [**First Name8 (NamePattern2) 2206**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, MSC 12-339
Completed by:[**2190-8-14**]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,335
| 173,484
|
40399
|
Discharge summary
|
report
|
Admission Date: [**2153-6-8**] Discharge Date: [**2153-6-26**]
Date of Birth: [**2072-4-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8810**]
Chief Complaint:
left sided hip pain
Major Surgical or Invasive Procedure:
Bone marrow biopsy
Temporary central venous catheter for dialysis - right internal
jugular
Right subclavian central venous catheter
Tunneled dialysis line placement
History of Present Illness:
81 yo M w/ L hip pain, wt. loss, anemia, and acute renal failure
presenting from visit at [**Hospital **] clinic due to acute rise in Cr.
Pt used to live in US but has been living back in his native
island of Dominica for last 3 years since the death of his wife.
Lived along and was very active and independent, doing his own
cooking and cleaning. He was visited by his two children [**First Name8 (NamePattern2) **]
[**Known lastname 88565**] and [**First Name8 (NamePattern2) **] [**Known lastname 88565**] four times a year.
.
One month prior to admission daughter reports he started
reported L hip pain. His PCP in [**Name9 (PRE) **] gave him one week of
predisone and tramadol which helped his symptoms. However, after
this course finished his symptoms returned. Last week his
daughter went from the US to visit him and found him to have
poor appetite. He was easily fatigued and rarely willing to
leave the house. He reports feeling slightly SOB over the last
few weeks and his daughter reports his sugars were abnormally
low (55-75 range when normally 90-110s). Found to have lost
roughly 30lbs in last 2-3 months. His daughter [**Name (NI) 4662**] him back
to the US this past week but his PCP was out of town. He saw the
[**Hospital **] clinic regarding his diabetes today and they found his
BUN/Cr to be extremely elevated from prior labs in Dominica (had
been Cr of 1.9 in [**2152-11-6**] but > 6 today). [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) 88566**]y to [**Hospital1 18**] for evaluation.
.
In ED VS were initially 98.2 72 124/50 18 100% RA. Pt was found
to be anemic but guiac negative. LDH was elevated and BUN 96
with Cr of 6.5. Hip xrays showed lytic lesion in proximal femur
and CT Abd/Pelvis confirmed this and also noted lytic lesions in
L hip and lumbar spine. In ED recieved 1L IVF. VS on transfer HR
74, BP 152/66, RR 18, 98% RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, 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:
- HTN
- DMII
- HLD
Social History:
Lived in Dominica last 3 years. Was living alone and
independently. Two children ([**Location (un) **] is daughter and [**Name (NI) **] is
son) live in [**Name (NI) 86**] area and are involved and concerned. Smoked
may years ago but quite in [**2112**]. No alcohol use.
Family History:
- DMII (3 sisters)
Physical Exam:
VS: 97.0 / 158/64 / 80 / 17 / 100% on RA
GA: AOx3, NAD, frail appearing
HEENT: PERRLA. dry MM. no LAD. no JVD. neck supple. large lipoma
on back of neck left of midline
Cards: RRR S1/S2 heard. mild systolic ejectin murmur, no
gallops/rubs.
Pulm: CTAB no crackles or wheezes on posterior exam
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, radial 2+, spotty skin
discoloration on lower extremities
Skin: patchy light discoloration on scalp as well as those
mentioned on lower extremities
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (patellar). sensation intact to LT. cerebellar fxn
intact (FTN, HTS). gait not tested. no asterixis.
Pertinent Results:
Labs upon admission:
[**2153-6-8**] 01:23PM BLOOD WBC-6.4 RBC-2.64* Hgb-7.8* Hct-22.4*
MCV-85 MCH-29.4 MCHC-34.6 RDW-16.6* Plt Ct-101*
[**2153-6-8**] 01:23PM BLOOD Neuts-64.7 Lymphs-24.3 Monos-8.4 Eos-2.0
Baso-0.6
[**2153-6-9**] 08:00AM BLOOD PT-13.4 PTT-30.2 INR(PT)-1.1
[**2153-6-11**] 05:43AM BLOOD Fibrino-499*
[**2153-6-9**] 08:00AM BLOOD ESR-25*
[**2153-6-9**] 08:00AM BLOOD Ret Aut-0.8*
[**2153-6-18**] 06:00AM BLOOD SerVisc-1.5
[**2153-6-8**] 01:23PM BLOOD Glucose-123* UreaN-96* Creat-6.5* Na-144
K-4.2 Cl-101 HCO3-29 AnGap-18
[**2153-6-8**] 01:23PM BLOOD ALT-14 AST-26 LD(LDH)-444* AlkPhos-72
TotBili-0.2
[**2153-6-11**] 05:43AM BLOOD Lipase-24
[**2153-6-10**] 07:25AM BLOOD CK-MB-29* MB Indx-8.5* cTropnT-0.29*
[**2153-6-8**] 01:23PM BLOOD TotProt-7.2 Calcium-15.2* Phos-6.7*
Mg-2.7* UricAcd-13.0* Iron-102
[**2153-6-8**] 01:23PM BLOOD calTIBC-295 Ferritn-991* TRF-227
[**2153-6-9**] 03:35PM BLOOD VitB12-1095* Folate-13.4
[**2153-6-11**] 04:25PM BLOOD Hapto-259*
[**2153-6-10**] 08:55AM BLOOD PTH-42
[**2153-6-18**] 06:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2153-6-9**] 08:00AM BLOOD CRP-1.6 PSA-6.5*
[**2153-6-8**] 01:23PM BLOOD PEP-TRACE ABNO IgG-683* IgA-19* IgM-16*
IFE-MONOCLONAL
[**2153-6-9**] 08:00AM BLOOD b2micro-16.3* IgG-534* IgA-15* IgM-13*
[**2153-6-9**]:
FREE KAPPA, SERUM [**Numeric Identifier **].0 H 3.3-19.4 mg/L
FREE LAMBDA, SERUM 10.4 5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO 1111.54 H 0.26-1.65
[**2153-6-14**]:
FREE KAPPA, SERUM 4260.0 H 3.3-19.4 mg/L
FREE LAMBDA, SERUM 6.5 5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO 655.38 H 0.26-1.65
Labs upon discharge:
[**2153-6-25**] 04:59AM BLOOD WBC-9.7 RBC-3.03* Hgb-8.9* Hct-25.3*
MCV-83 MCH-29.2 MCHC-35.0 RDW-14.3 Plt Ct-137*
[**2153-6-25**] 04:59AM BLOOD Glucose-180* UreaN-82* Creat-6.8*# Na-135
K-5.0 Cl-96 HCO3-26 AnGap-18
[**2153-6-19**] 05:33AM BLOOD ALT-121* AST-50* LD(LDH)-468* CK(CPK)-189
AlkPhos-78 TotBili-0.4
[**2153-6-25**] 04:59AM BLOOD LD(LDH)-383* AlkPhos-69
[**2153-6-19**] 05:33AM BLOOD CK-MB-3 cTropnT-2.74*
[**2153-6-25**] 04:59AM BLOOD Albumin-3.4* Calcium-7.8* Phos-7.1*#
Mg-2.3
CXR [**2153-6-21**]: FINDINGS: As compared to the previous radiograph,
the lung volumes have slightly decreased, and the size of the
cardiac silhouette has minimally increased. No pneumothorax.
Bilateral central venous access lines. No pleural effusions. No
pulmonary edema.
Hip films/AP pelvix [**2153-6-20**]:
There is again seen a very large expansile lesion within the
left proximal
femora: There is a cortical breakthrough along the more medial
aspect in the region of the lesser trochanter. The more lateral
and posterior aspects of the femoral cortex appears intact.
There are also diffuse lucent lesions throughout the pelvis and
findings and proximal femurs consistent with no myelomatous
deposits. Degenerative changes of bilateral hips are present.
There are vascular calcifications.
[**2153-6-18**]: CT head: IMPRESSION:
1. No acute intracranial hemorrhage.
2. Low-attenuating region within the left frontal cortex is
concerning for
chronic versus less likely subacute process. Findings were
discussed with Dr. [**Last Name (STitle) **], who reported no evidence of focal
neurological deficits in the patient's recent history.
3. Asymmetry of the ventricles with the left ventricle larger
than the right ventricle, likely representing ex vacuo
phenomenon.
4. Sequelae consistent with small vessel ischemic disease.
5. Mucosal thickening within the left maxillary sinus as well as
possible
mucus retention cyst within the left portion of the sphenoid
sinus.
CT chest [**2153-6-12**]: IMPRESSION:
1. Extensive ground-glass and consolidative parenchymal
opacities, involving all lobes, with a nondependent-dependent
gradient increased in severity, most compatible with ARDS.
2. Trace pericardial effusion.
3. Numerous mediastinal nodes, likely reactive.
4. Numerous destructive lytic osseous lesions, compatible with
history of
known multiple myeloma.
[**2153-6-11**]: IMPRESSION: Suboptimal image quality. Mild symmetric
left ventricular hypertrophy with preserved regional and global
systolic function. Mild right ventricular cavity enlargement
with low normal systolic function. Pulmonary artery systolic
hypertension. Moderate mitral regurgitation. Moderate tricuspid
regurgitation.
[**2153-6-9**]: Skeletal series: IMPRESSION: Diffuse lytic lesions
throughout the appendicular and peripheral skeleton, consistent
with myeloma or metastases.
Brief Hospital Course:
81 year old male who was admited for hip pain found to have
multiple myeloma.
.
Hypoxic respiratory failure: He was initially given aggressive
intravenous fluids (5L) to correct severe hypercalcemia and
developed pulmonary edema and acute respiratory failure
prompting intubation and ICU admission. He was placed on a
furosemide drip but urine output was minimal due to acutre renal
failure secondary to light chain nephrotoxicity. He required
CVVH (started [**2153-6-12**]) which successfully removed fluid and
allowed for extubation.
Multiple myeloma: He initially presented with calcium of 15 and
acute renal failure. He received aggressive intravenous fluids
and pamidronate infusion. SPEP/UPEP showed bence-[**Doctor Last Name 49**] protein
in his urine and free kappa chains were elevated. Skeletal
survey showed diffuse lytic lesions. He received a bone marrow
biopsy on [**2153-6-19**] that showed plasma cell myeloma with plasma
cells comprising 33% of aspirate. He was started on velcade and
dexamethasone on [**2153-6-18**], and needs his last dose of velcade on
[**2153-6-29**] and dexamethasone on [**2153-6-29**] and [**2153-6-30**]. He was
started on PCP prophylaxis with bactrim and continued on
acyclovir for HSV prophylaxis. He was seen by ortho/oncology
for his large lytic lesion in his left femur, but was deemed not
a surgical candidate for hip fixation due to his poor functional
status and multiple comorbidities. Alternatively he received
radiation to the femur lesion (total 5 treatments, last
treatment [**2153-6-27**]). He is touch down weight bearing on left
lower extremity with full assist with left leg lift due to his
high risk of femur fracture.
Acute Renal failure: Baseline creatinine from [**12/2152**] was <1.5.
Presented to ICU with creatinine of 5 to 6, with evidence of
fluid overload and worsening hyperkalemia. Initially as still
making urine and able to diuresis with Lasix, however the
patient became progressively anuric, with his creatinine peaking
at 9.9. CVVH was initiated as above. He commenced dialysis and
will continue with HD M/W/F as an outpatient. He may recover
kidney function once light chain burden decreases. He did not
receive plasmapheresis per recommendations from the transfusion
medicine team (data shows lack of benefit from plasmapheresis
with elevated light chains due to extensive tissue/fat
distribution and short half life of proteins).
NSTEMI: Presented with ST depressions in lateral leads while
extremely tachycardic during flash pulmonary edema. Repeat ECG
showed resolultion of ST changes. Follow up cardiac enzymes
showed up trending troponins with elevated but steady CK-MB.
Echo showed EF 55%, mild symmetric LVF, 2+ mitral regurg, 2+
tricuspid regurg, but no focal wall abnormalities. The study was
done in the setting of gross fluid overload. CKMB trended down,
although troponin T remained elevated likely secondary to renal
insufficiency. He developed non-sustained ventricular
tachcardia (one episode of ~50 beats, asymptomatic) on the
wards. He was seen by cardiology and started on metoprolol with
adequate rate control.
Anemia: Hct down to 17. Likely related to bone marrow
suppression from multiple myeloma and renal failure. Received a
total of 8 units of PRBCs during admission.
Thrombocytopenia: Likely secondary to multiple myeloma causing
bone marrow suppression. He was started on heparin SQ DVT
prophylaxis once platelets improved and should continue this
upon discharge due to ongoing immobility.
Mental status: Per baseline per family upon discharge. He
answers questions appropriately and is oriented to name and
place but not time.
He was FULL CODE for this admission.
Medications on Admission:
-simvastatin 20 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime
-glipizide 10 mg Tab Oral 1 Tablet(s) Once Daily
-lisinopril-hydrochlorothiazide 20 mg-12.5 mg 1 Tablet(s) Once
Daily
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
4. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea.
5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. insulin lispro 100 unit/mL Solution Sig: asdir Subcutaneous
ASDIR (AS DIRECTED): please see sliding scale.
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS): please crush.
11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): on hemodialysis days, please give AFTER
dialysis.
12. dexamethasone 4 mg Tablet Sig: Five (5) Tablet PO asdir for
2 doses: please give 20mg on [**2153-6-29**] and [**2153-6-30**].
13. VELCADE 3.5 mg Recon Soln Sig: 2.1 mg Intravenous once for 1
doses: to be given on [**2153-6-29**] at clinic appointment with Dr.
[**Last Name (STitle) 3759**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Multiple myeloma
Acute respiratory failure: pulmonary edema and ARDS
Diffuse Lytic bony lesions
Acute renal failure - secondary to light chains
Hypercalcemia
Non-sustained ventricular tachycardia
Anemia
Thrombocytopenia
Diabetes Mellitus type 2
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital because of hip pain. You were found to
have multiple myeloma. You received intravenous fluids due to
high calcium and temporarily required intubation because of
fluid overload in your lungs. Your kidneys were injured
secondary to multiple myeloma. You were started on
hemodialysis. You improved significantly overtime and were able
to begin chemotherapy. You were seen by orthopedics who
determined you have a high risk of left femur fracture, but
unfortunately surgery is not safe at this point. You are
receiving radiation to your femur to help prevent fracture.
We made the following changes to your medications:
- STOP simvastatin
- STOP glipizide
- STOP lisinopril-hydrochlorothiazide
- START senna 8.6mg twice daily as needed for constipation
- START colace 100mg twice daily as needed for constipation
- START miralax 17g daily as needed for constipation
- START compazine 10mg every 8 hours as needed for nausea
- START acyclovir 400mg daily
- START insulin sliding scale as directed
- START metoprolol 25mg three times daily
- START nephrocaps 1 cap daily
- START heparin SQ 5000 units three times daily
- START calcium acetate 2668mg three times daily with meals,
please crush
- START bactrim SS 1 tab daily
- START dexamethasone 20mg on [**6-29**] (with velcade) and [**6-30**] only
- Velcade 2.1mg IV to be given on [**2153-6-29**] at oncology clinic
appointment
It was a pleasure caring for you. We wish you a speedy
recovery.
Followup Instructions:
Radiation therapy
[**Hospital1 69**], [**Hospital Ward Name **]
Basement level, [**Hospital Unit Name **]
Wednesday [**2153-6-27**] at 4:00PM
Department: HEMATOLOGY/BMT
When: FRIDAY [**2153-6-29**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2153-6-29**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: FRIDAY [**2153-6-29**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2153-6-26**]
|
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icd9cm
|
[
[
[]
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[
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323, 490
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14247, 14294
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,113
| 162,590
|
4694+55597
|
Discharge summary
|
report+addendum
|
Admission Date: [**2137-3-11**] Discharge Date: [**2137-3-29**]
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
gentleman presenting to the Emergency Department for right
hip pain with difficulty ambulating times a week. Denied
chest pain, nausea, vomiting, shortness of breath, or trauma.
In the Emergency Department, patient became tachypnea
requiring more O2 requirement and was nasotracheally
intubated secondary to pending respiratory distress. The
patient then experienced an episode of hypotension down to
75/48, fluid responsive. Blood pressure normalized. Chest
x-ray showed pulmonary edema. Patient also had a fever of up
to 101.8 degrees and was empirically started on ceftriaxone 2
grams IV. Blood cultures were obtained.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Noninsulin-dependent diabetes.
3. Hypertension.
4. Increased cholesterol.
5. Hyperlipidemia.
6. Arthritis.
7. Benign prostatic hypertrophy.
MEDICATIONS AT HOME:
1. Atenolol 100 mg q day.
2. Flomax 0.4 mg q day.
3. Glyburide 5 mg [**Hospital1 **].
4. Lipitor 10 mg q day.
5. Nitroglycerin 0.4 mg sublingual prn.
6. Vioxx 25 mg q day.
7. Zestril 5 mg q day.
ALLERGIES: No known allergies.
SOCIAL HISTORY: The patient lives in a house with son. Is
retired and no recent travel or sick contacts, nonsmoker and
no alcohol.
REVIEW OF SYSTEMS: By review of systems, the patient came in
with a fever of unclear etiology, but blood cultures grew out
Gram positive Staphylococcus aureus, coag positive, and
suspected to have an infected endocarditis. On transthoracic
echocardiogram was not shown to have any vegetations. On
transesophageal echocardiogram, 5 mm vegetation was found on
the aortic valve on both sides of the leaflet without any
abscess in the aortic root. However, we also considered
other possible sources of infection to be considered
meningitis, and he was empirically started on ceftriaxone,
consider chest x-ray which did not reveal any acute
consolidations.
CT scan of the abdomen was negative. On genitourinary
examination, he had a right inguinal hernia that was examined
by surgery and felt to be reducible and nonincarcerated.
Another source of possible infection is right hip possible
osteomyelitis given the initial hip pain as well as urine.
Urinalysis was normal.
Once the blood cultures grew out Staphylococcus aureus,
sensitivities came back, he was switched to oxacillin and
gentamicin. Gentamicin for five days, oxacillin throughout
the duration of his course, and for a total of six weeks,
surveillance cultures were taken for three days, and they all
have since been negative.
In terms of his infective endocarditis, he was also started
on Xigris given multiorgan dysfunction. He was on Xigris for
96 hours. In addition, a cortisol level was checked, and
given that it was low, he was started on hydrocortisone 50
mcg q6h.
In the middle of his MICU course, he did have some low grade
spiking temperatures. One source that we did not rule out is
CNS. A lumbar puncture was performed and did not reveal an
infection in that system, no meningitis.
His second issue is his issue of hypotension. There is
debate whether there was some component of cardiogenic.
Given the positive blood cultures, it was confident that it
was sepsis, however, he had a depressed ejection fraction on
echocardiogram again likely secondary to sepsis. He was
given plenty of fluid boluses. Chest x-ray showed pulmonary
edema. He had a fever all suggesting to septic shock. He
was treated with Xigris and antibiotics with underlying source.
He was started on Neo-Synephrine that gradually was weaned off.
Next issue is pulmonary: He was nasotracheally intubated in
the Emergency Department. After several days, he was
switched to orotracheal intubation, endotracheal tube to minimize
possible sinusitis. Throughout the course, he was slowly weaned
to pressure support and was extubated without any complications.
In terms of cardiac issues, in the initial presentation, he
had ST depressions that resolved on repeat electrocardiogram.
He had an elevated troponin over 50. It was thought that this
was secondary to demand ischemia from his hypotension and sepsis
picture. A repeat transthoracic echocardiogram after clinical
improvement showed his ejection fraction improving to over 45%,
closer to his baseline. It was felt by ID and cardiology that
repeat transesophageal echocardiogram was not necessary unless he
had persistent fevers or blood cultures. After being extubated
for 1-2 days, he had another episode of tachycardia with rate-
related hypotension and ST chagnes. He went to urgent cardiac
cath which revealed 3VD and had two vessels PTCA'd.
Hip: He had a MRI that showed bony destruction of his right
hip likely osteomyelitis. Orthopedic Service was following,
and felt that he was too unstable during the MICU to consider
a surgical washout or any procedure at the time. They will
continue to follow and will give their recommendations once
patient is stable.
In terms of his inguinal hernia is reducible. It has been
stable and per Surgery is not acute, will continue to monitor
and follow.
In terms of his renal function, his renal function was very
stable throughout the hospital course. Creatinine was very
stable around 0.9. During his hospital course he was
diuresed aggressively given that he was net positive 10 of
liters of fluid. In terms of benign prostatic hypertrophy,
we will continue his Flomax.
He had a Foley in, and one issue with in terms of renal, he
had episodes of hematuria with clots that formed blocking the
Foley catheter. Urology was consulted. They placed a 24
French catheter, irrigated, and had a significant amount of
clots, replaced with a three-way Foley with continuous
bladder irrigation. He is continuing to have hematuria, but
the clots were minimized and hematocrit was stable.
In terms of hematocrit, his hematocrit was low in the
beginning we thought secondary to phlebotomy and boluses of
fluid. It did stabilize and was not an issue.
In terms of endocrine, he was on an insulin for his
non-insulin dependent-diabetes. Blood sugar remained stable.
GI: He was on Pepcid, and prophylaxis, and tube feeds at a
maximum goal.
In terms of Fluids, electrolytes, and nutrition:
Electrolytes were repleted as necessary and large fluid
boluses were given. Patient was called out to the floor in
stable condition and rest of his hospital course will be
dictated the Medicine [**Hospital1 **] Service.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 19796**]
MEDQUIST36
D: [**2137-3-29**] 14:40
T: [**2137-4-1**] 10:31
JOB#: [**Job Number 19797**]
Name: [**Known lastname 3264**], [**Known firstname **] Unit No: [**Numeric Identifier 3265**]
Admission Date: [**2137-3-11**] Discharge Date: [**2137-4-2**]
Date of Birth: [**2058-6-22**] Sex: M
Service: MICU
This is an addendum to previous discharge summary dictated by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
HOSPITAL COURSE: On [**2137-3-28**], the patient was transferred
to CCU for cardiac catheterization and postcatheterization
management. Cardiac catheterization revealed three vessel
coronary artery disease, mild diastolic left ventricular
dysfunction, successful stenting of the proximal and mid left
anterior descending artery was performed.
The patient was monitored in the CCU and was stable. Was
extubated without difficulty. Had no further episodes of
tachyarrhythmias, and was transferred to the floor on
[**2137-3-28**]. Patient was continued on previous medications.
1. CVS: A. Coronary artery disease: The patient was
continued on aspirin, Plavix, ACE inhibitor, beta blocker,
and was transfused if needed for a hematocrit less than 30.
He was continued on a statin.
B. Rhythm: He was monitored on Telemetry which revealed no
further episodes of tachyarrhythmias.
C. Pump: Ejection fraction of 45%. Cardiac output 4.9, CI
2.4. The patient was continued on ACE inhibitor and beta
blocker.
2. ID: The patient was continued on oxacillin x6 week course
for MSSA sepsis, A-V endocarditis, right hip osteomyelitis.
He has an appointment to see Dr. [**Last Name (STitle) **] on completion of
oxacillin treatment. At that time he should also followup
with Orthopedics for right hip MRI and possible aspiration
prior to surgical treatment.
3. Pulmonary: Continued to do well after while extubation.
4. Renal: Was stable with creatinine at baseline.
5. Patient is occult positive from nasogastric tube felt
possibly secondary to stress dosed steroids. He was
continued on [**Hospital1 **] proton-pump inhibitor and received blood
transfusions as needed for hematocrit less than 30. Patient
warrants GI workup as outpatient including endoscopy and
colonoscopy once other medical issues are stable.
6. Genitourinary: Patient with clots in urine after
beginning Integrilin and Plavix. Urology was consulted and
recommended continuous bladder irrigation.
7. Endocrine: Patient with Cosyntropin stim test revealing
adrenal insufficiency, was initially on hydrocortisone and
Florinef, but changed to po prednisone with a slow taper. He
needs a Cosyntropin stim test as an outpatient after steroid
taper is complete. He was continued on regular
insulin-sliding scale for type 2 diabetes and also initiated
Glyburide.
8. Heme: Anemia of inflammation/iron deficiency anemia.
Patient was started on iron 325 [**Hospital1 **] to replete iron stores.
9. FEN: Swallow study revealed puree food/thick liquids
only.
10. Access: PICC line was placed on [**2137-3-28**].
11. Neurologic: The patient was confused in Intensive Care
Unit. MRI was negative and lumbar puncture negative, was
felt likely due to Intensive Care Unit induced psychosis when
patient was transferred to the floor when confusion subsided.
He did not require prn Zyprexa for agitation.
12. Disposition: Patient is discharged to rehab with
outpatient followup with Orthopedics, Infectious Disease, and
Cardiology Services.
FINAL DIAGNOSES:
1. Methicillin-susceptible Staphylococcus aureus sepsis.
2. Hip osteomyelitis.
3. A-V endocarditis.
4. Non-ST elevation myocardial infarction status post
catheterization [**3-28**] with left anterior descending artery
stent.
5. Three vessel coronary artery disease.
6. Hematuria.
7. Adrenal insufficiency.
8. Anemia of inflammation/iron deficiency anemia.
9. Supraventricular tachycardia.
RECOMMENDED FOLLOWUP:
1. Orthopedic Surgery, Dr. [**Last Name (STitle) 3266**] in [**2-26**] weeks.
2. Cardiology, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3267**].
3. Infectious Disease Clinic, Dr. [**Last Name (STitle) **], [**5-2**] at 10 am.
DISCHARGE MEDICATIONS:
1. Atorvastatin 10 q day.
2. Albuterol prn.
3. Polyvinyl alcohol ophthalmic drops.
4. Heparin subQ.
5. Acetaminophen 325 q4-6h.
6. Lenapril ophthalmic ointment.
7. Colace 100 [**Hospital1 **].
8. Senna one po q day.
9. Lactulose prn.
10. Bisacodyl prn.
11. Nystatin 5 mL po tid.
12. Lidocaine solution to mucous membranes prn.
13. Plavix 75 mg po q day.
14. Aspirin 325 mg po q day.
15. Olanzapine 5 mg po q6h prn.
16. Amiodarone 200 mg po bid.
17. Regular insulin-sliding scale as written.
18. Iron 325 mg po bid.
19. Pantoprazole 40 mg po bid.
20. Prednisone taper.
21. Oxacillin 2 grams IV q4h until [**4-25**].
22. Lisinopril 10 mg po q day.
23. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 3112**] 20 mEq po q day.
DISCHARGE STATUS: Discharged to nursing home.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3268**], M.D. [**MD Number(1) 3269**]
Dictated By:[**Last Name (NamePattern1) 1464**]
MEDQUIST36
D: [**2137-4-2**] 03:05
T: [**2137-4-2**] 06:37
JOB#: [**Job Number 3270**]
|
[
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|
11710, 11993
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,230
| 123,966
|
35215
|
Discharge summary
|
report
|
Admission Date: [**2158-11-12**] Discharge Date: [**2158-11-16**]
Date of Birth: [**2079-10-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Iodine
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
recurrent mucous plugging at [**Hospital **] med center requiring transfer
to [**Hospital1 18**] for evaluation
Major Surgical or Invasive Procedure:
rigid bronchoscopy for tumor destruction w/ cryo
left pleural tap
History of Present Illness:
79 yo F with history of CLL, previously admitted to [**Hospital 1727**]
Medical
Center for continued management of recently diagnosed renal cell
cancer. During admission, patient had respiratory failure in
setting of pneumonia with extensive mucous plugging and
atelectasis. Patient exhibited some altered mental status during
her hospitalization and required intubation ([**2158-11-4**]) for
impending respiratory failure. She underwent bronchoscopy which
revealed large amounts of mucus plugging. Cultures grew
S.pneumonia and was treated with Vancomycin and Aztreonam (7 day
course). She was also given fluconazole for potential fungal
source, with pending cultures. While at OSH, she required
multiple bronchoscopies and mucous clearing which were all
unsuccessful. Patient failed to wean from her ventilator and
transferred here to [**Hospital1 18**] for further management and alternative
procedures.
Of note, patient with ARF with Cr 1.6, now 0.8 on admission most
likely pre-renal. L ear chondritis on moxifloxacin and gent gtt,
CT head neg for mets or mastoiditis.
Past Medical History:
PAST MEDICAL HISTORY:
-------------------
CLL, diabetes, HTN, osteoarthritis, renal cell carcinoma, left
ear chondritis, atrial fibrillation, acute kidney injury from
OSH; nasal polypectomy, left shoulder surgery, breast surgery,
[**Last Name (un) **] both eyes , L cataract repair
Social History:
married lives w/ family
Family History:
non-contributory
Physical Exam:
Physical Exam [**2158-11-14**]
Vitals: T: 97.3 P: 70-80's (SR on tele) R: 20's BP:
120-160's/40-60's SaO2: 98% on 4L NC
General: Awake, tachypneic with slightly labored breathing
HEENT: NC/AT, no scleral icterus noted, limited exam but no
oropharyngeal lesions noted' purulent, blood tinged fluid is
draining from her external auditory canal; no significant LAD
Neck: Supple, no carotid bruits appreciated but limited
secondary
to tachypnea. No nuchal rigidity
Pulmonary: diffuse rhonchi, decreased breath sounds at bases
Cardiac: nl S1, S2, limited auscultation due to transmitted
breath sounds
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: 3+ edema in UE bilaterally, 2+ in LE bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: awake, requires maximal cues to respond to
examiner. She otherwise sits, looking at the examiner,
tachypneic
but not answering any questions. With maximal cues she whispers
one-two word answers including her name and hospital. She does
not answer the date. She is able to name her children and
glasses
but not watch. She also only names one object on a card of
pictures despite repeated attempts. She does not read or repeat.
Her speech is hypophonic but not dysarthric and there are no
paraphasic errors. She does not follow most commands despite
maximum cuing.
CN
I: not tested
II,III: L lower lid droops and the upper lid does not close
voluntarily, L pupil is surgical, both pupils are reactive 2mm->
1mm, unable to visualize fundi secondary to myosis.
III,IV,V: EOMI. No nystagmus
V: sensation appears intact V1-V3 to LT, corneals are spared but
decreased on the L, nasal tickle minimal bilaterally
VII: marked facial asymmetry with a L facial droop, with
inability to smile or raise forehead on the L. Her forehead at
rest as no creases.
VIII: appears to have impaired hearing to voice on the L.
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**6-12**] bilaterally
XII: tongue lies midline but pt does not cooperate with tongue
extension
Motor: Normal bulk, decreased tone throughout. Pt does not
cooperate with formal strength testing but is only able to raise
her arms off the bed for 2 seconds bilaterally despite repeated
cues. She does not raise either leg off the bed but does
withdraw
symmetrically to nox stim.
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 0---------- Flexor
R 0---------- Mute
-Sensory: symmetric withdrawal to nox stim in all extremities
-Coordination: pt would not cooperate with testing
Pertinent Results:
[**Known lastname 1507**],[**Known firstname **] [**Medical Record Number 80347**] F 79 [**2079-10-21**]
Pathology Report Tissue: LEFT MAIN BRONCHO STEM. Study Date of
[**2158-11-13**]
Report not finalized.
Assigned Pathologist [**Last Name (LF) **],[**First Name3 (LF) **] C.
Please contact the pathology department, [**Name (NI) **] [**Numeric Identifier 1434**]
PATHOLOGY # [**-9/3864**]
LEFT MAIN BRONCHO STEM.
Brief Hospital Course:
Pt was admitted to the ICU intubated on [**2158-11-12**]. Bronch was done
which revealed copious mucous plugs. Taken to the OR for rigid
bronchoscopy for tumor debridement w/ cryo. Extubated w/o
difficulty. Left thoracentesis done for 300cc exudative. BNP
1864- diuresed.
Seen by ENT/ Neuro eval for drainage from left ear which pt
reports as ongoing x 1-6 months. Thought to be chrondritis at
OSH but now ENT/Neuro think that this is more likely [**Last Name (un) 80348**] Hunt.
Started on acyclovir in addition to cipro and dexamethasone
gtts. MRI to be done today to eval for CNS involvement. After
MRI will consider steriods 60mg prednisone for 2 weeks and then
taper over one week. Will need ongoing ENT/Neuro follow up.
Cultures and pathology pending at this time.
Medications on Admission:
Dulcolax, fent prn, montelukast 10', SQH", allopurinol 100',
propofol gtt, sucralfate 1"", RISS, metoprolol 37.5"", Colace
100", Senna', Mucomyst q4h, fluc 400', moxiflox 400', gent gtt",
Dornase alpha"
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. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two (2)
Drop Ophthalmic Q2H (every 2 hours).
7. Ciprofloxacin 0.3 % Drops Sig: Four (4) Drop Ophthalmic [**Hospital1 **]
(2 times a day) for 7 days.
8. Dexamethasone 0.1 % Drops, Suspension Sig: Four (4) Drop
Ophthalmic [**Hospital1 **] (2 times a day) for 7 days.
9. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic HS (at bedtime).
10. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for CHF.
12. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig:
Twenty (20) mg Intravenous Q24H (every 24 hours).
13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day) as needed for afib.
14. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs
Miscellaneous Q6H (every 6 hours) as needed.
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
16. regular insulin
qid per sliding scale finger stick
17. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 weeks: then taper.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1727**] Medical Center
Discharge Diagnosis:
Rigid bronch/ endobronchial biopsy/ Cryotherapy
? [**Last Name (un) 80348**] Hunt
Discharge Condition:
stable
Discharge Instructions:
Resume previous level of care including ongoing management for
CHF, [**Last Name (un) 80348**] Hunt (cultures pending) vs.left chondritis.
Followup Instructions:
No further follow up need with Dr. [**Last Name (STitle) **].
Should follow up w/ cardiology re: CHF and ENT / neurology for
chondritis vs. [**Last Name (un) 80348**] Hunt.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2158-11-21**]
|
[
"518.81",
"482.40",
"428.0",
"204.10",
"427.31",
"380.03",
"511.9",
"189.0",
"934.1",
"276.52",
"053.11",
"250.00",
"401.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.71",
"32.01",
"99.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
7675, 7736
|
5012, 5785
|
401, 469
|
7864, 7873
|
4567, 4989
|
8060, 8377
|
1936, 1954
|
6038, 7652
|
7759, 7843
|
5811, 6015
|
7897, 8037
|
1969, 2723
|
250, 363
|
497, 1573
|
2738, 4548
|
1617, 1879
|
1895, 1920
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,649
| 179,501
|
20540
|
Discharge summary
|
report
|
Admission Date: [**2114-4-27**] Discharge Date:
Date of Birth: [**2046-10-20**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 67 year old female
with a history of chronic obstructive pulmonary disease and
morbid obesity recently discharged from [**Hospital1 190**] on [**2114-4-18**], after a 40 day hospital course
for esophageal rupture secondary to food product getting
stuck and she is status post left thoraco abdominal surgical
repair of the perforation with omental flap and open
jejunostomy tube and gastrostomy tube. She presents to the
Emergency Department today from her rehabilitation facility
for complaint of shortness of breath.
The patient, during her prior hospital stay, had a prolonged
intubation complicated by tracheostomy tube placement and
mucous plugging requiring ventilatory assistance multiple
times with development of then vent associated bilobar
Klebsiella pneumonia treated with Meropenem. She also had
intra abdominal abscesses near her perforation site that was
drained with Interventional Radiology guidance. The patient
was doing well in the rehabilitation facility until several
days prior to admission when she developed shortness of
breath. A chest x-ray at the time at the outpatient facility
showed a white out of the left lung with a left shift in
trachea. The patient was in respiratory distress, had a low
grade fever and was admitted to the Intensive Care Unit at
[**Hospital1 69**] on the day of admission.
A CT scan with pulmonary embolus cuts was done which showed
no evidence of pulmonary embolus but did show left upper lobe
collapse versus consolidation. A bronchoscopy done on the
next hospital day yielded scant secretions and the patient
was started on meropenem and Vancomycin for presumed
recurrent pneumonia. The patient improved clinically over
the next one to two days. The patient also was noted to have
an enterococcal bacteremia that was thought secondary to her
peripherally inserted central catheter line which was pulled
at the time of report of positive blood cultures. A repeat
abdominal CT scan was done to evaluate the abscesses which
showed improvement of the fluid collections noted on the
prior study.
PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease
with baseline pCO2 of 45 to 60.
Asthma.
Hypertension.
Morbid Obesity.
Hypercholesterolemia.
MEDICATIONS: Her medications on transfer to the floor
included:
1. Colace 100 mg twice a day
2. Meropenem 1 gram intravenously q. Eight.
3. Senna.
4. Acetaminophen as needed.
5. Sliding scale insulin.
6. Ascorbic acid 500 twice a day
7. Zinc 220 q day.
8. Prednisone 10 q day.
9. Lansoprazole 30 q day.
10. Metoprolol 25 twice a day
11. Ipratropium nebs.
12. Albuterol nebs.
13. Heparin subcutaneously.
14. Vancomycin one gram q. 12.
PHYSICAL EXAMINATION: On admission revealed a temperature of
100.8 F.; pulse 126; blood pressure 95/50; respiratory rate
35; pulse oximetry 94 percent on 15 liters of trache mask.
In general, she is an obese female lying on a stretcher,
tachypneic, able to whisper some phrases, in mild respiratory
distress, intermittently less responsive and fatigued.
HEENT: Pupils equal, round and reactive to light.
Extraocular muscles intact. Dry mucous membranes.
Oropharynx was clear. Upper dentures were present. Neck
with no obvious jugular venous distention; supple.
Cardiovascular examination was tachycardic with a positive S1
and positive S2. No murmurs, rubs or gallops. Pulmonary
showed decreased breath sounds in the left anterior and
posterior lung fields, as well as an occasional expiratory
wheeze and right sided good air movement with occasional
wheeze and occasional rhonchi throughout. Her abdominal
examination showed it was soft, obese, nontender, positive
bowel sounds. No masses. Some palpable firm subcutaneous
nodules were evident likely from prior injection sites.
Extremities were warm with two plus distal pulses. No edema,
no cords. Equal bilaterally. Neurological examination: The
patient is moving all four extremities and answering
questions appropriately.
LABORATORY DATA: On admission, her white blood cell count
was 12.6, hematocrit 31.2, platelets 476, neutrophils 84
percent, 10 percent lymphocytes. No bands.
Her chem-7 was sodium of 136, potassium 4.5, chloride 96,
bicarbonate 30, BUN 23, creatinine 0.5, glucose 101, lactate
1.7. ABG 7.49, pCO2 of 40, paO2 of 84. O2 saturation 96
percent. Urinalysis negative.
Chest x-ray in the Emergency Department showed a complete
white out of the left thorax and left shift of trachea.
Chest x-ray after bronchoscopy showed minimal aeration of the
left thorax, left atelectasis, mild pleural effusion. CT
angiogram of the chest showed negative for pulmonary embolus,
left upper lobe collapse versus consolidation and left lower
lobe patchy atelectasis.
BRIEF SUMMARY OF HOSPITAL COURSE:
1. PULMONARY: In the Intensive Care Unit, the patient had a
bronchoscopy performed by Dr. [**First Name (STitle) **] [**Name (STitle) **], which yielded
thin frothy secretions in the right and left side of the
airways to subsegmental level, but no other pathology was
noted. The cultures from the bronchoscopy displayed no
growth to date. The bronchoscopy was performed on
[**2114-4-27**].
The patient was treated for a suspected recurrence of her
pneumonia with meropenem and Vancomycin for double coverage
of a Klebsiella or methicillin resistant Staphylococcus
aureus. The patient was ruled out for pulmonary embolus by
CT angiogram and the leading diagnosis was thought to be
secondary to mucous plugging from either difficulty clearing
secretions versus recurrence of her pneumonia. The patient
improved gradually and was transferred to the floor for
further care. She received nebulizer treatments on a regular
basis as well as was continued on her outpatient dose of
prednisone for her chronic obstructive pulmonary disease.
She will be treated for a total of 21 days for vent
associated pneumonia with meropenem, the course of which will
finish on [**2114-5-7**].
The patient was tolerating room air prior to discharge and
her O2 saturations were in the range of 93 to 96 percent. In
addition, the patient was able to clear her own secretions
through the tracheostomy tube. She was continued with chest
physical therapy and nebulized oxygen as needed.
1. BACTEREMIA: The patient was noted to have enterococcal
bacteremia on [**4-28**], which was thought secondary to a
peripherally inserted central catheter. The catheter was
removed when the culture results returned, and the patient
was started on linezolid with her history of Vancomycin
resistant enterococcus.
The patient also has noted abdominal abscesses and the source
of the enterococcal bacteremia with both species of
Enterococcal faecalis as well as a Staphylococcus epidermidis
bacteremia, it was felt possibly related to those abscess
sources; however, the CT scan showed regression of these
abscesses and it was thought to be less likely due to her
abdominal abscesses versus her line bacteremia.
Infectious Disease was consulted on [**2114-5-1**], for
assistance with antibiotic therapy and recommended
surveillance cultures to evaluate the patient's bacteremia.
The patient will be treated for a total of seven days of
linezolid if surveillance blood cultures remain negative.
The patient remained afebrile throughout the remainder of her
hospital stay with slight elevation in her white blood cell
count likely secondary to her chronic steroid use.
1. FLUID, ELECTROLYTES AND NUTRITION: The patient was
continued on tube feeds through her J-tube for feeding and
G-tube was used for decompression as needed. The patient
was given free water boluses to maintain euvolemic state.
1. PROPHYLAXIS: The patient was continued on heparin
subcutaneously as she remained immobile throughout her
hospital stay. In addition, a proton pump inhibitor was
added due to her chronic steroid use as well as her
possible risk for stress ulcerations.
DISCHARGE STATUS: The patient's discharge status was to a
rehabilitation facility with good pulmonary rehabilitation
abilities.
CONDITION ON DISCHARGE: Stable, afebrile, with negative
blood cultures.
DISCHARGE DIAGNOSES: Ventilator associated pneumonia.
Bacteremia secondary to line infection.
Chronic obstructive pulmonary disease.
Asthma.
Morbid obesity.
Hypertension.
DISCHARGE MEDICATIONS:
1. Heparin subcutaneously 5000 units q eight hours.
2. Nebulizer with ipratropium and Albuterol every six hours.
3. Metoprolol 25 mg twice a day; hold for blood pressure less
than 100.
4. Lansoprazole 30 mg q day.
5. Zinc 220 q day.
6. Ascorbic acid 500 twice a day
7. Tylenol as needed.
8. Senna, Colace.
9. Flovent 110, two puffs twice a day
10. Salmeterol 50 micrograms, one puff twice a day
11. Prednisone 10 q day.
12. Linezolid 600 mg intravenously q 12 hours for three
more days.
13. Meropenem 1000 mg intravenously q 8 hours for three
more days.
14. She is to continue taking her tube feeds as
indicated.
FOLLOW UP:
1. She is to followup with Infectious Disease with blood
cultures draw in approximately 10 to 14 days after
stopping antibiotics, which would start at the 17th to the
[**3-21**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 27875**]
Dictated By:[**Last Name (NamePattern1) 37098**]
MEDQUIST36
D: [**2114-5-2**] 17:06:31
T: [**2114-5-2**] 18:26:22
Job#: [**Job Number 54945**]
|
[
"790.6",
"482.0",
"933.1",
"482.40",
"790.7",
"V44.0",
"E932.0",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.21",
"96.6",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
8333, 8489
|
8512, 9165
|
9176, 9636
|
4923, 8237
|
2866, 4895
|
154, 2223
|
2246, 2843
|
8262, 8311
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,811
| 187,900
|
1817
|
Discharge summary
|
report
|
Admission Date: [**2167-9-15**] Discharge Date: [**2167-9-18**]
Date of Birth: [**2095-11-8**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Doxycycline / Morphine Sulfate / Cipro / Iodine;
Iodine Containing / Epinephrine
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
arterial line
History of Present Illness:
77 y/o female who presents to ED after fall last night. Patient
unclear about details of fall as she cannot remember too much of
the incidient but thinks it may have been after she took her
klonopin medication. Patient did bruise her hip and has multiple
abrasions on lower extremities. She denies any chest pain or
shortness of breath. In ED patient noted to have EKG changes
(lateral ST dep V4-V6, TWI V2-v3) and elevated CK and troponin.
Cards called to evaluate in the ED and decided to hold off on
heparin and cycle cardiac enzymes for now. Patient also noted to
have giuac positive brown stool in ED.
.
Patient was recently d/c from [**Hospital1 **] from neurology service on
[**2167-8-26**] for gait difficulty which was thought to be secondary to
BPPV vs cervical stenosis vs UTI. BP in 90's->70's, responds to
IVF boluses (rec'd total 4L NS in ED). Admit to MICU for
monitoring
Past Medical History:
essential tremor
HTN
GERD
s/p ampullary adenoma removal, [**3-9**]
s/p cholecystectomy
s/p appendectomy
s/p hysterectomy
s/p b/o oophorectomy
nephrolithiasis
(no stroke, seizure, cancer, or DM)
Social History:
retired, used to work in customer service. Not married, no
children. H/o 40py smoking, quit 12y ago. Drinks "2oz" vodka
nightly. Denies drug use.
Family History:
father with lung ca, brother w/ [**Name2 (NI) 499**] ca, mother with arrhythmia
and tremor
Physical Exam:
Vitals- T 97.8, BP 78/46- 100/63, HR 70 NSR, RR 20, 96% RA
Gen: pleasant, no acute distress
HEENT: membranes dry
Neck: no jvd
Lungs: clear to auscultation b/l
Cardiac: RRR. no m/r/g
Abdomen: soft, NT/ND. b/l hip echymoses
Ext: ant knee abrasions b/l. no c/c/e. cool LE's w/ 1+ pulses dp
b/l
Neuro: alert and oriented x 3. CNII-XII intact. motor fn intact
b/l UE/LE
Rect: trace guaiac + stool in ED
Pertinent Results:
ADMISSION LABS:
==============
[**2167-9-14**] 09:40PM WBC-9.8# RBC-4.67 HGB-13.6 HCT-38.8 MCV-83
MCH-29.2
[**2167-9-14**] 09:40PM NEUTS-81.3* BANDS-0 LYMPHS-14.5* MONOS-4.0
EOS-0.1
[**2167-9-14**] 09:40PM CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-2.1
[**2167-9-14**] 09:40PM CK(CPK)-1099*
[**2167-9-14**] 09:40PM GLUCOSE-111* UREA N-22* CREAT-0.9 SODIUM-138
POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-24 ANION GAP-20
[**2167-9-14**] 09:48PM LACTATE-2.7*
.
Cardiac Enzymes:
[**2167-9-14**] 09:40PM cTropnT-0.26*
[**2167-9-14**] 09:40PM CK-MB-12* MB INDX-1.1
[**2167-9-15**] 06:45AM CK-MB-8 cTropnT-0.15*
[**2167-9-15**] 06:45AM CK(CPK)-645*
[**2167-9-15**] 09:32AM CK-MB-9 cTropnT-0.12*
[**2167-9-15**] 09:32AM CK(CPK)-679*
.
[**2167-9-15**] 06:45AM calTIBC-164* VIT B12-957* FOLATE-5.7
FERRITIN-85 [**2167-9-15**] 06:45AM CALCIUM-6.5* PHOSPHATE-2.5*
MAGNESIUM-1.7 IRON-22*
[**2167-9-15**] 10:10AM CORTISOL-23.9*
[**2167-9-15**] 09:33AM CORTISOL-45.9*
[**2167-9-15**] 10:10AM TSH-1.1
.
MICRO:
=====
[**9-15**] Urine Cx: 10-100,000 Enterococcus
[**9-15**] Blood Cx: No growth to date
.
STUDIES:
========
EKG: NSR. TWI V2-V3; V4-V6 ST Depressions
.
SIX VIEWS, BILATERAL HIPS: There is no fracture or abnormal
alignment. The hip joints are preserved. The sacroiliac joints
are intact. There are mild degenerative changes of the lower
lumbar spine. Clips are seen in the right lower quadrant. No
fracture or dislocation.
.
CXR: No acute cardiopulmonary abnormality
Brief Hospital Course:
71 y/o female who presented to ED s/p fall with elevated cardiac
enzymes
.
## hypotension- Initially with SBP in 70's-80's, asymptomatic,
mentating well and with good urine output. Admitted to the ICU
for hemodynamic monitoring. Low blood pressure suspected
secondary to volume depletion in setting of decreased PO's and
UTI. Her blood pressure medications were initially held and she
was repleted with NS IVF hydration with good effect. She did not
require pressor support. Arterial line was placed for blood
pressure monitoring and this revealed stable blood pressures in
the 90's-100's after IVFs. In terms of other possible etiologies
of her hypotension, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim was performed which showed
normal adrenal reserve. Blood cultures were sent and revealed no
growth. Urinalysis was positive ([**11-23**] WBC, mod bacteria) and
she was treated with a 3 day course of bactrim. ECHO
demonstrated no new WMA, low EF or valvular dx, and her
troponins subsequently trended down (see below). Given her
clinical stability she was transferred to the medicine floor on
[**2167-9-15**].
.
## s/p fall- Patient with baseline low blood pressure. Also with
history of gait disturbance in the past. Patient most likely had
pre-syncopal episode from orthostatic hypotension secondary to
medications she takes such as klonopin, imipramine, propranolol
in setting of UTI. Initially held these medications, and
re-started prior to discharge. Medication regimen kept the same
after discussion with PCP who confirmed that these medications
have been long-standing in etiology. The urinary tract infection
was treated with bactrim as outlined above, and she was
evaluated by physical therapy prior to discharge.
.
## NSTEMI- Suspected demand ischemia in setting of
UTI/hypotension. Elevated troponin to 0.26 on admission. No
associated chest pain. EKG with lateral ST depressions.
Cardiology consulted in ER, and recommended holding off on
heparin. B-blocker also held given hypotension. Cardiac enzymes
cycled, and troponin trended down over next 24 hours. Repeat EKG
demonstrated normalization of ST changes. ECHO performed and
demonstrated no wall motion abnormalities and normal EF.
Recommend stress test to evaluate for underlying CAD.
Medications on Admission:
1. Abilify Oral
2. Zyprexa Oral
3. Primidone 150 mg PO HS
4. Clonazepam 0.5 mg PO DAILY
5. Propranolol 10 mg PO BID
6. Imipramine HCl 100 mg PO HS
7. Thiamine HCl 100 mg PO once a day.
8. Colace 100 mg PO twice a day.
9. Senna 8.6 mg PO twice a day.
10. Dulcolax 5 mg prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
hypotension, s/p fall
Discharge Condition:
stable
Discharge Instructions:
Please follow up with your primary care provider in the next 2
weeks.
Please present to the hospital or call your primary care
provider if you have fever/chills, shortness of breath or chest
pain, headache or dizzyness.
Please take all of your medications as directed.
Please have an oupatient cardiac stress test.
Followup Instructions:
You have the following appointments:
Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1954**]
Date/Time:[**2167-10-23**] 11:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Date/Time:[**2167-10-29**] 2:50
Provider: [**Name10 (NameIs) **] RADIOLOGY Phone:[**Telephone/Fax (1) 10164**]
Date/Time:[**2167-11-16**] 11:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"781.2",
"780.2",
"401.9",
"410.71",
"530.81",
"276.52",
"V10.09",
"458.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6333, 6412
|
3726, 6011
|
359, 374
|
6478, 6487
|
2217, 2217
|
6850, 7389
|
1688, 1780
|
6433, 6457
|
6037, 6310
|
6511, 6827
|
1795, 2198
|
2691, 3703
|
311, 321
|
402, 1292
|
2233, 2674
|
1314, 1509
|
1525, 1672
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,279
| 106,114
|
30275
|
Discharge summary
|
report
|
Admission Date: [**2158-10-20**] Discharge Date: [**2158-10-29**]
Date of Birth: [**2081-5-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
shortness of breath and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 yo Greek-speaking female with PMH of HTN, A Fib, CAD
presented to the ED with 3-day history of shortness of breath
and abdominal pain. Patient, speaking through her son, reported
worsening dyspnea, orthopnea, PND, and bilateral lower extremity
pitting edema, which has been a chronic problem for her. Her
functional status has been worsening, now only able to climb a
few steps before tiring. Reported a dry cough for 1-2 weeks.
Patient reported good medication compliance and no recent
changes in her diet. Patient also complained of abdominal
pain/bloating with early satiety and constipation. Stated
radiation of pain/burning up her chest. Denied vomiting,
diarrhea. Also complained of intermittent lower back pain
described as "somebody hitting her."
Patient presented to the ER with O2Sat=86% on RA. She received
nitro and lasix (20mg IV x 1) and ASA as well as steroids
(solumedrol 125mg x 1) given history of underlying interstitial
pulmonary disease. Sent for CT angiogram to rule out PE and then
transferred to the MICU. In the MICU, she was placed on a nitro
gtt and diuresed with IV lasix. When oxygen was weaned to 4L NC
with sats in the mid-90s, the patient was transferred to the
floor.
.
ROS: The patient denied any fevers, chills, weight change,
vomiting, diarrhea, melena, hematochezia, chest pain, urinary
frequency, urgency, lightheadedness, gait unsteadiness, focal
weakness, headache, rash or skin changes.
Stated recent retinal reattachment procedure.
Past Medical History:
Atrial fibrillation with progression to torsades during last
admission-s/p dofetilide with DCCV ? [**6-9**]
HTN
DMII
Mild COPD
Interstitial lung disease
Hyperlipidemia
AR
Social History:
Lives with her son and his family. Very functional at baseline
walking [**4-15**] blocks with no DOE. No EtoH or smoking history.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Vitals: T: 98.2 BP: 197/64 HR: 64 RR: 22 O2Sat: 96% on 2.5L
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, Dry MM, OP Clear
NECK: JVP 12-13cm, carotid pulses brisk, s/p R CEA, no carotid
bruits
COR: RRR, normal S1 and S2, + S4, SEM @ RUSB w/o radiation, and
[**2-15**] HSM at LLSB varied w/ inspiration
PULM: good air movement, bibasilar rales, expiratory wheezes
ABD: BS - , soft, NT, ND, no masses/organomegaly, no bruits
appreciated
BACK: No CVAT. Lipoma over lumbar spine. Nontender.
EXT: 3+ pitting edema to lower thighs, bilaterally symmetric and
venous stasis changes evident
NEURO: grossly normal
Pertinent Results:
[**2158-10-21**] 04:31PM BLOOD WBC-9.7 RBC-3.27* Hgb-9.9* Hct-28.8*
MCV-88 MCH-30.2 MCHC-34.3 RDW-15.8* Plt Ct-225
[**2158-10-21**] 03:41AM BLOOD Neuts-75.7* Lymphs-19.6 Monos-4.5 Eos-0.1
Baso-0.2
[**2158-10-21**] 03:41AM BLOOD PT-17.3* PTT-30.0 INR(PT)-1.6*
[**2158-10-21**] 04:31PM BLOOD Glucose-143* UreaN-36* Creat-1.7* Na-138
K-3.8 Cl-99 HCO3-32 AnGap-11
[**2158-10-21**] 03:41AM BLOOD LD(LDH)-185 CK(CPK)-13* TotBili-0.3
DirBili-0.1 IndBili-0.2
[**2158-10-20**] 08:01PM BLOOD Lipase-15
[**2158-10-21**] 03:41AM BLOOD CK-MB-2 cTropnT-0.02*
[**2158-10-20**] 08:01PM BLOOD CK-MB-3 cTropnT-0.02*
[**2158-10-20**] 10:40AM BLOOD cTropnT-0.03*
[**2158-10-20**] 10:40AM BLOOD CK-MB-NotDone proBNP-6228*
[**2158-10-21**] 04:31PM BLOOD Iron-31
[**2158-10-21**] 03:41AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.9
[**2158-10-21**] 04:31PM BLOOD calTIBC-243* Ferritn-84 TRF-187*
[**2158-10-20**] 10:40AM BLOOD TSH-23*
[**2158-10-20**] 08:01PM BLOOD Free T4-1.3
CTA Chest [**2158-10-20**]:
IMPRESSION:
1. Allowing for respiratory motion, no evidence of pulmonary
embolism seen.
2. Scarring and bronchiectasis in left upper lobe consistent
with history of interstitial lung disease. Prior studies, if
available, would be useful for comparison.
3. There is likely superimposed mild interstitial edema, with
small-to-
moderate right and small left pleural effusions and related
compressive
atelectasis. Numerous scattered sub-4-mm nodular opacities may
be related to early alveolar edema.
4. Evidence of prior granulomatous disease.
Renal U/S [**10-22**]:
1. Inability to perform full Doppler analysis to evaluate for
underlying
renal artery stenosis due to patient inability to breath-hold.
If high
clinical concern, a dedicated MRA could be performed.
2. Well-defined hyperechoic peripheral 1-cm left lower pole
lesion most
suggestive of a benign renal angiomyolipoma. Probable but not
definite 1-cm
right renal cyst. If not characterized by cross sectional
imaging, can get
follow up ultrasound in 6 months to confirm expected stability.
TTE [**10-24**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). 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. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild to moderate
([**1-11**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**1-11**]+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a small
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Left atrial dilation with mild diastolic LV dysfunction. Mild to
moderate aortic regurgitation. Mild to moderate mitral
regurgiation. Moderate pulmonary hypertension. Dilated ascending
aorta.
Compared with the prior study (images reviewed) of [**2157-6-27**],
degree of diastolic LV dysfunction, as well as mitral and aortic
regurgitation has increased. Pulmonary hypertension is now
identified. The other findings are similar.
EKG [**10-29**]:
Sinus rhythm with first degree A-V block with a P-R interval of
0.52. Left
anterior fascicular block. Non-specific intraventricular
conduction delay. Left
ventricular hypertrophy with ST-T wave changes. Poor R wave
progression could
be due to left anterior fascicular block and/or left ventricular
hypertrophy.
Non-specific ST-T wave changes are probably due to left
ventricular hypertrophy
but cannot exclude ischemia. Compared to the previous tracing of
[**2158-10-28**] the
ventricular rate is faster such that the P wave is generally
within the
T wave, except in leads V2-V3. The P wave can be seen at the
tail end of the
T wave and then there is one early beat such that the R-R
interval is longer
and you do see the P wave with the P-R interval of 0.52.
Brief Hospital Course:
77 year-old Greek-speaking female with a history of HTN, A Fib,
CAD, DMII, and ILD who presented with hypertensive urgency and
acute on chronic diastolic CHF exacerbation.
.
# HYPERTENSION: The patient has a history of hypertension, LVH
on EKG, diastolic dysfunction on her echo 1 year ago. Her blood
pressures in the ED peaked at 250/110. It was unclear whether
or not the patient had been taking her medications
appropriately. She denied recent dietary changes or increased
salt consumption. The patient was also felt to have a high
pretest probability of renal artery stenosis. She had renal
ultrasound completed but doppler could not be completed due to
technical difficulties. While awaiting MRA, the patient
developed acute on chronic renal failure.
Her initial home antihypertensive regimen was toprol xl 100mg
daily, benicar 40mg daily (max dose). Her meds were titrated up
with resolution of her hypertension and SBPs in the 120s-130s
range. When she developed ARF with eosinophilia, several meds
were stopped and she remained normotensive. She was discharged
on amlodipine, clonidine patch, and isosorbide and instructed to
follow up for an outpatient work up of potential RAS.
.
# CHF - This patient has acute on chronic diastolic dysfunction
with a preserved EF on an echo 1 year ago, 1+ AI and 1+ MR. She
was diuresed with IV lasix until near euvolemia and then placed
back on her home regimen of bumex 2mg daily. Bumex was stopped
in setting of what was thought to be drug-induced ARF as noted
above. The patient was clinically mildly hypervolemic and was
therefore started on a maintenance regimen of lasix 60mg PO
daily with return to euvolemia.
.
# 1st degree AV block: The patient's PR interval was noted to be
progressively longer up to .550 sec. Her amiodarone and
metoprolol were held and all other nodal agents were avoided.
She was asked to follow up as an outpatient for continued
management of this AV block in the setting of a history of PAF.
.
# Acute on Chronic Renal Insufficiency - Creatinine peaked at
2.5 with baseline 1.4-1.6. Her creatinine was trending down
prior to discharge. She had both a peripheral eosinophilia and
urine eos and was thereofre thought to likely have AIN [**2-11**] bumex
vs hydral vs protonix. These meds were stopped and replaced with
resolution of eosinophilia and downward trending creatinine.
.
# Normocytic Anemia: Hct ranging from 29 to 36, stable. BM guiac
negative. Non-localizing exam. Labs suggested some degree of
iron deficiency, no hemolysis. Iron held in setting of concern
for constipation. Suggested outpatient follow up with PCP.
.
# Hypothyroidism: Elevated TSH with normal T4. Patient takes
levothyroxine 125 mcg daily at home. Discussed with endocrine
who thought labs were c/w sick euthyroid syndrome and suggested
weighing benefit of addit levothyrox agaist risk of causing AF
to return. The patient was continued on her home dose of
levothyroxine and encouraged to follow up with her PCP.
.
# CAD: The patient has a history of 2VD, TTE with progression of
diastolic and valvular dysfunction. ASA 81mg and pravastatin
40mg daily were continued.
.
# Paroxsysmal Atrial Fibrillation: The patient remained in
normal sinus rhythm during her hospitalization. Her metoprolol
and amiodarone were held in the setting of both PR and QTc
prolongation. While PR interval remained prolonged, QTc returned
to normal range. The patient was continued on coumadin and
instruced to follow up as an outpatient.
.
#. ILD/COPD: Patient had oxygen saturations in the upper 90s
both sitting and with ambulation prior to discharge.
.
# NIDDM: HA1C 6.6. The patient is maintained on home oral
hypoglycemics which were held in favor of sliding scale insulin
during this hospitalization. She was instructed to restart oral
meds at time of discharge.
.
On [**10-29**], the patient was discharged to home in good condition
with stable vitals on room air with plan for follow up arranged.
Medications on Admission:
Glipizide 10mg po daily
Toprol 100mg po daily
Bumex 2mg po daily
Pravastatin 20mg daily
Clonidine 0.2mg po bid
Benicar 40mg po daily
Amiodarone 200mg po daily
ASA 81mg daily
cirpo 500mg daily (last dose 10/10)
coumadin 2.5mg daily except [**Month/Year (2) 766**] no coumadin and Wed / Friday
5mg daily
Levothyroxine 125mcg daily
calcium
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*90 Tablet(s)* Refills:*2*
6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
7. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly
Transdermal weekly ().
[**Month/Year (2) **]:*8 Patch Weekly(s)* Refills:*2*
8. Polyethylene Glycol 3350 100 % Powder Sig: One (1) capful PO
as needed as needed for constipation: Available over the
counter. .
9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
[**Month/Year (2) **]:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (WE,FR).
12. Outpatient Lab Work
Please have your INR and your kidney function checked on
Wednesday. Please have these results faxed to Dr. [**Last Name (STitle) 11139**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Hypertensive Crisis
Acute on Chronic Dyastolic Congestive Heart Failure
Acute on Chronic Renal Failure
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 liters
You were admitted to the hospital because your blood pressure
was very high and you developed fluid back up to your tissues
and your lung. You were given blood pressure medications to
reduce your blood pressure and were given medications to help
remove the extra fluid from your body. You were waiting to have
an MRI of the blood vessels that supply your kidneys to
determine if a blockage in those vessels (called Renal Artery
Stenosis) could account for your very high blood pressures.
While you were waiting to have this done, your labs showed that
your kidney was functioning abnormally. It seems as though your
kidney had a reaction to one of the medications you were on
previously. The main possibilities are: bumex or hydralazine or
pantoprazole. These medications were stopped and your kidney
function began to trend back towards normal. You should not take
these medications until otherwise instructed by Dr [**Last Name (STitle) 11139**] or Dr
[**Last Name (STitle) **].
You were started on a medication called Lasix which will help
remove extra fluid bluild up. (This replaces Bumex).
Your metoprolol and amiodarone were stopped because your EKG
showed changes suggesting the electrical system of your heart
was moving more slowly than we would want. The medications can
cause or worsen this and so you should continue to not take
these medications.
Medication Changes: As long as you can seperate what youre
taking from what you [**Last Name (un) 5497**] taking, you should keep the
medications you have at home in the case that your heart and
kidney function improve so that your doctor can safely
reintroduce the medications that can help you.
Stop taking Toprol 100mg daily
Stop taking Bumex 2mg daily
Stop taking Benicar until otherwise instructed.
Stop taking amiodarone.
Your pravastatin dose was increased from 20 to 40mg daily.
Your clonidine was changed from a pill to a patch and the dose
was increased from 0.2 to 0.4 mg.
New medications which you should continue to take: amlodipine,
isosorbide mononitrate sustained release, and lasix 60mg daily.
Please call Dr. [**Last Name (STitle) 11139**] or go to the emergency room if you
experience chest pain, shortness of breath, palpatations,
confusion, decreased urination, progressive swelling in your
legs, stomach, or hands, or any other concerning symptoms.
Followup Instructions:
Please see Dr. [**Last Name (STitle) 11139**] within the next week.
Please have your blood drawn on Wednesday to check your INR and
your kidney function. You should also follow up with Dr. [**Last Name (STitle) 11139**]
regarding your thyroid function as lab work suggested your
thyroid was not functioning entirely normally. This could be
secondary to simply being in the hospital or it could warrent
adjustments in your levotyroxine dose.
You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 3632**] on
[**Telephone/Fax (1) 766**] [**11-13**] at 12:45 PM. Please call for confirmation,
any questions, or to change your appointment.
|
[
"250.00",
"585.9",
"E944.4",
"424.1",
"E942.6",
"584.9",
"414.01",
"V45.89",
"244.9",
"403.00",
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"V43.64",
"790.92",
"428.33",
"496",
"280.9",
"515",
"E943.0",
"E942.0",
"428.0",
"794.31",
"V58.61",
"427.31",
"416.8",
"288.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12856, 12914
|
7197, 11144
|
355, 362
|
13061, 13068
|
3031, 7174
|
15583, 16291
|
2229, 2311
|
11532, 12833
|
12935, 13040
|
11170, 11509
|
13092, 14587
|
2326, 3012
|
14607, 15560
|
277, 317
|
390, 1871
|
1893, 2065
|
2081, 2213
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,781
| 158,300
|
34181
|
Discharge summary
|
report
|
Admission Date: [**2118-7-25**] Discharge Date: [**2118-7-29**]
Date of Birth: [**2036-6-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
CABGx3 (LIMA>LAD, SVG>OM, SVG>PDA) [**2118-7-25**]
History of Present Illness:
82 yo M with new DOE, +ETT and cath with 3VD referred for
surgery.
Past Medical History:
PMH: CAD, HTN, Hyperlipidemia, Diabetes II, per pt diet
controlled, CKD
PSH: RIH repair, appendectomy, bilateral cataracts surgery
Social History:
Social history is significant for the absence of current tobacco
use, pt quit smoking approximately 40 years ago. Consuming ~2
glasses per day. Denies history of abuse or withdrals.
Family History:
No history of premature cardiac disease or sudden death. Mother
died of CVA at age [**Age over 90 **].
Physical Exam:
HR 59 RR 13
NAD, flat after cath
Lungs CTAB ant/lat
Heart RRR
Abdomen soft, NT, ND
Extrem warm, no edema
Pertinent Results:
[**2118-7-29**] 08:05AM BLOOD WBC-6.7 RBC-2.92* Hgb-8.8* Hct-25.8*
MCV-88 MCH-30.1 MCHC-34.1 RDW-14.1 Plt Ct-197
[**2118-7-29**] 08:05AM BLOOD Plt Ct-197
[**2118-7-29**] 08:05AM BLOOD Glucose-134* UreaN-34* Creat-1.7* Na-140
K-3.9
Brief Hospital Course:
On [**7-25**] he underwent CABG x 3. He was transferred to the ICU in
stable condition. He was extubated post op but was reintubated
for respiratory failure. He was successfully extubated on POD #1
and transferred to the floor later that same day. He did well
postoperatively. His chest tubes and wires were removed without
incident. He was seen in consultation by the physical therapy
service. His beta blockade was maximized. By post-operative
day four he was ready for discharge to home in good condition.
Medications on Admission:
Aspirin 3255', Simvastatin 40', Lisinopril 20', Metoprolol
Tartrate 50'', Lasix 40'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD s/p CABG
PMH: CAD, HTN, Hyperlipidemia, Diabetes II, per pt diet
controlled, CKD
PSH: RIH repair, appendectomy, bilateral cataracts surgery
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 24862**] [**Telephone/Fax (1) 64296**]
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 7047**] 2 weeks
Completed by:[**2118-7-29**]
|
[
"414.01",
"403.90",
"585.9",
"518.81",
"250.00",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"96.04",
"96.71",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
3218, 3273
|
1345, 1858
|
325, 378
|
3461, 3469
|
1090, 1322
|
3782, 3998
|
845, 949
|
1992, 3195
|
3294, 3440
|
1884, 1969
|
3493, 3759
|
964, 1071
|
282, 287
|
406, 474
|
496, 629
|
645, 829
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,690
| 157,392
|
21267
|
Discharge summary
|
report
|
Admission Date: [**2155-7-2**] Discharge Date: [**2155-7-8**]
Date of Birth: [**2082-3-15**] Sex: F
Service: MED
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Respiratory Depression
Major Surgical or Invasive Procedure:
EMG, tracheostomy
History of Present Illness:
73F transferred from OSH for neuro eval and trach/PEG.
Initially presented [**6-6**] with gangrenous ileum-->resected,
extubated and transferred to floor. On [**6-8**], had cardiac arrest
and successfully resuscitated. Post-code, able to MAE and
follow commands. Had some ARF which has since resolved.
Treated for ?RML PNA with cefotetan and clinda [**Date range (1) 56274**]. Had
some diarrhea that resolved with changing her TFeeds. Also with
new hyperglycemia and now on insulin. Extubated [**6-19**] but
reintubated [**6-23**] for hypercarbic resp failure. While extubated,
had areflexia and weakness in all 4 extremities. CK and
Tensilon test WNL. Bu [**6-26**], no improvement in quadraparesis but
reflexes, sensation and CN intact. By [**7-1**], able to answer
questions by nodding yes/no and track with eyes. Did well on
TPiece trial so extubated [**7-1**] but reintubated that same day.
Past Medical History:
CAD s/p MI s/p LAD stent [**2153**], depression, HTN, OA, IBS, TAH,
bladder suspension
Social History:
Husband: [**Name (NI) **]
Lives in [**Location (un) 3844**]
Family History:
father with [**Name2 (NI) 56275**] but details unknown
Physical Exam:
VS: T 98.5 HR 94 BP 159/68 RR 17 99% on AC 500x12@ 30%
PEEP 5
G: Intubated, eyes open to voice
HEENT: Opens eyes, PERRLA
Lungs: Decr BS at bases
CV: RRR nl S1 S2
ABD: Soft, NT, ND, BS+
EXT: No edema
Neuro: Flaccid BL Upper and Lower Ext; BL Foot drop; opens eyes
to voice; moves neck; breathes spontaneously on PS; No Babinski;
DTR Intact throughout
Pertinent Results:
[**2155-7-7**] 04:28AM BLOOD WBC-8.6 RBC-3.30* Hgb-9.7* Hct-28.9*
MCV-88 MCH-29.5 MCHC-33.6 RDW-15.5 Plt Ct-191
[**2155-7-6**] 05:13PM BLOOD Hct-28.6*
[**2155-7-6**] 05:00AM BLOOD WBC-7.5 RBC-3.21* Hgb-9.6* Hct-28.1*
MCV-87 MCH-30.1 MCHC-34.4 RDW-15.6* Plt Ct-203
[**2155-7-5**] 06:59PM BLOOD WBC-9.4 RBC-3.44* Hgb-10.6* Hct-30.2*
MCV-88 MCH-30.8 MCHC-35.1* RDW-15.7* Plt Ct-235
[**2155-7-5**] 05:29AM BLOOD WBC-7.6 RBC-2.91* Hgb-8.6* Hct-26.7*
MCV-92 MCH-29.6 MCHC-32.2 RDW-15.0 Plt Ct-255
[**2155-7-4**] 11:48AM BLOOD Hct-27.3*
[**2155-7-4**] 04:00AM BLOOD WBC-7.5 RBC-2.99* Hgb-9.2* Hct-26.8*
MCV-90 MCH-30.8 MCHC-34.4 RDW-14.9 Plt Ct-255
[**2155-7-3**] 02:15AM BLOOD WBC-7.0 RBC-3.26* Hgb-9.5* Hct-29.8*
MCV-92 MCH-29.3 MCHC-32.0 RDW-15.0 Plt Ct-321
[**2155-7-2**] 02:45PM BLOOD WBC-7.4 RBC-3.31* Hgb-10.0* Hct-30.3*
MCV-91 MCH-30.2 MCHC-33.1 RDW-14.6 Plt Ct-335
[**2155-7-3**] 02:15AM BLOOD Neuts-80.8* Lymphs-11.6* Monos-4.2
Eos-3.0 Baso-0.4
[**2155-7-7**] 04:28AM BLOOD Plt Ct-191
[**2155-7-6**] 05:00AM BLOOD Plt Ct-203
[**2155-7-5**] 06:59PM BLOOD Plt Ct-235
[**2155-7-5**] 05:29AM BLOOD Plt Ct-255
[**2155-7-4**] 04:00AM BLOOD Plt Ct-255
[**2155-7-4**] 04:00AM BLOOD PT-12.6 PTT-36.0* INR(PT)-1.0
[**2155-7-3**] 02:15AM BLOOD Plt Ct-321
[**2155-7-3**] 02:15AM BLOOD PT-12.8 PTT-29.2 INR(PT)-1.1
[**2155-7-2**] 02:45PM BLOOD Plt Ct-335
[**2155-7-2**] 02:45PM BLOOD PT-12.9 PTT-33.0 INR(PT)-1.1
[**2155-7-2**] 02:45PM BLOOD Fibrino-596*
[**2155-7-7**] 12:47PM BLOOD K-3.8
[**2155-7-7**] 04:28AM BLOOD Glucose-74 UreaN-25* Creat-0.8 Na-143
K-2.7* Cl-103 HCO3-32* AnGap-11
[**2155-7-6**] 05:12PM BLOOD K-4.0
[**2155-7-6**] 05:00AM BLOOD Glucose-165* UreaN-27* Creat-0.8 Na-141
K-3.0* Cl-103 HCO3-31* AnGap-10
[**2155-7-5**] 06:59PM BLOOD Glucose-152* UreaN-24* Creat-0.8 Na-141
K-3.5 Cl-103 HCO3-31* AnGap-11
[**2155-7-5**] 05:29AM BLOOD Glucose-154* UreaN-24* Creat-0.7 Na-142
K-3.0* Cl-104 HCO3-31* AnGap-10
[**2155-7-4**] 11:48AM BLOOD K-3.6
[**2155-7-4**] 04:00AM BLOOD Glucose-189* UreaN-25* Creat-0.7 Na-138
K-4.9 Cl-103 HCO3-27 AnGap-13
[**2155-7-4**] 12:00AM BLOOD K-2.7*
[**2155-7-3**] 02:15AM BLOOD Glucose-124* UreaN-29* Creat-0.7 Na-138
K-3.3 Cl-101 HCO3-29 AnGap-11
[**2155-7-2**] 02:45PM BLOOD Glucose-107* UreaN-29* Creat-0.7 Na-139
K-3.8 Cl-103 HCO3-29 AnGap-11
[**2155-7-2**] 02:45PM BLOOD ALT-57* AST-41* CK(CPK)-39 AlkPhos-161*
TotBili-0.3
[**2155-7-2**] 02:45PM BLOOD CK-MB-4 cTropnT-0.09*
[**2155-7-7**] 04:28AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.8
[**2155-7-5**] 06:59PM BLOOD Calcium-8.8 Phos-2.9 Mg-1.6
[**2155-7-3**] 02:15AM BLOOD Calcium-7.9* Phos-3.8 Mg-2.0
[**2155-7-2**] 02:45PM BLOOD Albumin-2.3* Calcium-8.0* Phos-3.2 Mg-1.6
[**2155-7-3**] 02:15AM BLOOD TSH-1.4
[**2155-7-4**] 12:00PM BLOOD Type-ART pO2-161* pCO2-44 pH-7.48*
calHCO3-34* Base XS-9
[**2155-7-4**] 04:15AM BLOOD Type-ART Temp-37.2 Rates-/16 Tidal V-400
PEEP-5 O2-30 pO2-147* pCO2-42 pH-7.50* calHCO3-34* Base XS-8
Intubat-INTUBATED Vent-SPONTANEOU
[**2155-7-3**] 08:44AM BLOOD Type-ART Temp-37.7 Rates-/30 Tidal V-300
PEEP-5 O2-30 pO2-148* pCO2-46* pH-7.44 calHCO3-32* Base XS-6
Intubat-INTUBATED Vent-SPONTANEOU
[**2155-7-2**] 02:56PM BLOOD Type-ART Temp-36.9 Rates-[**12-13**] Tidal V-550
PEEP-5 O2-30 pO2-126* pCO2-44 pH-7.45 calHCO3-32* Base XS-6
-ASSIST/CON Intubat-INTUBATED
Brief Hospital Course:
Pt admitted to MICU for ventilatory support. UTI discovered on
admission: Pseudomonas tx'd with Zosyn, VRE tx'd with
Macrodantin. Pt required multiple medications for BP control.
MRI head and neck performed, showed no watershed infarcts and nl
neck. EMG limited due to electrical interference, but
determined that there is electrophysiological evidence for at
least a moderately severe generalized sensorimotor
polyneuropathy, predominantly axonal. Pt kept on vent support
throughout stay and upon reception of tracheostomy, is d/c back
to OSH for further rehab. Prior to d/c, pt developed fever felt
to be due to line infection (c-line), with cultures pending.
Line was d/c and is d/c to OSH on Vanco. On d/c pt vent
settings: PSV 12/5 FiO2 30%. Pt is beginning to have some
movement in Upper and Lower extremities. As per IV pulmonology,
trach sutures can be removed in 3 days. Pt completed 7 day
course Ab for Pseudomonas and Enterococcus UTI; however, pt
spiked [**7-6**]. Urine culture ([**7-5**]) grew GM+ Cocci, and
Pseudomonas, reflecting possible resistance. Pt should have
urine cultures, gm stains upon admission, for re-evaluation.
Upon D/C, were following temp spikes with Blood cultures, no
growth to date.
Medications on Admission:
Ambien, raloxifone, estrace, NTG, toprol XL 100, diovan 80, KCl,
Zocor 10, dexamethasone 40, centrum, caltrate, ASA, foltx
Discharge Medications:
1. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
QD (once a day).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
4. Nitroglycerin Transdermal 0.6 mg/hr Patch 24HR Sig: One (1)
Transdermal Q24H (every 24 hours).
5. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
7. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO QID (4 times a day) for 1 days.
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
9. Hydralazine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
10. Acetaminophen 160 mg/5 mL Elixir Sig: [**1-10**] PO Q4-6H (every 4
to 6 hours) as needed.
11. Metoprolol Tartrate 25 mg Tablet Sig: Five (5) Tablet PO TID
(3 times a day).
12. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime) as needed.
13. Insulin Regular Human 300 unit/3 mL Syringe Sig: per sliding
scale Subcutaneous four times a day.
14. Piperacillin-Tazobactam 4-0.5 g Recon Soln Sig: One (1)
Recon Soln Intravenous Q8H (every 8 hours) for 1 days.
1. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
QD (once a day).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
4. Nitroglycerin Transdermal 0.6 mg/hr Patch 24HR Sig: One (1)
Transdermal Q24H (every 24 hours).
5. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
9. Hydralazine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
10. Acetaminophen 160 mg/5 mL Elixir Sig: [**1-10**] PO Q4-6H (every 4
to 6 hours) as needed.
11. Metoprolol Tartrate 25 mg Tablet Sig: Five (5) Tablet PO TID
(3 times a day).
12. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime) as needed.
13. Insulin Regular Human 300 unit/3 mL Syringe Sig: per sliding
scale Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Critical Illness Polyneuropathy, CAD s/p MI s/p LAD stent,
depression, HTN, OA, IBS, TAH, bladder suspension
Discharge Condition:
Stable-intubated
Discharge Instructions:
See discharge summary
Followup Instructions:
To be determined upon d/c from other hospital
|
[
"285.9",
"356.9",
"401.9",
"412",
"599.0",
"414.00",
"V45.82",
"518.83",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.6",
"33.23",
"96.72",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
8948, 8963
|
5202, 6433
|
290, 310
|
9116, 9134
|
1898, 5179
|
9204, 9253
|
1448, 1504
|
6606, 8925
|
8984, 9095
|
6459, 6583
|
9158, 9181
|
1519, 1879
|
227, 252
|
338, 1245
|
1267, 1355
|
1371, 1432
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,376
| 106,638
|
28941
|
Discharge summary
|
report
|
Admission Date: [**2188-12-24**] Discharge Date: [**2189-1-1**]
Date of Birth: [**2109-7-19**] Sex: F
Service: NEUROLOGY
Allergies:
Ace Inhibitors / Tamoxifen
Attending:[**First Name3 (LF) 7567**]
Chief Complaint:
Seizures at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname **] [**Known lastname 69797**] is a 79 year-old woman who was transferred from [**Hospital1 **]
[**Location (un) 620**] after she had a prolonged seizure and was found by her
son. [**Name (NI) **] son reports that she was in her usual state of health
on
the prior evening and was not reporting any infectious symptoms
of any kind. Her son came over and found her in her bead with
her
head pushed up against the wall seizing. He described it as
whole
body seizing with foam coming out of her mouth. He is not sure
how long it lasted, but thinks she was probably seizing 10
minutes prior to being found and then another 15 after he found
her. By report she stopped seizing spontaneously, but then had
another seizure en route to [**Location (un) 620**]. She received 6 mg of Ativan
and then 1000 PE of Fosphenytoin. She was then transferred to
[**Hospital1 18**] for additional care.
On arrival there was no evidence of seizure activity, however at
approximately 7:00 pm she had left sided arm and leg rhythmic
jerking witnessed by neurology. She was given an additional 2 mg
of ativan which broke the seizure, and then midazolam was
started.
ROS unobtainable given intubation, but family reports no fevers
and no infectious symptoms.
Past Medical History:
- right posterior frontal stroke ([**2182**]) admitted with left arm
and facial weakness
- left PCA stroke in [**1-/2188**] treated at [**Hospital1 112**] with a R hemianopia
and memory deficits
-Breast ca [**2177**] with lymph node pos; s/p 6 wks chemo then
mastectomy, then xrt + chemo; gets q6mo mammograms
-HTN
-PAF
-S/p appy
Social History:
Former telephone company employee; distant tob (quit 20 yrs
ago);
occ etoh. Lives alone, has 3 children.
Family History:
No strokes, MIs.
Physical Exam:
Physical Exam on Admission:
Vitals: afebrile BP 102/50 P 68 SpO2 100% on 50% FiO2 w/ 5 PEEP
General: intubated and minimally responsive.
HEENT: NC/AT
Neck: in hard cervical collar
Pulmonary: ET tube
Cardiac: irregular rhythm
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: intubated and sedated. Grimaces to sternal rub.
Not following commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: unable to perform Doll's due to cervical collar
V: + corneals
VII: + corneals
VIII: unable to assess due to cervical collar.
IX, X: + gag
[**Doctor First Name 81**]: unable to assess.
XII: unable to assess
-Motor: slightly increased tone in the left upper extremity,
some
spontaneous movements of arms/legs b/l and resistance of the
triceps b/l. *there was rhythmic jerking of the left upper and
lower extremities for approxiamtely 5-10 minutes in ED -
resolved
w/ additional benzodiazepines
-Sensory: withdraws and localizes to pain bilaterally in arms
and
legs.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: unable to obtain given intubation
-Gait: unable to obtain given intubation
Pertinent Results:
ADMISSION LABS:
[**2188-12-24**] 06:10PM BLOOD WBC-10.4 RBC-3.81* Hgb-12.1 Hct-35.5*
MCV-93 MCH-31.7 MCHC-34.0 RDW-12.9 Plt Ct-148*
[**2188-12-24**] 06:10PM BLOOD Neuts-91.3* Lymphs-5.8* Monos-2.6 Eos-0.1
Baso-0.1
[**2188-12-24**] 06:10PM BLOOD PT-24.1* PTT-30.4 INR(PT)-2.3*
[**2188-12-24**] 10:21PM BLOOD Glucose-175* UreaN-18 Creat-0.8 Na-141
K-4.1 Cl-109* HCO3-25 AnGap-11
[**2188-12-24**] 10:21PM BLOOD ALT-60* AST-67* LD(LDH)-210 AlkPhos-111*
TotBili-0.8
[**2188-12-24**] 06:10PM BLOOD Calcium-9.4 Phos-3.0 Mg-1.9
[**2188-12-29**] 05:30AM BLOOD %HbA1c-6.0* eAG-126*
[**2188-12-29**] 05:30AM BLOOD Triglyc-63 HDL-52 CHOL/HD-2.5 LDLcalc-65
[**2188-12-28**] 02:29PM BLOOD Ammonia-60
[**2188-12-25**] 04:25AM BLOOD Phenyto-13.5
[**2188-12-24**] 10:21PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2188-12-24**] 06:21PM BLOOD Type-ART pO2-230* pCO2-44 pH-7.35
calTCO2-25 Base XS--1 Comment-GREEN-TOP
Labs during stay:
[**2189-1-1**] 06:26AM BLOOD freeCa-1.39*
Test Result Reference
Range/Units
LEVETIRACETAM (KEPPRA) 32.5 mcg/mL
EEG [**2188-12-24**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of diffuse background attenuation and slowing indicative of a
moderate
encephalopathy with non-specific etiology. There is diffuse
attenuation
of the left hemispheric activity compared to the right which
reflect
both cortical and subcortical dysfunction, which could be seen
in large
ischemic lesions. There are occasional independent left and
right
frontal sharp waves indicative of potential epileptogenic foci
in these
regions. No electrographic seizures are present.
EEG [**2188-12-25**]: This is an abnormal continuous ICU video EEG because
of
diffuse background attenuation and slowing indicative of a
moderate
encephalopathy. There is diffuse attenuation of the left
hemispheric
activity compared to the right which could be due to diffuse
left
hemispheric cortical and subcortical dysfunction such as is seen
in
large ischemic lesions. There are two pushbutton activations for
tremor of the left upper extremity which have no electrographic
correlate. No epileptiform discharges or electrographic seizures
are
present. Compared to the previous day's recording, this EEG
shows
improvement as there is improvement of background frequencies
and a more
representation of normal sleep potentials without clear
epileptiform
discharges.
EEG [**2188-12-26**]: This is an abnormal continuous ICU video EEG because
of
diffuse attenuation and slowing over the left hemisphere
indicative of
diffuse left hemispheric cortical and subcortical dysfunction.
In
addition, the posterior dominant rhythm on the right side,
although
reached 8 Hz, was low voltage and not well-sustained, indicative
of a
mild encephalopathy. Infrequent sharp wave discharges are
present in the
right frontocentral and rarely in the left frontotemporal
region,
consistent with areas of cortical irritability. Compared to
previous
day's recording, this EEG shows improvement as the background
appears
better organized and reaches 8 Hz.
EEG1/7/12: This is an abnormal video EEG monitoring session
because of
continuous focal slowing, focal attenuation and absent alpha
rhythm over
the left hemisphere. These findings are indicative of a focal
cortical
and subcortical structural lesion in the left hemisphere. There
is also
mild diffuse background slowing and epochs of frontal
intermittent
rhythmic delta activity (FIRDA). These findings indicate more
diffuse
mild cerebral dysfunction which is etiologically non-specific.
No
epileptiform discharges or electrographic seizures are present.
Compared to the prior day's recording, background rhythms have
improved
in frequency, and the left hemisphere focal slowing and
attenuation is
slightly less prominent.
EEG [**2188-12-28**]: This is an abnormal continuous EEG monitoring study
because
of background attenuation and slowing over the left hemispheric
most
consistent with diffuse left hemispheric cortical and
subcortical
dysfunction such as is seen in large ischemic lesions. The
background
activity appears normal over the right hemisphere and reaches 9
Hz
posterior dominant rhythm. Two isolated left temporal
epileptiform
discharges are present in the recording indicative of a
potential
epileptogenic focus in this region. No electrographic seizures
are
present. Compared to previous day's recording, this EEG shows
improvement as there are rare epileptiform discharges, there is
less
attenuation of background with faster frequencies appearing in
the left
hemisphere.
CXR [**2188-12-24**]: Appropriate positioning of ET and NG tubes.
Scattered
subsegmental atelectasis and top normal heart size.
MRI [**2188-12-24**]:
IMPRESSION: Encephalomalacic changes seen in the left occipital
lobe and
right frontal lobe as described above, likely represents
sequelae of prior
infarction.
NCHCT [**2188-12-31**]: No evidence of acute hemorrhage or mass effect.
Left occipital cystic encephalomalacia secondary to old infarct.
EKG [**2188-12-24**]: Atrial Fibrillation
Labs at the Time of Discharge
[**2189-1-1**] 05:20AM BLOOD WBC-5.2 RBC-3.36* Hgb-10.5* Hct-31.4*
MCV-93 MCH-31.3 MCHC-33.5 RDW-13.3 Plt Ct-175
[**2189-1-1**] 05:20AM BLOOD PT-11.0 INR(PT)-1.0
[**2189-1-1**] 05:20AM BLOOD Glucose-91 UreaN-18 Creat-0.7 Na-141
K-3.6 Cl-102 HCO3-34* AnGap-9
[**2188-12-31**] 05:24AM BLOOD ALT-53* AST-41* AlkPhos-95 TotBili-0.5
[**2189-1-1**] 05:20AM BLOOD Calcium-10.5* Phos-2.5* Mg-1.9
[**2188-12-29**] 05:30AM BLOOD %HbA1c-6.0* eAG-126*
[**2188-12-29**] 05:30AM BLOOD Triglyc-63 HDL-52 CHOL/HD-2.5 LDLcalc-65
PTH: Pending
Brief Hospital Course:
This is the case of 79 year-old woman with a hx of a fib and two
prior strokes transferred from [**Location (un) 620**] after being found at home
seizing, with generalized convulsions lasting up to 25 minutes.
Had recurrent seizure activity at [**Location (un) 620**] which was treated with
6 mg of Ativan and 1000mg of Fosphenytoin. She was intubated and
transferred to [**Hospital1 18**] for further care. Here she received an
additional 2mg ativan and 5mg/kg phenytoin for L arm and leg
shaking and was also started on a midazolam drip. She was
admitted to the neuro-ICU.
.
ICU course:
MRI head showed no acute infarct. There were several areas of
FLAIR hyperintensity
in the R posterior frontal lobe as well as periventricular
areas, and a large area of gliosis in L occipital cortex
consistent with her prior strokes. EEG showed significant
attenuation over the L hemisphere and some occasional R
frontocetral sharp waves without any electrographic seizures.
Midazolam drip was weaned off over the night of [**12-24**]. On exam she
was moving all extremities spontaneously with intact brain stem
reflexes but was not opening her eyes spontaneously or following
commands.
.
During the day on [**12-25**] she was noted to have several brief
episodes of low amplitude L arm and leg shaking. EEG again
showed R frontocentral sharp waves and some delta slowing but no
clear electrographic seizures. Clinical picture appeared more
consistent with tremor rather than a true seizure. Dilantin was
stopped, and she was loaded with Keppra 1000mg IV and started on
Keppra 1000mg [**Hospital1 **]. She remained seizure free.
.
On [**12-26**] she was beginning to wake up opening eyes spontaneously
and following commands. She was extubated without difficulty.
She subsequently remained awake and alert but was somewhat
confused and disoriented, saying she was in [**Hospital1 8**] at
"[**Hospital **] Hospital" and thought date was [**7-7**].
.
On [**12-27**] she was transferred to the neurology floor. Upon transfer
she remained confused and also became somewhat agitated and
paranoid, accusing staff of poisoning her. Oriented to hospital
but not date, saying she is here because she is "insane." UA and
CXR were repeated. Her coumadin was held for an INR of 5.2.
.
Floor course:
Ms. [**Known lastname **] was transferred to the floor. She no longer had
periods of active delirium and frank agitation. She remained
afebrile and hemodynamically stable.
- She was originally extubated to nasal cannula. Her
supplemental oxygen requirement was slowly weaned off.
- Her mental status cleared over the course of her stay on the
floor, particularly in terms of her level of orientation. There
were never any real language or speech deficits.
- She likely had several reasons to explain her delirium during
her stay here, including postICU delirium, post ictal changes,
the initiation of an AED, long standing baseline dementia, etc.
There were no major metabolic abnormalities on her routine blood
work, but her UA did appear consistent with a UTI. She was
treated with three days of IV ceftriaxone, and her cultures
ultimately returned back negative.
- Her INR wildly fluctuated during her stay, upto as high as ~6
(at which point warfarin was held), and then as low as 1.5 (at
which point warfarin was restarted, and she was initiated on a
lovenox bridge). She remains on a lovenox bridge to therapeutic
INR on coumadin.
- Two days prior to her discharge, she was noted to have the
development of left deltoid weakness, associated with a patchy
area of sensory loss over the left shoulder. We obtained an MRI
C-spine and MRI Head which showed no acute changes or unstable
spine findings. Her weakness improved on the day of her
discharge, but was still present.
- The patient was noted to have an elevated ionized calcium
level on the days prior to her discharge, with relatively low
phosphate levels. Her PTH levels is pending at this time. This
level does not appear to be high enough to contribute to her
altered mental status, but needs to be followed up in either
case.
- She remained rate controlled in terms of her atrial
fibrillation.
- Code Status/Contact: Full [**Name2 (NI) 7092**], HCP [**First Name8 (NamePattern2) **] [**Name (NI) 69797**],
[**Telephone/Fax (1) 69798**])
TRANSITIONAL ISSUES
- Please ensure that the patient follows up with her PCP and The
Neurology Department at [**Hospital1 18**]
- Please continue [**Hospital1 **] lovenox dosing SQ until the patient's INR
reaches the goal of 2.0 to 3.0. This may require adjustment of
her warfarin daily dose
- The patient was noted to have an elevated ionized calcium
level on the days prior to her discharge, with relatively low
phosphate levels. Her PTH levels is pending at this time. Please
consider a work up for primary hyperparathyroidism
- Please continue keppra 1g [**Hospital1 **] indefinitely. We did attempt to
wean down to 750mg [**Hospital1 **], but this did result in an acute
worsening in the frequency of epileptiform discharges.
- Do not hesitate to contact me with any further questions (Ph:
[**Telephone/Fax (1) 59691**], [**Pager number 69799**])
- Can consider an outpatient EMG to follow up her left deltoid
weakness, to verify findings of a possible C5 radiculopathy.
Medications on Admission:
Warfarin 3 mg daily
Aspirin 81 mg daily
Toprol 50 mg daily
Atorvastatin 10 mg DAILY
Arimidex
Losartan
Lasix 80 mg daily
MVI, B12
Lipitor 80 mg daily
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day): UNTIL INR reaches goal of 2.0-3.0.
4. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
5. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Status epilepticus
Paroxysmal atrial fibrillation
History of ischemic strokes x 2
Hypertension
Hyperlipidemia
Hypercalcemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during this stay. You
were admitted to [**Hospital1 69**] on [**2188-12-24**]
after at least two-three prolonged seizures that occurred at
home. These occur due to abnormal electrical activity in your
brain, which can happen after a history of ischemic strokes. An
MRI of your brain showed no abnormalities other than your two
previous strokes, and did not identify any new tumors, bleeding
or evidence of new strokes. We believe the most likely cause of
your seizure was the scar tissue in the brain from one of these
strokes. We started you on a medication called KEPPRA or
LEVETIRACETAM to reduce the risk of seizures in the future. We
ask that you continue to take this medication indefinitely. We
have been able to arrange follow up for you to see your primary
care physician, [**Name10 (NameIs) 3**] well as one of the doctors at the Department
of Neurology here at [**Hospital1 69**].
- Please take your medications as prescribed below.
- It is important that you follow up with your follow up
appointments.
- We were able to arrange for you to receive a short stint of
rehabilitation at [**Hospital **] REHAB. Here, they will provide you
the rehabilitation that you will need to remain safe at home.
- Do not hesitate to contact us if you have any further
questions.
- Please come to the ED should you experience of the following
below listed unexplained symptoms
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
Please follow up with your primary care physician
[**Name Initial (PRE) 3390**]: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 69800**]
([**Telephone/Fax (1) 69801**]
Friday, [**2189-1-2**] at 9:30a
Please follow up with the Department of Neurology at the [**Hospital1 18**]
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name 10314**]
[**Hospital Ward Name 23**] Building, [**Location (un) 858**]
[**Location (un) 830**], [**Location (un) **], MA: [**Numeric Identifier **]
Phone:[**Telephone/Fax (1) 3506**] Date/Time:[**2189-2-25**] 4:00
Completed by:[**2189-1-2**]
|
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icd9cm
|
[
[
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[
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15418, 15515
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15683, 15683
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1964, 2072
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,665
| 182,395
|
23385
|
Discharge summary
|
report
|
Admission Date: [**2147-6-17**] Discharge Date: [**2147-6-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] year old female with history of CHF (EF >55%), CAD presents
with dyspnea, bradycardia and hypotension. She developed sudden
onset of dyspnea at nursing home, at which time T 98.5, p60, bp
160/100, O2 sat 80-86% RA. She was transported to [**Hospital1 18**] ED,
where CXR showed bilateral alveolar infiltrates c/w pulmonary
edema vs PNA. She received ceftazidime and levofloxacin.
Initially she was stable with sbp 110s, 94% 4L NC, however she
subsequently became bradycardic to 40s with drop in sbp to 80s.
She received 0.5 mg IV atropine and was started on dopamine drip
peripherally with response in HR to 70s and sbp 120s. She also
became progressively hypoxic, requiring 100% NRB, O2 sat mid
90s. Currently, she denies shortness of breath, cough, fever,
chest pain, N/V, or abdominal pain.
Past Medical History:
1) CAD s/p MI
2) h/o CHF: [**11-12**] TTE [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3370**] dil, RA moderately dilated, mild
sym LVH, LVEF >55%, 1+ MR, mod pulm artery systolic HTN
per daughter 4 recent admission for PNA
3) seizure disorder
4) dementia
5) frequent falls
6) ? Parkinson's disease
Social History:
Pt lives with her daughter [**Name (NI) 440**] [**Name (NI) **], who is also her
healthcare proxy. [**Name (NI) 8003**]-speaking only. Denies hx EtOH, tob,
drug use.
Family History:
Noncontributory
Physical Exam:
PE:
VS: Tc 96.6, BP 134/92, HR 68, RR 46, O2 sats 95% on 15 lpm O2
by NRB
Gen: Thin, elderly, [**Name (NI) 8003**] speaking female, tachypneic, (+)
accessory muscle use, appears to be in moderate respiratory
distress but states she's doing "fine".
HEENT: Hematoma on L cheek and orbit. MM dry.
Neck: Supple. No LAD.
CV: RR, nl S1, S2. No m/r/g.
Lungs: Crackles [**1-12**] of the way up bilaterally, with scattered
wheezes.
Abd: Soft, NTND. + BS.
Ext: no c/c/e. 2+ PT pulses bilaterally.
Pertinent Results:
[**2147-6-17**] 10:29PM LACTATE-2.5*
[**2147-6-17**] 10:15PM GLUCOSE-521* UREA N-74* CREAT-1.8*
SODIUM-125* POTASSIUM-5.8* CHLORIDE-100 TOTAL CO2-14* ANION
GAP-17
[**2147-6-17**] 10:15PM ALT(SGPT)-25 AST(SGOT)-29 CK(CPK)-20*
AMYLASE-119* TOT BILI-0.3
[**2147-6-17**] 10:15PM LIPASE-49
[**2147-6-17**] 10:15PM cTropnT-<0.01
[**2147-6-17**] 10:15PM CK-MB-NotDone
[**2147-6-17**] 10:15PM ALBUMIN-3.3*
[**2147-6-17**] 10:15PM WBC-6.3# RBC-3.68* HGB-11.5* HCT-36.7
MCV-100*# MCH-31.3 MCHC-31.3 RDW-14.5
[**2147-6-17**] 10:15PM NEUTS-74.9* LYMPHS-18.7 MONOS-5.2 EOS-1.0
BASOS-0.2
[**2147-6-17**] 10:15PM MACROCYT-2+
[**2147-6-17**] 10:15PM PLT COUNT-148*
.
[**6-17**] CXR - Moderate congestive heart failure with small bilateral
pleural effusions. No evidence for infiltrate
Brief Hospital Course:
A/P: [**Age over 90 **] yo [**Age over 90 8003**] speaking female with MMP including CHF (LVEF
55%) sz d/o and CAD, presents to ED with hypoxia, hypotension,
and bilateral patchy infiltrates on CXR.
.
1. Respiratory distress: Based on the history of sudden onset
dyspnea with worsening O2 sats and her clinical exam (tachypnea,
diffuse crackles) patient was felt to be in CHF. She was ruled
out for an MI by enzymes and diuresed gentally. Her repiratory
status, clinical exam, and subjective symptoms improved with
diuresis.
Initially in the unit the patient required dobutamine for
pressure support but this was quickly weaned and her BP remained
stable for the remainder of the admission.
.
2. Possible pneumonia: Afebrile on admission w/ WBC of 6.3 and
75% neuts. CXR was inconclusive for pna and the patient was
started on levoflox. When she improved with diuresis the
antibiotics were stopped. She remained afebrile for the
remainder of the admission.
.
3. Chronic renal insufficiency: Baseline Cr 2.0, creatinine 1.8
on discharge.
.
4. Hyponatremia: Na of 125 on admission, resolved to 140's by
the time she was in the intensive care unit with no
intervention. ? lab error.
.
5. h/o CAD: History is unclear. Ruled out for MI. Cont on
bblocker, statin, asa.
6. Seizure d/o: Continued on dilantin.
7. Hypercholesterolemia: Continued on lipitor.
Code: DNR/DNI. No aggressive/invasive treatment. Pressors OK per
family. They understand that if respiratory status does not
improve, little more can be offered.
Contact: Daughter [**First Name8 (NamePattern2) 440**] [**Name (NI) **] [**Telephone/Fax (1) 60012**]
Medications on Admission:
Meds (on admit)
1) Tylenol as needed
2) ASA 325 mg PO daily
3) Lipitor 20 mg PO daily
4) NTG SL prn
5) Lasix 80 mg PO daily
6) Dilantin 300 mg PO BID
7) Isordil 80 mg PO TID
8) Ditropan XL 5 mg PO daily
9) Lisinopril 20 mg PO daily (d/c'd [**6-12**])
10) Lopressor 6.25 mg PO four times a day
11) Prilosec 20 mg PO daily
12) MOM prn
13) Simethicone prn
14) Dulcolax prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO BID (2 times a day).
6. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO Q8H (every 8 hours) as needed for anxiety.
7. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual every four (4) hours.
11. Ditropan XL 5 mg Tab, Sust Release Osmotic Push Sig: One (1)
Tab, Sust Release Osmotic Push PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1. Diastolic Heart Failure.
Secondary:
1. End Stage Renal Disease.
2. Anemia.
3. Seizure Disorder NOS.
4. Dementia.
5. Coronary Artery Disease.
Discharge Condition:
afebrile
vitals stable
eating
Discharge Instructions:
Please take all medications and make all appointments as listed
in the discharge paperwork. If you have shortness of breath,
chest pain, abdominal pain, fevers, chills please [**Name6 (MD) 138**] tour MD
or come to the hospital.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet. Also the patient's electrolytes
should be checked in 1 week.
Followup Instructions:
Please follow up with your primary care doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 60013**]
[**Telephone/Fax (1) 37824**] in 1 week.
|
[
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
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6139, 6210
|
3016, 4640
|
280, 287
|
6408, 6439
|
2201, 2993
|
6881, 7047
|
1662, 1679
|
5060, 6116
|
6231, 6387
|
4666, 5037
|
6463, 6858
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1694, 2182
|
221, 242
|
315, 1130
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1152, 1462
|
1478, 1646
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,787
| 192,259
|
7129
|
Discharge summary
|
report
|
Admission Date: [**2115-1-30**] Discharge Date: [**2115-2-7**]
Date of Birth: [**2036-12-31**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
s/p paracentesis
s/p attempt at central line placement
EGD
History of Present Illness:
Briefly, patient is a 77 yo Spanish speaking male with a history
of prostate cancer s/p XRT in [**2108**] w/hemorrhagic cystitis s/p
intraperitoneal bladder rupture w/open bladder repair [**2114-12-30**]
now admitted with recurrent ascites. Patient had a slow recovery
with persistent ascites, suprapubic bladder catheter recently
removed with some residual hematuria. Patient seen in [**Month/Day/Year **]
clinic for follow up and was admitted for worsening anasarca.
Cystoscopy with fluoroscopy was performed today showing no
leakage from the bladder.
.
Patient presents with c/o shortness of breath. Patient states
that upon discharge from the hospital he was short of breath at
baseline with abdominal distention. He has not been eating due
to distention and has been having ongoing diarrhea, dx with
C.diff on po flagyl. Patient also reports an overall 32 lb
weight gain despite lack of appetite. Otherwise patient denies
any fever, chills, no chest discomfort. No nausea/vomiting,
+diarrhea. No abdominal pain currently (resolved after surgery).
.
Patient admitted to medicine, s/p paracentesis with removal of
4L of fluid, also showing WBC 290, 9% polys, 80% lymphs, tot
prot 1.6, Cr 06, alb <1.0, SAAG>1.1 c/w mixed ascites. He was
diuresed with Lasix 20 mg IV which patient did not tolerate and
subsequently became hypotensive to 80-90/doppler associated with
a WCT thought to be SVT with aberrancy likely [**2-28**] to
intravascular depletion. Patient treated with IVF bolus 500 cc x
2, Lopressor 5 mg IV and Albumin. Patient transfered to CCU
(under MICU) for persistent recurrent SVT and hypotension.
Cardiology and Liver service consulted.
.
In the CCU, patient's BP improved transiently with IVF (500 cc
NS, PO hydration and Albumin 12.5 gm x 2) and gentle diuresis
(Lasix 40 mg PO QD). He had an episode of SVT which broke with
carotid massage. Beta blockade for SVT was attempted with
Metoprolol 12.5 mg PO, but this again caused hypotension to 80s
and was d/ced. Cards recommended Cardizem 30 mg [**Hospital1 **], but this
was not initiated given his low BP. Liver service recommended
Spironolactone and Lasix, which were started, and Nadolol,
however this was not started [**2-28**] to low BP. TTE showed preserved
EF and evidence of diastolic dysfunction with E/A <1. UA +,
growing GNR, speciation pending, started on Levo. Overnight his
pressures were stable in the 90s and in the morning he was felt
to be stable for transfer to the floor.
.
Upon transfer to the floor, patient continues to have boreline
BP 80-90s, mentating well, lasix d/ced. Patient started on
Aztreonam for coverage fo GNR UTI, also with GNR in blood,
speciation pending.
Past Medical History:
1. moderately differentiated prostatic adenocarcinoma of the
prostate, [**Doctor Last Name **] grade 3-4/5 of the left lobe s/p external beam
radiation '[**08**]
2. s/p urethotomy for membranous urethral stricture '[**12**]
3. HTN
4. NIDDM
5. s/p Left hip hemiarthroplasty '[**09**]
6. s/p right knee surgery
Social History:
married and lives at home
very involved family
Patient recently admitted to heavy alcohol use
Family History:
non-contrib
Physical Exam:
VS: T 96.0 (98.4) HR 76 (70s) BP 84/52 (70-90/40-60) R 22 O2 sat
93% RA, FS 129 wt 197 lbs I/Os 340/700
Gen: lying flat in bed, labored breathing, NAD
HEENT: Anicteric, MMM, edentulous
Neck: JVP difficulty to assess
Chest: rales b/l bases
CVS: nl S1 S2, RRR, soft ESM at LSB
Abd: markedly distended abdomen, NT, BS+, +fluid wave
GU: foley draining yellow urine; rectal tube draining liquid
brown stool
Ext: 3+ LE to mid calf; R 1+ pitting, no edema in b/l upper ext.
Pertinent Results:
On Admission:
[**2115-1-30**] 11:00AM URINE RBC-21-50* WBC-[**3-31**] BACTERIA-NONE
YEAST-NONE EPI-0
[**2115-1-30**] 11:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2115-1-30**] 11:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]->=1.035
[**2115-1-30**] 11:00AM PT-15.3* PTT-34.2 INR(PT)-1.6
[**2115-1-30**] 11:00AM PLT COUNT-190
[**2115-1-30**] 11:00AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+
[**2115-1-30**] 11:00AM NEUTS-80.4* LYMPHS-16.4* MONOS-2.9 EOS-0.3
BASOS-0.1
[**2115-1-30**] 11:00AM WBC-9.7# RBC-3.72*# HGB-11.2*# HCT-34.7*
MCV-93 MCH-30.1 MCHC-32.2 RDW-17.8*
[**2115-1-30**] 11:00AM ALBUMIN-2.3* CALCIUM-7.7* PHOSPHATE-2.3*
MAGNESIUM-1.7
[**2115-1-30**] 11:00AM CK-MB-6 cTropnT-0.01
[**2115-1-30**] 11:00AM ALT(SGPT)-15 AST(SGOT)-29 ALK PHOS-122*
AMYLASE-25 TOT BILI-0.6
[**2115-1-30**] 11:00AM GLUCOSE-130* UREA N-11 CREAT-0.8 SODIUM-135
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-26 ANION GAP-11
[**2115-1-30**] 07:24PM ASCITES WBC-290* RBC-130* POLYS-9* LYMPHS-81*
MONOS-6* MESOTHELI-4*
[**2115-1-30**] 07:24PM ASCITES TOT PROT-1.6 GLUCOSE-140 CREAT-0.6
LD(LDH)-74 ALBUMIN-<1.0
.
Interval Data/Discharge:
[**2115-2-7**] 05:50AM BLOOD WBC-6.5 RBC-3.27* Hgb-9.7* Hct-30.6*
MCV-94 MCH-29.7 MCHC-31.8 RDW-17.6* Plt Ct-156
[**2115-2-7**] 05:50AM BLOOD Plt Ct-156
[**2115-2-7**] 05:50AM BLOOD Glucose-108* UreaN-7 Creat-0.7 Na-137
K-4.6 Cl-101 HCO3-32 AnGap-9
[**2115-2-7**] 05:50AM BLOOD Mg-1.6
[**2115-2-3**] 07:15AM BLOOD Cortsol-17.0
[**2115-2-1**] 05:40AM BLOOD Cortsol-15.5
[**2115-2-1**] 05:40AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2115-2-6**] 06:12AM BLOOD AMA-PND
[**2115-2-1**] 02:36PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2115-2-6**] 06:12AM BLOOD HCV Ab-PND
.
Micro:
[**2115-1-30**] 7:24 pm PERITONEAL FLUID
GRAM STAIN (Final [**2115-1-31**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2115-2-3**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2115-2-6**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Time Taken Not Noted Log-In Date/Time: [**2115-1-31**] 10:59 am
FLUID RECEIVED IN BLOOD CULTURE BOTTLES Site: ASCITES
**FINAL REPORT [**2115-2-6**]**
AEROBIC BOTTLE (Final [**2115-2-6**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2115-2-6**]): NO GROWTH.
[**2115-2-1**] 2:31 pm URINE
**FINAL REPORT [**2115-2-6**]**
URINE CULTURE (Final [**2115-2-6**]):
AZTREONAM REQUESTED BY DR.[**First Name (STitle) **] ([**Numeric Identifier 21495**]).
ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVE TO
AZTREONAM.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. 2ND
MORPHOLOGY.
SENSITIVE TO AZTREONAM.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 16 I 16 I
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S 4 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN---------- =>8 R =>8 R
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I 64 I
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ 8 I 8 I
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
[**2115-2-1**] 2:08 pm BLOOD CULTURE
**FINAL REPORT [**2115-2-7**]**
AEROBIC BOTTLE (Final [**2115-2-7**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2115-2-4**]):
THIS IS A CORRECTED REPORT ( REPORTED BY PHONE TO [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 26538**] FA7
[**2115-2-3**] AT 1430).
BACILLUS SPECIES.
PREVIOUSLY REPORTED AS GRAM NEGATIVE RODS [**2115-2-2**].
ISOLATED FROM ONE SET ONLY.
[**2115-2-1**] 3:19 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2115-2-3**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2115-2-3**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2115-2-2**] 12:36 am URINE
**FINAL REPORT [**2115-2-4**]**
URINE CULTURE (Final [**2115-2-4**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
200-9895R
[**2114-2-1**].
[**2115-2-4**] 9:03 pm URINE
**FINAL REPORT [**2115-2-6**]**
URINE CULTURE (Final [**2115-2-6**]): NO GROWTH.
Blood Cultures 1/9: pending, no growth to date
.
Imaging:
ABDOMEN U.S. (COMPLETE STUDY) [**2115-1-30**] 2:22 PM
ABDOMEN U.S. (COMPLETE STUDY)
Reason: please eval for ascites, mark area to tap. also, please
chec
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with h/o etoh, bladder perf s/p repair [**12-31**],
p/w anasarca, alb 2.3, SOB.
REASON FOR THIS EXAMINATION:
please eval for ascites, mark area to tap. also, please check
doppler flow in liver.
PROCEDURE: A limited abdominal ultrasound.
INDICATION: Marked intraabdominal ascites. Mark spot for tap.
.
FINDINGS: Abdominal ultrasound of the four quadrants shows
marked ascites throughout the abdomen. A spot was marked in the
right lower quadrant for subsequent tap by the clinical team.
Limited assessment of the liver shows a shrunken and nodular
contour with heterogeneous echotexture. No definitive focal
lesions are found. Limited assessment of the intrahepatic main
portal vein shows patency with normal direction of flow. Limited
assessment of the kidneys shows no evidence of hydronephrosis.
Spleen appears normal in size.
IMPRESSION: Marked intraabdominal ascites. Limited assessment of
the portal vein, which appears patent with normal direction of
flow. Repeat assessment of the portal vein and its branches is
recommended after paracentesis for improved
visualization/technical performance of the study.
.
CHEST (PA & LAT) [**2115-1-30**] 12:01 PM
CHEST (PA & LAT)
Reason: r/o acute cardiopulmonary process
[**Hospital 93**] MEDICAL CONDITION:
sob. ascites. 32 lb weight gain
REASON FOR THIS EXAMINATION:
r/o acute cardiopulmonary process
INDICATION: 78-year-old man with shortness of breath, ascites
and 32 pound weight gain. Recent history of bladder wall
perforation.
AP & LATERAL CHEST: Abdominal distention and diffuse hazy
opacification of the abdomen is compatible with the submitted
history of ascites. Subtle lucency over the right upper quadrant
is suggestive of free air. The lung volumes are diminished and
have decreased since the prior examination. It is difficult to
judge the severity of interstitial edema due to the low lung
volumes. The low lung volumes also exaggerate the moderate
cardiomegaly which probably has not changed. The endotracheal
tube has been removed. The buckling of the trachea at the
thoracic inlet is rather severe and more pronounced than in the
prior study.
Findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on the day of this
study at 14:15.
IMPRESSION:
1) Large ascites and probable small free air. Findings should be
correlated with any recent history of paracentesis or surgical
intervention.
2) Diminished low lung volumes secondary to ascites.
3) Severe buckling of the trachea could result in significant
airway compromise.
.
Sinus rhythm
Left axis deviation
RBBB with left anterior fascicular block
Possible old inferior infarct
Possible anterior infarct - age undetermined
Lateral ST-T changes may be due to myocardial ischemia
Low QRS voltages in precordial leads
Since previous tracing of [**2115-1-14**], no significant change
.
DUPLEX DOPP ABD/PEL [**2115-1-31**] 2:15 PM
US ABD LIMIT, SINGLE ORGAN; -59 DISTINCT PROCEDURAL SERVIC
Reason: Abd US done in ED limited by massive ascites,
recommended re
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with h/o etoh, bladder perf s/p repair [**12-31**],
p/w anasarca, alb 2.3, SOB.
REASON FOR THIS EXAMINATION:
Abd US done in ED limited by massive ascites, recommended repeat
abd US for better visualization following paracentesis. Initial
evaluation showed shrunken, nodular liver not mentioned on
previous CT one month ago. Please examine liver and portal vein
for cirrhosis or other potential cause of ascites.
INDICATION: 78-year-old man with ascites, status post
paracentesis, please evaluate liver and portal vein.
TECHNIQUE: Right upper quadrant ultrasound, four-quadrant
ultrasound.
FINDINGS: Views are limited secondary to ascites and noise. The
liver appears small in size. No focal liver lesions are
identified. No gallbladder is identified, question prior
cholecystectomy. There is normal color flow and waveforms in the
hepatic veins, portal veins, hepatic arteries, and in the
inferior vena cava. There is a large amount of ascites. There is
mild splenomegaly.
IMPRESSION:
1. Patent hepatic veins, portal veins, hepatic arteries, and
inferior vena cava.
2. Small liver with no focal lesions identified.
3. Large amount of ascites.
4. Mild splenomegaly.
.
ECHO
MEASUREMENTS:
Left Atrium - Four Chamber Length: *5.4 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 3.3 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *0.5 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.2 cm
Left Ventricle - Fractional Shortening: 0.32 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.1 cm (nl <= 3.4 cm)
Aorta - Arch: *3.3 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 1.2 m/sec
Mitral Valve - E/A Ratio: 0.67
Mitral Valve - E Wave Deceleration Time: 320 msec
TR Gradient (+ RA = PASP): 25 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). Normal regional LV systolic function.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall
hypokinesis.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Trivial MR. LV inflow pattern c/w impaired
relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Compared with the findings of the prior study,
there has
been no significant change.
Conclusions:
1. The left atrium is moderately dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
3. The right ventricular cavity is mildly dilated. There is mild
global right
ventricular free wall hypokinesis.
4. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
5. Compared with the findings of the prior study of [**2114-12-28**],
there has been no
significant change.
.
UNILAT LOWER EXT VEINS LEFT [**2115-2-2**] 3:06 AM
UNILAT LOWER EXT VEINS LEFT
Reason: ? DVT
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with cirrhosis with worsening LE edema L>R
REASON FOR THIS EXAMINATION:
? DVT
INDICATION: Lower extremity swelling, left greater than right.
BILATERAL LOWER EXTREMITY ULTRASOUND: No prior studies for
comparison. Grayscale and Doppler son[**Name (NI) 867**] was performed of
the common femoral, greater saphenous, superficial femoral, and
popliteal veins bilaterally. On the left, venous structures
demonstrate normal flow, compressibility, waveforms, and
augmentation without evidence of intraluminal thrombus. On the
right, there is subocclusive thrombus in the common femoral
vein. Flow reconstitutes in the right superficial and popliteal
veins which also compress normally and demonstrate normal
waveforms and augmentation.
IMPRESSION: Subocclusive thrombus in the right common femoral
vein.
.
CT CHEST W/CONTRAST [**2115-2-4**] 1:11 AM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: ?retroperitoneal/intraperitoneal fluid collection,
localizat
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
77 year old man h/o prostate ca s/p xrt with subsequent
hemorrhagic cystitis c/b bladder perforation s/p repair of
bladder and peritoneum, now with ongoing ascites, hypotension,
paracentesis negative for infection
REASON FOR THIS EXAMINATION:
?retroperitoneal/intraperitoneal fluid collection, localization
of fluid.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATIONS: 77-year-old man with history of prostate cancer
status post radiation therapy, with persistent hemorrhagic
cystitis. He now has ongoing ascites and hypotension.
COMPARISONS: [**2114-12-29**].
TECHNIQUE: Axial CT images of the chest, abdomen, and pelvis
were obtained with oral and intravenous contrast, and sagittal
and coronal reconstructions were also performed.
CT OF THE CHEST WITH IV CONTRAST: There is no axillary, hilar,
or mediastinal lymphadenopathy. The heart, great vessels, and
pericardium appear unremarkable. There are coronary artery
calcifications. There are small bilateral pleural effusions.
There are parechymal opacities in the right middle lobe, with
air bronchograms, as well as similar bibasilar opacities. .
CT OF THE ABDOMEN WITH IV CONTRAST: There is a moderately large
amount of fluid-like ascites in the abdomen with low
attenuation. The liver appears normal. The gallbladder has been
removed. The pancreas is somewhat atrophic. The adrenal glands,
spleen and kidneys are within normal limits. The stomach shows a
fatty infiltration of the wall. The stomach, small and large
bowel, are otherwise unremarkable, except for diverticulosis,
which is present throughout the colon. There is no evidence of
free air. There is no retroperitoneal or mesenteric
lymphadenopathy.
CT OF THE PELVIS WITH IV CONTRAST: The bladder is not well
visualized because of streak artifact from left prosthesis, but
there is a Foley catheter and air within the bladder as well as
some draining contrast. The sigmoid and rectum are remarkable
only for diverticulosis. There is no definite pelvic or inguinal
lymphadenopathy, although it is difficult to assess for pelvic
lymphadenopathy because of the streak artifact.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
IMPRESSION:
1. Right middle lobe and bilateral lower lobe parenchymal
opacities, with pleural effusions. These may represent adjacent
compressive atelectasis, although the presence of underlying
pneumonia cannot be excluded.
2. Moderately large amount of ascites in the abdomen.
3. Diverticulosis.
4. Coronary arterial calcifications.
.
CHEST (PORTABLE AP) [**2115-2-6**] 11:16 AM
CHEST (PORTABLE AP)
Reason: interval change
[**Hospital 93**] MEDICAL CONDITION:
77 yo man with etoh acities, s/p bladder perf and repair, O2 sat
requirement inc to 3L likely [**2-28**] to mechanical effect however
concern for infiltrate
REASON FOR THIS EXAMINATION:
interval change
INDICATION: Alcoholic cirrhosis, status post bladder perforation
and repair. Now with increasing oxygen requirement.
Suboptimal study due to high diaphragms, presumably secondary to
ascites. Low lung volumes limit the assessment of volume status.
The heart size is probably enlarged as well as some increase in
the opacity on the right side. Consolidation cannot be excluded
in the right lower lobe.
IMPRESSION: Limited assessment of volume status. Cannot exclude
right lower lobe consolidation.
.
EGD:
Impression: Small hiatal hernia
Varices at the gastroesophageal junction
Mosaic appearance in the whole stomach compatible with portal
hypertensive gastropathy
.
ASCITES ANALYSIS WBC RBC Polys Lymphs Monos Mesothe
290* 130* 9* 81* 6* 4*
ASCITES CHEMISTRY TotPro Glucose Creat LD(LDH) Albumin
1.6 140 0.6 74 <1.0
Brief Hospital Course:
Mr. [**Known lastname 1005**] is a 77 yo man with history of prostate CA s/p XRT
c/b recurrent hemorrhagic cystitis s/p bladder perforation s/p
recent repair, now with progressive ascites. In term of his
individual medical problems.
.
Ascites. Patient did not initially have a clear etiology for
this new development of ascites, ddx included fluid from bladder
similar to last episode although repeat cystogram with Fluoro
did not show any perforation. Patient has had w/up in the past
regarding cardiac etiology, EF wnl, no evidence of liver
dysfunction although ALP 122, no obstruction on abd sono, renal
function wnl. Patient w/ hypoalbuminemia [**2-28**] to poor po intake
which likely exacerbating third spacing. Patient was fluid
overloaded on d/c from surgical service, no acute change,
possibly related to fluid resuscitation post op w/out adequate
diuresis although not likely to be an adequate explanation for a
32 lb weight gain. Patient later found to have significant ETOH
history. Diagnostic and therapeutic tap was performed with
removal of 4L of fluid. Ascitic fluid was consistent with
transudate and increased portal pressures. Abdominal son[**Name (NI) **]
was performed twice which did not reveal any portal vein
obstruction, mass or other venous occlusion. EGD performed also
showed esophageal varices confirming the diagnosis fo alcoholic
cirrhosis. Initially, patient was not treated with diuresis
since his blood pressure was on the low side after removal of 4L
of ascitic fluid. Patient currently is tolerating 20 mg of po
lasix daily with good diuresis. He was also started on
Spironolactone 50 mg daily. He was followed by the liver service
and is scheduled for follow up with the liver clinic. Patient
was not started on a beta blocker given his low pressures. He
would likely benefit from this in the future given his alcoholic
cirrhosis and episodes of SVT in hospital. Patient also not
tapped further given his borderline low pressures. Goal diuresis
should be 0.5 to 1L daily. His other blood pressure medications
are currently being held. The decision to restart these should
be made by his PCP.
.
Shortness of breath. This was not an acute change. Likely
secondary to gross fluid overload compressing diaphragm. Patient
requires O2 by NC currently although no infiltrates on CXR, no
evidence of vascular congestion. Weaning O2 by NC as needed to
maintain sat >92%. Of note, CXR showed tracheal buckling which
was not thought to be a new change.
.
Hemorrhagic cystitis. Continue hematuria although much improved
per [**Name (NI) **] notes, suprapubic catheter recently d/ced. Patient
seen by [**Name (NI) **] in clinic on day of admission, also in ER. No
evidence of recurrent perforation on cystogram. Patient is
scheduled for [**Name (NI) **] follow up. Continue Foley drainage for
now.
.
# E.coli UTI. patient with similar UTI on prior admission,
resistant to fluoroquinolones and patient allergic to PCN.
Patient therefore treated with IV Aztreonam (sensitive by
microbiology add on) for 7 days, he is to complete one more day
of treatment. Repeat urine cx showing no growth.
.
# Bacillus in blood. Likely a contaminant by ID evaluation.
Patient initially treated with 3 days of IV vanco then changed
to PO clindamycin per ID recommendations. He is to complete 3
more days of treatment.
.
# C.diff diarrhea. patient dx with C.diff at rehab, was on
Flagyl upon admission. Patient's diarrhea resolved but he is
continued on Flagyl until he completes his other antibiotics (7
more days).
.
# Hypotension. SBP ranging 80-90s after paracentesis. Thought to
be [**2-28**] to excessive fluid removal. Currently BP 100-110s and
stable. History of hypertension, meds being held for now.
.
# SVT. Patient with multiple episodes of SVT w/ aberrancy in
setting of hypotension. Currently with very few episodes with
spontaneous conversion. Not started on any beta blockers given
low pressures.
.
# DVT. Patient with asymmetric swelling of LE L>R however
patient found to have a right side DVT. Patient started on
Lovenox and is discharged on this medication. PCP will have to
determine need for ongoing anticoagulation, consideration of
starting Coumadin.
.
# DM type 2. Continue RISS. Currently off oral meds.
.
# Diet. Low sodium, high calorie diet.
.
# Prophylaxis: Hep SC tid, no bowel reg, PPI.
.
Code - Full
Medications on Admission:
- Vit C 500 [**Hospital1 **]
- Colace 200 [**Hospital1 **]
- Iron 325 [**Hospital1 **]
- Guaifenesin 600 [**Hospital1 **]
- Hep SC bid
- senna qhs
- Simvastatin 40 daily
- Insulin lispro SS [**Hospital1 **]
- Lisinopril 10 daily
- Flagyl 500 mg tid (day 9)
- Mirtazapine 15 mg qhs
- Nystatin
- Miconazole powder
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Clindamycin HCl 150 mg Capsule Sig: Four (4) Capsule PO Q6H
(every 6 hours) for 3 days.
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
10. Aztreonam in Dextrose(IsoOsm) 1 g/50 mL Piggyback Sig: One
(1) Intravenous every eight (8) hours for 1 days.
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Inpatient Satellite at [**Hospital 4415**]
Discharge Diagnosis:
1. Alcoholic cirrhosis with ascites and portal hypertension
2. Prostate CA s/p radiation, bladder perforation and repair
3. Hypoalbuminemia and poor nutrition
Secondary:
Diabetes
Hypertension (currently not active)
Discharge Condition:
Good - no abdominal pain, fevers. Ascites slowly improving with
diuresis, improved O2 saturation
Discharge Instructions:
Please take all of your medications as directed
Please make sure that you got the the appointments you have
listed below
Please return to the hospital if you have any fevers, chills,
abdominal pain, difficulty breathing or any other complaints
Followup Instructions:
1. PCP: [**Name10 (NameIs) 26539**],[**Name11 (NameIs) 26540**] [**Telephone/Fax (1) 26541**]
2. Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2115-2-20**]
10:30
3. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2115-3-22**] 9:00
Completed by:[**2115-2-7**]
|
[
"595.0",
"250.00",
"453.41",
"572.3",
"571.2",
"041.4",
"401.9",
"276.50",
"456.21",
"008.45",
"427.89",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
26451, 26537
|
20720, 25060
|
292, 353
|
26797, 26896
|
4027, 4027
|
27190, 27601
|
3510, 3523
|
25423, 26428
|
19631, 19788
|
26558, 26776
|
25086, 25400
|
26920, 27167
|
3538, 4008
|
6197, 9351
|
233, 254
|
19817, 20697
|
381, 3048
|
4041, 6164
|
3070, 3381
|
3397, 3494
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,651
| 114,659
|
40991
|
Discharge summary
|
report
|
Admission Date: [**2194-7-21**] Discharge Date: [**2194-7-26**]
Date of Birth: [**2125-4-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2194-7-21**] Coronary Artery Bypass Graft x 3 (Left internal mammary
artery > left anterior descending, Saphenous vein graft > obtuse
marginal, Saphenous vein graft > right coronary artery)
History of Present Illness:
69 year old gentleman with history of coronary artery disease
which was originally diagnosed in [**2173-2-25**] by
catheterization following a positive stress test. He has been
managed medically since that time and has done well. More
recently he has developed exertional chest pain and dyspnea
prompting a repeat stress test which was positive for ischemia.
A cardiac catheterization revealed an occluded right coronary
artery and a 99% left anterior descending artery stenosis. Given
the severity of his disease, he has been referred for surgical
evaluation.
Past Medical History:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Benign prostatic hypertrophy
Blind left eye from accident
2nd and 3rd digit on right hand amputated in machine accident
s/p Eye and right hand surgery for above injuries
Social History:
Lives with: Wife in [**Name2 (NI) 745**]
Occupation: Semi-retired
Tobacco: Denies
ETOH: [**3-28**] week
Family History:
Father died of MI at 56
Physical Exam:
Pulse: 66 Resp: 18 O2 sat: 96%
B/P Right: 120/66 Left: 115/69
Height: 5'4" Weight: 165 lbs
General: Well-developed male in NAD
Skin: Dry [X] intact [X]
HEENT: PERRLA/EOMI on right (blind on left)
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema/Varicosities:
None
[X]
Neuro: Grossly intact -
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2194-7-21**] Echo: PRE-CPB: 1. The left atrium is normal in size. The
left atrial appendage emptying velocity is depressed (<0.2m/s).
No thrombus is seen in the left atrial appendage. 2. No atrial
septal defect is seen by 2D or color Doppler.3. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with inferior
hypokinesis. 4. Right ventricular chamber size and free wall
motion are normal. 5. There are simple atheroma in the
descending thoracic aorta. 6. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. 7. Mild (1+) mitral
regurgitation is seen. Mild MAC is seen. POST-CPB: On infusion
of phenylephrine. A pacing for slow sinus rhythm. Preserved
biventricular systolic function with LVEF = 60%. MR, AI remain
1+. Aortic contour is normal post decannulation.
[**2194-7-26**] 06:45AM BLOOD WBC-4.2 RBC-3.71* Hgb-10.8* Hct-32.7*
MCV-88 MCH-29.1 MCHC-33.0 RDW-13.3 Plt Ct-121*
[**2194-7-26**] 06:45AM BLOOD PT-17.2* INR(PT)-1.5*
[**2194-7-26**] 06:45AM BLOOD Glucose-106* UreaN-29* Creat-1.2 Na-141
K-4.8 Cl-105 HCO3-29 AnGap-12
Brief Hospital Course:
He was admitted same day surgery and was brought to the
operating room for coronary artery bypass graft surgery. See
operative report for further details. He received cefazolin for
perioperative antibiotics and was transferred to the intensive
care unit for post operative management. That evening he was
weaned from sedation, awoke neurologically intact, and was
extubated without complications. On post operative day one he
was started on beta blockers and diuretics. He continued to do
well and was transferred to the floor. That evening he developed
atrial fibrillation and was treated with intravenous Lopressor
and amiodarone. He was then placed on amiodarone drip due to
persistent atrial fibrillation. He continued in atrial
fibrillation and received one bolus of diltiazem with no
response, beta blockers were continued to be increased and on
post operative day two he converted to normal sinus rhythm. His
Foley was removed and he was able to void post removal but then
had high residual and it was reinserted. He continued with the
Foley until post operative day four, at which time it was
removed and he had no further difficulties. His chest tubes and
wires were removed per protocol. He had further episodes of
atrial fibrillation that were treated with amiodarone and
titrating up beta blockers, and he was started on Coumadin for
anticoagulation. He was in sinus rhythm for more than
forty-eight hours prior to discharge. On post operative day five
he was ready for discharge home with services. All follow-up
appointments were advised.
Medications on Admission:
Atenolol 50mg twice daily
Lipitor 80mg daily
Tamsulosin 0.4mg daily
Aspirin 325mg daily
Multivitamin
Vitamin B complex
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 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. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day): Take 400mg TID for 7 days. Then 400mg [**Hospital1 **] for 7 days.
Then 200mg [**Hospital1 **] x 7 days. Finally 200mg dialy until stopped by
cardiologist.
Disp:*100 Tablet(s)* Refills:*1*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*2*
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 10 days.
Disp:*20 Tablet Extended Release(s)* Refills:*2*
11. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day: take
two tablets (4mg total) daily or as directed by the office of
Dr. [**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*2*
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(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 3
Post operative Atrial Fibrillation
Past medical history:
Hypertension
Hyperlipidemia
Benign prostatic hypertrophy
Blind left eye
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet as needed
Sternal Incision - healing well, no erythema or drainage
Left Leg EVH - 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:
You are scheduled for the following appointments:
Wound Check Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**2194-7-30**] at
10:30
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2194-8-14**] at 1:30 pm
Cardiologist Dr. [**First Name4 (NamePattern1) 21976**] [**Last Name (NamePattern1) 11679**] on [**8-25**] at 2:00 pm
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 30837**] in [**4-29**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation
Goal INR 2.0-2.5
First draw on [**2194-7-29**]
Results to Dr [**Last Name (STitle) **] phone [**Telephone/Fax (1) 30837**] fax [**Telephone/Fax (1) 30838**]
Please check monday, wednesday, and friday for two weeks and
then decrease as instructed by Dr [**Last Name (STitle) **]
Completed by:[**2194-7-26**]
|
[
"401.9",
"272.4",
"427.31",
"997.1",
"287.5",
"414.01",
"411.1",
"788.20",
"V49.62",
"369.60",
"E849.7",
"E878.2",
"600.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6916, 6975
|
3477, 5033
|
321, 515
|
7208, 7429
|
2207, 3454
|
8216, 9242
|
1487, 1512
|
5202, 6893
|
6996, 7092
|
5059, 5179
|
7453, 8193
|
1527, 2188
|
271, 283
|
543, 1105
|
7114, 7187
|
1366, 1471
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,457
| 118,690
|
36009
|
Discharge summary
|
report
|
Admission Date: [**2137-10-23**] Discharge Date: [**2137-10-27**]
Date of Birth: [**2081-1-2**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Called by Emergency Department to evaluate
ICH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 1661**] is a 56-year-old right-handed man with a history
of HTN and possible DM (both untreated by his choice) who
presents with left hemiparesis and slurred speech and was found
to have a right BG bleed. He was normal when he went to bed at 3
AM. He awoke at about 5 AM to use the bathroom, and when he got
out of bed he immediately fell to the ground, as his left leg
was
weak. His left arm was weak as well, and he was slurring his
speech. His fiancee tried to get him to go to the hospital, but
he refused, and she helped him back to bed. He awoke at 9:30
with
the same deficits. Around noon, his fiancee was able to convince
him to go the hospital.
He presented to [**Hospital3 7362**] with an initial BP of 185/101. A
head CT showed a R BG bleed of 2.5 x 1 cm on 6 cuts. For the BP,
he was started on a labetalol drip. He was given 1000 mg
Dilantin
and transferred to [**Hospital1 18**] ED.
Of note, he had a prior ICH (see below) reportedly due to HTN,
but has not taken any anti-hypertensives.
On neuro ROS, Mr. [**Known lastname 1661**] reports mild headache. He denies loss
of vision, blurred vision, diplopia, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending language. Denies focal numbness,
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, he denies recent fever or chills.
No night sweats or recent weight loss or gain. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Prior ICH - [**2134**], presented also with left sided weakness and
dysarthria, told it was due to his blood pressure
HTN - attempting to control only with diet and exercise
? DM - elevated glucose 2 years ago, but he says it resolved in
6 months with diet and exercise.
Social History:
Denies a history of smoking, alcohol use, and illicit
drug use. Works for the commuter rail. Has his own place but
spends considerable time at his fiance's place.
Family History:
Father had an MI at age 65
Physical Exam:
Vitals: T: 97.7 P: 74 R: 14 BP: 166/99 SaO2: 100%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: dry skin over B LE.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name DOW backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was moderately dysarthric.
Able to follow both midline and appendicular commands. The pt.
had good knowledge of current events. There was no evidence of
apraxia or neglect. Calculation intact.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Mild Left facial droop.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Spasticity of R LE > L LE. Flaccid L UE. No adventitious
movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 4- 5 5 4 5 5- 5- 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 2 1 2 1
R 2 1 2 3 2
Plantar response was flexor on the right, mute on the left.
-Coordination: Dysmetria of L UE out of proportion to weakness.
No intention tremor, no dysdiadochokinesia noted on right. No
dysmetria on HKS bilaterally.
-Gait: Deferred due to HTN.
Pertinent Results:
[**2137-10-26**] 08:00AM BLOOD WBC-7.2 RBC-4.90 Hgb-14.1 Hct-39.0*
MCV-80* MCH-28.7 MCHC-36.1* RDW-13.9 Plt Ct-237
[**2137-10-25**] 06:00AM BLOOD WBC-7.5 RBC-4.53* Hgb-12.9* Hct-36.6*
MCV-81* MCH-28.6 MCHC-35.4* RDW-13.9 Plt Ct-215
[**2137-10-24**] 02:59AM BLOOD WBC-6.9 RBC-4.37* Hgb-12.5* Hct-34.9*
MCV-80* MCH-28.5 MCHC-35.7* RDW-14.0 Plt Ct-212
[**2137-10-23**] 05:55PM BLOOD WBC-7.6 RBC-4.68 Hgb-13.2* Hct-37.6*
MCV-80* MCH-28.1 MCHC-35.0 RDW-14.0 Plt Ct-246
[**2137-10-23**] 05:55PM BLOOD Neuts-60.6 Lymphs-34.0 Monos-4.0 Eos-1.1
Baso-0.4
[**2137-10-26**] 08:00AM BLOOD Plt Ct-237
[**2137-10-25**] 06:00AM BLOOD PT-12.7 PTT-34.1 INR(PT)-1.1
[**2137-10-24**] 02:59AM BLOOD PT-13.5* PTT-35.1* INR(PT)-1.2*
[**2137-10-23**] 05:55PM BLOOD PT-13.7* PTT-36.3* INR(PT)-1.2*
[**2137-10-26**] 08:00AM BLOOD Glucose-150* UreaN-15 Creat-1.0 Na-139
K-4.4 Cl-104 HCO3-25 AnGap-14
[**2137-10-25**] 06:00AM BLOOD Glucose-115* UreaN-14 Creat-0.9 Na-141
K-3.6 Cl-104 HCO3-27 AnGap-14
[**2137-10-24**] 02:59AM BLOOD Glucose-203* UreaN-14 Creat-1.1 Na-140
K-3.4 Cl-107 HCO3-27 AnGap-9
[**2137-10-23**] 05:55PM BLOOD Glucose-157* UreaN-10 Creat-1.1 Na-141
K-4.0 Cl-105 HCO3-27 AnGap-13
[**2137-10-24**] 02:59AM BLOOD CK(CPK)-59
[**2137-10-23**] 05:55PM BLOOD CK(CPK)-72
[**2137-10-25**] 06:00AM BLOOD cTropnT-<0.01
[**2137-10-24**] 02:59AM BLOOD cTropnT-<0.01
[**2137-10-23**] 05:55PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2137-10-26**] 08:00AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1
[**2137-10-25**] 06:00AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.1
[**2137-10-24**] 02:59AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.3 Cholest-153
[**2137-10-24**] 02:59AM BLOOD %HbA1c-6.8*
[**2137-10-24**] 02:59AM BLOOD Triglyc-119 HDL-32 CHOL/HD-4.8 LDLcalc-97
Brief Hospital Course:
This 56 M was admitted with a right BG bleed which manifested as
dysarthria and LUE weakness. Over the course of admission, the
dysarthria almost completely resolved and there was only mild
weakness in the 4+ to 5- range at the left deltoid and left
wrist extensors. His bleed remained stable by CT. He was started
on Lisinopril 10 mg QD and HCTZ 12.5 mg QD which controlled his
SBP in the 120-130 range. He had a CTA head/neck, which showed
no vascular abnormality to explain the bleed, although note was
made of an incidental R-ICA pseudoaneurysm ~12 mm, with some
post-aneurysmal stenosis. He denies any history of trauma. He
was instructed to begin ASA 325 mg daily after one week. His
fasting blood sugars indicated some glucose intolerance. His
HgbA1C was 6.8, and he opted to manage this nutritionally for
now.
Medications on Admission:
none
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
right putaminal hemorrhage
hypertension
glucose intolerance
Discharge Condition:
mild dysarthria, 5-/5 deltoid and wrist extensor weakness.
Discharge Instructions:
You had a hemorrhagic stroke likely due to hypertension. You
have been started on lisinopril for your high blood pressure.
Please take medications as prescribed. Please keep your
follow-up appointments.
If you experience a recurrence of your symptoms, new or
worsening symptoms, please call your PCP or return to the ED.
Followup Instructions:
Please follow-up with your PCP ([**Name6 (MD) **] [**Name8 (MD) **], MD) within 1 week of
discharge. Phone: [**Telephone/Fax (1) 60502**]
Please follow-up in [**Hospital 4038**] clinic ([**First Name8 (NamePattern2) 2530**] [**Name8 (MD) **], MD) within 1
month of discharge. Phone: [**Telephone/Fax (1) 2574**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2137-11-4**]
|
[
"431",
"401.1",
"781.94",
"V12.54",
"784.5",
"728.89",
"250.00",
"437.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7782, 7788
|
6675, 7494
|
365, 372
|
7892, 7953
|
4940, 6652
|
8325, 8782
|
2614, 2642
|
7549, 7759
|
7809, 7871
|
7520, 7526
|
7977, 8302
|
3722, 4921
|
2657, 3159
|
278, 327
|
400, 2123
|
3174, 3705
|
2145, 2418
|
2434, 2598
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,284
| 170,066
|
27028
|
Discharge summary
|
report
|
Admission Date: [**2155-1-19**] Discharge Date: [**2155-1-19**]
Date of Birth: [**2133-6-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
21 yoM w/o sig PMH on no meds; brought to ED after friends
called EMS for delta MS after a night of drinking Southern
Comfort together. Friend denied trauma, falls; no evidence on
EMS evaluation of pt. EtOH level 610. VS in the ED were T
98.0, BP 153/104, HR 95, RR 16, 100% RA. FSBG 130's on
admission. Had no gag reflex on exam in the ED with some
concern for apneic episodes, so was intubated for airway
protection (with etomidate & succinate; propofol drip for
sedation).
Past Medical History:
None
Social History:
BU college student, studying engineering. Drinks on Friday and
Saturday nights, but denies drinking to excess usually. Social
tobacco use.
Family History:
NC
Physical Exam:
T 96.1, HR 88, BP 137/71, AC 500x12(19)/5/0.4
General: intubated, sedated
Lungs: CTA b/l, no wheezes or crackles
Cardio: RRR, no m/r/g
Abd: + BS, soft, NTND
Extremities: WWP, no edema or cyanosis
Skin: no rashes , no cyanosis
Neuro: sedated while intubated; + cough, neg gag; reflexes 2+
throughout, tone normal
Pertinent Results:
[**2155-1-19**] 12:15AM PLT COUNT-283
[**2155-1-19**] 12:15AM NEUTS-66.6 LYMPHS-28.4 MONOS-3.3 EOS-0.7
BASOS-1.0
[**2155-1-19**] 12:15AM WBC-12.3* RBC-4.83 HGB-15.7 HCT-43.0 MCV-89
MCH-32.5* MCHC-36.5* RDW-13.1
[**2155-1-19**] 12:15AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2155-1-19**] 12:15AM URINE HOURS-RANDOM
[**2155-1-19**] 12:15AM ASA-NEG ETHANOL-610* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2155-1-19**] 12:15AM estGFR-Using this
[**2155-1-19**] 12:15AM GLUCOSE-112* UREA N-13 CREAT-1.1 SODIUM-143
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-20* ANION GAP-22*
Brief Hospital Course:
The patient was intubated in the ED for airway protection. He
was admitted to the MICU, and extubated the following morning
when mental status improved. He had no fever or evidence of
infection. CXR was clear. He received IV fluids, as well as a
banana bag (IV multivitamin, IV folate, IV thiamine). He
tolerated a regular diet and ambulated without difficulty. He
was councelled not to drink to excess. Prophylaxis was given
with SC heparin.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
1. Alcohol Intoxication
2. Altered mental status
3. Mechanical ventilation
Discharge Condition:
Stable, breathing on room air.
Discharge Instructions:
You were admitted with severe alcohol intoxication, which
compromised your breathing. You needed to be on a ventilator (a
machine which breaths for you). Your breathing improved when
you sobered and you were taken off the machine.
You should not drink alcohol to excess.
Followup Instructions:
please follow up with your primary care physician
Completed by:[**2155-1-19**]
|
[
"980.0",
"780.09",
"E849.8",
"E860.0",
"305.01",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.07",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2604, 2610
|
2067, 2520
|
328, 341
|
2729, 2762
|
1406, 2044
|
3084, 3165
|
1054, 1058
|
2575, 2581
|
2631, 2708
|
2546, 2552
|
2786, 3061
|
1073, 1387
|
276, 290
|
369, 852
|
874, 880
|
896, 1038
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,377
| 110,053
|
40138
|
Discharge summary
|
report
|
Admission Date: [**2188-11-20**] Discharge Date: [**2188-12-18**]
Date of Birth: [**2164-7-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Tylenol Overdose
Major Surgical or Invasive Procedure:
[**2188-11-21**] Right IJ HD Catheter insertion, Left IJ triple lumen
catheter insertion
Hemodialysis
History of Present Illness:
Ms. [**Known lastname **] is a 24yF who is transferred from OSH with tylenol,
motrin, aleve and advil OD. On [**11-18**] the patient reports that
her boyfriend broke up with her and at 8:30pm she took ~80
extrastrength tylenol, ~20 aleve, ~20 advil, ~20 motrin. She
vomited shortly after taking the pills and vomitted ~10 tylenol
pills. She was driving at the time of the OD. She had severe
nausea and had multiple bouts of emesis. She denies hematemesis
but does report severe abdominal pain in the RUQ. The following
day at 3:30pm, she told her co-worker what she had done and was
taken to OSH by ambulance. At 6:30pm mucomyst and protonix gtt.
She remained hemodynamically stable with an intact mental
status. Lab values at OSH were significant for a tylenol level
of 153 and salicylate 21 at 22 hours after the OD. Alt 1209, Ast
1149, AO 69, Tb 4.7. The patient was transferred to [**Hospital1 18**] for
further managment.
Of note the patient did have a similar overdose when she was 11
years old--she either overdosed on her mother's "heart pills" or
tylenol. When asked if this was a suicide attempt, she insists
that she has never attempted suicide and that these two attempts
were to get attention.
Past Medical History:
PMH: OD at 11yrs--treated with NG lavage
PSH: none
HPV s/p LEEP
IUD placement
Social History:
Employed in cleaning houses. 12pack smoking year history, social
ETOH use. Marijuana in past but has not smoked in many years.
Denies hx IVDU.
Family History:
Mild MR in mother and sister. 3 sisters with asthma. "heart
disease" in mother
Physical Exam:
On Admission:
VS T 97.7 HR 74 BP 122/68 RR 96% SAT RA
Gen: A and O x 3. Flat affect. Minimal insight
Card: RRR midsystolic click. no m/r/g
Pulm: end expiratory wheeze
Abd: exquisitely TTP in RUQ. No rebound. Voluntary gaurding
Ext: No edema
PHYSICAL EXAMINATION: on admission to Liver service [**2188-11-27**]
VS (in SICU) 98.3 (tm 99.4 at 0400) BP 122/75 Hr 70 RR 18
O298/RA
GENERAL - young well nourished anxious appearing young caucasian
female, sitting in bed at bedside, flat affect, AOx3
HEENT - PERRL, b/l scleral hemorrhage w clear conjunctival
discharge, EOMI, unable to assess if sclerae icteric, MMM, OP
clear
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - soft/NT, mild tenderness, no rebound/guarding
EXTREMITIES - diffuse nonpitting edema in UE/LE, no c/c, 2+
peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-28**] throughout, sensation grossly intact throughout
Pertinent Results:
[**2188-11-20**] 03:23AM PT-58.5* PTT-40.1* INR(PT)-6.6*
[**2188-11-20**] 03:23AM WBC-31.1* RBC-4.52 HGB-14.3 HCT-41.9 MCV-93
MCH-31.6 MCHC-34.1 RDW-13.6
[**2188-11-20**] 03:23AM ASA-13.8 ETHANOL-NEG ACETMNPHN-72*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2188-11-20**] 03:23AM HCG-<5
[**2188-11-20**] 03:23AM ALBUMIN-3.8 CALCIUM-8.1* PHOSPHATE-3.9
MAGNESIUM-1.8
[**2188-11-20**] 03:23AM LIPASE-45
[**2188-11-20**] 03:23AM ALT(SGPT)-7485* AST(SGOT)-8310* LD(LDH)-6180*
CK(CPK)-107 ALK PHOS-50 AMYLASE-39 TOT BILI-3.1*
[**2188-11-20**] 03:23AM FIBRINOGE-144*
[**2188-11-20**] 03:23AM GLUCOSE-117* UREA N-11 CREAT-1.1 SODIUM-138
POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-13* ANION GAP-19
[**2188-11-20**] 05:13AM URINE BLOOD-SM NITRITE-NEG PROTEIN-75
GLUCOSE-TR KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM
[**2188-11-20**] 05:52AM HCV Ab-NEGATIVE
[**2188-11-20**] 05:52AM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc
Ab-NEGATIVE HAV Ab-NEGATIVE
[**11-21**] CXR: FINDINGS: In comparison with study of [**11-20**], there
has been placement of a right IJ catheter that extends to the
upper portion of the SVC and a left IJ catheter that extends
slightly more distally. No evidence of pneumothorax. There is
some increased prominence of the transverse diameter of the
heart with ill-defined pulmonary vessels suggesting elevated
pulmonary venous pressure. Hazy opacification in the right
hemithorax could represent layering effusion. Mild atelectatic
changes are seen at the bases.
[**11-26**] CXR: IMPRESSION:
1. New retrocardiac consolidation without evidence of volume
loss, likely pneumonia, but may represent atelectasis.
2. Small left pleural effusion with interval decrease in the
small right-sided effusion.
3. Stable position of right IJ line with slight advancement of
the left IJ line into the mid-to-lower SVC.
RUQ u/s [**2188-11-28**]
IMPRESSION: No hydronephrosis. No cyst or stone or solid mass
seen
bilaterally. Increased echogenicity of the kidneys bilaterally
is consistent
with diffuse parenchymal disease.
Liver u/s
MPRESSION:
1. Echogenic liver consistent with fatty infiltration; other
forms of more
severe hepatic fibrosis/cirrhosis cannot be ruled out.
2. Small bilateral pleural effusions.
3. Thickened gallbladder wall likely reactive given underlying
liver
disease/toxicity.
CT abd [**2188-12-2**]
IMPRESSION:
1. Left pleural effusion with associated passive atelectasis.
2. Diffuse subcutaneous anasarca as well as edema throughout the
mesentery, likely representing aggressive hydration.
3. No evidence of retroperitoneal bleed.
[**2188-12-15**] 06:00AM BLOOD HCV Ab-NEGATIVE
[**2188-11-20**] 05:52AM BLOOD HCV Ab-NEGATIVE
[**2188-12-16**] 4:35 am IMMUNOLOGY CHM S# [**Serial Number 88173**]H.
**FINAL REPORT [**2188-12-17**]**
HCV VIRAL LOAD (Final [**2188-12-17**]):
HCV RNA detected, less than 43 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
[**2188-12-12**] 4:20 am IMMUNOLOGY
CHM S# [**Serial Number **]H QUANTITATION BEYOND 850,000 IU/ML ADDED
[**12-12**].
**FINAL REPORT [**2188-12-15**]**
HCV VIRAL LOAD (Final [**2188-12-15**]):
HCV RNA detected, less than 43 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
[**2188-12-15**] 2:08 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2188-12-16**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2188-12-16**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2188-11-20**] 5:52 am SEROLOGY/BLOOD Source: Venipuncture.
**FINAL REPORT [**2188-11-21**]**
RAPID PLASMA REAGIN TEST (Final [**2188-11-21**]):
NONREACTIVE.
Reference Range: Non-Reactive.
COPPER
Test Result Reference
Range/Units
COPPER, 24 HOUR URINE 66 H 15-60 mcg/24 h
24 HR URINE VOLUME 1350 mL/24 h
REPORT COMMENT: PH:5
THIS TEST WAS PERFORMED AT:
[**Company **]/CHANTILLY
[**Numeric Identifier 14272**]
CHANTILLY, [**Numeric Identifier 14273**]
[**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 14274**], MD
Comment: Source: CVS
EGD [**2188-12-4**]
Findings: Esophagus: Normal esophagus.
Stomach:
Other Unable to visualize stomach due to large food bolus
Duodenum: Normal duodenum.
Impression: Unable to visualize stomach due to large food bolus
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Ms. [**Known lastname **] is a 24 year old female who was initially admitted to
the SICU [**11-20**] two days after intentional overdose of tylenol,
motrin, aleve, and advil resulting in fulminant hepatic failure
and acute renal failure requiring dialysis. In regards to her
liver failure, her tylenol level upon transfer was noted to be
153. She was maintained on a mucomyst drip which was initially
started immediately upon admission to the OSH approximately 22
hours after consumption of medications. This was continued
throughout her ICU course. Upon [**Hospital **] transfer to [**Hospital1 18**], her
bilirubin was elevated to 3.1, INR was 6.6, and transaminases
were in the 7000s. Her INR continued to rise as high as 10 on
HD#2 when this was reversed with FFP and vitamin K for CVL and
dialysis line placement. At the time of transfer her bilirubin
was Her transaminases continued to rise and peaked on at [**Numeric Identifier 2249**]
and [**Numeric Identifier 7206**] and are now trending down. They were 1166 and 57 at
the time of transfer out of the SICU. Her total bilirubin was
12.3 at the time of transfer. During her ICU course she was
noted to have worsening hepatic encephalopathy, however was
always arousable and oriented, and never required intubation or
placement of cerebral bolt. After several days however, her
lethargy began improving and at the time of transfer she was
alert, awake, oriented x 3, and following commands without
difficulty. Upon admission to the SICU she was evaluated by
social work and psychiatry because of the overdose and was
diagnosed with adjustment disorder vs. MDD, and was felt to
require psychiatric admission once medically cleared. She was
maintained on 1:1 during her entire SICU course.
#Tylenol overdose: Taken 80tabs at home prior to admission to
OSH after breakup with her boyfriend. She was transferred to
[**Hospital1 18**] for further care and consideration for liver transplant.
Pt has been on SICU followed by transplant surgery, hepatology,
toxicology, psychiatry and nephrology. Pt was listed as status 1
however did not require a transplant. Likely will not transplant
now unless she decompensates.
Labs on admisison: ([**11-20**]) INR 6.6, peaked later that day to
9.5. Creat (pk) 6.8, peak transaminases ALT [**Numeric Identifier 88174**], AST [**Numeric Identifier 7206**].
Admission bilirubin 3.1, and increased to peak 20.2 in setting
of concomitant infections: HAP, UTI, and Cdiff. Bilirubin and
WBc trended down after initiation of flagyl for ciff and
continuation of vanco and zosyn for HAP. She was started on NAC
@ 6.25mg/kg/hr on admission per toxicology recommendations and
was discontinued on [**2188-12-3**]. Synthetic function and glucose
levels improving and pt did not require insulin coverage after
transfer to general wards on [**2188-11-27**]. Postprandial nausea
eventually resolved.
She was transfused 1u pRBC on [**12-2**] and [**12-13**] for slowly
downtrending Hct. EGD negative for varices, gastropathy or other
findings. She was continued on PPI until dx'd w cdiff then
swtiched to H2 blocker. Most likely explanation for anemia is
gastritis [**2-26**] ICU stay and noncompliance w PPI during initial
days in transfer to general liver wards.
She was also started on pantoprazole until dx'd w Cdiff and then
changed to ranitidine. Pt was followed by psychiatry during her
stay. She was continued w 1:1 sitter while in-house with plan to
transfer to inpt psych unit when medically cleared. Sec. 12
signed, in chart.
She was taken for liver biopsy on [**12-16**] (transjugular) for
unresolving LFTs, low ceruloplasmin, and workup of possible
Wilson's D. Liver biopsy showed resolving inflammation [**2-26**]
tylenol overdose. Expect LFTs to resolve over time. Urine copper
slightly elevated. Possible KF rings on bedside ophthalmology
exam. She will follow up at ophthalmology clinic for slit lamp
exam - appt in DC plan. Liver copper level pending - Will be
followed up by Dr. [**Last Name (STitle) **] at liver clinic follow up in [**Month (only) 1096**].
Rest of liver workup to be completed as an outpatient. Medically
cleared from hepatic standpoint.
Plan for weekly labs drawn: cbc, chem10, coags, and lfts. To be
followed by the liver clinic.
# ARF: Course has been complicated by anuria on hospital day 2
and metabolic acidosis. She was seen and followed by nephrology.
Her UA was significant for muddy brown casts consistent with
ATN from tylenol and NSAID induced toxicity. Her Cr on
admission was initially 1.1, however this began to quickly rise
and she began having worsening oliguria. She was also noted to
have a gap and nongap metabolic acidosis. This was initially
treated with sodium bicarbonate. However, she ultimately
required dialysis. She is currently dialyzed on a Monday,
Wednesday, and Friday schedule.
Had first HD last Friday [**11-21**] via R-IJ, and was last dialyzed
on Wednesday [**12-3**]. Renal U/s obtained for prognostic value.
Tunneled line was deferred for improving renal function. HD was
discontinued on [**12-3**] after pt exhibited multiple days of
increasing urine output >1L daily and spontaneously decreasing
serum creatinine [**12-5**]. HD line was removed on [**12-3**]. Pt cont to
put out >2L urine daily, and serum creatinine resolving towards
normal. Renal team signed off given resolving kidney injury.
Would continue to avoid NSAIDs.
# HAP: HD# 7 her WBC count was noted to rise from 8.8 to 18.6.
Urine and blood cultures were sent and remain negative. A
portable chest xray was concerning for a retrocardiac opacity
that may represent a pneumonia. She was started on empiric
vancomycin and zosyn for HAP and questionable chest xray
findings on portable study. She continued to exhibit low grade
temps however was never hypoxic, and did not have cough, sputum
production, pleurisy, SOB or chest pain. She completed an 8 day
course of ABX. On [**12-11**] she complained of SOB and noted to have
fever to 102. Chest xray suggestive of pneumonia likely [**2-26**]
aspiration event from vomiting episode one day before. She was
started on Vancomycin, IV flagyl, and cefepime for broad
coverage given underlying liver disease and prior ICU stay. She
completed 8 day course on [**12-17**] w/o difficulty and has been
afebrile since initiation. Negative blood cultures. PICC removed
on [**12-18**].
# Cdiff: Pt continued to have abd pain and low grade temps on
the floor. Normal stool output. Cdiff positive on repeat toxin
assay and pt was started flagyl 500mg Q8 on [**12-1**] with plan to
continue coverage until [**12-15**]. WBC downtrended and low grade
temps abated after initiation of flagyl. Plan to continue PO
flagyl therapy for 2 weeks to prevent relapse given recent broad
spectrum antibiotic therapy.
# UTI: Urine cx growing coag neg staph that was obtained in ICU.
Foley cath dc'd and culture susceptibility to vancomycin - pt
completed 8 day course w concomitant coverage for HAP.
# Psych: Pt denies SI/HI/AH/VH however it is clear that she
intentionally overdosed. Pt is unable to signout AMA. Social
work and psychiatry following. Pt has no HCP, estranged from
mother/sisters, ex-boyfriend does not want to be involved, 5yo
daughter in full custody of grandparents.
Has been texting w ex boyfriend over last few days prior to
transfer to psych. Unwilling to discuss w team.
Describes abd discomfort likely [**2-26**] capsular irritation from
tylenol injury. Will cont to feel this sensation pending liver
healing up to 3-6months possible. Alleviated anxiety and
sensation w 0.25mg PO lorazepam QHS.
Insomnia managed with trazodone 25mg qhs w good effect.
Medications on Admission:
None
Discharge Medications:
1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-26**]
Drops Ophthalmic PRN (as needed) as needed for discomfort.
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 13 days: continue for 13 day course to prevent
relapse given recent broadspectrum abx.
Discharge Disposition:
Extended Care
Facility:
deaconness 4
Discharge Diagnosis:
Tylenol overdose
Hospital acquired pneumonia
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 an overdose on a number
of over the counter medications including tylenol. While you
were here, these medications caused your liver and kidneys to
fail. You required dialysis to filter your blood since your
kidneys could not do so. At the time of discharge, you are no
longer requiring dialysis as your kidneys have recovered. Also,
you were treated here for a pneumonia and a UTI. You were found
to have an infection in your colon which requires antibiotic
treatment. Your follow up test for this infection was negative
however you need to continue this antibiotic to prevent
recurrence for another 2 weeks.
.
The following changes were made to your medications:
STARTED Flagyl for 14 days
STARTED Ranitidine to prevent GI pain and formation of ulcers
.
Please follow up with your doctors as stated below.
Followup Instructions:
Department: [**Hospital3 1935**] CENTER
When: MONDAY [**2188-12-22**] at 1:45 PM
With: [**Name6 (MD) 6131**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 54295**] will contact you with appt information regarding time.
Department: LIVER CENTER
When: THURSDAY [**2189-1-8**]
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], 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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icd9pcs
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16070, 16109
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7988, 15628
|
334, 437
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16198, 16198
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16213, 16325
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1794, 1939
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,338
| 110,982
|
2921
|
Discharge summary
|
report
|
Admission Date: [**2113-4-26**] Discharge Date: [**2113-5-4**]
Date of Birth: [**2030-2-4**] Sex: F
Service: MEDICINE
Allergies:
Biaxin / Ibuprofen / Amoxicillin
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Left-sided hemiplegia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a lovely 83-year-old woman with a pmhx. significant for
adenocarcinoma of lung (dx in [**2107**], treated with surgery, chemo
and radiation), atypical meningioma (s/p R sided resection
5-years-ago), CLL (stage 0), and DVT/PE (on warfarin therapy)
who is transferred to [**Hospital1 18**] from [**Hospital 14076**] Hospital after acute
onset of left sided weakness while on a trip to Moheegan Sun.
Patient states that ever since she returned from [**State 108**] about 3
weeks ago, she has noticed increased weakness, apraxia (cannot
but button her shirt or put on socks), and confusion. On day
prior to admission, patient went to CT with her husband and some
friends on a "senior trip." While sitting at a lunch table
eating a bagel, patient started shaking and developed L-sided
weakness. Patient reports that she never lost consciousness,
though dose endorse some confusion surrounding the episode.
Ms. [**Name13 (STitle) 14077**] was taken to [**Hospital 14076**] Hospital in [**Location (un) 14078**], CT where MRI
showed hemorrhagic brain metastases. She was admitted to their
ICU her anticoagulation was reversed; INR had trended down to
1.9 prior to transfer. According to reports from [**Last Name (un) 14076**],
patient's mentation had improved overnight as well. Hct and
Chem 10 normal at OSH, as per report. Patient transferred to
[**Hospital1 18**] as all of her care has been here thus far; also discussion
of possible palliative XRT to [**Doctor Last Name **].
.
ROS: Patient endorses some confusion, left sided weakness.
Denies pain, though did have headache in ambulance during
transfer. No chest pain, shortness of breath, abdominal pain,
dysuria, fevers, chills, or any other concerning signs or
symptoms.
Past Medical History:
-NSCLA (stage IIIb) per above
-CLL.
-Left frontal meningioma.
-Peptic ulcer disease.
-Colonic adenoma.
-Goiter with hypothyroidism.
-Osteoporosis.
-Osteoarthritis.
-Hypercalcemia.
-Emphysema.
-Status post cholecystectomy.
-Atrial fibrillation with bilateral DVTs and IVC filter.
-Cataract.
-History of URI.
-Pulmonary emboli ([**2110**])
-DVT in [**2107**]
PAST ONCOLOGIC HISTORY:
- 83-year-old female with a history of stage zero CLL, underwent
resection of an atypical left frontal meningioma in 04/[**2107**]. At
that time, she had a CT chest, which showed a 1.5 cm speculated
mass in her right upper lobe.
- She underwent a right upper lobectomy and esophageal cavernous
hemangioma resection with tracheal laceration repair on
[**2108-8-24**]. At that time, it was a T4 adenocarcinoma and all
lymph nodes were negative.
- In [**2109-10-3**], she had a right lower lobe nodule which was
increasing in size. It was watched closely, and in [**11/2109**] it
once again was found to be increasing in size.
- On [**2109-12-27**], she underwent a wedge resection, which showed a
moderately differentiated adenocarcinoma, potentially
different from her first primary in the right lower lobe. She
has continued to be followed since that time.
- She was started on Navelbine therapy at a dose of 30 mg/m2 on
[**2110-8-21**]. This was decreased to 25mg/m2 on her 5th cycle due to
Neutropenia.
- She had evidence of disease progression on a CT scan performed
[**2111-4-2**] so the Navelbine was stopped.
- She received radiation to a bony lesion from [**Date range (1) 14079**]. She
had improvement of the pain after this.
- She started on Alimta on [**2112-3-31**]. She had a CT scan on
[**2112-8-18**]
which showed progression.
- She was started on Gemcitabine alone on [**2112-9-1**] which was
stopped due to pulmonary toxicity.
- She was started on Taxotere alone on [**2112-11-10**] which she
continued while in [**State 108**].
Social History:
: Lives with husband in condominium; daughter lives upstairs.
Was a homemaker, and also worked as a secretary for her husband.
Three children, 9 grandchildren, 9 great-grandchildren. Smoked
2 PPD for 27 years. Denies alcohol use. Was able to do most
ADLs up until about 3 weeks ago.
Family History:
mother died from bile duct CA age 89.
sister [**Name (NI) **] died from gastric CA age'[**48**].
sister [**Name (NI) **] died from esophageal CA age 74.
sister [**Name (NI) 4489**] died from lower extr DVT age 82.
father died from ?MI age [**Age over 90 **].
niece with pancreatic cancer
Physical Exam:
VS: T: 96.9, HR: 74, BP: 151/61, RR 23, SPO2: 93% on 2L
GENERAL: Elderly woman, lying in bed, no acute distress
HEENT: Mucous membranes dry, eyes slightly erythematous and
tearing, cavernous area on left upper skull, well-healed
CHEST: Diminished sounds at right base, otherwise CTA
CARDIAC: Regular rate and rhythm; no murmurs, rubs, or gallops
ABDOMEN: +BS, soft, non-tender, non-distended
EXT: Trace edema b/l
NEURO: Alert to person and time; knows president. Initially
confused as to oreientation -- this rapidly cleared by day 2
hospitalization. PEARLA, hearing intact to voice, tongue
midline, left facial droop. Complete left hemiplegia.
Sensation intact throughout.
Pertinent Results:
Admission labs:
[**2113-4-26**] 03:52PM BLOOD WBC-9.4 RBC-4.17* Hgb-11.5* Hct-36.2
MCV-87 MCH-27.7 MCHC-31.9 RDW-15.7* Plt Ct-221
[**2113-4-26**] 03:52PM BLOOD PT-17.8* PTT-26.7 INR(PT)-1.6*
[**2113-4-26**] 03:52PM BLOOD Glucose-122* UreaN-10 Creat-0.7 Na-140
K-4.7 Cl-108 HCO3-25 AnGap-12
[**2113-4-26**] 03:52PM BLOOD Calcium-8.8 Phos-2.8 Mg-2.2
STUDIES:
[**4-26**] CT Head:
1. New intraparenchymal hemorrhage within the right frontal
lobe, presumably representing a hemorrhagic metastatic lesion.
2. Additional smaller hemorrhagic metastatic lesions throughout
the
supratentorial brain.
3. Extensive vasogenic edema throughout the cerebral
hemispheres, without
evidence for midline shift or herniation.
4. Large soft tissue mass within the subcutaneous tissues of the
left frontal vertex and soft tissue nodule adjecent to the left
parotid gland, similar to prior MRI.
[**2113-4-28**] 03:20AM BLOOD WBC-12.6* RBC-3.99* Hgb-11.4* Hct-34.3*
MCV-86 MCH-28.7 MCHC-33.3 RDW-15.7* Plt Ct-207
[**2113-4-29**] 06:05AM BLOOD WBC-19.1*# RBC-4.07* Hgb-11.8* Hct-35.4*
MCV-87 MCH-28.9 MCHC-33.2 RDW-16.1* Plt Ct-190
[**2113-4-30**] 12:00AM BLOOD WBC-19.0* RBC-4.14* Hgb-11.7* Hct-35.9*
MCV-87 MCH-28.3 MCHC-32.7 RDW-15.9* Plt Ct-185
[**2113-5-2**] 12:30AM BLOOD WBC-28.3* RBC-4.62 Hgb-13.1 Hct-40.3
MCV-87 MCH-28.3 MCHC-32.4 RDW-16.1* Plt Ct-158
[**2113-5-3**] 04:10PM BLOOD WBC-38.7* RBC-4.83 Hgb-14.0 Hct-42.8
MCV-89 MCH-28.9 MCHC-32.6 RDW-16.1* Plt Ct-140*
[**2113-4-26**] 3:52 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2113-4-29**]**
MRSA SCREEN (Final [**2113-4-29**]): No MRSA isolated.
[**2113-4-29**] 2:15 pm URINE Site: CATHETER Source: Catheter.
**FINAL REPORT [**2113-5-1**]**
URINE CULTURE (Final [**2113-5-1**]):
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
This is an 83-year-old woman with a pmhx. of adenocarcinoma of
lung (s/p surgery and chemo), CLL, atypical meningioma who
presents from OSH with complete left-sided hemiplegia in setting
of hemorrhagic mets to [**Doctor Last Name **].
# METS TO BRAIN/LEFT HEMIPLEGIA: Patient now with new
hemiplegia and report of hemorrhagic mets to brain (upwards of
6) on MRI at OSH. Initially with confusion as well, but since
resolving. Likely mets are from previous adenocarcinoma of
lung, which is currently being treated by heme/onc (now on
regimen of Taxotere). Patient also had INR ~3 at OSH (on
coumadin for history of PE, afib), contributing to bleeding
around site of mets. As per report, MRI also showing cerebral
edema. At OSH, patient was started on decadron and Keppra;
neuro exam has been stable since arrival. CT head showed new
hemorrhage, as above. Neurosurgery was consulted, felt no
intervention was needed. Radiation oncology saw the patient and
began brain XRT, of which 6 of 10 treatements were completed.
She will undergo the rest from rehab. The patient was seen by
physical therapy and speech and swallow therapy. SHe was
continued on levetiracetam and dexamethasone.
# LUNG ADENOCARCINOMA: Patient is currently treated by
heme/onc (Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **] for lung cancer.
Currently on regimen of Taxotere since [**11-16**]. Last treatment
scheduled for [**4-13**] was held as patient wasn't feeling well
(complaining of diarrhea, deconditioning). The patient's primary
oncologist was notified of her admission.
# UTI: Pt had postive urine culture after leukocytosis noted. A
Proteus infection was treated with Cefpodoxime x 5 day.
# LEUKOCYTOSIS: Noted during hospitalization without fever. No
clear source, no hypoxia or increased cough. A UTI was treated.
Given history of prior CLL and current decadron, it was felt
that this was benign.
# Pre-renal Azotemia: Asymptomatic, rising BUN with stable HCT.
Noted on day of discharge. Was ordered for 1 liter of IV [**12-10**]
NS, but patient only able to recieve abut 125cc. Can be given
at [**Hospital3 **] 125cc/hr, and Chem 7 should be followed by
covering MD there.
# HYPOTHYROIDISM: Continue home synthroid
# Atrial Fibrillation/history of bilat DVTs: Was on Coumadin,
however given the brain hemorrhage this was discontinued. She
has an IVC filter in place, and is now maintained on
pneumoboots, which should be continued
# GERD: Continue home ranitidine
# CODE STATUS: Patient made clear her desire for DNR/DNI
status.
# Further ONC care need to be arrange with her Oncologist Dr.
[**Last Name (STitle) **] ([**Hospital1 18**]) and Radiation Oncologist (Dr. [**Last Name (STitle) **]. Her
consulting neurosurgeon is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Medications on Admission:
Albuterol inhaler prn
Alendronate 35 Qweek
Restasis eye drops
Fluticasone 50mcg [**12-10**] sprays in each nostril per day
Furosemide 20mg QD
Synthroid 100mcg QD
Lorazepam 0.5mg every 4 hours as needed for nausea (during
chemo)
Compazine
Ranitadine 150mg QD
Warfarin 2mg as directed by coumadin clinic (since [**2110**])
Docusate sodium
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO ONCE
(Once) for 1 doses.
7. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
8. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
L hemiplegia
Brain metastasis w/ hemorrhage
UTI - Proteus mirabilis
Leukocytosis w/ lymphocytosis - likely secondary to CLL +
steroids
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 dense L sided paralysis from hemorrhagic
stroke due to brain metastasis from cancer. You began Radiation
treatment and will receive a total of 10 treatments. You are
placed on thick liquids because of aspiration risk when you
drink think liquids, and you will be observed when eating.
You were taken off coumadin. You have an IVC filter in place for
protection from pulmonary embolus. You should be maintained of
pneumatic boots for DVT prophylaxis.
You were treated for a UTI.
You have a high white blood cell count without evidence of
infection. It is felt this is due to a combination of steroids
and CLL
Followup Instructions:
RADIATION ONCOLOGY APPTMENTS AT [**Hospital1 18**]
[**2113-5-5**] - XRT at 9:15 AM
[**Date range (3) 14080**] - no XRT
[**2113-5-9**], [**2113-5-10**] and [**2113-5-11**] - XRT at 8 AM each day
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: MONDAY [**2113-5-29**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6740**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
"533.90",
"599.0",
"244.9",
"431",
"162.8",
"530.81",
"204.10",
"788.99",
"V58.61",
"492.8",
"240.9",
"V12.51",
"198.3",
"V45.76",
"041.6",
"427.31",
"780.39",
"366.8",
"342.90",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
12002, 12073
|
7891, 10717
|
313, 319
|
12251, 12251
|
5376, 5376
|
13088, 13648
|
4368, 4657
|
11104, 11979
|
12094, 12230
|
10743, 11081
|
12426, 13065
|
4672, 5357
|
252, 275
|
347, 2090
|
5754, 7868
|
5392, 5745
|
12266, 12402
|
2112, 4047
|
4064, 4352
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,948
| 186,194
|
41031
|
Discharge summary
|
report
|
Admission Date: [**2110-4-9**] Discharge Date: [**2110-4-14**]
Date of Birth: [**2043-2-17**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Haldol
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Posterior fusion T11-L5
History of Present Illness:
Mr. [**Known lastname 73762**] has instrumentation that has failed in his lumbar
spine. He presents for surgical intervention.
Past Medical History:
-HTN
-Parkinson's Disease
-s/p multiple lumbar spine surgeries, including a recent
epidural hematoma evacuation for cauda equina syndrome.
Social History:
Former machinist; has a workshop at home. Lives in RI with wife.
3 children, one of whom is a physician in NY, other two live in
RI. Actively involved in woodworking, teaches [**Male First Name (un) 1573**] sailing.
Family History:
N/C
Physical Exam:
General: no wt loss, fevers, sweats
HEENT: no vision changes, no odynophagia, dysphagia, neck
stiffness
CARDIAC: no chest pain, palpitations, orthopnea
Pul: no shortness of breath or cough
GI: no nausea / vomiting / diarrhea
GU: no dysuria / frequency / urgency
CNS: no unilateral weakness / numbness / headache
MSK: no myalgia / arthralgia
Hematology: no bleeding, easy bruising
LYMPH: no swollen lymph nodes
DERM: no new skin rashes / lesions
PSYCH: no mood changes
ROS is otherwise negative.
PHYSICAL EXAM:
VS: 98.6 130/74 70 18 98RA
General: pleasant, NAD
EENT: PERRL, EOMI, sclerae anicteric, neck supple, moist mucous
membranes, no ulcers / lesions / thrush
CV: RRR, normal S1, S2, no murmurs / rubs / gallops
Pul: clear to auscultation bilaterally w/o wheezes / rhonchi /
rales
BACK: clean-appearing midline incision, with steri-strips in
place; no erythema or discharge; minimally tender
GI: normoactive bowel sounds, soft, non-tender, non-distended,
no hepatosplenomegaly
MSK: no joint swelling or erythema
Extremities: warm and well perfused, no edema, 2+ DP pulses
palpable bilaterally
LYMPH: no cervical, axillary, or inguinal lymphadenopathy
SKIN: no rashes, no jaundice
NEURO: awake, alert and oriented x3, CN 2-12 intact, [**5-17**]
strength bil, reflexes 1+ bilaterally, normal sensitivity
PSYCH: non-anxious, normal affect
Pertinent Results:
[**2110-4-13**] 01:30PM BLOOD WBC-6.6 RBC-3.36* Hgb-9.5* Hct-29.3*
MCV-87 MCH-28.2 MCHC-32.4 RDW-15.5 Plt Ct-308
[**2110-4-12**] 06:40AM BLOOD WBC-8.0 RBC-3.29* Hgb-9.7* Hct-29.3*
MCV-89 MCH-29.7 MCHC-33.3 RDW-15.4 Plt Ct-255
[**2110-4-11**] 10:35AM BLOOD WBC-10.0 RBC-3.54* Hgb-10.2* Hct-31.3*
MCV-89 MCH-28.8 MCHC-32.6 RDW-15.6* Plt Ct-248
[**2110-4-9**] 09:03PM BLOOD WBC-9.1 RBC-3.87* Hgb-11.2* Hct-34.0*
MCV-88 MCH-29.1 MCHC-33.1 RDW-15.6* Plt Ct-297
[**2110-4-13**] 01:30PM BLOOD Glucose-139* UreaN-8 Creat-0.9 Na-135
K-3.6 Cl-99 HCO3-27 AnGap-13
[**2110-4-9**] 09:03PM BLOOD Glucose-122* UreaN-11 Creat-0.9 Na-138
K-3.8 Cl-103 HCO3-27 AnGap-12
Brief Hospital Course:
Mr. [**Known lastname 73762**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a
thoracolumbar fusion. He was informed and consented and elected
to proceed. Please see Operative Note for procedure in detail.
Post-operatively he was given antibiotics and pain medication.
A hemovac drain was placed intra-operatively and this was
removed POD 2. His catheter was left in placed and can be
discharged when possible. He was seen by ID and recommendations
followed. He was discharged in good condition and will follow
up in the Orthopaedic Spine clinic.
Medications on Admission:
Amlodipine 10 mg PO daily
- Aspirin 325mg PO daily
- Atenolol 50mg PO daily
- Bisacodyl 10mg PR daily prn
- Carbidopa/Levodopa 25/250mg PO BID
- Carbidopa/Levodopa 75/300mg PO qHS
- Docusate 100mg PO BID
- Gabapentin 100mg PO q8H
- Heparin 5000U SC BID
- Insulin sliding scale
- Pramipexole 0.5mg PO q8H
- Senna 2 tabs daily qHS
- Bisacodyl PRN
- Hydromorphone 2-4mg PRN
- Vancomycin
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. carbidopa-levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
4. carbidopa-levodopa 25-250 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily): In pm.
5. rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
8. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO q8hours ().
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for indigestion.
11. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4H (every 4 hours) as needed for pain.
12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
syringe Injection TID (3 times a day).
13. minocycline 50 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 44243**] Health and Rehab in [**Location (un) **], CT.
Discharge Diagnosis:
Failure of lumbar instrumentation
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: POSTERIOR
Thoracolumbar 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 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
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please continue to change the dressing daily with dry, sterile
guaze.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2110-4-14**]
|
[
"709.2",
"737.10",
"996.49",
"E878.1",
"401.9",
"285.1",
"733.82",
"332.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.38",
"81.05",
"03.90",
"81.63",
"86.3"
] |
icd9pcs
|
[
[
[]
]
] |
5157, 5255
|
2933, 3550
|
280, 306
|
5333, 5340
|
2258, 2910
|
7511, 7591
|
876, 881
|
3984, 5134
|
5276, 5312
|
3576, 3961
|
5364, 5461
|
1407, 2239
|
7315, 7395
|
7417, 7488
|
5497, 5690
|
231, 242
|
5726, 6185
|
6197, 7297
|
334, 463
|
485, 626
|
642, 860
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,578
| 163,540
|
21787
|
Discharge summary
|
report
|
Admission Date: [**2200-5-30**] Discharge Date: [**2200-6-6**]
Date of Birth: [**2127-7-19**] Sex: F
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Hypotension and anemia
Major Surgical or Invasive Procedure:
EGD
Colonoscopy-diverticulosis
Bleeding Scan -tagged RBC
History of Present Illness:
Mrs. [**Known lastname 7168**] is a 72 year old female with a PMH significant for
HTN, CKD, and DVT admitted for hypotension and anemia. The
patient is a [**Hospital 4820**] nursing home resident who reports a 3 day
history of increased malaise and fatigue. This was accompanied
by left-sided flank pain radiating to her groin and nausea but
no emesis. She denies any hematochezia, melena, f/c/s, emesis,
CP, palpitations, orthopnea, or PND. The patient was noted at
[**Hospital1 **] to have an INR of 8.7 on [**5-30**] with a hct of 19.7 from 32
on [**2200-5-22**] with a BP of 80/p. She was then transferred to [**Hospital1 18**]
for further evaluation.
In the [**Hospital1 18**] ED, VS were 102/48 65 22 98%4L nc. 2 PIV and a RIJ
CVL were placed, and she received 2L IVF, 5 mg IV vitamin K, 1
unit PRBC, 1 unit FFP, and 40 mg IV protonix. She had a NGL that
was negative, but was noted to have gross blood in the rectal
vault. A CTAP demonstrated a 3 mm right mid-ureteral stone with
dilation of the proximal ureter but no hydronephrosis. She was
also noted to have a 3.9 x 2.7 cm intermediate density structre
in the left pelvis separate from the ovary suspicious for an
aneurysm. GI, urology, and general surgery were consulted, and
the patient was transferred to the [**Hospital Unit Name 153**] for further management.
Currently, the patient is resting comfortably without
complaints. Denies any flank pain, CP/SOB, f/c/s, n/v/d, abd
pain, HA.
Past Medical History:
- Schizophrenia vs schizo-affective disorder
- Hypertension
- CKD III, baselien 1.5-1.7
- DVT - left leg (pre-[**2194**]) unclear associated factors
- Right knee periprosthetic undisplaced medial condyle fracture
of the femur ([**11/2199**])
- Dementia
- major depressive disorder
- osteroarthritis both knees
- PVD
- Parkinsons?--resting tremor
- ?p Afib-daughter thinks
- Diabetes Insipidus [**12-23**] lithium
Social History:
Long-term resident of [**Hospital1 **] Seniior Care of [**Location (un) 55**].
Ambulates with walker and assistance, history of falls. Denies
EtOH, tobacco, IV, illicit, or herbal drug use.
Family History:
unknown
Physical Exam:
on discharge
Vitals: 98.6 178/100 72 18 95%RA
good UOP-incontinent
Pain: denies
Access: PIV
Gen: nad, off O2
HEENT: mm dry, no tenderness along temporal region or jaw
Neck: able to flex neck-no nuchal ridigity
CV: RRR, no m appreciated
Resp: CTAB,+ bibasilar crackles, improved with coughing
Abd; soft, obese, nontender, +BS
Ext; no edema
GU: foley removed
Neuro: A&OX3, grossly nonfocal, bedbound chronically
Skin: no new changes
psych: appropriate, pleasant, cooperative
.
Pertinent Results:
HCT 19 on admission-->s/p 9U prbc-->30 on discharge
Creat 2.3->1.9
BUN 69-->30
K 3.9 Mag 1.8
Na 147-->153-->151->147->151-->149-->141->143-->147
INR 5.4->1.1
Alb 3.3
.
UA/UCx neg
.
.
Imaging/results:
GI bleeding study: [**6-3**]:
Following intravenous injection of autologous red blood cells
labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the
abdomen for 90 minutes were obtained. A left lateral view of the
pelvis was also obtained. Blood flow images show no active
bleeding.
Dynamic blood pool images show no bleeding after 90 minutes.
Note is made of non-visualization of the kidneys and bladder,
uncertain etiology.
IMPRESSION:1.No evidence of active GI bleeding. 2.
Non-visualization of kidneys and bladder could relate to chronic
renal failure.
EGD [**6-2**]:
Three sessile polyps of benign appearance and ranging in size
from 2mm to 3mm were found in the stomach body.
Duodenum: Normal duodenum.
Impression: Polyps in the stomach body-->needs f/u for biopsy
Erythema in the cardia
.
C-scope: [**6-2**]: Diverticulosis of the sigmoid colon and distal
descending colon. no active bleeding. Polyp in the sigmoid colon
Polyp in the descending colon-->needs c-scope in near future for
removal.
.
CT c/a/p [**5-30**]: No RP bleed. 3 mm right mid-vreter stone with
dilatation of very proximal ureter, but no dilation immediately
upstream of the stone. Probable left internal iliac artery
aneurysm. Aneurysmal dilatation of the right common iliac artery
at the bifurcation. Lung with bibasilar Atx.
.
Renal US [**6-2**] CONCLUSION: Echogenic kidneys consistent with
chronic medical renal disease. No other abnormality identified
by ultrasound of the kidneys.
.
Head CT [**5-30**]:
1. No acute intracranial hemorrhage or other abnormality.
2. Changes consistent with chronic small vessel ischemic
disease.
.
CXR [**5-31**]: Decreased lung volumes. Increase peri-hilar fullness.
RIJ CVL terminating in RA. bibasilar opacities, likely Abx.
.
CXR [**6-5**]: prelim: improved basilar opacities. no infiltrates
.
KUB [**5-31**]: unremarkable.
.
ECG: NSR. NA-NI. No ST-T wave changes.
.
Brief Hospital Course:
72 year old female with schizophrenia, HTN, CKD III (1.5-1.6),
h/o DVT and ?afib on couamdin, chronic DI, PAD admitted for
malaise found to have a hct of 19 and active GI bleeding with
hypotension/ARF in setting of elevated INR. Got Vit K and ffp to
reverse INR and many units of blood (see below). Initially
admitted overnight to ICU, but remained stable, thus transfered
to Gen Med [**5-31**]. Has been HDS despite ongoing bleeding.
Underwent EGD/C-scope [**6-2**] unrevealing of source (C-scope
required two preps. Showed pan-diverticulosis with blood in
ascending colon but they couldnt identify exact source). Given
HCT still downtrending at that time, ordered bleeding scan on
[**6-2**], which was done when pt finally stopped bleeding on [**6-3**],
thus was negative. In total, has required 9U prbc, with HCT now
stable X3days w/o any evidence of further bleeding. Thought is
that this was either diverticular bleed or bleed from AVM. In
the future if recurrent bleeding, she should undergo repeat
cscope or consider pill endoscopy.
.
Hospital course complicated by Acute on Chronic renal failure,
improved with IVFs. Also had issues with recurrent
hypernatremia, per daughter has h/o DI and [**Month (only) **] free water here.
Got D5W fluids initially with improvement. Encouraged PO
hydration. Of note, pt is very sensitive and easily becomes
hyperNa if not give access to adequate free water, thus should
have large water available at bedside at all times. Her HAs seem
to correlate with dehydration/HyperNa as well. On dischage her
Na increased from 143->147, but she was given alot of free water
prior to transfer. Her Na should be followed closely at [**Hospital1 1501**] as
they were previously doing.
.
Her CT scan showed b/l iliac aneurysm, she has known vascular
disease and is followed as outpt, she can f/u with vascular on
nonurgent basis.
.
Finally, there was an incidental finding of ureteral stone, US
w/o hydro, started on course of flomax per urology until [**6-4**],
she needs f/u with Dr. [**Last Name (STitle) 3748**] at [**Hospital1 18**]. She should have f/u with
PCP shortly after [**Name Initial (PRE) **]/c to review medications (polypharmacy) and
hospital course.
.
Many medications have been held or changed: coumadin stopped as
no clear indicaiton. ASA and pentoxyfilline held on d/c but can
be resume 1 week after discharge if Hgb is stable. Toprol [**Month (only) **] to
100mg since pt has brady down to 40-50s. Lisinopril can be
titrated for better BP control as outpt. Trazadone, oxycodone,
flexeril all stopped given pt has not required them entire time
here and unclear indication. She finished course of Abx started
at [**Hospital1 **] for UTI.
.
Complicated patient and further details are outlined in progress
note from today below:
.
.
Acute GI Bleeding: in setting of supratherapeutic INR. marroon
stools ongoing until [**6-2**] night, finally no further marroon
stools, now dark/black stools, likely old blood. s/p 9U prbc
so far. s/p 3U ffp/Vit K. On [**6-2**] EGD with nonbleeding polyps,
c-scope with diverticulsosis but no bleeding identified, though
blood seen in ascending colon. GI bleeding scan [**6-3**] was
negative for acute bleeding, but clinically patient has stopped
bleeding as well. Suspect that this was a diverticular bleed in
setting of elevated INR. Other possibility is AVM and if pt has
recurrent bleeding, should consider pill endoscopy
-hct now has been stable for past three days
-if again starts to bleed, will need IR angio
-no more coumadin, holding ASA/pentoxyfilline also, can resume
in one week
-PPI PO Qd should suffice given EGD findings.
-note, needs repeat EGD and c-scope for biopsy of polyps on
discharge.
.
.
ARF on CKD III: Baseline 1.6-1.9 in [**2196**]. Per nursing home, most
recent creatinine ranging 1.9. Acute on chronic renal failure
likely secondary to low-flow state/prerenal/volume depletion.
Renal US no hydro.
- Creat 1.9 for couple days, near baseline
- encourage PO fluids
.
.
Hypernatremia, h/o DI: [**12-23**] dehydration and per daughter pt has
h/o DI [**12-23**] lithium and does get hypernatremic several times per
year requiring IVFs
-s/p IVFs with D5W, now taking good PO though very easily
becomes hypernatremic again
-this am Na 143->147, pt c/o thirst, will provide a lot of water
-will ask [**Hospital1 1501**] to closely monitor
.
.
Hypertension: has some brady down to 40-50 on tele. Have
decreased metoprolol from 75mg TID to 50mg [**Hospital1 **] (on toprol
200-->100) given bradycardia. cont imdur 90mg. Back on
lisinopril 5mg (note creat stable and K has been low), if BP
remains elevated, would increase lisinopril to 10mg as outpt
.
.
UTI: Diagnosed at nursing home, completed 7days of cefpodoxime
on [**6-3**].
-foley has been removed
-no urinary complaints
.
.
Malaise and chills: occurred on [**6-5**]. Given long hospitalization
and MMP concerning for early infection. However, has remained
afebrile and no leukocytosis, which is comforting.
-UA not sent for some reason. will defer as no leukocytosis or
fevers or urinary complaints.
-repet CXR prelim no infiltrates
-likely malaise due to long hospitalization. Feels better today.
.
.
Headaches: unclear etiology. Apparently chronic for past month.
Likey component of dehydration as HA seem worse when sodium is
high.
-encourage water
-tylenol, neurontin
-pt does not want oxycodone
.
.
Ureteral stone: No signs of hydronephrosis on CT. Urology per
urology, no surgical indication at this time. US no hydro.
- Follow-up with urology ([**Doctor Last Name 3748**]) as outpatient.
- Flomax 0.5 mg po daily x14 days, started [**5-30**]-->[**6-14**]
- resumed oxybutinin 5mg TID (on ER 5mg qd)
.
.
Pelvic mass: 3.9 x 2.7 cm intermediate density structure in the
left pelvis likely separate from ovary-->final read is iliac
aneursym. Can f/u vascular, non urgent
.
.
PVD: Holding ASA and pentoxyfilline in setting of GIB, will
likely hold on discharge with plan to resume if no further GIB
on repeat HCT in 1 week.
.
.
DVT: Uncertain associated factors, but from chart review appears
to have occurred prior to [**2195**]. Daugther doesnt think has
happened again.
- Have discussed risks/benefits of ongoing coumadin therapy with
daughter (HCP), esp in setting of possible parox Afib (none
documented here, per report only, but may be mis-diagnosed given
artifact with tremor). Plan is to NOT resume AC on discharge
given significant bleed.
.
.
Psych: Continue current regimen of risperdone, effexor, abilify.
holding trazadone, has not requested.
.
.
cough: nonproductive. CXR/CT with atelectasis. incentive
spirometer
.
.
Dementia: Continue current regimen.
.
.
Parkinsons?: Patient is currently taking sinemet 25/100 and has
a resting tremor, but with unclear diagnosis of Parkinsons.
- Continue sinemet
.
.
Chronic pain/arthritis/headaches: on neurontin 300mg tid, cont
home doses. flexeril and oxycodone held, has not requested so
will likely not resume on d/c given polypharmacy. on
glucosamine/chondroitin as outpt.
.
.
Dispo/Code: DNR/DNI (confirmed with patient). Plan d/c back to
EPHOC today
.
Contact: [**Name (NI) 622**] [**Name (NI) **] (daughter/HCP) [**Telephone/Fax (1) 57213**]. updated
in detail by phone [**6-4**].
Medications on Admission:
Coumadin 3.5 mg daily (held [**2200-5-29**] for INR 6)
ASA 81 mg daily
Carbidopa-levodopa ER 25-100, 1 tab daily
Docusate 100 mg, 2 tabs daily
Neurontin 300 mg po bid
Glucosamine-chondroitin cap
Isosorbide mononitrate SA 90 mg daily
Lisinopril 5 mg daily
Senna 2 tabs po qhs
Vitamin C
Acetaminophen prn
Bisacodyl prn
Cyclobenzaprine 5 mg daily prn
Toprol XL 200 mg po daily
Eye drops
MVI
Oxybutynin CL ER 5 mg daily
Pentoxifylline 400 mg tab po bid
Risperidone 0.5 mg QAM, 2 mg po qhs
Fleets prn
MOM prn
Oxycodone 10 mg po Q4H prn for pain
Trazodone 50 mg po qhs prn
Venlafaxine XR 225 mg po daily
Abilify 5 mg po daily
Vantin 200 mg po bid (started on [**5-29**] for UTI)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. Carbidopa-Levodopa 25-100 mg Tablet Sustained Release Sig:
One (1) Tablet PO BID (2 times a day).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
5. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily) for 7 days: until
[**6-14**].
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Isosorbide Mononitrate 120 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Oxybutynin Chloride 5 mg Tab,Sust Rel Osmotic Push 24hr Sig:
One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day.
12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
can be titrated if your blood pressure is high.
14. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
15. Glucosamine Chondroitin MaxStr 500-400 mg Capsule Sig: One
(1) Capsule PO twice a day.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
17. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day:
hold for diarrhea.
18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day:
start after 1 week after discharge if Hgb/Hct stable. .
19. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day: start after 1 week
after discharge if Hgb/Hct stable. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Primary:
Acute blood loss anemia due to GI bleed s/p 9U blood
coagulopathy due to coumadin
Hypernatremia due to DI and dehydration
Acute on chronic renal failure
Ureteral stone, incidental
UTI, treated
iliac aneurysm, incidental finding
Discharge Condition:
Hemodynamically stable, hematocrit stable, tolerating normal
diet
Discharge Instructions:
You were admitted with GI bleeding in the setting of an elevated
coumadin level. You recieved total 9Unit of blood. You will not
be restarted on coumadin. Your aspirin and pentoxyfilline are
held on discharge but can be restarted if you anemia is stable
in one week
.
your toprol dose is decreased due to bradycardia. your
lisinopril can be increased if you have uncontrolled HTN
.
you finished course of Abx for UTI
.
Your CT scan showed incidental finding of ureteral stone, you
are started on flomax until [**6-4**]. you had no consequence from
this stone (asymptomatic, no hydro). you can f/u with Dr. [**Last Name (STitle) 3748**]
in few weeks.
.
Your oxycodone, trazadone, flexeril are stopped as you have not
needed these and you are on too many medications
.
you are very sensitive to dehydration, you should drink plenty
of water daily
Seek immediate medical care if you develop abdominal pain,
fevers, or recurrent bleeding.
Followup Instructions:
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **].
You also need to arrange for f/u with vascular doctor at some
point.
you were seen by Dr. [**Last Name (STitle) 3748**] from urology at [**Hospital1 18**], you can
follow up with him in 2-3weeks for your ureteral stone.
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
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289, 347
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|
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2288, 2480
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,740
| 155,165
|
50184
|
Discharge summary
|
report
|
Admission Date: [**2155-9-18**] Discharge Date: [**2155-9-22**]
Date of Birth: [**2103-12-23**] Sex: M
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 3497**] is a 51 year-old man
with a history of hypertension, perforated diverticulitis in
[**2134**] status post partial colectomy and history of
hemodynamically significant lower GI bleed secondary to
diverticulosis in [**2154-5-9**]. At this time the patient was
and was treated with intra-superior mesenteric artery
vasopressin. He has done well since then with no further GI
bleeding until 8:00 p.m. on [**2155-9-17**] when he noted the onset
of bright red blood per rectum, approximately half a cup. He
has since then had two subsequent episodes and presented to
the Emergency Department. He denied abdominal pain, nausea,
vomiting, hematemesis, diarrhea, chest pain, shortness of
report recent nonsteroidal anti-inflammatory use of Aleve two
tabs q.h.s. for back pain for the past two weeks.
On arrival to the Emergency Department the patient was
hemodynamically stable and remained that way. His hematocrit
was 39 on arrival at 11 p.m. and 36 at 5:00 a.m. He received
vitamin K 10 units subQ for an INR of 1.5. He has had three
to four subsequent episodes of bright red blood per rectum
approximately half a cup since his arrival to the Emergency
Department. He underwent a bleeding scan, which showed
bleeding at the splenic flexure. Surgery was consulted and
they recommended angiography.
PAST MEDICAL HISTORY: 1. Hypertension. 2.
Hypercholesteremia. 3. Gastrointestinal bleed secondary to
diverticulosis in [**5-/2154**] treated with intra SMA vasopressin.
4. The patient is status post partial colectomy in [**2134**] for
perforated diverticulitis. 5. Chronic low back pain. 6.
Status post recent ACL tear. 7. Arthroscopic surgery eight
weeks ago. 8. History of an increased INR secondary to a
partial factor V deficiency.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: Cardizem CD 300 mg po q.d., Prinivil 40 mg po
q.d., Lipitor 10 mg po q.d., [**Doctor First Name **] 60 mg b.i.d. po, Aleve
two tabs po q.h.s. prn for the past two weeks.
SOCIAL HISTORY: The patient is a construction supervisor.
He has a remote history of smoking five pack years. He lives
with his wife. [**Name (NI) **] has occasional ethanol use.
FAMILY HISTORY: His father had a myocardial infarction at
the age of 75. His mother has hypertension and
hypercholesterolemia. His brother and sister are alive and
well.
PHYSICAL EXAMINATION: In general he appears comfortable in
no acute distress. His vital signs, he is afebrile. His
blood pressure is 160/109. Pulse 81. Respiratory rate 18.
O2 sat 97% on room air. HEENT pupils are equal, round and
reactive to light. Extraocular muscles are intact. He is
anicteric. His oropharynx is clear. His neck has no JVD and
no lymphadenopathy. Lungs are clear to auscultation. His
heart has a regular rate and rhythm. No murmurs, rubs or
gallops. Abdomen soft, nontender, nondistended. Bowel
sounds present. Rectal examination was notable for gross red
blood. Extremities no edema. Good distal pulses.
Neurological, cranial nerves II through XII intact, nonfocal.
LABORATORY: White count 8.1, hematocrit 39.3, platelets 253,
PT 15.1, INR 1.5, PTT 32.7, sodium 141, potassium 4.0,
chloride 104, bicarb 22, BUN 22, creatinine 0.9, glucose 126.
Bleeding scan revealed bleeding at the splenic flexure.
Electrocardiogram was normal sinus rhythm rate of 77. Normal
intervals. Normal axis. T wave inversion in 3. No ST or T
wave changes.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit. He had two large bore intravenous
placed. He was typed and crossed for two units of packed red
blood cells. Serial hematocrits were followed q 4 to 6 hours
and the patient underwent angiography by interventional
radiology who started him on vasopressin GTT into the
inferior mesenteric artery the left colic branch. The
patient remained hemodynamically stable with a heart rate in
the 80s, blood pressure 112 to 160/53 to 88. His hematocrit
dropped to 27.4 by 1:00 p.m. after being 39 on admission.
Gastroenterology was consulted and recommended that the
patient will need follow up for full colonoscopy since his
last colonoscopy was incomplete. On hospital day one the
patient was doing well with no complaints. He had no further
bright red blood per rectum. His hematocrit was 28.0. The
previously hematocrits were 28.0, 26.1 and 27.4. His
electrolytes were within normal limits. His PT was 16.6, PTT
28.4, INR was 1.8. He is continued on inferior mesenteric
artery vasopressin infusion.
Because his hematocrit dropped from 39 to 26 he was
transfused one unit of packed red blood cells. The
vasopressin infusion was discontinued at 11:00 a.m. on
[**2155-9-19**] and serial hematocrits remained stable on
[**2155-9-20**]. His hematocrit was 29.4 at 12:00 a.m. and 28.3 at
5:30 a.m. On [**2155-9-20**] the patient continued to do well with
no complaints. He was hemodynamically stable off the
vasopressin infusion and was transferred to the floor at
this time. His hematocrit was 28.3, INR 1.6, electrolytes
were within normal limits with the exception of a potassium
of 3.3, which was repleted with po K-Dur 40 milliequivalents.
Diet was advanced to clears at this time. His Foley catheter
was discontinued. He was encouraged to ambulate ad lib. His
diet was advanced to regular and his hematocrits were
followed.
On [**2155-9-21**] the patient was doing well with no complaints.
His T max was 100.5. His vital signs were stable. His
examination was unremarkable. His hematocrit was 27.8 and
27.7. He passed one formed stool, which was hemocult
positive, but not grossly bloody. On [**2155-9-22**] the patient
was doing well with no complaints. He reported he would like
to be discharged to home. He was afebrile with stable vital
signs. His examination was unremarkable. Follow up
hematocrit was 30.7.
He is discharged to home in stable condition. He is
instructed to avoid non-steroidal anti-inflammatory agents
and aspirin. He is instructed to follow up with his primary
care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 60542**] this week and to follow up with
GI as an outpatient for a full colonoscopy.
DISCHARGE CONDITION: Stable.
DISPOSITION: To home.
DISCHARGE DIAGNOSIS:
Status post lower gastrointestinal bleed secondary to
diverticulosis.
DISCHARGE MEDICATIONS: [**Doctor First Name **] 60 mg b.i.d., Lipitor 10 mg q
day, Cardizem 300 mg po q day, Prinivil 40 mg po q day. The
patient is to avoid all non-steroidal anti-inflammatories and
all aspirin containing products.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6243**]
Dictated By:[**Last Name (NamePattern1) 23443**]
MEDQUIST36
D: [**2155-9-22**] 13:02
T: [**2155-9-22**] 13:10
JOB#: [**Job Number **]
1
1
1
CON
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"96.34",
"99.29"
] |
icd9pcs
|
[
[
[]
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] |
6401, 6434
|
2397, 2554
|
6550, 7039
|
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|
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|
177, 1508
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|
2214, 2380
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,343
| 191,443
|
28138
|
Discharge summary
|
report
|
Admission Date: [**2104-2-3**] Discharge Date: [**2104-2-16**]
Date of Birth: [**2048-6-12**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
Decreased Sensation
Major Surgical or Invasive Procedure:
XRT to spine, C5-T4 fusion, posterior decompression of C6-C7 to
T3-T4
History of Present Illness:
Mr. [**Known lastname **] is a 55 yo M w/Stage IIIB Multiple Myeloma dx at
time of lumbar compression fx now s/p C5 Decadron [**Date range (1) 68404**]
and nightly Thalidomide who presents with numbness.
.
The patient reports feeling fairly well except for he has noted
diffuse chest/rib pain on the days off steroids including
starting on [**2-1**]. For these symptoms, his MS Contin was
increased with good effect. Also on [**2-1**], he noted numbness in
addition to the pain in his right breast/anterior shoulder. The
numbness then increased in a bandlike distibution across his
chest. Over the next day, the numbness spread down his abdomen
to his anterior thighs. He was not weak and was able to ambulate
so he did not originally go to the hospital but by Sunday when
the numbness had spread, he presented to [**Hospital3 **] ED. They
noted he had decreased sensation to the nipple and wanted him to
have an MRI but the machine was broken so he was transferred to
[**Hospital1 18**].
.
In the ED, neurology was consulted. They suggested a MRI of the
Tspine which was notable for severe cord compression at T2.
Ortho spine was consulted and he was given 40 mg IV Decadron.
Rad-Onc was consulted and he was taken for emergent radiation
therapy prior to arrival to the floor.
.
He denies f/c/sweats. He denies weakness, burning. He denies
urinary/fecal incontinence but notes constipation on narcotics.
He strained to have a BM 2 days ago - he notes it was hard and
blood streaked.
.
ROS: He reports good appetite. He denies weight loss. He denies
lightheadedness, palpitations. He denies n/v/abd pain. He denies
dysuria, urgency. He denies rashes.
Past Medical History:
PAST ONC HX: Mr. [**Known lastname **] was well until [**8-23**], when he
developed lower back pain. He was seen at [**Hospital3 **] ED and was
dx with MSK pain. His pain did not improve on NSAIDs, narcotics
so he went to his PCP. [**Name10 (NameIs) **] PCP ordered an MRI which was
significant for a compression fracture of L1 and L2 and abnormal
bone marrow signal in all vertebral bodies consistent with
abnormal marrow replacement. At that time, he had a calcium of
16.5, a creatinine of 3.4, a HCT of 32. SPEP revealed an IgG
lambda paraprotein at 23 mg/dL with decreased IgA and IgM at 69
and 22 respectively. Bone marrow biopsy revealed hypercellular
marrow with extensive involvement by CD 138 positive plasma
cells and plasma blasts. Cytogenetics revealed normal male
chromosomes without any evidence of a deletion of chromosome 13.
He was cx with Stage IIIB MM. The patient was started on
treatment with dexamethasone and thalidomide. He was also given
Aranesp and Zometa. His Beta-2-microglobulin was 4.6. In [**11-23**],
he developed a DVT in his RLE and was started on coumadin. He
remained on decadron/thalidomide with good response. A repeat bm
bx on [**2103-12-17**], revealed less than 5% blast cells.
.
PMH:
1) Cold induced asthma
2) DVT in RLE [**11-23**]
3) Diverticulitis [**12-24**] tx'd with abx
4) Compression fracture of vertebrae
Social History:
The patient denies current or past tobacco use. He has a history
of heavy alcohol use in the past but quit 1 year ago. Denies any
drug use. He works as a lab technician in the biochemistry lab
at [**University/College **].
Family History:
Father had an MI in his 50s. Mother with HTN. The patient has
one sister who is 50 years old and is healthy. 3 healthy
children
Physical Exam:
T 97.6 BP 128/61 HR 70 RR 16 O2 Sat 100%RA
GENL: NAD
HEENT: PERRL, EOMI, no nystagmus. Red flushed cheeks. Sclera
anicteric. MMM. No OP lesions.
NECK: Supple, No JVD, No LAD
BACK: minimal spinal tenderness T1-T6, no stepoff
CHEST: CTA b/l, no w/c/r
CV: RRR, nl S1, S2, no murmurs appreciated.
ABD: SNT ND NABS, no HSM appreciated
EXT: no edema, 2+ DP pulses
NEURO: AandOx3, CN 2-12 intact. M [**6-22**] throughout. Brisk reflexes
- biceps, patellar, toes downgoing, no clonus. S -decreased
appreciation for PP across chest and down abd to top of thighs
b/l. Cannot assess gait as pt must remain at 30 degrees in bed.
No dysmetria.
Pertinent Results:
[**2104-2-3**] 10:23AM GLUCOSE-119* UREA N-13 CREAT-0.4* SODIUM-137
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13
[**2104-2-3**] 10:23AM CK(CPK)-20*
[**2104-2-3**] 10:23AM cTropnT-<0.01
[**2104-2-3**] 10:23AM CK-MB-NotDone
[**2104-2-3**] 10:23AM CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-1.9
[**2104-2-3**] 02:55AM GLUCOSE-106* UREA N-15 CREAT-0.6 SODIUM-137
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13
[**2104-2-3**] 02:55AM estGFR-Using this
[**2104-2-3**] 02:55AM CK(CPK)-27*
[**2104-2-3**] 02:55AM cTropnT-0.02*
[**2104-2-3**] 02:55AM CK-MB-NotDone
[**2104-2-3**] 02:55AM URINE HOURS-RANDOM
[**2104-2-3**] 02:55AM URINE GR HOLD-HOLD
[**2104-2-3**] 02:55AM WBC-12.7* RBC-4.09* HGB-11.9* HCT-37.2*
MCV-91 MCH-29.2 MCHC-32.1 RDW-16.3*
[**2104-2-3**] 02:55AM NEUTS-92.2* BANDS-0 LYMPHS-4.9* MONOS-2.1
EOS-0.7 BASOS-0.1
[**2104-2-3**] 02:55AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL ENVELOP-1+
[**2104-2-3**] 02:55AM PLT COUNT-285
[**2104-2-3**] 02:55AM PT-30.8* PTT-34.0 INR(PT)-3.3*
[**2104-2-3**] 02:55AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2104-2-3**] 02:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
.
MRI T-spine
IMPRESSION: Findings consistent with diffuse metastatic disease
throughout the included spine with near total involvement of the
T2 vertebral body with severe compression deformity and
retropulsion of fragments causing severe central canal narrowing
at this level. There is a large soft tissue mass extending to
the right of the T2 vertebral body with extension into the
prevertebral space, to the right neural foramen, and into the
epidural space.
.
CT C-Spine:
IMPRESSION: Visualization of C1 through C7. No evidence of
fracture or malalignment. Numerous lytic lesions throughout the
cervical vertebral bodies consistent with history of metastatic
disease.
.
CT T-Spine:
IMPRESSION:
1. Multilevel metastatic disease with many compression
deformities most severe at T2,-T9, and T11 through L1 with
paraspinal mass at T2 which appears to infiltrate the spinal
canal and as demonstrated on recent MR [**First Name (Titles) **] [**Last Name (Titles) 68405**] the cord at
this level. Multilevel degenerative disease as noted above.
.
CT L-Spine:
1. Diffuse metastatic involvement of the lumbar spine with
multilevel compression deformities. Multilevel degenerative
change with mild compression of the thecal sac and moderate
neural foraminal stenosis at multiple levels as noted above.
2. Rounded calcific density in right upper quadrant likely
representing a gallstone within the neck of the gallbladder.
Brief Hospital Course:
A/P: Mr. [**Known lastname **] is a 55 yo M w/ Multiple Myeloma s/p C5
Decadron [**Date range (1) 29272**], on daily Thalidomide p/w decreased
sensation in the chest/abdomen; found to have compression fx and
cord compression at T2
.
# Multiple Myeloma: On admission, he was found to have new T2
compression fx and spinal cord compression by tumor. His
deficit was only sensory in nature and he had full strength in
his lower extremities. His pain was controlled with MS Contin
and Morphine for breakthrough. Thalidomide was held. He was
continued on Bactrim for PCP [**Name Initial (PRE) 1102**]. He was initiated on
high dose decadron (10mg IV q6) and daily XRT from T1-T5. He
had received two radiation treatments, and on HD #3 in AM, was
noted by house officer to have decreased strength in his lower
extremities about 8am (from 5/5 strength to [**4-22**]). Stat MRI was
ordered. Over the next 3 hours, the patient's strength in his
lower extremities decreased to [**2-22**]. He was taken emergently
from MRI scanner to OR for pathologic compression fracture T2
with spinal cord compression and spinal cord injury with lower
extremity paralysis. The patient had a cardiac arrest while
prone on the table. The patient was then taken to the surgical
intensive care unit in a guarded status. Discussions with the
family ensued. The following day he was stabilized and returned
for completion of his surgical procedure C5-T4 fusion, posterior
decompression of C6-C7 to T3-T4 from the previous day. After
surgery, Mr. [**Known lastname **] did not wake up very well possibly
secondary to hypoxic ischemic encephalopathy and myoclonus.
When poor prognosis for recovery determined based on EEG and
Neurology input, a meeting with the family was scheduled to
determine the course of Mr. [**Known lastname 34727**] care. On [**2104-2-16**],
Mr. [**Known lastname **] passed away hours after he was taken off of
ventilation.
# H/O DVT - Diagnosed in [**2103-11-18**], he was supratherapeutic
on admission, thus his coumadin was held.
.
#PPX - bowel regimen, on coumadin, PPI
.
#FEN - regular diet, IVFs x 1L, follow lytes
.
#CODE - Full
Medications on Admission:
1) Thalidamide 200mg QHS
2) Coumadin 2mg QD
3) Vicodin 2 tabs Q3-4H:PRN
4) MS Contin 45mg QAM, 30mg QPM
5) Dexamethasone 40mg 4 days on, 4 days off
6) Bactrim 1 tab 3x/wk
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased, hypoxic ischemic encephalopathy and myoclonus
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2104-3-5**]
|
[
"348.1",
"412",
"344.1",
"453.40",
"203.00",
"733.13",
"414.01",
"336.3",
"333.2",
"997.1",
"997.01",
"410.01",
"518.5",
"286.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.53",
"88.72",
"96.6",
"99.79",
"81.63",
"99.04",
"99.07",
"99.62",
"92.29",
"81.05",
"38.93",
"03.09",
"03.4",
"89.64",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9666, 9675
|
7273, 9416
|
310, 381
|
9774, 9784
|
4491, 7250
|
9837, 9871
|
3696, 3825
|
9637, 9643
|
9696, 9753
|
9442, 9614
|
9808, 9814
|
3840, 4472
|
251, 272
|
409, 2061
|
2083, 3440
|
3456, 3680
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,072
| 129,718
|
14991
|
Discharge summary
|
report
|
Admission Date: [**2194-1-20**] Discharge Date: [**2194-1-26**]
Date of Birth: [**2146-10-9**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
transient R sided weakness
Major Surgical or Invasive Procedure:
PICC line insertion [**2194-1-24**]
PICC line removed [**2194-1-26**]
History of Present Illness:
47 yo RHW s/p re-resection of large
tuberculum sellae meningioma [**1-16**], with silent L basal ganglia
infarct noted on post-op MRI, and now with 2 hr episode of R
weakness and speech difficulties yesterday.
The patient was initially diagnosed with meningioma [**2183**] when
she
presented with L vision changes. She underwent a resection in
[**2183**], then a repeat [**2194-1-16**] for enlargement. Neuro-optho evals
pre-op did not show any new visual problems. Surgery was
uncomplicated, but post-op MRI did not L basal ganglia infarct
not seen on prior MRI in [**Month (only) 1096**]. She denies ever having any
symptoms of right sided weakness or numbness during the past
several weeks, or having any problems post-op. She was
discharged
on Keppra 500 mg for prophylaxis and a dex taper. She went home
and was staying with her mother while she recovered.
Yesterday around 5pm, the patient was sitting watching TV when
she tried to stand and realized she was weak on the right side.
Her mother saw what happened, and began asking her questions.
The
patient could reply only "yes" "no" or "okay." She was also
repeatedly saying "hello mama" in a highpitched, child-like
voice. Her words were slurred. She was able to follow some
commands, and her mother fed her dinner, she chewed and
swallowed
without difficulty. No lip smacking, automatisms, tongue biting,
incontinence.
After about 2 hours, she was suddenly able to get up and walk.
She had a completely normal gait and no residual weakness at
this
time. The patient went to sleep, and the patient's mother
checked
on her with a flashlight every few hours- she would reply that
she was awake and she was OK. This morning, the patient was 100%
at her baseline.
During this episode, the patient's mother did call neurosurgery
on-call, who insisted she call 911 immediately, but the patient
had eaten dinner then went to sleep, so she waited until this
morning to drive her in.
The patient never had a seizure before, or any episode like
this.
In the ED, neurosurgery saw the patient and recommended
increasing Keppra to 1000 mg [**Hospital1 **] and admitting to neuro due to
neuroimaging findings.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain
or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria.
Past Medical History:
HTN x 7 yrs
duodenal ulcer
large tuberculum sellae meningioma resected [**2194-1-16**] with
evidence of silent left frontal and basal ganglia infarcts on
post-op MRI [**2194-1-17**]
Social History:
lives alone except since surgery staying with mother, works as
editor. No tobacco, etoh or illicits.
Family History:
MGM rectal cancer, MGF GI cancer, DM
Physical Exam:
Admission physical examination:
Vitals: T: 97.4 P: 64 R: 16 BP:124/71 SaO2:100/RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recalled [**1-3**] at
5 minutes (could not guess the 3rd even with multiple choice).
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages- L optic
disc pallor. No red desaturation. Visual acuity 20/20
bilaterally.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
intact graphesthesia.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
.
.
ICU transfer physical examination [**2194-1-22**]:
A+Ox3 but mild phasia with paraphasic errors and some
perseveration. Some left/right confusion. Mild RUE weakness
effort dependent with shoulder abd 4+/5 and finger Ext 4+/5. No
sensory or coordination abnormalities. Extensor plantar on
right.
.
.
Discharge examination:
A+Ox3 but mild aphasia with poor naming (only 6 animals and 3
words beginning with F) and difficulty with the finer details in
conversation. Full power all 4 limbs and mild right-sided
weaknes appears to have resolved. No sensory or coordination
abnormalities.
Pertinent Results:
Laboratory investigations:
[**2194-1-20**] 11:30AM BLOOD WBC-12.5* RBC-4.13* Hgb-12.4 Hct-34.2*
MCV-83 MCH-29.9 MCHC-36.2* RDW-13.9 Plt Ct-259
[**2194-1-20**] 11:30AM BLOOD Neuts-79.4* Lymphs-16.2* Monos-3.8
Eos-0.4 Baso-0.2
[**2194-1-20**] 11:30AM BLOOD PT-12.0 PTT-20.8* INR(PT)-1.1
[**2194-1-20**] 11:30AM BLOOD Glucose-168* UreaN-17 Creat-0.7 Na-140
K-3.7 Cl-102 HCO3-25 AnGap-17
.
Stroke risk factors:
[**2194-1-20**] 11:30AM BLOOD Cholest-192
[**2194-1-20**] 11:30AM BLOOD Triglyc-125 HDL-58 CHOL/HD-3.3
LDLcalc-109
[**2194-1-20**] 11:30AM BLOOD %HbA1c-5.3 eAG-105
.
Other pertinent labs:
[**2194-1-23**] 02:00AM BLOOD Osmolal-289
[**2194-1-24**] 07:40AM BLOOD CRP-1.4
[**2194-1-25**] 04:19AM BLOOD Cortsol-0.5*
[**2194-1-26**] 09:35AM BLOOD FSH-12 LH-3.9 Prolact-11 TSH-4.0
[**2194-1-26**] 09:35AM BLOOD Free T4-1.0
.
Discharge labs:
[**2194-1-26**] 09:35AM BLOOD WBC-12.0* RBC-3.69* Hgb-11.0* Hct-30.6*
MCV-83 MCH-29.7 MCHC-35.9* RDW-13.9 Plt Ct-290
[**2194-1-26**] 07:58AM BLOOD PT-23.2* PTT-31.3 INR(PT)-2.2*
[**2194-1-26**] 09:35AM BLOOD Glucose-122* UreaN-17 Creat-0.6 Na-138
K-3.8 Cl-101 HCO3-28 AnGap-13
[**2194-1-26**] 09:35AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8
.
.
Urine:
[**2194-1-24**] 10:40AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.017
[**2194-1-24**] 10:40AM URINE Blood-TR Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2194-1-24**] 10:40AM URINE RBC-3* WBC-40* Bacteri-FEW Yeast-NONE
Epi-<1
[**2194-1-24**] 10:40AM URINE Mucous-RARE
[**2194-1-23**] 02:21AM URINE Hours-RANDOM Creat-30 Na-104 K-7 Cl-91
[**2194-1-23**] 02:21AM URINE Osmolal-340
.
.
Microbiology:
[**2194-1-24**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2194-1-24**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2194-1-24**] 10:40 am URINE Source: Catheter.
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
PROTEUS SPECIES. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
.
Radiology:
CT HEAD W/O CONTRAST Study Date of [**2194-1-20**] 10:50 AM
FINDINGS:
Postoperative changes of the left frontal craniotomy are again
noted. There
is persistent pneumocephalus, decreased in comparison to prior
study from
[**2194-1-16**]. Additionally, there is now a small amount of
mixed
attenuation fluid in the left frontal region, consistent with
post-surgical
changes and non-hemorrhagic. Hyperdense material is again noted
in the region
of the sella (2:8), either representative of residual blood or
volume
averaging. There is no shift of normally midline structures. A
hypodensity
is again noted in the left globus pallidus (2:13), consistent
with previously
known subacute infarction. Additionally, a hypodensity is noted
in the left
inferior frontal lobe (2:10), likely representative of either
another evolving
infarction or post-surgical edema and partly seen on the axial
FLAIR sequence
of prior MR [**Name13 (STitle) 430**] study.
The visualized mastoid air cells and paranasal sinuses are
clear.
IMPRESSION:
1. Post-surgical changes again noted with left frontal
craniotomy and
expected postoperative changes with a small amount of
non-hemorrhagic fluid
and resolving pneumocephalus.
2. Subacute left globus pallidus infarct is again noted.
Additionally, again
noted is the hypodensity in the left frontal lobe near the
midline (2:10)
suggestive of either another evolving ischemic change or edema,
partly seen
earlier. Further characterization may be obtained with an MRI
and MRA if not
CI.
.
MRI BRAIN AND MRA HEAD/NECK W&W/O CONTRAST Study Date of
[**2194-1-20**] 3:46 PM
FINDINGS:
MRI HEAD:
The patient is status post left frontal craniotomy for resection
of recurrent
tuberculum sellae meningioma. There is expected resolution of
postoperative
pneumocephalus with persistent, yet less prominent left frontal
subdural fluid
collection (reduction from previous 9 to current 6 mm in maximal
thickness).
There is an unchanged 4-mm enhancing soft tissue focus in the
planum
sphenoidale which may be postoperative in nature or represent
residual
meningioma.
There is evolution of scattered infarcts involving the left
basal ganglia
(globus pallidus), the inferior and left lateral frontal, and
anterior left
temporal lobe. None of these infarcted areas demonstrates
interval mass
effect or hemorrhagic transformation. No new areas of infarct
are identified.
The cerebral sulci, ventricles, and extra-axial CSF containing
spaces are
otherwise normal in appearance, and there is no evidence of
hydrocephalus.
Again seen is fluid retention within the right mastoid air
cells. The
paranasal sinuses are clear.
MRA HEAD: There is a significant short segment stenosis at the
proximal
aspect of the left M1 segment with small caliber of the more
distal portions.
The M2 through M4 segments are patent.
The intracranial internal carotids, vertebrobasilar, and
anterior, right
middle, and posterior cerebral arteries are patent with normal
flow-related
enhancement and branching pattern. There is bilateral fetal
origin of the
posterior cerebral artery. No aneurysms or arteriovenous
malformations are
identified.
MRA NECK: The origins of the common carotid and vertebral
arteries are patent
without significant stenosis. The common, internal, and external
carotid
arteries are normal in appearance. There is no evidence of
hemodynamically
significant stenosis or dissection. The cerebral portions of the
vertebral
arteries likewise demonstrate normal contrast opacification.
IMPRESSION:
1. Status post left frontal craniotomy with interval reduction
of left frontal
subdural fluid collection.
2. Evolution of scattered infarcts involving the left basal
ganglia, inferior
and lateral frontal, and left temporal lobe.
3. High-grade stenosis at the proximal aspect of the left M1
segment with
small caliber of the more distal branches, correlation with CTA
is advised.
4. Unchanged focus of enhancement in the planum sphenoidale
which may be
postoperative in nature or represent a small amount of residual
tumor.
.
CTA HEAD W&W/O C & RECONS Study Date of [**2194-1-21**] 12:44 PM
FINDINGS:
NON-CONTRAST HEAD CT: Post-operative changes adjacent to the
left frontal
craniotomy are again noted. Pneumocephalus has decreased. There
is fluid in
the left frontal region consistent with post-surgical changes.
Previously
seen hyperdense material in the region of the sella is less
apparent and
likely represents evolving blood products. The hypodensities are
again noted
in the left globus pallidus, left inferior and lateral frontal
lobe, and left
temporal lobe. There are no new hypodensities. There are no new
areas of
edema or hemorrhage. There is no shift of normally midline
structures. The
ventricles and sulci are normal in size and configuration.
CTA OF THE HEAD: There is high-grade stenosis in the proximal
left M1
segment. The vessels distal to the stenosis are still opacified
however the
overall vessel caliber in the left MCA distribution are
decreased. The
visualized portions of the carotid and vertebral arteries are
patent with no
evidence of stenosis. The posterior circulation vessels are
normal and
patent. The posterior cerebral and anterior cerebral arteries
are patent
without evidence of stenosis.
IMPRESSION:
1. Previously seen hypodensities in the left basal ganglia,
inferior and
lateral left frontal lobe, and left temporal lobe are unchanged.
No new
hypodensities.
2. High-grade stenosis at the proximal aspect of the left M1
segment is again
seen with overall decreased caliber of more distal vessels of
the left middle
cerebral artery.
3. Status post left frontal craniotomy with some residual left
subdural fluid
collection, unchanged.
.
CT HEAD W/O CONTRAST Study Date of [**2194-1-22**] 6:17 AM
FINDINGS: Post-left frontal craniotomy changes are again seen
with a small
subdural collection and trace pneumocephalus as well as
overlying skin
staples. Allowing for streak artifact in the left
temporoparietal region,
there is no new hemorrhage. Previously seen hypodensity within
the left
globus pallidus is also unchanged. Ventricles and sulci are
similar in
caliber as before. Suprasellar and basilar cisterns are patent.
Patient is status post left frontal craniotomy. There is trace
polypoid
mucosal disease involving a single right posterior ethmoidal air
cell.
Remainder of paranasal sinuses and mastoid air cells are well
aerated. Globes
and orbits are within normal limits.
IMPRESSION: No short interval change since [**2194-1-20**].
.
PORTABLE HEAD CT W/O CONTRAST Study Date of [**2194-1-23**] 7:59 AM
FINDINGS:
Current examination is highly limited by streak artifacts from
metallic device
about the calvarium. Allowing for such, there is no significant
interval
change in the caliber of the lateral ventricles as compared to
most recent
preceding exam to indicate increased mass effect. The
suprasellar and basilar
cisterns remain patent. A sliver of left frontal subdural
collection is again
seen but not well assessed. Patient is status post left frontal
craniotomy
with trace operative pneumocephalus and overlying anterior scalp
surgical
staples. Parenchymal assessment is highly limited.
IMPRESSION:
Likely no increased mass effect since most recent preceding
exam.
.
CHEST (PORTABLE AP) Study Date of [**2194-1-24**] 2:01 PM
Cardiac size is top normal. There are low lung volumes. The
lungs are clear.
There is no pneumothorax or pleural effusion.
IMPRESSION: No evidence of pneumonia.
.
.
Cardiology:
Portable TTE (Congenital, complete) Done [**2194-1-22**] at 12:16:07
PM FINAL
Conclusions
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
0-5 mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The number of aortic valve
leaflets cannot be determined. The mitral valve leaflets are
structurally normal. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: No cardiac source of embolism identified. Preserved
global and regional biventricular systolic function. No
significant valvular abnormality seen.
.
.
Neurophysiology:
EEG Study Date of [**2194-1-21**]
FINDINGS:
ABNORMALITY #1: There are intermittent few second runs of
blunted sharp
waves in the left temporal area phase reversing at F7/T3. In
addition,
there are brief runs of independent left frontal sharp waves
lasting one
second or less with narrower base and lower amplitude as
compared to the
left temporal sharp discharges. The sharp waves are less
predominant in
sleep.
ABNORMALITY #2: The background activity is asymmetric showing an
[**7-10**] Hz rhythm on the right and a mixed theta and delta activity
on the
left reaching maximum [**5-8**] Hz posteriorly. Left-sided slowing is
more
prominently present over the temporal region.
BACKGROUND: The same as abnormality #2 and #1. There are no
epileptic
discharges or electrographic seizures. HYPERVENTILATION:
Hyperventilation could not be performed due to history of
intracranial
mass.
INTERMITTENT PHOTIC STIMULATION: Stepped photic stimulation from
[**12-30**]
flashes per second (fps) produces no activation of the record.
SLEEP:
The patient progresses to drowsiness and stage II sleep. During
sleep
the left sided sharp waves are suppressed.
CARDIAC MONITOR: A single EKG channel shows a generally regular
rhythm
with an average rate of 62 bpm.
IMPRESSION: This is an abnormal awake and sleep EEG, because of
background asymmetry with slowing over the left hemisphere more
prominently the left temporal region. This finding is indicative
of
diffuse cortical and subcortical dysfunction over the left
hemisphere
particularly the left temporal area. In addition, there are
intermittent
independent left temporal and left frontal epileptic discharges
indicative of epileptogenic foci in these regions. No
electrographic
seizures are present.
.
EEG Study Date of [**2194-1-22**]
FINDINGS:
ROUTINE SAMPLING: The background activity is asymmetric showing
a 9-9.5
Hz rhythm on the right and a slower [**4-6**] Hz rhythm over the left
hemisphere. There is continuous polymorphic delta slowing over
the left
frontotemporal regions. In addition, there are intermittent
broad-based
blunted sharp waves over the anterior left hemisphere phase
reversing at
F3/C3 and F7/T3. No electrographic seizures are present in the
recording.
SPIKE DETECTION PROGRAMS: There are 224 automated spike
detections
predominantly for electrode and movement artifact. There are no
epileptiform discharges in the automated file.
SEIZURE DETECTION PROGRAMS: There are no automated seizure
detections.
PUSHBUTTON ACTIVATIONS: There are no pushbutton activations.
SLEEP: The patient progresses to drowsiness and stage II sleep
with
well-formed sleep potentials over the right hemisphere.
CARDIAC MONITOR: Shows a generally regular rhythm with an
average rate
of 60-70 bpm.
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of asymmetric background with significant slowing over the left
hemisphere. This finding is indicative of diffuse left
hemispheric
cortical and subcortical dysfunction. In addition, there are
frequent
low voltage wide-based epileptiform discharges over the left
frontotemporal region as well as polymorphic slowing in the same
region.
These findings are indicative of a potential epileptogenic focus
in left
frontotemporal region with underlying structural abnormality. No
electrographic seizures are present in the recording. There are
no
significant changes compared to prior day's study.
.
EEG Study Date of [**2194-1-23**]
FINDINGS:
ROUTINE SAMPLING: The background activity is asymmetric showing
to 9 Hz
rhythm on the right and an attenuated slower [**5-8**] Hz rhythm over
the left
hemisphere. There is continuous left frontal temporal
polymorphic delta
slowing. In addition, there are intermittent blunted wide-based
sharp
discharges at T3 and F3. No electrographic seizures are present.
SPIKE DETECTION PROGRAMS: There are no automated spike
detections
predominantly for electrode and movement artifact. There are no
epileptiform discharges.
SEIZURE DETECTION PROGRAMS: There is one automated seizure
detection
for fast artifact at Cz electrode. There are no electrographic
seizures.
PUSHBUTTON ACTIVATIONS: There are no pushbutton activations.
SLEEP: The patient progresses from wakefulness to stage II, then
slow
wave sleep at appropriate times with sleep morphologies better
developed
over the right hemisphere.
CARDIAC MONITOR: A single EKG channel shows a generally regular
rhythm
with an average rate of 54 bpm.
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of asymmetric background with slowing over the left side
indicative of
cortical and subcortical dysfunction in these regions. In
addition,
there are low amplitude blunted epileptic discharges over the
left
fronotemporal regions with polymorphic delta slowing of
background
consistent with potential epileptogenic foci with underlying
subcortical
dysfunction. Compared to the prior day's recording, there are no
significant changes.
.
.
Neurology:
Transcranial Doppler Ultrasound Report [**2194-1-23**]
Impression: Abnormal TCD evaluation. In the distal left MCA,
there were blunted waveforms with lower velocities suggesting
that there is significant stenosis in the proximal left MCA.
Higher velocities in the left ACA and left P2 segment of the PCA
suggested that there is hemodynamically significant diversion of
flow from the left MCA to the left ACA and left P2 segment of
the
PCA. Clinical correlation is needed.
.
Transcranial Doppler Ultrasound Report [**2194-1-23**]
TCD Results: Transcranial doppler son[**Name (NI) 867**] was performed with
insonation of the left middle cerebral artery at a depth of 67mm
and at 56mm. At the start of the exam, the systolic BP was 138.
The patient was receiving phenylephrine at 1mcg/min for two
minutes. Then the phenylephrine dose was decreased to 0.5
mcg/min
for ten minutes. The SBP decreased to 128. For the next ten
minutes, phenylephrine drip was turned off. At the end of this
period, the SBP was 119. The total length of recording time was
22 minutes.
Results show normal velocities of the proximal left MCA. No
abnormal waveforms were seen. Five microembolic signals were
detected by manual inspection. Four of the microembolic signals
were seen at a depth of 67mm and one microembolic signal was
seen
at a depth of 56mm.
Impression: Abnormal TCD evaluation. Five microembolic signals
were detected. Clinical correlation is needed.
.
Transcranial Doppler Ultrasound Report [**2194-1-24**]
TCD Results: Transcranial doppler son[**Name (NI) 867**] was performed with
insonation of the left middle cerebral artery for 32 minutes at
a
depth of 63mm.
Results did not show any microembolic signals. There were normal
velocities of the proximal left MCA except for above normal
velocities at depth of 51mm. No abnormal waveforms were seen.
Impression: Abnormal TCD evaluation. Above normal velocities of
the left MCA at a distance of 51mm suggesting that there may be
stenosis at this distance. No microembolic signals were seen,
representing an improvement from the TCD study on [**2194-1-23**].
Clinical correlation is needed.
Brief Hospital Course:
47 yo RHW with HTN and recently s/p re-resection of large
tuberculum sellae meningioma [**1-16**], with silent L basal ganglia
infarct noted on post-op MRI, and presented on [**2194-1-20**] with a
2 hr episode of R weakness and speech difficulties [**1-19**] that
resolved after 2 hours and was taken to hospital the following
morning.
Initial neurological examination was unremarkable.
MRI showed scattered recent left frontal craniotomy with
interval reduction of left frontal subdural fluid collection,
evolution of scattered infarcts involving the left basal
ganglia, inferior and lateral frontal, and left temporal lobes
with an increase in the size of the left frontal lobe and most
significantly a high-grade stenosis at the proximal aspect of
the left M1 segment with small caliber of the more distal
branches on MRA. This confirmed on CTA which again demonstrated
a very high grade stenosis. She was therefore started on IV
heparin and started on concomitant warfarin.
Stroke risk factors were assessed with HbA1c 5.3%, FLP Chol 192
TGCs 125 HDL 58, LDL 109.
EEG LTM was performed which was asymmetric and demonstrated
right [**7-10**] Hz and left sided theta and delta slowing.
Patient developed sudden onset mild right arm weakness at 0600
on [**2194-1-22**] with persistent aphasia which was predominantly
expressive with some paraphasic errors and initial difficulty
following commands. Concern was for hypoperfusion given her very
significant left MCA stenosis and stat CT-head showed no new
infarct and EEG bedside monitoring showed pronounced left
hemisphere slowing but no seizures which could be compatible
with hypoperfusion. Echo with bubble on [**1-22**] showed no cardiac
source of embolism and EF 60-65% with preserved global and
regional biventricular systolic function. She was initially
trialled on the floor and latterly stepdown unit with aggressive
IVF resuscitation but her SBP was only maintained in 120s and
deemed not sufficient to maintain perfusion, with persistence
albeit with some improvement of her symptoms she was transferred
to the ICU on [**2194-1-22**] for initiation of pressors. Her EEG was
stopped when in the ICU as there had been no seizure activity
seen.
In the ICU she was continued on pressors and had a PICC line
inserted, which kept her SBP in the 130-140's. We then weaned
her off the pressors, and her neurological exam remained stable.
It was determined that she also had a UTI, so she was started
on ceftriaxone and treated for 3 days. Patient was having
microemboli felt due to her likely MCA dissection noted on TCD
on [**2194-1-23**] but this had settled by [**2194-1-24**]. She was started
on fludrocortisone to help maintain her BPs with an oral
medication and lisinopril was stopped and given patient
stability, she was able to be transferred back to the floor on
[**2194-1-24**].
On the floor, to further assess her hypotension, she had a
morning cortisol taken which was low at 0.5. Endocrinology felt
this was not concerning and was likely due to her concomitant
dexamethasone administration and did not require further
evaluation. Pituitary hormone panel with FSH, LH, TSH and
prolactin were all entirely normal. While on the floor, Keppra
was tapered and stopped and dexamethasone taper was completed
and stopped prior to discharge.
Therefore, her left MCA high-grade stenosis was felt likely
secondary to a dissection at the time of surgery which would
also account for her prior infarcts in this region. She was
started on fludrocortisone as above due to relative hypotension
to aid in left MCA perfusion.
Patient was assessed by PT/OT and deemed safe for discharge home
and warfarin was therapeutic with INR 2.2. Due to continued mild
aphasia persistent at the time of discharge and only obvious on
probing (poor ability to name animals as described) she was
discharged home on [**2194-1-26**] with outpatient speech therapy and
neurology stroke follow-up in addition to her planned
neuro-oncology follow-up. PICC line was removed on discharge.
Given her persistent language deficits, the need for formal
neuropsychological evaluation regarding aphasia will be
addressed at time of follow-up and possible functional language
necessary for return to work given her job as an editor. Patient
was therefore discharged on warfarin which will be managed by
her PCP and had instructions to have her INR drawn on [**2194-1-27**].
Medications on Admission:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain or fever > 101.4.
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily) for 1 months.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. dexamethasone 2 mg Tablet Sig: taper Tablet PO taper for 1
weeks: 4mg PO Q8h on [**1-18**], then 3mg PO Q8h x2days, 2mg PO Q8h
x2days,1mg PO Q8h x2 days then d/c.
Disp:*qs Tablet(s)* Refills:*0*
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Other home medications: Flonase PRN and multivitamin daily
Discharge Medications:
1. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
2. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed for as needed for possible dose changes: As needed for
possible dose changes.Do not take unless directed.
Disp:*20 Tablet(s)* Refills:*0*
3. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Outpatient Lab Work
INR to be taken on [**2194-1-27**] and faxed to patient's PCP DR [**Last Name (STitle) 43880**]
at [**Telephone/Fax (1) 43881**].
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Flonase 50 mcg/actuation Spray, Suspension Sig: One (1) spray
Nasal once a day as needed for allergy symptoms.
7. multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Outpatient Speech/Swallowing Therapy
Patient requires outpatient speech therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Likely left middle cerebral artery dissection likely traumatic
at the time of surgery with resultant high-grade stenosis and
prior left MCA distribution embolic infarcts
Relative hypotension and started on fludrocortisone to aid in
left MCA perfusion
Secondary diagnosis:
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent but still word-finding
difficulties which are relatively mild
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic:
A+Ox3 but mild aphasia with poor naming (only 6 animals and 3
words beginning with F) and difficulty with the finer details in
conversation. Full power all 4 limbs and mild right-sided
weaknes appears to have resolved. No sensory or coordination
abnormalities.
Discharge Instructions:
It was a pleasure taking care of you during your stay at the
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **].
You presented with transient right sided weakness and
word-finding difficulty. MRI showed strokes on the left side of
your brain which had also been present post-operatively. You
were also noted to have a very tight blood vessel supplying
blood to the left side of the brain. This was felt likely due to
a dissection (tear) of an artery called the left middle cerebral
artery, which we feel likely occurred at the time of your
surgery. As a result, you were started on IV heparin which is a
blood thinner in addition to warfarin to stop blood clots
forming at the site of this dissection and causing further
strokes. The heparin was stopped when the warfarin level was
therapeutic. You were briefly transferred to the ICU and treated
with IV medications to maintain higher blood pressures after a
further episode of word-finding difficulty and this improved and
we were then able to be transfer you back to the floor. You had
a PICC line inserted which was subsequently removed.
In order to improve blood flow to the left side of your brain,
given this narrowing in the blood vessel, we started you on a
medication to increase the blood pressure called
fludrocortisone. The continued need for this medication will be
assessed at the time of follow-up.
We also monitored you on EEG and as there was no evidence of
seizures, we have tapered and now stopped the keppra medication
you were taking. You have now also finished the dexamethasone
taper per neurosurgery.
You have been started on a medication called warfarin (as above)
which is a blood thinner and as a result, the major side-effect
is bleeding. If you have a cut or other area of bleeding, it
will therefore take longer for this to stop. In addition, if you
have a head injury, you are at risk of bleeding and should
always present to the ED for evaluation if this were to happen.
Warfarin requires close monitoring and therefore you should have
your labs taken tomorrow and regularly after this as your PCP
will have to let you know about any need for a dose change.
You also had evidence of a urinary tract infection which was
treated with 3 days of IV antibiotics.
You still have some word-finding difficulties and we have
referred you for out-patient speech therapy. You were seen by PT
and deemed safe for discharge. You have neurology follow-up and
Neuro-oncology follow-up as below. As above, you will need to
have labs taken tomorrow to assess your warfarin level (INR).
Medication changes:
We STARTED warfarin 5mg daily - as above please have your INR
drawn tomorrow
We STARTED fludrocortisone 0.1mg daily
We STOPPED dexamethasone as you have now finished your taper
We STOPPED keppra
We STOPPED lisinopril to allow for higer blood pressures given
your brain artery narrowing
Followup Instructions:
Given that we started you on warfarin you should have your
warfarin level (INR) taken tomorrow and checked by your PCP as
your dose may need to be changed. You should see your PCP as
soon as possible for follow-up.
In addition, we have arranged the following neurology stroke
follow-up:
Department: NEUROLOGY
When: FRIDAY [**2194-3-14**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You also have the following existing Neuro-oncology followup
where you will also be seen by neurosurgery:
Department: NEUROLOGY
When: MONDAY [**2194-2-3**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
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80,041
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303
|
Discharge summary
|
report
|
Admission Date: [**2198-7-16**] Discharge Date: [**2198-7-28**]
Date of Birth: [**2153-5-26**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Leg pain, erythema and swelling secondary to infection of left
femoral-poplital bypass
Major Surgical or Invasive Procedure:
1. Incision and drainage and pulse irrigation of left groin and
left above-knee popliteal site incisions with xxploration of
bypass graft ([**2198-7-16**])
2. Excision of entire left common femoral artery-to-above-knee
popliteal artery bypass graft; Repair of common femoral artery
and above-knee popliteal artery with harvested left arm cephalic
vein ([**2198-7-18**])
3. I and D/washout of left groin with complex wound closure over
2 drains
History of Present Illness:
Ms. [**Known lastname **] is a 45 y/o F who underwent a left fem-AK [**Doctor Last Name **] BPG with
PTFE over one month ago on [**2198-6-11**]. She had been doing well
postoperatively, and was seen in the clinic 6 days prior to
presentation. At this time, she acutely developed
nausea/vomiting, fevers, and progressive redness/swelling/pain
of her left thigh
directly at the surgical incision. She has been unable to keep
down food or liquids. At the time, she denied any ischemic-type
pain in her lower leg, and denied any chest pain or shortness
of breath.
Past Medical History:
PMH: current smoker (1-PPD), cocaine abuse (ceased 6-months
prior), asthma, diabetes type 2
PSH: bilateral lower extremity angiograms ([**2198-5-10**]), L knee
surgery x2, appendectomy, tonsillectomy, L fem-AK [**Doctor Last Name **] [**2198-6-11**]
Social History:
Moving in with her boyfriend. She has one child. She is
unemployed.
Smokes 1.5 ppd
Former cocaine use. (urine tox pos [**2197-11-22**], but pt denied use
for 2 years)
Drinks 5-6 drinks on weekends.
Hx of domestic violence.
Family History:
Mother had an abdominal aortic aneurysm status post repair, MI
in her mid 50s, carotid stenosis, cervical cancer, coronary
artery disease, other vascular lesions which were stented. She
died due to complications of a procedure. The patient's father
died young. The patient has one cousin with cervical cancer. Her
maternal grandmother had an MI in her 60s. Maternal grandfather
with MI, hypertension, and hypercholesteremia.
Physical Exam:
Upon presentation,
Vital Signs: Temp: 101.9 RR: 16 Pulse: 98 BP: 114/62
Neuro/Psych: Oriented x3, Affect Normal.
Neck: No masses, Trachea midline, No right carotid bruit, No
left
carotid bruit.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.
Skin: Abnormal: Cellulitis L thigh.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No hepatosplenomegally, No
hernia, No AAA.
Rectal: Not Examined.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No LLE Edema, No varicosities, abnormal: Tenderness,
erythema of L thigh.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P.
LUE Radial: P.
RLE Femoral: P. Popiteal: P. DP: P. PT: P.
LLE Femoral: P. Popiteal: P. DP: P. PT: P. Other: Graft: palp.
DESCRIPTION OF WOUND: R thigh incision without breakdown, but
tender, erythematous, and swollen especially superiorly. No
evidence of drainage or underlying fluctuance. pulses all
palpable
Pertinent Results:
[**2198-7-16**] 02:30AM BLOOD WBC-7.4 RBC-3.21*# Hgb-9.6* Hct-27.6*
MCV-86 MCH-29.9 MCHC-34.7 RDW-13.6 Plt Ct-161
[**2198-7-19**] 05:54AM BLOOD WBC-5.6 RBC-3.32* Hgb-10.2* Hct-28.7*
MCV-87 MCH-30.7 MCHC-35.5* RDW-14.1 Plt Ct-184
[**2198-7-27**] 05:06AM BLOOD WBC-7.8 RBC-2.98* Hgb-9.0* Hct-26.9*
MCV-90 MCH-30.4 MCHC-33.6 RDW-15.8* Plt Ct-398
[**2198-7-16**] 09:05AM BLOOD PT-13.9* PTT-36.4* INR(PT)-1.2*
[**2198-7-19**] 05:54AM BLOOD PT-13.1 PTT-29.8 INR(PT)-1.1
[**2198-7-16**] 02:30AM BLOOD Glucose-177* UreaN-20 Creat-1.0 Na-135
K-3.7 Cl-99 HCO3-23 AnGap-17
[**2198-7-27**] 05:06AM BLOOD Glucose-72 UreaN-10 Creat-0.6 Na-142
K-3.5 Cl-108 HCO3-27 AnGap-11
[**2198-7-17**] 10:15PM BLOOD CK(CPK)-99
[**2198-7-27**] 05:06AM BLOOD Calcium-8.3* Phos-4.6* Mg-1.9
[**2198-7-16**] 02:30AM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
Blood Culture, Routine (Final [**2198-7-22**]): NO GROWTH.
Brief Hospital Course:
The patient was admitted to the surgery service for evaluation
and treatment of her lower extremity bypass graft infection.
Neuro: The patient received IV pain medications with good effect
and adequate pain control. When tolerating oral intake, the
patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout this hospitalization.
GI/GU/FEN:
Post operatively, the patient was made NPO with IVF.
The patient's diet was advanced when appropriate, which was
tolerated well.
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Final blood cultures
were negative.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly and kept
within normal range.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required during this stay.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
Albuterol INH PRN
Fexofenadine 60mg 1 tablet [**Hospital1 **]
Fluticasone 50mcg two puffs daily
Percocet PRN
Glargine 35 units
Humalog SS
Lisinopril 40mg qd
Crestor 40mg qd
Metformin 1000mg [**Hospital1 **]
Reglan 5QACHS
Protonix 40mg qd
Tizanidine 4PRN
ASA 81mg qd
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
2. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 4 weeks: Take 1 tablet every 4 hours for a
total 4 week course. First day was [**7-27**].
10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day)
12. Metformin 1000mg [**Hospital1 **]
13. Humalog SS
14. Glargin 35 units (at discretion of patient while monitoring
blood sugars, to be followed-up by PCP)
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Infected left femoral-popliteal bypass graft
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent
Discharge Instructions:
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs with
an ace-wrap or compression stocking on your left leg.
?????? 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
-Monitor drainage from both JP drains. If either drains less
than 20cc in one day, please call Dr. [**Last Name (STitle) 2866**] at his clinic (see
number below). Your visiting nurse will teach you how to monitor
and care for your drains.
?????? 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
?????? Call and schedule an appointment to be seen in [**4-6**] weeks for
post procedure check and ultrasound
What to report to office:
?????? 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
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] on [**8-7**]: call his clinic at
([**Telephone/Fax (1) 2867**] to schedule an appointment.
Please follow-up with Dr. [**Last Name (STitle) 2866**] in two weeks; call his clinic
at ([**Telephone/Fax (1) 2868**] to schedule an appointment.
Completed by:[**2198-7-31**]
|
[
"401.9",
"250.00",
"E878.2",
"V58.31",
"682.6",
"041.11",
"285.9",
"493.90",
"443.9",
"996.62",
"V58.67",
"V15.82",
"790.7",
"790.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"86.59",
"39.49",
"39.56",
"86.28"
] |
icd9pcs
|
[
[
[]
]
] |
7724, 7782
|
4396, 6106
|
390, 836
|
7871, 7871
|
3418, 4373
|
9723, 10045
|
1962, 2388
|
6423, 7701
|
7803, 7850
|
6132, 6400
|
8021, 9126
|
9152, 9700
|
2403, 3399
|
264, 352
|
864, 1430
|
7886, 7997
|
1452, 1705
|
1721, 1946
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,105
| 137,587
|
45954
|
Discharge summary
|
report
|
Admission Date: [**2196-6-21**] Discharge Date: [**2196-6-24**]
Date of Birth: [**2132-11-18**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Premarin / Morphine / Crestor / Atorvastatin / Codeine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Nausea/Vomiting x3 days w/ 1 week of diarrhea.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HPI: Briefly, 63 yo F w/ CAD, h/o stroke with subsequent
hemiparesis, HTN, hyperlipidemia, DJD, DM type 2, CKD (baseline
Cr 1.2-1.4) and cortical blindness who came to ED w/ 3 days of
N/V. She had troponin leak. The N/V was thought ot be angina
equivalent. Cards were consulted and she was started on heparin
drip. However subsequently Cards recommended medical mgmt. She
also had AG of 15 with BG of 370. She was thought to be in DKA
and was started on insulin drip. The BG came back to normal and
the gap closed. The insulin drip was stopped and pt was started
on RISS. The pt conitnues to be nauseous and is not tolerating
POs. Nausea not so well controlled with meds.
.
At this time, pt c/o nausea. says she vomitted thrice today. not
taking in any solids. unable to keep liquids down. denies CP,
SOB, dizziness, palpitations. denies pain in abd. last BM 2 days
back and was loose.
Past Medical History:
HTN
DMII
Hyperlipidemia
h/o CVA w/ residual L sided hemiparesis
CAD- w/ stent '[**86**] and '[**89**]
Asthma
Rheumatic fever
Femoral Bypass - [**1-15**] complication of most recent cath
Asthma - last hospitalization mult years ago, uses rescue
albuterol inhaler 1-2 times per week
migraine headaches - tx with vicodin or tylenol
Breast Cancer - node negative (surgery only, no chemo, no rad)
Degenerative Disk Disease
Osteoarthritis
Osteoporosis
GERD
Social History:
Social history: Lives alone at home [**Location (un) 6409**]; wheelchair
bound s/p CVA; no h/o ETOH or tobacco use. Has had at home
health aide and visiting nurse services.
Family History:
NC
Physical Exam:
PE on discharge
97.1 94/62 71 20 100/RA
Gen: comfortable.
HEENT: anicteric, mmm, NCAT
chest: CTABL
heart: RRR,
abd: soft, NT, no HSM, BS+
extr: trace edema L>R
neuro: L-sided weakness, with reduced sensation in stocking and
glove distribution L>R. Blind. Alert and interactive.
Pertinent Results:
[**2196-6-21**] 06:18PM WBC-11.9* RBC-2.63* HGB-8.0* HCT-22.2* MCV-84
MCH-30.4 MCHC-36.0* RDW-15.0
[**2196-6-21**] 06:18PM CALCIUM-8.9 PHOSPHATE-2.5* MAGNESIUM-2.8*
[**2196-6-21**] 06:18PM CK-MB-5 cTropnT-0.27*
[**2196-6-21**] 06:18PM CK(CPK)-166*
[**2196-6-21**] 06:18PM GLUCOSE-232* UREA N-48* CREAT-1.3* SODIUM-143
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-28 ANION GAP-12
[**2196-6-21**] 11:40AM URINE RBC-[**2-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2196-6-21**] 11:40AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2196-6-21**] 11:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2196-6-21**] 11:40AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
CXR: IMPRESSION:
Cardiomegaly, interstitial pulmonary edema, small bilateral
pleural effusions.
CT: Abd/Pelvis: IMPRESSION:
1. No acute pathology is identified to explain the patient's
symptom. No
evidence of bowel ischemia or arterial dissection is identified.
2. Anasarca is present and there is a small amount of free
fluid within the
pelvis.
3. Cholelithiasis with no evidence of cholecystitis.
Echo:
Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with inferior hypokinesis. There is turbulent color
flow around the left main coronary artery coursing anteriorly.
This may reflect hyperemic coronary flow, but a coronary artery
A-V fistula cannot be excluded. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Brief Hospital Course:
HPI: Briefly, 63 yo F w/ CAD, h/o stroke with subsequent
hemiparesis, HTN, hyperlipidemia, DJD, DM type 2, CKD (baseline
Cr 1.2-1.4) and cortical blindness who came to ED w/ 3 days of
N/V. She had troponin leak. The N/V was thought ot be angina
equivalent. Cards were consulted and she was started on heparin
drip. However subsequently Cards recommended medical mgmt. She
also had AG of 15 with BG of 370. She was thought to be in DKA
and was started on insulin drip. The BG came back to normal and
the gap closed. The insulin drip was stopped and pt was started
on RISS. The pt conitnues to be nauseous and is not tolerating
POs. Nausea not so well controlled with meds.
.
On the floor, the patient was transitioned to lantus 10 units
qhs and restarted on metformin. Her hematocrit remained at her
pre-admission baseline and near post-transfusion levels. CT of
the abdomen revealed no evidence of any acute intra-abdominal
process. USD of the lower extremity was negative for any DVT.
Patient was restarted on at home meds on discharge. Her
hospital course was otherwise uncomplicated.
Medications on Admission:
ALBUTEROL prn
ROSIGLITAZONE 4 mg daily
BECLOMETHASONE (NASAL) 2 sprays daily
COLACE 100 mg [**Hospital1 **] prn
CARVEDILOL 6.25 mg [**Hospital1 **]
FUROSEMIDE 40 mg daily (recently up to 80 mg daily)
TERAZOSIN 5 mg qhs
METFORMIN 500 mg qhs
METFORMIN 850 mg qam
GABAPENTIN 300 mg daily
NIFEDIPINE 30 mg daily
NITROGLYCERIN prn
OMEPRAZOLE 20 mg [**Hospital1 **]
PLAVIX 75MG daily
TRIAMCINOLONE 2 puffs qid
COLESEVELAM 1300 mg [**Hospital1 **]
EZETEMIBE 10 mg daily
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
2. Metformin 850 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*30 Capsule(s)* Refills:*0*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 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. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous at bedtime.
Disp:*300 units* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1. Nausea and Vomiting NOS.
2. Hyperglycemia
3. Acute Renal Failure - Dehydration.
4. Left Heart Failure.
5. Non-ST Elevation Myocardial Infarction.
Secondary:
1. Bilateral parietal-occipital CVA.
2. Cortical Blindness - left hemiparesis
3. 2-Vessel CAD s/p IMI.
4. PTCA-Stent RCA and Lcx
5. Diabetes Mellitus Type II.
6. Hyperlipidemia
7. Asthma
8. Rheumatic fever
9. Post-Cath Mycotic Femoral Pseudoaneurysm s/p Bypass.
10. Migraine headaches
11. Breast Cancer - node negative (surgery only, no chemo, no
rad)
12. Degenerative Disk Disease
13. Osteoarthritis
14. Osteoporosis
15. Esophageal candidiasis.
16. Esophagitis/Gastritis
17. Chronic Kidney Disease Stage II/III
Discharge Condition:
Stable.
Discharge Instructions:
You have been admitted to the hospital for treatment of nausea,
vomiting, hyperglycemia (high blood sugar) and for blood loss
into your stomach from an unclear source. Your blood sugar was
treated with insulin and oral medications. Please take all
medications as directed when you return home. Your insulin dose
has been adjusted to Lantus 10 units subcutaneously at bed time.
You have been prescribed pre-filled syringes to use safely at
home - please use as directed. For your bleeding, you were
given a blood transfusion. Please follow-up with your Doctor [**First Name (Titles) 3**] [**Last Name (Titles) 97843**]d if you have any questions. Please go the Emergency
room or call your physician if you have any of the following
symptoms: severe chest pain, sudden shortness of breath,
bleeding of any kind, or any other symptom concerning to you.
As part of on going care for your heart failure, please remember
to weigh yourself every morning, [**Name8 (MD) 138**] MD if weight changes by
more than 3lbs. Adhere to 2 gm sodium (low salt diet) and
diabetic diet.
Followup Instructions:
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], ([**Telephone/Fax (1) 1921**], [**7-12**] at 10:50AM.
Please call the office for an earlier appointment.
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2196-6-28**]
9:30
Provider: [**Name10 (NameIs) **] FIELD SCREENING Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2196-6-28**] 10:00
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2196-6-29**] 9:00
|
[
"410.71",
"787.01",
"280.0",
"428.20",
"414.8",
"438.20",
"369.00",
"578.0",
"250.11",
"276.51",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7367, 7440
|
4477, 5569
|
371, 378
|
8180, 8190
|
2294, 4454
|
9313, 9889
|
1975, 1979
|
6082, 7344
|
7461, 8159
|
5595, 6059
|
8214, 9290
|
1994, 2275
|
285, 333
|
406, 1293
|
1315, 1767
|
1800, 1959
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,897
| 186,983
|
36366+58076
|
Discharge summary
|
report+addendum
|
Admission Date: [**2162-5-28**] Discharge Date: [**2162-6-5**]
Date of Birth: [**2098-1-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
non ST elevation mycardila infarction
Major Surgical or Invasive Procedure:
left heart catheterization, coronary angiogram
Coronary artery bypass grafts x 2(LIMA-LAD, SVG-OM) [**5-31**]
History of Present Illness:
this 64 year old white female presented to an outside hospital
with chest pain unrelieved with sublingual nitroglycerin. She
ruled in for infarction with troponin to 0.4. She was
transferred here for intervention. in the cath lab she was
found to have left main disease, but remained pain free on a
heparin infusion. She was referred for surgical
revascularization.
Past Medical History:
depression
hypercholesterolemia
hypertension
noninsulin dependent diabetes mellitus
gastic reflux
s/p right total knee replacement
s/p appendectomy
s/p total abdominal hysterectomy
esophageal stricture
Social History:
babysits for grandchildren
90 pack year smoker- stopped 20 years ago
denies ETOH use
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On admission -
VS: T=98.9 BP=131/55 HR=62 RR=18 O2 sat98%RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of *** cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2162-6-4**] 06:15AM BLOOD WBC-10.6 RBC-3.06* Hgb-8.4* Hct-25.6*
MCV-84 MCH-27.4 MCHC-32.6 RDW-14.4 Plt Ct-226
[**2162-6-4**] 06:15AM BLOOD Glucose-107* UreaN-16 Creat-0.7 Na-135
K-5.0 Cl-100 HCO3-25 AnGap-15
Brief Hospital Course:
Following admission she was begun on heparin and remained
painfree. Catheterization demonstrated left main disease and
surgery was recommended. She underwent a coronary artery bypass
graft times two on [**5-31**]. See the operative note for details.
She tolerated this procedure well and was transferred in
critical but stable condition to the surgical intensive care
unit. She was drowsy post-operatively, but became more alert
once narcotics were discontinued. Her chest tubes and
epicardial wires were removed. By post-operative day two she
was transferred to the step down floor. She was agressively
diuresed. She experienced several hours of atrial fibrillation
which was converted with intravenous amiodarone and beta
blockade. By post operative day 5 she was medically stable and
was transferred to rehab.
Medications on Admission:
Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
Lorazepam 0.5 mg PO Q8H:PRN insomnia
Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
Metoprolol Tartrate 12.5 mg PO BID
Aspirin EC 325 mg PO DAILY
Multivitamins 1 TAB PO DAILY
Nitroglycerin 0.05-0.2 mcg/kg/min IV DRIP TITRATE TO chest pain
free Order date: [**5-29**] @ 0044
Diltiazem 30 mg PO QID
Pantoprazole 40 mg PO Q24H Order date: [**5-29**] @ 0044
Docusate Sodium 100 mg PO BID constipation
Senna 1 TAB PO BID:PRN constipation
Fluoxetine 40 mg PO DAILY
Simvastatin 40 mg PO DAILY
Furosemide 40 mg PO DAILY
Plavix - last dose:
600mg loading dose [**2162-5-28**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Fluoxetine 10 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
5. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temp.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezes.
13. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): [**Hospital1 **] x 5 days then decrease to daily for 7 days then
decrease to 200mg daily ongoing.
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days: or until pre-op weight 113kg.
17. Potassium Chloride 20 mEq Packet Sig: One (1) PO DAILY
(Daily) for 7 days:
continue while on lasix then d/c when lasix d/c'd
hold if K >4.5.
18. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
19. Estradiol 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID PRN () as
needed for anxiety.
21. regular insuling per sliding scale finger stick
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
acute myocardial infarction- non ST elevation
left main coronary artery disease
depression
hypercholesterolemia
hypertension
noninsulin dependent diabetes mellitus
gastic reflux
s/p right total knee replacement
s/p appendectomy
s/p total abdominal hysterectomy
s/p coronary artery bypass grafts
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
wear your surgical bra at all times for 6 weeks. may take off
bra to bath then replace.
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks ([**Telephone/Fax (1) 3071**])
Dr. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 10543**] ([**Telephone/Fax (1) 4475**]) in [**1-15**] weeks
Dr.[**Last Name (STitle) 5076**] in 2 weeks
Please call for appointments
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2162-6-5**] Name: [**Known lastname 11758**],[**Known firstname **] Unit No: [**Numeric Identifier 13179**]
Admission Date: [**2162-5-28**] Discharge Date: [**2162-6-5**]
Date of Birth: [**2098-1-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 265**]
Addendum:
based on pre-op TTE Mrs. [**Known lastname **] was treated for acute
systolic heart failure w/ EF of 30%.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2162-7-8**]
|
[
"428.21",
"311",
"401.9",
"V43.65",
"997.1",
"427.31",
"414.01",
"E878.2",
"250.00",
"272.0",
"278.00",
"530.81",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"37.22",
"39.61",
"36.15",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7884, 8098
|
2419, 3241
|
313, 425
|
6403, 6410
|
2184, 2396
|
6902, 7861
|
1167, 1282
|
3903, 5944
|
6085, 6382
|
3267, 3880
|
6434, 6879
|
1297, 2165
|
236, 275
|
453, 824
|
846, 1049
|
1065, 1151
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,895
| 101,657
|
39332
|
Discharge summary
|
report
|
Admission Date: [**2134-1-31**] Discharge Date: [**2134-2-16**]
Date of Birth: [**2084-2-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Cafergot / Prochlorperazine / Penicillins / Chlorpromazine Hcl /
Prozac
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2134-2-1**] Mitral valve replacement with a 25 mm Biocor tissue
valve.
Tricuspid valve replacement with a 27 mm Biocor apical
tissue valve.
[**2134-2-4**] PICC placement
History of Present Illness:
49 year old female with history of paroxysmal atrial
fibrillation, rheumatic heart disease, Hepatitis C, liver
fibrosis found to have moderate MS and
mild tomoderate MR [**First Name (Titles) **] [**Last Name (Titles) 113**]. She reports symptoms of shortness of
breath and chest pain which have gotten progressively worse. She
states that she is unable to climb a flight of stairs without
stopping 3 times to rest.
Past Medical History:
Rheumatic heart disease with 2-3+ MR, minimal MS (valve area 1.3
cm2), [**1-22**]+ tricuspid regurgitation and mild pulmonary
hypertension
RVE/[**Last Name (un) **] with IVC dilation by [**Last Name (un) 113**]
Global RV dysfunction
AI
Prior IVDA-currently methadone clinic, stopped drugs 1.5 yrs ago
ETOH abuse-stopped about 1.5 yrs ago
Atypical chest pain
PAF-on Coumadin last dose [**2134-1-24**]
Chronic anemia
Hepatitis C c/b liver fibrosis->followed by Dr. [**Last Name (STitle) 86971**]
False Positive Syphilis Test
Fibromyalgia
Migraines
IBS
GERD
Prior suicide attempt
PTSD
Pleural effusion s/p evacuation
Bipolar Disorder
Arthritis
Acid reflux
Breast Lumpectomy
Endometriosis s/p laparoscopy
Syncope/fall -approx [**2130**]
Hypoglycemia
Cholecystectomy
Hysterectomy
Tonsillectomy
Endometriosis s/p laparoscopy
s/p tubal ligation
s/p lumpectomy from breast
Social History:
Lives with:husband- [**Name (NI) **]
Occupation: unemployed
Tobacco:1.5ppd x 30 years
ETOH:none in 1.5 yrs
Rec drugs: none in 1.5 yrs. H/o IVDA and cocaine use in past
Family History:
father died of an MI
mother died of heart problems
Brother died in his 50s from heart problems
Physical Exam:
Pulse:76 Resp:18 O2 sat:99% RA pO2 76 on 2L NC
B/P Right: 113/89 Left:
Height:5'1" Weight: 67.3 kg
General: NAD, alert and cooperative
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 [**1-24**] HSM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ sl. hepatomegaly
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None 2+ pitting edema on bilat. LE
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2134-2-16**] 05:10AM BLOOD WBC-6.5 RBC-3.15* Hgb-9.4* Hct-27.8*
MCV-89 MCH-29.8 MCHC-33.6 RDW-17.4* Plt Ct-215
[**2134-1-31**] 09:00PM BLOOD WBC-5.4 RBC-4.35 Hgb-13.1 Hct-36.6
MCV-84# MCH-30.1 MCHC-35.8* RDW-15.8* Plt Ct-151
[**2134-2-1**] 12:32PM BLOOD Neuts-89.2* Lymphs-9.1* Monos-1.1*
Eos-0.5 Baso-0.1
[**2134-2-16**] 05:10AM BLOOD Plt Ct-215
[**2134-2-16**] 05:10AM BLOOD PT-18.1* PTT-28.7 INR(PT)-1.6*
[**2134-1-31**] 09:00PM BLOOD PT-13.3 PTT-34.7 INR(PT)-1.1
[**2134-1-31**] 09:00PM BLOOD Plt Ct-151
[**2134-2-16**] 05:10AM BLOOD Glucose-108* UreaN-42* Creat-0.8 Na-133
K-3.6 Cl-96 HCO3-28 AnGap-13
[**2134-2-15**] 05:40PM BLOOD Glucose-119* UreaN-50* Creat-1.0 Na-133
K-4.6 Cl-95* HCO3-28 AnGap-15
[**2134-2-1**] 02:05PM BLOOD UreaN-8 Creat-0.6 Na-136 K-4.2 Cl-104
HCO3-27 AnGap-9
[**2134-1-31**] 09:00PM BLOOD Glucose-92 UreaN-9 Creat-0.7 Na-135 K-4.5
Cl-99 HCO3-29 AnGap-12
[**2134-2-9**] 03:04AM BLOOD ALT-17 AST-37 LD(LDH)-525* AlkPhos-67
TotBili-1.4
[**2134-1-31**] 09:00PM BLOOD ALT-41* AST-49* LD(LDH)-224 AlkPhos-87
Amylase-66 TotBili-0.6
[**2134-2-3**] 03:29AM BLOOD Lipase-11
[**2134-2-16**] 05:10AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.4
[**2134-1-31**] 09:00PM BLOOD %HbA1c-5.9 eAG-123
[**2134-2-5**] 05:14AM BLOOD Osmolal-276
[**2134-2-5**] 09:23AM BLOOD TSH-1.7
[**2134-2-5**] 09:23AM BLOOD T4-9.0 T3-78*
[**2134-2-5**] 09:23AM BLOOD Cortsol-36.1*
CHEST TWO VIEWS, [**2134-2-14**]
FINDINGS:
Two views of the chest compared to prior study from [**2134-2-11**].
There is
multifocal interstitial and airspace opacification, not
appreciably changed from the prior study, could represent a
combination of congestive failure or even ARDS. Heart is
enlarged. Mediastinum is within normal limits.
IMPRESSION: Left PICC unchanged in superior vena cava.
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.5 cm
Left Ventricle - Fractional Shortening: 0.38 >= 0.29
Left Ventricle - Ejection Fraction: 70% >= 55%
Left Ventricle - Lateral Peak E': *0.04 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.03 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *40 < 15
Aorta - Sinus Level: 2.4 cm <= 3.6 cm
Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - Peak Velocity: 1.4 m/sec
Mitral Valve - Mean Gradient: 6 mm Hg
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 2.00
Mitral Valve - E Wave deceleration time: *400 ms 140-250 ms
TR Gradient (+ RA = PASP): 7 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV free wall thickness. Dilated RV
cavity. RV function depressed.
AORTA: Normal aortic diameter at the sinus level.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR
well seated, with normal leaflet/disc motion and transvalvular
gradients.
TRICUSID VALVE: Bioprosthetic tricuspid valve (TVR). TVR well
seated, with normal leaflet motion and transvalvular gradients.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - bandages,
defibrillator pads or electrodes.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). The right ventricular free wall thickness is
normal. The right ventricular cavity is dilated with depressed
free wall contractility. A bioprosthetic mitral valve prosthesis
is present. The mitral prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. A
bioprosthetic tricuspid valve is present. The tricuspid
prosthesis appears well seated, with normal leaflet motion and
transvalvular gradients. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2133-8-3**], the mitral and tricuspid valves have been
replaced. The right ventricle is somewhat hypocontractile.
Brief Hospital Course:
Admitted [**2134-1-31**] for bridge from coumadin with heparin drip.
Completed preoperative workup and [**2134-2-1**] was brought to the
operating room and underwent mitral valve and tricuspid valve
replacements, see operative report for further details. She
was transferred to the intensive care unit for postoperative
management. In the first few hours she had significant
ventricular ectopy that was treated with amiodarone boluses and
drip with improvement however underlying rhythm was complete
heart block and continued to be paced with epicardial wires.
She remained intubated overnight for hemodynamics and was
extubated the morning of postoperative day one. She was started
on lasix for diuresis due to pulmonary edema and continued
amiodarone. Electrophysiology was consulted for rhythm
management and she was placed on lidocaine drip with improvement
but continued runs on ventricular tachycardia that worsened with
activity. Pain medications were adjusted, she was weaned off
lidocaine and started on betablockers for rhythm management.
She continues with ventricular ectopy but no ventricular
tachycardia. She was restarted on coumadin for history of
pulmonary embolism and atrial fibrillation. She was continued
to be diuresed for pulmonary edema, however was noted to have
hyponatremia with sodium to 122 with no clear cause that was
treated with hypertonic saline and saline tabs and sodium
improved however pulmonary edema worsened. Her oxygen
requirements increased and she continued to require aggressive
diuresis and non invasive ventilation for few days. She
continued to improve and respiratory status improved. She was
transferred to the floor for the remainder of her care.
Physical therapy worked with her on strength and mobility. She
continues on intravenous lasix for diuresis via PICC line that
she is being discharged to rehab with, and plan for PICC removal
when no longer requires IV lasix. She was discharged to acute
rehab on post operative day 15 to [**Hospital3 **] in [**Hospital1 **] new
[**Location (un) **].
Medications on Admission:
DIGOXIN - 250 mcg Tablet - 1 Tablet(s) by mouth daily in the PM
FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth daily
in
the PM
HYDROXYZINE HCL 25 mg Tablet by mouth twice a day
METHADONE - 40 mg Tablet Soluble - 1 Tablet(s) by mouth daily
plus 5mg tablet = 45mg daily dose
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth daily in the PM
POTASSIUM CHLORIDE [KLOR-CON 10] - 10 mEq Tablet Sustained
Release - 1 Tablet(s) by mouth daily
SERTRALINE - 100 mg Tablet in the PM
TRAZODONE - 100 mg Tablet - [**12-24**] Tablet(s) by mouth daily at hs
WARFARIN [COUMADIN] - 7.5 mg Tablet - 1 Tablet(s) by mouth daily
on Fridays only, 5mg all other days last dose [**2134-1-24**]
ZOLPIDEM [AMBIEN] 10 mg Tablet - 1 Tablet(s) by mouth at bedtime
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 once a
day.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO DAILY (Daily): total dose 45 mg .
9. methadone 5 mg Tablet Sig: One (1) Tablet PO once a day:
total dose 45 mg daily .
10. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation Q6H (every 6 hours).
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. guaifenesin 600 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO bid () for 2 days.
14. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. PICC line
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.
[**Month (only) 116**] remove PICC line when no longer on intravenous lasix
16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO twice a day for 3 days:
then decrease to 40 meq daily with IV lasix .
17. furosemide 10 mg/mL Solution Sig: Eighty (80) mg Injection
DAILY (Daily) for 3 days: then decrease to 40 mg IV daily .
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation every four (4) hours
as needed for shortness of breath or wheezing.
19. methadone clinic
Methadone clnic in [**Hospital1 487**], [**Street Address(2) 86972**]. Phone # [**Telephone/Fax (1) 86973**]. Open from 6am to 1015am daily
Has received 45 mg daily while in the hospital [**Date range (1) 86974**]
20. coumadin and INR
[**2-16**] coumadin 7.5 mg inr 1.6
[**2-15**] coumadin 4 mg inr 1.8
[**2-14**] coumadin 5 mg inr 1.9
[**2-13**] coumadin 2.5mg inr 2.2
[**2-12**] coumadin 4 mg inr 2.6
[**2-11**] coumadin 2.5mg inr 2.7
[**2-10**] coumadin 2.5mg inr 3.1
[**2-9**] coumadn 3mg inr 2.2
[**2-8**] coumadin 5 mg inr 1.9
[**2-7**] coumadin 5 mg inr 1.5
[**2-6**] coumadin 5 mg inr 1.4
nutriton had been poored and now improved with shakes (ensure)
which contain vitamin K
home doses prior to admission 5-7.5 mg daily
21. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation and
pulmonary embolism
Goal INR [**12-24**]
First draw wendesday [**2-17**]
Physician at rehab to monitor INR and dose coumadin based on
results - please check monday and wednesday and friday for 3
weeks to maintain close monitoring due to liver disease and then
twice a week
Please arrange for coumadin management with PCP prior to
discharge from rehab
22. Outpatient Lab Work
Chem 10 twice a week while on IV lasix
23. warfarin 5 mg Tablet Sig: Goal INR 2.0-3.0 Tablets PO once a
day: dose based on INR by rehab physician [**Name Initial (PRE) **] [**Name10 (NameIs) **] draw [**2-17**] for
further dosing .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Mitral regurgitation s/p MNR
Tricuspid regurgitation s/p TVR
Ventricular trachycardia
Respiratory failure
Rheumatic heart disease
Hypertension
Right ventricular failure
Prior IVDA-currently on methadone
ETOH abuse-stopped about 1.5 yrs ago
Atypical chest pain
paroxysmal atrial fibrillation
Chronic anemia
Hepatitis C
Liver fibrosis
Fibromyalgia
Migraines
Irritable bowel syndrome
Gastric esophageal reflux disease
Post traumatic stress disorder
Pleural effusion
Bipolar Disorder
Arthritis
Breast Lumpectomy
Endometriosis s/p laparoscopy
Syncope/fall -approx [**2130**]
Hypoglycemia
Cholecystectomy
Hysterectomy
Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with 1 assist
Incisional pain managed with tylenol prn
Continues on methadone 45 mg as prior to admission
Incisions:
Sternal - healing well, no erythema or drainage
Edema +1 bilateral LE
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2134-2-25**] 1:00
Cardiologist: Dr [**Last Name (STitle) 4783**] - cardiac surgery office to contact
you with appointment
Liver: Dr [**Last Name (STitle) 497**] [**Telephone/Fax (1) 2422**] [**2134-4-2**] 11:00
Please call to schedule appointments with your
Primary [**First Name (STitle) 86975**] in [**2-23**] weeks [**Telephone/Fax (1) 77368**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation and
pulmonary embolism
Goal INR [**12-24**]
First draw wendesday [**2-17**]
Physician at rehab to monitor INR and dose coumadin based on
results - please check monday and wednesday and friday for 3
weeks to maintain close monitoring due to liver disease and then
twice a week
Please arrange for coumadin management with PCP prior to
discharge from rehab
Completed by:[**2134-2-16**]
|
[
"V58.69",
"416.8",
"296.80",
"305.1",
"564.1",
"285.1",
"070.70",
"304.03",
"427.1",
"729.1",
"276.1",
"285.9",
"397.0",
"V58.61",
"571.2",
"427.31",
"426.0",
"530.81",
"309.81",
"304.23",
"303.93",
"394.1",
"518.81",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"39.61",
"38.97",
"35.27"
] |
icd9pcs
|
[
[
[]
]
] |
13698, 13745
|
7400, 9462
|
358, 553
|
14415, 14646
|
2936, 7377
|
15570, 16650
|
2089, 2186
|
10291, 13675
|
13766, 14394
|
9488, 10268
|
14670, 15547
|
2201, 2917
|
299, 320
|
581, 998
|
1020, 1887
|
1903, 2073
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,421
| 149,910
|
24934
|
Discharge summary
|
report
|
Admission Date: [**2151-10-21**] Discharge Date: [**2151-11-17**]
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Penicillins / Lisinopril
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
87 yo female admitted for elective AAA repair
Major Surgical or Invasive Procedure:
Resection and repair of abdominal aortic aneurysm with 20-mm
Dacron tube graft.
History of Present Illness:
This 87-year-old lady has an 8-cm infrarenal abdominal aortic
aneurysm which was 5.5 cm a month ago. She is not a candidate
for endovascular repair. She has
previously had a total abdominal colectomy and proctectomy for
ulcerative colitis.
Past Medical History:
PMH:
HTN,
CAD,
MI,
?ulcerative colitis,
OA,
a-fib,
CRI
PSH:
PTCA,
ileostomy/?total colectomy ([**2118**])
Social History:
neg tobacco
neg alcohol
Family History:
non contributary
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l, with slight crakles at bases
CARDIAC: RRR without murmers
ABDOMEN: Obese, Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2151-11-17**]
WBC-9.2 RBC-3.55* Hgb-10.7* Hct-31.7* MCV-89 MCH-30.2 MCHC-33.9
RDW-17.3* Plt Ct-346
[**2151-11-11**]
PT-12.4 PTT-24.5 INR(PT)-1.0
[**2151-11-17**]
Plt Ct-346
[**2151-11-17**]
Glucose-91 UreaN-71* Creat-1.7* Na-134 K-4.6 Cl-106 HCO3-17*
AnGap-16
[**2151-11-17**]
ALT-25 AST-25 AlkPhos-179* Amylase-245* TotBili-0.6
[**2151-11-17**]
Lipase-154*
[**2151-10-29**]
CK-MB-3 cTropnT-<0.01
[**2151-11-15**]
Calcium-10.4* Phos-3.6 Mg-2.0
[**2151-11-17**]
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.017
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2151-11-12**] 4:07 am STOOL CONSISTENCY: WATERY Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2151-11-12**]):
Reference Range: Negative.
[**2151-11-10**]
URINE RBC- WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0-2
URINE CastGr-0-2 CastHy-[**6-2**]
MRSA SCREEN (Final [**2151-11-11**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin sensitivity performed by agar screen.
STAPH AUREUS COAG +
OXACILLIN S
[**2151-11-15**] 5:30 PM
RENAL U.S.
INDICATION: Chronic renal insufficiency.
RENAL ULTRASOUND: The right kidney measures 11.2 cm. There is no
evidence for hydronephrosis. The left kidney is severely
atrophic and demonstrates severe hydronephrosis.
IMPRESSION:
1. Normal-appearing right kidney without evidence for
hydronephrosis.
2. Atrophic left kidney with severe end-stage hydronephrosis.
[**2151-11-11**]
CHEST (PORTABLE AP)
IMPRESSION: AP chest compared to [**11-2**], 2nd and 3rd:
Left lower lobe remains densely consolidated. Whether this is
atelectasis or has progressed to pneumonia is radiographically
indeterminate. Small left pleural effusion is larger than it was
on [**11-4**] while previous mild pulmonary edema has
resolved. Moderate cardiomegaly is stable. Nasogastric tube ends
in the upper stomach. Tip of the right jugular line projects
over the upper right atrium. No pneumothorax.
[**2151-11-11**] 9:23 PM
US ABD LIMIT, SINGLE ORGAN
Reason: Please assess for cholecystitis.
RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in
echotexture and contour. There is no intrahepatic biliary ductal
dilatation. The gallbladder is distended and demonstrates
minimal gallbladder wall edema measuring 3 mm. No definite
stones or sludge are seen within the gallbladder. A son[**Name (NI) 493**]
[**Name (NI) **] sign could not be elicited secondary to the patient's
somnolent state. The common bile duct measures 4 mm, which is
normal. The portal vein is patent and demonstrates normal
hepatopetal flow. The pancreas body contains a 2.0 x 1.0 cm
anechoic cyst. No pancreatic duct dilatation is identified.
Otherwise, the pancreas is normal in echogenicity. The
visualized right kidney is normal in appearance.
IMPRESSION:
1. Distended gallbladder with mild gallbladder wall edema
without stones or sludge. A [**Doctor Last Name **] sign could not be elicited
secondary to the patient's somnolence. Clinical correlation for
signs of cholecystitis is recommended.
2. No evidence for pancreatitis. Cyst within the body of the
pancreas.
[**2151-10-31**]
ECG Study Date of
Sinus rhythm with first degree A-V block. Poor R wave
progression. Diffuse
non-specific ST-T wave abnormalities. Compared to the previous
tracing
of [**2151-10-29**] junctional rhythm is no longer seen.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 140 96 378/424.57 18 -17 5 \
Cardiology Report ECHO Study Date of [**2151-10-29**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.5 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.6 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.7 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.2 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 1.7 cm
Left Ventricle - Fractional Shortening: 0.47 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 65% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec)
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function (LVEF>55%). Normal regional LV systolic
function.
AORTA: Normal aortic root diameter. Focal calcifications in
aortic root.
Normal ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
thickening of
mitral valve chordae. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen.The pulmonary artery systolic pressure could not be
determined. There is a prominent, circumferential, partially
echo-filled space c/w prominent
epicardial fat pad.
IMPRESSION: Preserved global and regional biventricular systolic
function. Mild mitral regurgitation. Prominent circumferential
epicardial fat.
[**2151-10-22**] 11:19 AM
CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS
CT ANGIOGRAM:
The lower thoracic and upper abdominal aorta are normal in
caliber. The aorta measures up to 2.8 cm AP x 2.4 cm transverse
at the level of the renal artery origin. There is mild
generalized atherosclerotic calcification. There is a large
fusiform infrarenal abdominal aortic aneurysm, which arises
approximately 1.5 cm inferior to the renal artery origins. At
its largest it measures up to 5.6 cm AP x 6.3 cm in transverse
dimension x 11.3cm SAG and extends to the aortic bifurcation.
Large amount of mural thrombus around the left side of the
enhancing luminal portion measuring up to 3.8 AP x 1.8 cm
transverse.
Inferior mesenteric artery is occluded. More proximally, the
celiac, SMA artery are patent. Each kidney is supplied by a
single renal artery, which are patent, the left renal artery is
much smaller in caliber, but the left kidney is grossly
atrophic, as described below.
Both common internal, external iliac arteries and common femoral
arteries are mildly atherosclerotic, but patent and normal in
caliber.
The volume of the abdominal aorta from below renal artery
origins to iliac bifurcation is 211 cc and 200 cc to the aortic
bifurcation. Aneurysm neck to aortic bifurcation measures 11.3
cm, to the right iliac bifurcation 17.4 cm, and to the left
iliac bifurcation 17.1 cm.
CT SCAN OF ABDOMEN WITH INTRAVENOUS CONTRAST:
The lung bases are clear. Moderate sized hiatal hernia noted.
Spleen, liver, gallbladder appear normal on CT. The pancreas is
normal in size.A 1.4 cm fluid attenuating cyst arises from the
anterior aspect of the neck (series 3, image 34). No pancreatic
ductal dilatation.
There is essentially a single right kidney which is normal in
size.A 6-7 mm ovoid hypodensity along the anterior interpolar
cortex is too small to characterize. Three small (less than [**2-4**]
mm) nonobstructing calculi noted. No hydronephrosis or
hydroureter.
The left kidney is grossly atrophic with only a thin(2-3mm
thick) remaining rim of enhancing cortex. A large staghorn
calculus in the right renal pelvis measuring up to 3.7 cm
transverse x 3 cm AP, with dilatation of the left renal pelvis
in keeping with chronic obstruction.
Patient has had a previous colectomy; the ileostomy located in
the right lower quadrant. Sizable parastomal herniation of small
bowel, without acute complication. The neck of this hernia
measures at least 2 cm in transverse dimension.
CT SCAN OF PELVIS WITH INTRAVENOUS CONTRAST:
Normal sized uterus lying posteriorly in the pelvis following
previous colectomy.
No bone lesions demonstrated. Some degenerative change noted in
the lumbar spine.
CONCLUSION:
1. Large 5.6cm x 6.3cm fusiform infrarenal abdominal aortic
aneurysm arising approximately 1.5 cm inferior to the renal
artery origins and extending to the aortic bifurcation.
2.Large calculus in the left renal pelvis with gross atrophy of
the left renal cortex.The right kidney is normal in size.
3. Moderate-sized hiatal hernia.
Brief Hospital Course:
Pt admitted on [**2151-10-21**]
[**Date range (3) 62682**]
Pt pre-op'd in the usual fashion.
Pt was an elderly female she needed a variety of pre-testing and
clearence, This was completed on [**10-25**]
[**2151-10-26**]
Pt undergoes a resection and repair of abdominal aortic aneurysm
with 20-mm Dacron tube graft. Pt tolerated the procedure well
there were no complications. Pt transfered to SICU in stable
condition. Intubated
[**2151-10-26**] - [**2151-11-5**]
Pt remained intubated / on a variety of drips / diuresis
Pt did have an increase in creat / variety of test performed, pt
found to have ATN. On DC her creat is 1.7 / much improved.
Pt also had an increase in NA / pt give free water / NA improved
on DC.
[**2151-11-6**] - [**2151-11-11**]
Pt extubated, remained in the SICU. The above creat / NA
monitered. Improved.
Pt also c/w diuresis / pulmonary toilet.
PT/rehab screening began.
[**2151-11-12**] - [**2151-11-17**]
Pt transfered to the floor in stable condition.
Pt found to have increase in lipase / Pt diagnosed with
pancreatitis. On DC Lipase and LFT's are normalizing.
On DC pt is stable. Needs rehab.
Taking minimum PO, TF with Nepro being cycled, Pt with rectal
tube - to be DC'd when stools improve / pos BM, pt with foley -
to be DC'd when pt ambualtory. Pt has NG tube, to be DC'd after
swallow eval.
Pt needs chem 7 to be followed, swallow eval, rectal tube DC'd,
foley DC'd, Needs tube feeds as ordered. This may be DC'd when
pt is taking PO.
Medications on Admission:
Norvasc 2.5,
amiodarone 100,
Lopressor 25"
Discharge Medications:
1. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4H
(every 4 hours) as needed.
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Rehabilitation and Nursing Center
Discharge Diagnosis:
AAA 5.5 cm.
Panacreatitis
ATN
Discharge Condition:
Stable
Discharge Instructions:
Follow Chem 7 weekly / follow creat / k - pt had ATN
Check BUN - pt on promo full strength
Other for pt / general care
DISCHARGE INSTRUCTIONS FOLLOWING AORTIC SURGERY
.
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 no specific restrictions on activity other than no
lifting an object heavier than twenty-five (25) pounds for the
first three (3) months. Gradually increase your level of
activity back to normal depending on how you feel. Fatigue is
normal, especially for the first month postoperative. Resume
driving when cleared by your surgeon, if you drive.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Severe and worsening abdominal pain .
.
Pain or swelling in one of your legs.
.
Increasing pain, redness or drainage related to your incision(s)
.
.
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 8 weeks.
.
If you drive, resume driving when you feel strong enough and
comfortable enough without needing pain medication .
.
No heavy lifting greater than 20 pounds for 8 weeks.
.
Avoid excessive bending at the hips and stooping for 4 weeks.
.
BATHING/SHOWERING:
.
You may shower immediately if the incision is dry upon coming
home. No baths until sutures / staples are removed. Dissolving
sutures may have been used. In either case, you can wash your
incision gently with soap and water.
.
WOUND CARE:
.
Suture / 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 / staples 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
two weeks after surgery.
.
MEDICATIONS:
.
You may resume taking medication you were on prior to your
surgery unless specifically instructed otherwise by your
physician [**Name9 (PRE) **] will be given a new prescription for pain
medication, which should 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 heavy lifting (over 20 pounds) for 8 weeks after surgery.
.
No strenuous activity for 4-6 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:
Call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 3121**]. schedule an
apppointment after rehab
Completed by:[**2151-11-17**]
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72,969
| 145,959
|
26127
|
Discharge summary
|
report
|
Admission Date: [**2174-11-24**] Discharge Date: [**2174-12-6**]
Date of Birth: [**2119-11-20**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Left leg pain and swelling
Major Surgical or Invasive Procedure:
Left IJ central venous catheter insertion [**2174-11-25**]
Left PICC line placed but not past axilla [**2174-12-1**]
Right PICC successfully inserted [**2174-12-2**] and left PICC
removed
History of Present Illness:
Mr. [**Known lastname 64819**] is a 54yo M w/hx of CP and AML s/p
busulfan/cyclophosphamide MUD allo-SCT [**5-26**] c/b chronic GVHD of
skin and mucous membranes s/p IL-2 study who presents as a
direct admit from clinic for left leg DVT. The patient reports
the he noticed pain and swelling of the left leg 2 days prior to
admission. He is still able to ambulate on that leg. He was
recently admitted from [**Date range (3) 64820**] for a GI Bleed. He was
having BPBPR and melena. He underwent EGD showing erosive
esophagitis without active bleeding (at OSH). Colonoscopy showed
diverticulosis without bleeding. CTA showed possible cecal AVM.
He was transfused a total of 5 units PRBCs during this
admission, last on [**2174-11-8**]. He denies any recent blood in his
stool, dark or tarry stools, or blood on the toilet paper. He
has 2 regular bowel movements per day without diarrhea. He
denies hematemsis, nausea or vomiting. Otherwise he feels well.
Past Medical History:
ONCOLOGIC HISTORY:
Diagnosed with AML in [**2170-1-21**] when he was found to have low
white count. CD34+, CD13+ with immature AML and had induction
chemo in [**1-/2170**] with 7+3 with cytarabine and idarubicin. He
then had 5 days of mitozantrone/etoposide after biopsy showing
residual leukemia. His cytarabine was held because his cerebral
palsy makes it difficult to follow him for evidence of
cerebellar toxicity. BM Bx on [**2170-3-29**] showed continued
presence of leukemic cells, 60% blasts. Repeat Bx [**2170-4-3**]
showed <5% blasts, but again on [**2170-4-13**] showed residual
disease. In [**5-26**], he had allogenic SCT following BU/CY. He has
been in remission since this transplant, but suffers from
chronic extensive GVHD manifesting as changes in the mouth and
eyes, skin changes, and most recently evidence of vasculopathy
with edema and poor perfusion in the feet. The patient has been
on a regimen of 15 b.i.d. of prednisone, CellCept at 500 b.i.d.,
and cyclosporine at 75 b.i.d; recently started rituximab.
<br><b>ADDITIONAL MEDICAL HISTORY</b>
1. Cerebral palsy/ (? autism/Asperger based on exam/history)
2. Psoriasis
3. S/p resection of SCC from cheek; has undergone multiple
biopsies of his left cheek, ?GVHD
4. History of UE DVT, s/p anticoagulation with Coumadin
5. S/p several orthopedic procedures
7. Chronic GVHD manifestations of rash, vasculopathy and LFT
abnormalities, also of eyes and mouth
8. LVH by echo
Social History:
Lives with his family in [**Location (un) **], NH. Does not smoke or drink.
Enjoys acting. knows [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 64821**]
Family History:
Father died of pancreatic cancer at 50yo. No h/o leukemia.
Physical Exam:
General: NAD, pleasant, no acute distress
HEENT: R eye slightly injected, anicteric
Neck: supple, no LAD
Lungs: CTA b/l
CV: RRR s1s2 no mrg
Abdomen: Distended, tympanitic, soft
Ext: Left lower extremity with 1+ edema to the knee and
tenderness to palpation. Palpable cord on posterior popliteal
area. Slight rubor of the left leg. Right leg without edema.
Rectal: normal tone, guaiac negative
Pertinent Results:
[**2174-12-5**] 10:55AM BLOOD WBC-11.9* RBC-3.15* Hgb-9.5* Hct-30.2*
MCV-96 MCH-30.2 MCHC-31.4 RDW-16.4* Plt Ct-627*
[**2174-12-5**] 12:00AM BLOOD WBC-9.5 RBC-2.95* Hgb-8.9* Hct-27.9*
MCV-95 MCH-30.3 MCHC-31.9 RDW-16.6* Plt Ct-590*
[**2174-12-4**] 12:00AM BLOOD WBC-9.2 RBC-3.14* Hgb-9.3* Hct-29.4*
MCV-94 MCH-29.4 MCHC-31.5 RDW-16.5* Plt Ct-568*
[**2174-12-3**] 12:00AM BLOOD WBC-8.2 RBC-2.91* Hgb-8.6* Hct-27.5*
MCV-95 MCH-29.6 MCHC-31.3 RDW-16.3* Plt Ct-476*
[**2174-12-2**] 06:45AM BLOOD WBC-9.9 RBC-3.49* Hgb-10.2* Hct-32.4*
MCV-93 MCH-29.1 MCHC-31.3 RDW-16.1* Plt Ct-461*
[**2174-12-1**] 06:00AM BLOOD WBC-12.0* RBC-3.49* Hgb-10.3* Hct-33.6*
MCV-96 MCH-29.4 MCHC-30.6* RDW-16.3* Plt Ct-412
[**2174-11-30**] 01:17PM BLOOD WBC-12.3* RBC-3.78* Hgb-11.1* Hct-35.2*
MCV-93 MCH-29.3 MCHC-31.4 RDW-15.9* Plt Ct-431
[**2174-11-30**] 06:00AM BLOOD WBC-12.3* RBC-3.36* Hgb-10.1* Hct-31.0*
MCV-92 MCH-30.2 MCHC-32.7 RDW-16.5* Plt Ct-353
[**2174-11-29**] 05:50AM BLOOD WBC-9.7 RBC-3.35* Hgb-9.9* Hct-31.3*
MCV-93 MCH-29.5 MCHC-31.6 RDW-16.2* Plt Ct-325
[**2174-11-28**] 05:55AM BLOOD WBC-12.3* RBC-3.00* Hgb-8.9* Hct-27.4*
MCV-92 MCH-29.5 MCHC-32.3 RDW-15.7* Plt Ct-275
[**2174-11-27**] 04:00AM BLOOD WBC-21.2* RBC-2.94* Hgb-8.9* Hct-27.8*
MCV-95 MCH-30.3 MCHC-32.0 RDW-16.3* Plt Ct-298
[**2174-11-26**] 10:14PM BLOOD WBC-23.5* RBC-2.89* Hgb-8.8* Hct-26.9*
MCV-93 MCH-30.5 MCHC-32.8 RDW-16.4* Plt Ct-285
[**2174-11-26**] 01:07PM BLOOD WBC-27.7* RBC-3.12* Hgb-9.2* Hct-29.2*
MCV-94 MCH-29.4 MCHC-31.4 RDW-15.9* Plt Ct-271
[**2174-11-26**] 01:27AM BLOOD WBC-31.6* RBC-3.15* Hgb-9.9* Hct-29.6*
MCV-94 MCH-31.3 MCHC-33.3 RDW-16.6* Plt Ct-313
[**2174-11-25**] 04:26PM BLOOD WBC-39.3*# RBC-3.40* Hgb-10.0* Hct-31.7*
MCV-93 MCH-29.5 MCHC-31.6 RDW-16.0* Plt Ct-336
[**2174-11-25**] 11:42AM BLOOD WBC-19.7*# RBC-2.82*# Hgb-8.7* Hct-27.2*
MCV-97 MCH-30.8 MCHC-31.9 RDW-16.5* Plt Ct-270
[**2174-11-25**] 07:00AM BLOOD WBC-11.7* RBC-3.78* Hgb-11.0* Hct-35.6*
MCV-94 MCH-29.1 MCHC-30.9* RDW-16.0* Plt Ct-325
[**2174-11-24**] 11:25AM BLOOD WBC-11.7* RBC-3.54* Hgb-10.5* Hct-33.2*
MCV-94 MCH-29.7 MCHC-31.7 RDW-15.8* Plt Ct-317
[**2174-12-5**] 12:00AM BLOOD Neuts-76* Bands-1 Lymphs-17* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2*
[**2174-12-4**] 12:00AM BLOOD Neuts-65.2 Bands-0 Lymphs-27.1 Monos-6.2
Eos-0.9 Baso-0.5
[**2174-12-3**] 12:00AM BLOOD Neuts-73* Bands-2 Lymphs-22 Monos-1*
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-6*
[**2174-12-2**] 06:45AM BLOOD Neuts-61 Bands-4 Lymphs-29 Monos-3 Eos-1
Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2174-12-1**] 06:00AM BLOOD Neuts-63.4 Bands-0 Lymphs-27.3 Monos-7.6
Eos-1.4 Baso-0.3
[**2174-11-30**] 01:17PM BLOOD Neuts-84.1* Bands-0 Lymphs-10.3*
Monos-4.7 Eos-0.8 Baso-0.2
[**2174-11-28**] 05:55AM BLOOD Neuts-78.1* Bands-0 Lymphs-15.2*
Monos-6.3 Eos-0.3 Baso-0.1
[**2174-11-26**] 01:27AM BLOOD Neuts-98* Bands-0 Lymphs-1* Monos-0 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2174-11-25**] 11:42AM BLOOD Neuts-98* Bands-0 Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-4*
[**2174-11-24**] 11:25AM BLOOD Neuts-83.4* Lymphs-8.6* Monos-7.6 Eos-0.2
Baso-0.2
[**2174-12-5**] 12:00AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-1+ Target-OCCASIONAL
[**2174-12-3**] 12:00AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Spheroc-1+ Target-1+
[**2174-12-2**] 06:45AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-1+
[**2174-12-1**] 06:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Target-OCCASIONAL Schisto-OCCASIONAL
[**2174-11-25**] 11:42AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ How-Jol-1+
[**2174-11-24**] 11:25AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
How-Jol-1+
[**2174-12-5**] 10:55AM BLOOD Plt Ct-627*
[**2174-12-5**] 12:00AM BLOOD Plt Smr-HIGH Plt Ct-590*
[**2174-12-5**] 12:00AM BLOOD PT-13.2 PTT-31.8 INR(PT)-1.1
[**2174-12-4**] 12:00AM BLOOD Plt Ct-568*
[**2174-12-4**] 12:00AM BLOOD PT-12.6 PTT-31.8 INR(PT)-1.1
[**2174-12-3**] 12:00AM BLOOD Plt Smr-HIGH Plt Ct-476*
[**2174-12-3**] 12:00AM BLOOD PT-12.5 PTT-30.9 INR(PT)-1.1
[**2174-12-2**] 06:45AM BLOOD PT-12.8 PTT-26.2 INR(PT)-1.1
[**2174-12-1**] 06:00AM BLOOD PT-12.2 PTT-27.5 INR(PT)-1.0
[**2174-11-27**] 09:46AM BLOOD PT-13.7* PTT-82.2* INR(PT)-1.2*
[**2174-11-27**] 04:00AM BLOOD PT-13.9* PTT-85.3* INR(PT)-1.2*
[**2174-11-26**] 10:17PM BLOOD PT-13.5* PTT-76.7* INR(PT)-1.2*
[**2174-11-26**] 05:07PM BLOOD PTT-99.1*
[**2174-11-26**] 07:29AM BLOOD PT-14.3* PTT-131.4* INR(PT)-1.2*
[**2174-11-26**] 01:27AM BLOOD PT-13.6* PTT-82.6* INR(PT)-1.2*
[**2174-11-25**] 11:42AM BLOOD PT-14.7* PTT-34.2 INR(PT)-1.3*
[**2174-11-25**] 07:00AM BLOOD PT-12.1 PTT-25.2 INR(PT)-1.0
[**2174-12-2**] 06:45AM BLOOD Ret Aut-3.5*
[**2174-12-5**] 02:27PM BLOOD LMWH-1.9
[**2174-12-5**] 12:00AM BLOOD Glucose-206* UreaN-12 Creat-0.8 Na-137
K-4.2 Cl-104 HCO3-26 AnGap-11
[**2174-12-4**] 12:00AM BLOOD Glucose-173* UreaN-11 Creat-0.8 Na-141
K-4.1 Cl-107 HCO3-27 AnGap-11
[**2174-12-3**] 12:00AM BLOOD Glucose-197* UreaN-11 Creat-0.7 Na-140
K-3.8 Cl-106 HCO3-26 AnGap-12
[**2174-12-2**] 06:45AM BLOOD Glucose-125* UreaN-13 Creat-0.8 Na-140
K-3.8 Cl-106 HCO3-26 AnGap-12
[**2174-12-1**] 06:00AM BLOOD Glucose-112* UreaN-14 Creat-0.8 Na-141
K-4.0 Cl-109* HCO3-26 AnGap-10
[**2174-11-30**] 06:00AM BLOOD Glucose-119* UreaN-12 Creat-0.7 Na-141
K-3.6 Cl-108 HCO3-28 AnGap-9
[**2174-11-29**] 05:50AM BLOOD Glucose-126* UreaN-11 Creat-0.6 Na-141
K-3.6 Cl-109* HCO3-26 AnGap-10
[**2174-11-28**] 05:55AM BLOOD Glucose-180* UreaN-15 Creat-0.8 Na-142
K-3.0* Cl-112* HCO3-27 AnGap-6*
[**2174-11-27**] 04:00AM BLOOD Glucose-131* UreaN-12 Creat-0.7 Na-143
K-3.0* Cl-110* HCO3-24 AnGap-12
[**2174-11-26**] 01:27AM BLOOD Glucose-223* UreaN-14 Creat-0.9 Na-143
K-3.8 Cl-108 HCO3-25 AnGap-14
[**2174-11-25**] 08:32PM BLOOD Glucose-242* UreaN-12 Creat-1.0 Na-139
K-4.5 Cl-108 HCO3-20* AnGap-16
[**2174-11-25**] 04:26PM BLOOD Glucose-182* UreaN-15 Creat-1.0 Na-140
K-4.6 Cl-107 HCO3-19* AnGap-19
[**2174-11-25**] 11:42AM BLOOD Glucose-155* UreaN-16 Creat-1.1 Na-140
K-3.9 Cl-109* HCO3-16* AnGap-19
[**2174-11-25**] 07:00AM BLOOD Glucose-85 UreaN-16 Creat-0.9 Na-141
K-4.4 Cl-104 HCO3-28 AnGap-13
[**2174-12-5**] 12:00AM BLOOD ALT-24 AST-15 LD(LDH)-239 AlkPhos-55
TotBili-0.2
[**2174-12-4**] 12:00AM BLOOD ALT-26 AST-16 LD(LDH)-205 AlkPhos-58
TotBili-0.2
[**2174-12-3**] 12:00AM BLOOD ALT-25 AST-18 LD(LDH)-230 AlkPhos-58
TotBili-0.2
[**2174-12-2**] 06:45AM BLOOD ALT-22 AST-14 LD(LDH)-217 AlkPhos-57
TotBili-0.3
[**2174-12-1**] 06:00AM BLOOD ALT-23 AST-14 LD(LDH)-208 AlkPhos-58
TotBili-0.3
[**2174-11-30**] 01:17PM BLOOD ALT-26 AST-17 AlkPhos-71 TotBili-0.3
[**2174-11-26**] 07:29AM BLOOD LD(LDH)-288* TotBili-0.2
[**2174-11-26**] 07:29AM BLOOD LD(LDH)-288* TotBili-0.2
[**2174-11-25**] 04:26PM BLOOD ALT-25 AST-23 LD(LDH)-317* CK(CPK)-64
AlkPhos-77 Amylase-15 TotBili-0.5
[**2174-11-24**] 11:25AM BLOOD ALT-27 AST-18 LD(LDH)-278* AlkPhos-82
TotBili-0.3
[**2174-11-25**] 04:26PM BLOOD Lipase-14
[**2174-11-26**] 07:29AM BLOOD CK-MB-5 cTropnT-0.10*
[**2174-11-26**] 01:27AM BLOOD CK-MB-6 cTropnT-0.09*
[**2174-11-25**] 04:26PM BLOOD CK-MB-4 cTropnT-0.03*
[**2174-12-5**] 12:00AM BLOOD Albumin-2.9* Calcium-8.5 Phos-3.2 Mg-2.0
[**2174-12-4**] 12:00AM BLOOD Albumin-2.8* Calcium-8.2* Phos-3.2 Mg-2.1
[**2174-12-3**] 12:00AM BLOOD Albumin-2.6* Calcium-8.1* Phos-3.2 Mg-2.1
[**2174-12-2**] 06:45AM BLOOD Albumin-2.7* Calcium-8.5 Phos-2.7 Mg-1.9
Iron-23*
[**2174-12-1**] 06:00AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.6*
Mg-1.8 UricAcd-2.8*
[**2174-11-30**] 06:00AM BLOOD Calcium-7.9* Phos-2.5* Mg-1.9
[**2174-11-29**] 05:50AM BLOOD Calcium-7.9* Phos-1.9* Mg-1.9
[**2174-11-27**] 04:00AM BLOOD Phos-2.8 Mg-2.0
[**2174-11-26**] 01:27AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9
[**2174-11-25**] 08:32PM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8
[**2174-11-25**] 04:26PM BLOOD Calcium-8.0* Phos-3.5# Mg-1.8
[**2174-11-25**] 07:00AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.2
[**2174-11-24**] 11:25AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3
[**2174-12-2**] 06:45AM BLOOD calTIBC-263 Ferritn-76 TRF-202
[**2174-11-26**] 07:29AM BLOOD Hapto-254*
[**2174-11-27**] 04:00AM BLOOD Vanco-17.9
[**2174-11-29**] 10:50AM BLOOD Cyclspr-LESS THAN
[**2174-11-27**] 08:52AM BLOOD Cyclspr-41*
[**2174-11-27**] 04:20AM BLOOD Type-[**Last Name (un) **] pH-7.44
[**2174-11-25**] 10:42AM BLOOD Type-ART pO2-26* pCO2-42 pH-7.41
calTCO2-28 Base XS-0
[**2174-11-26**] 08:19AM BLOOD Lactate-2.6*
[**2174-11-25**] 08:52PM BLOOD Lactate-2.7*
[**2174-11-25**] 04:44PM BLOOD Lactate-3.2*
[**2174-11-25**] 10:42AM BLOOD Lactate-3.6*
[**2174-11-27**] 04:20AM BLOOD freeCa-1.09*
.
.
Urine
.
[**2174-11-25**] 06:47PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.034
[**2174-11-25**] 06:47PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
[**2174-11-25**] 06:47PM URINE RBC-4* WBC-31* Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1
.
.
Microbiology
.
BC [**11-25**] x2, [**11-26**] x1, [**11-27**] x1, [**11-30**], [**12-2**] and [**12-3**] no growth
to date
.
[**2174-11-25**] 6:47 pm URINE Source: Catheter.
**FINAL REPORT [**2174-11-26**]**
URINE CULTURE (Final [**2174-11-26**]): NO GROWTH.
.
[**2174-11-25**] 8:33 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2174-11-28**]**
MRSA SCREEN (Final [**2174-11-28**]): No MRSA isolated.
.
C. Difficile [**11-26**], [**12-1**] and [**12-3**] negative for toxin
.
[**2174-11-27**] 3:41 pm CATHETER TIP-IV Source: left IJ TLCL.
**FINAL REPORT [**2174-11-29**]**
WOUND CULTURE (Final [**2174-11-29**]): No significant growth.
.
.
Radiology
.
U/S BILAT LOWER EXT VEINS Study Date of [**2174-11-24**] 2:42 PM
FINDINGS: The left proximal common femoral vein demonstrates
normal
compressibility. There is a completely occlusive clot extending
from the
distal left common femoral vein into the deep femoral vein and
distal
superficial femoral vein. There is minimal flow within the
popliteal vein.
The left posterior tibial and peroneal veins are grossly patent
on color
imaging.
The right common femoral vein and proximal superficial femoral
vein and
popliteal veins demonstrate normal compressibility, flow and
augmentation.
The right mid and the distal superficial femoral veins could not
be well seen.
The right posterior tibial and peroneal veins are grossly patent
on color
imaging.
IMPRESSION: Deep venous thrombosis extending from the left
distal common
femoral vein to the popliteal vein.
.
XR CHEST PORT. LINE PLACEMENT Study Date of [**2174-11-25**] 12:47 PM
FINDINGS: In comparison with the study of [**11-7**], there has been
placement of
a left IJ catheter that extends to the upper to mid portion of
the SVC.
Continued low lung volumes with probable effusion and
atelectasis at the left
base. Mild prominence of interstitial markings is consistent
with some
elevated pulmonary venous pressure. Enlargement of the cardiac
silhouette
persists.
.
CT [**Last Name (un) **]/PELVIS W&W/O C Study Date of [**2174-11-25**] 6:13 PM
Within the lung bases, again seen are small bilateral pleural
effusions and associated compressive atelectasis. Within the
left ventricle,
a filling defect measuring up to 2.3 x 2.0 cm (4A:5) was not
present on the CT
of [**2174-5-16**].
Within the abdomen, the liver, gallbladder, bilateral kidneys,
bilateral
adrenal glands, and spleen are unremarkable. There is fatty
infiltration of
the pancreas.
A focus of hyperdensity within the stomach (4b:109) is seen on
post-contrast
imaging.
Loops of small and large bowel are of normal size and caliber.
No abdominal
free air, free fluid or lymphadenopathy is seen.
Within the pelvis, the distal ureters and bladder are grossly
normal. Distal
loops of large bowel and rectum are unremarkable.
Within prostate gland, there is a 2.1 x 1.8 cm (4B:187)
hypodensity with some
peripheral rim enhancement within the right lobe concerning for
possible
abscess formation. Some adjacent thickening of the rectal wall
is likely
reactive in nature. No free air or free fluid is seen.
Known left femoral venous clot is again seen.
No concerning osseous lesion is seen.
IMPRESSION:
1. New hypodensity in right prostate gland concerning for
abscess formation.
2. Filling defect in the left ventricle, not present on the
examination of
[**2174-5-16**], incompletely evaluated and may represent clot.
Further
evaluation with echo may be performed.
3. Left femoral DVT as previously seen.
4. Hyperdense focus in stomach could potentially represent
source of bleed if
these symptoms are persisting.
.
XR CHEST (PA & LAT) Study Date of [**2174-11-28**] 2:19 PM
INDINGS: Moderate left and small-to-moderate right pleural
effusions are
increased since the prior study. Pulmonary vascular congestion
is also
increased. Mild-to-moderate cardiomegaly is stable. There is no
pneumothorax. There is no focal consolidation within the lungs.
The left
internal jugular catheter has been removed.
IMPRESSION: Increased moderate left and mild-to-moderate right
pleural
effusions with associated compressive atelectasis and increased
pulmonary
vascular congestion. No focal consolidations concerning for
pneumonia.
.
XR TOE(S), 2+ VIEW LEFT Study Date of [**2174-11-30**] 11:43 AM
FINDINGS: Mild degenerative changes at the first interphalangeal
and
metatarsal phalangeal joint with small osteophytes. No
suspicious lytic or
sclerotic bony lesions, fractures, or radiopaque foreign bodies.
Vascular
calcifications. Marked soft tissue swelling at the great toe and
the dorsum
of the foot. No periosteal reaction or osteolysis to indicated
osteomyelitis.
.
XR CHEST PORT. LINE PLACEMENT Study Date of [**2174-12-1**] 8:15 PM
PIC line is curled in the left axilla. Lung volumes are lower
today than on
[**11-28**] exaggerating size of mild-to-moderate cardiomegaly
and reflected in
moderate-to-severe bibasilar atelectasis left greater than
right. Pleural
effusion is small if any. No pneumothorax. Pager [**Numeric Identifier 11747**] was
contact[**Name (NI) **] as
requested.
.
PROSTATE U.S. Study Date of [**2174-12-2**] 9:57 AM
PROSTATE ULTRASOUND: Transrectal examination was performed. The
seminal
vesicles are unremarkable. The prostate gland measures 5.0 x 4.7
x 3.4 cm.
In the peripheral zone on the right there is a 2.0 x 1.8 x 1.9
cm hypoechoic
lesion with a somewhat thick border and some septations. No
further lesions
are seen. The prostate volume is 44.7 cc. The predicted PSA is
5.4.
IMPRESSION: 2-cm abscess in the peripheral zone on the right.
.
.
Cardiology
.
Cardiology Report ECG Study Date of [**2174-11-25**] 10:25:34 AM
Marked baseline artifact. Sinus tachycardia. Possible Q waves in
leads III and aVF and V1-V4. Compared to the previous tracing of
[**2171-12-19**]
the Q waves in the right precordial leads are new but may be
related
to altered lead placement. Consider interval anterior and
inferior myocardial
infarction.
.
Cardiology Report ECG Study Date of [**2174-11-25**] 11:46:22 AM
Sinus tachycardia, rate 153. There are Q waves in leads V1-V3
with ST segment
elevation suspicious for an acute anteroseptal myocardial
infarction. Low
voltage in the standard leads. Comparison with the previous
tracing of [**2174-11-25**],
is difficult because of the marked baseline artifact at that
time but it
seems very likely that the right precordial lead ST segment
elevation is new.
.
Cardiology Report ECG Study Date of [**2174-11-25**] 6:58:46 PM
Normal sinus rhythm, rate 76. Compared to tracing #1 there are Q
waves in
leads V2-V4. Low voltage in leads V4-V6. Terminal T wave
inversion consistent
with evolution of an acute anterior wall myocardial infarction.
TRACING #2
.
Portable TTE (Complete) Done [**2174-11-25**] at 3:55:25 PM
Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with apical akinesis. The remaining segments contract normally
(LVEF = 45-50%). A 1.8 x1.8 thrombus is seen in the apex left
ventricle, adjacent to the akinetic segment (best appreciated on
cine loop #50). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. Trivial
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Focal apical left ventricular akinesis with
intracavitary thrombus. No clinically-significant regurgitant
valvular disease seen.
Compared with the prior study (images reviewed) of [**2172-7-28**],
apical LV dysfunction and LV thrombus are new. Findings were
discussed with Dr. [**First Name (STitle) **] at 1605 hours on the day of the study.
.
TTE (Complete) Done [**2174-11-28**] at 12:21:23 PM
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with distal
anterior and anteroseptal hypokinesis. The apex is akinetic with
a probable thrombus present. Right ventricular chamber size and
free wall motion are normal. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2174-11-25**],
the current study has limited images. The other findings are
similar.
Brief Hospital Course:
Mr. [**Known lastname 64819**] is a 55yo M w/hx of CP and AML s/p MUD Allo-SCT
[**5-26**] complicated by GVHD of the skin and mucous membranes with a
hx of GIB who presented with a left lower extremity DVT and was
transferred to the [**Hospital Unit Name 153**] for hypotension sepsis and treated with
broad spectrum antibiotics as treatment. A CT abdomen/pelvis
showed possible prostatic abscess and this was later confirmed
on prostatic ultrasound. Urology were consulted and proststic
abscess not amenable to drainage. He received
Pip/Tazo/vanc/[**Doctor Last Name **] and this was changed on ID advice to
nafcillin in addition to high dose trim/sulfa. He was treated
with IV heparin drip and changed to LMWH. LV thrombus was
confirmed on echocardiogram and cardiology were consulted
recommending continued anticoagulation and repeat echo as an
out-patient. He was transferred to the floor on [**11-27**] and
remained afebrile and worked with PT with his mobility improving
on transfer to rehabilitation on [**12-6**].
.
# Sepsis and prostatic abscess: Mr [**Known lastname 64819**] [**Last Name (Titles) 28316**] a fever to
102.1F on [**11-25**] and became hypotensive requiring admission to the
[**Hospital Unit Name 153**] [**11-25**]. On arrival to the [**Hospital Unit Name 153**], pressors were initiated and a
left IJ central venous line was placed. His blood pressure
improved with dopamine and was successfully weaned off pressors
in less than 24 hours while continuing IVF boluses as needed. He
was initially placed on stress dose steroids due to risk of
adrenal insufficiency as he is on chronic prednisone. Once his
hemodynamics improved his hydrocortisone was stopped ([**2174-11-27**])
and he was resumed on his home dose of 10mg prednisone daily.
His HCT dropped slightly in the setting of intravenous
rehydration, but he did not have hematochezia, melena or
hematemesis. CT-abdomen/pelvis [**11-25**] showed a new hypodensity on
the right prostate gland concerning for abscess in addition to a
filling defect in the LV in keeping with clot. He was seen by
urology who determined that this hypodensity was not amenable to
drainage and advised IV antibiotics. Cultures were all negative
aside from a urine culture that grew Staph from [**2174-11-17**] and he
was started empirically on vancomycin, pip/tazo and
metronidazole on [**11-25**], and metronidazole was discontinued after
C.difficile toxin returned negative on [**11-27**]. He was transferred
to the BMT unit on [**11-27**] after hemodynamics were stabilised.
Follow-up urine cultures were negative and he was changed from
vanc/pip/tazo to naficillin 2g q4 on [**11-29**] in addition to
high-dose trim/sulfa to cover for prostate abscess. Prostatic
abscess was confirmed on prostatic U/S on [**12-2**]. He remained
afebrile on the unit and ID recommended a 2 week course of IV
antibiotics in addition to a 2 month course of oral trim/sulfa.
A PICC line was successfully inserted on [**12-2**] (unable to pass
axilla on left and difficult but successful insertion on right)
to complete his Abx course on Nafcillin IV to finish on [**12-9**]
and oral trim/sulfa to finish [**2175-1-23**]. He will be seen by ID
after 4 weeks of since IV antibiotic therapy with a repeat
prostatic ultrasound at that time. He will be seen by ID on [**12-29**]
and a prostate ultrasound will be repeated with an enema 1 hour
prior. He will be seen by urology (Dr [**First Name (STitle) **] on [**12-20**].
.
# DVT: Mr [**Known lastname 64819**] [**Last Name (Titles) **] with a unilateral swollen left leg
and a doppler U/S on [**11-24**] showed deep venous thrombosis
extending from the left distal common femoral vein to the
popliteal vein. He was admitted to the [**Hospital Unit Name 153**] on [**11-25**] and a
heparin IV infusion was started. He was switched to enoxaparin
on transfer to the floor. His left leg edema improved with
elevation and oral furosemide was commenced. fXa level on [**12-5**]
was 1.9 and dose was decreased to 80mg [**Hospital1 **].
.
# AML s/p allo SCT with Chronic GVHD: Stable. We continued
acyclovir, fluconazole for prophylaxis and immunosuppression for
GVHD with cyclosporine, dexamethasone+tacro swish and spit,
prednisone, restasis and tacrolimus lip ointment. He will be
seen by Dr [**Last Name (STitle) **] on [**12-12**].
.
#LV thrombus: CT Abdomen/pelvis on [**11-25**] was concerning for LV
thrombus and an echocardiogram on [**11-25**] showed LVEF 45-50%, mild
regional LV systolic dysfunction, focal apical LV akinesis with
an intracavitary thrombus 1.8 x 1.8. He was started on a
heparin IV infusion. Cardiology were consulted and recommended
continued anticoagulation with cardiology f/u and repeat ECHO as
outpatient to determine duration of treatment. Echo on [**11-28**]
showed persistent LV thrombus. He was started on metoprolol and
lisinopril as cardioprotective drugs. On [**12-5**] fXa level was
1.9 and dose was decreased from 100mg [**Hospital1 **] to 80mg [**Hospital1 **]. He will
be seen by cardiology on [**12-14**] with repeat echo in a few months.
.
# Possible clot in stomach on CT: Recent history of GI bleed.
patient was recently admitted from [**Date range (3) 64820**] for BPBPR
and melena. He underwent EGD showing erosive esophagitis without
active bleeding (at OSH in NH). Pt subsequently transferred to
[**Hospital1 18**] for further work up. CTA of Abdomen & Pelvis on [**11-8**] was
notable for possible cecal AVM without acute active bleeding.
Subsequent colonoscopy on [**11-9**] revealed moderate diverticulosis
and small clean-based shallow ulcer in the rectum without signs
of active bleeding. Patient was transfused a total of 5 units
PRBCs during this admission and was discharged to home as his
HCT stablized without further bleeding. A possible new clot was
seen in stomach on CT-abdomen/pelvis of [**11-25**]. He had no melena
or hematochezia. GI were consulted and recommended continuing
high dose PPI (pantoprazole) [**Hospital1 **] and if pt developed any sign of
GI bleeding, for repeat endoscopy. He had no recent GI bleeding
or guaiac +ve stool during his admission. He will have his
Hb/HCt closely monitored at rehab.
.
#Hyperlipidemia: We continued Pravastatin
.
# L toenail detached: L toenail fell off [**12-4**] and treated with
triamcinolone cream. This can be stopped as required by his PCP.
Medications on Admission:
ACYCLOVIR - 400 mg PO TID
CLOBETASOL - 0.05 % Ointment - Apply to affected areas TIW
CYCLOSPORINE MODIFIED - 25 mg PO BID
CYCLOSPORINE [RESTASIS] 0.05 %Dropperette - 1 dropperette ou [**Hospital1 **]
DEXAMETHASONE - 0.5 mg/5 mL Elixir - [**5-30**] ml(s) by mouth 1
time/day 5-10ml swish and spit 1 time/day prn mouth pain.
Patient mixes/swishes drug with Tacrolimus as prescribed below.
FLUCONAZOLE - 100 mg PO daily
OCTIVA - as needed for dry eyes or irritation
PENTAMIDINE [NEBUPENT] - (Dose adjustment - no new Rx) - 300 mg
Recon Soln - 300 mg(s) inh qmonth x 6 months diluted in 6ml
sterile water. Please administer via aerosol. Two puffs
albuterol
inh prior to treatment prn.
PILOCARPINE HCL 5 mg Tablet - 1 Tablet(s) by mouth TID
PRAVASTATIN - 40 mg Tablet - by mouth once a day
PREDNISONE - 10 mg Tablet PO daily
TACROLIMUS - (Prescribed by Other Provider; Dose adjustment - no
new Rx) - - 0.5mg/5ml Swish 5ml for 5 minutes then spit four
times a day PATIENT MIXES IT WITH THE DEXAMETHASONE MOUTHWASH
TACROLIMUS [PROTOPIC] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **].
[**Last Name (STitle) 27282**] - 0.1 % Ointment - Apply to lips twice a day as needed
for dryness as directed by Dr. [**Last Name (STitle) 27282**].
Medications - OTC
ACETAMINOPHEN [TYLENOL] - (OTC) - 325 mg Tablet - [**1-22**] Tablet(s)
by mouth q6-8h as needed for pain
ASPIRIN - 325 mg Tablet PO daily
DOCUSATE SODIUM [COLACE] - (Dose adjustment - no new Rx) - 100
mg Capsule - 2 Capsule(s) by mouth once a day as needed for
constipation Hold if diarrhea
FLUORIDE TOOTHPASTE - (Prescribed by Other Provider: [**Last Name (NamePattern4) **].
[**Last Name (STitle) 27282**] - Dosage uncertain
SENNA - (Prescribed by Other Provider; OTC) - 8.6 mg Tablet - 1
(One) Tablet(s) by mouth every other day as needed for
constipation
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical 3X/WEEK
(MO,WE,FR).
3. cyclosporine modified 25 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
4. cyclosporine 0.05 % Dropperette Sig: One (1) Ophthalmic
twice a day.
5. dexamethasone 0.5 mg/5 mL Elixir Sig: 5-10 MLs PO DAILY
(Daily): swish and spit 1 time/day prn mouth pain. Patient
mixes/swishes drug with Tacrolimus.
6. fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
7. pentamidine Inhalation
8. pilocarpine HCl 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
9. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. tacrolimus Oral
12. tacrolimus 0.1 % Ointment Sig: as directed Topical [**Hospital1 **] (2
times a day) as needed for lip dryness: as directed by dr.
[**Last Name (STitle) **].
13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. fluoride toothpaste Dental
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO every other day
as needed for constipation.
17. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): Continue until informed by cardiology to
stop.
18. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours) for 4 days: To stop end of
[**12-9**].
19. triamcinolone acetonide 0.1 % Cream Sig: One (1) Appl
Topical TID (3 times a day).
20. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
21. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
22. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
23. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
24. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
25. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for coughs.
26. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
27. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 weeks.
28. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-22**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
29. insulin regular human 100 unit/mL (3 mL) Insulin Pen Sig: as
per sliding scale Subcutaneous four times a day: See sliding
scale.
30. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten
(10) ML Intravenous PRN (as needed) as needed for line flush.
Disp:*qs ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**].
Discharge Diagnosis:
Primary Diagnoses:
Left Deep Venous Thrombosis
LV thrombus
Prostatic abscess and sepsis
.
Secondary diagnoses:
Acute Myeloid Leukemia s/p allo Stem Cell Transplant and chronic
Graft Versus Host Disease
Cerebral palsy
Psoriasis
UE DVT, s/p anticoagulation with Coumadin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive..
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you during your stay at the
[**Hospital1 69**]. You presented to hospital
following a painful and swollen left leg and you were found to
have a blood clot in the leg on ultrasound and you were started
on blood thinners for treatment for this. You had a fever and
your blood pressure dropped and you required transfer to the
Intensive Care Unit so you could have medication to support your
blood pressure. You were started on broad-spectrum intravenous
antibiotics and we investigated for the cause of your infection.
You were noted to have a urinary infection and a CT scan showed
an abscess in the prostate in addition to a clot in your heart.
You were seen by cardiology who recommended a prolonged
treatment with the blood thinner enoxaparin which should
continue until they advise you regarding duration of treatment
when they see you as an out-patient. You were transferred to the
floor on [**11-27**]. You had no further fevers and we continued you on
oral and IV antibiotics. You were treated with furosemide
(Lasix) for your leg swelling which improved. You had an
ultrasound of your prostate which confirmed the presence of an
abscess. You will finish IV antibiotics on [**12-9**] but will
continue oral antibiotic for a further 7 weeks. You workd with
PT and made progress and were transferred to rehabilitation on
[**12-6**]. You will be seen by Dr [**Last Name (STitle) **] on [**12-14**] and by Infectious
Diseases on [**12-29**] with a repeat prostatic ultrasound. You will be
seen by cardiology on [**12-14**] and a repeat echoardiogram will be
performed in a few months time. You will be seen by urology on
[**12-20**].
Changes to medications:
You will continue on IV nafcillin until [**12-9**]
You will continue on oral Bactrim
(Sulfamethoxazole/Trimethoprim) for a further 7 weeks
You were started on furosemide to reduce your leg swelling
ou were started on metoprolol and lisinopril for your heart rate
and blood pressure
You were started on enoxaparin (lovenox) to thin your blood and
you will continue on this until told to stop by cardiology as
this treats both your leg clot as well as the clot that was
found in your heart
You were started on oral pantoprazole to reduce the risk of
bleeding in your stomach
You were started on triamcinolone cream for your left toenail
which fell off
.
Patient instructions:
If you have a fever you must contact your primary oncologist or
if out-of-hours the BMT fellow on-call.
Followup Instructions:
The following appointments have been made for you:
Please make an appointment to see your PCP within the next 2
weeks.
Department: HEMATOLOGY/BMT
When: THURSDAY [**2174-12-12**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], Cardiology [**2174-12-14**] 10:00am
[**Hospital Ward Name 23**] Clinical Center 7
Tel: [**Telephone/Fax (1) 9832**]
Dr [**First Name (STitle) **], urology, [**2174-12-20**] 09:30
[**Hospital Ward Name 23**] Clinical Center 3
Dr [**Last Name (STitle) **], Infectious diseases [**2174-12-29**] 14:50
[**Hospital Unit Name **], [**Hospital1 18**] [**Hospital Ward Name 517**]
Tel: [**Telephone/Fax (1) 64822**]
You have a repeat prostate ultrasound booked for [**2174-12-29**] at
10am
You should present to the Radiology department which is located
on the [**Hospital1 18**] [**Hospital Ward Name 517**] Clinical Center [**Location (un) 470**] at 9am at
which point you will need a fleet enema. This must be purchased
beforehand.
|
[
"038.9",
"272.4",
"696.1",
"279.52",
"E879.8",
"429.89",
"601.2",
"205.01",
"995.91",
"V10.83",
"V12.51",
"453.40",
"343.8",
"996.85",
"453.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
32423, 32471
|
21406, 27765
|
297, 487
|
32784, 32784
|
3626, 21383
|
35465, 36719
|
3138, 3198
|
29645, 32400
|
32492, 32582
|
27791, 29622
|
32968, 35442
|
3213, 3607
|
32603, 32763
|
231, 259
|
515, 1469
|
32799, 32944
|
1491, 2936
|
2952, 3122
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,670
| 141,246
|
38010
|
Discharge summary
|
report
|
Admission Date: [**2122-8-21**] Discharge Date: [**2122-8-26**]
Date of Birth: [**2069-4-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Aortic valve stenosis. Ascending aortic aneurysm.
Major Surgical or Invasive Procedure:
[**2122-8-21**]:
1. Aortic valve replacement with a 27-mm St. [**Male First Name (un) 923**] Epic tissue
valve (reference number [**Serial Number 84901**]).
2. Ascending aorta replacement with a 28-mm Gelweave tube graft.
History of Present Illness:
This is a 53-year-old male with a history of aortic stenosis,
which is now symptomatic, and an ascending aortic aneurysm. He
had an echocardiogram which demonstrated a bicuspid aortic valve
with an aortic valve area of 0.8 cm2
and a mean gradient of 42 mmHg. He also had workup which
included a CAT scan demonstrating that his ascending aorta was
possibly 4.7 cm.
Past Medical History:
Past Medical History:
- Aortic stenosis - Bicuspid aortic valve
- Ascending aortic aneurysm
- Hypertension
- Obesity
- History of MRSA
- Recurrent diverticulitis with planned colonoscopy on [**2122-7-15**].
- Left index finger infection with MRSA
- Migraines
- Diverticulitis in past (Diverticular disease). Colectomy to be
performed in future.
Past Surgical History:
- Left inguinal hernia repair complicated by MRSA and complex
wound
healing requiring PICC and IV antibiotics @ [**Location (un) **]
- Right knee arthroscopy
- Finger surgery for washout
Social History:
Lives with wife, sales manager 20 pack-years, currently smoking
ETOH: social
Family History:
Father MI in 50's, Mother MI 6's
Sister with heart murmur
Physical Exam:
Pulse: 50 Resp: 16 O2 sat: 98%
B/P Right: 120/80 Left: 118/77
Height: 66" Weight: 218
General: WDWN in NAD
Skin: Warm, Dry and intact. Small area of scale and redness at
wrist band of watch on left wrist c/w dermatitis.
HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign, teeth in
good repair.
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: Sinus bradycardia, Nl S1-S2, III-IV/VI SEM
Abdomen: Soft [X] non-distended [X] Mild left lower quadrant
tenderness, bowel sounds + [X] Obese
Extremities: Warm [X], well-perfused [X] Edema trace LE
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Discharge:
Pertinent Results:
Echocardiogram: [**2122-8-21**]
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Aorta - Annulus: 2.8 cm <= 3.0 cm
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.3 cm <= 3.0 cm
Aorta - Ascending: *4.6 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Aortic Valve - Peak Gradient: *48 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 30 mm Hg
Aortic Valve - LVOT diam: 2.4 cm
Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildy dilated aortic root. Moderately dilated ascending
aorta Normal aortic arch diameter. Mildly dilated descending
aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed
aortic valve leaflets. Severe AS (area 0.8-1.0cm2). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta. The aortic valve is bicuspid with
a horizontal commissure. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). No aortic regurgitation is seen. Mild mitral
regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the
results at time of surgery.
POST-BYPASS: The patient is on no inotropic infusions. There is
a well-seated, well-functioning bioprosthetic valve in the
aortic position. Trace aortic regurgitation is seen. There is a
peak gradient of 31 mmHg with a mean gradient of 14 mmHg at a
cardiac output of 5.5 L/min across the aortic valve. An
echogenic pattern is seen in the ascending aorta consistent with
ascending aortic tube graft. Biventricular function remains
unchanged. The aortic arch and descending aorta are intact.
CXR:
[**2122-8-22**]: There is a residual right IJ Cordis.
Chest tubes, mediastinal drains, endotracheal tube, and feeding
tube have been removed as well. There are no residual
pneumothoraces. The heart size is grossly normal. There are some
streaky densities at the right base, likely represents
atelectasis.
[**2122-8-25**] 09:00AM BLOOD WBC-7.8 RBC-2.67* Hgb-9.3* Hct-25.2*
MCV-94 MCH-34.8* MCHC-36.9* RDW-12.8 Plt Ct-198
[**2122-8-25**] 09:00AM BLOOD Plt Ct-198
[**2122-8-26**] 07:05AM BLOOD Glucose-116* UreaN-16 Creat-0.9 Na-139
K-3.8 Cl-98 HCO3-30 AnGap-15
Brief Hospital Course:
The patient was brought to the operating room on [**2122-8-21**] where
the patient underwent Aortic valve replacement with a 27-mm St.
[**Male First Name (un) 923**] Epic tissue valve. Ascending aorta replacement with a 28-mm
Gelweave tube graft. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He tolerated the
procedure well and was transferred to the CVICU, intubated and
sedated in critical but stable condtion. He was weaned from low
dose Neo Synephrine, awoke neurologically intact and was
extubated the night of surgery. All lines and drains were
discontinued per protocol. He was begun on Beta
blockers/Aspirin, diuresed and transferred to the floor on POD
#1. He developed sternal drainage, elevated WBC on POD2 and was
started on Keflex. His sternal drainage resolved and CXR
revealed intact wires. 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 wound was healing and pain was controlled
with tylenol and low dose Ativan. The patient was discharged on
POD#5 in good condition with appropriate follow up instructions.
Sternal precautions reinforced.
Medications on Admission:
Propranolol slow release 120-mg/day
Lisinopril 20-mg [**Hospital1 **]
Amlodipine 10-mg/day
Aspirin 81-mg/day.
Miralax
Probiotics
Discharge Medications:
1. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
Disp:*14 Tablet Extended Release(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*14 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. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
Disp:*30 * Refills:*2*
5. cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 10 days.
Disp:*80 Capsule(s)* Refills:*0*
6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: then decrease to 200mg daily for 2 weeks weeks.
Disp:*28 Tablet(s)* Refills:*0*
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed.
Disp:*20 Tablet(s)* Refills:*0*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*30 Tablet(s)* Refills:*2*
12. guaifenesin 600 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO BID ().
Disp:*30 Tablet Extended Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
- Aortic stenosis - Bicuspid aortic valve
- Ascending aortic aneurysm
- Hypertension
- Obesity
- History of MRSA
- Recurrent diverticulitis with planned colonoscopy on [**2122-7-15**].
- Left index finger infection with MRSA
- Migraines
- Diverticulitis in past (Diverticular disease). Colectomy to be
performed in future.
Past Surgical History:
- Left inguinal hernia repair complicated by MRSA and complex
wound
healing requiring PICC and IV antibiotics @ [**Location (un) **]
- Right knee arthroscopy
- Finger surgery for washout
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**]
Surgeon Dr. [**Last Name (STitle) **] [**10-8**] @ 1pm [**Location (un) 551**] [**Hospital Ward Name **] Bld [**Telephone/Fax (1) 170**]
Cardiologist Dr.[**Last Name (STitle) 1911**] [**9-10**] 9AM [**Location (un) **] Office
Wound Check [**9-3**] @ 10AM [**Hospital Ward Name **] Bld [**Location (un) **]
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **] [**4-7**] 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:[**2122-8-26**]
|
[
"564.00",
"E878.2",
"530.81",
"401.9",
"562.10",
"V02.54",
"997.1",
"441.2",
"305.1",
"746.4",
"427.31",
"278.00",
"346.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.45",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
9208, 9257
|
6144, 7517
|
362, 586
|
9834, 9990
|
2550, 6121
|
10778, 11493
|
1671, 1731
|
7697, 9185
|
9278, 9601
|
7543, 7674
|
10014, 10755
|
9624, 9813
|
1746, 2531
|
271, 324
|
614, 981
|
1026, 1349
|
1577, 1655
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,518
| 161,438
|
34455
|
Discharge summary
|
report
|
Admission Date: [**2134-4-15**] Discharge Date: [**2134-4-21**]
Date of Birth: [**2099-2-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
Hypoxia and delirium
Major Surgical or Invasive Procedure:
Hip joint aspirate on [**2134-4-16**]
IR-guided lumbar puncture on [**2134-4-16**]
History of Present Illness:
Mr. [**Known lastname 79199**] is a 35 M who was brought to the ED from his sober
house tremulous, somnolent, and with slurred speech. Per report,
he took ten 1 mg pills of Xanax at 4pm on the day prior to
admission and 2 1mg Xanax tablets again on the day of admission,
3 hours prior to presentation.
In the ED, initial vs were: T 100.4 P 132 BP 165/118 R 26 O2 sat
92%. Initial chest X-ray showed bilateral patchy opacities
greater in the lower lung fields. Patient was given duonebs.
Labs were significant for a WBC of 13.0 with a bandemia of 7%.
Urine tox was positive for benzodiazepines, opiates, and
amphetamines. A right groin central venous catheter was placed.
Given fever and leukocytosis, patient was given Vancomycin and
levofloxacin. Urine and blood cultures were sent. In the ED, he
was also given 3L NS, with improvement of his heart rate. Prior
to transfer to the ICU, the patient spiked a temperature.
On arrival to the ICU, the patient's VS were T 100.8 HR 122 BP
138/61 RR 22 O2 Sat 96% on 2L. He was oriented x 3; however, he
was somnolent with slurred speech and unable to give a complete
history. He admitted to injecting cocaine and heroin prior to
admission. He also admitted to recently drinking beer. He gave
differing stories regarding his Xanax use. He admitted to some
slight shortness of breath and to cough. He also endorsed chest
tightness. He denied any nausea or recent vomiting. He also
endorsed a headache and some neck pain.
Of note, he does report a recent episode of falling on ice. He
endorses some left shoulder pain, knee pain, and right ankle
pain since this fall. It is unclear whether he hit his head in
this fall.
Past Medical History:
- Hepatitis C
- Chronic low back pain
- Polysubstance abuse
- Asthma
- Prior history of being stabbed in the chest requiring a
sternotomy and open repair with a synthetic patch. This surgery
was performed at [**Hospital1 2177**].
Social History:
Smokes 1 pack per day. Denies heavy alcohol use. Admits to
marijuana and heroin use. Reports that he rarely uses cocaine.
Family History:
Not relevant to the current admission.
Physical Exam:
INITIAL PHYSICAL EXAM ON ARRIVAL TO ICU:
Vitals: T: 100.8 BP: 138/61 P: 122 R: 22 O2: 96% on 2L
General: Somnolent, arousable to voice but quickly falls asleep,
oriented x 3
HEENT: Sclera anicteric, dry MM
Neck: supple, JVP not elevated
Lungs: Bilateral crackles, greater in the lower lung fields
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, tenderness of left shoulder, right ankle
Pertinent Results:
ADMISSION LABORATORY STUDIES:
[**2134-4-15**] 12:00PM BLOOD WBC-13.0* RBC-4.99 Hgb-16.3 Hct-47.1
MCV-95 MCH-32.7* MCHC-34.6 RDW-13.0 Plt Ct-222
[**2134-4-15**] 12:00PM BLOOD Glucose-89 UreaN-11 Creat-0.9 Na-139
K-4.4 Cl-103 HCO3-29 AnGap-11
[**2134-4-15**] 12:00PM BLOOD ALT-91* AST-71* LD(LDH)-269* CK(CPK)-187
AlkPhos-88 TotBili-0.6
[**2134-4-15**] 12:17PM BLOOD Lactate-1.7
[**2134-4-15**] 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
OTHER NOTABLE STUDIES:
[**2134-4-16**] 03:20AM BLOOD WBC-22.8*# RBC-4.72 Hgb-15.5 Hct-42.9
MCV-91 MCH-32.8* MCHC-36.0* RDW-12.6 Plt Ct-182
[**2134-4-17**] 03:46AM BLOOD HIV Ab-NEGATIVE
[**2134-4-17**] 03:46AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2134-4-17**] 03:46AM BLOOD HCV Ab-POSITIVE*
DISCHARGE LABORATORY STUDIES:
[**2134-4-20**] 06:40AM BLOOD WBC-14.7* RBC-4.89 Hgb-15.8 Hct-46.3
MCV-95 MCH-32.3* MCHC-34.1 RDW-12.5 Plt Ct-179
[**2134-4-20**] 06:40AM BLOOD Glucose-85 UreaN-14 Creat-0.9 Na-138
K-4.1 Cl-103 HCO3-27 AnGap-12
[**2134-4-19**] 12:55PM BLOOD ALT-57* AST-43* AlkPhos-54 TotBili-0.4
MICROBIOLOGY:
[**2134-4-15**] Legionella Urinary Antigen - Negative
[**2134-4-15**] SPUTUM Culture: SPARSE GROWTH Commensal Respiratory
Flora [**2134-4-15**] MRSA SCREEN MRSA SCREEN - No MRSA isolated.
[**2134-4-15**] BLOOD CULTURE - No Growth
[**2134-4-15**] URINE CULTURE - GRAM POSITIVE RODS~[**2123**]/ML.
[**2134-4-15**] BLOOD CULTURE - No Growth
[**2134-4-16**] JOINT FLUID: GRAM STAIN-Negative. No PMNs. No Growth
on Culture.
[**2134-4-16**] CSF FLUID: GRAM STAIN-Negative. No PMNs. No Growth
on Culture.
[**2134-4-16**] CSF CRYPTOCOCCAL ANTIGEN - CRYPTOCOCCAL ANTIGEN NOT
DETECTED
[**2134-4-16**] CSF FLUID: PCR negative for HSV.
[**2134-4-16**] BLOOD CULTURE - No Growth
[**2134-4-16**] Influenza Swab: DIRECT INFLUENZA A ANTIGEN TEST
Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST
Negative for Influenza B.
[**2134-4-17**] SPUTUM Culture: RARE GROWTH of commensal respiratory
flora and SPARSE GROWTH of yeast with TWO COLONIAL MORPHOLOGIES.
RADIOLOGY:
[**2134-4-15**] Portable Chest X-Ray:
1. Underpenetrated exam, presumably from patient body habitus.
2. Low lung volumes with suggestion of patchy bilateral
mid-to-lower lung opacities, which may in part relate to low
lung volumes and technique, however, multifocal infection or
edema are also a consideration depending on clinical situation.
Followup recommended and if clinically feasible, PA and lateral
views for further and better evaluation. 3. Status post median
sternotomy. Mild enlargement of the cardiac silhouette.
[**2134-4-15**] CT Head:
No definite acute intracranial process is seen. If high clinical
concern for meningitis or acute ischemia, consider MRI if
patient is able to cooperate.
[**2134-4-16**] Left Hip Plain Film: No acute abnormality. If there is
concern for a joint effusion, recommend further evaluation with
MRI.
[**2134-4-16**] CT Left Lower Extremities without contrast: No acute
abnormalities. Specifically, no evidence of osteomyelitis, hip
joint
effusion, or necrotizing fasciitis.
[**2134-4-16**] CT of the Chest, Abdomen, and Pelvis: Suboptimal timing
of the IV bolus (no peripheral line available, femoral line was
hand injected by radiologist). 1. Multifocal ground-glass lung
opacities, worse on the left, concerning for multifocal
pneumonia in appropriate clinical setting. 2. Bibasilar
opacities, more confluent, could be bibasilar atelectasis;
however, cannot exclude aspiration. 3. Moderate cardiomegaly. 4.
Small amount of free fluid in the pelvis. 5. Left renal cyst
with probable dependent punctate stones in the interpolar region
of the left kidney. No hydronephrosis. 6. Possible fatty liver,
difficult to assess with certainty post-contrast.
[**2134-4-20**] TTE: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 65%). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
arch is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. No masses or vegetations are
seen on the aortic valve. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. The pulmonary artery systolic pressure could not be
determined. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion. If clinically indicated, a
transesophageal echocardiographic examination is recommended to
exclude vegetation. IMPRESSION: no vegetations seen
Brief Hospital Course:
Mr. [**Known lastname 79199**] is a 35 year-old male with a medical history notable
for polysubstance abuse and hepatitis C. He presented with
fevers, somnolence, and hypoxia in the setting of having taking
at least cocaine, heroin, and Xanax prior to admission. He was
initially admitted to the ICU and underwent a broad infectious
evaluation that included influenza swabs, a lumbar puncture,
aspiration of his left hip, and imaging of his heart, chest,
abdomen, pelvis, and left hip/lower extremity. The left hip and
leg were evaluated as he developed a rapidly progressive rash on
his left hip shortly after admission concerning for an infected
joint and/or necrotizing fascitis. This ultimately proved to be
non-infectious and resolved without further intervention.
He was initially treated with broad-spectrum antibiotics
including treatment for pneumonia, necrotizing fasciitis,
meningitis, and herpes encephalitis. Each treatment was slowly
discontinued as his above evaluation returned negative.
Ultimately, he likely had either an aspiration pneumonitis or
bacterial community-acquired pneumonia in the setting of
polysubstance abuse. He will complete a 7-day course of
levofloxacin/moxifloxacin for community-acquired pneumonia and
return to treatment for his polysubstance abuse. Management of
specific problems outlined below.
1. Aspiration pneumonitis and/or bacterial community-acquired
pneumonia
- complete 7 days of antibiotics on [**2134-4-22**]. Received
levofloxacin as an inpatient and will complete moxifloxacin as
an outpatient.
2. Polysubstance abuse
- will return to his sober house in [**Location (un) 669**]
- he receives his Suboxone through New Horizons in [**Location (un) **]
and will be seeing them on the day of discharge at 11am
- starting to see a new psychiatrist (name unknown) in [**Hospital1 392**],
MA
3. Chronic low back pain
- He has a history of chronic opioid abuse. In an attempt to
avoid NSAIDs and Tylenol (to monitor fever curve) he initially
received small doses of morphine to control his back pain. He
was eventually restarted on his home gabapentin and the morphine
was discontinued prior to discharge.
There were no changes made to his medications and he will
follow-up with Dr. [**Last Name (STitle) 75650**] (an infectious disease doctor) as he
has no current PCP and his new psychiatrist. There were no tests
pending at discharge.
Medications on Admission:
suboxone 8mg twice daily
gabapentin 800mg four times daily
Motrin as needed for back pain
Discharge Medications:
1. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO four times
a day.
2. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for back pain.
3. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: first dose on [**4-21**] and last dose 3/17.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
polysubstance abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Lungs were clear to auscultation and oxygen saturations of 97%
on room air.
Discharge Instructions:
Dear Mr. [**Known lastname 79199**],
You were admitted with fever and confusion. We think this was
from drugs you took and a pneumonia. You are slowly improving on
antibiotics and you should continue to take them with your next
dose on [**4-21**] and your last dose on [**4-22**].
You should also continue your gabapentin for your back pain. You
have follow-up arranged with the New Horizons in [**Location (un) **] on
[**4-21**] to restart your Suboxone therapy. We made no other changes
to your medications.
You should also stop smoking. It is one of the most important
things you can do for your health.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 1955**] J.
Address: [**Location (un) 79200**], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 31449**]
Phone: [**Telephone/Fax (1) 79201**]
Appt: We have notified Dr. [**Last Name (STitle) 75650**] that you need a follow up
appt with in the next week from your hospital stay. We have
instructed them to call you at home with an appt. If you dont
hear from them by Thursday, please call them directly to book
one.
|
[
"507.0",
"724.2",
"070.54",
"493.90",
"482.9",
"348.30",
"338.29",
"304.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"03.31",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
11011, 11017
|
8128, 10527
|
327, 411
|
11091, 11091
|
3200, 5841
|
11952, 12443
|
2513, 2553
|
10668, 10988
|
11038, 11070
|
10553, 10645
|
11317, 11929
|
2568, 3181
|
267, 289
|
439, 2104
|
5850, 8105
|
11106, 11293
|
2126, 2357
|
2373, 2497
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,137
| 183,860
|
35049
|
Discharge summary
|
report
|
Admission Date: [**2120-9-15**] Discharge Date: [**2120-9-19**]
Date of Birth: [**2101-4-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest Pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 19 year old college student with no significant past
medical history, who presented with chest pain starting on the
morning of admission. He had recently had a sore throat with
frontal bilateral squeezing headache on Thursday/Friday,
sleeping most of Friday and experiencing some "cold sweats". He
also noted myalgias and rhinorrhea. He felt better on Saturday
and went out with friends and had 8 drinks. The next day, the
day of admission, he woke up and had sharp chest pains. This
pain was not positional.
.
He was seen on the day of admission at his college health
services. He was noted to have diffuse ST elevations on his EKG
and was sent to the [**Hospital1 18**] ED. He denies palpitations; he denies
diarrhea, nausea or vomiting; he denies any sick contacts; his
family lives in a rural high-tick area; he has traveled only to
[**Location (un) **] two weeks ago but nowhere else.
.
In the emergency department, his vitals on arrival were 96.3,
75, 98/58, 19, 100% RA. He received 2L NS; GI cocktail of 30 cc
maalox, 15 cc lidocaine; ibuprofen 600 mg (appears to be x2 for
total of 1200), morphine 2 mg IV x2, and an additional morphine
2 mg listed as PO but likely to be an additional dose of IV,
zofran 4 mg IV. On subsequent blood pressure check, he was
noted to be hypotensive to SBP 70s, and was given 2 L IVF with
BP to 100s. He had an echocardiogram in ED by cardiology fellow
and was noted to have trace pericardial effusion with normal
systolic function. Cardiac enzymes were positive with trop T of
1.29 and CK 1324 with MBI 9.1. He was admitted to the [**Hospital Unit Name 196**]
service with myocarditis.
Past Medical History:
Bilateral [**Last Name (un) **]-Calve-Parthes with right hip surgery 3 years ago
Social History:
He had a sexual encounter with a woman five days ago; denies any
oral sex and used condoms for intercourse; he denies any sex
with men.
-Tobacco history: none
-ETOH: drinks socially; last night had "6 beers and 2 shots";
says this is a typical night out for him; does not drink on
nights he does not go out with friends; typically goes out with
friends on weekends except in summer when he goes out more.
-Illicit drugs: denies any; specifically denies cocaine
Family History:
Aunt with lupus. No family history of early MI or diabetes.
Physical Exam:
On Admission:
VS: 102, 110/60, 74, 18, 100% Non-rebreather
GENERAL: Young well-nourished male in discomfort
HEENT: NCAT. Sclera anicteric. EOMI. No erythema or exudate.
NECK: Supple, JVP elevated to ~10-12 cm
CARDIAC: RRR, normal S1, S2. No rub. No murmurs or gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar crackles.
ABDOMEN: Soft, ND, BS+. Mildly tender to palpation.
EXTREMITIES: No c/c/e.
SKIN: No lesions or rashes on extremities or torso.
PULSES:
Right: DP 2+
Left: DP 2+
On Discharge:
VS Tm 98.3, BP 112/63/ HR 58, RR 18, O2 Sat 98% on RA
Exam otherwise not significantly different from on admission
except lung exam reveals clear to auscultation bilaterally and
no further JVD, otherwise exam unchanged and benign.
Pertinent Results:
ON ADMISSION
WBC-11.6* RBC-4.78 Hgb-14.2 Hct-40.5 MCV-85 Plt Ct-206
Neuts-81.8* Lymphs-13.6* Monos-4.2 Eos-0.3 Baso-0.2
Glucose-95 UreaN-7 Creat-0.7 Na-141 K-3.7 Cl-103 HCO3-23
ALT-29 AST-145* AlkPhos-126* TotBili-0.4
Lipase-14
CK(CPK)-1324*, cTropnT-1.29* CK-MB-118* MB Indx-9.8*
.
ON DISCHARGE:
WBC-6.4 RBC-4.14* Hgb-13.2* Hct-36.0* MCV-87 Plt Ct-346
Neuts-79.5* Lymphs-15.1* Monos-4.4 Eos-0.8 Baso-0.2
Glucose-102 UreaN-12 Creat-0.8 Na-140 K-4.3 Cl-105 HCO3-25
Calcium-8.3* Phos-3.7 Mg-1.6
BLOOD CK(CPK)-40, cTropnT-0.78* CK-MB-NotDone
.
OTHER LABS OF NOTE:
TSH-5.5*, Free T4-1.5
calTIBC-283 Ferritn-212 TRF-218
[**Doctor First Name **]= negative
..
RADIOGRAPHIC STUDIES:
.
CXR ([**2120-9-15**])
The cardiomediastinal silhouette is unremarkable. The lungs are
clear. There is no pleural effusion or focal pulmonary
consolidation.
CONCLUSION: No acute cardiopulmonary process
.
CXR ([**2120-9-16**])
In comparison with the study of earlier in this date, there is
extensive opacification at both bases consistent with pleural
effusions. No definite pulmonary vascular congestion is
appreciated. Of course, the possibility of some supervening
aspiration cannot be unequivocally excluded in the absence of a
lateral view.
.
CXR ([**2120-9-18**])
IMPRESSION: AP chest compared to [**9-16**] and 9: Previous
pleural effusions have decreased, small on both sides. Heart
size normal. Lungs clear.
.
CXR ([**2120-9-19**])
IMPRESSION: Heart size and pulmonary vascularity are normal, and
lungs are clear. No pleural effusions.
..
ECHOCARDIOGRAMS:
.
TTE ([**2120-9-15**])
CONCLUSIONS: The left atrium is normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Global
systolic function is good (cannot assess regional function).
Overall systolic function is good (LVEF >40%). Right ventricular
chamber size is normal. There is no pericardial effusion.
.
TTE ([**2120-9-16**])
CONCLUSIONS: The left atrium and right atrium are normal in
cavity size. The estimated right atrial pressure is 0-5 mmHg.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Transmitral and tissue Doppler
imaging suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Preserved global and regional biventricular systolic
function. Mild mitral regurgitation with normal valve
morphology. Compared with the prior study (images reviewed) of
[**2120-9-15**], biventricular systolic function is better defined on
the current study and appears to be normal.
.
TTE ([**2120-9-18**])
CONCLUSIONS: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. There is no
aortic valve stenosis. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion. Compared with
the prior study (images reviewed) of [**2120-9-16**], no change.
..
ELECTROCARDIOGRAM ([**2120-9-15**])
Sinus arrhythmia. Extensive ST segment elevation suggests
pericarditis.
No previous tracing available for comparison.
Brief Hospital Course:
In summary, this is a 19-year old young man with no significant
past medical history, who presented with chest pain and
dramatically elevated cardiac enzymes and diffuse ST changes
consistent with pericarditis with myocardial involvment.
# MYOCARDITIS/PERICARDITIS: The patient's initial presentation
as a young, otherwise healthy man with chest pain and diffuse ST
elevations was quite consistent with pericarditis. Grossly
elevated cardiac enzymes and signs of fluid overload/ increased
oxygen requirement suggested myocardial involvement as well.
Initial suspicion was for idiopathic or viral
myocarditis/pericarditis given epidemiology and history of viral
prodromal symptoms (sore throat, headache) as well as fever.
.
Despite this presumptive diagnosis other etiologies were
excluded with negative [**Doctor First Name **] (given family history of lupus),
negative lyme titers, normal iron studies (providing evidence
against hemochromatosis), and normal T4 (suggesting no thyroid
abnormality despite elevated TSH).
.
Regarding management, on initial presentation he was quite
tachycardic on the floor so he was given multiple fluid boluses
with the presumption of dehydration as cause. This did not seem
to help tachycardia, but the patient did have increasing oxygen
requirement leading to his transfer to the CCU after requiring
time on non-rebreather. In the CCU he received furosemide in 10
mg doses in order to help with presumptive fluid overload and
over the next day he was negative over two liters in his overall
fluid balance. He was also initially hypotensive but as this
resolved he was started on Captopril for afterload reduction so
as to not stress the heart in the acute phase of his illness.
Captopril should be continued for 3 to 6 weeks in the setting of
myocardial inflammation to prevent remodeling and ventricular
dysfunction.
.
He initially continued to have worsening chest radiographs
showing increasing pulmonary edema and by the second CCU day he
appeared quite toxic on morning exam becoming winded with as
little effort as rising from recumbent to seated. He was
diuresed and was also started on Azithromycin as mycoplasma is
one potentially treatable etiology of myocarditis/pericarditis
(mycoplasma titers pending at discharge).
.
On his third day in the CCU he began to show considerable
improvement in his symptoms with decreasing pain and dyspnea as
well as smalled oxygen requirements. His tachycardia also began
to resolve and chest radiographs improved with less dramatic
pleural effusions and interstitial markings. He had sequential
echos which repeatedly showed globally preserved systolic
function and normal EF without pericardial effusion. His pain
was well-controlled with oxycodone initially and then
acetaminophen. By the day before discharge he was maintaining
95% oxygen saturations on room air and on the day of discharge
he was pain free without analgesics and his chest radiograph had
basically resolved. He was transitioned to once a day
lisinopril at discharge for afterload reduction and
cardioprotection. He will complete one more day of a five day
course of azithromycin. He will follow up with Dr. [**Last Name (STitle) **] in
cardiology clinic.
..
# HYPOTENSION: He was hypotensive with SBP's into the 80's on
his first and second hospital days, but this improved with fluid
boluses. This did not recur.
..
# He was ordered for a cardiac, heart healthy diet.
Subcutaneous heparin for DVT prophylaxis. He remained full code
throughout the hospital course.
Medications on Admission:
None
Discharge Medications:
1. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*2 Tablet(s)* Refills:*0*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Pericarditis with myocardial involvement
Discharge Condition:
Vital signs stable; normal oxygen saturations on room air,
afebrile and pain free.
Discharge Instructions:
You were admitted due to chest pain and shortness of breath.
This was due to an inflammatory condition that affected your
heart and the lining around it. This inflammation led to fluid
accumulating in your lungs, which made you short of breath. We
gave you medications to help get rid of this fluid and started
medications to help keep your blood pressure from being high and
stressing your heart. We let you go home to complete your
recovery after we felt safe that your heart wasn't being further
damaged and you no longer needed supplementary oxygen.
.
You were started on medications to control your blood pressure
and protect your heart. You will be sent home on LISINOPRIL,
which is a once a day version of this type of medication.
Please continue to take this medication until you are told to
stop doing so by a cardiologist. You have also been started on
AZITHROMYCIN, which can treat one particular type of infection
that can cause inflammation of the heart and the sac around it.
You will need to take one more day of this antibiotic after
discharge. You may continue to take tylenol for pain control.
You can take up to 1 gram of tylenol each four hours in order
control your fever and pain. Please do not exceed this dose.
Do not drink alcohol while you are taking this much tylenol.
.
Please limit your exertion in the coming weeks. It is important
you don't exert yourself over the next few weeks in order to
allow your heart to heal.
.
Please keep all scheduled follow-up appointments as these are
important to manage your health.
.
Please return to the ED or call your doctor if you have fever
>101, increasing shortness of breath, worsening of your chest
pain, lower extremity swelling, or any other distressing changes
to your health.
Followup Instructions:
CARDIOLOGY
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time:
[**9-30**] at 4:20pm. [**Hospital Ward Name 23**] building, [**Location (un) 436**], [**Hospital Ward Name **].
Completed by:[**2120-9-20**]
|
[
"458.9",
"427.89",
"514",
"799.02",
"420.91",
"428.40",
"428.0",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11388, 11394
|
7475, 11013
|
327, 334
|
11497, 11582
|
3505, 3789
|
13391, 13670
|
2609, 2671
|
11068, 11365
|
11415, 11476
|
11039, 11045
|
11606, 13368
|
2686, 2686
|
3803, 7452
|
276, 289
|
362, 2010
|
2700, 3240
|
2032, 2115
|
2131, 2593
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,550
| 143,229
|
29212
|
Discharge summary
|
report
|
Admission Date: [**2118-12-16**] Discharge Date: [**2118-12-20**]
Date of Birth: [**2058-3-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2118-12-16**] Removal of Right Atrial Mass
History of Present Illness:
This is a 60 year old female with incidental finding of right
atrial mass on echocardiogram. Cardiac MRI in [**2118-11-4**]
confirmed right atrial mass. It was also notable for a bicuspid
aortic valve without aortic stenosis and only mild aortic
insufficiency at that time. Her ascending aorta was dilated. Her
left ventricular function was normal, and she had moderate
tricuspid regurgitation and moderate mitral regurgitation.
Follow up TEE in [**2118-11-4**] also confirmed a penduculated
mass in the right atrium, measuring 2.0 x 1.6 centimeters. TEE
showed only mild MR, mild TR and mild AI. In preperation for
surgical intervention, she underwent cardiac catheterization in
[**2118-12-5**] which showed normal coronary arteries.
Past Medical History:
Bicuspid aortic valve with ?Dilated Asc Aorta
Hypercholesterolemia
Hypothyroidism
Osteoporosis
Undeveloped Pituatary Gland with Growth Retardation and
Amenorrhea
Hiatal Hernia
Tonsillectomy
Social History:
No history of tobacco. Occasional ETOH. Currently employed as a
book keeper. Currently lives with her mother.
Family History:
No history of premature coronary artery disease
Physical Exam:
Afebrile, 110/70, 100
Very pleasant, little female in no acute distress
Skin unremarkable
Neck supple without JVD
Lungs CTA bilaterally
Heart with RR, normal s1s2, without murmur or rub
Abdomen benign
Ext warm, tr edema
Neuro alert and oriented, no focal deficits
Pulses 2+ distally
Pertinent Results:
[**2118-12-19**] 05:45AM BLOOD WBC-8.3 RBC-3.51* Hgb-10.7* Hct-31.2*
MCV-89 MCH-30.3 MCHC-34.2 RDW-13.7 Plt Ct-154
[**2118-12-19**] 05:45AM BLOOD Glucose-83 UreaN-16 Creat-0.4 Na-137
K-3.8 Cl-100 HCO3-27 AnGap-14
[**2118-12-19**] 05:45AM BLOOD Mg-2.0
[**2118-12-20**] Chest x-ray Small bilateral pleural effusions. Heart
size normal unchanged, with probable left atrial enlargement. No
pulmonary edema. No pneumothorax. Lateral view shows small
retrosternal air and fluid collection a common postoperative
finding following median sternotomy and heart surgery.
Brief Hospital Course:
Ms. [**Known lastname 57806**] was admitted and taken directly to the operating room
where Dr. [**Last Name (STitle) 914**] performed a removal of a right atrial mass.
For further surgical details, please see seperate dictated
operative note. Following the operation, she was brought to the
CSRu for invasive monitoring. She initially required atrial
pacing for junctional rhythm. Within 24 hours, she awoke
neurologically intact and was extubated without incident. She
was transfused with PRBC to maintain hematocrit near 30%. Her
heart rhythm and rate improved to sinus rhythm in the 60-80
range. Her CSRU course was otherwise uneventful and she
transferred to the SDU on postoperative day two. She remained
mostly in a normal sinus rhythm but occasional periods of
accelerated juntional rhythm were noted. She also had a short
burst of atrial fibrillation on postoperative day two. Given
junctional rhythm, beta blockade was avoided. She otherwise
continued to make clinical improvements and was eventually
cleared for discharge on postoperative day four. At time of
discharge, pathology of the right atrial mass was still pending.
She will be discharged on Lasix for persistent small bilateral
effusions.
Medications on Admission:
aspirin 81 qd
fosamax
levothyroxine
tums
multivitamin
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
8. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week.
Disp:*4 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
RA Mass - s/p removal
Bicuspid aortic valve with ?Dilated Asc Aorta
Hypercholesterolemia
Hypothyroidism
Osteoporosis
Undeveloped Pituatary Gland with Growth Retardation and
Amenorrhea
Hiatal Hernia
Tonsillectomy
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
no driving for 1 month
no lifting > 10# for 10 weeks
Followup Instructions:
with Dr. [**Last Name (STitle) 5419**] in [**1-7**] weeks
with Dr. [**Last Name (STitle) **] in [**1-7**] weeks
with Dr. [**Last Name (STitle) 914**] in [**3-9**] weeks
Completed by:[**2118-12-21**]
|
[
"429.9",
"244.9",
"272.0",
"746.4",
"511.9",
"997.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.33"
] |
icd9pcs
|
[
[
[]
]
] |
4922, 4971
|
2413, 3623
|
292, 339
|
5227, 5234
|
1827, 2390
|
5429, 5630
|
1459, 1508
|
3727, 4899
|
4992, 5206
|
3649, 3704
|
5258, 5406
|
1523, 1808
|
240, 254
|
367, 1103
|
1125, 1316
|
1332, 1443
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,051
| 113,986
|
9707
|
Discharge summary
|
report
|
Admission Date: [**2101-1-14**] Discharge Date: [**2101-1-19**]
Service: CCU
REASON FOR ADMISSION: Transfer from outside hospital for
cardiac catheterization.
HISTORY OF PRESENT ILLNESS: The patient is an 88 year old
woman with a history of hypertension who presented to an
outside hospital on [**2101-1-5**] with unstable angina with
symptomatic substernal chest pain relieved with
nitroglycerin. She was found to have slight elevation in her
troponin to 2.0 and EKG changes with anterolateral T wave
inversions. At that time she had initially refused cardiac
catheterization and was treated medically with aspirin,
Plavix and heparin drip. She became pain free for several
days. Echocardiogram at the outside hospital on [**1-9**] showed
that she had septal apical and anterior hypokinesis with an
ejection fraction of 35%. She was sent to [**Hospital1 346**] for catheterization which revealed
clean coronaries. No interventions were made. Her post-cath
course was complicated by a large right groin hematoma.
Post-cath she was initially very agitated, requiring
escalating doses of Haldol, Versed and fentanyl in the cath
lab.
PAST MEDICAL HISTORY: Hypertension. Recurrent C.diff.
Patient has taken p.o. vanco in the past. Prior GI bleed.
Right hip surgery. DVT. Appendectomy.
MEDICATIONS ON TRANSFER: Enoxaparin 60 mg b.i.d., Lopressor
12.5 b.i.d., atorvastatin 10 q.day, Ativan 0.5 to 1 mg
p.r.n., Plavix 75, aspirin, Avapro, prednisone 5 mg.
SOCIAL HISTORY: The patient has a 1.5 pack per day smoking
history for 40 years. She said she quit three years ago.
PHYSICAL EXAMINATION: On admission to the CCU patient was
complaining of a great deal of pain in the right groin. Her
exam showed that she was afebrile with temperature of 98.6,
blood pressure 111 to 134 over 46 to 53, respiratory rate
ranged in the teens and heart rate was in the 70s. She was
100% in room air. In general, she appeared to be in pain.
Pupils were anicteric. Pertinent physical findings relate
only to the right groin which showed a large, firm hematoma
measuring approximately 8 to 10 cm with ecchymosis extending
into the labia majora, the medial thigh and above the
inguinal ligament to the right flank. Pulses were
dopplerable bilaterally.
LABORATORY DATA: EKG from the outside hospital revealed
atrial fibrillation at a rate of 150 with T wave inversions
in the lateral leads. On admission to CCU hematocrit was
30.3, down from 35.5 pre-cath. Chem-7 revealed no
significant findings with BUN and creatinine of 39 and 1.1
respectively. Cardiac cath revealed a 35% ejection fraction
from LV-gram with 1+ mitral regurgitation. Coronary
angiography showed a 30% mid-LAD lesion which was not flow
limiting, otherwise there were no angiographically apparent
coronary artery lesions.
HOSPITAL COURSE:
1. Cardiovascular. Post-cath patient was admitted to the
CCU for monitoring of her large right groin hematoma. She
was in a great deal of pain and was very anxious and was
given low doses of both morphine and Ativan. That evening
patient still continued with pain and was given another low
dose of morphine and approximately 30 minutes later was found
to be very lethargic and hypotensive with blood pressure of
40s over 30s. She was given a dose of Narcan 0.2 mg and then
repeated again which caused her to become immediately much
more alert with an increase in her respiratory rate and blood
pressure after a bolus of 500 cc of normal saline. Her
hematocrit fell as low as 24. She was transfused repeatedly
to keep her hematocrit above 30. The groin hematoma remained
stable in size. Over time it began to soften. Vascular
surgery was consulted, whom patient initially refused to see.
They recommended ultrasound evaluation which revealed no
pseudoaneurysm formation nor AV fistula formation. They
recommended medical management and repeat ultrasound the
following day, which again revealed no pathologic findings.
In total she received 3 units of packed red blood cells. Her
hematocrit was stable for the 48 hours prior to discharge.
Regarding her chest pain, based on the catheterization
showing clean coronaries, it was felt that her chest pain was
likely from a GI source including reflux disease or
esophageal spasm. During one episode of chest pain she was
given Maalox, which did provide relief of her chest pain,
making that even more suggestive of a GI source. Given the
fact that she did not have any flow limiting coronary artery
disease, aspirin and Plavix were discontinued as was heparin
drip. She was continued on metoprolol which was increased to
25 mg b.i.d. She was also continued on angiotensin receptor
blocker for blood pressure control.
2. Deconditioning. The patient was seen and evaluated by
the physical therapy service who felt that it was unsafe for
her to return home. For this reason she was screened and
accepted to a rehab facility where she will be discharged.
DISCHARGE MEDICATIONS:
1. Irbesartan 150 mg p.o. q.day.
2. Metoprolol 25 mg p.o. b.i.d.
3. Lipitor 10 mg p.o. q.day.
4. Colace 100 mg p.o. b.i.d.
5. Senna one tab p.o. b.i.d. p.r.n.
6. Dulcolax 10 mg p.o./p.r. q.d. p.r.n.
7. Tylenol 325 to 650 mg q.four to six hours p.r.n.
8. Maalox 15 to 30 cc p.o. q.i.d. p.r.n.
DISCHARGE DIAGNOSES:
1. Noncardiac chest pain.
2. Status post cardiac cath complicated by large groin
hematoma.
3. Hypertension.
CONDITION ON DISCHARGE: Good.
DISPOSITION: The patient is discharged to the [**Hospital **]
rehab facility with instructions to have her hematocrit
checked two days after discharge and to be transfused if
hematocrit is less than 28. Patient was instructed to follow
up with her primary care physician in the next one to two
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Doctor Last Name 26904**]
MEDQUIST36
D: [**2101-1-19**] 11:02
T: [**2101-1-19**] 11:01
JOB#: [**Job Number 32789**]
|
[
"998.12",
"458.2",
"786.59",
"285.1",
"V15.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.53",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
5289, 5401
|
4967, 5268
|
2828, 4944
|
1622, 2811
|
202, 1154
|
1336, 1480
|
1177, 1310
|
1497, 1599
|
5426, 6007
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,543
| 171,793
|
32324
|
Discharge summary
|
report
|
Admission Date: [**2144-7-1**] Discharge Date: [**2144-7-3**]
Date of Birth: [**2064-1-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
descending thoracic aortic aneursym
Major Surgical or Invasive Procedure:
Endovascular Repair of Descending Thoracic Aortic Aneurysm with
[**Doctor Last Name 4726**] TAG
History of Present Illness:
Mr. [**Name14 (STitle) 75532**] has been followed by the vascular clinic for
some time for a descending thoracic aortic aneurysm. The
aneurysm has grown substantially over the past year and is now
6.8cm. He is admitted for endovascular repair.
Past Medical History:
Hypertension, hypercholesterolemia, gout, prostate CA
(adenocarcinoma), radiation proctitis, anemia of chronic
disease, chronic renal insufficency, AAA, descending thoracic
aortic aneurysm
PSH: AAA repair in [**2136**]
Social History:
lives at home with wife
travels to [**Country 5881**] frequently
etoh - socially
tobacco - denies
Family History:
Coronary artery disease, hypertension
Physical Exam:
afebrile
VSS
Gen: well appearing 80yom, in NAD
Lungs: CTA bilat
Card: RRR
Extremities: warm, palpable pulses bilat. Full ROM of bilat LE's
with equal strength bilat. Groin puncture wounds c/d/i
Pertinent Results:
[**2144-7-3**] 04:14AM BLOOD WBC-11.0 RBC-3.65* Hgb-9.5* Hct-28.7*
MCV-79* MCH-26.1* MCHC-33.2 RDW-17.6* Plt Ct-199
[**2144-7-2**] 03:58PM BLOOD WBC-10.3 RBC-3.68* Hgb-9.4* Hct-28.8*
MCV-78* MCH-25.5* MCHC-32.6 RDW-17.3* Plt Ct-204
[**2144-7-2**] 03:03AM BLOOD WBC-12.5* RBC-3.80* Hgb-9.7* Hct-30.0*
MCV-79* MCH-25.5* MCHC-32.4 RDW-17.4* Plt Ct-236
[**2144-7-1**] 04:06PM BLOOD Neuts-72.2* Lymphs-19.5 Monos-4.3 Eos-3.8
Baso-0.1
[**2144-7-3**] 05:04AM BLOOD PT-12.8 PTT-29.3 INR(PT)-1.1
[**2144-7-3**] 04:14AM BLOOD Glucose-126* UreaN-22* Creat-1.2 Na-138
K-3.7 Cl-102 HCO3-27 AnGap-13
[**2144-7-3**] 04:14AM BLOOD CK(CPK)-64
[**2144-7-3**] 04:14AM BLOOD Calcium-9.5 Phos-2.9 Mg-1.8
[**2144-7-2**] 03:58PM BLOOD Glucose-142* UreaN-21* Creat-1.3* Na-139
K-3.7 Cl-100 HCO3-30 AnGap-13
[**2144-7-2**] 03:03AM BLOOD Glucose-172* UreaN-22* Creat-1.2 Na-136
K-3.2* Cl-97 HCO3-30 AnGap-12
[**2144-7-1**] 04:06PM BLOOD Glucose-229* UreaN-26* Creat-1.3* Na-137
K-3.1* Cl-100 HCO3-30 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 75533**] was admitted on [**2144-7-1**] and underwent an
Endovascular repair of his descending thoracic aorta with [**Doctor Last Name **]
TAG stent. He did have a spinal drain placed intraoperatively.
He tolerated the procedure well, was awakened and found to be
neurovascularlly intact. He was transfered to the CV ICU
overnight where he remained hemodynamically and neurologically
stable overnight. His systolic blood pressure were kept in the
140-150 range. On POD 1 he was doing very well. The spinal drain
was removed and he was able to tolerate a regular diet and void
on his own. He was transfered to the step down VICU where he was
monitored closely. Mr. [**Known lastname 75533**] remained hemodynically and
neurologically stable and was able to ambulate on his own. POD2
No overnight events. VSS. All drains discontinued. Diet
advanced. On POD 3 he was stable for discharge to home. Home
medications continued. Fasting BS widely varied 100-240 range.
Will send records and discharge summary to PCP for follow up. In
addition, appointment scheduled with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**7-13**].
Medications on Admission:
ALLOPURINOL 150mg qd; Lotrel (AMLODIPINE-BENAZEPRIL) 5mg-10 mg
1 tab QAM, [**1-25**] tab QPM; ATENOLOL 25mg qd; Simvasstatin 20 qd;
HYDROCHLOROTHIAZIDE 50 qd; ASPIRIN 81 qd, Klor con 10meq daily,
Lumigan 2.5mg daily,
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): as needed.
2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Lotrel 5-10 mg Capsule Sig: One (1) Capsule PO twice a day:
Resume [**Last Name (un) **] dose of 5mg QAM, 2.5mg QPM.
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once
a day.
8. Klor-Con 10 10 mEq Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Descending Thoracic Aortic Aneurysm, s/p TEVAR [**7-1**]
PMH: Hypertension, hypercholesterolemia, gout, prostate CA
(adenocarcinoma), radiation proctitis, anemia of chronic
disease, chronic renal insufficency.
PSH: AAA repair in [**2136**]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Aortic Aneurysm Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? 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 to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-26**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? 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 lifting, pushing or pulling (greater than 10 lbs) for 4
weeks. No lifting more than 70lbs for the rest of your life
?????? 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
?????? Keep your follow up appointment to be seen in 4 weeks for post
procedure check and CTA
What to report to office:
?????? Weakness, 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 or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 week with CTA:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2144-7-30**] 2:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2144-7-30**] 2:50
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2695**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2144-10-8**] 10:00
Follow up with PCP [**Last Name (NamePattern4) **]/ [**Last Name (un) **] [**Telephone/Fax (1) 26774**] scheduled for [**7-13**]
at 230pm. This is a follow up from hospitalization and to follow
up blood sugars as you required occasional insulin while
inpatient.
Completed by:[**2144-7-3**]
|
[
"585.9",
"274.9",
"403.90",
"272.4",
"441.2",
"285.21",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.73",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
4612, 4618
|
2375, 3542
|
348, 446
|
4902, 4902
|
1368, 2352
|
7762, 8512
|
1096, 1136
|
3812, 4589
|
4639, 4881
|
3568, 3789
|
5179, 7172
|
7198, 7739
|
1151, 1349
|
273, 310
|
474, 721
|
5043, 5155
|
743, 964
|
980, 1080
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,523
| 104,932
|
41386
|
Discharge summary
|
report
|
Admission Date: [**2156-3-20**] Discharge Date: [**2156-3-22**]
Date of Birth: [**2096-5-10**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Necrotizing Pancreatitis, Abdominal Compartment Syndrome
Major Surgical or Invasive Procedure:
[**3-21**] - Exploratory Laparotomy
[**3-22**] - Exploratory Laparotomy, Total Abdominal Colectomy, Small
Bowel Resection, Partial Necrosectomy
History of Present Illness:
59 F with no significant medical history being transferred
from [**Hospital6 **] hemodinamically unstable, on 3
pressors with severe abdominal pain. Patient has a history of
heavy alcohol use, and had developed a severe abdominal pain
since 1 day prior to presentation, after drinking some alcohol
(unknown how much). Per OSH recors, pt had pain mostly in the
upper abdomen, associated with nausea and vomiting, reason why
pt
went to [**Hospital **] hospital and was found to have a necrotizing
pancreatitis. At the OSH, she was doing progressively worse
requiring intubation and 3 pressors to keep her stable. Bladder
pressures extremely high up to 200 and peak pressures in the 40s
by the time she was transferred to us.
Past Medical History:
None
Past Surgical History: None
Social History:
H/o tob. ~2 glassed red wine/day
Family History:
Mother w/ lung Ca
Physical Exam:
On Admission:
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: Firm, tense and dilated, diffusely tender to palpation,
with
severe guarding.
Ext: No LE edema, LE warm and well perfused
On Discharge: Deceased
Pertinent Results:
CT A/P (OSH): Large right and small left pleural effusion with
extensive adjacent atelectasis. Small amount of pericardial
fluid
or pericardial thickening. Small to moderate ascites with large
amount of fluid surrounding the pancreas. No free air. Segmental
mural thickening involving jejunum from treitz, secondary to
ascites vs. enteritis vs. ischemic causes
Brief Hospital Course:
The patient was seen in the emergency department and admitted
directly to the surgical icu. At the time of admission, she was
requiring three pressors to maintain a perfusing pressure. She
was taken to the operating room for a decompressive laparotomy,
and tolerate the procedure without an acute change in her
status. Her abdomen was left open with a [**Location (un) **] bag in place,
and the patient returned to the ICU overnight. Over the course
of the night, she continued to require three pressors and had
lactates ranging from [**5-20**]. Her LFTs were rising, consistent with
shock liver. Additionally, her abdominal pressures continued to
be in the upper twenties despite her open abdome. On [**3-22**] she
returned to the operating room were she was found to have
ischemia of her entire colon, ileum and large segments of the
jejunum. This was resected and the patient was left in
discontinuity. A small area of necrotic pancreas was also
resected. The patient was left with an open abdomen and returned
to the ICU. A family meeting was held regarding the patients
condition and it was determined that CMO status was most in line
with her wishes. On [**3-22**] she was made CMO and was pronounced at
16:19.
Medications on Admission:
None
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Necrotizing Pancreatitis
Mesenteric/Colonic ischemia
Abdominal Compartment Syndrome
Discharge Condition:
Deceased
Discharge Instructions:
N/a
Followup Instructions:
N/a
|
[
"995.92",
"584.9",
"276.4",
"287.5",
"557.0",
"785.52",
"423.9",
"577.0",
"511.9",
"570",
"569.83",
"729.73",
"038.9",
"305.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.82",
"96.71",
"45.62",
"39.95",
"34.04",
"38.95",
"38.91",
"52.22",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
3410, 3419
|
2107, 3327
|
359, 505
|
3546, 3556
|
1722, 2084
|
3608, 3614
|
1380, 1399
|
3382, 3387
|
3440, 3525
|
3353, 3359
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3580, 3585
|
1308, 1314
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1414, 1414
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1693, 1703
|
263, 321
|
533, 1257
|
1428, 1679
|
1279, 1285
|
1330, 1364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,264
| 193,530
|
9143
|
Discharge summary
|
report
|
Admission Date: [**2104-10-3**] Discharge Date: [**2104-10-7**]
Date of Birth: [**2061-5-10**] Sex: F
Service: MEDICINE
Allergies:
Wellbutrin / Tramadol
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43yo female w/ complicated surgical history, chronic pain
requiring narcotics, and severe Cdiff infection requiring
sub-total colectomy, who presents with lethargy for the last [**1-3**]
days, and one day of recurrent vomiting. She has been feeling
generally unwell for the last few weeks, with recurrent dizzy
spells, worsening of her chronic nausea, and a new rash on her
legs. The dizzy spells include tunnel vision, and sometimes
falls, and come on unexpectedly. The rash is a widespread,
palpable rash on her bilateral LEs; in dermatology, the rash was
thought to look like leukocytoclastic vasculitis, but the
pathology was not consistent. She was started on a trial of
topical clobetasol, that has partially improved the rash. She
also has angular chelitis and dry eyes. An extensive
rheumtologic work-up was negative. Two days ago she had a fever
at home, and many nights she has been having shaking chills.
[**9-23**] she had a positive strep throat swab and is being treated
with Penicillin, along with prophylactic PO vanco. Four days ago
she treated herself with fluconazole for a yeast infection.
Wednesday she went to see her PCP with similar, and had EKG with
ST wave flattening. Yesterday her lightheadedness was worse than
usual and she actually passed out. Today, feeling generally
unwell, and and had nausea and vomiting of clear fluid, called
her PCP and then came in.
In the ED, initial VS were: 99.5 76 64/42 18 95% RA. Abdomen
noted to be distended, KUB showed air-fluid level. NG tube put
out 100cc of gastric fluid and patient felt more comfortable.
Surgery doesn't feel like this is an acute surgical issue. They
recommended bowel rest. Tachycardic to 130s. Got 5L fluids. EKG
unconcerning. Treated hyperkalemia. BPs typically in the 80s.
Patient [**Month/Year (2) 28316**] 102.8, got Vanc/Zosyn. Access is 20G PIV.
Vitals prior to transfer were 137 117/72 100%RA 18.
On the floor, she is complaining of nausea and vomiting up clear
fluid. She appears chronically ill and uncomfortable. She has
been having more watery BMs than usual. She continues to have
chronic back pain. The rest of her ROS is negative.
Past Medical History:
Past Medical History:
- [**2103-7-26**] L5-S1 osteomyelitis and pseudomonal bacteremia,
discharged from [**Hospital1 18**] on [**2103-8-9**]
- C.diff colitis recurrent; s/p colectomy in [**2102-12-1**]
- hx of nausea, vomiting and dry heaving w/ vomiting of all
medications, with 60 lb weight loss over past yr, improved after
initiation of TPN from [**10-8**] - [**11-7**], restarted on TPN on
[**2103-5-10**] because of N, V, malnutrition with port placement
- Seizure disorder: last seizure episode over 4 yrs ago,
possibly grand mal in setting of Ultram
- Status post gastric bypass in [**2092**], revision of
jejunojejunostomy for concern for obstruction
- DJD L5-S1, facet DJD and L4-L5 annular tear.
- Systolic, diastolic congestive heart failure due to
cardiomyopathy of unclear etiology, likely viral diagnosed in
09/[**2101**]. EBV IgM negative. CMV IgM equivocal. Lyme negative.
Since then resolved
- Depression.
- Chronic back pain. Narcotic dependence for the past several
months
- Normocytic anemia per notes attributed to iron deficiency in
the past although no evidence in lab values here.
Past surgical history:
s/p gastric bypass laparoscopic [**2092**], complicated by
peritonitis,
s/p revision of jejunjejunostomy [**2092**]
s/p abdominoplasty [**2093**]
s/p total colectomy, ileostomy, g-tube [**2102-12-26**]
s/p exploratory laparotomy, adhesiolysis, closure of mesenteric
defect in [**2103-3-1**]
Social History:
Ms. [**Known lastname 18036**] lives with her mom and is on disability. She used
to work as an administrative assistant. Denies any previous or
current tobacco use, no current alcohol use. No illegal drugs or
IV drug use.Recently stopped methadone.
Family History:
Father with cirrhosis of the liver. No CAD/CVA/Cancer/DM.
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, anxious, tearful
HEENT: Sclera anicteric, NG tube in place, dry MM, oropharynx
clear, angular chelitis
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, hyperdynamic but regular, without murmurs.
Abdomen: extensive well-healed scars. Mild, diffuse tenderness
to palpation. No organomegaly.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: aaox3, CNs [**1-12**] intact, strength and sensation grossly
nl.
DISCHARGE EXAM:
***
Pertinent Results:
ADMISSION LABS:
[**2104-10-3**] 01:20PM BLOOD WBC-14.1* RBC-3.31* Hgb-9.5* Hct-29.8*
MCV-90 MCH-28.8 MCHC-31.9 RDW-13.2 Plt Ct-407
[**2104-10-3**] 01:20PM BLOOD Neuts-71.8* Lymphs-22.7 Monos-4.7 Eos-0.5
Baso-0.3
[**2104-10-3**] 01:20PM BLOOD PT-15.3* PTT-34.6 INR(PT)-1.3*
[**2104-10-3**] 01:20PM BLOOD Glucose-117* UreaN-22* Creat-1.4* Na-129*
K-6.6* Cl-98 HCO3-25 AnGap-13
[**2104-10-3**] 01:20PM BLOOD ALT-31 AST-34 AlkPhos-160* TotBili-0.4
[**2104-10-3**] 01:20PM BLOOD proBNP-597*
[**2104-10-3**] 01:20PM BLOOD cTropnT-<0.01
[**2104-10-3**] 01:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
URINE:
[**2104-10-3**] 05:40PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.002
[**2104-10-3**] 05:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
[**2104-10-3**] 05:40PM URINE RBC-<1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
[**2104-10-3**] 05:40PM URINE UCG-NEGATIVE
OTHER PERTINENT STUDIES:
***
MICROBIOLOGY:
[**2104-10-3**] BCx: ***
[**2104-10-4**] UCx: ***
[**2104-10-4**] MRSA Screen: ***
STUDIES:
[**2104-10-3**] CXR:
Stable chest x-ray examination with no acute pulmonary process
[**2104-10-3**] KUB:
***
[**2104-10-3**] CT abd/pelvis:
Moderate substantial dilatation of small bowel loops, mostly
proximal and in the right lower quadrant, some of which fluid
distended without a definite transition point and trace
perihepatic ascites. In this patient with total colectomy and
gastric bypass with widely patent anastomosis as well as air in
the rectum, overall picture could represent enteritis and ileus,
however cannot exclude early or evolving obstruction. Serial
abdominal exam and KUB would be prudent.
DISCHARGE LABS:
***
Brief Hospital Course:
Ms. [**Known lastname 18036**] is a 43yo female w/ complicated surgical history
and previous cardiomyopathy, who presents with 3 weeks of
dizziness and rash, as well as lethargy and hypotension.
# Hypotension: Most likely hypovolemia in from vomiting and poor
PO intake, with or without sepsis from infection (unclear
source). BP has been stable after IVF resuscitation. No clear
source of infection, so holding Abx. Continuing on IVF while NPO
for bowel rest. Metoprolol held on admission, restarted at
12.5mg PO BID. The patient had an AM cortisol sent which
returned low at 4.9. While not diagnostic for adrenal
insufficiency, this may be the udnerlying process for the
patient's paroxysmal hypotension, nausea and vomiting.
# Malnutrition, moderate, with hypoalbuminemia and possible
vitamin deficiency: She was seen by nutrition, who recommended
supplements and multivitamins. She stated that she does take
multivitamins and refused the supplements. Her nutritional
status, including her angular cheilitis and albumin levels,
should be followed up as an outpatient.
#Sicca: Negative workup for sjogren's syndrome. The patient had
spit pooling on physical exam, making sicca or sjorgren's highly
unlikely. Most likely etiology is drug effect from venlafaxine
and/or amitryptiline.
# Fever: Ddx infection vs vasculitic process. The source of
infection would be very unclear. CXR clear, UA clean, no clear
infection on CT abdomen. Finishing outpatient regimen for strep
throat with PCN and Cdiff ppx with PO Vanc. Resending Cdiff and
following up cultures, which was negative.
# Possible SBO: The patient was found to have a small bowel
obstruction. This resolved with conservative management, and
the patient was tolerating POs at discharge.
# Rash: Patient with diffuse b/l LE rash, ?leukocytoclastic
leukocytosis per last derm note, but not on pathology report.
This was resolving by time of discharge with clobetesol cream.
# Acute on chronic renal failure: likely pre-renal in the
setting of vomiting, worsening of chronic diarrhea and poor PO
intake. Resolved with IVF.
# Strep throat: recent positive throat culture, started on
penicillin. Unclear whether ever symptomatic. Continued PCN to
finish course, continued prophylactic PO Vanc
# Chronic diarrhea: initial work-up by GI team was negative. She
is currently empirically on PO vancomycin, which we continued.
Sent stool for Cdiff, which returned negative.
# Anxiety/depression: continued home diazepam and Effexor.
# Chronic pain: continued amitryptyline, oxycontin and PRN
oxycodone for breakthrough.
Medications on Admission:
- amitriptyline 50mg QHS
- clobetasol 0.05% ointment [**Hospital1 **]
- vitamin B-12 1,000mcg injection weekly
- desonide/econazole cream to mix
- diazepam 2mg [**Hospital1 **]
- Vitamin d2 50,000 units weekly
- fentanyl patch 75mcg/hr
- fluconazole 150mg PRN yeast infection
- folic acid 1mg daily
- levetiracetam 500mg [**Hospital1 **]
- metoprolol succinate 25mg daily for migraines
- omeprazole 40mg daily
- ondansetron 8mg Q8hrs
- oxycodone 15mg Q6hrs PRN
- oxycontin 40mg TID
- penicillin V 500mg [**Hospital1 **]
- rizatriptan 10mg daily for PRN migraines
- tizanidine 4-8mg [**Hospital1 **] PRN back pain
- vancomycin 125mg PO QID
- venlafaxine XR 300mg daily
- artificial saliva
- calcium carbonate 400mg [**Hospital1 **]
- loperamide 2mg [**Hospital1 **]
- Metamucil, thiamine
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 17 days: Continue taking your current prescription
given by Dr. [**Last Name (STitle) 438**] until finished.
3. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. tizanidine 2 mg Tablet Sig: 2-4 Tablets PO BID (2 times a
day) as needed for pain, insomnia.
6. oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6
hours) as needed for pain.
7. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
8. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Four (4)
Capsule, Ext Release 24 hr PO DAILY (Daily).
9. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-2**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
10. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
11. desonide 0.05 % Cream Sig: One (1) appl Topical twice a day.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. multivitamin Capsule Sig: One (1) Capsule PO once a day.
[**Hospital1 **]:*30 Capsule(s)* Refills:*2*
14. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
15. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
16. econazole 1 % Cream Sig: One (1) appl Topical twice a day:
Apply to lips for cracks, fissures.
17. rizatriptan 10 mg Tablet Sig: One (1) Tablet PO once a day
as needed for migraine.
Discharge Disposition:
Home
Discharge Diagnosis:
Partial small bowel obstruction.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 18036**],
You were admitted to the hospital with fever, nausea, vomiting
and [**Doctor Last Name **] blood pressure. Your fever was likely due to the strep
throat that you had, for which you received a course of
antibiotics. Your nausea and vomiting was from a partial small
bowel obstruction which has resolved with conservative
treatment.
You also had some tests to evaluate for vitamin deficiencies as
a cause of your ongoing symptoms, however your B12 and folate
levels came back in the normal range. We also spoke with the
rheumatologists concerning your dry mouth and eyes. Given the
labs that we have drawn, this is unlikely to be Sjogren's
syndrome. Some of your medications can cause chronic dry mouth
and lightheadedness, however from what you told us none of these
have been changed recently.
Finally, you had a cortisol level drawn which was slightly low
at 4.9, which indicates that you may have a condition called
adrenal insufficiency. This may be a cause of many of your
symptoms and you should discuss with Dr. [**Last Name (STitle) 438**] what further
tests you may need to confirm or disprove this diagnosis.
The following medications have been changed:
START multivitamin daily.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2104-10-16**] at 2:10 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] North [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2104-10-10**]
|
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icd9cm
|
[
[
[]
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[] |
icd9pcs
|
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11859, 11865
|
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292, 299
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13,837
| 189,371
|
10731
|
Discharge summary
|
report
|
Admission Date: [**2154-5-8**] Discharge Date: [**2154-5-17**]
Date of Birth: [**2086-7-12**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 67-year-old
woman with a past medical history significant for
longstanding diabetes mellitus and chronic renal
insufficiency as well as hypertension (which has been
difficult to control).
She awoke on the morning of admission with shortness of
breath. She took her blood pressure at home, and her
systolic blood pressure was in the 200s. Overall, she felt
unwell and could not get enough air, so she called 911 to
come to the Emergency Department.
She denied any headache that morning; although, she notes
that she did have some blurring of her vision. She denied
any chest pain or abdominal pain at home. She had good urine
output. She denied any antecedent upper respiratory tract
infection type symptoms. She denied any fevers, chills,
nausea, vomiting, dysuria, urinary frequency, constipation,
or diarrhea. Review of systems was otherwise negative.
On arrival to the Emergency Department, her blood pressure
was 264/130. She did not have any complaints at this time
except for shortness of breath. Her physical examination was
notable for bibasilar crackles with diffuse wheezing. There
was 1+ peripheral pitting edema.
In the Emergency Department, she was started on a
nitroglycerin drip and was given 15 mg of intravenous
Lopressor as well as 50 mg of oral Lopressor. At that point,
her systolic blood pressure dropped to 86/40 with a heart
rate of 38. Her nitroglycerin drip was stopped at that
point. Her blood pressure then rose to 196/94, at which
point the nitroglycerin drip was restarted, and the patient
was treated with 10 mg of intravenous hydralazine and 50 mg
of oral hydralazine.
She was then admitted to the hospital on the regular medical
floor. At that time her systolic blood pressure was in the
230s. She also reported some left upper quadrant abdominal
pain. Electrocardiogram done on admission prior to the
development of the left upper quadrant pain was unchanged
from a previous baseline electrocardiogram. After receiving
her Lopressor, with a decrease in the heart rate, the
electrocardiogram demonstrated normal sinus rhythm with
T wave inversions in V4 through V6 and leads II, III, and F.
On arrival to the floor, the patient's blood pressure
was 230, and she was complaining of left upper quadrant pain.
At that time, the electrocardiogram demonstrated a normal
sinus rhythm at 70 beats per minute, with normal axis, T wave
inversions in leads II, F, V4 through V6 with biphasic T
waves in lead V3. At that time, the patient was given 20 mg
of intravenous hydralazine along with intravenous
nitroglycerin drip without improvement in her blood pressure.
At that point, she was transferred to the Coronary Care Unit.
PAST MEDICAL HISTORY:
1. Diabetes mellitus times 20 years.
2. Chronic renal insufficiency with a baseline creatinine
of 3.
3. Gout.
4. Sarcoid times 30 years (by report, she has only had
ocular complications until now).
5. Hypertension.
MEDICATIONS ON ADMISSION: Allopurinol 200 mg p.o. q.d.,
Protonix 40 mg p.o. q.d., Lopressor 50 mg p.o. b.i.d.,
hydralazine 75 mg p.o. t.i.d., Diovan 80 mg p.o. q.d.,
Lasix 20 mg p.o. q.o.d., clonidine 0.3 mg p.o. t.i.d.,
aspirin 81 mg p.o. q.d., Colace 200 mg p.o. q.d., Tums 500 mg
p.o. t.i.d., Niferex 150 mg p.o. b.i.d.
ALLERGIES: LIPITOR and COLCHICINE (both have caused muscle
problems in the past).
SOCIAL HISTORY: She denies any tobacco or alcohol use. She
lives with her two daughters.
FAMILY HISTORY: Family history is negative for coronary
artery disease; however, her mother had a stroke.
PHYSICAL EXAMINATION ON PRESENTATION: Examination on
admission to the Intensive Care Unit revealed a temperature
of 96.9, heart rate of 68, blood pressure of 187/87,
respiratory rate of 12, oxygen saturation of 98% on 3 liters
by nasal cannula. She was in no apparent distress, lying in
bed at a 45-degree angle. Head and neck examination was
notable for jugular venous distention to 8 cm. Funduscopic
examination was difficult. No frank hemorrhages were seen.
Heart was regular in rate and rhythm with no murmurs, rubs or
gallops. There was a displaced/diffuse point of maximal
impulse. There were bibasilar crackles halfway up the
posterior lung fields. The lateral left upper quadrant of
the abdomen was tender. No clubbing or cyanosis was
demonstrated on peripheral examination.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data
revealed a white blood cell count of 6.2, hematocrit of 37.6,
platelets of 397. Sodium of 142, potassium of 3.8, blood
urea nitrogen of 31, creatinine of 3.3, glucose of 83.
Creatine kinase of 108, troponin of less than 0.3. A
urinalysis showed no evidence of a urinary tract infection.
RADIOLOGY/IMAGING: Chest x-ray demonstrated bilateral
pleural effusions with cephalization consistent with mild
heart failure.
An ultrasound of the abdomen demonstrated a normal caliber
aorta. The pancreas was not visualized. The left kidney was
11.7 cm, and the right kidney was 9.7 cm.
HOSPITAL COURSE: Ms. [**Known lastname **] was admitted to the hospital
for management of her acute congestive heart failure
exacerbation.
1. CARDIOVASCULAR: Given her hypertensive emergency, the
patient was admitted to the Coronary Care Unit. She was
started on intravenous nitroprusside for acute blood pressure
control. Her oral blood pressure medications were also
increased.
Given her nonspecific T wave inversions on electrocardiogram,
she was ruled out for myocardial infarction. Serial creatine
kinases were 90, 80, and 78. Troponins were less than 0.3,
0.7, and 0.8.
She had an echocardiogram while in the Coronary Care Unit.
This demonstrated an ejection fraction of 60%, mild left
atrial dilatation, mild right atrial dilatation, mild
symmetric left ventricular hypertrophy, and no significant
valvular disease. She was weaned off the nitroprusside drip
while in the Coronary Care Unit and converted to all oral
blood pressure medications. She was transferred out of the
Coronary Care Unit with systolic blood pressures ranging from
110 to 180.
While on the floor, her blood pressure continued to be
difficult to control with occasional bursts in systolic blood
pressures of up to 250. Her oral blood pressure medications
continued to be increased while she was on the floor. At the
time of transfer to rehabilitation, her systolic blood
pressures were running between 140 and 200. The goal of the
Renal and Cardiology consultations was a systolic blood
pressure in the range of 140 to 150.
2. RENAL: She has a history of baseline chronic renal
insufficiency with a creatinine of approximately 3. During
the course of her hospital stay, her creatinine began rising.
The creatinine peaked at 6.3.
On the fifth day of admission, her Diovan was discontinued.
The creatinine stayed elevated between 6 to 6.3 for the next
three days, and has since started to trend down. On the day
prior to discharge, the creatinine was 4.8. It was thought
that the elevation in creatinine and acute renal failure with
transient oliguria was due to a combination of the
angiotensin receptor blocker (Diovan) and transient
hypoperfusion. She was oliguric for several days, but her
urine output picked up. At the time of discharge, she was
maintaining excellent urine output.
During the course of her hospital stay, she was worked up for
a possible renal artery stenosis given her presentation of
extremely elevated blood pressure and a history of difficult
to control blood pressure on multiple antihypertensive
medications. A magnetic resonance angiography was performed
and demonstrated a moderate stenosis in the proximal left
renal artery of approximately 50% to 70% of the diameter.
There was minimal post stenotic dilatation of the renal
artery. The right renal artery was normal.
She was seen in consultation by the Renal Service and the
Cardiology Service. It was their thought that the left renal
artery stenosis was not hemodynamically significant and was
an unlikely etiology of the patient's presentation.
3. GASTROINTESTINAL: The patient complained of intermittent
left upper quadrant pain during the course of her hospital
stay. She also had several episodes of vomiting and was
intermittently nauseated. She had no evidence of
intra-abdominal pathology on an abdominal ultrasound on the
day of admission or on the magnetic resonance angiography of
the abdomen two days after admission.
A portable abdominal x-ray was performed during the course of
her hospital stay which demonstrated a nonobstructive bowel
gas pattern and a prominent amount of stool throughout the
right hemicolon. She was given standing doses of stool
softeners and given lactulose for management of her
constipation. She was also started on Reglan for the
possibility that some of this symptomatology was related to
diabetic gastroparesis.
CONDITION ON TRANSFER: Condition on transfer to
rehabilitation was good.
DISCHARGE DIAGNOSES:
1. Hypertensive emergency leading to congestive heart
failure exacerbation.
2. Acute renal failure, secondary to hypoperfusion versus
angiotensin receptor blocker.
3. Diabetes mellitus.
4. Gout.
5. Sarcoid.
6. Hypertension.
MEDICATIONS ON DISCHARGE:
1. Hydralazine 100 mg p.o. q.6h.
2. Procardia-XL 60 mg p.o. b.i.d.
3. Clonidine 0.3 mg p.o. t.i.d.
4. Labetalol 20 mg p.o. b.i.d.
5. Epogen 4000 units subcutaneous every Monday, Wednesday
and Friday.
6. Protonix 40 mg p.o. q.d.
7. Tums 500 mg p.o. t.i.d.
8. Allopurinol 100 mg p.o. q.d.
9. NPH insulin 20 units q.a.m.
10. Reglan 10 mg p.o. t.i.d. with meals and q.h.s.
11. Lactulose 15 cc p.o. q.6h.
12. Senna 2 tablets p.o. q.d. p.r.n. for constipation.
13. Tylenol 640 mg p.o. q.4-6h. p.r.n.
14. Serax 10 mg p.o. q.h.s. p.r.n.
15. Colace 100 mg p.o. t.i.d.
16. Dulcolax 10 mg p.o./p.r. q.d. p.r.n.
17. Insulin sliding-scale.
DISCHARGE FOLLOWUP/INSTRUCTIONS:
1. The patient was to follow up with her primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] will arrange
outpatient followup with a nephrologist.
2. Her blood urea nitrogen and creatinine should be checked
daily until they remain at a constant level. Of note, prior
to this admission, she had a bowel sounds creatinine of
approximately 3.
3. All of her blood pressure medications should be held if
her systolic blood pressure drops below 140.
[**First Name11 (Name Pattern1) 8207**] [**Last Name (NamePattern4) 8208**], M.D.
[**MD Number(1) 8209**]
Dictated By:[**Last Name (NamePattern1) 7787**]
MEDQUIST36
D: [**2154-5-16**] 18:37
T: [**2154-5-16**] 17:44
JOB#: [**Job Number 35107**]
|
[
"E942.6",
"564.00",
"135",
"599.0",
"250.40",
"404.93",
"274.9",
"518.82",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
3626, 5154
|
9104, 9335
|
9362, 10841
|
3135, 3517
|
5172, 9083
|
159, 2865
|
2887, 3108
|
3534, 3609
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,804
| 191,196
|
35460
|
Discharge summary
|
report
|
Admission Date: [**2128-2-14**] Discharge Date: [**2128-2-18**]
Date of Birth: [**2060-11-16**] Sex: F
Service: SURGERY
Allergies:
Fentanyl
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Intracranial hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
67F reportedly being transported from Nursing Home to ambulance
by stretcher for anticipated dialysis when she reportedly fell
to the ground, striking her head. She was found to be unconcious
and was intubated at the scene, then transferred to [**Hospital1 3325**] where a CT of the head was obtained. This study
demonstrated subarachnoid hemorrhage and a large left temporal
subdural hematoma. A significant left to right midline shift was
also noted. She was then transferred to [**Hospital1 18**] for evaluation by
Neurosurgery and Trauma services. In the ER here at [**Hospital1 18**], she
was unresponsive with fixed and dilated pupils. She was noted to
have minimal brainstem reflexes. No other traumatic injuries
were noted. An emergent Neurosurgery consultation was obtained
in the ER. After review of the films and the patient, their
recommendations were that the patient had incurred catastrophic
injuries that could not be reversed with surgical or medical
management. They explained to the patient's family that a brain
injury of this degree carried an extremely poor prognosis. She
was admitted from the ER to the Trauma SICU for further
managment.
Past Medical History:
ESRD on dialysis
PVD
IDDM
CHF
depression
arthritis
GERD
fibromyalgia
Social History:
Living in a Nursing Home. Separated from husband. [**Name (NI) **] adult
children.
Family History:
Non-contributory.
Physical Exam:
General: Pale. Cold.
Neuro: Absent corneal, gag, cough reflex. No movement. Pupils
fixed and dilated.
CV: Asystolic.
Pulm: Absent respirations.
Brief Hospital Course:
The decision was made by the family to change to the patient's
code status to DNR upon admission, however they wanted to
maintain supportive measures until family members could come to
a conclusion regarding the plan of care. The patient was
admitted to the Trauma SICU where she remained intubated and was
maintained on IVF's. No invasive interventions were performed.
Repeated neurologic examinations confirmed initially minimal
brain stem reflexes, and later in the hospital course, absent
brain stem reflexes. At no time did she exhibit any signs of
higher cortical functioning or neurologic improvement. There
were several conversations held by the ICU team, Neurosurgery,
and Neurology, with the family regarding prognosis. On hospital
day #5 she was noted to have absent brain stem reflexes and she
was not noted to be triggering the ventilator for over 24 hours.
The family then decided to change to plan of care to comfort
measures only after extensive discussion. She expired shortly
thereafter, with time of death being pronounced at 3:01PM.
Medications on Admission:
Phenylephrine gtt
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Traumatic brain injury, intracranial hemorrhage, brain death
Discharge Condition:
Expired
Discharge Instructions:
Not applicable.
Followup Instructions:
None.
|
[
"428.0",
"729.1",
"357.2",
"585.6",
"852.05",
"852.25",
"530.81",
"250.60",
"E884.4",
"707.14",
"V58.67",
"427.31",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
3053, 3062
|
1901, 2955
|
293, 299
|
3166, 3175
|
3239, 3247
|
1699, 1718
|
3024, 3030
|
3083, 3145
|
2981, 3001
|
3199, 3216
|
1733, 1878
|
230, 255
|
327, 1491
|
1513, 1583
|
1599, 1683
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,789
| 170,069
|
15470
|
Discharge summary
|
report
|
Admission Date: [**2201-1-8**] Discharge Date: [**2201-1-15**]
Date of Birth: [**2124-5-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ace Inhibitors / Sulfa (Sulfonamide Antibiotics) /
Azithromycin / Iodine-Iodine Containing / Atenolol / Metoprolol
Tartrate / Lipitor / Clindamycin
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2201-1-8**] endotracheal intubation
History of Present Illness:
Ms. [**Known lastname 3646**] is a 76 year old female with asthma requiring 2LNC at
home though no PFTs in the system and coronary artery disease
complicated by ischemic cardiomyopathy with LVEF of 35-40% on
TTE in [**2198**] who has had frequent ED visits and hospitilization
for shortness of breath this year. She recently presented to
[**Hospital1 18**] ED on [**2200-12-11**] with asthma exacerbation and tranferred
to [**Hospital **] hospital per her wish. At [**Hospital **] hospital, she was
treated for asthma exacerbation and discharged home. She saw
her PCP [**Last Name (NamePattern4) **] [**12-30**]. SBP was 172. Oxygen saturation was normal.
There was concern for running out of oxygen. Home VNA:
[**Hospital1 **] [**Location (un) 86**] VNA [**Telephone/Fax (1) 44868**] who saw her last was concerned
about her medical noncompliance with her medications. She
presented to [**Location (un) **] ED on [**1-6**] with SOB and discharged that
day without any prednsione per patient.
.
She presents to ED last night with 7 days of shortness of
breath.
.
In the ED, initial VS were: 96.9 86 173/113 36 100% 15L
nonrebreather. ABG showed 7.49/35/45. Labs were notable for
normal electrolytes, creatinine, troponin less than 0.01, BNP of
1080, HCT of 34, normal WBC and coags. CXR showed no acute
process with mild hilar congestion. EKG showed sinus rhythm
with IVCD and LVH without any acute ST-T changes compared to
prior EKG. She was given combivent nebs X 2 and solumedrol
along with magnesium for asthama exacerbatoin. She was given
levaquin for empiric coverage of community acquird pneumonia and
lasix IV 40 mg x 1 for acute on chronic systolic heart failure.
She was placed on BiPAP for hypoxemic respiratory failure with
imporvement to ABG of 7.42/42/479 and clinical improvement of
respiratory status. Four hours later, she failed weaning off
BiPAP due to increase in respiratory effort. She was
subsequently transferred to MICU for further evaluation and
management of hypoxemic respiratory failure.
.
.
On arrival to the MICU, she reports feeling slightly better
though is a poor historian and her only complain is epigastric
pain. She reports feeling short of breath for past seven days
but does not report fever, cough, chest pain, palpatations,
abdominal pain, nausea/diarrhea/joint pain/rash. She does not
report sick contacts, eating out or high sodium intake.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
1. Coronary artery disease.
2. Ischemic cardiomyopathy. EF 35-40% on ECHO in [**2198**].
3. Asthma, though no PFTs in system and no documented outside
PFTs. uses 2LNC at home
4. Lower extremity DVT that was diagnosed at [**Hospital1 2025**] at an unknown
time and was treated for an unknown length of time, but this was
many years ago.
5. Dyslipidemia.
6. Hypertension.
7. Normocytic anemia.
8. Chronic rhinosinusitis.
9. Depression.
10. Adenoid hyperplasia
Social History:
Home: Lives in [**Location 686**] with her daughter (40 y/o) and
grand-son (16 y/o). However, the patient also states that her
daughter frequently disappears from home for a few weeks at a
time because she is "mixed up in drugs." The patient does not
currently know where her daughter is or how to get in touch with
her. She is tearful and worried when talking about her home
situation.
- Exposures: The patient states that there are no pets at home.
There is no mold, dust, construction in or around the home.
- ADL: The patient is wheelchair-bound at baseline but uses a
cane to take a few steps. Her activity is limited due to
musculoskeltetal discomfort as well as dyspnea. She is able to
dress and shower by herself.
- Smoking: denies.
- EtOH: denies.
- Illicits: denies.
Family History:
She has several members of family with coronary artery disease
and heart attacks, no diabetes, no cancer reported.
Physical Exam:
PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2. , rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
ADMISSION LABS:
[**2201-1-8**] 03:45AM BLOOD WBC-5.3 RBC-3.99* Hgb-11.4* Hct-34.0*
MCV-85 MCH-28.6 MCHC-33.5 RDW-13.9 Plt Ct-308
[**2201-1-8**] 03:45AM BLOOD Neuts-57.0 Lymphs-36.4 Monos-4.3 Eos-1.8
Baso-0.4
[**2201-1-8**] 03:45AM BLOOD PT-10.7 PTT-25.4 INR(PT)-1.0
[**2201-1-8**] 03:45AM BLOOD Glucose-107* UreaN-20 Creat-1.0 Na-140
K-3.8 Cl-102 HCO3-28 AnGap-14
[**2201-1-8**] 01:19PM BLOOD ALT-15 AST-13 LD(LDH)-205 CK(CPK)-62
AlkPhos-81 TotBili-0.2
[**2201-1-8**] 04:37PM BLOOD Lipase-27
[**2201-1-8**] 03:45AM BLOOD proBNP-1080*
[**2201-1-8**] 03:53AM BLOOD cTropnT-<0.01
[**2201-1-8**] 01:19PM BLOOD CK-MB-2 cTropnT-<0.01
[**2201-1-8**] 04:37PM BLOOD CK-MB-3 cTropnT-<0.01
[**2201-1-8**] 04:37PM BLOOD Albumin-4.2 Calcium-9.9 Phos-4.0 Mg-2.4
[**2201-1-8**] 03:51AM BLOOD Type-[**Last Name (un) **] pO2-45* pCO2-35 pH-7.49*
calTCO2-27 Base XS-3 Intubat-NOT INTUBA Comment-NEBULIZER
[**2201-1-8**] 06:05PM BLOOD Lactate-8.0*
[**2201-1-8**] 11:41PM BLOOD Lactate-2.0
[**2201-1-9**] 01:55PM BLOOD Lactate-2.4*
[**2201-1-10**] 02:42AM BLOOD Lactate-1.4
[**2201-1-10**] 08:10AM BLOOD Lactate-1.3
.
Discharge Labs:
[**2201-1-15**] 05:55AM BLOOD WBC-7.9 RBC-3.23* Hgb-9.4* Hct-28.4*
MCV-88 MCH-29.1 MCHC-33.2 RDW-14.2 Plt Ct-265
[**2201-1-15**] 05:55AM BLOOD Glucose-93 UreaN-19 Creat-0.8 Na-138
K-4.3 Cl-103 HCO3-30 AnGap-9
[**2201-1-15**] 05:55AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.4
.
MICRO:
[**1-8**] BLOOD CULTURE NO GROWTH TO DATE
[**1-8**] MRSA SCREEN POSITIVE
.
IMAGING:
[**2201-1-8**] TTE: There is regional left ventricular systolic
dysfunction with inferior hypokinesis similar to prior echo in
[**2198**]. There is an inferoposterobasal left ventricular aneurysm.
Left ventricular dyssynchrony consistent with left bundle branch
block. Right ventricular chamber size and free wall motion are
normal. There is an anterior space which most likely represents
a prominent fat pad. LVEF 45%.
.
[**2201-1-9**] TEE: This study was compared to the prior study of
[**2201-1-8**].
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Complex (>4mm) atheroma in the ascending aorta. Complex (>4mm)
atheroma in the aortic arch. Complex (>4mm) atheroma in the
descending thoracic aorta. No thoracic aortic dissection.
AORTIC VALVE: Normal aortic valve leaflets (3). Moderately
thickened aortic valve leaflets. Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR. Dilated 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 monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was sedated for the TEE.
Medications and dosages are listed above (see Test Information
section). No glycopyrrolate was administered. No TEE related
complications. The patient appears to be in sinus rhythm.
Echocardiographic results were reviewed with the houseofficer
caring for the patient.
Conclusions
No atrial septal defect is seen by 2D or color Doppler.Right
ventricular systolic function is [**Doctor First Name **], with normal free wall
contractility. The ascending aorta is mildly dilated. There are
complex (>4mm) atheroma in the ascending aorta, aortic arch, and
descending thoracic aorta. No thoracic aortic dissection is seen
from the aortic root to the descending aorta at 40 cm from the
incisors. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. The aortic valve leaflets
are moderately thickened and there is moderate aortic
regurgitation.The mitral valve leaflets are mildly thickened and
there is mild mitral regurgitation. The tricuspid valve leaflets
are mildly thickened. The main pulmonary artery is dilated.
There is no pericardial effusion.
IMPRESSION: No aortic dissection seen. No saddle pulmonary
embolus seen. Dilated main PA. Normal right ventricular systolic
function. Moderate aortic regurgitation. If clinically
indicated, evaluation for smaller pulmonary emboli may be
prudent.
Compared with the prior study (images reviewed) of [**2198-11-30**], the
degree of aortic regurgitation is similar.
.
[**2201-1-9**] LUNG SCAN: INTERPRETATION: Ventilation images could not
be obtained because the patient was intubated and ventilated via
respirator.
Perfusion images in 6 views show no evidence of perfusion
defects.
Chest CT shows right lung base atelectasis.
IMPRESSION: Low likelihood ratio for recent pulmonary embolism.
.
[**2201-1-9**] CT CHEST/ABD/PELVIS: COMPARISONS: CT chest without
contrast from [**2195-6-5**].
TECHNIQUE: MDCT axial images were obtained from the thoracic
inlet to the
pubic symphysis without the administration of intravenous
contrast material. Coronal and sagittal reformats were
completed. DLP: 1088.78 mGy-cm.
CT CHEST WITHOUT CONTRAST: The thyroid gland is incompletely
visualized but unremarkable. There is no supraclavicular,
axillary, or mediastinal
lymphadenopathy. There is a central venous catheter terminating
in the distal SVC. ET tube terminates at the right mainstem
bronchus. There is an NG tube terminating within the stomach.
The heart and pericardium are notable for a small pericardial
effusion which was seen on the prior exam. There are bibasilar
opacities, which may represent aspiration vs. atelectasis or
infectious process. The airways are patent to the subsegmental
levels. There are no lung masses or nodules seen.
CT ABDOMEN WITHOUT CONTRAST: Evaluation of the intra-abdominal
solid organs and vasculature is limited without the
administration of intravenous contrast material. Given these
limitations, there are no focal liver lesions. The gallbladder,
pancreas, spleen, adrenal glands, and kidneys are unremarkable.
There is no hydronephrosis or focal lesions. Evaluation of the
bowel is limited without the administration of intravenous or
oral contrast; however, the stomach, small and intra-abdominal
large bowel are unremarkable. There is no evidence of bowel wall
thickening or pneumatosis to suggest ischemia. There is no free
fluid or free air within the abdomen. There are atherosclerotic
calcifications of the abdominal aorta extending to the iliac
arteries.
CT PELVIS: There is a Foley catheter within the bladder, which
is otherwise unremarkable. The rectum, uterus, sigmoid colon are
unremarkable. There is no free fluid or free air,
lymphadenopathy within the pelvis.
OSSEOUS STRUCTURES: Degenerative changes of the spine at
multiple levels with disc space narrowing and anterior
osteophytes of the lumbar spine. There are no suspicious lytic
or sclerotic lesions.
IMPRESSION:
1. No evidence of pneumatosis or bowel wall edema to suggest
ischemia;
however, the study is limited due to lack of contrast
administration. No
evidence of obstruction.
2. ET tube at the level of the right main stem bronchus which
needs to be
retracted.
3. Small bilateral consolidations at the lung bases which may
represent
atelectasis, aspiration, or infection.
.
[**2201-1-9**] BILATERAL LOWER EXTREMITY DOPPLERS: COMPARISON: Right
leg ultrasound [**2200-8-12**].
FINDINGS: Grayscale, color and Doppler images were obtained of
bilateral
common femoral, superficial femoral, popliteal and tibial veins.
Nonocclusive thrombus is seen at the junction of the left deep
femoral vein and common femoral vein. At this level and the
vessel does not compress appropriately. Vascular flow continues
to course past this thrombus.
Normal flow and compression is seen in the remainder of the
veins of the left leg and in all of the veins of the right leg.
IMPRESSION: Acute left DVT with nonocclusive thrombus seen at
the junction of the left deep femoral vein and the left common
femoral vein. No DVT seen in the right leg.
Brief Hospital Course:
Ms. [**Known lastname 3646**] is a 76 year old female with asthma (2LNC at home) and
CAD complicated by ischemic cardiomyopathy (LVEF of 35-40%) who
presents with hypoxemic respiratory failure.
.
# Hypoxemic respiratory failure: Likely due to asthma
exacerbation precipitated by medical noncompliance and seasonal
allergies. She was treated with albuterol and ipratroprium
nebulizers as well as methylprednisolone tapered to prednisone.
She had to be briefly intubated to resolve her hypoxia. There
was also initial concern for pulmonary embolism though unlikely
with appropriate augmentation of oxygenation on biPAP. Because
she did not improve over the course of a few hours, she
underwent a V/Q scan which was negative for PE with limitations
due to being intubated. She also underwent a TEE to assess for
aortic dissection as the cause of her shortness of breath, new
left bundle branch block, and chest pain, however this was
negative for dissection. Her LVEF was 45%, not significantly
worse from baseline in [**2198**]. Finally, she underwent a CT torso
to assess for mesenteric ischemia as a cause for her elevated
lactate, hypertension, chest pain, and shortness of breath,
however this was also negative and all lab values rapidly
corrected. The most likely cause was determined to be a
combination of asthma and heart failure.
.
# Chronic ischemic Systolic heart failure with EF of 35-40%: Her
troponins did not rise and her ECHOs did not show acute change
in LVEF. Continued home aspirin, simvastatin, and imdur. Due
to hypertensive urgency, she was initially treated aggressively
with Lasix, Imdur, and hydralazine. Her home diltiazem was
changed to amlodipine as this is the only calcium channel
blocker known to be safe in ischemic heart failure. The patient
endorses 6-pillow orthopnea and PND at home, consistent with
moderate heart failure.
.
# Medication Adherence: The patient has a very difficult time
with medication adherence, and we noted that her medication list
from her PCP is very different from that in our online system,
possibly due to the involvement of multiple specialists. We
attempted to streamline this list to the necessary respiratory
and cardiac medications. It may be necessary to adjust this
further to control her blood pressure and breathing.
.
# DVT: LE ultrasound found non-occlusive unilateral lower
extremity deep vein thrombosis. For the DVT, she was started on
heparin, transitioned to Lovenox for outpatient management. As
her daughter notes that she also has frequent clotting, it would
be helpful to do an outpatient hypercoagulable workup and
determine if the patient should be on Lovenox for 6 months or
for life.
.
# Hypertensive urgency: While in the ICU, she was treated with
nitro gtt to keep SBP < 120 to prevent flash pulmonary edema due
to LVH and systolic dysfunction. As she recovered, her PO
regimen was optimized.
.
# Hyperlipidemia: Continued simvastatin
.
# Depression: Tapered amytriptiline to 50 mg po qhs as patient
has QRS prolongation.
.
TRANSITIONAL ISSUES:
- Patient is not on ACE-I and BB due to allergies of unknown
etiology. There needs to be a discussion with her regarding
benefit of these medications. It may be possible to find drugs
in these classes that she can take despite her allergies.
- In lieu of recent data of benefit of spironolactone in
patients with systolic heart failure with any NHYA class and her
inability to take ACE-I or BB as described above, suggest
instead starting spironolactone.
- The patient will need an outpatient EGD to follow-up her GERD.
- The patient will need outpatient ENT follow-up for her
secretion management.
- We streamlined the patient's medication list and provided
blister packed medication to improve compliance. It may be
necessary to add back inhalers or blood pressure mediations (as
noted above).
- The patient's daughter states she has frequent clotting and
has used Lovenox in the past. The patient may benefit from a
hypercoagulable workup to determine if she needs Lovenox for
life.
Medications on Admission:
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler
amitriptyline 100 mg po qhs
aspirin 325 mg po qdaily
azelastine 137 mcg 2 sprays inh [**Hospital1 **]
cetirizine 10 mg po qdaily
cholecalciferol (vitamin D3) 2,000 unit Tablet po qdaily
diltiazem HCl 180 mg Capsule, Extended Release po qdaily
Nexium 40 mg po BID
fluticasone 50 mcg/Actuation Spray 2 sprays daily
fluticasone 110 mcg/Actuation Aerosol 2 puff [**Hospital1 **]
ipratropium bromide 0.02 % inh [**Hospital1 **] SOB
isosorbide mononitrate 30 mg Tablet ER po qdaily
nitroglycerin 0.3 mg Tablet SL prn
simvastatin 10 mg po qdialy
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 * Refills:*11*
2. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*11*
3. Vitamin D-3 2,000 unit Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*11*
4. diltiazem HCl 180 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*11*
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day: 2 sprays each nostril daily.
Disp:*1 unit* Refills:*11*
6. enoxaparin 150 mg/mL Syringe Sig: One (1) injection
Subcutaneous once a day.
Disp:*30 * Refills:*3*
7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*11*
8. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day: Take 30 minutes
before a meal.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*11*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Acute asthma exacerbation
SECONDARY DIAGNOSIS
Chronic systolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 3646**],
You were admitted to the hospital because you were having
shortness of breath. We think that you had an exacerbation of
your asthma which caused this. Sometimes asthma is exacerbated
by cold weather, a viral illness, or allergies. It is also
possible that your blood pressure got too high which caused
fluid to build up in your lungs and cause shortness of breath.
For a short time, you were put on a ventilator to support your
breathing and you were treated with antibiotics, steroids, and
blood pressure lowering medications.
As you improved you were transferred to a regular medicine
floor. There we continued your inhaler and antibiotics for your
breathing. We used your home medications to lower your blood
pressure.
We want to give you fewer mediations to manage, so that it is
easier to get and take your medicine. Your primary care
physician will continue to adjust this list, so please work with
Dr [**Last Name (STitle) **] to make sure your blood pressure and asthma are well
treated.
We made the following changes to your medications:
- STOP amitriptyline, aspirin, azelastine, doxepin, Nexium,
Fluticasone inhaler, iprtropium inhaler, Imdur, and
nitroglycerin
- START cetirizine for allergies
- START vitamin D
- START Flonase nasal spray for allergies
- START Lovenox injections for your blood clot
It is very important that you keep all of the follow-up
appointments listed below.
Weigh yourself every morning, call Dr [**Last Name (STitle) **] if your weight
goes up more than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Location: [**Hospital **] MEDICAL GROUP
Address: [**Street Address(2) 44869**]., [**Location (un) **],[**Numeric Identifier 8538**]
Phone: [**Telephone/Fax (1) 44870**]
Appointment: Thursday [**1-15**] at 3:00pm
Department: OTOLARYNGOLOGY (ENT)
When: WEDNESDAY [**2201-1-28**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Department: GASTROENTEROLOGY
When: FRIDAY [**2201-2-6**] at 12:30 PM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
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"272.4",
"428.0",
"401.9",
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
"88.72",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
19369, 19426
|
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|
441, 482
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2931, 3344
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381, 403
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510, 2912
|
5413, 6495
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19580, 19723
|
3366, 3835
|
3852, 4631
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,227
| 173,758
|
2348
|
Discharge summary
|
report
|
Admission Date: [**2189-2-10**] Discharge Date: [**2189-2-20**]
Date of Birth: [**2107-8-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
hematuria
Major Surgical or Invasive Procedure:
continuous bladder irrigation
History of Present Illness:
Mr. [**Known lastname 12236**] is an 81 year old gentleman with a history of
prostate cancer in remission, COPD, HTN, abestosis, dementia,
likely malignant pulmonary nodule who initially presented to
[**Hospital1 18**] ED on [**2-10**]
after 1 day of urinary incontinence and gross hematuria at home.
In ED, afebrile, BP 107/70, HR 102, RR 16, 95% RA although he
reportedly had labile HR in the ED, ranging from 80s to 140s as
well as O2 desaturation requiring 4L of NC. He was found to have
ARF with a Cr of 1.7 (from BL 1.0), and BUN in 50s. Hct was 30
at his baseline. He was found to have frank blood clots in his
urine and was started on CBI. Urology consulted and thought c/w
radiation cystitis. While in the ED he had ~ 400 mL of coffee
ground emesis although NG lavage returned on scant amounts of
coffee grounds. He was then admitted to the MICU for close
monitoring.
.
In the MICU, he was made NPO and started on IV PPI [**Hospital1 **] and
repeat Hct had dropped to 24.7 so he received 2 unit of PRBCs
with post-transfusion Hct of 27. He had no melena or maroon
stools while in the MICU but continued to have large amounts of
blood on CBI. Repeat Hct his afternoon again down to 25.7 with
repeat 25. Cr peaked at 2.5 and repeat this afternoon 2.4.
Initial WBC 13K increased to 27K in MICU and he was treated with
Cipro for presumed UTI. He has remained hemodynamically stable
with normal blood pressure and no tachycardia. Lisinopril and
verapamil have been held in the setting of GI bleeding. GI
planning to do EGD in am.
.
Currently, patient is without complaint. Denies fevers, chills,
cough, abdominal pain. He does recall feeling nauseous with
episode of hematemesis. Otherwise without complaints.
Past Medical History:
# COPD
# HTN
# Asbestosis
# Pulmonary nodule, ? malignant
- spiculated, RUL
- followed by Dr. [**Last Name (STitle) 2168**]
- No further work-up currently due to high risks of biopsy and
potential treatment
# Prostate cancer
- [**Doctor Last Name **] [**8-31**], T2a
- s/p XRT and neoadjuvant chemotherapy, hormonal therapy
- now in remission for ~ 10 years
# Larynx tumor
- approximately 10 years ago
- reportedly benign
# Cataract in R eye
# dementia, multi-infarct
# Macular degeneration
# h/o colon polyps
# h/o neck cyst removal [**2179**]
# hearing loss
# h/o lumbar compression fracture
Social History:
Patient lives with his son, who is bipolar. He used to work in
the paint industry. He also quit smoking fifteen years ago but
has a 160 pack-year history (4ppd x ~40 years). He uses a walker
at home.
Family History:
[**Name (NI) 12237**] HTN
[**Name (NI) 12238**] "oxygen problems" ([**Name2 (NI) 1818**])
Daughter- lung cancer
Physical Exam:
T: 97.4 BP: 125/52 HR: 86 RR: 19 O2 98% RA
Gen: Pleasant, cachectic male, chronically ill appearing, NAD
HEENT: Pale conjunctiva. MMM. OP clear.
NECK: Supple, No LAD. JVP low
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: Decreased BS throughout.
ABD: Thin. Firm. NT, ND. +suprapubic tenderness
EXT: WWP, No edema. Full distal pulses
SKIN: No skin breakdown
NEURO: Alert and oriented x2, knows he's in hospital. Pleasant.
Follows commands. CN 2-12 grossly intact. Moving all extremities
GU: Three way foley in place draining red urine without clots
Pertinent Results:
[**2-11**] renal u/s:
1. Mild left renal hydronephrosis. Simple left renal cyst.
2. Echogenic material within the urinary bladder presumed to be
blood clot. History of hematuria is provided. No definite
etiology for hematuria is identified and MRI could be helpful
for further evaluation.
.
[**2-10**] CXR:
In comparison with study of [**2188-8-11**], there is again
hyperexpansion of the lungs with coarseness of interstitial
markings consistent with chronic pulmonary disease. Pleural
calcification is again consistent with asbestos-related
disorder.
Tip of nasogastric tube extends only to the lower esophagus.
This information was telephoned to the referring clinician by
the resident on call.
Brief Hospital Course:
81 year old male with a history of prostate cancer in remission,
COPD, HTN, abestosis, dementia, and presumed malignant pulmonary
nodule here with hematuria, ARF, leukocytosis, and coffee ground
emesis.
.
# Coffee ground emesis: Patient had initial Hct drop although he
had no recurrent hematemesis. He underwent upper endoscopy
which revealed an ulcer at the GE junction with clot but no
evidence of active bleeding. This was not treated given its
location. Felt to be pill esophagitis vs PUD. His Hct remained
stable after 4 units of PRBCs. He was continued on PPI [**Hospital1 **] with
IV transition to po after 72 hours. His diet was advanced
following EGD without issue. He will need to have endoscopy
repeated in [**3-25**] weeks to assess for resolution per GI
recommendations.
.
# Hematuria: required CBI for >1 week while in house. Per
Urology concerned about radiation cystitis although XRT in
distant past. No obvious etiology seen on ultrasound. Patient
had persitent hematuria with clots despite multiple days of CBI.
Urology changed to larger foley catheter and after aggressive
manual irrigation, cleared multiple blood clots. A CTU was
obtained which showed nonspecific bladder wall thickening but
was otherwise unremarkable. He was continued on CBI. It was
recommended that he have outpatient cystoscopy performed. He was
continued on oxybutynin with foley in place to prevent spasm but
that was stopped once CBI discontinued to prevent urinary
retention. He was also started on flomax. He was treated with a
7 day course of cipro for possible UTI although it was never
clear that he had active infection in his urine. PSA was normal.
Foley removed upon discharge and was able to urinate
.
# ARF: Cr 1.7 on admission, from baseline 1.0. Peak in ICU 2.5
and then downtrended to settle around 1.2. Initially concern
for obstructive pathology given clots and hematuria but renal
u/s showed only unlateral hydronephrosis. Thought to be most
likely pre-renal ARF due to acute GI bleed which resolved to IVF
and blood transfusions. He had a CTU performed which showed
renal cysts without other abnormality. His lisinopril was held
in the setting of ARF.
.
# leukocytosis: unclear source at this time. Left shifted.
Given known GU pathology, would make this most likely source
although U/A was unrevealing and urine cultures were negative.
No other obvious source of infection outside GU tract. CXR
without obvious infiltrate although known lung nodule could
predispose to pneumonia or superinfection. No diarrhea. Mental
status at baseline. Could also be stress response in the setting
of GU and GI processes. WBC count trended down and he received a
7 day course of cipro.
.
# COPD: no spirometry in our system but severe emphysema on CT
chest 10/[**2188**]. Former tobacco use. He received alb/atrovent
nebs
.
# htn: normotensive in setting of GIB and verapamil and
lisinopril held. Once stabilized, BPs increased and verapamil
was restarted at low dose. Lisinopril was restarted without
change in creatinine and improvement in hypertensive episodes
.
# Code: FULL for now confirmed with HCP. However patient's PCP
feels that son who has untreated bipolar does not have capacity
to make decisions for patient. Social work and social services
involved.
.
# Comm: A family meeting was held on [**2189-2-18**] with discussion
about his HCP. Discussion included the patient's extensive care
requirements. The patient does have care requirements that
exceed those that his family is able to provide. Prior to
discharge from [**Hospital1 1501**], the PCP (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] should be
contact[**Name (NI) **])
-[**Name (NI) 449**] "[**Doctor First Name 12239**]" [**Known lastname 12236**] [**Telephone/Fax (1) 12240**]
-[**First Name8 (NamePattern2) **] [**Known lastname 12236**] [**Telephone/Fax (1) 12241**](HCP)
-[**Name (NI) **] [**Name (NI) 12236**] [**Telephone/Fax (1) 12242**]
Medications on Admission:
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg 1-2 Tablets PO BID prn
Acetaminophen 325 mg 1-2 Tablets PO Q4H as needed.
Oxybutynin Chloride 7.5 mg [**Hospital1 **]
Verapamil 360 mg Tablet Sustained Release Q24H
Ferrous Sulfate 325 mg DAILY
Multivitamin,Tx-Minerals DAILY
Lisinopril 10 mg DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Primary:
- hematuria
- acute renal failure, post-obstructive
- upper GI bleed
- acute blood loss anemia
Secondary:
- COPD
- HTN
- Asbestosis
- Pulmonary nodule, ? malignant
- Prostate cancer
- Larynx tumor
- Cataract in R eye
- dementia, multi-infarct
- Macular degeneration
- h/o colon polyps
- h/o neck cyst removal [**2179**]
- hearing loss
- h/o lumbar compression fracture
Discharge Condition:
Afebrile. Hemodynamically stable.
Discharge Instructions:
You were admitted to the hospital for blood in your urine.
Please continue to take all medications as prescribed.
.
Please follow up with your primary providers as listed below.
.
Please call your doctor or return to the hospital for fevers,
chills, chest pain, shortness of breath, recurrent blood in your
urine, decreased urine output, abdominal pain, nausea, vomiting,
blood in your stools, black stools, or any other concerns.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] 1-2 weeks after
discharge Phone: [**Telephone/Fax (1) 1579**].
.
Please have repeat endoscopy [**3-25**] wks after initial EGD.
.
Please follow up with Urology.
.
Please follow up with Dr. [**Last Name (STitle) 2168**] of Pulmonary in [**2-24**]
weeksPhone: ([**Telephone/Fax (1) 513**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
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icd9pcs
|
[
[
[]
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9458, 9550
|
4398, 8356
|
324, 355
|
9973, 10009
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3675, 4375
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2736, 2937
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,713
| 176,119
|
50308
|
Discharge summary
|
report
|
Admission Date: [**2147-4-30**] Discharge Date: [**2147-5-9**]
Date of Birth: [**2096-10-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Hypoxia and Hypotension.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname **] is a 50 year old female with paraplegia secondary to
traumatic injury with recurrent infections, noted by her husband
to be lethargic and hypoxic to 70s on RA at home.
In the ED, her vitals were T 98.6, HR 109, BP 113/79, RR 26, 79%
on 2lNC. She was given vancomycin and zosyn. SHe was given a
combivent neb as well. She was given lovenox for empiric
treatment of PE. A CTA was unable to be obtained due to lack of
peripheral IV. In the ED, her BP fell to to 79/39. She was given
1LNS.
Upon arrival to the MICU, patient denies shortness of breath.
She reports cough productive of green sputum. She denies fevers
at home. She denies chest pain, nausea, vomiting, diarrhea,
headache, neck stiffness or any other complaints. She denies
bladder pressure, dysuria, or urinary frequency. Per her
husband, her mental status is at 80%.
Of note, she had been recently discharged from [**Hospital1 18**] for UTI,
treated with irtapenem. Of note, patient hospitalized
[**Date range (1) 104917**] for PNA and was treated with 7 day course of
levaquin.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. 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:
1. T1-T2 paraplegia following MVC [**1-5**]
2. Recurrent UTIs
3. HCV, viral load suppressed after 3 months of therapy
4. H/o recurrent PNAs
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Chronic gastritis
11. H/o obstructive lung disease
12. Anemia of chronic disease
Social History:
The patient currently lives at home wiht her husband and 2
children, ages 15 and 22. Former 35 packyear smoker. Denies
current tobacco or alcohol use.
Family History:
Non-contributory.
Physical Exam:
On admission:
Vitals: T 100.2, HR 99, BP 135/60, RR 24, 100% on 6LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased breath sounds at right base, scattered wheezes,
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, + b/l LE edema w/o erythema
Pertinent Results:
Labs on admission:
[**2147-4-30**] 12:20PM BLOOD WBC-20.3*# RBC-4.19*# Hgb-12.5# Hct-36.5#
MCV-87 MCH-29.8 MCHC-34.2 RDW-16.0* Plt Ct-171
[**2147-4-30**] 12:20PM BLOOD Neuts-92* Bands-0 Lymphs-6* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2147-4-30**] 01:45PM BLOOD PT-15.9* PTT-35.1* INR(PT)-1.4*
[**2147-4-30**] 01:45PM BLOOD Glucose-105 UreaN-14 Creat-0.4 Na-137
K-4.5 Cl-98 HCO3-31 AnGap-13
[**2147-4-30**] 01:45PM BLOOD CK(CPK)-36
[**2147-4-30**] 01:45PM BLOOD cTropnT-<0.01
[**2147-5-1**] 03:30AM BLOOD Calcium-7.7* Phos-1.9* Mg-1.8
[**2147-4-30**] 12:39PM BLOOD pO2-43* pCO2-53* pH-7.41 calTCO2-35* Base
XS-6
[**2147-4-30**] 02:08PM BLOOD Lactate-0.8
Chest x-ray [**2147-4-30**]:
Persistent opacity obscuring the right hemidiaphragm, could
reflect pleural effusion, consolidation or atelectasis.
Chest x-ray [**2147-5-1**]:
Minimal change in the cardiomegaly, bibasilar opacities, and
small right pleural effusion.
Brief Hospital Course:
This is a 50 year old female with paraplegia secondonary to MVA
in [**2142**], history of recurrent resistant infections, here with
pneumonia and hypotension.
# pneumonia/sepsis: patient presented with hypotension and
radiographic evidence of bilateral pneumonia. She required
levophed for blood pressure support for a few days for SBP 70-90
range. She was given broad spectrum antibiotics for vancomycin
and zosyn. She was also worked up for other sources with a
negative urinalysis and culture, negative legionella urinary
antigen and two sputum cultures which were oral flora only. She
did come in with a PICC line in place and there was thought this
might be a source of infection but blood cultures remained
negative and the site was clean. In addition, the PICC was only
in for 10 days on admission. She completed a 7 day course of
antibiotics for healthcare associated pneumonia. She had
aggressive chest PT and incentive spirometry use. She is being
discharged on 2L NC oxygen as her oxygen saturation declined to
the mid 80's on room air with activity. Of note she has required
oxygen at home on and off prior to this admission.
# Anemia:
Baseline HCT 30-35. In the hospital she was stable at about
27-25 range. Prior studies have shown anemia of chronic disease.
Her HCT was closely monitored.
# Delirium:
She was very anxious and delirius in the ICU and a psychiatric
consult was obtained. She likely was delirius from being in the
ICU and for polypharmacy and from her illness. Her medication
regimen was optimized and cut down to help prevent delirium. She
was offered an appointment with psychopharmacology to further
help with this, but she refused. She was provided with the
number at discharge if she changes her mind.
# Chronic pain:
She was given her home methadone, baclofen, and lyrica. The
doses were lowered while she was delirius and then increased to
her home dose at discharge. She complained of significant
chronic pain not controlled since [**2147-1-2**]. She was encouraged
to follow up with the psychopharmacologist for this which she
refused and also with her PCP and SW as we explained that pain
can be affected by many things including depression.
# Hypothyroidism:
She was maintained on Levothyroxine.
# Depression:
Home Citalopram 40 mg was continued. Psychiatry and social work
consults were following along.
# Constipation:
She was on an aggressive bowel regimen to maintain her as
regular.
# Access: PICC line which was removed prior to discharge.
Medications on Admission:
Tylenol PRN
Oxycodone 5 mg prn
Pregabalin 150, 75, 150 mg
Calcium carbonate 500 mg [**Hospital1 **]
Baclofen 20, 10, 20 mg
Clonazepam 2 mg QID prn
Oxybutynin 10, 5, 10
Trazodone 100 mg qhs prn
Methadone 5 mg TID
Omeprazole 20 mg daily
Citalopram 40 mg
Levothyroxine 75 mcg daily
Nicotine 14 mg/24 hr daily
Ipratropium-Albuterol prn
Sucralfate 1 gram QID
Polyethylene Glycol 17 grams daily
Docusate Sodium 100 mg PO BID
Senna 8.6 mg [**Hospital1 **]
Ertapenem 1 gram daily completed [**2147-4-27**]
Discharge Medications:
1. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for muscle spasms.
2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Pregabalin 75 mg Capsule Sig: [**2-3**] Capsules PO TID (3 times a
day): Please take 150mg in the morning and at night. Please take
75mg in the afternoon.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily).
11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
sepsis
anxiety
anemia of chronic disease
chronic pain
paraplegia
Discharge Condition:
stable with resting oxygen saturation of 93% on RA but
ambulatory saturation of 86% on RA and 96% on 2L NC.
Discharge Instructions:
You were admitted with severe pneumonia causing sepsis (or low
blood pressure). You were treated with antibiotics and completed
the course. Your stay was complicated by delirium and anxiety
and a psychiatric consult helped us care for you.
You still require oxygen by nasal cannual at home. Please keep
2L on at all times. You should continue aggressive chest
physical therapy three times a day. Continue to use your
incentive spirometer and get out of bed to a chair as much as
possible to help your lungs expand.
You should take your medications as prescribed.
We recommend that you keep all of your appointments as written
below. We also recommend that you see a psychopharmacologist.
This appointment was not made because you did not want it, but
the number is provided below if you change your mind. This is
recommended to help you develop a working medical regimen to
help control your pain and also keep you thinking clearly and
without side effects.
You should call your doctor or go to the emergency room if you
have fevers over 102, chills, chest pain, trouble breathing,
bleeding or any other symptoms which is concerning to you.
Followup Instructions:
Social work:
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 23482**], LICSW Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2147-5-12**] 12:00
[**Hospital Ward Name 23**] building [**Location (un) **] [**Hospital1 18**] [**Hospital Ward Name **]
Hepatology:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2147-5-12**] 1:20
Primary care:
[**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2147-6-6**] 1:20
[**Hospital1 18**] [**Hospital Ward Name 23**] building [**Location (un) **]
Psychopharmacology:
[**Telephone/Fax (1) 1387**] We recommend you call and schedule an appointment.
Completed by:[**2147-5-10**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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2192, 2344
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,381
| 111,381
|
27167
|
Discharge summary
|
report
|
Admission Date: [**2110-5-2**] Discharge Date: [**2110-5-7**]
Date of Birth: [**2067-9-8**] Sex: M
Service: MEDICINE
Allergies:
Depakote / Ibuprofen
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: [**Name10 (NameIs) **] [**Name10 (NameIs) **] (ATRIUS)
Mr. [**Known lastname 66658**] is a 42 year old man with history of chronic back
pain, spinal stenosis, on chronic pain medications, as well as
hypertension, morbid obesity, and asthma, who is admitted with
acute exacerbation of his back pain. He reports that the day
prior to admission, he had returned from running errands and
started to watch the basketball game. He was lying down when he
noticed pain in his neck radiating down the spine to his
feet/legs. The pain was so intense that he had to rush to the
car (he reports that his son carried him to the car). He has
numbness and tingling in his feet but is able to ambulate with
severe pain. This had never happened before. He says that he has
had surgery in the past, and has seen multiple surgeons for
While in the ED, triage vitals were T99F, BP 170/117, HR 110, RR
14, Sat 97%. He complained of chest pain, sharp, substernal,
without radiation or associated symptoms. CXR and CTA showed no
obvious etiology. He was given Toradol x 1 and dilaudid x 1 and
subsequently admitted to the hospital for further pain control.
All systems were reviewed and are negative except as noted
above.
Additional information was obtained from the PCP: [**Name10 (NameIs) **] has a long
history of acute episodes of back pain; most of which do not
result in admission. He is quite concerned about the "tumors" in
his back (epidural lipomatosis), but his most recent MRI shows
no evidence of cord compression. He has a narcotics contract
with her.
Past Medical History:
-Hypertension, benign
-Morbid obesity
-Obstructive sleep apnea
-Esophageal reflux
-Lumbar spinal stenosis: surgery [**2-23**] at BUMC ([**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **], M.D.)
L3-L5 decompress lami, L2-S1 medial hemi-faectectomies, debulk
lipomatosis [**2105**] extensive w/u for ongoing pain: no further
surgical intervention recommended; last MRI at [**Hospital1 18**] [**3-1**]
-Epidural lipomatosis
-Asthma
-Erectile dysfunction
-Leukocytosis, unspecified
-Plantar fasciitis
Social History:
Tobacco: Yes
Alcohol: Yes
Lives with wife and son
Family History:
Noncontributory
Physical Exam:
General: Well appearing obese man in no acute distress
Vitals: T97.4F, BP 118/83, HR 74, RR 20, Sat 97%RA, pain [**8-31**]
HEENT: EOMI, PERRL
Neck: Unable to appreciate JVP due to body habitus
Heart: RRR normal S1/S2, no m/r/g
Lungs: CTA bilaterally
Abd: Soft, diffuse mild tenderness, + bowel sounds
Back: Diffuse spinal tenderness and paraspinal tenderness
Neuro: Strength 5/5 in both upper and lower extremities
bilaterally. 1+ reflexes bilaterally
Ext: Warm, well-perfused, no c/c/e
Pertinent Results:
[**2110-5-2**] 03:53AM WBC-12.3* RBC-5.02 HGB-13.9* HCT-41.6 MCV-83
MCH-27.6 MCHC-33.3 RDW-15.5
[**2110-5-2**] 03:53AM NEUTS-52.7 LYMPHS-41.1 MONOS-2.9 EOS-2.0
BASOS-1.2
[**2110-5-2**] 03:53AM PLT COUNT-366
[**2110-5-2**] 03:53AM CK-MB-1
[**2110-5-2**] 03:53AM cTropnT-LESS THAN
[**2110-5-2**] 03:53AM CK(CPK)-148
[**2110-5-2**] 03:53AM GLUCOSE-134* UREA N-14 CREAT-0.9 SODIUM-139
POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-23 ANION GAP-23*
.
CTA: No evidence of acute aortic syndromes.
.
CXR: As compared to the previous radiograph, the lung volumes
have
decreased. Newly occurred bilateral basal areas of opacity.
Although
atelectasis is the most likely diagnosis, early pneumonia cannot
be excluded. Short-term PA and lateral confirmatory radiographs
should be performed.
.
MRI OF THE THORACIC SPINE: Vertebral body height, signal, and
alignment are preserved. There is no STIR signal abnormality.
There is no disc herniation. There is prominent posterior
epidural fat, unchanged, suggestive of epidural lipomatosis.
There is thickening and calcification of the ligamentum flavum
at several levels.
There is no abnormal STIR signal in the paraspinal soft tissues.
The thoracic cord is normal in signal and morphology.
Sag T2 weighted images of the cervical spine demonstrate normal
sagittal
alignment and no cord signal abnormality. There is right neural
foraminal
narrowing at T2-3 due to prominent calcified ligamentum flavum.
MRI OF THE LUMBAR SPINE: Vertebral body height and sagittal
alignment are
preserved. The conus terminates at L1. There is normal signal
within the
conus medullaris and the cauda equina. There have been prior
laminectomies at L3 through S1. The axial images are overall
degraded by motion. There is no high-grade canal or foraminal
stenosis. Disc bulges are suggested at L4-5 and L5-S1 which do
not cause significant canal or foraminal stenosis. There does
not appear to be abnormal enhancement after the administration
of gadolinium. Given the motion degradation on the axial, it is
difficult to discern the epidural scarring described on the
prior MRI. There are some foci of susceptibility artifact in the
surgical postoperative bed at the L5-S1 level which appears
unchanged. There is subcutaneous STIR signal abnormality in the
area of the lumbar spine which is nonspecific.
IMPRESSION:
No evidence of infection involving the thoracic or lumbar spine.
No evidence of drainable fluid collection. Stable post-surgical
changes at L3 through S1.
.
ANKLE FILM:
Three views of the foot and three of the ankle show no evidence
of
acute fracture or dislocation. There is a small bony
opacification projected between the medial aspect of the talus
and the inferior projection of the medial malleolus. This most
likely represents a sequela of previous injury. No associated
soft tissue swelling is seen.
Small inferior calcaneal spur is seen. There is also a spur
arising from the posterosuperior aspect of the navicular.
.
SHOULDER FILM:
No previous images. Degenerative changes are seen about the
glenohumeral joint. The acromioclavicular joint is not
adequately assessed on any view presented, and the possibility
of subluxation cannot be excluded.
.
CTA:
1. Normal thoracic aorta with no evidence of dissection.
2. One perifissural nodule and one subpleural nodule measuring 4
mm each. If the patient has no risk factors for malignancy no
further follow up is
required.
Brief Hospital Course:
42 male with multiple medical problems including obstructive
sleep apnea and chronic back pain admitted on [**2110-5-2**] for
worsening back pain with hospital course complicated by fever
and altered mental status.
.
BACK PAIN: Patient with a longstanding history of chronic lower
back
after sustaining a fall s/p multiple spinal surgeries at outside
hospital admitted with worsening back pain with relatively
normal neurological exam. He was initially admitted to the [**Location 66659**] service and later transferred to the West service
following a brief ICU stay. During this hospital course, he
spiked a temperature to 103 requiring a cooling blanket. The
neurosurgery service was consulted for concern for infectious
spinal processes given his back pain and fever. An MRI was
performed that showed no evidence of fluid collection or
infectious spinal process or any other process requiring acute
intervention. His pain was controlled with his home dose
narcotics in addition to ketorolac, which he received for 48
hours, and lidocaine patch. On discharge he was ambulating
without assistance and felt his back pain was well controlled.
He declined follow up with the pain service to manage his back
pain as an outpatient.
.
ALTERED MENTAL STATUS: He was given higher doses of opiates in
addition to his home neurontin and benzodiazepines for pain
control. He became obtunded responding only to sternal rub. His
mentus improved with narcan and being transiently placed on
Bipap given his history of obstructive sleep apnea. Blood gas in
the ICU was consistent with chronic respiratory acidosis. He was
transferred to the ICU given his fever, worsening back pain, and
altered mental status. His mental status slowly improved over 24
hours and he was called out to the general medicine floor where
his mental status was at baseline.
.
ELEVATED CK LEVEL: The patient complained of muscle weakness and
right shoulder and foot pain during the admission. As part of
evaluation for muscle weakness and myalgia CK have been
monitored. His CK went from 100s (normal) on [**2110-5-2**] to 4500 on
[**2110-5-6**]. Several etiologies for this were considered. It is
possible that he developed rhabdomylosis in the setting of being
obtunded and not mobile for >24 hours although renal function
was at baseline at that time and electrolytes were largely
normal (urine myoglobin pending at d/c). Medication induced
secondary to increased doses of opiates was considered. An
infectious myopathy, such as a viral illness, was considered
given his fever and reports of malaise and myalgia/arthralgia.
His exam was not consistent with septic joints and blood
cultures were negative. Neuroleptic malignant syndrome was
considered given his use of risperidol although there was no
evidence of muscle rigidity or autonomic instability. The CK was
trending down to 3400 at discharge. He will follow up with his
PCP on [**Name9 (PRE) 2974**] to get his CK and chem-10 checked.
.
ACUTE RENAL FAILURE: His creatinine increased from baseline of 1
to 1.8 also with evidence of urinary retention. Urinalysis
showed trace blood with normal culture.
This was likely due to increased doses of opiates. A foley
catheter was temporarily placed and his renal function improved.
Medications were renally dosed. His renal function returned to
baseline and there he was voiding without difficulty at
discharge.
.
? PNEUMONIA: The patient had was found to have a perihilar
infiltrate on his chest film when he was being evaluated for
altered mental status and fever. He was started on broad
spectrum antibiotics in the ICU, which were transitioned to
ceftriaxone and azithromycin on the medicine floor for 48 hours.
Given the absence of respiratory complaints these were
discontinued.
.
HYPOTHYROID: TSH was borderline high and T4 was pending on
discharge. He will follow up with PCP to get rechecked in 6
weeks.
.
SHOULDER PAIN: He complained of right shoulder pain in the ICU.
Bacteremia and possible septic joint considered given joint pain
and fever but blood cultures no growth to date and exam was not
consistent with infectious etiology. An x-ray showed
degenerative changes. He was given his home dose narcotics and
ketorolac for the pain. There was rapid improvement in pain and
range of motion within 24-36 hours and he was at baseline on
discharge.
.
#ELEVATED LFT: He had a mildly elevated hepatocellular pattern
LFTs as well as LDH. This was likely due to myolysis. These will
be followed as an outpatient.
.
#
NOTE: The Chest CTA showed pulmonary nodules that needs to be
followed up with interval CT as he is a smoker and at risk for
cancer.
Medications on Admission:
- Oxycontin 80mg [**Hospital1 **]
- Percocet 5-325, 1-2 tablets Q4-6 hours PRN pain (takes 8
pills/day)
- Valium 5mg PRN back pain (takes up to 8 pills/day)
- Omeprazole 40mg [**Hospital1 **]
- Cialis 20mg PRN
- Hydrochlorothiazide 25mg daily
- Amlodipine 10mg daily
- Risperdal 4mg [**Hospital1 **]
- Fluticasone 50mcg 1-2puffs daily
- Neurontin 1200mg TID
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
3. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back spasm.
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
5. OxyContin 80 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day.
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Outpatient Lab Work
Chem-10, CK level
11. Risperidone 4 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
Back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname 66658**]. You
were admitted to [**Hospital1 18**] for back pain and fever. You had an MRI
that showed no evidence of infection or abscess. You were
evaluated by the neurosurgery service who felt there was no
indication for surgery at this time. Your pain was controlled
on your home pain regimen. You are able to walk without
assistance using your walker. Please follow up with your
primary care physician within one week.
There was evidence of temporary muscle damage during your stay
here (elevated CK level on blood test). That value was improving
at discharge. It is possible that it was due to the higher doses
of narcotics and lying in bed for several days. Please follow up
with your primary care physician this [**Name9 (PRE) 2974**] to get the level
re-checked.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 **] MEDICAL ASSOC - [**Location (un) 2277**]
INTERNAL MEDICINE DEPT
Address: [**Location (un) **], BLDG 2, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
This Friday at 9:30AM
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12527, 12575
|
6473, 7711
|
288, 294
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12629, 12629
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3036, 6450
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,047
| 177,408
|
46045
|
Discharge summary
|
report
|
Admission Date: [**2101-2-16**] Discharge Date: [**2101-2-17**]
Date of Birth: [**2031-3-13**] Sex: F
Service:
CHIEF COMPLAINT: Hypotension, low grade temperatures, and
acute mental status changes.
HISTORY OF PRESENT ILLNESS: A 69-year-old female with
end-stage renal disease requiring hemodialysis, paraplegia
x35 years, and a history of ischemic bowel who began to feel
fatigued last evening. Daughter noticed the patient had a
low grade fever of about 99 and had one episode of shaking
chills. The patient denied cough, sputum production,
dysuria, and frequency, but did have two large [**Location (un) 2452**] colored
jelly-like bowel movements last night. The patient denied
crampy abdominal pain prior to meals or after eating.
According to the daughter, the patient has had very poor po
intake over the past few days, new onset in attentiveness and
somnolence since last night. The daughter denied any
purulent discharge from the femoral A-V fistula site, but
noted some blood at the site yesterday. The patient did not
have any recent travel. No eating undercooked or raw foods
recently. Of note, the patient was recently treated for a
right toe cellulitis with Levaquin 250 mg po q day,
prescribed by Vascular Surgery which she completed. She has
not noticed any increasing erythema or swelling of the right
lower extremity. Due to her paraplegia, she cannot relay any
increased pain at that site.
Per the daughter, the patient has Stage I decubitus ulcers in
the sacral region which have been stable, and they have been
treated with wet-to-dry dressing changes tid.
Patient was also noted to have some dizziness yesterday
evening, but denied palpitations or tachycardia. The patient
did not have any episodes of chest pain, shortness of breath,
PND, or worsening peripheral edema. Over the past few days,
no recent medication changes in her hypertension regimen.
Patient was brought to the Emergency Room, where systolic
blood pressure was initially noted to be 70 mm Hg, but
quickly dropped to 40 mm Hg. The patient had a left femoral
line placed status post repeated attempts at right IJ and
right subclavian lines. The patient was given 1 liter of
normal saline rapidly with systolic blood pressure returning
to 80 mm Hg. Dizziness improved status post the normal
saline infusion. The patient was also given 1 gram of IV
Vancomycin, 1 gram of ceftriaxone, and a MICU evaluation was
requested, but pressors were not initiated in the Emergency
Room.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis secondary to
diabetes Monday, Wednesday, Friday.
2. Diabetes mellitus.
3. Hypertension.
4. Paraplegia x35 years status post secondary to
complications from epidural placement.
5. History of gallstones status post ERCP and sphincterotomy.
6. Ischemic bowel per colonoscopy at [**Hospital 1263**] Hospital
diagnosed in [**2099-11-17**].
7. Urostomy with urinary diversion.
8. Skin and decubitus ulcers status post flap followed by
Vascular Surgery who has been recently considering amputation
of some of the patient's toes due to poor vascular flow.
9. Multiple A-V graft thrombosis and clots in the past
requiring thrombectomy and graft revisions.
10. Hypercholesterolemia.
11. Chronic left shoulder pain.
12. Osteomyelitis of the ankle.
13. Tricuspid regurgitation 1+. Echocardiogram in [**12/2099**]
demonstrated an ejection fraction of greater than 55%, no
wall motion abnormalities.
14. Ulcerative colitis.
MEDICATIONS ON ADMISSION:
1. Albuterol MDI prn.
2. Nephrocaps one tablet po q day.
3. Levaquin 250 mg q day, stopped two weeks ago.
4. Zestril 10 mg po q day.
5. Asacol 800 mg po bid.
6. Humalog insulin 10 units q am, 10 units q hs.
7. Coumadin 3 mg po q hs.
8. Pepcid 20 mg po q hs.
9. Lopressor 12.5 mg po bid.
10. Doxazosin 2 mg po q day.
11. Tums 1,500 mg tid with meals.
12. Sublingual nitroglycerin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco or alcohol use. The patient has
supportive children who are active in her care.
FAMILY HISTORY: Positive family history of diabetes in
parents and siblings.
PHYSICAL EXAMINATION UPON PRESENTATION: Vital signs:
Temperature 96.1, blood pressure 85/54, heart rate 72,
respiratory rate 12. HEENT examination: Mucous membranes
dry, 2 cm cyst in the right anterior cervical region, mobile,
nontender, no erythema or purulence, no jugular venous
distention. Cardiac examination: Normal S1, S2, no murmurs,
rubs, or gallops. Tachycardic rate. Lungs are clear to
auscultation bilaterally. Abdominal examination: Positive
bowel sounds, soft, nontender, nondistended, no rebound or
guarding. Back examination: No costovertebral angle
tenderness. Stage I decubitus ulcers, no purulent discharge,
3 cm in diameter with chronic hypopigmentation, superficial
blisters, and excoriation. Extremities: Cool to touch, 1+
dorsalis pedis pulses, A-V graft with good thrill, no
purulence noted, no erythema. Numerous ulcers between toes
with dry eschar, Stage I-II ulcer on heel with surrounding
erythema. No [**Last Name (un) 5813**] or cords. Neurologic examination:
Alert and oriented times three, mildly sluggish and
responsive.
LABORATORIES UPON ADMISSION: White blood cell count 4.7,
hematocrit 31.7, platelets 229. PT 21.2, PTT 33.8, INR 3.0.
Sodium 133, potassium 4.7, chloride 92, bicarbonate 19, BUN
58, creatinine 5.8, glucose 138, ALT 20, AST 34, alkaline
phosphatase 220, albumin 2.9, T bilirubin 0.6, amylase 32,
lipase 12. CK 71, MB negative, troponin less than 0.3.
Blood cultures: No growth to date.
CHEST X-RAY: No acute cardiopulmonary disease.
ELECTROCARDIOGRAM: Sinus tachycardia at 100 beats per
minute. Q in II, no ST segment changes, but changes compared
to [**2101-1-15**].
ARTERIAL BLOOD GAS: 7.26, 33, 117, lactate 9.1.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit service and monitored very closely with the Surgery
team. Patient's differential returned revealing 46% bands,
36% neutrophils, 2% lymphocytes, and 13% metamyelocytes.
Given the patient's very high bandemia, we were quite
concerned that patient had a very severe infection. The
patient's hypotension which had initially responded to 1
liter of normal saline and IV antibiotics subsequently began
to worsen.
Patient required triple pressors, Levophed, Neo-Synephrine,
and vasopressin. Patient was electively intubated secondary
to severe metabolic acidosis with bicarbs reaching as low as
9 mEq. Patient's mental status continued to worsen. Radial
A-lines were attempted, but could not be placed secondary to
the patient's severe peripheral vascular disease and her low
flow state, as well as one arm which contained an A-V
fistula. A femoral A-line was placed by Anesthesiology.
Abdominal CT scan was done in the setting of a possible
Clostridium difficile infection versus ischemic bowel given
progressively increasing lactate level overnight, increased
up to 11.6. Abdominal CT scan revealed no gross
intraabdominal process. No thickened bowel or free air.
Patient was subsequently also given 2 units of packed red
blood cells and 5 liters of normal saline to provide volume
resuscitation. Patient was found to be in DIC subsequently
with INR rising to 7.8. Decision was made not to reverse
anticoagulation given risk of graft rethrombosis given her
past medical history.
Patient was also subsequently given 6 amps of bicarb
throughout the night, 2 mg of magnesium, 6 mg of calcium for
electrolyte replacement.
Due to the patient's severe sepsis and lack of response to
aggressive fluid resuscitation and IV antibiotics, and given
her poor prognosis, the patient was started on Xigris with a
hope that this may provide some marginal mortality benefit.
Subsequent blood cultures revealed [**11-18**] gram-positive cocci in
pairs and clusters drawn from the night before. The Surgery
team continued to follow the patient very closely and agreed
with our management, and did not believe that the patient was
a surgical candidate even if she was to have ischemic bowel.
Family meeting was called, and the patient's grave condition
was explained to the family. The patient continued to
deteriorate given Xigris therapy, Vancomycin, ceftriaxone,
Flagyl, as well as triple pressors, and aggressive
electrolyte replacement with bicarbonate and other
electrolytes. The family understood the patient's condition,
and decided to make the patient comfort measures only after
thorough discussion amongst themselves.
At that time, all antibiotics and Xigris were stopped and
patient passed away within moments of cessation of pressor
therapy. The family discussed amongst themselves and decided
that there would be no reason to pursue autopsy. Patient's
time of death was 4:30 pm on [**2101-2-17**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-697
Dictated By:[**Name8 (MD) 4712**]
MEDQUIST36
D: [**2101-4-25**] 23:00
T: [**2101-4-26**] 06:03
JOB#: [**Job Number 97998**]
|
[
"276.2",
"518.81",
"707.0",
"995.92",
"276.5",
"403.91",
"276.7",
"038.9",
"286.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.11",
"38.91",
"96.04",
"38.93",
"39.95",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4053, 5098
|
3507, 3926
|
5831, 9006
|
149, 220
|
249, 2504
|
5217, 5813
|
5122, 5202
|
2526, 3481
|
3943, 4036
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,013
| 169,831
|
1492
|
Discharge summary
|
report
|
Admission Date: [**2188-3-5**] Discharge Date: [**2188-3-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
This is an 87-year-old man with colon cancer who presents with
several months of shortness of breath, dyspnea on exertion, and
leg edema. He was initially noted to have a right pleural
effusion back on [**2188-2-25**] when his cardiologist ordered a chest CT
scan. He was seen today in the oncology clinic for evaluation
of this possible malignant effusion, and he was noted to be
hypoxic in the mid to high 80's on room air and he desaturated
to 81% with ambulation. He was referred to the ED.
He states that he has actually had slowly progressive dyspnea
over the past year or more, and that he has also had leg edema
for that same time period. He has noticed a recent worsening,
but more with fatigue, poor appetite, and decreased ability to
ambulate the same distances he was able to do before. he cannot
go up stairs. he has not had any urinary symptoms, abdominal
pain, fevers, or chills. he has had a midly productive cough.
He has brown stools, but occasionally sees a little blood.
Past Medical History:
1) sick sinus syndrome and bifascicular block s/p pacemaker [**2184**]
2) paroxysmal atrial fibrillation not on coumadin, SVT [**2185**] and
atrial flutter status post ablation
3) cataracts. declined surgery
4) Echo [**2186**]: mild-to-moderate mitral regurgitation, RA and LA
5) BPH s/p TURMP [**2187**]
6) b/l edema with skin changes
7) hard of hearing
8) hx of guiaic positive stools/GI bleeding
9) osteoarthritis
10) osteoporosis
11) subclinical hypothyroid state as per record
12) hx of syncope
13) renal insufficiency
14) right pleural effusion
Social History:
Lives alone. Former smoker with 35-pk-yrs. No longer drinking
alcohol, formerly had a couple of drinks a week.
Family History:
brother had [**Name2 (NI) 500**] marrow stem cell transplant at age 82
Sister died from heart attack. Also had an unknown cancer.
Mother died from an unknown cancer.
Neice has unknown cancer.
Physical Exam:
T 98.0, HR 70, BP 120/81, RR 16, O2 sat 88-93% on 3-4L NC
GEN: Alert and oriented. NAD.
HEENT: Supple neck. Anicteric sclera. Slightly dry MM. No
cervical LAD.
CV: RRR, II/VI systolic murmur at LLSB
LUNGS: Decreased BS and + dullness at right base. Some coarse
BS at the left base.
ABD: Soft, mildly protuberant. Nontender.
EXT: Chronic venous stasis changes in both legs with 1+
bilateral pitting edema of the legs.
NEURO: A+O. Non-focal.
Pertinent Results:
CT ABD:
1. No definite evidence of central venous thrombosis although
the
opacifications of the veins is suboptimal.
2. Probable "apple core" lesion in the hepatic flexure of the
colon, which may be the area of suspected cancer. Please
correlate with other history.
3. New patchy opacity in the left lower lobe could represent
aspiration or developing pneumonia.
4. Large right-sided pleural effusion with associated lower
lobe atelectasis, similar in appearance to the prior study.
5. Bilateral kidney cysts, the largest of which are simple
fluid attenuation.
6. Enlarged prostate with central calcifications
CXR: Two views are compared with radiographs dated [**2-26**] and the
recent
[**2188-2-25**] chest CT. There is cardiomegaly with pulmonary vascular
congestion and blurring and interstitial edema, as before. The
moderately large layering right pleural effusion is not much
changed. The moderately severe centrilobular emphysema and
several bilateral upper lobe pulmonary nodules are better
appreciated on the cross-sectional study.
CXR [**2188-3-24**]: IMPRESSION: PA and lateral chest compared to
[**3-5**] through [**3-22**]. Small bilateral pleural effusions
have both decreased since [**3-22**], but severe right basal
atelectasis has worsened. Top normal heart size unchanged.
Transvenous right atrial and right ventricular pacer leads are
unchanged in their respective positions. Upper lungs clear. No
pneumothorax.
CXR [**2188-3-27**]: IMPRESSION: Slight improvement in pleural effusions
and left lower lobe atelectasis, but persistent right middle and
lower lobe atelectasis.
CXT [**2188-3-31**]: IMPRESSION: Stable unchanged bilateral
small-to-moderate pleural effusions and persistent unchanged
left lower lobe atelectasis and right middle and lower lobe
atelectasis.
[**2188-3-28**] VQ Scan: IMPRESSION: Stable unchanged bilateral
small-to-moderate pleural effusions and persistent unchanged
left lower lobe atelectasis and right middle and lower lobe
atelectasis.
GLUCOSE-97 UREA N-26* CREAT-1.3* SODIUM-145 POTASSIUM-4.8
CHLORIDE-108 TOTAL CO2-31 ANION GAP-11
WBC-4.9 HCT-34.1* MCV-93 [**2188-3-5**] PLT 225
(NEUTS-69.6 LYMPHS-19.0 MONOS-8.6 EOS-2.3 BASOS-0.5)
Brief Hospital Course:
87 y/o male w/ multiple medical problems including untreated
colon ca, BPH, severe PHTN, admitted from [**Hospital **] clinic w/ hypoxia
of 81% on room air, transferred from floors w/ worsened hypoxia,
hypotension, fevers, and leukocytosis consistent with urosepsis
due to prolonged manipulation and trauma during Foley insertion.
Patient grew our ceftriaxone sensitive e.coli and treated for a
2 week course with ceftriaxone. Patient s/p continuous bladder
irrigation with resolution of his hematuria. Patient required
pressors initially but was successfully weaned. Patient was
hypoxic at baseline with known transudative pleural effusions
requiring tap on [**3-18**]. Etiology likely heart failure.
Hospital Course by Problem:
Hypoxia:
- Patient w/ significant dyspnea for last few months, had been
seen in oncology clinic to work up possible malignant pleural
effuions. Etiology of the effusions unclear. [**Name2 (NI) **] had 2
pleural tap while in the hospital, the first one [**3-6**] with over
1L fluid, and the second one [**2188-3-18**] with 1.2L of fluids
removed. Both taps c/w transudate, w/ negative cytology. TTE
showed severe PHTN and RV diastolic dysfunction w/ fluid
overload. No WML or EKG abn to suggest IMI. High suspicion of PE
in this cancer patient, but still does not explain etiology of
effusions. Degree of effusions seemed disproportionate to degree
of RV diastolic HF. Patient also has centrolobular emphysema on
CT scan in the past. Patient transferred to the oncology medical
unit from the ICU.. He was aggressively diuresed with IV lasix
with drastic improvement of lower extremity edema. Mild to
moderate pulmonary effussions persistent on follow up CXRs. The
etiology of the initial edema is [**Last Name (un) 8787**] likely heart failure
related. He is being discharged with persistent oxygen
requirement that has been weaned down from 5-6L NC to 2-3L NC,
and will go home on this. The Oxygen reqirement is likely
multifactorial and related to heart failure, COPD, and ? PE
causing RLL persistent effussion and atelectasis.
- No CTA [**2-23**] to ARF, V/Q scan not an option [**2-23**] to effusions
- no empiric anticoagulation [**2-23**] h/o GI bleed
- Pleurodesis not a good option given transudative etiology
- VQ scan indeterminent because of persistent stable effusion,
atelectasis and underlying emphysema.
.
# Septic Shock:
- acute sepsis from GU source in setting of prolonged urologic
manipulation during foley insertion. Patient intitially w/
fevers and leukocytosis.
- Was on vanc/zosyn/cipro for double coverage to intial growth
of GNR from Ucx. Sensitivities back, cipro/vanc d/c??????d and zosyn
switched to CTX on [**3-19**], continued through [**2188-3-31**].
- Hypotension w/ infection and concominant diursesis. Started on
neo/levo/vaso for pressors, subsequently d/c??????d and pressures
stable.
.
# Hematuria/BPH: Patient with tramautic foley insertion as
above. He is s/p CBI with resolution of hematuria. Pt
transferred from ICU to oncology floor with foley catheter. Pt
failed voiding trial on [**3-27**], and foley resinserted on [**3-28**]. He
has an outpatient follow appointment made with urology for
several days after discharge. continue terazosin
.
# Diarrhea: Patient with multiple, loose bowel movements. C diff
negative x6. Likely antibiotics related diarrhea given multiple
abx for sepsis. Treated with Imodium PRN, now without diarrhea.
.
# PAF, sick sinus syndrome: on amiodarone at home, no RVR.
Continue home dose, currently in sinus. Not anticoagulated
given fungating colon CA.
# Colon Ca: fungating mass dx in [**2184**], patient declined
treatment. Was in [**Hospital **] clinic to evaluate pleural effusions. No
malignant cells on cytology. While palliative resection was one
therapeutic option given pencil thin stools, patient declining
further work up /treatment. Stools guaiac positive.
.
# ARF: Acute on chronic. Worsened Cr of 1.1 on admission, 2.4
now and stable. Pre renal from septic shock/ diuresis vs ATN
from hypotension. Renal u/s r/o??????d post-renal obstruction. Not
that CBI complete, will monitor urine output.
Medications on Admission:
AMIODARONE 200 mg--1 tablet(s) by mouth daily
ASPIRIN 81 mg--1 tablet(s) by mouth daily
LASIX 20 mg--2 tablet(s) by mouth daily
METOPROLOL SUCCINATE 25 mg--1 tablet(s) by mouth daily
TERAZOSIN 5 mg--1 capsule(s) by mouth daily
Tylenol 650 mg daily
MVI
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Terazosin 5 mg Capsule Sig: One (1) Capsule PO once a day.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Hypoxia
2. Urosepsis
3. Urinary Retention
4. Acute Exacerbation of Congestive Heart Failure
5. Pneumonia
6. COPD
7. diarrhea
.
SECONDARY DIAGNOSIS:
- sick sinus syndrome
Discharge Condition:
Stable, no shortness of breath, requiring 3L O2 for sats >90%.
Discharge Instructions:
You were admitted to the hospital with shortness of breath. This
was thought most likely due to lung disease from smoking, heart
failure, atelectasis (collapsed lung), fluid in your lung, and
pneumonia. We treated you for pneumonia with antibiotics, we
also removed fluid from your lungs and this has not
re-accumulated, and we have treated you with diuretics (water
pills) to help remove fluid from your lungs. Your breathing has
improved significantly, although you are still requiring 3L of
oxygen. We would recommend that you continue to use 3L of
oxygen.
.
While you were here, you also developed a very serious blood
infection related to your bladder. You were treated with
antibiotics in the intensive care unit and you recovered very
well from this infection.
.
Please continue to take all your medications as prescribed. The
following changes have been made:
- Nebulizer treatments: you should take albuterol and
ipratroprium nebulizers every 6 hours
- oxygen: you should use at least 3L of oxygen for daily
activity
.
If you have symptoms of worsening fevers, chills, night sweats,
chest pain, abdominal pain, light-headedness, pain or burning
with urination, shortness of breath, or worsened lower extremity
swelling, please seek immediate medical attention.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Please follow up with Urology on THursday [**4-3**] at 9:45am
in [**Hospital Ward Name 23**] 3.
[**Last Name (un) 6267**] follow up with your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 1713**] in
[**2-24**] weeks.
Completed by:[**2188-3-31**]
|
[
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"416.0",
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"496",
"038.42",
"427.31",
"585.3",
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icd9cm
|
[
[
[]
]
] |
[
"34.91",
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] |
icd9pcs
|
[
[
[]
]
] |
10269, 10335
|
4953, 5656
|
281, 306
|
10571, 10636
|
2728, 4930
|
12055, 12348
|
2054, 2248
|
9376, 10246
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10356, 10356
|
9100, 9353
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10660, 12032
|
2263, 2709
|
222, 243
|
5685, 9074
|
334, 1334
|
10526, 10550
|
10375, 10505
|
1356, 1908
|
1924, 2038
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,060
| 194,191
|
24300
|
Discharge summary
|
report
|
Admission Date: [**2181-8-20**] Discharge Date: [**2181-8-21**]
Date of Birth: [**2144-9-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
etoh w/d
Major Surgical or Invasive Procedure:
none
History of Present Illness:
36 year old homeless man with h/o polysubstance abuse and
frequent ICU admissions returns with alcohol intoxication. He
reports that he has been drinking daily since being released
from prison on [**7-10**]. He drinks enough vodka or listerine so
that he blacks out daily. He believes he was brought in by EMS
or a local after he was found intoxicated. Per ED reports, he
was BIBA after being found down.
He was most recently admitted for EtOh withdrawal from [**2-24**] -
[**3-5**] and left AMA after his valium dose was tapered. He returned
on [**7-4**] with a fall but was discharged from the ED after a
negative head CT.
.
ED: VS on arrival 98.5 114 128/62 16 97% RA. Tox was negative
for cocaine, amphetamines. Serum tox was positive for etoh 448
and benzos. Had anion gap of 18 but VBG of 7.49/33/58 and
lactate of 3.1. We was given 60-70 IV valium for withdrawal sx
of agitation, hypertension, and tachycardia. Also received 3L
IVF.
.
Currently, the patient reports having chest pain x1wk. he
thinks he was punched in the chest and has since had
intermittently dull/sharp nonradiating substernal chest pain.
Now it is [**9-16**] and sharp. It is not exertional nor assoc with
SOB or diaphoresis/n/v. Worse w palpation. Also reports
falling and hitting right forehead 10d ago. Has had no fevers
or residual HA since that time.
.
ROS otherwise pos for URI-like sx. no diarrhea.
Past Medical History:
Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines
Hepatitis C
Hepatitis B
Compartment syndrome RLE, [**2171**]
OCD and anxiety
Depression with hx suicidal ideations and attempts
Alcohol abuse, hx DTs and withdrawal seizures - once sent under
section 35 to prison due to concern that he was a severe threat
to himself with his drinking. required intubation in the past.
- has been seen recently by psychiatry in the past to evaluate
for possible section 35.
Social History:
Drinks regularly, prefers listerine and vodka. Has been
drinking heavily since release from prison on [**8-9**].
Homeless, lives on streets. Denies IVDU for >10yrs. Denies
cigs for>10 yrs. Denies SI or HI
Family History:
Father with depression and alcoholism. Mother died of DM
complications.
Physical Exam:
VS: 99.8 110 96% RA RR12 133/111
gen: agitated but redirectable.
Neuro: aao to person, place, time, situation.
- cn ii-xii intact
- motor [**6-11**] bilat upper/lower
- slightly tremulous upper ex
- [**Last Name (un) 36**] to light touch
- gait wide based and unsteady
- f-n intact bilat
- h-s impaired bilat
heent: old scar on right forehead. mm dry, jvp flat
cards: tachy, reg, no murmurs
resp: ctab
abd: BS+ NT ND soft, no rebound, no stigmata of liver dz
Ext: no edema. good pulses
Pertinent Results:
EKG: Sinus tachy, nl axis, nl intervals, no acute st-t changes.
.
Labs:
VBG: 7.49/33/58
Lactate 3.1
.
142 102 10
----------------< 87
4.1 22 0.9
Ca: 9.4 Mg: 2.0 P: 2.9
Serum EtOH 448
Serum Benzo Pos
Serum ASA, Acetmnphn, Barb, Tricyc Negative
.
WBC: 9.5
HCT: 35.7 - at baseline
PLT: 208
N:64.2 L:30.8 M:3.5 E:1.1 Bas:0.5
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
.
Repeat chemistry:
140 108 8
-------------< 73
3.3 20 0.7
Ca: 8.0 Mg: 1.6 P: 1.9
repeat lactate 3.1
Brief Hospital Course:
36M with ETOH dependence and frequent admissions for EtOH
intoxication presents with EtOH withdrawal. ICU-east course by
problem:
.
# Alcohol withdrawal: presented with signs of withdrawal with
agitation, hypertension, tachycardia, and slight tremor of upper
ex bilat. Has gait unsteadiness which is likely [**3-10**] acute intox
but appears to be chronic based on records.
- given that he has hx of DTs and w/d seizures, we treated
aggressively with valium in ICU. He received either 60-70 IV
valium in the ED. On arrival to the ICU, he was written for
valium 20mg PO q15m prn CIWA>10 and he received it almost as
frequently as written. He became less agitated after approx
80-100mg (in addition to the IV given in the ED) and then the
CIWA scale was spread out to 20mg PO prn q1h. He tolerated
this transition well.
- He received multivit, folate, thiamine in IVF then PO
- social work was consulted the morning after admission when
patient was demanding to leave. He felt he had enough valium
and actually refused another dose. We explained to him that we
preferred that he stay for full evaluation and treatment of etoh
w/d and his electrolyte abnormalities. He expressed
understanding of our concerns and was able to verbalize the
risks and benefits of leaving against our advice. He signed out
AMA with plans to seek outpatient treatment.
.
# Psych: No SI. We had plans to contact psychiatry morning
after admission particularly given his high valium need.
However, he expressed interest in leaving and we felt he had
capacity to make this decision. Social wk was involved but
psychiatry was not consulted.
.
# chest pain: EKG without ischemic changes. CP was reproducible
on palpation. Suspected MSK pain. He received one dose of
morphine for cp. We then treated with toradol, motrin, and
tylenol. We would recommend avoiding narcotics in the future if
at all possible and if clinically indicated. His pain improved
when his agitation improved.
.
# elevated lactate: ddx included dehydration, infection, liver
disease, hypovolemia, poor sample. Lactic acidosis not likely
given the alkalosis seen on VBG. Consider dehydration vs poor
quality sample. Infection less likely given no fever or
hypotension or any localizing signs of infection. Repeat
lactate remained 3.1. Etiology unclear and workup hindered by
patient leaving AMA.
.
# Anion gap: AG 18 in the ED with a normal HCO3 and alkalosis on
VBG. ASA negative as were other toxins. Difficult to interpret
but wonder if slightly increased AG is from the elevated
lactate. Repeat chemistries showed normal anion gap.
.
#Anemia - normocytic anemia, Hct at baseline
.
# PPx: Heparin sc tid, PPI given etoh abuse, bowel reg
.
# FEN: Regular diet, replete lytes prn, banana bag then IVF
.
# Access: PIV x1
.
# Code: FULL
.
# Communication: Patient
.
# Dispo: Patient left AMA.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
ETOH Intoxication/Withdrawal
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital because you were found
intoxicated by EMS. You were admitted to the ICU and treated
with Valium for withdrawal. You were advised to stay in the
hospital for continued care and treatment of withdrawal however
you decided against medical advice that you no longer wished to
receive care. You spoke with the social worker before you left
the hospital and were advised to return to [**Street Address(1) 5904**] Inn
to speak with your outreach worker there.
You signed out against medical advise.
Followup Instructions:
Please speak with the Outreach worker [**Street Address(1) 29735**] Inn.
Please return to the hospital should you have any concerning
symptoms including difficulty breathing, falls or injuries
requiring medical attention, concerning withdrawal symptoms.
|
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icd9cm
|
[
[
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|
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281, 288
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,128
| 129,834
|
52961
|
Discharge summary
|
report
|
Admission Date: [**2120-3-12**] Discharge Date: [**2120-3-22**]
Date of Birth: [**2056-1-3**] Sex: F
Service: MICU-[**Hospital1 **]
CHIEF COMPLAINT: Confusion.
HISTORY OF PRESENT ILLNESS: This is a 64-year-old white female
with a history of multiple myeloma, complicated by end-stage
renal disease on hemodialysis, complicated by multiple clots on
Coumadin, who was brought to an outside hospital by her boyfriend
with confusion, nausea and vomiting of black vomitus, and
headache. Evidently, approximately one month prior to admission
the patient had fallen and hit her head without any neurological
symptoms, loss of consciousness, or sequelae. Then,
approximately three days prior to admission, the patient was
noted to have increasing confusion by her boyfriend and daughter.
The patient was also noted to have an increase in easy bruising,
anorexia, nausea and vomiting. Evidently, the patient had been
inadvertently taking Coumadin thinking that it was darvocet,
which she was taking for low back pain.
On review of systems, the patient reported an approximately 60
pound weight loss over the course of six months from a weight of
greater than 200 pounds, with anorexia, diffuse abdominal pain
for about four months, and some bright red blood per rectum for
approximately two months.
At the outside hospital, head CT showed a multiloculated acute on
chronic subdural hematoma, with an INR of 8.3 and a hematocrit of
24. Initial management included decadron to decrease brain
edema, phenytoin to decrease the risk of seizure, mannitol to
decrease intracranial pressure, and fresh frozen plasma and
Vitamin K to reverse the coagulation deficit.
The patient was transferred to the [**Hospital6 2018**] and admitted to the Medical Intensive Care Unit for
neurological checks, neurosurgical evaluation, and serial head
CTs.
PAST MEDICAL HISTORY: 1) Multiple myeloma with light chain
disease for approximately eight years treated with
Thalidomide. 2) Secondary end-stage renal disease, now on
hemodialysis three times per week. 3) Multiple thromboses of
upper extremity AV graft, status post multiple
thrombectomies. 4) SVC syndrome secondary to central line
thrombosis. 5) Hypothyroidism. 6) Chronic anemia.
ALLERGIES: The patient has GI upset from demerol and
percocet.
MEDICATIONS AT HOME PRIOR TO ADMISSION: 1) Thalidomide 100
mg po qd, 2) ativan with hemodialysis 1 mg tid, 3) Premarin
0.3 mg po qd, 4) Synthroid 0.25 mg po qd, 5) Effexor 150 mg
po qd, 6) Coumadin 2.5 mg po qd, 7) darvocet prn, 8) PhosLo
667 mg po tid.
SOCIAL HISTORY: The patient lives with her boyfriend. [**Name (NI) **]
daughter lives a few houses away on the same street as her. The
patient is a former [**Hospital6 **] employee where
she worked in Telemetry. The patient denies any tobacco use. The
patient has a history of alcohol use, but claims to have quit
several years ago.
PHYSICAL EXAM UPON ADMISSION: Temperature 100.8, blood
pressure 153/53, pulse 84, respirations 16, oxygen saturation
98% on room air. General - the patient is an elderly lady
lying in bed in mild distress with some agitation. HEENT -
extraocular movements intact, pupils equal, round and
reactive to light bilaterally, no carotid bruits. Cardiac -
regular rate and rhythm with a II/VI systolic murmur at the
left upper sternal border. Lungs - mild crackles at the
bases, otherwise clear to auscultation. Abdomen - soft,
nontender, nondistended, positive bowel sounds, somewhat
decreased, guaiac positive, positive retroperitoneal
bruising. Extremities - warm, no edema, 2+ dorsalis pedis
pulses, a left thigh fistula with a positive thrill.
Neurological - the patient is alert and responds verbally
with fluent speech, oriented x 3 with one correction from
[**2020**] to [**2120**] with prompting, tongue midline, facial motor
symmetric, repeats short phrases without difficulty but
recall is limited, patient had a question of mild left-sided
neglect, movement of all extremities spontaneously, no
obvious upper extremity drift, but positive right upper
extremity ataxia-type tremor. Extremity strength 4+-5
throughout and symmetric, deep tendon reflexes 2+ throughout,
Babinski downgoing, sensation intact throughout to light
touch.
LABORATORY DATA UPON ADMISSION: CBC with a white blood cell
count of 5.6, with a differential of 69 neutrophils, 29.3
lymphocytes, 3 monocytes, 0.8 eosinophils, 1.3 basophils.
Hematocrit 22.0, platelets 85. Coagulation studies with a PT
of 29.2, INR 5.6, PTT 43. Chem-7 with a sodium of 123,
potassium 5.0, chloride 84, BUN 54, creatinine 6.2, glucose
136. Urinalysis - specific gravity of 1.020, with a small
amount of blood, 100 protein, pH 8.5, negative for nitrite
and leukocytes.
HEAD CT ON ADMISSION: A loculated collection, hemorrhage,
probably of different ages in the right temporal lobe,
asymmetry of the lateral ventricles with mass effect on the
right lateral ventricle, effacement with foci in the right
and a small amount of midline shift to the left.
ASSESSMENT: A 64-year-old female with acute on chronic subdural
hemorrhage secondary to supertherapeutic Coumadin and fall.
HOSPITAL COURSE - 1) NEUROLOGICAL: The patient was admitted to
the Medical Intensive Care Unit for neurological checks,
neurosurgical evaluation, and serial head CTs. Due to the
multiloculated and small size of the subdural hematoma which was
deemed to be acute on chronic, evacuation by neurosurgery was
deferred, although they continued to follow closely throughout
her admission. The subdural hematoma was treated conservatively
with decadron to reduce brain edema, rapid correction of the INR
with fresh frozen plasma, platelet transfusion to increase the
platelets and keep the level above 100,000, DDAVP to correct
uremic platelet dysfunction. Upon presentation, the patient's
neurological exam was nonfocal with a question of left-sided
neglect. After admission to the MICU, the patient developed a
more obvious left facial droop and decreased movement of the left
extremity. These neurological symptoms had resolved completely
by the time of discharge. The patient was monitored with serial
head CT scans, receiving a head CT initially twice a day, then
once per day, and then once every other day. All of these scans
showed a subdural hemorrhage, stable, from the time of admission.
At the time discharge, the subdural hemorrhage continued to be
stable in size and appearance. The patient was also noted on EEG
during the admission to have evidence of epileptiform activity.
Therefore, the patient was continued on phenytoin throughout
the admission with modification of the dosing based on free
phenytoin levels.
2) PULMONARY: After admission to the Medical Intensive Care
Unit, the patient became less responsive, agitated, and
tachypneic. Therefore, the patient was intubated and placed
on a propofol drip. After the patient's status improved, the
patient was extubated on hospital day #2, and transferred to
the neurological service. Early on the morning after
transferring to the neurological service, the patient became
again agitated, tachypneic, with oxygen saturations down to the
70s on 100% oxygen via nonrebreather. The corresponding ABG at
that time was a pH of 7.26, PCO2 47, O2 55. A code was called at
this point, and the patient was reintubated and transferred back
to the MICU. Of note, the patient had missed her dialysis
session the previous day due to multiple studies on that day. In
addition, the patient's previous dialysis session had been cut
short due to studies. Also, at that time the patient was 10 kg
over her baseline weight. In addition, the patient had been
maintained on intravenous fluids after admission to the
neurological service. Therefore, it was felt that the episode of
respiratory failure was most likely due to pulmonary edema in the
setting of volume overload and secondary congestive heart
failure. With dialysis and careful monitoring of volume status,
the patient improved and was extubated for the second time on
hospital day #5. After extubation, the patient was noted to
have bulb stridor and wheezing. The stridor was treated with
racemic epinephrine, heliox, decadron, and a discontinuation
of her ACE inhibitor. The bronchospasm was responsive to
albuterol and ipratropium nebulizers. In addition, the beta
blocker was discontinued for concern of exacerbating
bronchospasm. After that point, the patient's wheezing steadily
improved and nebulizers were weaned. At the time of discharge,
the patient was no longer wheezing or requiring nebulizers.
3) HEENT: Due to the postexpiratory stridor, an
otolaryngological consult was obtained. Under direct
laryngoscopy, the patient was observed to have erythema and
swelling of the posterior larynx. This was thought to be
consistent with irritation due to gastroesophageal reflux
disease, in addition to intubation. The patient's stridor
gradually improved and was completely absent by the time of
discharge.
4) CARDIAC: Following the episode of respiratory failure,
cardiac enzyme levels were obtained, and the patient was observed
to have a small increase in troponin levels. This was thought to
be due to cardiac stress in the setting of volume overload, and
the possibility of contribution from coronary artery disease. The
patient was started on low dose aspirin after consultation with
the neurosurgical team. The patient's blood pressure and rate
were controlled with diltiazem.
5) INFECTIOUS DISEASE: After admission to the MICU for the
second time, the patient was noted to have an infiltrate on chest
x-ray which was thought to be consistent with an aspiration
pneumonia. Therefore, the patient was started on a 7-day course
of Levofloxacin and Flagyl. The patient was also noted to have a
urinary tract infection by UA for which the patient was covered
by Levofloxacin. Blood cultures were obtained in addition to the
urine culture, both of which came back positive for streptococcal
bovis. Given the association of streptococcal bovis with GI
pathology, in addition to the patient's symptoms of
gastrointestinal bleeding and history of weight loss, abdominal
pain and bright red blood per rectum, there was concern for the
possibility of a GI source of the infection. The patient was
started on ceftriaxone with plan for at least a 4-week course of
ceftriaxone to cover for the possibility of endocarditis,
especially considering the patient's valvular disease with mitral
regurgitation. A TTE showed no evidence of vegetations, but a
TEE was declined due to inability to visualize the upper GI tract
and concern for bleeding with a history of black emesis.
6) GASTROINTESTINAL: The patient was admitted with a history
of black emesis, in addition to bright red blood per rectum.
As noted above, this in combination with weight loss, abdominal
pain, streptococcal bovis bacteremia, and urinary tract infection
raised concern for the possibility of a gastrointestinal source
such as a colonic malignancy. It was determined that the patient
would need a colonoscopy to evaluate the lower GI tract, in
addition to an EGD if colonoscopy was negative. Due to concern
for risk of bleeding, these studies were not performed as an
inpatient. The plan was to follow-up in two to three weeks with
GI for colonoscopy and EGD.
7) RENAL: The patient has end-stage renal disease secondary to
light chain multiple myeloma. The patient was continued on
dialysis three times per week, Monday, Wednesday, Friday, during
her admission. The patient was also started on calcium carbonate
for decreased calcium levels and high phosphate levels.
8) ENDOCRINE: The patient has a history of hypothyroidism and is
being maintained on levothyroxine. Endocrine consult followed
the patient during the admission. Thyroid function tests were
obtained prior to discharge. These showed a very low TSH level
and a low T3 level, but these findings were thought to be
unreliable in the acute setting. It was recommended that the
thyroid function tests be followed up as an outpatient. In
addition, due to the patient being maintained on dexamethasone,
finger stick blood sugars were obtained daily, and the patient
was on regular insulin sliding scale.
9) HEMATOLOGY: As noted above, the patient's INR was rapidly
corrected with fresh frozen plasma and Vitamin K upon admission.
In addition, the patient's low platelet levels were corrected
with platelet transfusion. Presumed uremic platelet dysfunction
was treated with DDAVP, as well as dialysis. All anticoagulation
and antiplatelet agents were initially held. However, in
addition the patient has a significant history of AV graft
thrombosis and SVC syndrome. There was concern for procoagulant
risk. The patient's Thalidomide was discontinued for its
procoagulant effects. In addition, the patient was started on
low dose aspirin after discovery of slightly increased troponin
levels. The low dose was later increased to 325 mg qd prior to
discharge in an attempt to decrease the risk of thrombosis. The
plan at discharge was to hold all additional anticoagulation
until there was radiographic evidence of no repeat subdural
hemorrhage for approximately four weeks. It was planned for the
patient to have a repeat head CT scan two weeks after discharge.
If that head CT showed no progression of the subdural hematoma
or new bleed, then anticoagulation with Coumadin could be
restarted two weeks later.
10) ONCOLOGY: The patient has a history of multiple myeloma that
was seen to be active with multiple lytic lesions in the skull
seen on head CT. The patient's Thalidomide was held due to
procoagulant risk.
11) FLUID, ELECTROLYTES AND NUTRITION: Due to risk of
aspiration, a swallowing study was obtained after the patient was
transferred to the floor on hospital day #5. This showed no
evidence of aspiration, and the patient was restarted on a full
PO diet.
12) ACCESS: The patient was given a central line during the stay
in the Medical Intensive Care Unit. Prior to discharge, the
patient received a PICC line for administration of long-term
ceftriaxone for streptococcal bovis bacteremia.
13) CODE STATUS: Full.
DISCHARGE STATUS: To acute rehab.
DISCHARGE CONDITION: Stable but in need of close
neurological observation.
DISCHARGE DIAGNOSES: 1) Subdural hemorrhage secondary to
supertherapeutic Coumadin. 2) Gastrointestinal bleed. 3)
Streptococcal bovis bacteremia. 4) Urinary tract infection.
5) Pulmonary edema. 6) Non-Q wave myocardial infarction, 7)
Aspiration pneumonia. 8) Epileptiform electroencephalogram
activity. 9) Laryngeal edema secondary to gastroesophageal
reflux disease and intubation. 10) Bronchospasm.
DISCHARGE MEDICATIONS: 1) Ceftriaxone 1 gm qd for 26 more
days (total course of 4 weeks), 2) diltiazem 60 mg tid, 3)
pantoprazole 40 mg qd, 4) aspirin 325 mg qd, 5) levothyroxine
25 mcg qd, 6) dexamethasone 2 mg qd for 2 weeks, to be
continued until after repeat head CT in 2 weeks, at that
point a neurologist should be contact[**Name (NI) **] regarding tapering
the dexamethasone, 7) phenytoin 150 mg q am, 200 mg q pm, 8)
calcium carbonate 1,000 mg qd, 9) albuterol/ipratropium
103-18 mcg aerosol 1-2 puffs inhalation q 4-6 h prn shortness
of breath or wheezing.
FOLLOW-UP: The patient should be followed closely for any
change in neurological status. Any change (such as focal
signs, increased somnolence) should prompt a repeat head CT to
rule out repeat bleed or increased edema from nontolerance of
dexamethasone tapering.
If the patient is stable, a repeat head CT should be obtained in
two weeks. If this shows no repeat bleed and gastrointestinal
work-up is negative, then two weeks later (four weeks from
discharge), the patient can be started on anticoagulation again.
Also, based on the level of edema seen on the head CT, the
patient's dexamethasone can be slowly tapered.
Gastrointestinal follow-up needs to be obtained for a colonoscopy
and gastroduodenoscopy in approximately two weeks. This should
be obtained by calling Dr. [**First Name (STitle) **] at ([**Telephone/Fax (1) 1582**], or Dr. [**Last Name (STitle) **]
at ([**Telephone/Fax (1) 8892**] to schedule an appointment. This is to rule
out any gastrointestinal malignancy or gastrointestinal source of
the streptococcal bovis bacteremia, in addition to the
gastrointestinal bleed.
The patient should also follow-up with her primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], after leaving the acute rehab
setting. His telephone number is ([**Telephone/Fax (1) 27577**].
In addition, due to the patient's abnormal thyroid function
tests during this inpatient setting, the patient's thyroid
function tests should be repeated as an outpatient.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Name8 (MD) 109165**]
MEDQUIST36
D: [**2120-3-22**] 14:00
T: [**2120-3-22**] 13:25
JOB#: [**Job Number 109166**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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14248, 14303
|
14325, 14713
|
14737, 17050
|
171, 183
|
212, 1857
|
4763, 14226
|
1880, 2569
|
2586, 2922
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,878
| 176,393
|
47164
|
Discharge summary
|
report
|
Admission Date: [**2129-7-20**] Discharge Date: [**2129-7-28**]
Date of Birth: [**2060-2-27**] 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:
[**2129-7-22**] Coronary Artery Bypass Graft x 3 (Left Internal Mamary
Artery to Left Anterior Descending artery, Saphenous Vein Graft
to RAMUS, Saphenous Vein Graft to Obtuse Marginal)
[**7-20**] Cardiac Cath
History of Present Illness:
69 yo M with PMH significant for hypertension, hyperlipidemia,
IDDM, and family history of CAD who presented to [**Hospital3 **]
with chest pain. The patient states that he has been
experiencing substernal chest pressure with exertion, such as
walking up stairs, for 2 months. EKG showed T-wave inversions,
but enzymes were negative. He was transferred to [**Hospital1 18**] for
cardiac cath which showed LM and 2VD.
Past Medical History:
Hypertension
Hyperlipidemia
Insulin Dependent Diabetes Mellitus (?non-adherence to medical
regime per chart)
Retinopathy
Erectile Dysfunction
Low back pain s/p epidural steroid injections L4-L5 (last inj.
[**2127**])
Vitamin D Deficiency
Torn Right rotator cuff-unrepaired
Torn posterior medial meniscus Left Knee-unrepaired
Chronic insomnia ?Obstructive Sleep Apnea
Social History:
Race:African American
Last Dental Exam:many years ago, full denture on top, bottom
teeth are his own
Lives with:wife
Occupation:Recently retired from the court system
Tobacco:+Cigars, chews on them only
ETOH:Denies
Rec drugs: Denies
Family History:
Father died age 53 CAD
Physical Exam:
Pulse:61 Resp:21 O2 sat: 99%RA
B/P Right:161/79 Left:154/80
Height:5'7" Weight:210 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
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: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: Cath site Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2129-7-20**] Cath: 1. Selective coronary angiography in this
left-dominant system demonstrated left main and 2-vessel
disease. The LMCA had 60-70% distal stenosis. The LAD had 90%
stenosis at the origin. The IM had 70% stenosis at the origin.
The distal LCx had 30% stenosis. The RCA was non-dominant. 2.
Resting hemodynamics reveals moderate to severe systemic
arterial systolic hypertension with an SBP of 177 mmHg. 3. Left
ventriculography revealed an estimated EF of 55% with no
apparent mitral regurgitation.
[**7-22**] Echo: PREBYPASS: The left atrium is normal in size. No
spontaneous echo contrast is seen in the body of the left atrium
or left atrial appendage. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular free wall contractility is normal.
The ascending aorta is borderline mildly dilated. The aortic
valve leaflets (3) are mildly thickened. There is mild aortic
valve stenosis (valve area 1.6cm2) with peak/mean gradients of
[**11-9**] mmHg. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is no pericardial effusion.
POSTBYPASS: The patient is in sinus rhythm and is not on any
infusions. Left ventricular function continues to be normal
(LVEF>55%). Trace mitral regurgitation, trace aortic
regurgitation, and mild tricuspid regurgitation persist. Normal
thoracic aorta.
Pre operative
[**2129-7-20**] 02:13PM PT-13.9* PTT-99.7* INR(PT)-1.2*
[**2129-7-20**] 02:13PM PLT COUNT-202
[**2129-7-20**] 02:13PM WBC-5.6 RBC-4.01* HGB-11.6* HCT-33.9* MCV-85
MCH-28.9 MCHC-34.2 RDW-13.7
[**2129-7-20**] 02:13PM TRIGLYCER-99 HDL CHOL-48 CHOL/HDL-4.6
LDL(CALC)-151*
[**2129-7-20**] 02:13PM %HbA1c-10.9* eAG-266*
[**2129-7-20**] 02:13PM ALBUMIN-1.9* CHOLEST-219*
[**2129-7-20**] 02:13PM ALT(SGPT)-4 AST(SGOT)-8 CK(CPK)-56 ALK
PHOS-74 AMYLASE-7 TOT BILI-0.4
[**2129-7-20**] 02:13PM GLUCOSE-191* UREA N-7 CREAT-0.3* SODIUM-127*
POTASSIUM-3.3 CHLORIDE-97 TOTAL CO2-22 ANION GAP-11
[**2129-7-20**] 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
Discharge
[**2129-7-27**] 05:50AM BLOOD WBC-10.2 RBC-3.42* Hgb-9.9* Hct-29.8*
MCV-87 MCH-29.0 MCHC-33.4 RDW-13.9 Plt Ct-264#
[**2129-7-27**] 05:50AM BLOOD Plt Ct-264#
[**2129-7-22**] 12:44PM BLOOD PT-14.3* PTT-27.5 INR(PT)-1.2*
[**2129-7-28**] 05:20AM BLOOD Glucose-87 UreaN-16 Creat-0.9 Na-138
K-3.7 Cl-101 HCO3-27 AnGap-14
[**2129-7-25**] 04:17AM BLOOD ALT-34 AST-49* AlkPhos-96 Amylase-32
TotBili-0.9
Radiology Report CHEST (PA & LAT) Study Date of [**2129-7-27**] 10:07
AM
[**Hospital 93**] MEDICAL CONDITION: 69 year old man with s/p cabg
Final Report PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: Status post CABG evaluate for pleural effusion.
Moderate cardiomegaly is stable. Small bilateral effusion left
greater than right are associated with minimal adjacent
atelectasis. There is no
pneumothorax. Sternal wires are aligned. Moderate degenerative
changes in
the thoracic spine.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
[**Known lastname 18169**],[**Known firstname **] L [**Medical Record Number 99936**] M 69 [**2060-2-27**]
Radiology Report ABDOMEN U.S. Study Date of [**2129-7-25**]
[**Hospital 93**] MEDICAL CONDITION: 69 year old man with Rt upper and
lower quadrant tenderness after cabg
REASON FOR THIS EXAMINATION: assess for cholecystitis
Final Report
FINDINGS: The liver is mildly echogenic consistent with mild
fatty
infiltration. No focal liver lesion is identified. No biliary
dilatation is seen and the common duct measures 0.5 cm. The
gallbladder is normal. The pancreas and midline structures are
obscured from view by overlying bowel. The spleen is
unremarkable and measures 10.3 cm. No hydronephrosis is seen.
The right kidney measures 11.3 cm and the left kidney measures
10.8 cm. A left pleural effusion is seen.
IMPRESSION:
1. Normal gallbladder.
2. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
3. Left pleural effusion.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20982**], RDMS DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) 7832**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2129-7-24**]
1:02 PM
[**Hospital 93**] MEDICAL CONDITION: 69 year old man s/p CABG X3,CHANGE
IN MS
Final Report
HISTORY: 69-year-old man, status post CABG x 3. Now with acute
change of
mental status. Assess for acute ischemic events.
FINDINGS/IMPRESSION:
1. No acute intracranial process. If clinical concern for acute
ischemic
event persists, MRI is more sensitive.
2. Small air-fluid level in the right sphenoid sinus.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/DR. [**First Name (STitle) **] [**Name (STitle) 12563**]
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] was transferred from an
outside hospital to [**Hospital1 18**] for cardiac cath. Cath revealed left
main and two vessel coronary artery disease. He was
appropriately worked-up for bypass surgery and received medical
care until surgery. On [**7-22**] he was brought to the operating room
where he underwent a coronary artery bypass grafting. Please see
operative report for surgical details. In summary he had:
Coronary artery bypass grafting x3 with left internal mammary to
left anterior descending coronary; reverse saphenous vein single
graft from aorta to ramus
intermedius coronary artery; reverse saphenous vein single graft
from aorta to first obtuse marginal coronary artery. Endoscopic
left greater saphenous vein harvesting.
Epiaortic duplex scanning. His CARDIOPULMONARY BYPASS TIME was
71 minutes, with a
CROSSCLAMP TIME of 56 minutes. He tolerated the operation well
and was transferred from the operating room to the CVICU for
invasive monitoring in stable condition. Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one beta-blockers and diuretics were started and
he was diuresed towards his pre-op weight. Chest tubes and
epicardial pacing wires were removed per protocol. Had brief
mental status change with gaze preference to right. Head CT was
negative. Narcotics were stopped and this continued to slowly
improve. He complained of right upper quadrant abdominal pain,
liver function tests were in normal ranges and an abdominal US
showed normal gallbladder without cholestasis. On post-op day 4
he was transferred to the telemetry floor for further recovery
from surgery. He progressed slowly and on POD #6 was discharged
to rehabilitation at [**Location (un) 5481**] in [**Location (un) 2624**]. Pt is to follow up
as per discharge instructions.
Medications on Admission:
Medications at home:
ASA 81mg po daily
Lantus
Vitamin D 1000units daily
Benicar 40/12.5mg po daily
Meds on transfer:
Lipitor 80mg po daily
Plavix 75mg po daily
Lantus 20 units q HS
Metoprolol 25mg po daily
ASA 325mg po daily
NPH 40 units po qAM
Plavix - last dose: 75 mg [**7-20**], 300mg [**7-19**]
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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily): stop
when Lasix d/c'd.
8. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day:
until at preop weight (210 lbs).
9. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty Eight (28)
units Subcutaneous Q AM.
10. Insulin Lispro 100 unit/mL Cartridge Sig: One (1)
Subcutaneous ACHS: per SS.
Discharge Disposition:
Extended Care
Facility:
Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**])
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary artery bypass graft x 3
Past medical history:
Hypertension
Hyperlipidemia
Insulin Dependent Diabetes Mellitus (?non-adherence to medical
regime per chart)
Retinopathy
Erectile Dysfunction
Low back pain s/p epidural steroid injections L4-L5 (last inj.
[**2127**])
Vitamin D Deficiency
Torn Right rotator cuff-unrepaired
Torn posterior medial meniscus Left Knee-unrepaired
Chronic insomnia ?Obstructive Sleep Apnea
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg- Left - healing well, no erythema or drainage.
Edema-none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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:Dr. [**Last Name (STitle) 914**] on Tuesday [**8-16**] @ 2:15 pm [**Hospital Ward Name **] 2A
Cardiologist Dr. [**Last Name (STitle) 10543**] [**Name (STitle) 766**] [**8-29**]@ 1:45 pm
Please call to schedule appointments with your:
Primary Care Dr. [**Last Name (STitle) **] [**Name (STitle) 17369**] in [**3-7**] weeks [**Telephone/Fax (1) 17368**]
**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:[**2129-7-28**]
|
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56,316
| 186,090
|
40306
|
Discharge summary
|
report
|
Admission Date: [**2190-10-7**] Discharge Date: [**2190-10-14**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
[**10-7**]: Left femoral neck fracture status post percutaneous
fixation with 7.3 mm screws of nondisplaced valgus impacted
femoral neck fracture.
History of Present Illness:
This is a [**Age over 90 **] year old female with a past medical history of CVA
on coumadin and seizure disorder presenting from OSH for recent
diagnosis of left non-displaced femoral neck fracture with
hypoxemia and moderately sized right sided pleural effusions. Ms
[**Known lastname 16254**] was in her usual state of health last week when she got up
from her sofa and bumped into a coffee table and fell. She had
no presyncopal symptoms, no fevers, no chest pain or shortness
of breath surrounding the event; no loss of consciousness. After
her fall, she crawled to the phone and called EMS. Other than
pain, she had no significant other symptoms. At the OSH, she was
imaged with a CT spine, CT chest, and CT pelvis. Pelvic imaging
revealed a left femoral neck fracture, non-displaced. CT chest
revealed a moderately sized left sided and small right sided
pleural effusions. She was transferred to [**Hospital1 18**] for further
management when these effusions were detected. In the ED at
[**Hospital1 18**], radiology reviewed these films and felt they were
consistent with pleural effusions not hemothorax. She did have
hypoxemia with O2 sats in the high 80s; she was placed on a
non-rebreather with improvement to the high 90s. She did not
endorse significant dyspnea or chest pain. EKG demonstrated
T-wave inversions in inferior leads; a single set of cardiac
enzymes were negative. She received ceftriaxone and azithromycin
given her pleural effusions and fentanyl for her hip pain.
Orthopedics evaluated her and felt her to be an operative
candidate for hemiarthroplasty. Her health care proxy, her son
[**Name (NI) **], declined consent for any surgery and he stated he would
reconsider in the morning after discussing her status with the
attending. At time of transfer to the MICU, she was in mild hip
pain but with no other complaints. She was weaned to 4 L NC with
O2 sats between 97-100, with HRs in the 80s, BPs 120s, and was
afebrile.
.
She has otherwise been healthy other than her chronic seizure
disorder and coumadin therapy for her CVA. She has good exercise
tolerance frequently climbing her [**7-8**] stairs to get to the
[**Location (un) 1773**] of her house without significant dyspnea or
fatigue.
Past Medical History:
1. seizure disorder (unclear what type, apparently has had for
several decades)
2. CVA X 2 (unclear what type) dating back a couple of decades
3. hypertension
4. hyperlipidemia
5. paroxysmal afib
Social History:
Lives at home by herself in [**Location (un) 14840**], MA; her son, [**Name (NI) **], who
lives at [**Location (un) **] visits her frequently and helps with
groceries, maintenance of house, otherwise she does most of her
ADLs and is very active at home. Denies smoking, alcohol use.
Family History:
Non-contributory
Physical Exam:
VS BP 129/67, HR 74, afebrile, SpO2 98% on 4 L NC
Gen: Sitting up in bed in NAD
Neuro: Alert, cannot tell us year and identifies hospital as
"[**Location (un) **]," however she is able to give us a detailed history of
her fall and converses brightly and intelligently. Moving all
extremities; lower extremity exam limited by pain.
Cardiac: Systolic ejection murmur loudest at left lower sternal
border grade III/VI
Pulm: moderate dullness to percussion over left lung base,
mildly diminished breath sounds at left and right lung base,
exam somewhat limited by inability to sit up secondary to hip
pain
Abd: very soft and nontender, normoactive bowel sounds
Ext: Limited secondary to hip pain, no edema noted
Pertinent Results:
I. Labs
A. Admission
[**2190-10-6**] 11:20PM BLOOD WBC-13.5* RBC-4.60 Hgb-12.9 Hct-39.2
MCV-85 MCH-28.1 MCHC-33.0 RDW-15.2 Plt Ct-293
[**2190-10-7**] 05:52AM BLOOD Neuts-89.8* Lymphs-5.2* Monos-4.5 Eos-0.1
Baso-0.4
[**2190-10-6**] 11:20PM BLOOD PT-27.9* PTT-30.9 INR(PT)-2.7*
[**2190-10-6**] 11:20PM BLOOD Plt Ct-293
[**2190-10-6**] 11:20PM BLOOD Fibrino-296
[**2190-10-6**] 11:20PM BLOOD UreaN-23* Creat-0.5
[**2190-10-7**] 05:52AM BLOOD ALT-27 AST-34 LD(LDH)-357* AlkPhos-93
TotBili-0.3
[**2190-10-6**] 11:20PM BLOOD Lipase-41
[**2190-10-6**] 11:20PM BLOOD cTropnT-0.01
[**2190-10-7**] 05:52AM BLOOD Albumin-4.1 Calcium-8.4 Phos-4.0 Mg-2.1
[**2190-10-6**] 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2190-10-6**] 11:28PM BLOOD Glucose-124* Lactate-2.0 Na-140 K-4.1
Cl-103 calHCO3-20*
[**2190-10-6**] 11:28PM BLOOD Hgb-13.4 calcHCT-40
B. Discharge
[**2190-10-14**] 06:55AM BLOOD WBC-8.5 RBC-4.13* Hgb-11.4* Hct-35.9*
MCV-87 MCH-27.6 MCHC-31.8 RDW-16.6* Plt Ct-263
[**2190-10-14**] 06:55AM BLOOD Plt Ct-263
[**2190-10-14**] 06:55AM BLOOD Glucose-108* UreaN-24* Creat-0.4 Na-146*
K-3.7 Cl-110* HCO3-28 AnGap-12
[**2190-10-14**] 06:55AM BLOOD ALT-30 AST-48* AlkPhos-68 TotBili-0.3
[**2190-10-14**] 06:55AM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.4 Mg-2.1
C. Urine
[**2190-10-12**] 09:30AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.028
[**2190-10-12**] 09:30AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2190-10-12**] 09:30AM URINE RBC-64* WBC-13* Bacteri-MANY Yeast-NONE
Epi-6
[**2190-10-12**] 09:30AM URINE Mucous-MANY
II. Microbiology
[**2190-10-13**] URINE URINE CULTURE-FINAL INPATIENT
[**2190-10-11**] URINE ANAEROBIC CULTURE-FINAL INPATIENT
[**2190-10-7**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2190-10-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2190-10-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
III. Radiology
A. Video Swallow ([**2190-10-13**])
INDICATION: Coughing with meals, dysphagia, history of
esophageal dilatation.
VIDEO OROPHARYNGEAL SWALLOW: The study was conducted in
collaboration with
speech pathology. Various consistencies of barium were
administered by mouth including thin, nectar, puree, and ground.
There is a solitary incidence of penetration into the vestibule
with thin consistency. There is no aspiration into the airway.
There is a small amount of nasal regurgitation with thin
consistency. There is a small amount of residue with nectar
consistency. There is a moderate amount of residue with puree
consistency. This clears with subsequent swallows.
IMPRESSION: No aspiration seen.
B. CXR ([**2190-10-12**])
HISTORY: [**Age over 90 **]-year-old woman with respiratory difficulty and
altered mental
status.
COMPARISON: [**2190-10-7**].
SINGLE UPRIGHT VIEW OF THE CHEST AT 9:15 A.M.: There has been an
increase in size of a layering right pleural effusion, now
moderate, and development of a new left pleural effusion, small.
Bilateral retrocardiac opacities are compatible with associated
compressive atelectasis. There is good aeration of the upper
lungs, without consolidation or pneumothorax. Parenchymal
opacities, particularly in the left upper lung have improved.
There is no new hilar or mediastinal enlargement. Pulmonary
vascularity is near normal in caliber. Aortic arch
calcifications are noted. Degenerative changes are present in
the spine.
A surgical clip at the thoracic inlet is compatible with prior
thyroid
surgery.
IMPRESSION:
Increased pleural effusions (moderate on the right and small on
the left), in combination with improved aeration of the upper
lungs is compatible with improving pulmonary edema.
C. MRI Brain ([**2190-10-11**])
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with history of CVA with left
non-displaced
femoral head fracture, has hypoxia and right-sided pleural
effusion, for
further evaluation to exclude intracranial abnormality.
TECHNIQUE: T1 sagittal and FLAIR, T2, susceptibility and
diffusion axial
images of the brain were acquired.
FINDINGS: Diffusion images demonstrate no evidence of acute
infarct. There
is a chronic infarct identified in the left occipital region
with
encephalomalacia and ex vacuo dilatation of the occipital [**Doctor Last Name 534**]
of the left
lateral ventricle. There are diffuse hyperintensities in the
white matter
indicative of small vessel disease. Moderate-to-severe brain
atrophy and
medial temporal atrophy is also seen. No evidence of chronic
microhemorrhages. Suprasellar and craniocervical regions are
normal on the
sagittal images. Incidentally noted are plexus cysts within the
region of
atrium bilaterally.
IMPRESSION: No acute infarct. Chronic left occipital infarct.
Brain atrophy
and small vessel disease. No signs of acute hypoxic injury to
the brain.
D. Hip nailing ([**2190-10-8**])STUDY: LEFT HIP INTRAOPERATIVE STUDY,
[**2190-10-8**].
CLINICAL HISTORY: [**Age over 90 **]-year-old woman with left hip fracture.
Status post
fixation.
FINDINGS: Two views of the left hip from the operating room
demonstrates
interval placement of cannulated screws fixating a femoral neck
fracture in
the left side. There are no signs for hardware-related
complications. Please
refer to the operative note for additional details.
E. Head CT
INDICATION: [**Age over 90 **]-year-old female status post fall.
COMPARISON: No prior study available for comparison.
TECHNIQUE: Contiguous axial images were obtained through the
brain without IV
contrast at [**Hospital3 934**] Hospital. Several initial sections
were degraded
by motion artifact and subsequently repeated. Images are
submitted for formal
second opinion.
FINDINGS: Within limits of motion artifact, there is no acute
intracranial
hemorrhage, major vascular territory infarction, mass effect or
edema.
Hypodensity in the left occipital region may represent an area
of
encephalomalacia related to prior infarct. [**Doctor Last Name **]-white matter
differentiation
is elsewhere preserved. Periventricular white matter hypodensity
is
consistent with chronic small vessel ischemic disease.
Age-appropriate
prominence of ventricles and sulci is compatible with diffuse
parenchymal
volume loss.
Globes and left lens are intact. There has been prior right lens
replacement.
Visualized paranasal sinuses and left mastoid air cells are well
aerated.
There is under pneumatization and opacification of some of the
right mastoid
air cells. No osseous abnormality is identified. There is
calcification of
the bilateral cavernous carotid arteries.
IMPRESSION:
1. No acute intracranial abnormality.
2. Findings compatible with chronic small vessel ischemic
disease and
age-related involutional change.
3. Hypodensity in the left occipital region may represent an
area of
encephalomalacia related to prior infarct.
4. Underpneumatization and partial opacification of some of the
right mastoid
air cells.
F. CT Abdomen
INDICATION: [**Age over 90 **]-year-old female status post fall. Rule out
injury.
COMPARISON: No prior study available for comparison.
TECHNIQUE: MDCT-acquired axial images were obtained through the
abdomen and
pelvis after administration of 130 mL IV Optiray contrast.
Coronal and
sagittal reformats were displayed.
CT ABDOMEN WITH IV CONTRAST: Large right and moderate left
pleural effusions
with associated atelectasis demonstrate simple fluid
attenuation, and are
better evaluated on chest CT performed at the outside hospital
earlier the
same day. There is atherosclerotic calcification of the coronary
arteries,
but the heart is otherwise unremarkable. There is a
small-to-moderate hiatal
hernia. Focal calcification in the left pleural space may be
related to
pleural or diaphragmatic calcifications.
There is a wedge-shaped hyperenhancing perfusion abnormality in
the right lobe
of the liver (segment 8). The gallbladder, pancreas, spleen, and
right
adrenal gland are normal. The left adrenal gland is slightly
full. The kidneys
enhance and excrete contrast symmetrically without evidence of
hydronephrosis
or hydroureter. There are multiple hypodensities in the
bilateral kidneys,
most of which are too small to characterize, but likely simple
cysts. The
largest hypodensity is in the interpolar region of the right
kidney measuring
2.2 x 2.2 cm and with low attenuation, compatible with a simple
cyst. Some
regions of cortical thinning may be from insults related to
prior infection.
The non-opacified stomach and intra-abdominal loops of bowel are
normal.
There is no free air or fluid in the abdomen. No mesenteric or
retroperitoneal lymphadenopathy meeting CT criteria for
pathologic enlargement
is noted.
The aorta is of normal caliber throughout, but with marked
atherosclerotic
calcification and likely stenoses involving the origins of the
celiac axis,
SMA, [**Female First Name (un) 899**] and bilateral renal arteries. Soft plaque in the aorta
is also noted.
CT PELVIS WITH IV CONTRAST: The urinary bladder is collapsed
around a Foley
catheter. The distal ureters, uterus, left adnexa and rectum are
normal.
There is a 2.4 x 2.4 cm cystic structure in the right adnexa.
There is mild
sigmoid diverticulosis without evidence of acute diverticulitis.
BONE WINDOWS: There is an ill-defined lucency through the left
proximal
femoral neck, best seen on the sagittal images (301B:46)
compatible with acute
fracture. In addition, there is a lucency in the left ischium,
which could
also represent an acute fracture (2:70).
There is no suspicious lytic or sclerotic osseous lesion
identified. There is
multilevel degenerative change of the thoracolumbar spine with
endplate
osteophyte formation, loss of disc height and vacuum disc
phenomenon at
multiple levels. There is a grade 1 anterolisthesis of L5 on S1,
likely
chronic given the degenerative change.
IMPRESSION:
1. No evidence of solid organ injury in the abdomen or pelvis.
2. Nondisplaced left femoral neck fracture and possible left
ischial
fracture.
3. Bilateral pleural effusions, better evaluated on CT chest
performed
earlier the same day at an outside hospital.
4. Marked atherosclerotic calcification of the abdominal aorta
and coronary
arteries.
5. Moderate hiatal hernia.
6. Bilateral renal hypodensities, most likely simple cysts.
7. 2.4 cm right adnexal cyst can be further evaluated with
non-emergent
pelvic ultrasound.
8. Marked lumbar degenerative change with L5 on S1
anterolisthesis, likely
chronic given the degenerative changes.
IV. Cardiology
Atrial fibrillation with rapid ventricular response. Possible
left ventricular
hypertrophy. Non-specific ST-T wave changes. Compared to the
previous tracing
of [**2190-10-7**] rapid atrial fibrillation is new.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
113 0 114 348/440 0 57 -80
Brief Hospital Course:
[**Age over 90 **]-year-old female with baseline dementia, prior CVA x 2,
seizure disorder with left femoral neck fracture status post
pinning from mechanical fall on [**2190-10-8**] with course complicated
by hypoxia from pleural effusions and delirium from possible UTI
and metabolic etiologies.
# Femoral neck fracture: s/p percutaneous fixation with 7.3 mm
screws of
nondisplaced valgus impacted femoral neck fracture on [**2190-10-7**].
The patient had no apparent complications after the operation.
She needs to remain TD weight bearing on the left until she
follows up in ortho clinic in 2 months.
#BILATERAL PLEURAL EFFUSIONS/CHF: Effusions likely related to
acute CHF exacerbation. BNP elevated. CE neg x 1. ECG with TWI
in II and III otherwise no apparent ischemic changes. She should
have an ECHO as an outpt to assess EF as she has no known
history of heart failure.
# Hypoxemia: Hypoxemic on admission with 4L O2 requirement.
Likely related to bilateral effusions. No e/o PNA. O2
requirement now 1-2L. Diuresed initially with IV lasix. No need
for thoracentesis. O2 can likely continue to be weaned off as
tolerated to keep O2 sats>92-93%.
.
# Atrial Fibrillation: New Afib on this admission. TSH normal.
Likely related to longstanding HTN. Her outpt regimen of
atenolol 100 [**Hospital1 **] changed to metoprolol 62.5 [**Hospital1 **]. Systemic
anti-coagulation continued. Given INR became subtherapeutic she
was started on a lovenox bridge which can be stopped when INR
between [**2-3**] for 2 consec days. She will need close outpt follow
up for this new issue and should have an ECHO as outpt.
.
# Altered mental status/Delirium: Developed in MICU. Likely
multifactorial in setting of surgery, pain, hypoxemia, UTI and
hospitalization. Given her h/o prior stroke she had brain MRI
that indicated prior stroke BUT no acute infarct with non-focal.
AMS improved after she was started on ABX for UTI. She is now
oriented to person but remains otherwise disoriented. Per her
family, she is fully oriented at baseline. We anticipate that
her MS will slowly improve.
# Dysarthria with aspiration
Speech and swallow evaluted the patient given clinical suspicion
of aspiration with initial test confirming aspiration. She was
subsequently re-evaluated after her mental status changes
resolved with the following recommendations:
1. Suggest a PO diet of thin liquids and soft consistency solids
2. Strict 1:1 supervision for all PO intake given her current
mental status.
3. Meds crushed with puree.
4. TID oral care
5. Please feed only when most awake and alert.
6. If intake is limited due to her mental status, suggest a
nutrition consult
7. Please page if there are any additional questions or
concerns.
# Urinary tract infection: Problem with initial cx so no
organisms were isolated. We feel she should get a total 7 day
course of cipro 250mg [**Hospital1 **]. Last day [**2190-10-19**].
.
# Seizure disorder - She was continued on her home Keppra,
depakote and phenytoin
.
# Hypertension - The patient's nifedipine and lisinopril were
held given the peri-procedural period and relative volume
depletion. We are restarting lisinopril at 5mg daily and holding
nifedipine for now given BP in normotensive range. Would suggest
titrating up lisinopril to keep normotensive.
.
# Hyperlipidemia - She was continued on simvastatin 20 mg daily
.
# Code: DNR/DNI
.
# Emergency Contacts:
[**Name (NI) **] [**Name (NI) 58397**] (HCP) - [**Telephone/Fax (1) 88428**], [**Telephone/Fax (1) 88429**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 58397**] - [**Telephone/Fax (1) 88430**]
[**Name (NI) 11923**] (granddaughter)- [**Telephone/Fax (1) 88431**]
# Imaging Incidentals
- Bilateral renal hypodensities, most likely simple cysts.
- 2.4 cm right adnexal cyst can be further evaluated with
non-emergent
pelvic ultrasound. The team contact[**Name (NI) **] her family to let them
know of this mass too.
Medications on Admission:
- Kepra 500 mg at noon and 1000 mg [**Hospital1 **]
- lisinopril 40 mg qam
- phenytoin ex 100 mg tid
- nifedepine 90 mg qhs
- atenolol 100 mg [**Hospital1 **]
- coumadin 5'
- simvastatin 20'
- depakote 250 mg qam, 500 qhs
Discharge Medications:
1. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days: Stop date: [**2190-10-19**].
2. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous Q 12H (Every 12 Hours): Continue until INR [**2-3**] for
two consecutive days and then discontinue.
3. divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO HS (at bedtime).
4. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO q AM.
5. metoprolol tartrate 25 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
8. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please give at noon.
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
please monitor INR closely.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 7168**]
Discharge Diagnosis:
Non-displaced left femoral neck fracture
Atrial fibrillation
Delirium
Congestive Heart Failure Exacerbation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname 16254**],
You were treated for a hip fracture. During your hospitalization
you also had a new heart arrythmia, urinary tract infection and
delirium.
Medications
================
STOP nifedepine
STOP atenolol
.
START ciprofloxacin 250 mg by mouth twice daily (take until
[**10-19**])
enoxaparin 40 mg subcutaneously twice daily
- continue enoxaparin until INR is [**2-3**] for two consecutive days,
then discontinue
START metoprolol to 62.5 mg
DECREASE warfarin to 2 mg by mouth daily
DECREASE lisinopril from 40 mg to 5 mg
Followup Instructions:
Follow up with [**Doctor Last Name **] Derosiers, Orthopaedics NP, in 2 months.
You can call [**Telephone/Fax (1) 1228**] to make that appointment.
Please follow-up with your primary care doctor after rehab:
[**Last Name (LF) **],[**First Name3 (LF) **] S.
Address: [**Doctor Last Name 87203**], [**Apartment Address(1) 34213**], [**Location (un) **],[**Numeric Identifier 72271**]
Phone: [**Telephone/Fax (1) **]
|
[
"428.0",
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"345.90",
"V49.86",
"288.60",
"V49.87",
"V43.65",
"276.50",
"V12.04",
"784.51",
"V58.61",
"V15.88",
"401.9",
"290.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.55"
] |
icd9pcs
|
[
[
[]
]
] |
20113, 20201
|
14826, 18759
|
257, 407
|
20353, 20353
|
3959, 14803
|
21116, 21534
|
3197, 3215
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19032, 20090
|
20222, 20332
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18785, 19009
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20538, 21093
|
3230, 3940
|
213, 219
|
435, 2661
|
20368, 20514
|
2683, 2881
|
2897, 3181
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,513
| 157,785
|
29379
|
Discharge summary
|
report
|
Admission Date: [**2162-4-28**] Discharge Date: [**2162-4-30**]
Date of Birth: [**2103-8-23**] Sex: M
Service: NEUROSURGERY
Allergies:
Shellfish
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Left Frontal Mass
Major Surgical or Invasive Procedure:
[**2162-4-28**]: Left Frontal Craniotomy for Mass
History of Present Illness:
Patient is a 58M with a PMH significant for metastatic melanoma.
He presents for elective admission for craniotomy for
resection/decompression of left frontal mass
Past Medical History:
Melanoma
DVT
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
on Discharge:
Alert, oriented to person place and date. Right facial droop
with slurred speech. There is 0/5 strength of the right hand,
and 4/5 weakness of the other muscle goups of the RUE. He is
otherwise full strength. Wound is clean, dry and intact.
Pertinent Results:
Labs on Admission:
[**2162-4-29**] 03:15AM BLOOD WBC-15.3*# RBC-5.51 Hgb-14.5 Hct-43.3
MCV-79* MCH-26.4* MCHC-33.5 RDW-12.8 Plt Ct-232
[**2162-4-29**] 03:15AM BLOOD PT-12.2 PTT-27.2 INR(PT)-1.0
[**2162-4-29**] 03:15AM BLOOD Glucose-132* UreaN-17 Creat-1.0 Na-140
K-4.4 Cl-105 HCO3-25 AnGap-14
[**2162-4-29**] 03:15AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0
Labs on Discharge:
[**2162-4-30**] 05:35AM BLOOD WBC-14.7* RBC-5.28 Hgb-14.1 Hct-41.8
MCV-79* MCH-26.7* MCHC-33.8 RDW-13.0 Plt Ct-228
[**2162-4-30**] 05:35AM BLOOD PT-11.4 PTT-28.2 INR(PT)-0.9
[**2162-4-30**] 05:35AM BLOOD Glucose-118* UreaN-22* Creat-0.9 Na-138
K-4.4 Cl-103 HCO3-27 AnGap-12
[**2162-4-30**] 05:35AM BLOOD Calcium-9.1 Phos-2.2* Mg-2.2
----------------
IMAGING:
----------------
CT Head [**4-28**]:
PFI: Expected postoperative changes. Pneumocephalus. Small
amount of blood
in the surgical bed. No enlarged hemorrhage or extraaxial fluid
collection. No significant mass effect. Underlying edema similar
in appearance to [**2162-4-14**].
MRI Head [**4-29**]:
final read pending at this time.
Brief Hospital Course:
Patient was electively admitted to the hospital on [**4-28**] for
craniotomy for decompression of left frontal mass.
Post-operatively, he was returned to the ICU for close
monitoring. His post-operative examination was significant for a
right facial droop, slurred speech, and weak right sided grip.
This was thought to be due to local edema and surgical
manipulation, and is expected to improve. Because of this, his
steroid taper was slightly prolonged.
In the morning of POD#1([**4-29**]), he was determined to be stable to
transfer to the neurosurgical floor. Prior to transfer, his
foley catheter and arterial line were removed. He was then seen
and evaluated by PT and OT who determined he would be
appropriate for disoposition with outpatient services.
Medications on Admission:
Finasteride, Lexapro, Zinc, Vit C, B-Complex, melatonin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
3. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
6. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Melatonin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
11. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO q6h ()
for 2 days.
Disp:*16 Tablet(s)* Refills:*0*
12. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO tid () for
2 days.
Disp:*6 Tablet(s)* Refills:*0*
13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO bid () for
99 doses.
Disp:*60 Tablet(s)* Refills:*0*
14. Outpatient Speech/Swallowing Therapy
15. Outpatient Occupational Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Left Frontal Mass **Metastatic Melanoma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????Please return to the office in [**11-11**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**5-24**]
at 2 pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will need an MRI of the brain with & without gadolinium
contrast. This is to be at 11:55am on [**2162-5-24**]. It will also be
on the [**Hospital Ward Name **], [**Hospital Ward Name 23**] 4.
Completed by:[**2162-4-30**]
|
[
"V12.51",
"198.3",
"197.8",
"V10.82",
"351.8",
"V10.11",
"780.39",
"196.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
4192, 4198
|
2018, 2780
|
292, 344
|
4282, 4306
|
931, 936
|
9391, 10423
|
623, 641
|
2886, 4169
|
4219, 4261
|
2806, 2863
|
4330, 4351
|
656, 656
|
670, 912
|
7560, 9368
|
235, 254
|
1303, 1995
|
4363, 7533
|
372, 537
|
950, 1283
|
559, 573
|
589, 607
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,061
| 151,077
|
53197
|
Discharge summary
|
report
|
Admission Date: [**2164-11-23**] Discharge Date: [**2164-12-10**]
Date of Birth: [**2089-8-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 yo female with multiple medical problems including CAD,
hypertension, osteoporosis, CHF who presents with 2-3 days of
woresning back pain to the point that it has become very
difficult for her to walk and ambulate. She denies any numbness,
tingling sensation, or other associate symptoms like fever,
chills. Just complaining of pain and diffculty ambulating
secondary to pain. No dysuria, urinary or bowel incontinence.
Was seen by Dr. [**Last Name (STitle) 18068**] who gave her Percocet and she was
taking [**12-11**] tablet every night and pain did not improve. Came in
to the ED for further evaluation. Had imaging in the ED that did
not show any evidence of acute fracture or any misalignment.
Being admitted for pain control and possible rehab placement.
Past Medical History:
1. CAD s/p MI and stent to LCx
2. Hypertension
3. Osteoporosis
4. Renal Artery Stenosis s/p stent to R renal artery
5. CHF
6. Hyperlipidemia
7. GERD
8. Fe deficiency Anemia
9. COPD
10. s/p lap chole
11. s/p L shoulder hemiarhtroplasty
Social History:
Lives at home with good social support; denies any EtOH, tobacco
use or an IV drug or recreational drug use
Family History:
Non contributory
Physical Exam:
VS: T 97.6, pulse 71, BP 109/72, RR 92% room air
Gen: moderately discomfort secondary to pain
HEENT: PERRLA, EOMI, OP clear
Neck: supple, no JVD
Heart: S1, S2, RRR, no murmurs, rubs, gallops
Abd: soft, ND, NT, no HSM
Extrem: paraspinal tenderness, no rashes
Neuro: AAO x 3, good sensation and [**4-11**] motor strength, decrease
range of motion mainly secondary to pain
Pertinent Results:
[**2164-11-23**] 03:00PM PT-13.5 PTT-38.0* INR(PT)-1.1
[**2164-11-23**] 03:00PM WBC-8.1 RBC-5.25# HGB-11.6*# HCT-37.0#
MCV-71* MCH-22.0* MCHC-31.3 RDW-16.9*
[**2164-11-23**] 03:00PM GLUCOSE-119* UREA N-40* CREAT-1.7* SODIUM-138
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
[**2164-11-23**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2164-11-23**] 03:00PM URINE RBC-0-2 WBC-[**10-27**]* BACTERIA-RARE
YEAST-NONE EPI-[**5-17**] RENAL EPI-0-2
Brief Hospital Course:
75 yo female with multiple medical problems who presents with
back pain and difficulty ambulating but no evidence of any
fractures. Hospital course was complicated be hypotension and
hypoxia leading to mesenteric ischemic colitis and MRSA
pneumonia.
1. MRSA Pneumonia - patient was diagnosed with MRSA pneumonia
and so was started on Vancomycin 1000mg IV daily. She had a PICC
line placed, and will need an additional 2 weeks of total
antibiotics. In addition, given her history of COPD, she will
need aggressive pulmonary toilet / chest physical therapy as she
is at an increased risk of mucous plugging if she does not clear
well.
2. Mesenteric Ischemia - this was diagnosed on CT abdomen. This
was likely secondary to her being hypotensive for a long period
of time but throughout the hospital course, her diet was
advanced and she tolerated it well. Her abdominal exam was
benign.
3. Hypertension - her BP has been labile for most of the
hospital course, but we finally were able to reach a regimen
that was well tolerated by her. Given her history of renal
artery stents, our goal is to keep her SBP around 140s and so
she is currently on Diltiazem, and Isosorbide Dintrate.
4. CAD - she should continue her Aspirin, Plavix, and
Simvastatin
5. Back Pain - likey secondary to her osteoporosis with possible
compression fractures; she had plain films of her lumbar and
thoracic areas that showed no evidence of fractures or
misalignment. However, given her extent of pain, there was
concern for compression fracture but an MRI could not be obtain
due to her recent shoulder surgery and her history of renal
artery stents. At that time, it was decided to obtain a CT of
her lumbar and thoracic area that also did nto show any
fractures - only some foramenal narrowing. Her pain was
initially controlled with Ultram, Oxycodone, and Valium but she
had an episode of becoming hypotensive and so her pain
medications were switched around to Tylenol around the clock,
with Calcitonin nasal spray.
6. Renal - she is s/p stent to the R renal artery from stenosis;
she was seen by the Renal team who agreed with our current
medication plans. Her baseline Creat is between 1.4 and 1.7 and
she is well below her baseline at this the time of discharge.
Medications on Admission:
1. Imdur 120mg po daily
2. Aspirin 325 mg po daily
3. Zocor 80mg po daily
4. Toprol XL 100mg po daily
5. Plavix 75mg po daily
6. Fosamax 70mg po q week
7. Zetia 10mg po daily
8. Norvasc 10mg po daily
9. Trazadone 50mg po qhs
10. Atrovent 2 puffs qid
11. Uniretic 15-25mg po daily
12. Percocet [**12-11**] tablet prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
6. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QMON
(every Monday).
7. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) spray Nasal DAILY (Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
14. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Vancomycin HCl 10 g Recon Soln Sig: 1000 (1000) mg
Intravenous Q24H (every 24 hours) for 14 days.
18. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
19. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
20. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
treatment Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
21. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) inhaler Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
1. MRSA Pneumonia
2. Back Pain
3. Hypertension
4. Renal Artery Stenosis s/p renal artery stents
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as directed.
Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **] [**12-9**] weeks.
Please take your blood pressure medications with caution as we
would like your blood pressure around 140 systolic. Please hold
medications if SBP less than 140.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2164-12-18**] 2:00
|
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"518.82",
"458.29",
"557.0",
"733.13",
"401.9",
"599.0",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90",
"99.04",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
7052, 7149
|
2505, 4756
|
326, 332
|
7289, 7297
|
1949, 2482
|
7654, 7854
|
1525, 1543
|
5123, 7029
|
7170, 7268
|
4782, 5100
|
7321, 7631
|
1558, 1930
|
277, 288
|
360, 1125
|
1147, 1383
|
1399, 1509
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,209
| 137,438
|
29533
|
Discharge summary
|
report
|
Admission Date: [**2141-6-15**] Discharge Date: [**2141-6-23**]
Date of Birth: [**2083-9-7**] Sex: M
Service: MEDICINE
Allergies:
Cefazolin
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
ICD firing x3
Major Surgical or Invasive Procedure:
EP study with ablation
History of Present Illness:
Mr. [**Known lastname **] is a 57 yo Mandarin speaking male with PMH of
non-ischemic cardiomyopathy EF 25%, s/p ICD placement in [**12-10**]
for VT with associated syncope, who presents with ICD firing and
VT. Of note his ICD has fired on three separate occasions since
its placement. Most recently it fired prior to his admission
[**4-11**]. At that time his medication regimen was adjusted and he
was discharged on mexiletine 200mg [**Hospital1 **] and metoprolol 12.5mg
[**Hospital1 **]. His sotalol was discontinued due to QTc prolongation.
.
He reports that he was in his usual state of health today, was
walking his granddaughter to school when he felt his ICD shock.
He sat down and he felt it shock twice more. He did not fall or
injury himself at the time of the shock. He reports pain due to
the shock but denies any any other preceding chest pain,
dyspnea, nausea, vomiting, lightheadedness, weakness,
palpitation or other symptoms.
.
In the ED T98.5 HR 84 RR18 BP 117/75 RR 18 99% 4L NC. He was
given 1L NS. He was evaluated by EP who interrogated his
pacemaker and noted that he had VT with rate in 150's, got
antitachycardia paced x3 and then had ICD firing.
.
On initial arrival to the floor he reports feeling in his usual
health but is afraid that his pacemaker will fire again and is
frustrated that it has happened again. Shortly after arrival to
the floor he went back into sustained, stable VT, rate in the
140's -150's and was shocked x1. EP was present on the floor and
went to bedside. His pacemaker was interrogated and his
Anti-tachycardia pacing rate was decreased to pace for a rate of
135. He had several prolonged periods of VT lasting greater than
5 minutes, he had several rounds of AT pacing that did not break
his VT however he eventually converted back into sinus rhythm on
his own. His blood pressure was stable throughout the episode
ranging from SBP 100-120's. He was given amiodarone 150mg IV
bolus x2 and started on an amiodarone gtt.
Past Medical History:
-Ventricular tachycardia s/p ICD placement in [**12-10**]
-mechanical AVR in [**Country 651**] [**2113**] due to presumed endocarditis from
a septic knee.
-non-ischemic cardiomyopathy (possibly alcoholic) with an EF of
20-30% and focal inferobasal an apical aneurysm.
-systolic CHF with EF 20-30% per ECHO [**2-9**]
-arthritis
-hypertension
-hyperlipidemia
Social History:
He arrived in this country from [**Country 651**] 1 year ago (although
travels back frequently), currently living with his son and his
family. Formerly smoked 2ppd x 40 years but quit 6 months ago,
Etoh use significant for red wine 1 bottle/day for over 20 years
but none in past several months.
Family History:
Family History: No known family history of cardiac disease
Physical Exam:
Gen: thin asian male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: [**Country 12476**]. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP flat.
CV: Pacemaker on left side of chest, 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. CTAB, no crackles,
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.
Pertinent Results:
[**2141-6-23**] CXR: No acute cardiopulmonary abnormalities. Incomplete
visualization of the attachment of the pacemaker/defibrillator
leads to the AICD device in the left axilla, otherwise leads are
intact.
[**2141-6-21**] CT ABD/PELVIS:
1. No evidence of intra-abdominal hemorrhage identified.
2. Questionable filling defect seen adjacent to a markedly
thinned left
ventricular apex. These findings are discussed with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at the time
of dictation.
[**2141-6-21**] ECHO:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is severely depressed (LVEF= 30 %)
with akinesis to dyskinesis of the inferior and lateral walls.
There is a focal apical inferior aneurysm . Right ventricular
chamber size is normal. with moderate global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. A bileaflet aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
EKG demonstrated regular WCT, rate 100, possibly SR/ST with LBBB
vs accel jxnl with no significant change compared with prior
dated [**2141-6-21**].
CARDIAC CATH performed on [**2141-12-18**] demonstrated:
1. Coronary angiography of this right dominant system revealed
no
obstructive coronary disease in the LMCA, LAD, LCX, and RCA.
2. Resting hemodynamics revealed mildly elevated right heart
pressures with an RA of 7 mm Hg, RVSP of 37 mm Hg, PASP of 37 mm
Hg, and moderately elevated mean PCW pressure of 20 mm Hg.
Cardiac output was 4.7 and cardiac index 2.7.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Moderately elevated PCW pressure with mild pulmonary
hypertension.
.
OTHER TESTING:
.
[**2141-6-15**] CXR: Mild cardiomegaly is noted which appears
improved when compared to previous exams from [**2140-12-3**]
and [**1-3**] of [**2141**]. The patient is status post median
sternotomy with fractured superior mediastinal wire unchanged in
position. A left-sided AICD is in unchanged position. Pulmonary
vasculature is within normal limits. Right-sided pleural
thickening is stable. No focal pulmonary opacities are
identified. A likely left-sided nipple shadow is identified.
IMPRESSION: No acute cardiopulmonary disease.
Brief Hospital Course:
Mr. [**Known lastname **] is a 57 yo Mandarin-speaking male with likely ETOH DCM,
EF 30%, s/p ICD placement in [**12-10**] for VT, failed prior
ablation, sotalol, and mexiletine, who presents following ICD
firing.
1)Sustained Ventricular Tachycardia - s/p PPM/ICD placement for
VT in [**12/2140**], has failed prior attempts at ablation as well as
sotalol and mexiletine. On admission he had ventricular
tachycardia with rate in the 140's-150's that was sustaining >5
minutes and he was not anti-tachycardia pacing out of his VT.
His ICD fired once shortly after admission. He remained
hemodynamically stable but was transferred to CCU for closer
monitoring and started on amiodarone IV bolus +gtt. He had EP
study with ablation of several inducible sites of VT on [**2141-6-20**]
however it was unclear if they were able to ablate the site that
was causing the VT. He was hypotensive s/p EP procedure with
SBP in 70's -80's despite IVF bolus of about 5L. He had a ECHO
post procedure which did not show any evidence of pericardial
effusion or worsened systolic function and he had a CT scan
which did not show any evidence of RP bleeding. About 32 hours
after his EP study and ablation his blood pressure returned to
[**Location **] with systolic in 110's. He did not have any recurrance
of his VT over the next two days and was discharged on
amiodarone and metoprolol.
2)Acute Renal Failure - baseline creatinine 1.1 on admission,
elevated to 1.4 during this admission most likely due to
pre-renal/dehydration. Creatinine returned to 1.1 after getting
total of 5L fluid in the setting of hypotension post EP study.
He was discharged on home regimen of lisinopril and lasix.
3)Chronic Systolic Dysfunction: EF of 30-35% on most recent Echo
[**4-11**] and [**6-21**]; [**2-4**] dilated, non-ischemic cardiomyopathy. In
addition, he has aneurysm of infero/lateral walls of LV. He
tolerated the 5L IVF given for hypotension post EP study without
any peripheral edema or shortness of breath. He was discharged
on metoprolol, lisinopril and lasix.
4)Mechanical Aortic Valve - on coumadin at baseline, with goal
INR [**2-5**]. He was discahrged on home dose coumadin 6mg daily with
INR follow up to adjust dose given that he is now on amiodarone.
5)Hyperlipidemia: Continue Simvastatin 20 mg Tablet PO HS
6)Anemia: baseline HCT 32-35. Currently slightly decreased at
30, however no evidence of acute bleeding. Had ct scan post
procedure which didn't any evidence of RP bleed. He was
continued on Ferrous Sulfate 325 mg daily on discharge.
7) Code: Full (confirmed with pt via interpretor)
8)Contact: [**Name (NI) **]: Shun [**Name (NI) **] [**Telephone/Fax (1) 70840**]
Medications on Admission:
1. Simvastatin 20 mg Tablet PO HS
2. Ferrous Sulfate 325 mg daily
3. Lisinopril 5 mg daily
4. Warfarin 6 mg daily
5. Mexiletine 200 mg PO Q8H
6. Metoprolol XL 25 mg daily
7. Aspirin 81 mg daily
8. Multivitamin
9. Lasix 10 mg daily
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM: please adjust dose as directed by your physician.
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 weeks: Last day at this dose is Thursday [**6-29**].
Disp:*28 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 weeks: From Friday [**6-30**] to Thursday [**7-13**].
Disp:*28 Tablet(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Please start on Friday, [**7-14**].
Disp:*30 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
Please draw patient's INR on [**Last Name (LF) 766**], [**6-26**].
11. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis: Ventricular tachycardia
Secondary diagnoses: history of Mechanical valve repair,
hypotension, acute renal failure, chronic systolic heart failure
Discharge Condition:
Vital signs stable, no further episodes of ventricular
tachycardia with appropriate follow-up.
Discharge Instructions:
You were admitted with a heart rhythm called ventricular
tachycardia. You had an ablation done and you have a pacemaker
with a defibrillator. You were also started on medications to
help keep your heart out of ventricular tachycardia.
1. Please take all medications as prescribed.
- We started you on amiodarone; please follow the instructions
carefully as your dose will change from one week to the next.
- We suggest you take only 4mg of coumadin on [**Last Name (LF) 1017**], [**6-25**].
- We stopped your mexiletine
- We stopped your lisinopril, although it might be restarted
again in the future.
2. Please attend all follow-up appointments listed below.
3. Please call your doctor or return to the hospital if you
develop chest pain, palpitations, lightheadedness, fevers,
shortness of breath, or any other concerning symptom.
4. You are on a medication called coumadin that thins your
blood. You will need to have your blood drawn on [**Last Name (LF) 766**], [**6-26**] at Dr.[**Name (NI) 22054**] office and adjust your dose of coumadin as
directed by Dr. [**First Name (STitle) **]. We recommend that you continue to take 6mg
of coumadin daily except for this [**Last Name (LF) 1017**], [**6-25**], when you
should take 4mg.
Followup Instructions:
1. Please arrange to see your primary doctor (Dr. [**First Name (STitle) **] [**Name (STitle) **])
within 2-3 weeks. You can call [**Telephone/Fax (1) 10349**] for an appointment.
2. We scheduled an appointment for you with the nurse
practitioner for electrophysiology: [**7-12**] at 2pm, [**Hospital Ward Name 23**]
building [**Location (un) 436**]. Please bring your son along as an
interpreter.
3. You will need to have pulmonary function tests. These have
been ordered for you, and you will be contact[**Name (NI) **] by phone to set
up an appointment. If you do not hear from the pulmonary lab in
1 week, please call [**Telephone/Fax (1) 609**] to book an appointment.
Please keep your previously scheduled appointments:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2141-7-12**] 11:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 285**]
Date/Time:[**2141-7-12**] 2:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2141-8-1**]
3:00
You will also see Dr. [**Last Name (STitle) **] on [**8-1**] after your device
check.
|
[
"458.29",
"425.5",
"428.0",
"V58.66",
"272.4",
"V15.82",
"276.51",
"285.9",
"V43.3",
"428.22",
"427.1",
"401.9",
"584.9",
"V45.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"37.27",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
10734, 10809
|
6636, 9324
|
282, 307
|
11020, 11117
|
3847, 5937
|
12408, 13680
|
3042, 3087
|
9606, 10711
|
10830, 10830
|
9350, 9583
|
5954, 6613
|
11141, 12385
|
3102, 3828
|
10896, 10999
|
229, 244
|
336, 2313
|
10850, 10874
|
2335, 2696
|
2712, 3010
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,717
| 198,291
|
53031
|
Discharge summary
|
report
|
Admission Date: [**2108-2-23**] Discharge Date: [**2108-2-29**]
Date of Birth: [**2043-11-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Quinolones
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
intermittent chest pain at rest
Major Surgical or Invasive Procedure:
[**2108-2-24**]
Coronary Artery Bypass x 1 (LIMA-LAD)
Atrial Septal Defect closure
History of Present Illness:
64 year old man has been bothered by
atypical chest discomfort since [**2107-4-3**]. He describes the
discomfort as a squeezing sensation under the sternum that is
quite random and in most situations occurs when he is at rest.
The longest episode lasted about one hour. There have been times
where he has had up to four episodes in a day. He is able to
tolerate aerobic exercise without provoking this pain although
he
has noticed the discomfort when he lifts heavy objects. Stress
testing in [**2107-5-4**] did not reveal perfusion defects. A recent
chest CT revealed a 60-70% stenosis at the origin of the LAD. He
was referred for coronary angiography to further evaluate. He
was
found to have coronary artery disease and is now being referred
to cardiac surgery for revascularization.
Past Medical History:
Coronary Artery Disease
Atrial Septal Defect
PMH:
Elevated triglycerides
CRI (stage III)
Crohn's disease x 30 years, s/p resection of terminal ileum in
[**2075**]
Kidney stones [**2087**]
GERD
Avascular necrosis (from prednisone use)
Osteoporosis
Vitamin D deficiency
Dry eyes
Freckle on retina
Depression
Past Surgical History:
Bilateral hernia repair
Benign growth removed from hand
s/p resection of terminal ileum in [**2075**]
Left shoulder rotator cuff surgery
Social History:
Lives with:wife
Contact:[**Name (NI) **] [**Name (NI) 109302**] (wife) [**Telephone/Fax (1) 109303**] cell
Occupation:Retired- Previously worked as a software engineer
Cigarettes: Smoked no [] yes [x]Hx:quit 26 years ago, smoked 1
ppd x 20 years
Other Tobacco use:denies
ETOH: 2 ounces a night
Illicit drug use: denies
Family History:
Premature coronary artery disease- Father with
angina in his 70's and underwent coronary stenting
Physical Exam:
Pulse:72 Resp:12 O2 sat:97/RA
B/P Right:118/64 Left:127/67
Height:5'9" Weight:147 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade II/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:- Left:-
Pertinent Results:
Intra-op TEE [**2108-2-24**]
Conclusions
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No spontaneous echo
contrast is seen in the body of the right atrium or right atrial
appendage.
There is color flow consistent with a small secundum atrial
septal defect. A bubble study was negative. Color doppler
indicates Left to right flow. A defect cannot be visualized in
2D or 3D images.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed (LVEF= 40 %). The
septal and anteroseptal walls are moderately hypokinetic from
mid base to apex.
The diameters of aorta at the sinus, ascending and arch levels
are normal. There are simple atheroma in the descending thoracic
aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room.
POSTBYPASS:
The patient is A paced on low dose phenylephrine. There is
improved biventricular function. There is color flow consistent
with stitch artifact on the right atrial side of the interatrial
septum, but no further left to right color flow is seen. RV
function is maintained. The LV function is mildly improved, EF
45% with mild improvement in the septal & anteroseptal
hypokinesis seen prebypass. The aorta remains intact. The valves
remain unchanged.
[**2108-2-28**] 05:10AM BLOOD WBC-5.9 RBC-3.49* Hgb-10.2* Hct-33.2*
MCV-95 MCH-29.2 MCHC-30.6* RDW-14.4 Plt Ct-244#
[**2108-2-27**] 05:52AM BLOOD WBC-4.7 RBC-3.03* Hgb-8.8* Hct-28.6*
MCV-95 MCH-28.9 MCHC-30.6* RDW-14.4 Plt Ct-147*
[**2108-2-28**] 05:10AM BLOOD Glucose-101* UreaN-15 Creat-1.5* Na-139
K-4.5 Cl-102 HCO3-30 AnGap-12
[**2108-2-27**] 05:52AM BLOOD Glucose-94 UreaN-10 Creat-1.1 Na-137
K-4.4 Cl-105 HCO3-27 AnGap-9
[**2108-2-26**] 03:59AM BLOOD Glucose-97 UreaN-12 Creat-1.1 Na-138
K-3.9 Cl-105 HCO3-28 AnGap-9
[**2108-2-28**] 05:10AM BLOOD Mg-2.7*
[**2108-2-27**] 05:52AM BLOOD Calcium-8.5 Mg-1.9
[**2108-2-29**] 05:35AM BLOOD Glucose-120* UreaN-14 Creat-1.5* Na-137
K-4.3 Cl-101 HCO3-29 AnGap-11
Brief Hospital Course:
The patient was brought to the Operating Room on [**2-24**]/12where
the patient underwent CABG x 1 and ASD closure with Dr. [**Last 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.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and blood pressure was supported with Neo synephrine. This was
weaned. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. He did not tolerate
Lopressor and was changed to Coreg with good effect. 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 wound was healing and pain was controlled with oral
analgesics. The patient was discharged home in good condition
with appropriate follow up instructions. ACE Inhibitor was not
started due to renal insufficiency.
Medications on Admission:
ADALIMUMAB [HUMIRA] 40 mg/0.8 mL Kit - took 160mg last week x 1,
scheduled for 80mg x 1 week of [**2108-2-27**]
ALENDRONATE 70 mg once a week (Friday)
CHOLESTYRAMINE (WITH SUGAR) 4 gram Packet twice a day
VITAMIN B-12 1,000 mcg/mL once a month
CYCLOBENZAPRINE 5 mg Daily
CYCLOSPORINE [RESTASIS] 0.05 % Dropperette - 1 drop OU twice a
day
PREVACID 30 mg [**Hospital1 **]
CALCIUM CARBONATE-VITAMIN D3 600 mg calcium/200 unit Capsule
Daily
VITAMIN D3 2,000 unit daily
FERROUS SULFATE 325 mg daily
FISH OIL-DHA-EPA 1,200 mg-144 mg-216 mg- 1 Capsule [**Hospital1 **]
FLAXSEED OIL 1,000 mg Capsule [**Hospital1 **]
FOLIC ACID 0.4 mg daily
MULTIVITAMIN,TX-MINERALS Daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
Disp:*4 Tablet(s)* Refills:*2*
5. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease
Atrial Septal Defect
PMH:
Elevated triglycerides
CRI (stage III)
Crohn's disease x 30 years, s/p resection of terminal ileum in
[**2075**]
Kidney stones [**2087**]
GERD
Avascular necrosis (from prednisone use)
Osteoporosis
Vitamin D deficiency
Dry eyes
Freckle on retina
Depression
Past Surgical History:
Bilateral hernia repair
Benign growth removed from hand
s/p resection of terminal ileum in [**2075**]
Left shoulder rotator cuff surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office, [**Telephone/Fax (1) 170**], [**2108-3-8**],
11:00
Surgeon Dr. [**Last Name (STitle) **] [**2108-4-4**] 1:00, [**Telephone/Fax (1) 170**]
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2920**] [**Telephone/Fax (1) 2258**] (office will call you
with appt.)
Please call to schedule the following:
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-8**] 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:[**2108-2-29**]
|
[
"414.01",
"V13.89",
"555.9",
"458.29",
"530.81",
"585.3",
"733.09",
"413.9",
"745.5",
"V13.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"35.71"
] |
icd9pcs
|
[
[
[]
]
] |
8008, 8057
|
5196, 6403
|
310, 395
|
8566, 8734
|
2824, 5173
|
9522, 10234
|
2056, 2155
|
7119, 7985
|
8078, 8384
|
6429, 7096
|
8758, 9499
|
8407, 8545
|
2170, 2805
|
238, 272
|
423, 1213
|
1235, 1541
|
1719, 2040
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,993
| 181,118
|
26176
|
Discharge summary
|
report
|
Admission Date: [**2111-1-5**] Discharge Date: [**2111-1-19**]
Date of Birth: [**2047-4-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Plavix
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
admitted for CEA
Major Surgical or Invasive Procedure:
Left Carotid Endarterectomy [**2111-1-5**]
[**1-12**] CABGx4 (LIMA->LAD,SVG->Diag, SVG->PDA, SVG->Y-graft->OM)
History of Present Illness:
63 yo M with h/o PVD admitted for L CEA.
Past Medical History:
GERD, h/o GIB [**11-8**], Anxiety, +tobacco 50 pack year, s/p R
rotator cuff surgery, s/p B common iliac stenting, LLE iliac
stenting, R common femoral endarterectomy [**11-8**]
Social History:
unemployed
current tobacco @[**2-4**] ppd
no etoh
Family History:
nc
Physical Exam:
Admission
VS HR 80 RR 17 182/76
Gen NAD
Lungs decreased at both bases bilat
Neck L CEA C/D/I, well healed right CEA
Heart RRR
Abdomen benign
Extrem warm, stasis changes, 1+dp pulses, non-palp PT pulses
Discharge
VS T 98.5 HR 79SR BP 136/68 RR 18 O2sat 94%RA
Gen: NAD
Neuro Alert and oriented, nonfocal exam
Pulm rales at bases
CV RRR, no murmur. Sternum stable with min draiange at lower
pole
Abdm soft, NT/+BS
Ext warm 1+ pedal edema
Pertinent Results:
[**1-7**] CXR: There is mild cardiomegaly. Mediastinal and hilar
contours are within normal limits. There is moderately severe
congestive heart failure indicated by upper zone [**Month/Day (1) 1106**]
redistribution and perihilar haze, and peribronchial cuffing and
[**Last Name (un) 16765**] lines. There is a small left effusion. No pneumothorax.
[**1-8**] Cath: 1. Coronary angiography of this right dominant system
revealed a distal 80% LMCA plaque involving the ostial LCX and
LAD. The LAD had moderate diffuse disease and the LCX had a 90%
ostial lesion. The RCA was 100% occluded and filled by left to
right collaterals. 2. Resting hemodynamics revealed elevated
left and right-sided filling pressures. RASP was 15 mmHg, RVEDP
20 mm Hg, PASP 39 mm Hg, PCWP 43 mm Hg, and LVEDP 43 mm Hg.
Systemic arterial pressure was normal with an SBP of 131 mm Hg.
3. Left ventriculography was performed and showed an EF of 60%
with 2+ mitral regurgitation. 4. 80 mg IV lasix was administered
for diuresis.
[**1-12**] Echo: PRE BYPASS: No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the ascending aorta
confirmed by epi-aortic scanning,. Cross clamp and canullation
sights were based on epiaortic scan. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. POST BYPASS: Preserved
biventricular systolic function is preserved. The study is
otherwise unchanged fom prebypass.
[**1-16**] CXR: Small bilateral pleural effusions greater on the left
side are unchanged allowing the difference in positioning and
technique. Adjacent bibasilar atelectases are slightly improved.
The patient is post-median sternotomy and CABG. Small anterior
pneumomediastinum is present. Mild generalized interstitial
pulmonary abnormality is unchanged from [**2109**] and is of unknown
significance.
[**2111-1-6**] 03:35AM BLOOD WBC-8.7 RBC-3.60*# Hgb-11.0*# Hct-32.0*#
MCV-89 MCH-30.6 MCHC-34.4 RDW-14.6 Plt Ct-194
[**2111-1-17**] 08:20AM BLOOD WBC-8.4 RBC-3.08* Hgb-9.6* Hct-28.7*
MCV-93 MCH-31.3 MCHC-33.6 RDW-14.3 Plt Ct-375
[**2111-1-8**] 05:35PM BLOOD PT-12.6 PTT-27.5 INR(PT)-1.1
[**2111-1-12**] 01:13PM BLOOD PT-15.0* PTT-34.2 INR(PT)-1.3*
[**2111-1-6**] 03:35AM BLOOD Glucose-105 UreaN-27* Creat-1.1 Na-134
K-3.8 Cl-102 HCO3-25 AnGap-11
[**2111-1-17**] 08:20AM BLOOD Glucose-124* UreaN-30* Creat-1.1 Na-135
K-3.8 Cl-97 HCO3-29 AnGap-13
[**2111-1-11**] 10:35PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-8* pH-5.0 Leuks-NEG
[**2111-1-11**] 10:35PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
Brief Hospital Course:
He underwent L CEA on [**1-5**]. He was transferred to the floor in
stable condition. He developed chest pain on POD #1 and cardiac
enzymes were positive. Cardiac cath showed LM & 3VD and he was
admitted to the CCU. He was seen by cardiac surgery. He was
taken to the operating room on [**1-12**] where he underwent a CABG x
4 with LIMA-LAD, SVG-Diag and Y-OM, SVG-PDA, the bypass time was
87 minutes and crossclamp was 60 minutes. See OR report for full
details. He tolerated the operation well and he was transferred
to the ICU in critical but stable condition on propofol and neo.
He did well in the immediate post-op period and was extubated on
POD #1. He was also transferred to the floor on POD #1. He did
well postoperatively, his epicardial wires and chest tubes were
removed and he remained hemodynamically stable throughout this
period. His activity was advanced with the assistance of PT and
nursing. He did have some sternal drainage at lower pole and was
started on antibiotics. On post-op day seven it was decided he
was stable and ready for discharge home with VNA and the
appropriate follow-up appointments.
Medications on Admission:
Diovan 160/12.5', simvastatin 40', metoprolol 100", doxazosin
8', protonix 40', ASA 325', alprazolam 0.5 PRN
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for 5 days.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
Disp:*150 Tablet(s)* Refills:*1*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours) for 7 days.
Disp:*42 Capsule(s)* Refills:*0*
8. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. 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:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
11. Alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Coronary Artery Disease now s/p Coronary Artery Bypass Graft x 4
Left Carotid stenosis now s/p CEA
PMH:NSTEMI,GERD, h/o GIB [**11-8**], Anxiety, +tobacco 50 pack year,
s/p R rotator cuff surgery, s/p B common iliac stenting, LLE
iliac stenting, R common femoral endarterectomy [**11-8**]
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 1 month.
7) Call with any questions or concerns.
Division of [**Telephone/Fax (1) **] and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions
What to expect when you go home:
1. Surgical Incision: It is normal to have some swelling and
feel a firm ridge along the incision
?????? Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a mild headache, especially on the side of your
surgery
??????Try ibuprofen, acetaminophen, or your discharge pain medication
??????If headache worsens, is associated with visual changes or lasts
longer than 2 hours- call [**Telephone/Fax (1) 1106**] [**Telephone/Fax (1) 5059**]??????s office
3. It is normal to feel tired, this will last for 4-6 weeks
??????You should get up out of bed every day and gradually increase
your activity each day
??????You may walk and you may go up and down stairs
??????Increase your activities as you can tolerate
5. It is normal to have a decreased appetite, your appetite will
return with time
??????You will probably lose your taste for food and lose some weight
??????Eat small frequent meals
??????It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
What activities you can and cannot do:
??????No driving until post-op visit and you are no longer taking
pain medications
??????No excessive head turning, lifting, pushing or pulling (greater
than 5 lbs) until your post op visit
??????You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
??????Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
??????Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
??????Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
??????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
?????? sudden change in the ability to move or use your arm or leg or
the ability to feel your arm or leg
??????Temperature greater than 101.5F for 24 hours
??????Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
NO DRIVING UNTIL YOUR FOLLOW-UP APPOINTMENT.
Followup Instructions:
Wound Check on Thursday [**1-22**] on [**Hospital Ward Name 121**] 6
Dr [**Last Name (STitle) **] in 4 weeks, pt to call [**Telephone/Fax (1) 1504**] to schedule
appointment
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 7960**] 2-3 weeks
Call clinic and return in 2 weeks.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2111-1-20**] 11:30
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2111-2-13**]
8:00
Dr. [**Last Name (STitle) **] in [**2-4**] weeks
Completed by:[**2111-1-19**]
|
[
"511.9",
"E878.2",
"V64.1",
"E849.7",
"433.10",
"401.9",
"V14.8",
"433.30",
"300.4",
"428.0",
"998.81",
"440.20",
"518.0",
"998.32",
"410.71",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"36.13",
"88.53",
"38.12",
"36.15",
"00.40",
"37.23",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
6912, 6946
|
4191, 5316
|
288, 401
|
7277, 7283
|
1234, 4168
|
10531, 11143
|
755, 759
|
5475, 6889
|
6967, 7256
|
5342, 5452
|
7307, 9948
|
9974, 10508
|
774, 1215
|
232, 250
|
429, 471
|
493, 672
|
688, 739
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,242
| 142,672
|
31280
|
Discharge summary
|
report
|
Admission Date: [**2124-8-5**] Discharge Date: [**2124-8-31**]
Date of Birth: [**2078-8-18**] Sex: M
Service: MEDICINE
Allergies:
Nafcillin
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Epidural abscess and vertebral osteomyelitis and discitis
Major Surgical or Invasive Procedure:
[**8-9**]: s/p L thoracotomy, vertebrectomy T10, partial
vertebrectomy T11, instrumented fusion T9-T11. Chest tube to 20
cm H2O continuous suction.
[**8-14**]: Rigid bronchoscopy x2. Removed chest tube.
[**8-15**]: posterior spinal fusion T5-L2, est blood loss 1050 mL
transfused 3 u PRBC, 2 U FFP.
History of Present Illness:
Mr. [**Known lastname 32493**] is a 45yo man with ESRD on HD, DM, h/o "staph
bacteremia" in [**Month (only) 547**] for which he was treated at an OSH, h/o
T11-12 discitis in [**Month (only) 116**] who presents as a transfer from [**Hospital **]
Hospital with report of possible epidural abcess. MRI was read
at OSH (by attg) as T11-12 discitis vs. osteomyelitis with a
possible epidural abcess and small cord compression. He was
transferred here for neurosurgical eval and was seen by ortho
spine team in the ER. The ortho and radiology residents
examined the MRI and are not convinced the pt has epidural
abcess, although are unsure. The pt was admitted to medicine for
perioperative management.
ROS:
Past Medical History:
ESRD on HD
DM
T11-12 discitis in [**Month (only) 116**]
?Staph bacteremia in [**Month (only) 547**]
Social History:
Works as police dispatcher, lives in [**Location 47**] with a roommate.
.
Family History:
noncontributory
Physical Exam:
vitals T 99.6 BP 154/88 AR 130 RR 21 O2 sat 93% on NRB, 5L NC
Gen: Patient appears acutely ill
HEENT: MMM
Heart: Sinus tachycardia, +systolic murmur
Lungs: Decreased BSs from on L from posterior base to apex,
scattered crackles on R side
Abdomen: soft, NT/ND, +NS
Extremities: No edema, 2+ DP/PT pulses bilaterally
Pertinent Results:
GLUCOSE-103 UREA N-18 CREAT-4.5* SODIUM-144 POTASSIUM-4.3
CHLORIDE-100 TOTAL CO2-32
WBC-6.5 RBC-4.19* HGB-12.3* HCT-37.8* MCV-90 MCH-29.3 MCHC-32.5
RDW-16.5*
PLT COUNT-319
- NEUTS-68.3 LYMPHS-22.1 MONOS-7.0 EOS-1.5 BASOS-1.0
Lactate 1.0.
.
Ct [**Location **] - Anterior wedge deformities of T10 and T11 with
moderate kyphosis. There is fragmentation and destruction of
the inferior T10 and superior T12 endplates concerning for
osteomyelitis/discitis. Surrounding soft tissue density may
represent phelgmon. No paraspinal fluid collections identified.
CT does not provide intrathecal detail, and MRI is recommeded
for further evaluation of the spinal cord.
.
MR [**Name13 (STitle) **] at OSH: T11-12 discitis vs osteomyelitis with possible
epidural abcess and some possible cord compression
.
1)Cxray ([**8-10**]): Improved aeration of the left lower lobe.
.
2)Cxray ([**8-12**]): New complete opacification of the left
hemithorax with associated minimal right to left shift of the
trachea likely reflects underlying effusion and atelectasis,
cannot exclude pneumonia.
Brief Hospital Course:
Mr. [**Known lastname 32493**] is a 45yo male transferred to [**Hospital1 18**] from [**Hospital1 25157**] where he presented to the ER with c/o chronic,
severe lower back pain & weakness in his LE bilaterally.
.
BACK PAIN/OSTEOMYELITIS
On arrival to ER was given Dilaudid 1 mg IV with no relief & was
subsequently given morphine 7 mg IV. Stat MRI of the spine was
ordered which showed "Progression of osteomyelitis versus
discitis at the T10-T11 region with further collapse. Possible
pus in the disc space. There is compression of the anterior
cord which is significantly increased from [**2124-5-26**]."
.
Per neurosurgery at [**Hospital1 **] (Dr. [**Last Name (STitle) 73785**] pt would need surgery
with anterior approach & thus transfer to tertiary care
facility. Patient was discussed with Dr. [**Last Name (STitle) 8494**] at [**Hospital1 18**] and
transferred in stable condition.
.
Mr. [**Known lastname 32493**] was seen in [**Hospital1 18**] ER by ortho spine team; ortho
spine and radiology residents examined MRI from OSH and were not
convinced of presence of epidural abscess, although unsure.
Patient was thus admitted to medicine service for perioperative
management.
.
In our ED he received Dilaudid for pain, a CT of his T-spine and
additional blood cultures were drawn. CT of T-spine showed
"Anterior wedge deformities of T10 & T11 with moderate kyphosis.
There is fragmentation and destruction of inferior T10 and
superior T12 endplates concerning for osteomyelitis/discitis.
Surrounding soft tissue density may represent phlegmon. No
paraspinal fluid collections identified." Further orthopedics
consult recommended non-emergent surgical decompression and
debridement due to failure of medical management and progression
of symptoms.
.
Renal was made aware of pt with ESRD who receives scheduled HD
on MWF & recommended to hold colchicine in HD patient. ID also
consulted on day of admission ([**8-5**]) and advised to hold abx and
perform TTE prior to surgery (performed [**8-7**] which showed no
vegitations). Patient was made NPO overnight for surgery the
following morning and coags/type & screen were sent. Surgery
not performed [**8-6**], was examined by Dr. [**Last Name (STitle) 363**] of neurosurgery
for 2nd opinion who also recommended anterior/posterior
decompression with fusion.
.
Patient went to OR [**2124-8-9**] for L thoracotomy with T10
vertebrectomy and T11 partial vertebrectomy with fusion/anterior
cage placement T9-T11. Patient remained sedated on propafol &
intubated with L pleural chest tube post-operatively and was
extubated [**8-10**], mom[**Name (NI) 11711**] placed on CPAP and weaned to O2 by
NC. For pain control pt received dilaudid PCA with scheduled
dilaudid 2 mg Q 2 hours.
.
Started on IV nafcillin for history of recurrent MSSA
bacteremia; on POD#3 operative tissue cultures grew MSSA,
confirming this diagnosis.
Patient also noted to be tachycardic post-operatively, most
likely due to uncontrolled pain, and required increase in
lopressor dose.
.
Patient remained sedated on propafol and intubated and was sent
back to OR on [**8-15**] for completion of posterior spinal fusion.
.
Post-operatively patient received care in MICU and antibiotics
were changed back to IV nafcillin. Per ID recs, would need at
least a [**10-6**] week course of cefazolin due to his h/o recurrent
MSSA bacteremia. He will then likely require lifetime
suppressive therapy. ID follow-up needs are described in page
1/discharge instructions.
.
As he recovered from the problems described below, he continued
to have flares of intense back pain which we attempted to
control.
.
He was successfully moved out of bed with a torso brace on, on
[**8-30**]. Physical therapy continuing to work with Mr [**Known lastname 32493**] to
facilitate his recovery. Current neuro exam: hard to assess
weakness in this context, possible L weaker than R; loss of
sensation of first three toes of L toe.
.
RESPIRATORY FAILURE
During HD POD#3 ([**8-12**]) patient noted to have O2 sat of 80% and
with NRB recovered sats to 99%. CXR showed complete
opacification of L lung and patient was transferred to MICU Team
[**Location (un) **] for respiratory distress. At that time differential dx
was mucous plugging vs. L chest tube malfunction and per surgery
patient was noted to have ++ secretions.
.
In MICU patient was started on face mask, empiric ceftriaxone
and azithromycin for CAP, atrovent & albuterol neb treatments.
Sputum samples were sent for culture. Patient was bronched [**8-13**]
@ 17:30 by the MICU service. Thick, purulent, mucoid secretions
were visualized in the L mainstem and L lingula. BAL was
perfomed in the lingula after which he developed copious fresh
blood requiring intubation. Post bronch CXR (17:45) actually
revealed an aerated L lung with significant improvement.
.
He was bronched again at 19:30 which revealed thick secretions
in the L mainstem and the end of the ETT. Post-bronch CXR
(19:45) demonstrated L PTX and again L white-out.Later that day
patient was intubated & bronchoscopy was performed which showed
thick, purulent secretions in L mainstem and L lingula. BAL was
peformed in L lingula after which developed copious fresh blood.
Wedge was kept in, bleeding slowed and fibrinous bloody
material was suctioned from ETT.
.
On CXRs L chest tube appeared to be kinked at chest wall, was
pulled and restitched in an attempt to reposition the tube and
decrease the kink. Chest tube was D/C'd on [**8-14**].
.
Started on IV vancomycin and zosyn to cover S.aureus and gram
negative/anaerobes.
.
THROMBOCYTOPENIA
HIT +. Platelets decreased to 12 [**8-17**]. The differential
diagnosis was DIC vs HIT vs drug effect (?nafcillin). Did have
elevated fibrinogen and D-dimer, but this was muddied by the
fact that he still had active osteomyelitis and these are acute
phase reactants. Fibrinogen was increased and thus less
concerning for DIC. He was transfused one unit of platelets, and
heparin and nafcillin were discontinued.
.
He was switched to cefazolin for his osteomyelitis. He received
argatroban on 8.25 with a plan to bridge to coumadin. However he
got a very high INR with this (up to 9.4) and required 2 units
FFP and 10 mg vitamin K, with INR going down to 1.5 on [**8-23**].
Argatroban was discontinued. Low dose warfarin was briefly
started. A PF4 assay was weakly positive for HIT antibodies
(optical density just over threshold for judging positive) and a
confirmatory serotonin release assay was negative, strongly
suggesting that HIT was not responsible for the platelet drop.
Therefore the likely culprit was judged to be nafcillin based on
prior case reports of this phenomenon and based on timing.
Cefazolin was kept as the antibiotic as above; subcutaneous
heparin was restarted for DVT prophylaxis.
.
PAIN
continues to be uncontrolled. pain service on board. Initially
on dilaudid PCA for control but started ketamine & fentanyl
drips per pain mgmt recommendations. Drips eventually weaned &
discontinued on [**8-22**]. Fentanyl patch continued and dilaudid PCA
restarted on [**8-22**]. Prior to transfer to floor patient started
on oral regimen of Diluadid 6 mg PO Q 3 hrs. Fentanyl patch
increased, PCA weaned off, and patient now on oral regimens. Of
note, pt has much increased pain with movement/ transport/
physical therapy; should likely be pre-medicated for PT, may
need to increase doses of PO PRN meds as PT becomes more
frequent.
.
ELEVATED BILIRUBIN
Did have elevated bilirubin during some of MICU stay. Total
bilirubin trending down since [**8-18**]: 8.3--> 5.3-->4.5;
Direct bilirubin 7.2 on [**8-18**]. By [**8-28**] it was 1.3
after a long downward trend. RUQ US showed sludge in gallbladder
with no evidence of cholelithiasis/cholecystitis. No clear
diagnosis for elevation but now fine.
.
TYPE 2 DM
Was on standing NPH and humalog sliding scale as outpatient with
hypoglycemia. BS were reasonably well-controlled though some
adjustments in dose were needed. He was restarted on NPH on the
floor and has been doing well with this, again with a few
adjustments to optimize his regimen. [**Hospital **] clinic consult
service saw him and advised re his regimen.
.
RENAL FAILURE
Continued dialysis here in the hospital. Received lanthanum as a
phosphate binder.
Renal dialysis team followed along with care. Per renal fellow,
fine to transition from lanthanum to renagel (selvalamer) 1600
mg PO TID. (Discharge meds reflect this recommendation; change
was made on discharge, not before.)
.
HTN
Transitioned back to home BP meds when diet was advanced.
.
GOUT
Continued with home allopurinol
.
FEN
Diabetic PO diet. Bowel regimen.
.
PROPHYLAXIS
+compression boots, subcutaneous heparin, PPI
.
ACCESS
RIJ in place since admission, discontinued on [**8-24**] upon
placement of right PICC line
.
CODE
Full
.
Medications on Admission:
??
1. lidoderm patch q 12 hrs
2. fentenyl patch 75mcg q3 days
3. celebrex 200mg daily
4. atenolol 25mg daily
5. ambien 5mg qhs prn
6. zetia 10mg daily
7. NPH 55 units qam/70qunits q pm
8. nephrocaps 1 daily
9. nystatin powder
10. humalog sliding scale
11. colchicine 0.6mg daily
12. allopurinol 100mg daily
13. ASA 81mg daily
14. catapres q monday
Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical HS
(at bedtime).
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO with meals.
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed.
8. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
14. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
15. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
20. Prochlorperazine 10 mg Tablet Sig: 0.5-1 Tablet PO Q6H
(every 6 hours) as needed for nausea.
21. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) patch
Transdermal Q72H (every 72 hours): total fentanyl dose should
total 175 mcg/hr, in any configuration of doses for patch(es).
22. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours.
23. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
24. CefazoLIN 2 gm IV POST HD ON MONDAY AND WEDNESDAY
25. CefazoLIN 3 gm IV POST HD ON FRIDAY
26. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
27. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
28. Insulin Lispro 100 unit/mL Solution Sig: One (1) injection
Subcutaneous with meals, and at bedtime, per sliding scale:
SLIDING SCALE. DOSE BY GLUCOSE LEVEL. MEAL SCALE, BREAKFAST,
LUNCH, DINNER: GLU 76-150: 0 UNITS. GLU 151-200: 2 UNITS. GLU
201-250: 5 UNITS. GLU 251-300: 8 UNITS. GLU 301-350: 11 UNITS.
SCALE: GLU 76-150: 0 UNITS. GLU 151-200: 0 UNITS. GLU 201-250: 2
UNITS. GLU 251-300: 4 UNITS. GLU 301-350: 6 UNITS. GLU 351-400:
JUICE AND RECHECK.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary:
Osteomyelitis/diskitis
MSSA septicemia
.
Secondary:
Diabetes Mellitus type 2
End-stage renal failure on hemodialysis
Discharge Condition:
Good
Discharge Instructions:
As much as your pain will permit, work with physical therapists
to try to use your muscles and progress towards walking as soon
as possible.
Followup Instructions:
Please obtain weekly CBC and chem 7, fax results to infectious
disease department (attn: Dr [**Last Name (STitle) 976**]:[**Telephone/Fax (1) 1419**]
.
Nephrology/Hemodialysis: as arranged by dialysis unit
.
Infectious Disease Clinic:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7380**],MD MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 457**] Date/Time:[**2124-9-19**]
11:00
.
Orthopedic/Spine Clinic:
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2124-9-7**] 10:00
ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2124-9-7**] 9:40
.
|
[
"486",
"997.3",
"403.91",
"250.40",
"737.10",
"730.08",
"287.4",
"722.72",
"998.11",
"733.13",
"272.4",
"518.0",
"041.11",
"585.6",
"998.12",
"933.1",
"274.9",
"285.1",
"790.7",
"324.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"81.64",
"81.62",
"34.04",
"84.51",
"99.04",
"77.71",
"81.04",
"39.95",
"38.93",
"80.51",
"99.07",
"81.05",
"33.23",
"96.72",
"99.05",
"96.56",
"99.77"
] |
icd9pcs
|
[
[
[]
]
] |
15186, 15331
|
3060, 11884
|
327, 628
|
15501, 15508
|
1960, 3037
|
15698, 16378
|
1593, 1610
|
12283, 15163
|
15352, 15480
|
11910, 12260
|
15532, 15675
|
1625, 1941
|
230, 289
|
656, 1362
|
1384, 1485
|
1501, 1577
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,387
| 141,520
|
36139
|
Discharge summary
|
report
|
Admission Date: [**2163-11-25**] Discharge Date: [**2164-1-4**]
Date of Birth: [**2095-12-10**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5341**]
Chief Complaint:
Disorientation, confusion.
Major Surgical or Invasive Procedure:
-bilateral EVD placements [**2163-11-27**]
-stereotactic brain biopsy
-Bifurcated VP shunt [**2163-12-2**]
-Cyberknife radiotherapy to your brain.
History of Present Illness:
This is a 61 year old female with a history of hypertension who
presented after being found confused while in a local
restaurant. The patient was somewhat encephalopathic and unable
to relate a cognant history the events leading to presentation
at [**Hospital1 18**]. She stated that she had felt generally unwell for
several days prior to admission. She is uncertain of how or why
she came to the hospital. She stated that she had a mild dull
bifrontal headache which was of recent onset. She denied a
recent history of headache otherwise. She denied nausea,
weakness, numbness, tingling, visual disturbances. She denied
pain.
Past Medical History:
-Hypertension
Social History:
Lives at home alone. Brother [**Name (NI) **] [**Name (NI) 81966**] C: [**Telephone/Fax (1) 81967**]
H:[**Telephone/Fax (1) 81968**] Cousin [**Name (NI) **] ([**Telephone/Fax (1) 81969**]). She denied use of
tobacco, alcohol, or illicit drugs.
Family History:
Non-contributory.
Physical Exam:
On admission:
GENERAL: The patient is alert, very pleasant.
VITAL SIGNS: Afebrile B/P is 128/58, pulse of 69, RR 16, O2Sat
95% on room air.
CARDIOVASCULAR: Showed regular rate and rhythm. No
murmurs,gallops, or rubs.
RESPIRATORY: CTA bil.
SKIN/HEME/LYMPH: No clubbing or cyanosis.
NEUROLOGIC: Alert and oriented x3. Intact naming, repitition &
following simple commands. Right-left disorientation, no
apraxia. Recall was [**11-26**] respectively.
HEENT: Head was normocephalic. No JVD or Carotid
bruits/upstrokes
Eyes: PERRLA to mm. Extraocular movements full to testing.
Visual fields are full. There is no nystagmus. Tongue was
midline, palate elevated symmetrically. Facial symmetry even,
smile symmetric. No dysarthria. Sternocleidomastoids were [**3-27**].
Shoulder shrug was strong. On motor evaluation, she is [**3-27**]
bilaterally. There is some effort dependence. Normal tone, no
drift. Sensation intact to light touch throughout. Cerebellar:
mild decrease in fine motor dexterity in the left hand with
finger tapping, but finger-nose-finger and rapid alternating
movements were intact. I did not test the gait as the patient
is on bed rest. Reflexes were 3+ throughout with downgoing toes.
On discharge:
VS: T 97.2, BP 101/61, HR 81, RR 16, 96% on RA
Tm 98.6, 96-112/50-70, 80-92, 16-20, 95-99% on RA
GEN: Lying in bed, responsive, speaking, more alert but does not
answer all questions. Does appear depressed, though does not
speak about it.
HEENT: no scleral icterus
CV: regular, S1/S1
LUNGS: CTAB anteriorly
ABD: soft, NT, ND
EXT: no edema
NEURO: Alert, nods to questions. Able to move all extremities,
right much greater than left.
Pertinent Results:
Labs on Admission:
[**2163-11-25**] 09:00PM BLOOD WBC-6.9 RBC-4.05* Hgb-12.1 Hct-33.5*
MCV-83 MCH-29.9 MCHC-36.1* RDW-13.6 Plt Ct-298
[**2163-11-25**] 09:00PM BLOOD Neuts-77.8* Lymphs-16.7* Monos-4.0
Eos-0.8 Baso-0.7
[**2163-11-25**] 10:53PM BLOOD PT-13.3 PTT-25.0 INR(PT)-1.1
[**2163-11-25**] 09:00PM BLOOD Glucose-100 UreaN-42* Creat-1.1 Na-141
K-4.0 Cl-101 HCO3-31 AnGap-13
[**2163-11-25**] 09:00PM BLOOD ALT-13 AST-21 LD(LDH)-157 AlkPhos-57
TotBili-0.6
[**2163-11-25**] 09:00PM BLOOD Calcium-9.6 Phos-2.5* Mg-2.6
Labs on discharge:
[**2164-1-4**] 06:45AM BLOOD WBC-8.0 RBC-3.80* Hgb-11.2* Hct-33.2*
MCV-87 MCH-29.6 MCHC-33.9 RDW-15.1 Plt Ct-424
[**2164-1-4**] 06:45AM BLOOD Glucose-135* UreaN-28* Creat-0.6 Na-137
K-4.2 Cl-99 HCO3-30 AnGap-12
[**2164-1-4**] 06:45AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.2
Imaging:
Head CT [**11-25**]: IMPRESSION: 4.1 x 3.1 cm mass centered in the
septum pellucidum causing obstructing hydrocephalus.
Differential considerations include a central neurocytoma,
subependymoma, metastasis, or less likely, atypical meningioma.
MRI Head [**11-26**]:
IMPRESSION: Approximately 3 x 3.5 cm intraventricular mass
attached to the septum pellucidum with characteristics as
described above. The differential diagnosis includes a central
neurocytoma, subependymoma, and less likely metastatic disease.
Given the degree of enhancement, central neurocytoma appears
more likely. Other changes as described above, specifically,
decrease in size of the ventricles compared to the previous CT
after interval placement of the bifrontal intraventricular
drains.
CT Chest/Abdomen/Pelvis [**11-26**]:
IMPRESSION:
1. No evidence of occult malignancy.
2. Dilated pancreatic duct as well as multiple cystic
dilatations which is suggestive of IPMT. Further evaluation with
MRI can be performed if needed.
3. Gallstones.
EKG [**11-28**]:
Sinus rhythm. Compared to the previous tracing of [**2163-11-25**] no
change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 94 80 378/399 59 46 27
Brain Biopsy Pathology [**11-30**]:
"-4" (F): Glioblastoma, WHO Grade IV, with microvascular
proliferation.
Head CT [**12-2**]:
IMPRESSION:
1. Unchanged size of intraventricular mass. The differential
diagnosis favors central neurocytoma, or, less likely,
subependymoma, and more remotely, metastatic disease.
2. Unchanged small intraventricular hemorrhage in occipital [**Doctor Last Name 534**]
of right lateral ventricle.
3. Unchanged size of the lateral ventricles, s/p bilateral
ventriculostomy.
CxR [**12-8**]:
FINDINGS: In comparison with the study of [**12-7**], the Dobbhoff
tube has been somewhat pulled back with the tip just distal to
the esophagogastric junction. Lungs remain clear.
CT head [**2163-12-23**]:
Bifrontal ventricular catheters are again noted with little
change in position. There is increased prominence to the right
frontal [**Doctor Last Name 534**] lateral ventricle with decreased size of the atria,
currently measuring 14 mm in transverse dimension (previously 17
mm). A large mass is again noted to arise from the septum
pellucidum with peripheral hyperdensity. A drainage catheter
extending from the right temporal approach with tip in the
suprasellar cistern is again appreciated without change. There
is no evidence of infarction or hemorrhage. The major basilar
cisterns remain preserved without evidence of new herniation.
The visualized paranasal sinuses and mastoid air cells remain
clear. No fracture is detected. Orbital regions remains stable.
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] after being found "confused" at a
local resturant. Head CT was peformed, which revealed a large
intraventricular mass, with resultant obstructive hydrocephalus.
Emergent bilateral external ventricular drains were placed. She
subsequently had CT of her torso which was unremarkable for
primary disease identification. She underwent stereotactic
brain biopsy on [**11-30**], and final pathology identified a WHO grade
IV glioblastoma multiforme. [**12-2**], she underwent bifurcated VP
shunt placement for her ongoing shunt dependency. On [**12-5**], she
was observed to have dysphagia, and speak and swallow was
consulted. SP&SW recommended thin liquids with puree. A dobhoff
was placed, but the patient did not tolerate this well,
self-discontinued by the patient. On [**12-9**] Psychiatry was
consulted to identify patient's capacity and to address
anhedonia. Their recommendations were to start effexor, which
was started. She was also determined to be incapable of
self-determination, and her brother was designated as health
care proxy. She was discussed at brain tumor conference and the
decision was made to place a Rickham reservoir due to her
enlarged temporal [**Doctor Last Name 534**], which was placed on [**12-19**]. As for her
treatment plan, a family meeting wa held and her next-of-[**Doctor First Name **]
offered consent to pursue cyberknife treatment for her
intraventricular mass.
Since her admission, the patient's mental status has been on the
decline. She has tolerated cyberknife treatments with some
improvement, however, overall the patient still remains
disoriented, following commands intermittently, and speaking
rarely. Her Effexor was discontinued due to her poor mental
status, a G-tube was placed to help supplement the patient
nutritionally while she undergoes therapy and she has been
tolerating tube feeds. She was observed for several days on the
oncology floor during cyberknife treatment and tolerated the
treatment with slight improvement in her mental status.
Medications on Admission:
-HCTZ
-lisinopril (she is uncertain of the doses)
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
2. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO TID (3 times a
day).
3. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety .
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for constipation.
7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
11. Fiber Strength Tube Feeds
At goal of 55cc/hr continuous
12. Insulin Lispro 100 unit/mL Solution Sig: One (1) Unit
Subcutaneous ASDIR (AS DIRECTED): Please administer Lispro
sliding scale as needed for hyperglycemia.
13. Ondansetron 4 mg IV Q8H:PRN nausea
14. Metoclopramide 10 mg IV Q8H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
-WHO Grade IV GBM
-Dysphagia
Discharge Condition:
neurologically stable, A&O x1
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair now that your sutures and staples have
been removed.
?????? 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 Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????You have an appointment with Dr. [**Last Name (STitle) 4253**] in the Brain [**Hospital 341**]
Clinic on [**2164-1-23**] @ 03:00p. The Brain [**Hospital 341**] Clinic is located
on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their
phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change
your appointment, or require additional directions.
You will also need an MRI around the time of your appointment on
[**2164-1-23**] - you will be contact[**Name (NI) **] with this appointment time at a
later date. Please call to confirm if you have not heard about
your appointment time by [**2164-1-14**].
Completed by:[**2164-1-24**]
|
[
"348.39",
"342.90",
"401.9",
"348.5",
"294.9",
"707.22",
"276.8",
"191.5",
"331.4",
"707.03",
"348.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"96.6",
"92.29",
"02.39",
"01.13",
"02.34",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
10096, 10144
|
6698, 8754
|
345, 493
|
10217, 10249
|
3183, 3188
|
12315, 13066
|
1466, 1485
|
8855, 10073
|
10165, 10196
|
8780, 8832
|
10273, 12292
|
1500, 1500
|
2731, 3164
|
278, 307
|
3720, 6675
|
521, 1150
|
3202, 3701
|
1172, 1187
|
1203, 1450
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,986
| 186,209
|
39213
|
Discharge summary
|
report
|
Admission Date: [**2141-1-25**] Discharge Date: [**2141-2-24**]
Date of Birth: [**2103-6-28**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 26411**]
Chief Complaint:
s/p slip and fall on ice sustaining intramuscular bleed c/b
development of necrotizing fasciitis and compartment syndrome of
RUE
Major Surgical or Invasive Procedure:
[**2141-1-26**] Washout, debridement and wound vac to right upper
extremity
[**2141-1-27**] Debridement of triceps, deltoid and musculature of right
upper extremity. Exposure of neuroplasty of radial nerve and
ulnar nerve to protect against injury while debriding posterior
musculature. Irrigation and debridement anterior forearm and
anterior biceps and upper arm compartments. Biopsies of muscle,
multiple. Irrigation and debridement of the right chest wall
with resections of portions of the latissimus dorsi and the
teres muscle group.
[**2141-1-29**] Irrigation and debridement, right upper extremity. Deep
cultures. Placement of extensive vacuum dressings.
[**2141-1-31**] Debridement down to muscle upper arm. Debridement down
to muscle in forearm.
[**2141-2-2**] Staged irrigation and debridement down to and inclusive
of muscle of posterior wounds including remaining triceps and
latissimus. Closure of posterior wound along the arm as well as
closure of posterior wound extending towards the axilla and
lateral flank. Plastics team-->Debridement and complex wound
closure of right upper extremity anterior aspect.
[**2141-2-6**] Debridement of right upper extremity with partial complex
wound closure, posterior and anterior arm, total measuring
approximately 15 cm.nPlacement of a large V.A.C. sponges on the
anterior-posterior surface of the arm.
[**2141-2-9**] Debridement of right upper extremity, reopening of back
wound with significant amount of debridement and complicated
wound closure with stay sutures and placement of large
vacuum-assisted closure devices onto the upper extremity.
[**2141-2-13**] Surgical preparation of right anterior and posterior arm
(> 100 square cm) in preparation for split-thickness skin
grafting with debridement and application of VAC dressing
[**2141-2-16**] Split-thickness skin grafting right upper extremity,
open wounds greater than 100 cm2.
History of Present Illness:
Mr. [**Known lastname 86806**] is a 37 yo gentleman who was transferred to [**Hospital1 18**]
from [**Hospital1 2436**]. The patient was in his usual state of health
until he suffered a fall on [**1-21**] onto ice, and fell onto his
right shoulder. When he awoke on the morning of [**1-22**], he noted
chills, fevers, and malaise. He then presented to [**Hospital1 **], where he was found to be febrile to 103. He was given
a prescription for tamiflu, and then discharged home from the
emergency room. His malaise continued, and his right arm pain
worsened. He then presented to his PCP [**Last Name (NamePattern4) **] [**1-24**] with continued
symptoms, and given continued fevers, was sent back to
[**Hospital3 **] for additional evaluation. Blood cultures
were drawn (and by report to [**Name8 (MD) 10115**] RN are growing GAS) and the
patient was then transferred
to [**Hospital1 18**] for evaluation of possible necrotizing fascitis. Upon
presentation, the patient was hypotensive (SBPs 70s-80s),
tachycardic, and febrile.
In addition, he was found to have acute kidney injury,
rhabomyolysis, and A-fib with RVR. CT revealed there was no
vascular injury. Compartment pressures were found to be
elevated.
Past Medical History:
PMH: Allergic rhinitis
PSH: none
[**Last Name (un) 1724**]: none
Social History:
Originally from [**Country 4754**], lived in US for the past 16 years,
works as a painter. Married with four children. Occasional
alcohol, no illicits, no tobacco.
Family History:
Mother with diabetes
Physical Exam:
Exam on Admission:
T 98.9, HR 94, BP 106/61, RR 20, O2Sa 99%2L
GCS 15
Gen - in acute pain but responsive/appropriate
HEENT - PERRL, EOMI, nares clear, no hemotympanum
CVS - AFib w/ RVR
PULM - no respiratory distress; CTAB
PULSE - dopplerable RUE radial/ulnar pulses; palpable LUE, BLE
pulses
ABD - S/NT/ND
GU - deferred
Exam on Discharge:
T 98.6 HR 85 BP 117/77 RR 18 SaO2 97% RA
Gen - AOx 3, NAD
HEENT- NCAT
Pulm- CTAB
CV- S1/S2 w/o MGR
Abd - soft NTND
Ext- RUE with skin graft intact, well perfused. wound with 1cm
distal portion open, no drainage or erythema.
Pertinent Results:
On admission;
[**2141-1-25**] 8:05 pm BLOOD CULTURE
**FINAL REPORT [**2141-1-31**]**
Blood Culture, Routine (Final [**2141-1-31**]):
BETA STREPTOCOCCUS GROUP A.
SENSITIVITIES REQUESTED BY [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Numeric Identifier 86807**].
FINAL SENSITIVITIES. Sensitivity testing performed by
Sensititre.
SENSITIVE TO CLINDAMYCIN (<=0.12 MCG/ML).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP A
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2141-1-26**]):
REPORTED BY PHONE TO DR. [**First Name (STitle) **] [**2141-1-26**], 12PM.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final [**2141-1-26**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**2141-1-26**] 1:50 am TISSUE Site: ARM FOREARM FASCIA.
**FINAL REPORT [**2141-2-2**]**
GRAM STAIN (Final [**2141-1-26**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2141-1-26**] AT 0530.
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
TISSUE (Final [**2141-2-2**]):
BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH.
SENSITIVITY REQUESTED BY [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 86808**] [**3-/5000**] [**2141-1-29**].
SENSITIVITY PERFORMED BY SENSITITRE. CLINDAMYCIN <=
0.12 MCG/ML.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**7-/2437**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
CLINDAMYCIN SENSITIVITY REQUESTED BY DR. [**Last Name (STitle) 86809**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP A
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CLINDAMYCIN----------- S <=0.25 S
ERYTHROMYCIN----------<=0.25 S =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G----------<=0.06 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S 2 S
ANAEROBIC CULTURE (Final [**2141-1-30**]): NO ANAEROBES ISOLATED.
[**2141-1-25**] 10:56PM TYPE-ART PO2-94 PCO2-40 PH-7.25* TOTAL
CO2-18* BASE XS--9
[**2141-1-25**] 10:56PM LACTATE-3.8*
[**2141-1-25**] 10:56PM HGB-12.6* calcHCT-38
[**2141-1-25**] 10:15PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.031
[**2141-1-25**] 10:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-100 KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG
[**2141-1-25**] 10:15PM URINE RBC-[**3-10**]* WBC-[**11-25**]* BACTERIA-MOD
YEAST-NONE EPI-0
[**2141-1-25**] 10:15PM URINE GRANULAR-12* CELL-0-2
[**2141-1-25**] 07:54PM COMMENTS-GREENTOP
[**2141-1-25**] 07:54PM GLUCOSE-125* LACTATE-3.8* K+-4.5
[**2141-1-25**] 07:50PM GLUCOSE-135* UREA N-22* CREAT-1.5* SODIUM-137
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-19* ANION GAP-18
[**2141-1-25**] 07:50PM estGFR-Using this
[**2141-1-25**] 07:50PM ALT(SGPT)-24 AST(SGOT)-69* CK(CPK)-2792* ALK
PHOS-37* TOT BILI-0.8
[**2141-1-25**] 07:50PM LIPASE-8
[**2141-1-25**] 07:50PM cTropnT-<0.01
[**2141-1-25**] 07:50PM CK-MB-19* MB INDX-0.7
[**2141-1-25**] 07:50PM CALCIUM-7.4* PHOSPHATE-2.7 MAGNESIUM-1.7
[**2141-1-25**] 07:50PM WBC-1.9* RBC-4.82 HGB-14.1 HCT-41.4 MCV-86
MCH-29.2 MCHC-34.0 RDW-13.3
[**2141-1-25**] 07:50PM NEUTS-47* BANDS-24* LYMPHS-7* MONOS-13* EOS-0
BASOS-0 ATYPS-0 METAS-9* MYELOS-0
[**2141-1-25**] 07:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2141-1-25**] 07:50PM PLT SMR-NORMAL PLT COUNT-152
[**2141-1-25**] 07:50PM PT-12.3 PTT-31.7 INR(PT)-1.0
Brief Hospital Course:
The patient was diagnosed with compartment syndrome and was
taken to the OR emergently on [**1-26**] for fascial release and
debridement, and started on vancomycin/zosyn perioperatively for
coverage. Intraoperatively, the anterior portion of the arm was
noted to be relatively normal (OR report with edema, no frank
purulence, odor, or obvious signs of necrotizing fascilitis or
muscle necrosis), however, over the posterior deltoid, there was
noted to be significant hematoma, as well as both partially
necrotic and fully necrotic muscle. This tissue was extensively
debrided, and tissue cultures were sent, which returned all with
group A beta strep. His antibiotics were tailored to clinda and
PCN G per the infectious disease team's recommendations. In
addition, he received IVIG.
The patient was aggressively fluid resuscitated for evidence of
rhabdomyolysis. He was transfused packed red blood cells as
needed to maintain a goal hct of 25. He converted to sinus
rhythm and his heart rate remained controlled without the need
for cardiac medications.
Over the course of his hospital stay, the patient returned to
the OR multiple times with orthopedics for serial
debridements/washouts of his RUE as well as complex partial
closures by the plastics team.
On [**2141-2-16**] the patient was again taken to the OR where a STSG
was taken from his right thigh and appropriately applied to
posterior arm with VAC placement per wound management protocol.
The patient tolerated the procedure well and on POD 5 the VAC
was removed and the graft appeared well. He was fitted for
elbow and wrist splints and received OT for stiffness in joints.
His wounds were dressed with xeroform dressings and a small
aspect of the distal forearm wound was packed with WTD gauze.
The rest of the [**Hospital 228**] hospital course is summarize below by
system:
Neuro: The patient was intubated and sedated in the ICU for the
immediate portion of his hospital stay. upon extubation, his
pain was controlled with morphine PCA, then weaned down with
methadone and percocet for breakthrough pain. Upon discharge,
the patient was only on percocet.
GI: The patient was placed on stool softeners and took reglan
and zofran for nausea, which resolved with decreasing pain
medications.
ID: The patient was empirically started on Vancomycin/zosyn upon
admission. His cultures grew Group A Strep. he was started on
ampicillin and clindamycin. On [**2141-2-7**] all antibiotics were
stopped. An ID consult was obtained on [**2-8**]. He was started on
ancef on [**2141-2-8**], and remained on this antibiotic untl the day
before discharge. He was discharged home without antibiotics.
Proph: The patient was mainatined on a PPI, Sub-cutaneous
heparin and [**Hospital 32111**] [**Hospital 49997**] hospital stay.
Medications on Admission:
none
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)) as needed for nausea.
Disp:*60 Tablet(s)* Refills:*0*
2. 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*
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
necrotizing fasciitis
compartment syndrome
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted on [**2141-1-25**] for management of a right arm
infection/injury. Please follow these discharge instructions:
.
Medications:
* Resume your regular medications unless instructed otherwise.
* You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
* Take prescription pain medications for pain not relieved by
tylenol.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication.
* Take Colace, 100 mg by mouth 2 times per day, while taking the
prescription pain medication. You may use a different
over-the-counter stool softerner if you wish.
.
Call the office IMMEDIATELY if you have any of the following:
* Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
* A large amount of bleeding from the incision(s).
* Fever greater than 101.5 oF
* Severe pain NOT relieved by your medication.
* Acute and severe swelling of your right arm/hand/fingers
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
Activities:
* No strenuous activity involving your right arm
* Please do active range of motion exercises with right arm,
right hand and fingers to keep your everything mobile. Please
do the exercises you were taught by the Occupational Therapists.
* Unless directed by your physician, [**Name10 (NameIs) **] not take any medicines
such as Motrin, Aspirin, Advil or Ibuprofen etc
.
Comments:
* Please keep your right arm elevated on several pillows to
help decrease swelling
* Please maintain the right wrist and right elbow splint as
instructed.
* Your right arm graft site needs to be cleansed and dressed
once a day. A Visiting Nurse [**First Name (Titles) **] [**Last Name (Titles) **] and teach you about
dressing changes.
* Your left thigh donor site should be kept dry.
* Please follow up in Hand Clinic on Tuesday (see below)
Followup Instructions:
Please follow up in the Hand Clinic on Tuesday, [**2141-2-28**]. You
must call ([**Telephone/Fax (1) 32269**] to make an appointment so they know you
are coming. The clinic is open from 8-12pm most Tuesdays and
you may show up at any time between those hours, despite your
formal appointment time. The clinic is located on the [**Hospital Ward Name 5074**], [**Hospital Ward Name 23**] Building, [**Location (un) **]. Please make sure that you
obtain a referral from your insurance company prior to your
clinic appointment.
|
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76,541
| 139,921
|
38685
|
Discharge summary
|
report
|
Admission Date: [**2168-3-16**] Discharge Date: [**2168-4-20**]
Date of Birth: [**2122-10-18**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Shellfish Derived
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Intubation
EGD with banding of esophageal varices [**2168-3-16**]
Dobhoff placed with nasal septal bridling [**2168-4-8**].
Diagnostic paracentesis by radiology [**2168-4-11**]
PICC placement x2 - patient self removed both times
Multiple blood transfusions
History of Present Illness:
Ms. [**Known lastname 85927**] is a 45 year old female with past medical history
significant for discoid lupus, anorexia/bulimia who was admitted
[**2168-3-15**] to [**Hospital 1562**] Hospital with lethargy and jaundice. Father
called EMS after seeing her jaundice and the patient was not
speaking clearly to him and was complaining of weakness, joint
aches and malaise. Patient unable to provide full history but
per OSH notes and reports from her father she was very socially
withdrawn for past few months and has refused to let family and
her boyfriend visit her all but a few times. Father was not sure
whether patient has been abusing laxatives or using recent drugs
or alcohol.
.
At OSH, she presented with extreme lethargy, coffee ground
emesis and additional melanotic stools. She was seen by GI and
placed on Octreotide drip, IV PPI, and abdominal US showed
ascites and portal HTN but no GB stones and common bile duct was
normal size.
.
Per OSH records, labs there were significant for
hyperbilirubinemia to 28 range ( direct 15, indirect 12) and
elevated LFTs with AST 96, ALT 52, ALP 197. Given her lethargy a
head CT done which was negative. She had a Hct drop to 20-22
range and she was given a total of 4 Units PRBCs, 6 Units FFP,
3L IVFs and HCT improved to 27 range prior to transport. She
also had hypotension to 70s systolic per rMs. [**Known lastname 85927**] is a 45
year old female with past medical history significant for
discoid lupus, anorexia/bulimia who was admitted [**2168-3-15**] to
[**Hospital 1562**] Hospital with lethargy and jaundice. Father called EMS
after seeing her jaundice and the patient was not speaking
clearly to him and was complaining of weakness, joint aches and
malaise. Patient unable to provide full history but per OSH
notes and reports from her father she was very socially
withdrawn for past few months and has refused to let family and
her boyfriend visit her all but a few times. Father was not sure
whether patient has been abusing laxatives or using recent drugs
or alcohol.
.
At OSH, she presented with extreme lethargy, coffee ground
emesis and additional melanotic stools. She was seen by GI and
placed on Octreotide drip, IV PPI, and abdominal US showed
ascites and portal HTN but no GB stones and common bile duct was
normal size.
.
Per OSH records, labs there were significant for
hyperbilirubinemia to 28 range ( direct 15, indirect 12) and
elevated LFTs with AST 96, ALT 52, ALP 197. Given her lethargy a
head CT done which was negative. She had a Hct drop to 20-22
range and she was given a total of 4 Units PRBCs, 6 Units FFP,
3L IVFs and HCT improved to 27 range prior to transport. She
also had hypotension to 70s systolic per records on initial
presentation and for blood pressure control she required 2
pressors; Levophed and Vasopressin.
.
On arrival here to ICU, vitals were: T 97.1F, BP 110/62, HR 82.
Patient with A/C mode vent on arrival with RR set 12 ( patient
at 19),Tv 480, PEEP 5 and O2 sats 100% on .50 FiO2 with Tv. She
was sedated and intubated.
ecords on initial presentation and for blood pressure control
she required 2 pressors; Levophed and Vasopressin.
.
On arrival here to ICU, vitals were: T 97.1F, BP 110/62, HR 82.
Patient with A/C mode vent on arrival with RR set 12 ( patient
at 19),Tv 480, PEEP 5 and O2 sats 100% on .50 FiO2 with Tv. She
was sedated and intubated.
Past Medical History:
-Discoid Lupus Erythematosis
-anorexia
-bulimia
-h/o esophageal varices (dx [**2158**])
Social History:
Patient had been working as a bartender but is currently
unemployed. Lives alone, has a boyfriend. [**Name (NI) **] been living very
secluded for several months per father. Social history
significant for significant ETOH use in past. Sister saw Vodka
at house this past week. Smokes cigarettes intermittently but
not on regular basis.
Family History:
according to patient's father no other lupus in family,
patient's mother died at age 50 of overdose
Physical Exam:
On MICU admission [**2168-3-16**]:
Vitals: T 97.1F, BP 110/62, HR 82. Patient with A/C mode vent on
arrival with RR set 12 ( patient at 19),Tv 480, PEEP 5 and O2
sats 100% on .50 FiO2 with Tv. She was sedated and intubated.
Weight: 60.6 kgs. (133.60 lbs) on [**2168-3-17**] (bed scale)
General : patient intubated, sedated, very jaundiced
HEENT: OP clear,+scleral icteris, EOMI, nares clear
NECK: supple, RIJ in place, JVP 9-cm
Pulmonary: mild bibasilar crackles, no wheezes
CVS: S1/S2 regular, RRR, no murmurs/rubs/gallops
Abd: soft, slightly hypoactive bowel sounds, splenomegaly
appreciated and liver edge 2-3cm beyond costal margin
Extremities: 2+ pedal pulses, no edema, warm
Neuro: limited exam/sedated, PERRL, EOMI
Derm: no petechiae appreciated, very jaundiced
Lines/tubes/drains: Right IJ, PIV x2, foley
Exam on transfer to floor:
Vitals: T 95.4 axillary, BP via cuff 87/47, BP via a-line
108/49, HR 58, R 17 O2 100% RA
General Appearance: Thin and disheveld woman sleepy appearing
but in NAD
HEENT: scleral icterus, mouth with brown dried up emesis vs
sputum around lips and on tongue
CV: RRR no m/g/r
PULM: bibasilar crackles
ABD: s/nt/mildly distended, +BS, palpable spleen, liver edge not
palpable
EXT: 2+ pitting edema BLE, DPI, extremities cool
NEURO: oriented to person and ??????hospital,?????? answers simple
questions with idiomatic phrases that are give the impression
that she is not understanding but able to confabulate. She has
poor tone and prximal UE weakness R>L that appears to be
deconditioning.
Exam on discharge:
Tm: 98.6 Tc: 98.4 HR:101 BP: 131 Range: 117-131/68-74 RR:18
Resp: 100%
general: thin, comfortable, disheveled, NAD
HEENT: scleral icterus, mucous membranes moistm, dobhoff with
bridal in place.
CVS: RRR,no M/R/G, S1 S2 clear
Lung:CTA-B
ABD: +bs, soft, nt, mildly distended, palpable spleen, liver
edge not palpable
EXT: 1+ pitting edema BLE, DPI, extremeties cool
Neuro: oriented to person, place and time.
Strength:poor muscle tone and bulk, 5/5 strength
Pertinent Results:
Labs on admission [**2168-3-16**]:
WBC-15.2* RBC-2.90* HGB-9.6* HCT-26.9* MCV-93 MCH-33.2*
MCHC-35.7* RDW-23.0*
NEUTS-88.3* LYMPHS-6.5* MONOS-3.7 EOS-1.2 BASOS-0.3
ALT(SGPT)-46* AST(SGOT)-66* CK(CPK)-100 ALK PHOS-182* TOT
BILI-33.6*
GLUCOSE-223* UREA N-86* CREAT-4.0* SODIUM-138 POTASSIUM-3.9
CHLORIDE-109* TOTAL CO2-11* ANION GAP-22*
LACTATE-2.0
CK-MB-4 cTropnT-0.01
Serum Tox screen: negative
Urine [**2168-3-16**]:
BLOOD-LG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-TR
BILIRUBIN-LG UROBILNGN-4* PH-6.5 LEUK-TR
RBC-21-50* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2
.
Peritoneal fluid [**2168-3-16**]:
WBC-125* RBC-2550* POLYS-34* LYMPHS-33* MONOS-31* OTHER-2*
TOT PROT-0.2 GLUCOSE-262 CREAT-5.0 LD(LDH)-64 AMYLASE-4
ALBUMIN-LESS THAN
.
Other labs:
[**2168-3-17**] calTIBC-177* Ferritn-1428* TRF-136*
[**2168-4-2**] TSH-3.1
[**2168-4-3**] AM Cortsol-10.2
[**2168-4-5**] HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV
Ab-POSITIVE
[**2168-4-5**] HCV Ab-NEGATIVE
[**2168-3-17**] AMA-NEGATIVE
[**2168-3-17**] IgG-1241
[**2168-3-17**] CERULOPLASMIN 25 (18-53 mg/dL)
.
Labs on discharge:
HCT: 28.8
WBC: 5.8
Platelets: 51
Hg: 9.5
Na: 142
K+: 3.8
Chloride: 108
Bicarb: 25
BUN: 23
Cr: 1.0
Glucose: 119
Ca: 9.0
Mg; 1.9
Phos: 2.9
ALT: 37
AST:70
AP: 153
LDH:195
TBILI: 17.2
.
HIT labs: pending
.
MICRO:
[**2168-3-16**] MRSA screen - positive
[**2168-3-23**] VRE Swab: negative
[**2168-3-16**] Peritoneal culture - negative
.
[**2168-3-20**] Sputum:
_________________________________________________________
STAPH AUREUS COAG +
| STAPH AUREUS COAG +
| |
CLINDAMYCIN----------- =>8 R =>8 R
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
VANCOMYCIN------------ 1 S 1 S
[**2168-4-7**] UCx: [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.
>100,000 ORG/ML
[**2168-4-7**] UCx: YEAST. >100,000 ORGANISMS/ML..
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.-Alpha
hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp.
All blood and stool cultures negative
C diff negative x 7
[**2168-4-14**] C diff negative; Stool cx NGTD
[**2168-4-11**] Peritoneal culture: NGTD. Fluid cx: preliminary: no
fungus isolated.
[**2168-4-11**] BCx: NGTD
[**2168-4-11**] BCx/Mycolytic: NGTD
[**2168-4-11**] UCx: Yeast
[**2168-4-11**] 3:10 pm PERITONEAL FLUID
.
IMAGING:
[**2168-3-16**] Pleural fluid: cytology negative for malignant cells
[**2168-3-16**] EGD in ICU demonstrated 4 oozing esopahgeal varices
(grade II/III) which were banded, there was also evidence of
gastric varices.
[**3-17**] ECHO: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF 70%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The estimated pulmonary
artery systolic pressure is normal. No vegetation/mass is seen
on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: no vegetations seen.
[**3-17**] CT head
1. Very subtle hypodensity of the left thalamus more conspicuous
on today's exam than on the CT from [**2168-3-17**]. MRI of the
head or followup CT might be considered if clinically indicated.
2. No intracranial hemorrhage, significant edema or mass effect.
[**3-17**] RUQ u/s
1. No hydronephrosis.
2. No evidence of renal artery stenosis although this is a
limited Doppler
study.
3. Minimal ascites.
[**4-4**] Abd US:
1. Reverse flow seen in the anterior and posterior right portal
veins with
forward flow seen in the main and left portal veins. Patent
umbilical vein.
2. No focal liver lesion identified.
3. Moderate amount of ascites.
4. Splenomegaly.
[**2168-4-8**] EGD:
Varices at the distal esophagus (2 cords, grade 1)
Erythema in the duodenum compatible with duodenitis
Post-pyloric feeding tube with bridle was placed.
Mosaic appearance in the stomach compatible with portal
hypertensive gastropathy
Otherwise normal EGD to third part of the duodenum
[**2168-4-8**] KUB: Tip of enteric likely in the expected location of
the proximal jejunum.
[**4-11**] Abd US (to evaluate for fungus ball or hydronephrosis given
renal failure and persistent funguria): No hydronephrosis and no
focal renal lesions.
[**2168-4-19**]: Nasointestinal tube placement: advanced beyond pylorus
to third portion of duodenum confirmed by fluoroscopy.
Brief Hospital Course:
45 yo female with history of eating disorders, ETOH cirrhosis
here with fulminant hepatic failure, GIB, acute renal failure,
and shock found to have alcoholic hepatitis.
# Alcoholic hepatitis/EtOH Cirrhosis - In the ICU, pt was
started on solumedrol for EtOH hepatitis, but given GIB,
patient's steroids were not continued and instead she was
treated with pentoxifylline (day 1= [**2168-3-17**]). She was initiated
on tube feeds (Dobhoff placed [**2168-3-18**]) and treated for hepatic
encephalopathy with rifaximin and lactulose. Pt self dc'd
dobhoff several times, and it was most recently replaced on
[**2168-4-19**]. She was continued on thiamine. Hepatitis serologies
negative for infection. Since admission she had had a direct
hyperbilirunemia raising the possibility that she had [**Doctor Last Name 9376**]
disease, exacerbated by concurrent illness. She should continue
to have monitoring of her LFTs in rehab.Pt was continued on MVI,
folate, and IV thiamine given Wernicke's/Korsakoff's (see
below). She was continued on lactulose and rifaximin with
resolution of hepatic encephalopathy. She completed
pentoxyfilline x 1 month (ended [**2168-4-15**]). She self removed her
Dobhoff and her LFTs/T bili again trended up. After discussion
with family, Dobhoff was replaced [**4-7**] endoscopically with nasal
septal bridling with significant improvement of LFTs and Tbili.
Nadolol was restarted on discharge.IV thiamine was changed to PO
thiamine at discharge.
.
# Respiratory failure - She was extubated on [**2168-3-20**]. On [**3-20**],
she was noted to have worsening sputum production, so sputum
culture was obtained and given one dose Vanc/Cefepime, but this
was stopped due to low suspicion for PNA.
.
# Leukocytosis: As above, pt received vancomycin x1 doses while
in ICU given MRSA in sputum noted [**2168-3-20**], but team had low
suspicion for pneumonia. On the floor, pt had persistent
leukocytosis and was restarted on vancomycin for full course
([**Date range (2) 85928**]) with resolution of leukocytosis. She was
cultured numerous times for hypothermia or low grade fevers, all
negative or NGTD. Imaging negative for fungus ball in kidneys
given persistent funguria. Paracentesis negative for SBP.
.
# Altered mental status- In the ICU, likely due to hepatic
encephalopathy, perhaps with contribution from UTI. She was
started on cipro for urine cultures at the OSH with
pan-sensitive E Coli (transferred on levo) as well as GI
bleeding in cirrhotic. Her MS improved with initiation of
rifaximin and lactulose. Patient's head CT showed no evidence of
edema or major bleeding to account for her confusion on
admission. Ascites showed no evidence of SBP.
.
# Korsakoffs/Wernicke's: Pt's electrolyte abnormalities and
hepatic encephalopathy improved as above (asterixis resolved),
but she remained confused, confabulated and was noted to be
ataxic, and teams in consultation with psychiatry were concerned
about Korsakoff's/Wernicke's syndrome, esp given history of
drinking and eating disorder. Pt had subtle hypodensity in
thalamus on CT which can be finding in Korsakoff's. Confusion
began to improve suggesting Wernicke's rather than Korsakoff.
Team opted not to obtain MRI to clarify thalamic lesion and look
for signs of Wernicke/Korsakoff's (mamillary body destruction,
thalamic hemorrhages/lesions) given improving mental status and
it will not change management. Pt was continued on IV thiamine
until discharge when she was changed to PO thiamine.
.
# Variceal bleeding/anemia - On [**2168-3-16**], she had EGD in ICU
which demonstrated 4 oozing esopahgeal varices (grade II/III)
which were banded, there was also evidence of gastric varices.
She was started on octreotide and protonix. Her hematocrit
remained stable. She was on ciprofloxacin for her UTI, which
also provided coverage in the setting of bleed. She was started
on nadalol, which was stopped during episode of hypotension. Fe
studies [**Date range (1) 61323**] suggest anemia of chronic disease, B12 and
folate normal. Repeat EGD [**4-8**] with 2 cords of grade I varices.
She required occassional transfusions during her hospitalization
for volume and anemia (slowly decreasing Hct likely due to
portal gastropathy, with appropriate increase in Hct after
transfusion). He hematocrit was 28.8 on discharge. Nadolol was
restarted on discharge. She can be transfused for HCT less than
24.
.
Thrombocytopenia: She had thrombocytopenia since admission
thought [**1-5**] chronic liver disease +/- marrow suppression from
ETOH use and likely splenomegaly. A month into her
hospitalization her thrombocytopenia had worsened with platelet
nadir of 25 from the 40-50 range previously. There was a concern
that there may be a medication effect contributing to her
thrombocytopenia. Pantoprozole was discontinued and replaced
with sucralfate.HIT antibodies were sent and were found to be
positive shortly prior to discharge. She last received heparin 2
weeks prior to her discharge. Heparin has been listed as an
allergy and she should receive heparin products in any form. A
serotonin assay should be sent at rehab to be interpreted by
rehab MD.
.
# Acute renal failure/Hepatorenal syndrome - In the ICU, renal
failure was felt to be likely due to ATN. Patient's Cr improved
to baseline with fluids in the ICU. After Cr normalized in ICU,
she again developed ARF, likely due to HRS given ascites and
hypotension. No improvement in Cr with albumin 50g IV x2
challenge (she had gotten small doses until then volume). Cr
slowly returned to baseline (baseline 0.5-1.0) after treatment
for HRS with albumin, octreotide and midodrine with improvement
of blood pressure (SBP 80s-90s--> SBP 110s-120s). Octreotide,
midodrine and albumin were stopped. Pt had some episodes of
hypernatremia that resolved with D5W or increasing free water in
tube feeds, likely in setting of poor PO intake.
.
# Hypothermia/hypotension - Inititally attributed to liver
failure with peripheral vasodilation given that core body temp
was low but skin is warm; however, pt was continued on diuretics
with poor PO intake (refusing meds) and may have been volume
depleted. Diuretics and nadolol stopped given hypotension.
Vitals improved with volume resuscitation with pRBC/albumin/NS.
Concern for infection on [**4-3**] and she has completed 5 days zosyn
(stopped [**2168-4-7**]; completed vanc as above). WBC improved and
cultures negative except for prior sputum with MRSA and urine
with [**Female First Name (un) 564**].
.
# Anasarca - Slowly improved once renal failure resolved.
Difficult to assess fluid status based on I/O's as pt was
incontinent. Weights were difficult to follow given weights
taken with different scales (71-73 standing weights; 60-63kg bed
scale). She was not hypoxic and did not have tense ascites.
.
# History of anorexia/bulimia: Per family, pt has long history
of untreated eating disorder. PO intake was encouraged but
patient continued to eat little. She was started on tube feeds
with improvement in her liver function. She was frequently
nauseated with tube feeds (post pyloric tube in place) and there
was concern that it was part of her bulemia. Upon discharge from
rehab, she will need close monitoring and follow up for
psychiatric issues, including eating disorder.
.
# Depressed mood /Substance Abuse/Eating disorder- as patient's
mental status, encephalopathy, and Wernicke's syndrome improved,
her affect became more depressed, which is appropriate given her
situation prior to hospitalization. She was started on remeron
to be uptitrated as outpatient. She will require continued
evaluation by a psychiatrist when she is in rehab, who will then
determine what kind of outpatient psychiatric program she will
require. She will require very close psychiatry follow up given
her history of severe untreated depression.
.
# Alcohol abuse - pt has longstanding history of alcohol abuse.
Family and boyfriend were relatively unaware until recently. She
will require very close follow up as outpatient for relapse
prevention/substance abuse treatment. Her boyfriend, [**Name (NI) 892**] can be
excellent advocate for her during treatment.
.
# Goals of care- In attempts to define goals of care numerous
team meetings involving the family, ethics, social work, legal
and members of the care team were held during her
hospitalization. While the family initial wish was for CMO
status, the team felt that this was not appropriate given the
patients expression of her wishes to receive care and get
better. She continued to improve over the course of her
admission and was able to express her wishes to continue to have
care. She agreed to Dobhoff tube placement and after two
separate discussions with patient she designated her father as
her health care proxy. She was initially made DNR/DNI however
given her continued recovery, she has changed her own code
status to Full Code as of [**2168-4-17**].
.
# CONTACT: HCP is father [**Name (NI) **] [**Name (NI) 85927**] # [**0-0-**]
(designated by patient with witnesses); sister [**Name (NI) **] at cell
#[**Telephone/Fax (1) 85929**], home #[**Telephone/Fax (1) 85930**]?, boyfriend [**Name (NI) 892**] [**Name (NI) 85931**]
[**Telephone/Fax (1) 85932**]
Medications on Admission:
Medications at home: none
On transfer from OSH:
Hydrocortisone 100mg IV q 6 hrs
Levaquin 500mg q24 hrs
Flagyl 500mg IV q8hrs
Vitamin K 10mg IV qdaily
Vasopressin .drip 04 Units/ minute (30ml/hr)
Levophed drip .5mcg/min
Zofran 4mg IV q8 hrs PRN
Octreotide @ 25mcg/hr drip
Protonix 40mg IV BID
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for on buttock.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day).
6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-5**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
8. Mirtazapine 15 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO HS (at bedtime).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
.
Allergies: Heparin
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Alcoholic hepatitis
Alcoholic cirrhosis
Wernicke's syndrome
Anemia
Esophageal varices
Hepatorenal syndrome
Depression
Anorexia/bulemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Weight: 62.8kg
Discharge Instructions:
Ms. [**Known lastname 85927**], you were admitted to [**Hospital1 18**] with inflammation of
your liver due to alcohol use (acute alcoholic hepatitis). You
also have chronic scarring of your liver due to prolonged
alcohol use (alcoholic cirrhosis). Your kidneys were injured due
to your liver disease and recovered. You had some bleeding from
your gastrointestinal tract and had a procedure to stop the
bleeding. You were treated with antibiotics for an infection.
While you have gotten much better in the hospital, continued
improvement will depend on you. You were very depressed and were
started on medication for this. You should see a psychiatrist to
get help for your depression. It is also very important that you
not drink alcohol again as it could be fatal.
We have started you on a number of medications. Please see your
discharge mediation list. It is very important that you take all
of them exactly as prescribed.
Followup Instructions:
Liver appointment:
Dr [**Name (STitle) 23173**]
Monday [**2168-5-9**]
9:10
[**Hospital Unit Name **] [**Location (un) 85933**]
tel: [**Telephone/Fax (1) 2422**]
|
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icd9cm
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[
[
[]
]
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[
"54.91",
"38.93",
"96.71",
"42.33",
"38.91",
"45.13",
"96.6"
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icd9pcs
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[
[
[]
]
] |
22034, 22105
|
11621, 20824
|
319, 578
|
22284, 22284
|
6591, 7327
|
23515, 23679
|
4452, 4553
|
21168, 22011
|
22126, 22263
|
20850, 20850
|
22562, 23492
|
20871, 21145
|
4568, 6095
|
258, 281
|
7675, 11598
|
606, 3973
|
6114, 6572
|
22299, 22538
|
3995, 4084
|
4100, 4436
|
7339, 7656
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,644
| 138,099
|
42353
|
Discharge summary
|
report
|
Admission Date: [**2154-8-5**] Discharge Date: [**2154-8-9**]
Date of Birth: [**2090-8-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / lobster
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2154-8-5**] Coronary artery bypass grafting x2: Left internal
mammary artery to left anterior descending artery, and reverse
saphenous vein graft to the obtuse marginal artery.
History of Present Illness:
This 63 year old patient has been experiencing dyspnea on
exertion for the past year that she feels has gotten
progressively worse. She describes dyspnea after walking just a
few feet within her home. She denies chest pain. She denies
claudication, edema, orthopnea, PND and lightheadedness. She was
referred to Dr. [**Last Name (STitle) **] and underwent stress testing and cardiac
CTA as below. Due to abnormalities and continued dyspnea,
patient was referred for cardiac catheterization which revealed
significant left main coronary artery disease. She is referred
for surgical revascularization.
Past Medical History:
Coronary Artery Disease
PMH:
COPD
macular hole right eye s/p surgery
cataract
hypertension
hyperlipidemia
anxiety
Right cataract
Past Surgical History:
Tubal ligation
Social History:
Lives with:Daughter who is ill with Lupus
Contact: [**Name (NI) 43395**], daughter home # [**Telephone/Fax (1) 91736**].
Occupation:takes care of ill daugher at home
Cigarettes: Smoked no [] yes [] last cigarette _____ Hx:
Other Tobacco use:[**1-21**] PPD x 30+ yrs
ETOH:denies < 1 drink/week [] [**2-26**] drinks/week [] >8 drinks/week
[]
Illicit drug use: none
Family History:
Father had CABG at 63yo
Physical Exam:
Pulse: 78 Resp: 18 O2 sat: 94%RA
B/P Right: 136/51
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [] Edema [] _trace_
Varicosities: None [] spider veins
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +2 Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: 2+ Left:+2
Carotid Bruit Right: None Left:none
Pertinent Results:
[**2154-8-5**] TEE
Conclusions
PRE BYPASS The left atrium is moderately dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the ascending aorta.
There are simple atheroma in the aortic arch. There are complex
(>4mm) atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **]
was notified in person of the results in the operating room at
the time of the study.
POST BYPASS The patient is atrially paced. There is normal
biventricular systolic function. Valvular function is unchanged
from pre-bypass. The thoracic aorta is intact after
decannulation
.
Brief Hospital Course:
The patient was brought to the operating room on [**2154-8-5**] where
the patient underwent coronary artery bypass grafting times two
with Dr. [**Last 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. Post operative
day one 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 post operative day four the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to [**Hospital 392**]
Rehab in good condition with appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Atorvastatin 80 mg PO DAILY
2. Ipratropium Bromide MDI 2 PUFF IH QID
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Acetaminophen 650 mg PO Q4H:PRN pain, fever
4. Albuterol-Ipratropium [**1-21**] PUFF IH Q4H:PRN dyspnea
5. Docusate Sodium 100 mg PO BID
6. Furosemide 40 mg PO BID Duration: 10 Days
titrate per clinical exam
7. Metoprolol Tartrate 25 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
9. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
10. Ipratropium Bromide MDI 2 PUFF IH QID
11. Oxycodone-Acetaminophen (5mg-325mg) [**1-21**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**1-21**] tablet(s) by mouth
every four hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Hospital 392**] Rehabilitation & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
Coronary Artery Disease
PMH:
COPD
macular hole right eye s/p surgery
cataract
hypertension
hyperlipidemia
anxiety
Right cataract
Past Surgical History:
Tubal ligation
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: 1+ LE
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**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**]
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2154-9-12**] at 1:00PM
Cardiologist Dr. [**Last Name (STitle) **] [**2154-8-22**] at 11:00 [**Street Address(2) 4472**], [**Apartment Address(1) 91737**], [**Hospital1 **],[**Numeric Identifier 4474**]
Wound check in the cardiac surgery office in the [**Hospital Unit Name **]
[**Hospital Unit Name **] on [**2154-8-15**] at 10:15AM
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 89247**] in [**4-25**] weeks [**Telephone/Fax (1) 9489**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2154-8-9**]
|
[
"414.01",
"493.20",
"327.23",
"401.9",
"300.00",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
5817, 5916
|
3611, 4765
|
306, 489
|
6128, 6297
|
2396, 3588
|
7169, 8017
|
1712, 1738
|
5052, 5794
|
5937, 6067
|
4791, 5029
|
6321, 7146
|
6090, 6107
|
1753, 2377
|
247, 268
|
517, 1122
|
1144, 1274
|
1330, 1696
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,419
| 153,545
|
32577
|
Discharge summary
|
report
|
Admission Date: [**2102-10-24**] Discharge Date: [**2102-11-6**]
Date of Birth: [**2034-1-27**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Fall of approximately 8 feet from ladder. Mid throacic pain and
neck pain
Major Surgical or Invasive Procedure:
1. Posterior instrumented fusion thoracic spine, T1 - T7.
2. Laminectomies of T4 and T5
3. Lamino-foraminotomies C7, T1, T2, T3
3. Closed treatment C1 fracture.
4. HALO application.
History of Present Illness:
Mr. [**Known lastname 75210**] was brought to [**Hospital1 18**] after a fall from
approximately 8 feet off of a ladder. He reported cervical and
mid back pain. CT scan showed C1 ring fracture with T3 & T4
fracture.
Past Medical History:
Coronary artery disease with history of myocardial infarction
Hypertension
Diabetes-Insulin dependent
Social History:
Per pt he lives in a house with his wife on the Community of
Christ [**Name (NI) 75953**] in [**Location (un) **] MA. He has 3 children - 2
daughters in [**Name2 (NI) **] ages 41 and 46, one son age 38 who lives in
[**Location 5944**]. He has two grandchildren ages 25 and 27 and two great
grandchildren ages 12 and 8. He has been an elder at Community
of Christ since age 27.
Physical Exam:
On physical exam Mr. [**Known lastname 75210**] was awake and in no acute
distress. His breathing was regular. Musculoskeletal exam
revealed no obvious bony abnormality or decrease in strength.
Rectal tone was normal, refelxes were equal throughout. He
showed no neurologic compromise. He was negative for clonus,
hoffmans sign, saddle anesthesia.
Pertinent Results:
[**2102-10-24**] CT C-spine:
IMPRESSION:
1. Comminuted [**Location (un) 5621**] type C1 fracture through the right and
left anterior arch and lateral masses, as well as right
posterior arch, with floating fragment adjacent to the dens
(C2).
2. Possible C7 spinous process fracture.
[**2102-10-24**] CT Chest:
IMPRESSION:
1. T3 and T4 vertebral body (and T4 transverse process)
fractures with no evidence of retropulsion or listhesis.
2. Bilateral posterior 2nd rib fractures
3. No evidence of soft organ injury.
4. Very small bilateral pleural effusions.
[**2102-10-25**] MRI of Cervical, Thoracic & Lumbar spine:
IMPRESSION:
1. Edema of the T2 and T3 vertebral bodies as well as
intervening disc space with paraspinal edema/hematoma. A
fracture line through the posterior superior corner of the T3
vertebral body is also seen. There may be minimal retropulsion
but without significant canal stenosis.
2. Edema related to the C1 burst fracture with prevertebral
hematoma/edema extending from the skull base to the C6 level.
3. Edema of the posterior cervical soft tissues extending from
the skull base to T1 is noted, and injury to the interspinous
and supraspinous ligaments cannot be excluded.
CT Head [**2102-10-28**]:
IMPRESSION:
1. Multiple dural-based lesions as described above, of which
the left frontal is definitively a calcified meningioma.
Statistically, the additional two right parafalx lesions
represent meningiomas in varying stages of calcification.
Although the right frontal parafalx lesion could also
theoretically represent a small subdural collection, the
multiplicity of dural-based lesions strongly favors meningiomas.
Further characterization with MR brain with contrast would
provide further clarification.
2. Stable very small bifrontal low-density subdural collections
(hygromas
versus chronic subdural hemorrhages versus enlarged CSF spaces).
Brief Hospital Course:
Mr. [**Known lastname 75210**] was brought to [**Hospital1 18**] after 8 foot fall from
ladder. CT & MRI images showed C1, T3 & T4 fractures with soft
tissue damage from T2-T6. He was neurologically intact on exam.
He was placed in a C-collar and placed on log roll precautions.
He was concented for posterior thoracic stabilization and halo
placement.
1. Spine fractures- Mr. [**Known lastname 75210**] [**Last Name (Titles) 1834**] a T1-T7 posterior
thoracic stabilization with halo placement. After his surgical
procedure, Mr. [**Known lastname 75210**] was transfered to the PACU. At that
time he could not tolerated extubation. He was transfered to
the SICU for monitoring. After two days in the SICU, he was
transfered to the floor. The rest of his hospital course was
unremarkable.
2. Mental Status changes- On his third night of admission, Mr.
[**Known lastname 75210**] experienced mental status changes and was hostile
towards the nursing staff. Psychiatry was consulted and a CT of
his head was ordered to rule out changes.
3. Metabolic alkalosis-Mr. [**Known lastname 75210**] had an episode of alkalosis
on [**2102-11-1**]. His lasix & HCTZ were held and he was given IV
fluids. Medicine was consulted. They recomended continued
current care. His bicarb began to trend down. He showed no
signs of alkalosis during this time.
Medications on Admission:
Asprin 325mg
Atenlol 100mg
Avalide 300/25mg [**Hospital1 **]
Lipitor 20mg
Flomax 0.4mg
Glubmetformin 1.25/250
Verapamil 240mg
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. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): may d/c if pt is up and moving.
8. Verapamil 80 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
9. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO daily ().
10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain.
15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for breakthrough pain.
16. Glyburide-Metformin 1.25-250 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
17. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): d/c on [**2102-11-19**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
1. C1 fracture.
2. T3 fracture.
3. T4 fracture.
4. T4 and T5 lamina fractures.
Discharge Condition:
Stable to outside facility
Discharge Instructions:
Please keep incision clean and dry. You may shower in 48 hours,
but please do not soak the incision. Change the dressing daily
with clean dry gauze. If you notice drainage or redness around
the incision, or if you have a fever greater than 100.5, please
call the office at [**Telephone/Fax (1) **]. Please resume all home
mediciation as prescribed by your primary care physician. [**Name10 (NameIs) **]
you have questions concerning activity, please refer to the
activity sheet.
Physical Therapy:
Activity as tolerated by pain.
Treatments Frequency:
Please change dressing daily with dry gauze.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1007**] at two weeks from the date of
surgery. You can make that appointment by calling [**Telephone/Fax (1) **]
Completed by:[**2102-11-6**]
|
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icd9cm
|
[
[
[]
]
] |
[
"02.94",
"03.53",
"96.6",
"81.63",
"03.09",
"81.05",
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icd9pcs
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[
[
[]
]
] |
6685, 6797
|
3638, 4994
|
395, 579
|
6920, 6949
|
1736, 3615
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607, 826
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848, 951
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967, 1349
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,205
| 197,225
|
46016
|
Discharge summary
|
report
|
Admission Date: [**2138-1-19**] Discharge Date: [**2139-1-21**]
Date of Birth: [**2070-1-22**] Sex: M
Service: MEDICAL INTENSIVE CARE UNIT
HISTORY OF PRESENT ILLNESS: This is a 68-year-old male with
multiple medical problems significant for coronary artery
disease, congestive heart failure and anemia, who had
previously been admitted to [**Hospital6 2018**] on [**2138-12-3**], for back pain and anemia. The
patient had developed a lumbar and thoracic compression
fracture. He also developed bilateral pleural effusions with
a right-sided hemothorax which was subsequently drained via
chest thoracostomy tube.
The patient then developed respiratory failure and was
intubated. He had a failure to wean and had a tracheostomy
performed, as well as peripherally inserted endoscopic
gastrojejunostomy tube.
The patient then developed aspiration pneumonia while
hospitalized and was treated for vent-assisted pneumonia.
The patient also had suffered bouts of tracheal cellulitis
around the tracheal insertion area and was treated with
Vancomycin for a course of ten days.
The patient also developed blood loss anemia while
hospitalize previously. The patient had been slowly weaning
and had been transferred to [**Hospital3 7**] on [**2139-1-14**], for prolonged vent management in anticipated prolonged
weaning.
While at [**Hospital1 **] on [**2139-1-15**], until [**2139-1-19**], the patient had been doing well on CPAP with pressure
support. It was noted on [**Year (4 digits) 2974**] that he developed an upper
posterior oropharynx bleed. This is the same area that the
patient had a bleed secondary to nasogastric tube trauma
while hospitalized previously.
The patient had been seen by ENT previously secondary to this
nasogastric tube insertion and subsequently his left and
right nares were packed with a Foley balloon catheter.
While at [**Hospital1 **], the patient developed bleeding in the
site. He bled through the course of the week, and his
hematocrit dropped from 32 to 24. The patient was
transferred to [**Hospital6 256**] for
management of his bleeding and anemia.
PAST MEDICAL HISTORY: 1. Anemia. 2. History of
asbestosis. 3. Degenerative joint disease. 4. Glaucoma.
5. Paroxysmal atrial fibrillation and flutter. 6.
Laryngeal cancer status post resection and radiation therapy.
7. Diabetes mellitus type 2. 8. Hypercholesterolemia. 9.
Congestive heart failure. 10. Coronary artery disease
status post non-Q-wave myocardial infarction and coronary
artery bypass grafting. 11. Failure to wean with subsequent
tracheostomy and PEG tube placement. 12. Aspiration
pneumonia. 13. Tracheal site cellulitis. 14. Bilateral
pleural effusions.
SOCIAL HISTORY: The patient is a retired bar owner who lives
with his wife. [**Name (NI) **] has a history of smoking and alcohol
abuse.
FAMILY HISTORY: Brother with a history of multiple
sclerosis.
MEDICATIONS ON PRESENTATION: Albuterol nebs, Atrovent nebs,
Heparin 500 mg subcue b.i.d., Aspirin 81 mg q.d., Mucomyst
nebs 4 times daily, Prevacid 30 mg b.i.d., Lactulose 30 ml
b.i.d., Nitroglycerin sublingual p.r.n., Lipitor 20 mg q.d.,
Levothyroxine 88 mcg q.d., Sotalol 40 mg b.i.d., Isosorbide
Nitrate 20 b.i.d., Celexa 20 mg q.d., Captopril 100 mg
t.i.d., Metoprolol 50 mg b.i.d., Zinc, Vitamin C, Ativan 0.5
mg, Senna 2 tab b.i.d., Amphojel 330 q.6 through the PEG
tube, Vancomycin 1 g q.24 until [**2139-1-19**].
PHYSICAL EXAMINATION: Vital signs: On presentation in the
Emergency Department, the patient's initial heart rate was
64, blood pressure 176/69, oxygen saturation 100% on SIMV
with pressure support of [**9-13**], titer volume 600, respirations
12, PEEP 5. It was noted that the patient had copious saliva
and blood filled up the posterior oropharynx that was
suctioned for approximately 200 cc of serosanguinous and
clot-filled material. He had deep suction through
tracheostomy tube which revealed no blood in the distal
trachea or bronchi. General: He was comfortable in no
apparent distress. HEENT: Extraocular movements intact.
Pupils equal, round and reactive to light. He did have dry
clots in his nose and mouth. His conjunctiva were minimally
pale. Neck: Exam revealed tracheal site erythema with no
warmth, no fluctuants. No jugular venous distention. No
carotid bruits. Chest: He had diffuse rhonchi bilaterally
on the vent. Cardiovascular: He had distant heart sounds.
Regular, rate and rhythm. No murmurs, rubs, or gallops.
Abdomen: Soft, nontender, nondistended. PEG tube was in
place and clean and dry without blood around the site.
Extremities: No clubbing, cyanosis, or edema. Warm with god
pulses. Neurological: He was alert and answering questions
with nodding yes and no appropriately. He was following
suggestions. No focal deficits on neurological exam. His
deep tendon reflexes were intact.
LABORATORY DATA: Upon presentation in the Emergency Room, he
had a hematocrit of 25.9, white count 7.8, platelet count
229; CHEM7 revealed a sodium of 131, potassium 5.6, chloride
90, bicarb 37, BUN 36, creatinine 1; PTT 29.2, PT 12.6, INR
1.
Electrocardiogram showed normal sinus rhythm at 75, with
borderline intraventricular conduction delay, and ST
elevation in lead V2 only.
Chest x-ray revealed right middle lobe and lower lobe
opacities, unchanged from previous x-ray, with bilateral
small pleural effusions.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit on [**2139-1-19**]. The patient was
seen by Otolaryngology in the Emergency Department.
Subsequent to his previous history of traumatic nasogastric
tube insertion and subsequent left nares laceration with
bleeding, the left nares laceration required posterior nasal
packing to control the bleeding.
Otolaryngology performed a fiberoptic laryngoscope of both
nares, as well as the oropharynx, as well as the distal
trachea. They noted no active bleeding. They noted copious
dry blood in the posterior oropharynx. They also noted
previous left posterior nasal pharynx laceration secondary to
traumatic nasogastric tube insertion. The laryngoscopy was
also performed through the trachea which revealed no distal
tracheal bleeding or bleeding around the trach site.
Otolaryngology recommended Afrin 3 times daily during the
hospitalization.
The patient required 2 U of blood to be transfused in the
Emergency Department subsequent to his initial presentation
hematocrit of 25.9. After 2 U of blood, this corrected his
hematocrit to 27.9. He was subsequently transfused two more
units prior to discharge. The patient had no further
episodes of bleeding throughout the hospitalization. His
hematocrit remained stable. The patient's vitals signs
remained stable throughout the hospitalization. He had no
bouts of hypotension or tachycardia secondary to his anemia.
Due to the patient's coronary artery disease history, he
subsequently had serial cardiac enzymes drawn which revealed
showed normal CKs and normal troponins with an unremarkable
electrocardiogram. It is highly that the patient suffered
myocardial ischemia during this hospitalization.
The patient remained on ventilatory support throughout the
hospitalization. The patient is known to be a failure to
wean and was sent to [**Hospital1 **] for prolonged vent weaning.
The patient remained on pressure support throughout the
hospitalization with intermittent deep suctioning secondary
to secretions.
The patient was continued on his current cardiovascular
regimen of low-dose Aspirin, beta-blocker, ACE inhibitor,
sublingual Nitroglycerin, Isosorbide, and a statin, as well
as to continue Sotalol for his paroxysmal atrial
fibrillation.
The patient had his tube feeds held initially secondary to
the question of GI bleed. He was started on protime pump
inhibitor. His PEG site lavage was negative. He was noted
to be [**Hospital1 **] positive most likely due to swallowed blood from
the posterior oropharynx bleed.
We would consider outpatient colonoscopy and
esophagogastroduodenoscopy if the patient has prolonged or
subsequently undergoes another bleed. The patient was also
noted to be hyperkalemic initially in the Emergency
Department without changes in electrocardiogram suggesting
symptomatic hyperkalemia. He was given a dose of Kayexalate
30 mg x 1 and had his electrolytes rechecked. He
subsequently had a potassium that was normalized to 5.0.
The patient also has a history of hypothyroidism with a TSH
of 31. His Levothyroxine was increased from 88 mcg to 100
mcg q.d.
The issue of tracheal cellulitis was resolved subsequently
due to the fact that it was noted that the patient's tracheal
site erythema had not changed, and there had been no warmth.
The patient had completed a course of intravenous Vancomycin
for his tracheal cellulitis prior to admission to the
hospital.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSIS:
1. Posterior oropharynx and left nares bleed.
2. Coronary artery disease.
3. Anemia.
4. Depression.
5. Diabetes.
6. Paroxysmal atrial fibrillation.
7. Hyperlipidemia.
8. Hypothyroidism.
9. History of pleural effusions.
10. Status post myocardial infarction.
11. History of Intensive Care Unit acquired pneumonia.
12. Hypertension.
DISCHARGE MEDICATIONS: Lansoprazole 30 mg p.o. b.i.d.,
Albuterol nebs, Ipratropium nebs, Aspirin 81 mg p.o. q.d.,
Mucomyst nebs q.[**3-15**], Lactulose 30 ml p.o. b.i.d., sublingual
Nitroglycerin 0.4 mg p.r.n., Levothyroxine 100 mcg p.o. q.d.,
Atorvastatin 20 mg p.o. q.d., Isosorbide Dinitrate 20 mg p.o.
b.i.d., Celexa 20 mg p.o. q.d., Zinc Sulfate 220 mg p.o.
q.d., Ascorbic Acid 500 mg p.o. q.d., Lorazepam 0.5 mg q.4-6
hours p.r.n., Senna 2 tab p.o. b.i.d., Folic Acid 1 mg p.o.
q.d., Ferrous Sulfate 325 mg p.o. q.d., Aluminum Hydroxide
suspension 30 ml NG q.4 p.r.n., Metoprolol 50 mg p.o. t.i.d.,
Sotalol 40 mg p.o. b.i.d., Captopril 100 mg p.o. t.i.d.
Note: Further addendum will be dictated as necessary.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 5747**]
MEDQUIST36
D: [**2139-1-20**] 14:37
T: [**2139-1-20**] 14:42
JOB#: [**Job Number **]
|
[
"250.00",
"276.7",
"285.9",
"428.0",
"V45.81",
"412",
"874.4",
"V44.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2871, 3441
|
9312, 10277
|
8947, 9288
|
5420, 8855
|
3464, 5402
|
189, 2118
|
2141, 2714
|
2731, 2854
|
8880, 8926
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,313
| 195,912
|
1958
|
Discharge summary
|
report
|
Admission Date: [**2141-2-4**] Discharge Date: [**2141-2-15**]
Date of Birth: [**2072-6-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
confusion and hypotension
Major Surgical or Invasive Procedure:
R femoral central line
History of Present Illness:
HPI (From records, pt unable to give Hx)
68 y/o male ESRD, s/p failed renal transplant who presents w/
transient hypotention to 80s systolic and delta MS [**First Name (Titles) 767**] [**Last Name (Titles) 10807**]s. At dialysis was noted to become lethargic during HD
with decreaed BP. Dialysis was stopped 55m early. Vitals at that
time were T96.1BP100/70 P 74 and 94% on 2L. Per HD records pt at
baseline is AOX2 .
In ED vitals 96 100/70 80 14. FS 145. Also was noted to have
zoster on RUE. Was given acyclovir, ceftriaxone, vancomycin, and
decadron. Pt was combative during attempts to place IV, was
given 5 mg IM haldol and 2 mg IM ativan. Line was then placed.
.
Upon presentation to [**Name (NI) 153**], pt is lethargic. VItals signs stable.
Past Medical History:
#status post failed cadaver renal transplant in [**2134**] with
explantation in [**12-19**] (path acute and chronic rejection).
Complicated by wound infection with ENTEROCOCCUS and BACTEROIDES
FRAGILIS .
#hypertension
#diastolic dysfunction
#congestive heart failure (Echo [**3-19**] EF 60%, 2+MR, 2+TR,
moderate pulmonary artery hypertension)
#diabetes type 2
#hepatitis C virus
#chronic anemia
#status post mitral valve replacement in [**2131**]
#history of IV drug abuse with recent cocaine and heroin
#h/o PTX
#h/o depression
#positive PPD s/p INH
#s/p L eye loss after accident
#cervical radiculitis
#Reports HIV negative.
Social History:
Retired water meter reader, now disabled +ETOH/tobacco IVDA,
cocaine lives alone On methadone maintenance program, but still
using cocaine and IV heroin.
.
Family History:
Father -- CVA (50's),Mother -- CAD,Sister -- SLE (deceased @ 60
due to renal/cardiac complications)
Physical Exam:
VITALS T 97.0 BP 125/67 HR 90 RR 24 O2sat 98% on 2L NC
GEN Cachectic, lethargic man
SKIN multple old track marks of fore arms. RIJ line attempt site
covered with dressing, oozing fresh blood. L SCL dialysis line
c/d/i. Vesicular rash on right chest, under arm and on R back i
T2 distribution. Poorly healed sugical incision in R groin~14cm,
center open with pink granulation tissue and small amount of
pus. R femoral central line in place.
HEENT Pupils 2-3mm and minimally reactive. Sclera white. mm dry
NECK No LAD,unable to touch chin to chest.
CV RRR nl s1-s2. II/VI systolic murmur beard best at RUSB
LUNGS decreased breath sounds otherwise CTAB
ABD Soft, non-distended BS+
EXT ppp, no edema, old venous access device felt in L forearm
NEURO Does not follow commands. location-"dialysis". Why are you
here -no answer. plantar reflex down going. With draws from
pain. Moves all extremities. No asterixis.
Pertinent Results:
Admission Labs:
[**2141-2-4**] 01:30PM BLOOD WBC-7.0 RBC-3.63* Hgb-10.5* Hct-31.4*
MCV-86 MCH-29.0 MCHC-33.6 RDW-16.8* Plt Ct-107*#
[**2141-2-4**] 01:30PM BLOOD Neuts-64.4 Lymphs-27.4 Monos-6.0 Eos-1.7
Baso-0.4
[**2141-2-4**] 01:30PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Microcy-1+
[**2141-2-4**] 01:30PM BLOOD Plt Ct-107*#
[**2141-2-5**] 05:15AM BLOOD Fibrino-197# D-Dimer-854*
[**2141-2-5**] 09:20AM BLOOD FDP-40-80
[**2141-2-4**] 01:30PM BLOOD Glucose-99 UreaN-41* Creat-5.1* Na-140
K-4.4 Cl-98 HCO3-23 AnGap-23*
[**2141-2-4**] 01:30PM BLOOD ALT-42* AST-38 CK(CPK)-103 AlkPhos-121*
Amylase-84 TotBili-0.4
[**2141-2-4**] 09:17PM BLOOD CK(CPK)-121
[**2141-2-4**] 01:30PM BLOOD Lipase-39
[**2141-2-4**] 01:30PM BLOOD CK-MB-3 cTropnT-0.09*
[**2141-2-4**] 01:30PM BLOOD Mg-1.8
[**2141-2-4**] 09:17PM BLOOD Calcium-8.5 Phos-4.7* Mg-1.7
[**2141-2-5**] 05:15AM BLOOD calTIBC-176* Hapto-99 Ferritn-1900*
TRF-135*
[**2141-2-6**] 07:18AM BLOOD PTH-202*
[**2141-2-4**] 09:17PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2141-2-4**] 11:41PM BLOOD Type-ART pO2-218* pCO2-40 pH-7.32*
calHCO3-22 Base XS--5
[**2141-2-4**] 04:34PM BLOOD Lactate-5.5*
[**2141-2-11**] 06:38PM BLOOD SEROTONIN RELEASE ANTIBODY-PND
Discharge and Pertinent Labs:
[**2141-2-14**] 03:40AM BLOOD WBC-8.0 RBC-3.34* Hgb-9.7* Hct-26.3*
MCV-79* MCH-29.2 MCHC-37.1* RDW-15.8* Plt Ct-65*
[**2141-2-11**] 01:54PM BLOOD Neuts-77* Bands-3 Lymphs-10* Monos-7
Eos-1 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2141-2-11**] 01:54PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
[**2141-2-14**] 03:40AM BLOOD Plt Ct-65*
[**2141-2-8**] 05:01AM BLOOD FDP-0-10
[**2141-2-8**] 05:01AM BLOOD Fibrino-180 D-Dimer-911*
[**2141-2-14**] 03:40AM BLOOD Glucose-106* UreaN-71* Creat-6.7*# Na-137
K-3.4 Cl-105 HCO3-23 AnGap-12
[**2141-2-11**] 08:30AM BLOOD LD(LDH)-179 TotBili-0.3 DirBili-0.2
IndBili-0.1
[**2141-2-14**] 03:40AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.8
[**2141-2-11**] 08:30AM BLOOD Hapto-63
[**2141-2-12**] 09:09AM BLOOD Lactate-0.6
Abd CTA [**2-9**]:
1. Abnormally enhancing stomach, duodenum, and scattered loops
of jejunum and ileum without significant bowel wall thickening,
free fluid, or pneumatosis intestinalis. Small amount of
stranding and free fluid around the duodenum. These findings are
not in an arterial distribution making arterial insufficiency or
emboli less likely. Possibilities for these findings include
venous congestion secondary to portal hypertension or a
hypotensive state. The flat IVC is supportive of the latter
possibility.
2. Left groin pseudoaneurysm likely arising from the profunda
femoris artery. There is an associated large groin hematoma.
3. Small left pleural effusion.
4. Atrophic kidneys and bilateral renal cysts.
Echo [**2-10**]:
- left atrium is mildly dilated.
- moderate symmetric LVH with normal cavity size and systolic
function (LVEF >55%
- Regional left ventricular wall motion is normal
- The aortic valve leaflets (3) are moderately thickened, but
aortic stenosis is not present; Mild [1+] aortic regurgitation
is seen
- The mitral valve leaflets are moderately thickened with
extensive mitral annular calcification. There is moderate mitral
stenosis. An eccentric jet of at least mild (1+) mitral
regurgitation is seen.
- The tricuspid valve leaflets are mildly thickened.
- There is moderate pulmonary artery systolic hypertension.
- There is no pericardial effusion.
.
Colonoscopy [**10-19**]: Erythema and congestion in the sigmoid colon
compatible with indetermined colitis. Biopsy showing Melanosis
coli.
.
EGD [**10-19**]: Congestion and erythema in the whole stomach
compatible with gastritis. Hiatal hernia
.
EGD [**2140-2-13**]: Multiple cratered ulcers ranging in size from 5mm
to 20mm were found in the first part of the duodenum and second
part of the duodenum. A visible vessel suggested recent
bleeding. Three 5cc Epinephrine 1/[**Numeric Identifier 961**] injections were applied
for hemostasis with success. [**Hospital1 **]-CAP Electrocautery was applied
for hemostasis successfully.
Brief Hospital Course:
First ICU Course:
#Confusion - Broad differential includes neurologic and systemic
causes. At this time exam complicated by sedating medication
given in ED. Negative head CT makes bleed unlikely. No Hx of
trauma. Possible stroke given known cardiovasular disease.
Infection a consideration as well. Has [**Hospital1 9813**] raising the
concern of disseminated HSV given chronic immunosupression.
Patient and family refused LP. Tox screen was done which was
only positive for [**Hospital1 10808**] (pt on taper). RPR was negative.
More history was obtained from family who said that the
patient's mental status had been unchanged compared to prior to
admission. Patient remained A&O X2 in ICU. He was transferred
to the floor and his mental status remained as this new
baseline, ID requested cryptococcal antigen be sent, as there
was concern for high risk behavior and the possibility of HIV
associated disease.
.
Acidosis - Unclear etiology. No overt sepsis on admission aside
from low plt count. Pt had elevated lactate. Given a concern
for linezolid causing lactic acidosis, this was stopped and
pharmacy was consulted for any other meds causing lactic
acidosis. Pt later complained of increased abdominal pain and
surgery was consulted for concern for gut ischemia. CTA was
done which showed abnormality in stomach and several parts of
small bowel however no clear one vessel distribution, this was
thought to be secondary to hypotension. Given concern for
thiamine deficiency causing lactic acidosis thiamine was also
started. After discontinuing linezolid and giving IVF lactate
improved and anion gap closed.
.
#[**Name (NI) 10809**] Unclear [**Name2 (NI) 10810**]. No history of coumadin use. [**Month (only) 116**]
get some heparin with HD but not enough to explain PTT of 150 on
admission. Both PTT and INR are elevated suggesting liver
disease, DIC or aquired inhibitors. LFTs not elevated and no
stigmata of chronic liver disease although has Hx of hep C. PLTs
50% below last [**Hospital1 **] value rasing concer for DIC. DIC labs,
haptoglobin, fibrinogen, FDP, and d-dimer were checked and
followed during admission. Labs concerning for ?DIC however the
values remained stable. Plt count also stabilized.
.
#Hypotension - During dialysis. Was brief and resolved quickly
into the admission to ICU. Given low plt count there was some
concern for sepsis and pt was given IVF. After admission pt was
noted to be hypertensive.
.
# Hypertension - restarted outpt dose of diltiazem and
metoprolol.
.
# ID - Pt was on linezolid on admission which was changed over
to daptomycin as above given concern for linezolid causing
lactic acidosis. Pt also had budding yeast in [**1-16**] blood cx
bottle drawn from dialysis catheter. This line was pulled by
transplant surgery and pt was started on ambisome. Pt did not
have a positive peripheral culture. Another dialysis line was
placed by IR and femoral line was discontinued thereafter. The
patient finished his course of daptomycin on [**2141-2-10**].
.
#ESRD - Renal saw pt and dialysis was done T/TH/Sat.
.
# L femoral pseudo aneurysm - noted on CTabdomen. This was
checked with a femoral ultrasound which showed a pseudoaneurysm
however no active flow.
.
#Drug abuse - No acute issues. Initially methadone was held but
was restarted once mental status was found to be baseline. Per
PCP pt was on [**First Name9 (NamePattern2) 10808**] [**Last Name (LF) **], [**First Name3 (LF) **] he was tapered down to 5mg
daily. This dose was continued with plan for taper later.
.
#Diabetes - sliding scale insulin
.
#[**Name (NI) **] - Pt had received famvir prior to admission was given
acyclovir initially but this was later discontinued.
.
Course on FLoor:
Pt was transferred to the floor on [**2-9**]. On day prior to second
MICU stay, pt noted to have plts decreased to 47. Heparin
flushed were d/c'd, HIT ab sent and he was given one unit of
platelets given melena. On [**2-10**], pt's hct noted to be 22 (from
26 the day prior). He received 2U of PRBCs with an increase to
26. GI was consulted and he was placed on a [**Hospital1 **] PPI. There was
concern for TTP given delta MS, renal insufficiency,
thrombocytopenia, anemia. Total bili, LDH, haptoglobin WNL.
Smear for megakaryocytes (r/o ITP) and schistocytes. The next
day, hct again down to 23.8 and he received another 2U with an
increase to 32.9. Hct was followed q6hrs and again, dropped to
28 --> 26 --> 22. He was then transferred to the MICU for
colonoscopy.
Second ICU stay:
EGD performed in the ICU revealed multiple cratered ulcers
ranging in size from 5mm to 20mm in the first part of the
duodenum and second part of the duodenum. A visible vessel
suggested recent bleeding. Three 5cc Epinephrine 1/[**Numeric Identifier 961**]
injections were applied for hemostasis with success. [**Hospital1 **]-CAP
Electrocautery was applied for hemostasis successfully. He was
kept in the ICU for 2 days and his Hct was stable at 29, dropped
to 26 prior to discharge, which was attributed to primarily
fluid shifts. He should have repeat Hct drawn tomorrow. He was
continued on the ambisome, which should be continued until 14
days after the HD line was pulled ([**2-10**]). Renal continued
hemodialysis, although phosphate binders were d/c'd due to low
phosphate. His CMV VL was pending on discharge, checked as a
possible etiology for the gastric ulcers. He was continued on
[**Hospital1 **] PPI IV.
Medications on Admission:
Famvir 500 mg po X7 days last dose 1/26
Diltiazem SR 120 mg po qd
MTI 1 tab po qd
Ca2+ carbonate 1g po tid
prednisone 5 mg po qd
linezolid 600 mg po q12h X6wks (last dose 2/1)
levofloxacin 250 mg po q48h
atorvastatin 10 mg po qd
metoprolol 75 mg po tid
aranesp 60 mcg sc qwk on tuesday
methadone 10 mg po X3d (end [**2-5**])
methadone 5 mg po qd x3d (start [**2-6**] then d/c)
Sliding scale insulin increments of 50 starting at 151 2 units
and going up by 2
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Gastric ulcers
Anemia
ESRD
HTN
DM
Diastolic CHF
Candidemia
Hepatitis C
Depression
Discharge Condition:
Stable
Discharge Instructions:
Continue hemodialysis.
Continue medications as written.
If you experience worsening abdominal pain, lightheadedness,
chest pain, low hematocrit, shortness of breath, or other
concerning symptoms, call your primary care physician or go
directly to the Emergency department.
Followup Instructions:
Continue hemodialysis as scheduled.
Continue ambisome for 10 days to complete a 14 day course.
Please check Hct tomorrow [**2-15**], and follow up results with your
primary care physician.
Follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2141-2-15**]
|
[
"250.00",
"112.5",
"V09.81",
"790.92",
"285.21",
"285.1",
"998.83",
"053.9",
"532.00",
"070.70",
"442.3",
"348.39",
"997.2",
"287.5",
"276.2",
"428.30",
"304.01",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"38.95",
"99.04",
"44.43",
"00.14",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13090, 13145
|
7141, 12581
|
340, 364
|
13271, 13280
|
3033, 3033
|
13603, 14032
|
1986, 2088
|
13166, 13250
|
12607, 13067
|
13304, 13580
|
2103, 3014
|
275, 302
|
392, 1144
|
3050, 4281
|
4298, 7118
|
1166, 1796
|
1812, 1970
|
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