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31,941
| 144,283
|
46984
|
Discharge summary
|
report
|
Admission Date: [**2112-5-30**] Discharge Date: [**2112-6-4**]
Date of Birth: [**2053-10-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58F with dm2, recently diagnosed temporal arteritis now on
steroids who now presents with hyperglycemia. She was recently
diagnosed with temporal arteritis confirmed by temporal artery
biopsy and she was started on prednisone roughly 4 weeks ago at
60mg daily (now on 40 daily). She had labs drawn on the day of
admission which revealed hyperglycemia, hyperkalemia, and ARF.
She does now endorse sympoms of polyuria, polydipsia. She denies
f/c/n/v. She denies cough, dysuria. There were symptoms of itchy
eyes for which she was treated with Ilotycin for conjunctivitis
on [**5-27**]. Once the lab work returned, she was advised to seek
care in the ED. ECG showed peaked t waves in setting of K of 6.8
and glucose was 765. She was given calcium, bicarb one amp,
insulin 10 units, kayexalate. She was admitted to ICU.
Past Medical History:
dm2
temporal arteritis
htn
hyperlipidemia
thyroid nodule
Social History:
The patient does not smoke any cigarettes, and she does not
drink any alcohol. She denies any illicit drug use. She works in
the department of revenue full-time but did take time off from
work because of the above symptoms and for the biopsy. She is
married and has two children from two successful pregnancies.
Both children are healthy.
Family History:
non-contributory
Physical Exam:
VS: Temp: 98.6 BP: 129/78 HR: 112 RR: 22 O2sat: 97 RA FS 315
GEN: awake, alert, NAD
HEENT: PERRL, EOMI,jvp flat
NECK: no supraclavicular or cervical lymphadenopathy, no jvd
RESP: CTAB
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 SP pulses intact
SKIN: no rashes/no jaundice
Pertinent Results:
[**2112-5-30**] 10:37PM GLUCOSE-648* UREA N-61* CREAT-2.7*
SODIUM-129* POTASSIUM-4.5 CHLORIDE-92* TOTAL CO2-21* ANION
GAP-21
[**2112-5-30**] 09:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2112-5-30**] 09:20PM GLUCOSE-743* K+-5.2
[**2112-5-30**] 09:09PM GLUCOSE-814* UREA N-68* CREAT-3.1*
SODIUM-123* POTASSIUM-5.5* CHLORIDE-85* TOTAL CO2-23 ANION
GAP-21*
[**2112-5-30**] 09:09PM ALT(SGPT)-27 AST(SGOT)-17 ALK PHOS-169*
AMYLASE-65 TOT BILI-0.3
[**2112-5-30**] 09:09PM LIPASE-75*
[**2112-5-30**] 09:09PM ALBUMIN-3.9 CALCIUM-9.1 PHOSPHATE-5.1*
MAGNESIUM-3.1*
[**2112-5-30**] 09:09PM WBC-10.4 RBC-5.82* HGB-13.4 HCT-40.7 MCV-70*
MCH-23.1* MCHC-33.0 RDW-14.1
[**2112-5-30**] 01:00PM UREA N-65* CREAT-2.6*# SODIUM-127*
POTASSIUM-6.8* CHLORIDE-88* TOTAL CO2-24 ANION GAP-22*
[**2112-5-30**] 01:00PM SED RATE-46*
[**2112-5-30**] 01:00PM PLT COUNT-339
.
CHEST (PORTABLE AP) [**2112-5-30**] 10:11 PM
.
AP CHEST RADIOGRAPH: Lung volumes are diminished. Surgical clips
identified to the right of the trachea. Allowing for this, the
heart, mediastinum, and hila are stable. The aorta is tortuous.
No consolidation is identified. No pleural effusion is detected.
.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
# Hyperglycemia/DM: Pt with longstanding diabetes, that became
poorly controlled with the initiation of steroids for TA. Was
treated for hyperglycemic crisis and now improved however given
still on steroids needs further titration of insulin regimen.
Previously on byetta and glyburide. Initially transitioned to
NPH and having much tighter control of glucoses. Patient seen
by [**Last Name (un) **]. Switched to Humalog 75/25 and titrated up. Will go
home on glyburide and insulin. Already has glucose testing
equipment at home. Will hold on Byetta until off insulin.
.
# ARF: Initially with creatinine of 3.1, went to baseline with
hydration.
.
# Temperol Arteritis: Pt with temporal arteritis based on
biopsy. Now on steroids. Started on 60mg and now down to 40mg.
After 1 month can usually begin tapering by 10 percent every 2
weeks. Given steroids started Ca, Vit D, PPI. Will follow up
with rheum as an outpatient.
.
# HTN: ACEI held in the setting of renal failure. Restarted
once resolved.
.
# Hypothryoid: Continued on levothyroxine.
.
# FEN: Diabetic diet
# Access: PIVs
# PPx: Hep SQ, ppi
# Code: Full
Medications on Admission:
prednisone 60'
Byetta injections,
Micronase 5 mg p.o. b.i.d.,
lisinopril 10'
Synthroid 100 mcg'
simvastatin 80'
Diflucan 150 mg tablet p.o. weekly.
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. CALCIUM 500+D 500-400 mg-unit Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Insulin Regular Human Injection
8. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Fifty
(50) units Subcutaneous qam: please take with steroids.
Disp:*QS 1 month units* Refills:*2*
9. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
four times a day: Take as directed on sliding scale.
Disp:*QS 1 month units* Refills:*2*
10. Insulin Syringes (Disposable) Syringe Sig: One (1)
needle Miscellaneous four times a day: please use with insulin.
Disp:*QS 1 month syringe* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetes Mellitus
Hyperglycemia secondary to steroids
Discharge Condition:
Stable. Blood sugars stable.
Discharge Instructions:
Please take all medications and make all appointments as listed
in the discharge paperwork. Please check your blood sugars
regularly at home and call your doctor if your blood sugars are
consistently over 200.
Take your morning insulin dose at the time you take your
prednisone.
Please call your doctor or 911 if you experience sweating,
lightheadedness, dizziness, chest pain, shortness of breath.
Followup Instructions:
Please call [**Hospital6 733**] (Dr.[**Month (only) 28614**] Office)
[**Telephone/Fax (1) 250**] to make an appointment next week with him or his
partners.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2112-6-22**]
11:50
Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2112-8-2**] 4:00
Provider: [**Name10 (NameIs) 843**] [**Name8 (MD) 844**], MD Phone:[**Telephone/Fax (1) 10533**]
Date/Time:[**2112-6-23**] 3:45
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,719
| 116,627
|
2071
|
Discharge summary
|
report
|
Admission Date: [**2132-9-30**] Discharge Date: [**2132-10-6**]
Service: ORTHOPAEDICS
Allergies:
Bactrim
Attending:[**First Name3 (LF) 11261**]
Chief Complaint:
Ms. [**Known lastname 11257**] presents for definitive treatment to her right hip.
Major Surgical or Invasive Procedure:
Right hip revision
Past Medical History:
-CAD with CABG*4 in [**2117**]
-Hypertension
-Diabetes
-Hypothyroidism
-Osteoarthritis
-Status post choleycystectomy
-Status post hysterectomy for unclear reasons
-Status post right hip arthroplasty in [**2119**]
Social History:
Does not use tabacco or ETOH. She currently lives with her
daughter.
Family History:
Patient reports both her parents died of pneumonia in middle
age. She is otherwise unable to give much family history.
Physical Exam:
On discharge:
Afebrile, All vital signs stable
General: Alert and oriented, No acute distress
Extremities: right lower
Weight bearing: partial weight bearing
Incision: intact, no swelling/erythema/drainage
Dressing: clean/dry/intact
Sensation intact to light touch
Neurovascular intact distally
Capillary refill brisk
2+ pulses
Pertinent Results:
[**2132-9-30**] 11:02AM BLOOD WBC-14.6*# RBC-4.23 Hgb-10.8* Hct-33.2*
MCV-78* MCH-25.5* MCHC-32.5 RDW-16.1* Plt Ct-221
[**2132-10-2**] 05:00AM BLOOD WBC-11.2* RBC-3.43* Hgb-8.6* Hct-26.8*
MCV-78* MCH-25.0* MCHC-32.0 RDW-17.4* Plt Ct-180
[**2132-10-5**] 04:50AM BLOOD WBC-8.1 RBC-3.66* Hgb-9.6* Hct-28.7*
MCV-79* MCH-26.1* MCHC-33.3 RDW-17.0* Plt Ct-239
[**2132-9-30**] 11:02AM BLOOD Neuts-70.1* Lymphs-23.3 Monos-4.2 Eos-2.0
Baso-0.4
[**2132-9-30**] 11:02AM BLOOD Glucose-126* UreaN-47* Creat-1.8* Na-141
K-4.6 Cl-105 HCO3-27 AnGap-14
[**2132-10-3**] 09:00AM BLOOD Glucose-142* UreaN-44* Creat-1.9* Na-141
K-4.2 Cl-107 HCO3-26 AnGap-12
[**2132-10-5**] 04:50AM BLOOD Glucose-125* UreaN-52* Creat-1.9* Na-142
K-3.4 Cl-107 HCO3-28 AnGap-10
[**2132-9-30**] 11:02AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.1
[**2132-10-3**] 09:00AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.1
[**2132-10-5**] 04:50AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9
[**2132-9-30**] 08:45AM BLOOD Type-ART pO2-146* pCO2-46* pH-7.42
calTCO2-31* Base XS-5 Intubat-INTUBATED
[**2132-9-30**] 08:45AM BLOOD Glucose-112* Lactate-1.3 Na-142 K-4.0
Cl-101
Brief Hospital Course:
Mrs.[**Known lastname 11257**] was admitted to [**Hospital1 18**] on [**2132-9-30**] for an elective
right total hip replacement. Pre-operatively, she was consented,
prepped, and brought to the operating room. Intra-operatively,
she was closely monitored and remained hemodynamically stable.
She tolerated the procedure well without any complication.
Post-operatively, she was transferred to the PACU/SICU and floor
for further recovery. On the floor,she was consulted by
geriatric services due to some confusion/agitation whose
recommendations were appreciated and followed. On [**10-3**] hct was
24.5 and received 2 units prbc, chest xray normal no
consolodation, u/a normal. [**Last Name (un) **] recommendations appreciated as
well. [**10-4**] hct 28.7 bun 52/1.9 geriatric services
aware. she remained hemodynamically stable. Her pain was
controlled. Sh progressed with physical therapy to improve her
strength and mobility. Sh was discharged today in stable
condition.
Medications on Admission:
clopidograel 75mg', Levothyroxine 88mcg', ASA 325mg', Furosemide
40mg', Gliburide 10mg'',
Allergies: Bactrim
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
OA right hip
Discharge Condition:
Stable
Discharge Instructions:
If you experience any shortness of breath, new redness,
increased swelling, pain, or drainage, or have a temperature
>101, please call your doctor or go to the emergency room for
evaluation.
You may not bear weight on your right leg. Please use your
crutches for ambulation.
You may resume all of the medications you took prior to your
hospital admission. Take all medication as prescribed by your
doctor.
You have been prescribed a narcotic pain medication. Please do
not drive or operate any machinery while taking this medication.
* Continue your warfarin as prescribed to help prevent blood
clots. You need to have weekly blood draws while taking this
medication. We may change your medication dose depending upon
your INR level.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2132-11-5**] 2:30
Completed by:[**2132-10-6**]
|
[
"250.82",
"496",
"V45.81",
"585.9",
"518.83",
"276.50",
"285.21",
"996.41",
"424.1",
"244.9",
"403.90",
"584.9",
"V43.64",
"996.77"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.70",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3416, 3475
|
2275, 3256
|
303, 324
|
3532, 3541
|
1159, 2252
|
4329, 4588
|
664, 786
|
3496, 3511
|
3282, 3393
|
3565, 4306
|
801, 801
|
815, 1140
|
181, 265
|
346, 561
|
577, 648
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,000
| 158,788
|
50949
|
Discharge summary
|
report
|
Admission Date: [**2127-7-30**] Discharge Date: [**2127-8-4**]
Date of Birth: [**2082-10-26**] Sex: F
Service: PLASTIC
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 1430**]
Chief Complaint:
Pt. presented for elective surgery for previously diagnosed
ductal carcinoma in situ of the right breast.
Major Surgical or Invasive Procedure:
Right skin sparing mastectomy with breast reconstruction with
latissimus flap and silicone gel implant; left breast reduction
History of Present Illness:
[**Known firstname **] [**Known lastname 284**] was diagnosed with ductal carcinoma in situ of
the right breast after a new indeterminate cluster of
microcalcifications were found on a screening mammogram on
[**2127-4-24**]. There were 2 suspicious clusters: 1 at the 12 o'clock
and one at the 6 o'clock position. She had previously had
ductal carcinoma of the left breast, which recurred after a wide
excision only and on [**2121-12-23**], she underwent a left total
mastectomy with immediate reconstruction using a TRAM flap
reconstruction to medial pectoralis vessels. She also has a
prior history of Hodgkins disease, diagnosed in [**2101**], treated
with MOPP, 6 cycles and mantle radiation.
Past Medical History:
Her past medical history is significant for hypothyroidism after
a total thyroidectomy in [**2122**] for bilateral papillary carcinoma.
She also underwent aortic and mitral valve replacement for
radiation-induced valvular disease in [**2123-8-24**].
Social History:
The patient does not smoke. She drinks alcohol occasionally. She
is married, but has no children. She owns a gift store.
Family History:
Family history is negative for breast cancer.
Physical Exam:
Gen:NAD
Neuro: AOx3, EOMI
CV: RRR, no M/R/G
Chest: bilat. basilar crackles
Abd: BS+, soft, NTND
Wound: Right breast tender to deep palpation, swollen,
non-erythematous; Left breast non-erythematous; Back: tender to
light touch
Ext: no C/C/E; radial/DP/PT 1+ pulses bilat.
Drains: JPx3
Pertinent Results:
Hct Levels
[**2127-8-4**] 6:20A 26.8
[**2127-8-3**] 9:10P 28.4
[**2127-8-3**] 4:06A 27.2
[**2127-8-2**] 4:30P 26.6
[**2127-8-2**] 6:05A 28.2
[**2127-8-1**] 11:19P 28.3
[**2127-8-1**] 9:09P 29.8
[**2127-8-1**] 5:20P 23.0
[**2127-8-1**] 12:40P 25.3
[**2127-8-1**] 8:54A 22.6 -> Hematoma excision
[**2127-8-1**] 5:20A 29.5
[**2127-7-31**] 5:30A 29.5 POD 1
Brief Hospital Course:
Mrs [**Known lastname 284**] tolerated the procedure and on [**7-30**] was afebrile
with her vital signs stable. She was started on coumadin and
lovenox as per her ccardiologist. On [**7-31**] her temperature spiked
101.6 ~11pm, encouraged IS. She also had a bout of Emesis
(~400cc, non-bilious) ~3am, ordered anzemet and IV pain meds. At
~4am her temperature rose to 102.1, added CBC to AM labs, no
incisional erythema or drainage.
[**8-1**] Her hematocrit went from 29 preop to 21 post op. She also
developed an area of hematoma accumilation at the posterior
incision site.She was taken to the OR for evacuation of
hematoma. The old back incision was opened and about 500 cc of
clot and blood were evacuated. There was also an acute active
bleeding once the clot was evacuated. A single vessel bleeding
from some paraspinous musculature, for which 2 figure-of-eight
Vicryl sutures were placed that clearly stopped the bleeding. A
third [**Doctor Last Name **] drain was added. She received two units of pRBC in
the OR. She tolerated the procedure and her post op HCT was 25.
Her Hct dropped to 23 and she was given 2 [**Location (un) **] units of pRBC's.
Her Hct rose to 29 where it stbalized over the next couple of
days.
She was admitted to the ICU and had no acute events. She was
transferred to the floor and then discharged home.
Medications on Admission:
Lasix 20 per day, Synthroid 0.15 mg per day, Toprol 25 per day,
Coumadin 8 mg 4 days per week and 6 mg the other 3 days with an
INR in the 2.5 to 3.5 range.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Right breast cancer
Discharge Condition:
Good
Discharge Instructions:
Activity as Tolerated
Call or go to ED for fever >101.5, Nause/Vomiting, increasing
erythema or drainage from the wound sites
Followup Instructions:
Call Dr[**Name (NI) 17485**] clinic for follow up in 6 weeks
Call Dr[**Name (NI) 27221**] clinic for Thurs appt for drain removal
Completed by:[**2127-8-7**]
|
[
"V58.61",
"174.8",
"201.90",
"E878.6",
"V10.3",
"V43.3",
"244.9",
"998.12",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.85",
"85.53",
"85.31",
"40.23",
"83.02",
"85.34"
] |
icd9pcs
|
[
[
[]
]
] |
4233, 4288
|
2411, 3750
|
378, 506
|
4352, 4359
|
2031, 2388
|
4533, 4693
|
1662, 1710
|
3957, 4210
|
4309, 4331
|
3776, 3934
|
4383, 4510
|
1725, 2012
|
233, 340
|
534, 1233
|
1255, 1507
|
1523, 1646
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,131
| 178,742
|
27450
|
Discharge summary
|
report
|
Admission Date: [**2197-4-11**] Discharge Date: [**2197-4-24**]
Date of Birth: [**2134-3-10**] Sex: F
Service: MEDICINE
Allergies:
Tegretol
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
transferred from [**Hospital3 **] per family preference
Major Surgical or Invasive Procedure:
intubation, mechanical ventilation, R IJ central line placement,
L radial arterial line placement
History of Present Illness:
63 yo F who is transferred from [**Hospital3 **], after
presenting on [**2197-4-7**] with 3 weeks of "cold symptoms" and one
week of body ache and malaises with R-sided chest and abdomal
pain and hand swelling. Patient was found to have CAP with
r-sided effusion. She was admitted to the ICU and a chest tube
was placed [**2197-4-9**] for drainage of parapneumonic effusion (see
labs below) when her WBC was 22.3. Patients initial blood cx
showed [**2-18**] growing step pneumo resistent to levaquin. Her
respiratory status worsened and her O2 requirement increased.
She developed 10cc of hempotysis, She was intubated [**2197-4-11**] for
increased work of breathing and respiratory distress, and it was
noted the intubation may have been complicated by aspiration.
ABG prior to intubation was 7.37/45/76 on 100% nonrebreather.
Per report, was hypotensive peri-intubation but responded to
fluid bolus.
.
Patient's family requested transfer of care to [**Hospital1 18**].
Past Medical History:
Htn, hyperchol, arthritis, GERD, s/p appu, s/p tonsillectomy,
neck disk surgery x2 with fusion, s/p R breast bx of benign
lesion, s/p open removal of kidney stones,
Social History:
Smoked ppd x30 years, quit 12 years ago. No EtOH or drug use.
Married, lives with husband and son. [**Name (NI) **] exposure hx. Had flu
shot in [**2196**]. Has not had pneumovax. Works at Princess House.
Family History:
Fam Hx: Cardiac disease, brother with MI at 43. Colon cancer.
Physical Exam:
98.9 111/60 108 87 98%
Vent Settings: AC 450 12 5 .5
Gen: Intubated and sedated, appears comfortable, chest tube
draining serous fluid
HEENT: mmm, et tube in place, neck supple, OG tube with bilious
contents
CV: rrr I/VI SEM
Pulm: Decreased breath sounds R base, few crackles R upper lung
fields, L side fairly clear
Abd: slightly distended, tympanic, few bowel sounds, soft
Ext: non-pitting edema, well perfused
Nuero: sedated
Pertinent Results:
OSH labs: WBC 12.5 2% bands, 75% segs, Hct 26.1, Plts 185, INR
1.29, Cr .9
Pleural fluid [**4-9**]: WBC 7062; 96% polys, 4% monocytes. Total
protein<2.5, glucose 80, amylase and triglyceride low, LDH 1024.
Ph 7.27.
.
Influenza pharyngeal swab negative for type A and B
.
Blood Cx [**4-7**]: S. pneumoniae resistent to Levaquin,
.
[**4-7**]: CT abd/pelvis: no acute pathology
.
[**4-7**]: abd US: no cholelithiasis
[**2197-4-11**] 11:30PM PLT COUNT-191
[**2197-4-11**] 11:30PM WBC-9.8 RBC-2.81* HGB-9.1* HCT-26.6* MCV-95
MCH-32.3* MCHC-34.1 RDW-14.3
[**2197-4-11**] 11:30PM CALCIUM-7.9* PHOSPHATE-1.2* MAGNESIUM-1.2*
[**2197-4-11**] 11:30PM GLUCOSE-80 UREA N-11 CREAT-0.4 SODIUM-144
POTASSIUM-3.2* CHLORIDE-114* TOTAL CO2-25 ANION GAP-8
.
CT Chest [**2197-4-12**]
IMPRESSION:
1. Multifocal pneumonia, may be bacterial with bilateral pleural
effusions and mediastinal lymphadenopathy. If this does not fit
the clinical scenario, then lymphoma is a consideration.
2. Right small apical pneumothorax.
3. Tiny pericardial effusion.
4. High-density material in the gallbladder. [**Month (only) 116**] be sludge or
contrast from prior procedure.
.
ECHO [**2197-4-20**]
Conclusions:
1. The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. There is
severe mitral
annular calcification. Physiologic mitral regurgitation is seen
(within normal limits).
6.There is moderate pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
Brief Hospital Course:
Ms. [**Known lastname 67167**] is a 63 yo woman transferred from OSH with R-sided
pneumonia, para pneumonic pleural effusion, chest tube, and
recent bacteremia with Levofloxacin resistant organisms,
Penicillin/CTX resistant (intermediate) strep pneumonia. She
was intubated and a chest tube was placed at [**Hospital3 **].
She was initially started on vancomycin pending sensitivities,
and once they returned she was continued on this course, however
the patient appeared to be worsening, so Zosyn was added for
broader coverage. She was transferred to [**Hospital1 18**] for family
preference.
At [**Hospital1 18**] all cultures of blood, sputum, stool, and urine
remained negative. The patient continued to spike fevers for
the first few days of her stay but eventually this resolved.
She was continued on [**Doctor Last Name **] co and Zosyn and completed a 14 day
course. She was also treated with a 6 day course of steroids
for possible underlying COPD (pt has no history, but has a 30py
smoking history).
The patient had labile blood pressure in the unit, requiring
metoprolol which was slowly increased to her home atenolol dose
equivalent, however on several occasions she had hypotension
requiring fluid boluses. This resolved for the last three days
the patient spent in the ICU and she was kept on her beta
blocker without problem.
The patient was sedated with fentanyl and versed, as well as
Haldol for agitation while on the ventilator. Initial trial of
extubation was quickly failed, as the patient began wheezing
almost immediately. She was quickly reintubated and follow up
CXR showed pulmonary edema. The pt was noted to have a small
right apical pneumothorax. The patient was positive 8 L during
her stay in the unit, and this was then aggressively diuresed.
After diuresis the patient was again extubated, with
nitroglycerin drip used for 30 minutes peri-extubation, this
time successfully and she remained on shovel mask, follow by NC
and saturations remained consistently in the mid to high 90s.
She was called out of the ICU to the floor.
On the floor, the pt's pneumothorax was noted to resolve on
repeat CXR, she remained afebrile and did not have a significant
oxygen requirement. She was given a Pneumovax vaccine. The pt
was discharged with instructions to follow-up with her primary
care provider for evaluation of her anemia and was recommended a
colonoscopy and was recommended to avoid air travel for 1 week
after discharge.
Medications on Admission:
Home Meds: Atenolol. Zetia, Zantac
.
Meds on Transfer: Zantac 50mg IV q24, Vancomycin 1g q12h,
Protonix 40mg daily, KCl, Versed gtt, Zosyn, Dilauded, Ativan,
tylenol.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain, fever.
Disp:*30 Tablet(s)* Refills:*0*
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash for 7 days: apply to afected
areas as needed.
Disp:*1 bottle* Refills:*0*
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inhalation
every 4-6 hours as needed for shortness of breath or wheezing:
until resolution of shortness of breath.
Disp:*2 inhalers* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] home care
Discharge Diagnosis:
Primary: Pneumonia
.
Secondary:
Hypertension
Hypercholesterolemia
Arthritis
GERD
S/p appendectomy
S/p tonsillectomy
Neck disk surgery x2 with fusion
S/p R breast bx of benign lesion
S/p open removal of kidney stones
Discharge Condition:
Stable, able to ambulate and maintain oxygen saturation on room
air.
Discharge Instructions:
Please report to then nearest emergency department if you have
fever, chills, nausea, vomiting, diarrhea, or difficulty
breathing. If you have any problems between the time of
discharge and your appointment with your primary care provider,
[**Name10 (NameIs) **] call [**Hospital6 733**] ([**Company 191**]) at [**Telephone/Fax (1) 250**].
.
There has been a change in your medications.
.
You have been scheduled for a follow-up appointment with your
new primary care physician, [**Name10 (NameIs) 3**] indicated below. Please ask your
PCP to work up your anemia or low blood count. You will likely
need also need a colonoscopy.
.
You have requested a transfer of your care to [**Hospital1 771**]. You will need to call your insurance
company and update your primary care provider.
.
You will need to call [**Telephone/Fax (1) 250**] to verify your demographics
on file prior to your appointment.
.
We have discussed your case with cardiothoracic surgery. They
recommend that you avoid flying in an aeroplane for at least
another week after discharge.
Followup Instructions:
PRIMARY CARE PHYSICIAN:
[**Name Initial (NameIs) 2169**]: [**Name10 (NameIs) **] [**Name11 (NameIs) 67168**] [**Name12 (NameIs) **], MD (works with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 216**])Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2197-5-1**] 2:30
Completed by:[**2197-6-6**]
|
[
"511.9",
"496",
"401.9",
"V45.4",
"787.91",
"518.81",
"428.31",
"481",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8000, 8057
|
4327, 6799
|
324, 423
|
8317, 8388
|
2394, 4302
|
9488, 9803
|
1860, 1926
|
7017, 7977
|
8078, 8296
|
6825, 6863
|
8412, 9465
|
1941, 2375
|
229, 286
|
451, 1428
|
1450, 1617
|
1633, 1844
|
6881, 6994
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,128
| 199,723
|
7215
|
Discharge summary
|
report
|
Admission Date: [**2125-10-17**] Discharge Date: [**2125-11-6**]
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Albuterol / Tetanus
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
compound R ankle fracture s/p fall at [**Hospital3 **] facility
Major Surgical or Invasive Procedure:
Open reduction internal fixation right tibia/fibula
Wash out of wound
Removal of hardware
PICC placement
History of Present Illness:
83F with a-fib (not on anticoagulation), diastolic CHF (with
history of rate-related flash pulmonary edema), HTN, spinal
stenosis, PMR on chronic prednisone, COPD, colon cancer s/p
resection who presented to the ED following a mechanical fall at
[**Hospital3 **] facility overnight.
.
ROS: no fevers/chills
Past Medical History:
atrial fibrillation; not on anticoagulation; rate-controlled
diastolic CHF (normal TTE at [**Location (un) 620**] in [**9-/2125**] with LVEF 55%
and normal valve function)
P-MIBI ([**2-/2123**]): fixed inferior wall defect
colon cancer s/p resection in [**2122**]
HTN
PMR on chronic prednisone
anxiety disorder
depression
COPD (on 3L home oxygen)
chronic renal insufficiency (baseline creatinine 1.0-1.2)
spinal stenosis
Right-sided TKR
Right-sided ORIF of hip fracture
Social History:
She lives at [**Location **] Crossing [**Hospital3 **]. She quit smoking 10
years ago. She ambulates with a walker. She has home O2.
Family History:
non-contributory
Physical Exam:
T 99 BP 112/44 HR 57 RR 14 Sat 98% on 3Lnc
Gen: elderly woman in obvious pain
HEENT: dry MM
CV: irreg irreg, normal s1s2, no murmurs
Pulm: cta b/l
Abd: soft NTND, normal BS
Extr: R ankle in cast, 1+ bilateral DP pulses, warm
Neuro: A&O x3
Pertinent Results:
Admission Labs:
[**2125-10-17**] 04:21AM PT-11.2 PTT-22.8 INR(PT)-0.9
[**2125-10-17**] 04:21AM PLT COUNT-328
[**2125-10-17**] 04:21AM MACROCYT-1+
[**2125-10-17**] 04:21AM NEUTS-82.3* LYMPHS-12.1* MONOS-4.6 EOS-0.8
BASOS-0.2
[**2125-10-17**] 04:21AM WBC-12.1* RBC-3.40* HGB-11.0* HCT-32.2*
MCV-95 MCH-32.5* MCHC-34.3 RDW-14.7
[**2125-10-17**] 04:21AM DIGOXIN-1.5
[**2125-10-17**] 04:21AM CK-MB-NotDone
[**2125-10-17**] 04:21AM cTropnT-0.07*
[**2125-10-17**] 04:21AM CK(CPK)-47
[**2125-10-17**] 04:21AM GLUCOSE-108* UREA N-43* CREAT-2.1*
SODIUM-129* POTASSIUM-3.8 CHLORIDE-79* TOTAL CO2-45* ANION GAP-9
[**2125-10-17**] 05:45AM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2125-10-17**] 05:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM
[**2125-10-17**] 05:45AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2125-10-17**] 12:10PM freeCa-0.93*
[**2125-10-17**] 12:10PM HGB-8.4* calcHCT-25
[**2125-10-17**] 12:10PM GLUCOSE-104 LACTATE-1.0 NA+-133* K+-2.9*
CL--99*
[**2125-10-17**] 12:10PM TYPE-ART PO2-241* PCO2-41 PH-7.49* TOTAL
CO2-32* BASE XS-8
[**2125-10-17**] 02:31PM freeCa-1.04*
[**2125-10-17**] 02:31PM HGB-10.4* calcHCT-31
[**2125-10-17**] 02:31PM GLUCOSE-145* LACTATE-2.0 NA+-134* K+-3.6
CL--94*
[**2125-10-17**] 02:31PM TYPE-ART PO2-216* PCO2-43 PH-7.51* TOTAL
CO2-36* BASE XS-10 INTUBATED-INTUBATED
[**2125-10-17**] 03:59PM PT-10.9 PTT-22.0 INR(PT)-0.9
[**2125-10-17**] 03:59PM PLT COUNT-266
[**2125-10-17**] 03:59PM WBC-17.0* RBC-3.43* HGB-11.2* HCT-31.8*
MCV-93 MCH-32.8* MCHC-35.3* RDW-15.9*
[**2125-10-17**] 03:59PM CALCIUM-8.3* PHOSPHATE-3.3 MAGNESIUM-2.8*
[**2125-10-17**] 03:59PM CK-MB-NotDone cTropnT-0.05*
[**2125-10-17**] 03:59PM CK(CPK)-69
[**2125-10-17**] 03:59PM GLUCOSE-174* UREA N-33* CREAT-1.4* SODIUM-133
POTASSIUM-4.2 CHLORIDE-92* TOTAL CO2-32 ANION GAP-13
[**2125-10-17**] 04:13PM TYPE-ART PO2-94 PCO2-68* PH-7.37 TOTAL
CO2-41* BASE XS-10
[**2125-10-17**] 06:25PM GLUCOSE-197* UREA N-33* CREAT-1.5* SODIUM-133
POTASSIUM-4.2 CHLORIDE-92* TOTAL CO2-33* ANION GAP-12
[**2125-10-17**] 06:28PM TEMP-36.7 PO2-102 PCO2-70* PH-7.34* TOTAL
CO2-39* BASE XS-9
.
Micro:
[**2125-11-2**] 5:20 pm TISSUE Site: ANKLE BONE R ANKLE.
GRAM STAIN (Final [**2125-11-2**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 156**] @2145 ON [**2125-11-2**].
TISSUE (Final [**2125-11-5**]):
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. MODERATE
GROWTH.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
NON-FERMENTER, NOT PSEUDOMONAS
AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- <=2 S
CEFTRIAXONE----------- 16 I
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ 2 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- S
MEROPENEM------------- S
PIPERACILLIN---------- 64 I
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=2 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
.
R tib/fib film ([**10-17**]):
Bimalleolar fracture of the ankle, with severe widening of the
ankle mortise and lateral displacement of the talar dome with
respect to the tibial plafond. Evaluation of the ankle fracture
is severely limited due to an overlying splint. Right total knee
replacement without evidence of hardware-related complication.
Status post ORIF of a right femoral neck fracture with
persistent deformity of the right femoral head/neck junction.
.
Trauma CXR/pelvis x-ray ([**10-17**]):
12 mm nodule that projects in the right mid lung. Deformity of
the left 10th rib laterally consistent with a fracture, age
indeterminant.
.
Head CT ([**10-17**]):
No evidence of acute intracranial hemorrhage. Multiple vague
hypodense foci in the cerebral white matter, consistent with
sequela of chronic small vessel infarction.
.
CT C-cpine ([**10-17**]):
Grade 2 anterolisthesis of C5 on C6, that is probably
degenerative in nature; however, this cannot be unequivocally
distinguished from a traumatic etiology without prior studies
for comparison. Multilevel degenerative changes as well. No
fracture identified.
.
[**10-31**] pMIBI:
INTERPRETATION:
The image quality is good.
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal a predominantly fixed
moderately severe distal anterior and apical perfusion defect
and a predominantly fixed mild septal defect.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 54%.
No comparison studies.
IMPRESSION: On pharmacologic stress imaging, there is a
predominantly fixed
moderatel distal anterior wall and apical perfusion defect and a
predominantly fixed mild septal defect. There is normal left
ventricular wall motion with an LVEF of 54%.
.
[**10-31**] Pharmacologic Stress Test:
INTERPRETATION: This 83 yo female was referred to the lab for
new
onset atrial fibrillation & CHF. The patient was infused with
0.142
mg/kg/min of IV Persantine over 4 minutes. The patient denied
any arm,
neck, back or chest discomfort throughout the study. There were
no
significant ST segment changes noted beyond baseline. The rhythm
was
atrial fibrillation with rare VPB's. There was an appropriate
hemodynamic response. Persantine was reversed with 125 mg of IV
Aminophylline.
IMPRESSION: No ischemic EKG changes noted beyond baseline. No
anginal
symptoms. Nuclear report sent separately.
Brief Hospital Course:
83F with rate-controlled a-fib, diastolic CHF, COPD, spinal
stenosis, PMR on chronic steroids here with compound R ankle
fracture s/p ORIF. Her hospital course is as follows:
.
Compound R ankle fracture: Patient was taken to the OR for ORIF.
Team had trouble closing her wound given her friable skin, and
vac was placed with a plan to close the wound at a later date.
She also had difficulty and had a short stay in the ICU. The
patient was put on a dilaudid PCA briefly for pain control,
which was stopped after an episode of over sedation and
hypotension after receiving ambien concurrently. The patient
was taken back to the OR for a wash out on [**10-24**] and tolerated
the procedure well. Ortho maintained her on wet-to-dry
dressings daily. However, they held off on bone grafting.
Likewise, plastics wanted to see good granulation of the wound.
Ortho decided to take the patient back to the OR for [**Last Name (un) **] and VAC
placement. She went to the OR on [**11-2**] with good result. WTD
dressings were maintained.
.
Chest pain/SOB: The patient had episodes of chest pain with SOB.
During these times, she became more tachycardic. Troponins
were drawn and were mildly elevated. However, there were no EKG
changes and her troponitis was thought to be demand ischemia.
Her CKs remained flat. However, the patient had another episode
and this time her troponin increased from 0.12 to 0.14.
Cardiology was consulted and raised the concern for ischemia.
She was maintained on ASA, BB, and ACEI. She was taken for a
pMIBI and pharmacologic stress test on [**10-31**]. It showed
irreversible defects. After cardiology reviewed the study, they
determined that these defects may be artifact. They stratified
her as low-intermediate risk for an intermediate risk operation.
The patient's heart rate was optimally controlled and she was
sent to the OR. She can continue her Toprol XL 250mg PO qDay
.
Diastolic CHF: The patient did have a history of rate related
flash pulmonary edema. Her low dose beta blocker was continued.
Her diuretics were held. Shewas given gentle IVF to maintain
pre-load and to treat a drop in urine otput. Nevertheless, she
did have 02 requirements during her stay. Her outpatient lasix
was re-started on [**10-27**] to which she diuresed well. However, it
was held again for over diuresis and contraction alkalosis. The
patient was given gentle IVF with improvement of her contraction
alkalosis. She maintained her baseline 02 sats.
.
Afib: Her afib was managed with low dose beta blockers for rate
control. She was not put on anticoagulation given her
surgeries. Her BB was uptitrated to achieve better control from
25mg PO BID to QID dosing per cardiology recommendations. We
uptitrated her to 62.5mg PO QID with improved control to 75-90,
finally switching to Toprol XL 250mg PO qDay. Further titration
can be addressed as an outpatient, though she is tolerating this
well.
.
Lymphocytosis: Although the patient was on chronic steroids, she
was started on vanco/flagyl cipro. Urine culture was negative.
Her white count did trend down. Her cipro/flagyl were D/C'd
with negative culture data and a clean wound. She was continued
on vanco for gram positive coverage for her open wound.
However, repeat tissue culture grew Pseudomonas sensitive to
Levaquin, which she was switched to. She will need continued
levaquin while her wound is open - can be discussed with
orthopedics regarding definitive course.
.
COPD: Maintained on supplemental 02 with prn nebulizers.
.
Acute on chronic renal failure: Her baseline Cr is 1-1.2. Her
renal dysfunction was treated with gently hydration and improved
to baseline.
.
C-spine anterolisthesis: Cleared for surgery, but required
fiberoptic intubation.
.
Polymyalgia Rheumatica: The patient was maintained on prednisone
5mg. However, she was started on stress dose steroids with
Hydrocortisone 50mg IV q6 for her surgeries. A random cortisol
level was 2.9. She was put back on Prednisone 5mg PO qDay after
her surgery. However, she can begin a prednisone taper.
.
? Depression: Patient was found to be tearful and pessimistic.
Psychiatry was consulted for depression. They agreed with
depressive symptoms vs. adjustment and recommended
anti-depressant. However, the patient adamantly refused. This
should be re-considered as an outpatient.
.
Code: DNR/DNI for this admission.
.
To do for follow up:
1. Patient has follow up with ortho to decide ultimate
management of fracture. Length of anticoagulation and
antibiotics should be discussed.
2. Patient is scheduled for a CT Chest to follow up incidental
lung nodule/fusiform aneurysm. Test is scheduled for [**2125-12-4**] at
11am in [**Hospital Ward Name 452**] 3. Please arrange transport and have PCP enter
requisition in computer system.
3. Patient will need follow up TFTs.
4. Can start to taper prednisone gradually for her PMR.
5. ? Depression. pt refused anti-depressants, may benefit in
future. Discuss psychiatry follow up as outpatient.
Medications on Admission:
Lasix 60mg daily
Zaroxylyn 5mg daily
Flonase 0.025mg [**Hospital1 **] prn
ipratropium [**2-3**] nebs daily
prednisone 4mg daily
digoxin 0.125mg every other day
Percocet prn
Ambien 5mg at bedtime prn
senna,
diltiazem 30mg QID
Synthroid 100mcg daily
Neurontin 400 mg [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TIDAC (3 times a day (before meals)).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for insomnia, anxiety.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): DVT prophylaxis.
14. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-4**] Sprays Nasal
TID (3 times a day) as needed.
16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
18. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
19. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours): Please continue for open wound.
20. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: Five (5) Tablet Sustained Release 24HR PO DAILY (Daily).
21. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed).
22. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO Q 8H (Every 8 Hours).
23. 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.
24. Morphine Sulfate 1-5 mg IV Q4H:PRN pain
for breakthrough pain only, hold for RR <12
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary Diagnosis:
Right compound distal tibia/fibula fracture
.
Secondary Diagnoses;
Atrial fibrillation
Diastolic congestive heart failure
Chronic obstructive pulmonary disease
Polymyalgia Rheumatic
Lung nodule
Hypothyroidism
Hypertension
Discharge Condition:
Good, afebrile, hemodynamically stable
Discharge Instructions:
Please take all medications as prescribed. Please keep all
follow up appointments. Please return to the hospital if you
experience fevers/chills, chest pain, worsening leg pain or
signs of infection, or any other symptoms that concern you.
.
Patient is to follow up with orthopedics regarding her fracture
.
Patient is scheduled for a CT chest on [**2125-12-4**] at 11AM in [**Hospital Ward Name 452**] 3.
Please arrange transport. Please have PCP enter outpatient
requisition for this test.
.
Patient will need follow up thyroid function tests
Followup Instructions:
Please follow up with Orthopedics As below:
Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2125-11-19**] 10:00
Provider: [**Name10 (NameIs) 13978**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2125-11-19**]
10:20
.
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 26735**] in [**12-4**] weeks.
[**Telephone/Fax (1) 26736**]
.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2125-12-4**] 11:15
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,127
| 188,165
|
41546
|
Discharge summary
|
report
|
Admission Date: [**2156-9-3**] Discharge Date: [**2156-9-6**]
Date of Birth: [**2099-9-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Name (NI) 9308**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
PCI
Hemodialysis
History of Present Illness:
56M ESRD on HD HTN DM HL s/p CABG [**5-/2155**] (3vd, 5-CABG with LIMA
to LAD double touchdown with endarterectomy from D1 to apex;
SVG1 to OM1 and jump to OM2; and SVG2 to PDA; good resolution of
symptoms, follow up stress echo in [**Month (only) 359**] showing small apical
scar with some peri-apical ischemia and a preserved EF (50%)
felt [**3-17**] diffusely diseased LAD) who presents s/p VF arrest. He
reports that about 2-4 weeks ago he began to note chest
discomfort which he thought was just gas since it often occurred
with burping. The pain was dull, center of chest, did not
radiate to arm or jaw, no associated shortness of breath,
nausea, vomiting or diaphoresis. The episodes lasted minutes,
resolved on their own, occured a few times a week, not
associated with exercise. Since he thought it was GI related he
did not seek further attention.
.
Last night he had worsening of discomfort which continued on
through most of the night. This morning started to go to his
routine HD appointment but 1 block from home felt poorly with
midsternal nonradiating chest pressure. He went home and asked
his wife to call 911. In the ambulance on the way over he went
into a VF arrest and was promptly resucitated. He had not taken
his morning metoprolol.
.
He was taken to [**Hospital6 33**] where on arrival his EKG at
[**Hospital6 33**] showed new downsloping in leads aVF II III
V3-V6
His pain went away with nitroglycerin. He was started on heparin
and integrilin and sent to [**Hospital1 18**] for cardiac catheterization.
.
His cardiac cath (Attending: Dr. [**Last Name (STitle) 33746**] showed patent grafts to
the PDA and LIMA to LAD but an occluded graft to OM1. Flow to
territority through native circumflex. Given tight left main
stenosis as well as 80% proximal left circumflex stenosis two
long drug eluting stents (a Promus 3.5mm x 23 mm and a Promus
3.5mm x 18mm) were placed in the left main and left circumflex
respectively. Entry sites were closed with an 8F RFA AngioSeal
in right groin and 5F RFA sheath pull in left. Of note his blood
pressure dropped to systolics in the 60s during both baloon
inflations. He otherwise tolerated the procedure without any
complications.
.
Prior to the catheterization his potassium was 6.1. No EKG
changes of hyperkalemia. Received 10 units of insulin, D50 and
2gm of calcium gluconate. Post-cath K+ same at 6.1. Also
received some D5W for blood sugars in the 80s. He reports having
taken his NPH the morning of admissions.
.
On arrival to the CCU he was comfortable and in NAD. All of his
prior symptoms had resolved and he had no current complaints.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension,
Tobacco use
2. CARDIAC HISTORY:
- CABG: [**2155-12-9**] CABG x 5, PTCA to 6th.
- PERCUTANEOUS CORONARY INTERVENTIONS: [**2156-9-3**]
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-Diabetes mellitus with renal complications, and neuropathy,
-retinopathy. Most recent Hg A1c in [**Month (only) 116**] was 7.3 from previous <
7.0.
-Obstructive Sleep Apnea (previously on CPAP, now resolved after
weight loss)
-Hypertension, Essential
-Cataract
-Charcot foot due to diabetes mellitus
-History of tobacco use
-Hypothyroidism
-Hyperlipidemia
-Obesity s/p Lap Band ([**2154**])
-Hyperparathyroidism [**3-17**] renal
-Renal osteodystrophy
-Pulmonary Nodule (Solitary)
-History of Colonic Adenoma
Social History:
- Tobacco history: 30 pack year history, quit at time of CABG ~1
year ago
- ETOH: never
- Illicit drugs: denies
Family History:
Father with kidney disease. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death. Uncle
with cancer, NOS.
Physical Exam:
ADMISSION EXAM
Vitals: 97.9 93/45 (69-98) 65 19 99%RA
Wt 105.5 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
edema
Access: left forearm AVF + thrill/bruit
DISCHARGE EXAM
Vitals: 97.7, 89, 106/61, 19, 99% on RA
GEN: AOX3, NAD
HEENT: anicteric sclera, MMM, PERRL
NECK: JVP not elevated
HEART: RRR, grade 2 systolic murmur heard best at LSB/2ICS, no
radiation to neck or axilla
LUNG: CTA bilaterally
ABD: soft, NT/ND, +BS, no hepatosplenomegaly
EXT: nonpitting edema to ankle bilaterally, peripheral pulse 2+
in LE bilaterally, fistula with thrills over left forearm
Pertinent Results:
ADMISSION LABS
[**2156-9-3**] 02:45PM BLOOD WBC-8.2 RBC-3.47* Hgb-11.4* Hct-32.6*
MCV-94 MCH-32.8* MCHC-35.0 RDW-15.1 Plt Ct-170
[**2156-9-3**] 02:45PM BLOOD Neuts-66.6 Lymphs-23.5 Monos-5.0 Eos-3.7
Baso-1.2
[**2156-9-3**] 10:23PM BLOOD PT-12.4 PTT-26.2 INR(PT)-1.0
[**2156-9-3**] 08:50AM BLOOD Glucose-159* UreaN-51* Creat-8.8* Na-139
K-6.1* Cl-95* HCO3-28 AnGap-22*
[**2156-9-3**] 10:23PM BLOOD ALT-39 AST-69* CK(CPK)-321 AlkPhos-94
TotBili-0.6
[**2156-9-3**] 08:50AM BLOOD Calcium-9.9 Phos-4.6* Mg-3.2*
PERTINENT LABS
[**2156-9-3**] 08:50AM BLOOD CK-MB-20* MB Indx-9.8* cTropnT-0.59*
[**2156-9-3**] 10:23PM BLOOD CK-MB-35* MB Indx-10.9* cTropnT-2.49*
[**2156-9-4**] 04:32AM BLOOD CK-MB-22* MB Indx-10.3*
[**2156-9-4**] 04:50PM BLOOD CK-MB-12* MB Indx-5.8 cTropnT-2.35*
DISCHARGE LABS
[**2156-9-6**] 06:32AM BLOOD WBC-5.6 RBC-2.72* Hgb-9.1* Hct-25.4*
MCV-93 MCH-33.5* MCHC-35.9* RDW-14.6 Plt Ct-130*
[**2156-9-6**] 06:32AM BLOOD Glucose-105* UreaN-63* Creat-10.3*#
Na-135 K-6.2* Cl-94* HCO3-28 AnGap-19
[**2156-9-6**] 06:32AM BLOOD Calcium-8.2* Phos-6.0* Mg-2.8*
PERTINENT STUDIES
# [**9-4**] ECHO
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with mild
hypokinesis of the inferolateral wall and basal inferior
segment. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with borderline-normal free
wall contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Mild focal left ventricular systolic dysfunction.
Mildly dilated right ventricle with borderline normal systolic
function. No significant valvular abnormality seen.
# [**9-3**] cardiac catheterization
1. Severe left main and 3 vessel native CAD. 4 patent grafts out
of 5.
2. Successful PTCA/stenting of left main and LCx using DES
Brief Hospital Course:
56M ESRD on HD, HTN, DM, HL s/p CABG [**5-/2155**] (3vd, 5-CABG with
LIMA to LAD double touchdown with endarterectomy from D1 to
apex; SVG1 to OM1 and jump to OM2; and SVG2 to PDA; good
resolution of symptoms, follow up stress echo in [**Month (only) 359**] showing
small apical scar with some peri-apical ischemia and a preserved
EF (50%) felt [**3-17**] diffusely diseased LAD) who presents NSTEMI
s/p VF arrest and underwent stenting in LCA and LCx.
ACTIVE ISSUES:
1. CAD s/p VF Arrest: Patient is s/p 5-CABG in [**2155**]. Cardiac
cath this admission showed severe left main and 3v native CAD
with 4 out of 5 grafts patent. Had 2x DES placed in left main
and left circumflex. Continued on aspirin and plavix. Integrilin
stopped in cath lab. Repeat echo showed no change in LVEF.
2. CHF: Patient with ESRD but normal EF ~50% on prior echo.
Initial CXR and exam c/w fluid overload which improved with HD.
He had a repeat echo which showed no change in his EF. No
indications for ICD. Should continue to weigh self regularly and
follow a low salt diet.
3. ESRD: Dialyzed immediately post cath and then again on day of
discharge. Removed 1.5L post cath but HD session was not
completed due to asymptomatic hypotension with MAPs down to 42.
Tolerated additional HD on hospital day #3 (day of discharge)
and removed ~4L. Had ongoing asymptomatic hypotension which was
felt consistent with the patient's baseline during HD. Will have
next HD at his regular time on Wednesday.
4. Hyperkalemia: K 6.1 on admission, no hyperkalemic EKG
changes, given insulin and D5 and calc gluc. Resolved with HD.
K+ 6.2 on morning of discharge prior to HD. Felt appropriate to
recheck labs at follow up appointment or next HD session on
wednesday.
5. DM, Type II: long-standing diabetic now managed on insulin.
Most recent A1c ~7.5, notes slightly worse control recently as
he has been less careful with what he eats. Managed on HISS
inhouse, restarted home regimen of Aspart/NPH on discharge.
6. HLD: Previously on simvastatin 40mg daily which was switched
to atorvastatin 80mg in the setting of an acute MI.
CHRONIC ISSUES
Pt has documented history of hypothyroidism. Home dose
levothyroxine was continued.
TRANSITIONAL ISSUES
Pt maintained a full code.
Pt has a followup appointment with Dr. [**Last Name (STitle) 66687**] on Tuesday ([**9-7**]).
Medications on Admission:
1. FoLIC Acid 1 mg PO/NG DAILY
2. Heparin 5000 UNIT SC TID
3. Insulin SC (per Insulin Flowsheet)
4. Aspirin EC 325 mg PO DAILY
5. Levothyroxine Sodium 300 mcg PO/NG DAILY
6. Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
7. Mupirocin Cream 2% 1 Appl TP [**Hospital1 **]
8. Atorvastatin 80 mg PO/NG DAILY
9. Metoprolol Tartrate 25 mg PO/NG [**Hospital1 **]
10. Clopidogrel 75 mg PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Clopidogrel 300 mg PO/NG ONCE
13. Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
14. sevelamer CARBONATE 1600 mg PO TID W/MEALS
15. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. sevelamer carbonate 2.4 gram Powder in Packet Sig: Two (2)
envelopes PO three times a day.
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. insulin aspart 100 unit/mL Solution Sig: 0-20 units per
sliding scale units Subcutaneous three times a day.
9. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
10-20 units daily as directed units Subcutaneous once a day.
10. mupirocin 2 % Ointment Topical
11. epoetin alfa 2,000 unit/mL Solution Sig: 3.5 ml Injection
three times a week with dialysis for 1 doses.
12. paricalcitol 2 mcg/mL Solution Sig: Two (2) ml Intravenous
three times a week with dialysis.
13. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO twice a day:
Please hold morning dose on the day of dialysis.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. non ST elevation myocardial infartion
2. congestive heart failure
SECONDARY:
1. chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were sent to our hospital by ambulance and was found to have
a heart attack. You had a dangerous heart rhythm on the
ambulance en route to our hospital, and was successfully
corrected in time. After arrival, you underwent catheterization
of your heart. Two stents were placed to open up your occluded
coronary vessels. You also had a hemodialysis on the day of
your discharge, which you tolerated well. You recovered well
from your heart attack. We think you are now safe to go home
and continue recovery.
Please note that the following medications have been changed:
- Please STOP taking simvastatin
- Please START taking atorvastatin 80 mg by mouth daily
You have a followup appointment with your new cardiologist Dr.
[**Last Name (STitle) 66687**] at [**Hospital1 392**] center at 4 pm on Tuesday ([**9-7**]).
Please also be sure to have your labs checked either at your
cardiology appointment on Tuesday ([**9-7**]) or Wednesday ([**9-8**]) at
dialysis.
It has been a pleasure to take care of you here at [**Hospital1 18**]. We
hope you have a speedy recovery.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66687**], [**First Name3 (LF) **], Cardiology
[**Hospital1 **], [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **]
TIME: Tuesday ([**9-7**]) at 4 pm
LOCATION: [**Location (un) **], [**Hospital1 392**], [**Numeric Identifier 10727**]
CONTACT: ([**Telephone/Fax (1) 90366**]
|
[
"414.02",
"403.91",
"414.2",
"414.01",
"366.8",
"410.71",
"362.01",
"585.6",
"272.4",
"357.2",
"276.7",
"250.60",
"V45.11",
"244.9",
"327.23",
"427.41",
"V58.67",
"250.40",
"250.50",
"518.89",
"V15.82",
"278.00",
"713.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"39.95",
"37.22",
"00.66",
"36.07",
"88.56",
"88.49",
"88.53",
"00.24",
"00.41",
"00.46"
] |
icd9pcs
|
[
[
[]
]
] |
11463, 11469
|
7231, 7685
|
306, 325
|
11629, 11629
|
5031, 7208
|
12917, 13277
|
3888, 4027
|
10208, 11440
|
11490, 11608
|
9598, 10185
|
11780, 12894
|
4042, 5012
|
3082, 3202
|
256, 268
|
7700, 9572
|
353, 2965
|
11644, 11756
|
3233, 3743
|
2987, 3062
|
3759, 3872
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,715
| 193,039
|
16996+56815
|
Discharge summary
|
report+addendum
|
Admission Date: [**2108-5-28**] Discharge Date: [**2108-6-9**]
Date of Birth: [**2036-12-3**] Sex: F
Service: CME
HISTORY OF PRESENT ILLNESS: This is a 71-year-old female
with non-small cell lung carcinoma, obstructive-sleep apnea,
COPD, and obesity, who was admitted on [**2108-5-28**] to the
Medical team with report of months of chronic dyspnea, two
weeks of increased shortness of breath associated with a
recent medication change of decreased Lasix dose around that
time. She also reported positive bilateral lower extremity
edema and a dry cough, but denied any fevers and chills.
On presentation to the Emergency Department, the patient was
afebrile, tachycardic with a heart rate of 110, and blood
pressure of 119/60. On 4 liters of oxygen by nasal cannula,
the patient's O2 saturation was 95 percent. Based on
examination and chest x-ray findings of small bilateral
pleural effusions, the patient was treated by the Medical
team for presumed CHF exacerbation. She was noted to have
decreased symptoms with IV diuresis after being given first
60 IV and then 20 mg of IV Lasix. The following day the
patient had an echocardiogram, which demonstrated a large
pericardial effusion circumferential without any signs of
tamponade physiology.
The patient was then reexamined by the medical team. On
examination was without jugular venous distention or pulsus
paradoxus. The diuretics and ACE inhibitor that she had been
presented on were discontinued. Patient was then taken for
pericardiocentesis on [**5-30**] and transferred to the [**Hospital Unit Name 196**]
service. On pericardiocentesis, there was drained
approximately 800 cc of hemorrhagic fluid. The postoperative
course was complicated by atrial fibrillation with a rapid
ventricular rate, which returned to [**Location 213**] sinus rhythm with
one dose of diltiazem and no other intervention. Amiodarone
load was given and then continued at 400 mg b.i.d. for seven
days, then 400 mg once a day up to a total of 21 days.
On [**2108-6-2**], the patient underwent a pericardial window and
bilateral chest tube placement for pleural effusions.
Postoperative course from that, the patient had a fever to
102.6. Was treated with vancomycin, levofloxacin, and Flagyl
for presumed pneumonia. The chest tube output was minimal
draining some serosanguinous fluid. Patient also had
transient hypotension to 80/40s, treated transiently with
Levophed drip. The etiology of hypotension was questionable
potentially due to medications.
Patient then had a chest CT on [**6-2**], which demonstrated
right upper lobe opacities posteriorly, bilateral pleural
effusions right greater than left and a moderate pericardial
effusion that was present. The effusion on the right side
appeared to be loculated and fibrotic, and on the left side,
there is a small pneumothorax that was well loculated. The
patient had been intubated during the pericardial window and
was extubated on the 16th, maintained on BiPAP overnight
thereafter. At that point, the patient was transferred to
the MICU service for continued management of the dyspnea.
PAST MEDICAL HISTORY:
1. Lung cancer non-small cell status post chemotherapy and
radiation therapy as well as initial resection. The
patient also had an endobronchial invasion with the tumor
and is now status post stent placement, which was then
later found to be migrated and was taken out by
Interventional Pulmonology.
2. COPD with a FEV1 of 0.39.
3. CHF. She has a severely depressed left ventricular
ejection fraction.
4. Obstructive-sleep apnea on nighttime BiPAP.
5. Hypertension.
6. Diabetes.
7. Obesity.
8. Hypercholesterolemia.
PAST SURGICAL HISTORY:
1. Status post appendectomy.
2. Status post cholecystectomy.
3. Status post total abdominal hysterectomy.
ALLERGIES: Codeine.
SOCIAL HISTORY: The patient was a 40 pack year tobacco
smoker. Denies any IV drug use or alcohol abuse. The
patient lives at home with her second husband.
LAB VALUES ON TRANSFER FROM THE CCU TO THE MICU TEAM: The
white blood cell count was 9.5, hematocrit was 29.9, platelet
count was 239. On chemistry panel, the sodium is 141,
potassium 3.6, chloride 101, bicarb 32, BUN 21, creatinine
0.6, glucose 170, calcium 8.3, magnesium 1.9, phosphorus 3.3.
At the time, pathology had been sent off on the pericardial
tissue as well as pericardial and pleural fluid.
Chest x-ray done postoperatively on the 16th still
demonstrated bilateral pleural effusions, but no change from
the prior day.
As far as microbiology data, the patient had no significant
organisms grow from blood cultures, urine cultures, sputum
cultures, or pericardial or pleural fluid.
Vital signs on transfer to the MICU team were a temperature
of 96, pulse of 107, blood pressure 94/42, respiratory rate
20, and pulse oximetry of 96 percent on 10 liters of O2 by
face mask. On examination, this patient is a pleasant
elderly female, who was in mild respiratory distress, but
speaking in full sentences. HEENT: Mucous membranes were
moist. There was no jugular venous distention. There was a
right internal jugular central line, and mild erythema, and
mild tenderness, but no pus. Cardiovascular: The heart
sounds were distant, but regular, rate, and rhythm, normal
S1, S2. No murmurs, rubs, or gallops. Pulmonary exam:
Breath sounds were audible bilaterally with decreased breath
sounds at the bases, occasional wheeze was noted. Abdominal
exam was protuberant, but nondistended, soft, positive bowel
sounds, and nontender. Extremities were warm with 2 plus
pulses bilaterally bilateral lower extremities. No lower
extremity edema was noted. There was some chronic venous
stasis changes.
HOSPITAL COURSE: The hospital course post transfer from the
CCU to MICU team is as follows:
1. For the patient's dyspnea, the patient's dyspnea improved
status post pericardial window. The bilateral chest tubes
had minimal drainage and it was felt that the right chest
was unsuccessful in draining the loculated pleural
effusion that remained towards the right base on the CAT
scan done on the [**12-3**].
At the time of this dictation, Cardiothoracic Surgery final
input as to the effusion was that no further intervention
would be potential for draining this effusion. At the time
of this dictation, the MICU team had also asked for the input
of Interventional Pulmonology and Interventional Radiology to
decide whether the effusion, which was thought to be a small
component or possible moderate component to this patient's
dyspnea would be amenable to any drainage or if we should
hold off until any further worsening of the effusion should
happen in the future. It was noted by CT Surgery that no
pleurodesis would be possible at this time.
The pericardial effusion did end up showing a cytology
positive for malignant cells, therefore demonstrating the
patient with Stage IV lung cancer. A followup echocardiogram
was also done two days after surgery, which demonstrated a
small pericardial effusion, which was thus not thought not to
be further contributing to the patient's dyspnea. There is
also consideration that this patient may have thromboembolic
disease, therefore a CTA was attempted twice. This study was
suboptimal due to bolus timing of the contrast dye. It
showed no massive pulmonary embolus, but it did not show the
subsegmental or segmental pulmonary arteries. Given the fact
the patient was not amenable to anticoagulation, we did get
lower extremity ultrasounds done, which showed no evidence of
clots.
For the possibility of CHF as a component of the dyspnea,
this patient was diuresed, however, on diuresis, the patient
entered atrial fibrillation, which was controlled with a dose
of diltiazem and some IV fluids. Therefore, the goal was to
keep this patient approximately even as far as fluid balance
goes.
For his COPD, there was not thought to be a major
contribution to her dyspnea. The patient was stopped with
albuterol due to anxiety and tachycardia and kept on Atrovent
nebulizers MDI. Steroids were not started, and for the
pneumonia, the patient finished a seven day course of
vancomycin, levo, and Flagyl.
1. For cardiovascular issues, for CHF: The patient does have
a significantly low ejection fraction. We did titrate up
the ACE inhibitor during the hospitalization. Patient
will be discharged on captopril, and we did end up using
Lasix to keep the patient on an even fluid balance.
For atrial fibrillation, the patient is on amiodarone. Will
continue on amiodarone 400 q.d. for approximately three weeks
after discharge.
1. For her oncologic issues, the patient was advised that she
does have Stage IV lung cancer signifying progression of
her original disease. This patient will be followed up
for this issue with her oncologist, Dr. [**Last Name (STitle) 3274**].
1. For her diabetes, the patient was on a insulin-sliding
scale and was restarted on NPH at 10 units b.i.d. for
glucose control.
1. For anxiety, the patient was kept on her Xanax dose of
0.25 q.i.d.
1. FEN: The patient was kept on a diabetic low-sodium diet
with a fluid goal of net even.
For overall disposition, based on a discussion with this
patient of the progression of the cancer, it was decided that
the patient would transition to home hospice care, so the
patient will be likely discharged to home with hospice care
as well as palliative care and full home services. Again at
the time of this discharge dictation, the only issue that had
not been completely discussed was the issue of the right
pleural effusion for which we are still awaiting final
interpretation from Interventional Pulmonary and
Interventional Radiology.
FINAL DISCHARGE MEDICATIONS: Can be done at the time of the
patient's discharge.
FINAL DISCHARGE DIAGNOSES:
1. Stage IV non-small cell lung cancer.
2. Pericardial effusion status post pericardiocentesis and
pericardial window.
3. Bilateral pleural effusions.
4. Chronic obstructive pulmonary disease.
5. Congestive heart failure.
6. Question of pneumonia status post seven day course of
vancomycin, levofloxacin, and Flagyl.
7. Atrial fibrillation.
8. Diabetes.
9. Anxiety.
FOLLOW-UP PLANS:
1. This patient will be followed by palliative and hospice
care.
2. The patient will follow up with her oncologist, Dr.
[**Last Name (STitle) 3274**].
Any further events will be dictated prior to the patient's
discharge from the hospital.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 47814**]
Dictated By:[**Last Name (NamePattern4) 27246**]
MEDQUIST36
D: [**2108-6-8**] 11:22:43
T: [**2108-6-8**] 12:14:28
Job#: [**Job Number 47815**]
Name: [**Known lastname **], [**Known firstname **] A Unit No: [**Numeric Identifier 8823**]
Admission Date: [**2108-6-8**] Discharge Date: [**2108-6-11**]
Date of Birth: [**2036-12-3**] Sex: F
Service:
ADDENDUM: This discharge summary addendum is from [**2108-6-8**]
until discharge, [**2108-6-11**].
[**Hospital 8824**] HOSPITAL COURSE:
1. Pericardial effusion, malignant. Status post pericardial
window and bilateral chest tube placement with loculated
pleural effusions and chest tubes walled off. Chest tubes
were discontinued and interventional pulmonology not able
to intervene further. The patient was made DNR/DNI and
was transitioned to home hospice care.
2. Pulmonary stage IV non-small cell lung cancer, metastatic,
awaiting home hospice placement. Status post bilateral
chest tubes and pericardial window for a malignant
pericardial effusion. No further interventional pulmonary
procedures available. The patient will continue BiPap at
night and home oxygen.
3. Infectious disease. The patient had one out of two blood
cultures positive for coag-negative staph and urine
culture with coag negative staph. She is completing two
weeks of vancomycin by PICC which was placed on the floor.
4. Code status. The patient was made do not resuscitate and
do not intubate on the floor.
DISCHARGE DISPOSITION: Stable.
DISCHARGE STATUS: The patient was discharged to home with
VNA as a bridge to hospice care.
DISCHARGE MEDICATIONS:
1. Flovent 2 puffs b.i.d. 110 mcg
2. Senna 1 tablet p.o. b.i.d. as needed.
3. Colace 100 mg p.o. b.i.d.
4. Ipratropium 0.02% one nebulizer every six hours.
5. Lasix 20 mg p.o. q.d.
6. Amiodarone 400 mg p.o. q.d. times 3 weeks then 200 mg p.o.
q.d.
7. Alprazolam 0.5 mg p.o. t.i.d.
8. Lactulose 30 cc p.o. b.i.d. p.r.n.
9. Lisinopril 10 mg p.o. q.d.
10. Ambien 5 mg p.o. h.s.
11. Scopolamine patch one transdermal q.72h., 1.5 mg
patch as needed for shortness of breath.
12. Lorazepam 0.5 to 1 mg p.o. q. Four to six hours
p.r.n.
13. Morphine sulfate 20 mg/cc solution 1-5 cc p.o. q. 1
hour p.r.n., titrate to comfort.
FOLLOW-UP PLANS:
1. The patient is to follow with her primary care provider,
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], INT in the next 1-2 weeks as
needed.
2. She is to follow-up with her pulmonologist, Dr. [**Last Name (STitle) 2306**],
as needed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8825**]
Dictated By:[**Last Name (NamePattern1) 5109**]
MEDQUIST36
D: [**2108-11-4**] 13:24:16
T: [**2108-11-6**] 05:05:00
Job#: [**Job Number 8826**]
|
[
"428.0",
"197.2",
"780.57",
"482.40",
"790.7",
"250.00",
"162.8",
"423.8",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"34.04",
"37.12",
"37.0",
"96.6",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
12153, 12255
|
12278, 12921
|
11127, 12129
|
3707, 3837
|
12938, 13540
|
9847, 10221
|
164, 3124
|
3146, 3684
|
3854, 5712
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,779
| 103,741
|
33835+57909
|
Discharge summary
|
report+addendum
|
Admission Date: [**2105-12-7**] Discharge Date: [**2105-12-30**]
Date of Birth: [**2042-8-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Pulmonary Embolus
Major Surgical or Invasive Procedure:
EGD
CVC insertion
Intubation
IVC filter placement
History of Present Illness:
Mr. [**Known lastname 31624**] is a 63 yo man w/hx of esophageal CA, who presents
to the MICU now with hypotension, unresponsive requiring
intubation on the medicine floors and melena. Pt was found to be
slightly confused per nursing, nightfloat was called to the room
and pt shortly thereafter became unresponsive and was found to
have a BP of 60's/palp. He maintained a pulse but was intubated
for airway protection. He was noted to have dark red blood from
his G-tube. He also had melena noted in the bed. He was then
transferred to the MICU for further care and monitoring. He
presented to medicine on [**12-7**] with complaints of SOB and was
found to have PE on CTA Pt is a 63 yo man w/hx of esophageal CA
in the 90's, s/p J-tube on [**2105-10-7**]. Pt presents with 3 days of
shaking chills w/SOB; he denies having a fever but noted that
the shaking chills would come on at various times during the
day. He has chronic abd and back pain but htis had not changed
in character. No CP, cough or syncope. He presented to his PCP
who was worried about a possible PE. A CTA was obtained which
showed segmental and subsegmental pulmonary emboli in superior
segment of right upper lobe and right middle lobe. He was
started on a heparin gtt, and LENI's from [**12-9**] showed no DVT.
Of note, he had a guaiac positive stool on initial presentation
to the ED, but no s/s bleeding on the medicine floors. He had
noted low-grade fevers to 100.1 on [**12-8**], but no fevers in
previous 24hrs.
ROS as above. Unable to obtain complete ROS given unresponsive.
On the floor, pt was intubated, with initial settings of CMV/A
Vt 600, RR 14, PEEP 5, FiO2 100%. He received one unit of blood
overnight, and the second was transfusing on transfer. There was
gross melena in the bed.
Past Medical History:
Esophageal Cancer, bowel obstruction, TEF, Left vocal cord
paralysis, Depression s/p ECT (following [**2091**] surgery), Anxiety
Past Surgical History: Esophagectomy at [**Hospital1 112**] in [**2091**] complicated
by stricture and tracheal esophageal fistula s/p dilation x2 and
Y-stent for the TEF on [**6-23**], exploratory laparotomy/LOA/biliary
diversion with G and J Tube placement [**2103-7-9**], Repair of TE
fistula w/intercostal flap [**8-19**], Roux-n-Y gastrojejunostomy
(esophageal conduit) with intra-thoracic anastomosis, small
bowel
resection, J-tube on [**10-7**]
Social History:
General Surgeon, lives w/ wife and 2 small children ages 5 and
7.
non-smoker
Family History:
non-contributory
Physical Exam:
ON Arrival to MICU from floors: On ventilator: CMV/A Vt 600, RR
14, PEEP 5, FiO2 100%
General: unresponsive, intubated, in distress
HEENT: Sclera anicteric, MMM
Neck: supple, JVP difficult to assess given use of accessory mm
of breathing
Lungs: using accessory mm to breath, intubated, breath sounds
present bilaterally anteriorly, no wheezes or crackles
appreciated in anterior lung fields
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-distended, bowel sounds present, using
abdominal mm to breath, gross melena in bed
GU: no foley
Ext: warm, 2+ DP pulses, slight mottling of lower extremities
Neuro: unresponsive, not following commands, sedated
.
On Discharge:
General Appearance: No(t) Well nourished, No acute distress,
No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t)
Conjunctiva pale, No(t) Sclera edema
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition,
No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube
Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t)
Cervical adenopathy
Cardiovascular: (PMI No(t) Normal, No(t) Hyperdynamic), (S1:
Normal, No(t) Absent), (S2: Normal, No(t) Distant, No(t) Loud,
No(t) Widely split , No(t) Fixed), No(t) S3, S4, No(t) Rub,
(Murmur: Systolic, No(t) Diastolic), [**1-21**] holosyst m
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),
(Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness
: ), (Breath Sounds: No(t) Clear : , Crackles : rare, No(t)
Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent
: , No(t) Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender: , No(t) Obese
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace, No(t) Cyanosis, No(t) Clubbing
Musculoskeletal: Muscle wasting, Unable to stand
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Purposeful, No(t)
Sedated, No(t) Paralyzed, Tone: Not assessed
Pertinent Results:
ADMISSION LABS:
---------------
[**2105-12-7**] 10:45PM PTT-45.8*
[**2105-12-7**] 03:40PM GLUCOSE-111* UREA N-30* CREAT-1.1 SODIUM-136
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15
[**2105-12-7**] 03:40PM estGFR-Using this
[**2105-12-7**] 03:40PM D-DIMER-1116*
[**2105-12-7**] 03:40PM WBC-6.6 RBC-3.86* HGB-10.1* HCT-30.9*
MCV-80*# MCH-26.1*# MCHC-32.5 RDW-14.6
[**2105-12-7**] 03:40PM NEUTS-78.0* LYMPHS-12.0* MONOS-8.2 EOS-1.1
BASOS-0.7
[**2105-12-7**] 03:40PM PLT COUNT-338
.
DISCHARGE LABS:
----------------
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
8.6 4.54* 12.2* 37.4* 82 27.0 32.8 16.2* 442*
Glucose UreaN Creat Na K Cl HCO3 AnGap
139*1 65* 2.0* 133 4.5 95* 26 17
.
MICROBIOLOGY:
-------------
[**2105-12-25**] 4:02 pm BLOOD CULTURE Source: Line-piv.
Blood Culture, Routine (Preliminary):
GRAM POSITIVE RODS. CONSISTENT WITH CLOSTRIDIUM OR BACILLUS
SPECIES.
.
Blood Culture, Routine (Final [**2105-12-30**]):
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
.
[**2105-12-10**]: [**Female First Name (un) 564**]
.
IMAGING:
--------
CT chest w/o [**12-7**]:
IMPRESSION:
1. Segmental and subsegmental pulmonary emboli in superior
segment of right upper lobe and right middle lobe.
2. Right lower lobe consolidation/aspiration, less likely
pulmonary infarct.
3. Stable right upper lobe peripheral tree-in-[**Male First Name (un) 239**] opacities and
calcified granulomas as compared to [**2105-8-26**].
4. Stable post-surgical changes of esophagectomy and
neoesophageal
reconstruction.
.
Emergent EGD after large-volume bleed ([**12-10**]): Sp Esophagectomy
with neoesophagus and gastrojejunostomy (Roux-n-Y) Large ulcer
with visible vessel seen at the gastrojejunostomy site. No
active bleeding. Diverticulum in the upper third of the
esophagus Otherwise normal EGD to jejunum.
.
2nd EGD done [**12-11**] (day after bleed):One endoclip was
successfully applied for the purpose of radiographic marker. It
was placed at the distal end of the ulcer bed.
.
Head CT [**12-12**]: Atypical appearing hypodense lesions, largest
involving left periatrial parieto-occipital lobe, and smaller
lesions involving bilateral centrum semiovale and possibly also
right frontal lobe and left cerebellum. These are incompletely
evaluated, but concerning for infection or embolic process in a
patient with fungemia, less likely neoplastic. Recommend further
evaluation by MRI if not contraindicated. Coiling of feeding
tube within the oronasopharynx. Recommend repositioning.
.
Echo [**12-16**]: The left atrium is mildly dilated. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The right ventricular
cavity is moderately dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate to severe (3+)
mitral regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2105-12-12**],
the degrees of mitral and tricuspid regurgitation and of
pulmonary hypertension have all worsened. The right ventricle is
dilated and moderately hypokinetic on the current study. It was
described as normal in size on the prior echo but image quality
was suboptimal. It appears to be more hypokinetic. LV systolic
function is similar. Negative bubble study on the current exam
.
RUQ U/S [**12-18**]:Small stones with [**Doctor Last Name 5691**] and sludge seen within the
gallbladder. No signs of cholecystitis. No biliary dilatation
identified.
.
Brief Hospital Course:
Hypotension: Patient was hypotensive and unresponsive during
episode that brought him to the MICU. This was in the setting
of large-volme GI bleed, so hypotension was the most likely
source. However, the patient had also had low-grade fevers
before transfer to the MICU and had prfound enough hypotension
to require vasopressors, so was started on broad-spectrum
antibiotics for potential septic component. He was transfused
with 5 units within the first 48 hours, and recovered
hemodynamic stability within the first several hours of
resuscitation and was weaned from pressors.
.
GI bleed: Large volume GIB which required intubation for airway
protection. Patient required 5 UpRBCs in first 48 hours in ICU.
EGD showed large ulcer with large pulsatile vessel lying
underneath in the area of patient's esophageal anastomosis.
Discussion with thoracic team revealed that d/t esophagectomy
with revision, only one vessel (gastroepiploic) supplies this
portion of the anastomosis. Decision was made not to attemt
endoscopic manipulation of the pulsatile vessel d/t concern for
interruption of vascular supply to the entire anatomic
esophagus. The patient was monitored in the ensuing weeks in
the ICU, and despite a few episodes of maroon stool a week after
the initial bleed, the h/h remained stable and there was no
other evidence of repeat bleed. GI receommended an outpt EGD in
6 weeks from time of discharge. This will need to be scheduled.
.
Fungemia: While in the ICU, patient intermittently spiked
fevers. Surveillance cultures showed candidemia out of the
a-line and a peripheral. Micafungin was started initially and
then changed to ambisome at a concentration sufficient to treat
CNS infection, with a target course that will end [**12-26**] and then
change to fluconazole until [**1-9**]. All lines were resited or
d/ced after the fungemia, and patient defervesced.
.
Watershed Infarct: Patient was intubated and sedated upon
initial arrival to ICU. Upon sedation wean, patient was poorly
responsive to verbal and tactile stimuli, with residual
hemiparesis. Head CT showed hypodensities in the white matter,
with a differential of seeding of fungi vs. lacunar infarcts.
Patient could not get an MRI due to his tenuous hemodynamics and
the fact that a metal clip had been placed during EGD to mark
the bleeding vessel for potential IR embolization. Repeat head
CT showed similar findings, and given the time course and
appearance, these hypodensities were thought to represent
lacunar watershed infarcts rather than infectious seeding. The
patient initiated physical therapy, occupational therapy, and
speech therapy in the ICU. At time of discharge he was alert and
orientedx 3 and following simple commands.
.
Myocardial event: patient with EKG changes on presentation and
elevated troponin which peaked. This was attributed to demain
ischemia. Given patient's GI bleed and tenuous status, he was
not a candidate for PCI or for heparinization. Echocardiograms
demonstrated impaired function after initial event, and valvular
dysfunction that was worsening over time. ECHO on [**12-16**] showed EF
50-55% with severe MR [**First Name (Titles) **] [**Last Name (Titles) **]. Clinically, MR improved with
diuresis and pt euvolemic at time of discharge. He will require
outpt cardiology follow up.
.
Pulmonary Embolism: patient presented to hospital with
subsegmental PE, was on heparin before transfer to ICU with GIB.
Has hx of PE and bleeds after anticoag. previously in [**2103**], and
has SVC filter from that time. In MICU, heparin was held and
LENIs tracing to the iliacs did not demonstrate any lower ext.
clot, so no IVC was placed. Patient was put on pneumoboots for
first week in unit until GIB was stable, and then switched to
heparin. The patient had an IVC filter placed by vascular
surgery.
.
Atrial fibrillation: Patient intermittently in afib with RVR
while in ICU. Was initially managed with fluids and metoprolol,
but borderline pressures prevented metoprolol as the standing
treatment. As a result patient was loaded with 10g amiodarone
via drip and then placed on PO amio. Intermittently had
afib/rvr despite amio, and vagal maneuvers and/or small iv
metoprolol were sufficient to break episodes into NSR.
Cardiology was consulted, and recommended focus on afterload
reduction in addition to rate/rhythm control. The patient was
ultimately placed on metoprolol, amiodarone, isosorbide, and
hydralazine as per discharge medication list. Amiodarone should
be 400mg daily through [**1-20**] at which time decrease
amiodarone to 200mg daily. Pt should follow up with Atrius
cardiology in [**4-21**] weeks. An appt will need to be made.
.
Volume Overload: Pt determined to be fluid overloaded towards
the end of his MICU course. Likely related to initial
resucitation. He was diuresed aggressively with a lasix gtt and
then IV lasix boluses and is euvolemic at time of discharge.
Creatinine was elevated briefly in setting of aggressive
diuresis and improved to normal baseline when diuresis stopped
and pt given some volume back. We suspect he will require
diuresis in the future given a dilated and mildly hypokinetic
RV. Would suggest monitoring volume status closely and if he
does appear to be developing LE edema or gaining weight starting
lasix 20mg PO daily.
.
Bacteremia: Patient with staph aureus in [**2-19**] blood cultures
assoc w/ fever and leukocytosis. Patient started on vancomycin
on [**2105-12-25**]. Surveillance cultures have been negative. Patient
will need to be continued on vancomycin through [**2106-1-8**] for
full 2 week course. Dose was changed to vancomycin 750mg Q24 to
start on [**2105-12-31**] based on renal failure and level of 24.9 on
[**2105-12-30**]. A vancomycin level will need to be checked on [**2106-1-3**]
before the fourth dose.
.
Anxiety/Depression: Pt has known history of anxiety and
depression. Prior to admission he was taking clonazepam for
anxiety. Clonazepam was stopped in setting of his critical
illness and he was treated with diazepam for withdrawl symptoms.
Patient seen by psychiatry who suggested [**Last Name (un) **] starting
antidepressant at this time. They did suggest using low dose
quetiapine 12.5-25 mg for anxiety-this was not trialed during
his inpt stay. Psychiatry has also recommeded having patient
followed by psychiatry when he goes to rehab. He has an outpt
psychiatrist who he should follow with at time of discharge.
.
Acute Renal Failure: Patient now has new baseline Cr around
1.6-2.0, which was 2.0 on discharge. This is felt to be due to
combination of ATN while hypotensive in setting of GI bleed and
also with some component of poor forward flow from volume
overload. Creatinine stable at time of discharge.
.
Transamitis: Patient w/ elevated transaminases in setting of
hypotension, now trended down to ALT 47, AST 38.
Medications on Admission:
clonazepam 1mg 4 times per day--> pt state usually takes ~12 per
day
percocet 1-2tabs by mouth q4hr;prn
levothyroxine 50mg daily
trazadone 150mg qhs
colace
senna
Discharge Medications:
1. white petrolatum-mineral oil 56.8-42.5 % Ointment [**Last Name (un) **]: One
(1) Appl Ophthalmic TID (3 times a day).
2. fentanyl 25 mcg/hr Patch 72 hr [**Last Name (un) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. fluconazole 200 mg Tablet [**Last Name (un) **]: Two (2) Tablet PO once a day:
Start date: [**12-28**]
End date: [**1-9**] .
4. metoprolol tartrate 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO QAM
(once a day (in the morning)).
5. metoprolol tartrate 25 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO QPM (once
a day (in the evening)).
6. hydralazine 10 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO Q8H (every
8 hours).
7. amiodarone 200 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily): 400mg daily through [**2105-1-20**] then decrease to 200mg
daily.
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Seroquel 25 mg Tablet [**Last Name (STitle) **]: 0.5-1 Tablet PO once a day as
needed for agitation/anxiety/insomnia.
10. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1)
PO DAILY (Daily).
11. isosorbide dinitrate 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
12. 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.
13. vancomycin 750 mg Recon Soln [**Last Name (STitle) **]: Seven [**Age over 90 1230**]y (750)
mg Intravenous once a day: check level before dose on [**1-3**],
last day is [**1-8**].
14. Synthroid 50 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Pulmonary embolism, gastrointestinal bleed secondary to
ulcer, atrial fibrillation, acute renal failure, transaminitis,
respiratory failure, [**Female First Name (un) **] fungemia, stroke, coag negative
staphylococcus bacteremia
Secondary: esophageal cancer, anxiety, depression
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were initially admitted for a pulmonary embolism (blood clot
in the lung) with a resultant gastrointestinal bleed from
anticoagulation. Your hospital course was complicated by
respiratory failure, stroke, atrial fibrillation/flutter (fast
heart rate) and blood infections.
.
Medication changes:
START fluconazole 400mg daily through [**1-9**]
START fentanyl patch 25 mcg/hr
START artificial tears
START lansoprazole
START metoprolol 25mg in the morning and 12.5mg at night
START amiodarone 400mg daily through [**2105-1-20**] and then 200mg daily
thereafter
START miralax
START seroquel for anxiety/agitation/insomnia
START vancomycin 750mg IV every 24 hours through [**2106-1-8**]
STOP clonazepam
STOP percocet
STOP trazodone
Followup Instructions:
You will need to follow up with a cardiologist at Atrius/[**Hospital1 2292**] in [**4-21**] weeks. Please call [**Telephone/Fax (1) **].
.
You will need to follow up with your primary care physician 1
weekk after you are discharged from rehab.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Name: [**Known lastname 12705**],[**Known firstname 77**] C. Unit No: [**Numeric Identifier 12706**]
Admission Date: [**2105-12-7**] Discharge Date: [**2105-12-30**]
Date of Birth: [**2042-8-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 3776**]
Addendum:
Of note, gram positive rods on [**12-25**] growing in one bottle felt
to be contaminant after discussion with micro lab and infectious
diseases. However, at time of discharge, sample had already been
sent to [**Hospital3 4910**] for further identification (though GP rod
noted to be vanco resistant and growing aerobically, leading us
to believe not likely a clostridium species). Final speciation
should be followed up, but patient had no fever/leukocytosis at
time of discharge and looks clinically well. Surveillance
cultures have been negative.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**]
Completed by:[**2105-12-30**]
|
[
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"999.31",
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"311",
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"041.19",
"285.1",
"414.8",
"784.3",
"518.81",
"348.30",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"96.72",
"96.6",
"38.97",
"96.04",
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icd9pcs
|
[
[
[]
]
] |
21323, 21565
|
9851, 16699
|
329, 381
|
19045, 19045
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5204, 5204
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2900, 2918
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16911, 18619
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18733, 19024
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16725, 16888
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19222, 19501
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5720, 5987
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2358, 2789
|
2933, 3615
|
6025, 9828
|
3629, 5185
|
19522, 19957
|
272, 291
|
409, 2182
|
5220, 5704
|
19060, 19198
|
2204, 2335
|
2805, 2884
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,354
| 109,791
|
30485
|
Discharge summary
|
report
|
Admission Date: [**2189-3-23**] Discharge Date: [**2189-3-28**]
Date of Birth: [**2117-6-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
s/p Atrial flutter ablation on [**2189-3-24**]
s/p cardiac catheterization on [**2189-3-26**]
History of Present Illness:
71 year old male with no known cardiac history and likely [**Hospital 2182**]
transferred from OSH with afib with RVR (vs aflutter), EKG
suggestive of past MI and 9 beat run of VTach. Patient
travelled to South America 3 weeks prior to admission where he
developed shortness of breath, cough. Patient denies any fever,
although this was documented in OSH records. He was on an 11
day trip to [**Location (un) 72427**] and Patagonia with his fiancee. He
noted dyspnea on exertion when he was carrying luggage on a 95
degree day. He states his symptoms seemed to be intermittent,
although he admits that they probably never completely resolved
and have persisted since. Symptom onset was approximately 3
weeks ago. He returned home around [**2189-3-9**] and thought his
symptoms were getting better. However, noted non-productive
cough, dyspnea on exertion and orthopnea which seemed to be
worsening and his fiancee convinced him to go to the [**Location (un) 59322**] ED. He did not c/o chest pain, fever or palpitations,
although he was found to be in AFib with RVR. His EKG was
notable for poor r wave progression, nonspecific T wave changes
suggestive of possible old anterior MI. His troponin was
negative. His CXR and Chest CT showed mild interstitial edema
and hyperinflated lungs (possible COPD, mild CHF). Echo done
showed EF 30%. He was started on Cardizem gtt and continued at
8mg/hr although HR remains 100-120's in AFib. He was also
started on heparin and coumadin, but the coumadin was stopped on
[**3-21**] when INR 3.1 given possible transfer to [**Hospital1 18**] for cardiac
cath. On [**3-20**], he had a 9 beat run of VTach.
Past Medical History:
(has not seen a doctor [**First Name (Titles) **] [**Last Name (Titles) **] 50 yrs)
s/p tonsillectomy
likely COPD
former tobacco
Social History:
Former 50 pack-year tobacco, quit [**2187**]. Rare EtOH (1
drink/month). No other drug use. Engaged. 4 grown children.
Family History:
No sudden cardiac death
Physical Exam:
VS - 96.0F HR 147 BP 114/69 RR 24 100%RA
Gen: WDWN elderly male with red face, otherwise, NAD. Speaking
in full sentences. Oriented x3. Mood, affect appropriate.
Seemed to have dyspnea with moving around in bed.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Regular, tachycardic, normal S1, S2.
Chest: No chest wall deformities, scoliosis or kyphosis. Limited
air movement bilaterally. No wheezes, rales, rhonchi
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation.
Ext: warm, well-perfused, no edema
Skin: No stasis dermatitis, ulcers
Pertinent Results:
[**2189-3-23**] WBC-7.3 RBC-5.88 Hgb-16.8 Hct-48.8 MCV-83 MCH-28.6
MCHC-34.4 RDW-15.0 Plt Ct-231 Neuts-76.3* Lymphs-17.2* Monos-5.7
Eos-0.6 Baso-0.2
[**2189-3-24**] WBC-6.9 RBC-5.63 Hgb-16.2 Hct-47.0 MCV-84 MCH-28.8
MCHC-34.5 RDW-15.2 Plt Ct-223
[**2189-3-24**] WBC-6.5 RBC-5.65 Hgb-16.2 Hct-47.5 MCV-84 MCH-28.7
MCHC-34.1 RDW-15.1 Plt Ct-222
[**2189-3-25**] WBC-7.1 RBC-5.70 Hgb-16.2 Hct-47.7 MCV-84 MCH-28.4
MCHC-33.9 RDW-15.1 Plt Ct-187
[**2189-3-26**] WBC-6.0 RBC-5.78 Hgb-16.1 Hct-48.6 MCV-84 MCH-28.0
MCHC-33.2 RDW-15.3 Plt Ct-222
[**2189-3-28**] WBC-6.7 RBC-5.26 Hgb-15.2 Hct-44.9 MCV-85 MCH-28.8
MCHC-33.8 RDW-15.4 Plt Ct-225
.
[**2189-3-23**] PT-20.5* PTT-36.7* INR(PT)-2.0*
[**2189-3-24**] PT-19.6* PTT-91.3* INR(PT)-1.9*
[**2189-3-25**] PT-18.8* PTT-58.2* INR(PT)-1.8*
[**2189-3-26**] PT-16.4* PTT-65.5* INR(PT)-1.5
[**2189-3-28**] 07:10AM BLOOD PT-17.9* PTT-150* INR(PT)-1.7
.
[**2189-3-23**] Glucose-111* UreaN-19 Creat-1.0 Na-136 K-4.5 Cl-98
HCO3-27 Calcium-9.4 Phos-3.5 Mg-2.0
[**2189-3-24**] Glucose-117* UreaN-16 Creat-1.0 Na-136 K-4.4 Cl-101
HCO3-26 Calcium-9.1 Phos-3.6 Mg-2.1 Cholest-142
[**2189-3-25**] Glucose-97 UreaN-18 Creat-0.9 Na-135 K-4.7 Cl-99
HCO3-26 Calcium-8.6 Phos-3.1 Mg-2.1
[**2189-3-26**] Glucose-128* UreaN-17 Creat-0.9 Na-134 K-4.3 Cl-100
HCO3-22
[**2189-3-28**] Glucose-124* UreaN-18 Creat-1.2 Na-135 K-4.4 Cl-99
HCO3-26 Calcium-9.1 Phos-3.9 Mg-2.2
.
[**2189-3-26**] 09:00AM CK(CPK)-41 CK-MB-NotDone cTropnT-0.10*
[**2189-3-26**] 07:42PM CK(CPK)-31* CK-MB-2 cTropnT-0.06*
[**2189-3-27**] 06:03AM BLOOD CK(CPK)-26* CK-MB-NotDone
*
[**2189-3-26**] 07:42PM BLOOD ALT-28 AST-24 CK(CPK)-31* AlkPhos-73
TotBili-1.9*
.
[**2189-3-24**] 08:05AM BLOOD Triglyc-95 HDL-37 CHOL/HD-3.8 LDLcalc-86
[**2189-3-26**] 07:42PM BLOOD TSH-2.0
.
[**3-27**] CXR: [**Month (only) 116**] be minimal edema in the lower lungs. Upper lungs
clear. Heart size is normal. There is no pleural effusion.
.
[**3-26**] Cardiac Catheterization:
report not finalized
Brief Hospital Course:
71 year old male with HTN, hyperlipidemia, possible CAD (EKG
with poor R wave progression, EF 30%) transferred from OSH with
Atrial flutter/atrial fibrillation.
.
#. CAD - no known CAD although patient with risk factors: former
tobacco, EKG with poor R wave progression, EF 30%. Continued
aspirin and statin dose increased from 10 to 40mg qday. Holding
on ACE Inhibitor during hospitalization. He underwent cardiac
catheterization on [**3-26**] with stents placed to LAD and left
circumflex coronary arteries.
.
#. Pump - Echo at OSH with EF 30%. Held ACE Inhibitor in
setting of cardiac catheterization. Mild volume overload on
admission resolved with lasix. Patient should likely have
repeat ECHO as outpatient.
.
#. Rhythm - In Atrial flutter on admission that was very
difficult to rate/rhythm control despite diltiazem drip and
beta-blockers. He underwent atrial flutter ablation on [**3-24**].
He converted to sinus rhythm, but then [**Doctor First Name **] into atrial
fibrillation with rapid ventricular response. He under went
cardiac catheterization as above (once INR < 1.5) and load on
amiodarone in the CCU post-cath. On [**3-27**], he converted to sinus
rhythm on amiodarone and beta-blockers. He was monitored on
telemetry throughout hospitalization. Coumadin was held prior
to cathaterization and he was bridged with heparin drip during
this time. Coumadin was started post-cath. His INR on
discharge was 1.8. He is to bridge with lovenox at home and
have outpatient primary care physician follow INR as outpatient
and adjust coumadin, stop lovenox once INR therapeutic. He is to
continue amiodarone taper as outpatient.
.
# COPD - started on advair and combivent inhalers at OSH. Also
underwent pulmonary function tests at OSH.
.
#. PPx: anticoagulated on heparin gtt/coumadin, PPI
.
#. FULL CODE
.
#. Dispo: patient was discharged to home with primary care and
cardiology follow-up. He was instructed to have INR blood
levels drawn every 3 days as an outpatient until INR
therapeutic. He will bridge with lovenox until INR therapeutic
and received lovenox teaching. He is to continue amiodarone
taper as outpatient.
Medications on Admission:
Medications on transfer:
cardizem gtt 8mg/hr
coumadin (on hold since [**3-21**])
heparin gtt
combivent 2 puffs inh qdaily
advair 250/50 inh [**Hospital1 **]
lasix 20mg po qdaily
lisinopril 2.5mg po qdaily
lopressor 50mg po qdaily
KCl 10mEq qdaily
ASA 81 qdaily
xanax prn
protonix 40mg po qdaily
.
home medications:
ASA 81mg qdaily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*6*
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-6**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath.
Disp:*qs 1 month * Refills:*3*
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400mg (2 tablets) twice daily for 5 days,
then take 400mg once daily for 7 days, then take 200mg daily
indefinitely thereafter.
Disp:*120 Tablet(s)* Refills:*0*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime: You
must have your blood INR level checked frequently while taking
this medication.
Disp:*60 Tablet(s)* Refills:*2*
8. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous twice
a day for 5 days: Have your INR checked while taking this
medication and stop using the medication when INR is greater
than 2.
Disp:*10 * Refills:*1*
9. Outpatient Lab Work
You must follow up on Monday [**2189-3-27**] at an outpatient lab to
have your blood INR level checked. You should continue to have
this level checked 3 times per week. Please send these results
to Dr. [**Last Name (STitle) **] (phone [**Telephone/Fax (1) 5003**]; fax [**Telephone/Fax (1) 9672**]) and Dr.
[**Last Name (STitle) 11250**] (phone [**Telephone/Fax (1) 11254**]). They will give you
instructions regarding adjusting your coumadin dose and when to
stop taking Lovenox.
10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
coronary artery disease
atrial flutter
atrial fibrillation
congestive heart failure EF 30%
COPD
Discharge Condition:
stable, ambulating, breathing comfortably on room air
Discharge Instructions:
Please call your primary care physician or call 911 if you
experience chest pain, shortness of breath, palpitations, leg
swelling, bleeding, or other concerning symptoms.
.
You have been started on new medications. It is very important
to continue to take your plavix every day to keep your stent
open. Amiodarone was started to help control your heart
rate/rhythm. This will be decreased over the next couple of
weeks (please follow the prescribed instructions).
.
A medication called coumadin has also been started. This is a
blood thinner. You must follow up on Monday [**2189-3-27**] at an
outpatient lab to have your blood INR level checked. You should
continue to have this level checked 3 times per week. Please
send these results to Dr. [**Last Name (STitle) **] (phone [**Telephone/Fax (1) 5003**]; fax
[**Telephone/Fax (1) 9672**]) and Dr. [**Last Name (STitle) 11250**] (phone [**Telephone/Fax (1) 11254**]).
.
You will also take Lovenox until your blood INR level is found
to be greater than 2 on coumadin. Please discuss with Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) 11250**] to determine when the Lovenox can be
discontinued.
Followup Instructions:
Please schedule a follow-up with a primary care physician. [**Name10 (NameIs) **]
you need a primary care physician you can be seen at the [**Hospital1 **] and can schedule an outpatient appointment at
[**Telephone/Fax (1) 250**].
.
We have started a medication called coumadin. It is important
that you get your blood drawn to check your coumadin level in 3
days after discharge from the hospital. Please go to the
nearest blood draw center and have these results sent to your
primary care physician.
.
Please schedule a follow-up appointment with Electrophysiology.
Completed by:[**2189-3-29**]
|
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icd9cm
|
[
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] |
icd9pcs
|
[
[
[]
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9802, 9808
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5218, 7373
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334, 429
|
9948, 10004
|
3203, 5195
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,724
| 131,406
|
34604
|
Discharge summary
|
report
|
Admission Date: [**2149-8-4**] Discharge Date: [**2149-8-8**]
Date of Birth: [**2074-9-22**] Sex: M
Service: NEUROLOGY
Allergies:
Codeine / NSAIDS / lamotrigine
Attending:[**First Name3 (LF) 848**]
Chief Complaint:
Altered Mental Status, Speech Difficulty, Right-sided tremor
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname 79408**] is a 74 y/o right handed man with a complex past
medical history who comes in today for speech difficulty and
right side clonic movements. He was recently discharged from our
inpatient service for non-convulsive status. He has since been
stable with reports of no seizures but of lately has had his
dilantin titrated down given a high level. His phenytoin level
at Quest lab on [**2149-7-15**] was 26.3. He was titrated down from
100/100/200. On [**2149-7-25**], his phenytoin level was 29.3
and his dilantin was decreased further. Currently he is taking
dilantin at 100 TID. This morning at 8 am he took all his
morning medications and about 30 min afterward was noted by his
wife to be saying "hey, hey, hey" She asked what was going on,
and he said "I think, I think, I think". The wife knew that he
was having a seizure so gave him two 100mg dilantin pills, one
0.25 clonazepam dose, and one 1500mg Keppra dose. She called Dr.
[**Last Name (STitle) **] who referred them to our ED. Aside from his speech
difficulties which were both expressive and receptive per
reports she also noted right hand/arm and right foot clonic
movements that have not subsided by the time he was seen here.
Here the patient had no acute complaints except his right arm
movements and he himself noted that his speech was off. His wife
reported that his speech
had improved from the time he left home but still with both
expressive and receptive deficits. He noted no pain and no new
weakness. The wife noted no new weakness as well, she states
that he required some assistance with going down stairs when he
was placed in the car. No missed doses noted, no fever, no
cough, was not complaining of anything over the proceeding days.
No missed
doses of medications except as directed (Last Thursday was told
to hold a dose given the dilantin level).
The patient's neurologic history begins around [**2143**] and [**2144**]. He
first began to notice difficulty with walking as well as marked
difficulty sensation in his left leg. His sensation was
predominantly inability knowing where his leg was in space as
well as numbness. He was worked up for this and was found to
have a meningioma in his thoracic spine at T8-T9. This was
operated on and removed and he had improvement in his
functioning of the lower extremities; however, it was
complicated by a MRSA infection. This infection was discovered
while he was at rehab status post the surgery. The infection
continued to get worse and he was transferred to a nearby
hospital. The infection became systemic and he required an ICU
stay. During this time, he was noted to have a generalized
seizure and they believe he was started on seizure medications
at that time in the form of Keppra. He eventually overcame the
systemic infection and was discharged to a rehab; however, he
was soon returned to the hospital after he had a reported
stroke.
We are not completely clear on the details of the stroke and
whether this was an actual stroke or seizure. Dr. [**Last Name (STitle) 11903**] notes
that in [**2143**], an MRI was done which showed bilateral occipital
FLAIR hyperintensities, right worse than left, which was more
consistent with a diagnosis of PRES. In addition, there was a
note of a T2 right parietal lobe hyperintensity and it was
unclear if this was part of the PRES or an ischemic event;
however, there was no evidence of restricted diffusion.
The patient was discharged from the hospital and rehab on Keppra
and continued to do well on his current dose for the next three
years. He denied any symptoms during this time. No loss of
consciousness, no episodes of shaking no focal weakness and no
tremor or gait difficulty.
His history picks up again around [**2146**], when he had a sudden
onset of language difficulties. These were described by his
family as he was talking in gibberish and could not think of the
words that he wanted to produce. There were unsure if he had
any comprehension at that time. He was hospitalized and worked
up for a stroke; however, it was felt that this was more likely
due to seizures.
His medications were titrated up and he was released. For the
rest of [**2146**] and [**2147**], the patient had multiple similar
episodes, which were thought to be seizures. Every two to four
months, the patient be rehospitalized and his medications would
be altered in some fashion. On some occasions, the Keppra was
up titrated and on other occasions it was down titrated. There
was one episode of a seizure where the patient mistakenly
thought he was supposed
to be on 750 mg b.i.d., when in fact he was found to be on a
higher dose. These episodes occurred intermittently until early
in [**2148-11-17**], when he had another episode.
He at that time was referred to Dr. [**Last Name (STitle) **] who began to change
his antiepileptic medications. He at this time had lamotrigine.
The patient did well until [**Month (only) 116**] when he began to have more
frequent seizures and was hospitalized then transferred to [**Hospital1 18**]
for management of refractory seizures.
The hospitalization was quite extended at [**Hospital1 18**] and he was
admitted on [**2149-4-8**], and eventually discharged on [**2149-5-15**]. Initially, he had presented to another outside hospital
with confusion and right arm and leg myoclonic jerking over his
baseline right hand tremor. His seizures were difficult to
control and a number of medications were made stopping Zonegran
and starting Topamax and increasing his dose of Keppra. As his
seizures were not improving, he required a neuro ICU stay.
Phenytoin was added. Initially, the patient was noted to be
very inattentive, perseverative could not follow commands as
well as
having a fluent aphasia.
He had quite extensive workup including a negative infectious
workup in the CSF, an empiric treatment for meningitis,
encephalitis, MRIs of the brain, which showed some interval
atrophy of the left cerebral hemisphere which raised the
concerns for possible atypical [**Doctor Last Name **] encephalitis or
another
inflammatory encephalitis. A brain biopsy was performed, which
only showed reactive changes and no evidence CBD or other
telepathies and it did not give a clear diagnosis. He was
eventually controlled and discharged from the ICU on Keppra,
phenytoin and extended lorazepam. Additionally, he was given a
course of five days of IV methylprednisone, which have been
correlated to an interval improvement in his seizures and exam.
As the improvement was limited, he then underwent a five days of
IVIG treatment for this presumed autoimmune or para neoplastic
encephalitis. His condition has gradually improved after these
treatments and he stopped having seizures and was eventually
discharged to rehabilitation.
He had an autoimmune and paraneoplastic panel sent his serum and
CSF all of which have been negative including anti NMDA,
anti-[**Last Name (un) **] serum antibodies. He had a negative VGKC antibody
test and included in the paraneoplastic panel. He had negative
[**Doctor First Name **] 1, 2 and 3 antibodies, negative anti-glial antibodies,
negative
Purkinje cells, cytoplasmic antibodies, negative amphiphysin,
negative CRNP, negative test for myasthenia, negative VGKC
antibodies. Negative PQ and striatal muscle antibodies and
negative. Negative GAD antibodies.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, vertigo. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence. On
general review of systems, the pt denies recent fever or chills.
No night sweats or recent weight loss or gain. Denies cough,
shortness of breath. Denies chest pain. Denies nausea,
vomiting, diarrhea. No recent change in bowel or bladder
habits. No dysuria. Denies arthralgias or myalgias. Denies
rash.
Past Medical History:
SEIZURE Hx:
Multiple complex partial seizures sometimes with secondary
generalization: 1st Sz [**10/2144**],
Semiology: garbled speech, disorientation,
currently on: Keppra, Zonegran,
AEDs in past:
Lamictal --> d/c [**12-19**] tremors
T8-T9 extramedullary intradural thoracic meningioma sp resection
in [**2143**] c/b seroma at the site of his surgical incision found to
be growing MRSA.
DVT in [**2144-10-17**]; ? PE (no documentation)
? PRES : [**2144-10-17**] (MRI of the brain that showed increased
T2 hyperintensities in the bilateral occipital and posterior
right parietal lobe consistent with posterior reversible
encephalopathy syndrome)
Vertebral artery stenoses (b/l)
Tremor (thought to be medication related and not parkinsonian,
large amplitude)
Neuropathy: burning in toes bilaterally
HTN - Amitriptyline
HL - Lipitor,
PVD - left leg bypass done by Dr. [**First Name (STitle) 10378**] in [**Hospital1 1474**] for 65%
stenosis of a right leg artery.
Hx of asystole 30secs, requiring chest compressions
Social History:
He finished high school. He was a former butcher and is now
retired. Married to [**Doctor Last Name 2048**]. Does not smoke cigarettes, drink
alcohol, or use any illegal drugs. He had no learning
disabilities.
Family History:
His maternal uncle had 2 children and both of these cousins had
epilepsy. The patient himself has no history of birth
complications, or head trauma.
Physical Exam:
Vitals: 97.9 75 170/94 16 96%
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM.
Neck: No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT.
Extremities: No edema or deformities.
Skin: no rashes or lesions noted.
Neurologic: his Neuro Exam fluctuated a [**Hospital1 **] during the
evaluation:
Specifically with language.
-Mental Status: Alert, oriented to self, date but not the
hospital name which he says he never remembers. When given a
choices he was able to pick out [**Hospital1 **]. Able to relate history
somewhat but with difficulty and would refer to his wife. Unable
to do digit span foreward beyond three numbers. His
conprehension
waxed and waned, worse towards the end. At first was able to
answer and follow simple commands although his speech output was
sparse would say " to bad this hand", Right thumb, this". Would
get most one step commands, but not two step commands. He got
confused when trying to test praxis. He had difficulty naming
hand, finger (eventually got them), named thumb not no other
fingers. Was able to name [**Last Name (un) 2753**] as the president but then could
not remember past that.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF; He seems to have decreased
blink to threat coming from the right.
III, IV, VI: EOMI without nystagmus. Square wave jerks present,
limit on up gaze.
V: Facial sensation intact to light touch.
VII: No facial droop on smile.
VIII: decreased hearing on the right to finger rub.
IX, X: Palate elevates symmetrically but problem with guttural
sounds
[**Doctor First Name 81**]: 5/5 strength in trapezii bilaterally.
XII: Tongue protrudes in midline with clumsy side to side
movements.
-Motor: Normal bulk, tone increased on the right with
cogwheeling with contralateral activation. Right foot 4 hz [**1-19**]
cm clonic movements and similar movements in the right hand.
Strength was full on the left right, except Right hand movements
which because of the clonic movements were not able to be
tested.
-Sensory: Decreased on the right to PP, LT. With extinction
(right) to DSS.
-DTRs: [**Name2 (NI) **] 2 throughout except the ankles (0). Plantar
response was extensor on the right, equivical on the left.
-Coordination: Bilateral tremor postural. Also thumb rolling
tremor seen at the end of the exam on the right. Had trouble
understanding me at the end with finger nose finger.
-Gait: not tested
DISCHARGE EXAM:
***************
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM.
Neck: No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT.
Extremities: No edema or deformities.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self, date but needed prompt
for hospital name which he identified out of 4 hospitals. Able
to relate history, appropriately answer questions with only
minor errors, some [**12-19**] poor hearing. Comprehension was improved
as also noted by the patient's wife who stated "he's more with
it than he is at home". Follows most multistep commands, only
minor right/left confusion. Named both high and low frequency
items, good knowledge of recent events.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF
III, IV, VI: EOMI without nystagmus. Square wave jerks present,
limit on up gaze.
V: Facial sensation intact to light touch.
VII: No facial droop on smile.
VIII: Decreased hearing bilaterally, worse on the right to
finger snapping.
IX, X: Palate elevates symmetrically but some trouble with
guttural sounds
[**Doctor First Name 81**]: 5/5 strength in trapezii / SCM bilaterally.
XII: Tongue protrudes in midline with clumsy side to side
movements.
-Motor: Normal bulk, tone increased bilaterally.
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: Decreased on the right to pinprick, light touch. All
other modalities and locations intact.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was extensor on the right, equivical on the
left.
-Coordination: Bilateral tremor postural notable most
prominently in right thumb. Finger nose finger intact
bilaterally with increased tremor.
-Gait: Ataxic, wide based with short steps
Pertinent Results:
[**2149-8-7**] 05:50AM BLOOD WBC-6.8 RBC-4.31* Hgb-13.8* Hct-41.5
MCV-97 MCH-32.0 MCHC-33.2 RDW-13.1 Plt Ct-156
[**2149-8-4**] 11:45AM BLOOD WBC-3.9* RBC-4.98# Hgb-16.1# Hct-46.7#
MCV-94 MCH-32.3* MCHC-34.5 RDW-13.2 Plt Ct-166
[**2149-8-6**] 09:30AM BLOOD Neuts-55.3 Lymphs-34.4 Monos-5.7 Eos-4.2*
Baso-0.3
[**2149-8-4**] 11:45AM BLOOD Neuts-52.0 Lymphs-39.5 Monos-5.4 Eos-2.4
Baso-0.8
[**2149-8-7**] 05:50AM BLOOD Plt Ct-156
[**2149-8-5**] 04:24AM BLOOD PT-23.1* PTT-38.4* INR(PT)-2.2*
[**2149-8-7**] 05:50AM BLOOD Glucose-123* UreaN-18 Creat-1.1 Na-143
K-4.2 Cl-107 HCO3-30 AnGap-10
[**2149-8-5**] 04:24AM BLOOD Glucose-143* UreaN-14 Creat-0.9 Na-140
K-3.8 Cl-105 HCO3-27 AnGap-12
[**2149-8-7**] 05:50AM BLOOD ALT-51* AST-46* LD(LDH)-140 AlkPhos-121
TotBili-0.2
[**2149-8-5**] 04:24AM BLOOD ALT-53* AST-44* LD(LDH)-145 AlkPhos-129
TotBili-0.2
[**2149-8-7**] 05:50AM BLOOD Albumin-3.4* Calcium-10.1 Phos-4.1 Mg-1.7
[**2149-8-5**] 04:24AM BLOOD Albumin-4.0 Calcium-10.2 Phos-2.8 Mg-1.7
Cholest-151
[**2149-8-5**] 04:24AM BLOOD Triglyc-72 HDL-51 CHOL/HD-3.0 LDLcalc-86
[**2149-8-5**] 04:24AM BLOOD %HbA1c-5.9 eAG-123
[**2149-8-7**] 05:50AM BLOOD Phenyto-13.1
[**2149-8-4**] 11:45AM BLOOD Phenyto-16.8
[**2149-8-4**] 11:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2149-8-4**] 11:59AM BLOOD Glucose-118* Na-144 K-4.3 Cl-100
calHCO3-30
CHEST PA/LAT IMPRESSION: Heart size and mediastinum are stable.
Lungs are well aerated with improvement of basal opacities on
the current study, most likely consistent with improvement of
atelectasis/aspiration. No new consolidations have developed.
No appreciable pleural effusion or pneumothorax is seen.
MRI HEAD IMPRESSION: Stable appearance of cerebral atrophy,
predominantly affecting the left temporal lobe and left
hemisphere. Study is limited due to patient motion.
EEG IMPRESSION: This is an abnormal continuous ICU monitoring
study because of the bilateral independent-appearing abnormality
in background rhythm suggesting multifocal pathology and deep
midline pathology. The left lateral temporal region predominates
followed by the left central region. Superimposed upon this is a
periodic lateralized epileptiform discharge maximum in the
posterior quadrant on the left side. No clearly sustained
electrical or clinical seizure activity was recorded.
Brief Hospital Course:
Mr. [**Known lastname 79408**] is a 74 y/o RH man with history of seizures and
progressive left hemisphere atrophy possibly [**12-19**] auto-immune
process presented to ED yesterday after wife heard him
perseverating, repeating non-sensical statements over and over,
also found to have worsened right arm weakness, increased over
known baseline weakness, and tremor.
# Neurologic:
Code stroke was called, but stroke fellow felt presentation was
more c/w status epilepticus [**12-19**] rhythmic movements in hands and
mouth. Admitted to epilepsy for further w/u, but on floor was
found to have altered mental status with poor comprehension,
disorientation; was found to be hypertensive to the 200s/100s.
Received 10mg IV hydralazine after 5mg IV metoprolol which did
not improve BP. Transferred to ICU with unclear etiology of AMS
with differential including status, CVA, ICH, PRES, and
toxic/metabolic/infectious etiologies.
He was monitored on vEEG for >24 hrs which showed PLEDS but no
seizures. He recieved Dilantin 150mg TID, increased to Keppra 2g
[**Hospital1 **] from 1.5g, and Clonazepam 1mg TID from [**Hospital1 **]. Dilantin levels
were consistently measured within theraputic levels.
After one day of ICU management, the patient was transferred to
the floor and was noted to have SBP within 120-140s. His
cognitive status was noted to improve.
# CVS:
After the patients initial hypertensive episodes requiring ICU
monitoring, Mr. [**Known lastname 79408**] was restarted on Lisinopril 20 mg PO
BID and Metoprolol Tartrate 75 mg PO BID with Hydralazine IV for
breakthrough SBP > 180. BP in the ICU improved to between
110-159/49-60, and has been 120-140s systolic throughout the
course of the inpatient floor stay. EKG was obtained which
showed V1-V2 Q-waves likely indicative of previous ischemia,
however no ectopy or other acute abnormalities were noted on
telemetry.
# Respiratory:
Mr. [**Known lastname 79408**] was noted to have apneic episodes over the course
of his evenings which were coincident with desaturations to 88%
at most. Of note, the patient has not had any formal sleep
evaluation; therefore, an appointment was scheduled for him for
a sleep study with possible CPAP placement for apnea.
Transitions of Care:
- The patient was noted to have apneic periods throughout the
course of the hospitalization. A sleep study has been scheduled
for the patient through [**Hospital1 18**] sleep center on [**2149-9-2**] @
9:30pm.
- Please monitor the patient's oxygen saturations overnight and
provide supplemental oxygen as necessary.
Medications on Admission:
- Atorvastatin 80 daily
- Clonazepam 0.25 [**Hospital1 **]
- Colchicine
- Lunesta 3mg HS
- Keppra 1500 mg [**Hospital1 **]
- Lisinopril 20 [**Hospital1 **]
- Metoprolol 75 [**Hospital1 **]
- Omeprazole 20
- Dilantin 100 TID
- Trazadone 100 HS
- Coumadin 5mg Daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain or temp >100.4
2. Atorvastatin 80 mg PO DAILY
3. B-12 DOTS *NF* (cyanocobalamin (vitamin B-12)) 1000 mcg Oral
Daily Reason for Ordering: Wish to maintain preadmission
medication while hospitalized, as there is no acceptable
substitute drug product available on formulary.
4. Clonazepam 1 mg PO TID
Hold for RR<12
5. LeVETiracetam [**2136**] mg PO BID
6. Lisinopril 20 mg PO BID
Hold for SBP <105
7. Omeprazole 20 mg PO DAILY
8. Phenytoin (Suspension) 150 mg PO Q8H
9. traZODONE 100 mg PO HS
10. Warfarin 5 mg PO DAILY16
11. Ondansetron 4 mg PO Q8H:PRN Nausea
12. Multivitamins 1 TAB PO DAILY
13. Metoprolol Tartrate 75 mg PO BID
Hold for HR<60 or SBP<105
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were evaluated at [**Hospital1 69**] for
your complaint of right arm weakness, repeating non-sensical
statements, and tremor which were concerning for ongoing seizure
activity. We performed an MRI study of the brain which showed
some abnormalities which were unchanged from previous studies.
We evaluated your cardiac activity with an EKG which showed no
acute findings suggesting new onset heart damage. We also
performed an EEG study which did not show any specific
seizure-related abnormality, although findings consistent with
multiple areas of abnormal brainwave patterns consistent with
the MRI findings.
We also had our physical therapists work with you; they
recommended you continue rehabilitation at a facility for a
short term after your discharge. Please follow up with your
appointments as scheduled below once you have completed your
rehabilitation which will not be longer than 30 days.
Because of the risk of future seizures, you must take the
following SEIZURE PRECAUTIONS:
- You cannot drive a motor vehicle for at least 6 months after
your last seizure during which you had impairment of
consciousness (a staring spell or full loss of consciousness).
- Avoid swimming in a pool or body of water unattended.
- When using the bathroom at home, please do not lock the door
(so that if you have a seizure someone can reach you).
- Do not climb to high heights (e.g. trees, ladders, etc.).
- Do not engage in activities where temporary impairment of
consciousness might cause you to fall or be placed in a
dangerous position.
As notice to the rehabilitation facility, please monitor the
patient's oxygen saturations overnight and provide supplemental
oxygen as necessary. He has been scheduled for an outpatient
sleep study to assess for sleep apnea.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2149-10-10**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 857**]
Date/Time:[**2149-12-1**] 11:30
A sleep study has been tenatively scheduled for you at BIDH -
[**Hospital 620**] Campus Lab [**Street Address(2) **]., [**Location (un) 620**], [**Numeric Identifier 3002**]
Tel: [**Telephone/Fax (1) 79409**]
Fax: [**Telephone/Fax (1) 79410**]
Completed by:[**2149-8-8**]
|
[
"V58.61",
"443.9",
"786.03",
"272.4",
"V12.51",
"345.3",
"331.9",
"274.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20175, 20272
|
16568, 18799
|
350, 356
|
20325, 20325
|
14203, 16545
|
22278, 22857
|
9536, 9688
|
19451, 20152
|
20293, 20304
|
19163, 19428
|
20478, 22255
|
12928, 14184
|
9703, 10069
|
12169, 12425
|
250, 312
|
384, 8248
|
20340, 20454
|
18820, 19137
|
8270, 9289
|
9305, 9520
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,969
| 178,748
|
47116
|
Discharge summary
|
report
|
Admission Date: [**2136-3-19**] Discharge Date: [**2136-3-30**]
Date of Birth: [**2073-12-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
lower extremity swelling
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Enteroenterostomy of afferent pancreaticobiliary drainage
limb.
3. Placement of a feeding jejunostomy tube into the afferent
limb distal to the stomach.
History of Present Illness:
62 yo F w/ metastatic pancreatic cancer s/p Whipple procedure in
[**2131**] currently C1D19 Gemcitabine presenting with 2-3 weeks of
leg swelling. She reports ~3 weeks of lower extremity swelling.
Per her oncologist, the swelling preceded initiation of
gemcitabine chmotherapy. She denies pain but feels that her legs
are heavy and she is having difficulty ambulating. She denies
redness, warmth, fevers, chills, sweats. She reports that the
amount of swelling has remained stable but over the past day her
legs have been blistering and weeping so she came to the ED.
She denies trauma. She denies shortness of breath, chest pain,
palpitations, PND, orthopnea, cough. She denies change in
urinary output, hematuria.
.
In the ED, she was HD stable with O2 Sats 100% RA. She was given
40 mg IV lasix.
Past Medical History:
Ms. [**Known lastname 14840**] has chronic pancreatitis with exocrine
and endocrine insufficiency, status post Whipple surgery by Dr.
[**Last Name (STitle) 468**] in [**9-22**]. Pathology from this surgery revealed chronic
pancreatitis as well as low-grade dysplasia, pancreatic
intraepithelial neoplasm. Prior to surgery, her CA-19.9 was
measured at 13. She was doing fairly well until [**2-24**], when she
noted weight loss and abdominal pain similar to her previous
pancreatitis pain. At that time, MRI abdomen was notable for an
irregular duct but no stricture at the pancreaticojejunostomy
site. By [**5-25**], her CA [**47**]-9 has risen from 13 to 143 as well as
her CEA was elevated at 4.6. She had an EGD/[**Last Name (un) **] on [**2135-6-14**],
notable for gastritis. She continued to note weight loss and
pain, so she had a CTA abd in [**9-25**] notable for a pancreatic
tail mass extending into the mesentery, occluding the splenic
vein and encasing the splenic artery. She underwent an EGD and
EUS which showed a 3 cm hypoechoic mass in the body of the
pancreas in [**10-25**]. FNA was c/w adenocarcinoma. She was seen by
Dr. [**Last Name (STitle) 468**] who felt she was not a surgical candidate. She
started C1 Gemcitabine on [**2136-3-1**]. Her first cycle has been c/b
low counts, thrush treated with fluconazole and lower extremity
edema. She received C1D15 Gemcitabine on [**2136-3-15**].
.
PMH:
1. Chronic Pancreatitis as above. S/P Whipple in [**9-22**]. Now with
exocrine and endocrine dysfunction.
2. HTN
Social History:
(+) tobacco use - 20 pack year - currently [**4-26**] cigarettes per
day. She has no h/o alcohol use. She lives alone in [**Location (un) 2498**].
Family History:
Her mother and sister had breast cancer. Her mother's mom had
stomach cancer and her mother's brother had liver cancer.
Physical Exam:
VITAL SIGNS: Blood pressure 132/79 , pulse 76 , temperature
96.6, O2 sat 100 RA, respirations 12.
GENERAL: cachectic, NAD, alert and oriented x3.
HEENT: Pupils are equal and reactive to light. Extraocular
movements are intact bilaterally. dry MM. [**12-24**] pearly nodules on
tongue.
NECK: Supple. JVP - flat.
NODES: No supraclavicular, submandibular, cervical, axillary,
or inguinal lymphadenopathy.
LUNGS: Clear to auscultation bilaterally. No w/c/r.
HEART: Regular rate and rhythm. nl s1, s2. No S3, S4. no m/g/r.
ABDOMEN: Thin, Soft, nondistended. No hepatosplenomegaly. Mild
pain to palpation LUandLLQ. No masses palpated. No
rebound/guarding.
EXTREMITIES: Cool, 3+ edema feet and ankles, symmetric, pitting.
No palpable cords or calf tenderness. 2x3cm macular rash on left
foot and Weeping blisters on tops of feet. No redness, warmth.
SKIN: Otherwise without lesions except ecchymoses on UE.
Neuro: CN 2-12 intact. UE [**3-24**]. LE - quads/hamstrings/DF/PF - [**3-24**]
if isolate and support feet which she reports are too heavy.
Unable to wiggle toes due to swelling.
Pertinent Results:
CXR - The cardiomediastinal silhouette is within normal limits,
and there is no pulmonary vascular congestion, pleural effusion,
or other evidence of CHF. Evidence of hyperinflation.
.
CT ABDOMEN/PELVIS [**2136-3-20**]:
1. Dilated loop of excluded jejunum (s/p Whipple), which may be
due to the necrotic pancreatic tail mass, an adhesion, or
stricture/
swelling at the anastomotic site. This loop does appear to be
compressing the IVC at the level of the aortic bifurcation,
though no significant venous collaterals are seen suggesting
that there is not complete occlusion.
2. Mild right hydronephrosis and hydroureter of unknown
etiology.
3. Necrotic pancreatic tail mass which appears slightly smaller
than the prior exam, however, this may be due to distortion of
abdominal contents due to the dilated small bowel loops.
4. Persistently thrombosed splenic vein with heterogeneous
enhancement of the spleen.
5. Multiple hypodensities within the liver are poorly evaluated
due to contrast timing, however remain worrisome for metastases.
.
CXR [**2136-3-28**]: There has been further improved aeration in the left
lower lobe since the recent chest radiograph of [**2136-3-26**] and
more marked improvement when compared to the earlier radiograph
of [**3-21**]. Right lung is clear. Bilateral pleural effusions are
present, left greater than right.
IMPRESSION: Continued improved aeration in left lower lobe.
Bilateral
pleural effusions, left greater than right.
.
[**2136-3-29**] CT ABDOMEN/PELVIS:
1. No definite thrombosis is noted within the IVC to suggest
thrombosis;
however, the infrarenal IVC is being pressed by a dilated loop
of jejunum,
which is unlikely to cause IVC obstruction since there is no
collateral
formation and no distal dilatation of iliac veins.
2. New interval development of moderate bilateral pleural
effusion and
massive ascites and anasarca suggest volume overload
state/heart failure as the cause of lower extemity edema .
3. Unchanged appearance of mild right hydronephrosis and
hydroureter of
unknown etiology.
4. Unchanged appearance of necrotic pancreatic tail mass.
5. Small hypodense liver lesion within the dome of the liverthat
is too small to characterize.
Brief Hospital Course:
A/P: 62 yo F w/ pancreatic cancer on C1D19 Gemcitabine with
several weeks of LE swelling. Following admission, patient
underwent work-up for lower extremity edema. Ultrasound of the
lower extremities was performed and negative for DVT. CT of her
abdomen and pelvis revealed IVC compression by obstructed
afferent loop due to necrotic adenocarcinoma in tail of the
pancreas. EGD was performed but not amenable to stent across
obstruction. Following discussion with patient and family
regarding pursuing comfort measures care versus surgical
decompression, patient opted to undergo surgical intervention.
Enteroenterostomy of afferent pancreaticobiliary drainage limb
was performed, along with placement of a feeding jejunostomy
tube into the afferent limb distal to the stomach. IVC filter
was placed on the firt post-operative day. Her post-operative
course was complicated by hypothermia, hyponatremia, and
hypoglycemia. She was treated with a 7-day course of
peri-operative prophylactic anbtibiotics. She was transferred
back to the Oncology service on post-op day 5. The following is
an outline of her ongoing medical issues:
.
1) Hyponatremia: Serum sodium nadired at 126 in the
post-operative course. Calculated FeNa 0.7 points to effective
intravascular volume depletion. She was treated with normal
saline, NaCl tablets and free water restriction. On day of
discharge, her sodium serum was stable at 131.
.
2) Generalized anarsarca: She developed new pleural effusions,
ascites, and generalized anasarca in the post-operative period,
likely the result of her hypoalbuminemia. She also had some
intermittent and persitent lower extremity edema
post-operatively, likely the result of dependent edema. She was
treated with albumin infusion with concomitant lasix x 3 days
with good result. Leg edema was complicated by 4 areas of stage
II skin breakdown over her distal lower extremities. Leg edema
improved with elevation of her extremities.
.
3) Thrombocytopenia - Patient's platelets trended down from >500
on admission to 114. Lovenox was temporarily discontinued and
heparin dependent antibody was sent. Heparin dependent antibody
returned with negative result. A second test was pending at the
time of discharge, and Lovenox was resumed.
.
4) Pancreatic insufficiency - Patient is s/p whipple with
insulin dependence. Prior to her surgical intervention, she was
found unresponsive with a blood glucose of 11; it is unknown how
long she had been hypoglycemic. This event occurred after
receiving Lantus 3 units. Her mental status improved with D50
infusion. All insulin was discontinued following this event.
She continued to have interval hypoglycemia post-operatively.
Following transfer back to the Oncology service, her blood
glucoses were persistently between 300-500, and she was
restarted on a Humalog sliding scale. Prior to discharge, [**Last Name (un) **]
Diabetes was consulted and recommended that she resume Lantus 2
units qAM plus the prescribed sliding scale.
.
5) Pancreatic cancer - Further chemotherapy deferred until
completion of wound healing and pending further discussion with
her Oncologist. .
.
6) Pain control - She was managed with PRN Dilaudid in the
peri-operative period. She was later transitioned to her
previous regimen of MScontin once able to swallow pills.
.
7) Prophylaxis - Patient with hypercoagulable state with
underlying malignancy. Given her minimal subcutaneous tissue
for medication administration, she was maintained on Lovenox at
prophylaxis dosing. Lovenox was temporarily held with concern
for HIT but was resumed prior to discharge. She is was
maintained on PPI as GI prophylaxis and Acyclovir as HSV
prophylaxis given her immunocompromised status.
.
8) FEN - Patient is chronically malnourished. During her
surgical procedure, placement of a feeding jejunostomy tube into
the afferent limb distal to the stomach was accomplished. Per
recommendations from Nutrition consultant, she was titrated to
tube feed goal of full-strength Impact at 35 cc/hour. She also
continues to tolerate a regular PO diet.
.
9) Skin breakdown: Wound care consultant recommends foam
dressing to partial-thickness breakdown of coccyx with change q
3 days. She also has 4 small areas of skin breakdown over
distal lower extremities, secondary to profound edema.
Recommend Adaptic non-adherent dressing, covered with dry gauze
and Kerlex wrap, no tape on skin. Recommend daily changes to
lower extremity dressing. Advise pressure relief and good skin
moisturization.
10) Code status: DNR/DNI.
Medications on Admission:
MSCONTIN 30 [**Hospital1 **]
Percocet for breakthrough
Lantus 3 qhs
Humalog [**2141-3-29**]
Compazine
Creon
Fluconazole 200 daily
Acyclovir 400 tid
Nystatin
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
2. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
6. 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)).
7. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
9. Lantus 100 unit/mL Solution Sig: Two (2) units Subcutaneous
qAM.
10. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
11. Humalog 100 unit/mL Solution Sig: Per sliding scale
Subcutaneous qACHS.
12. Sodium Chloride 1 g Tablet Sig: Two (2) Tablet PO Q6 ().
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for breakthrough pain.
14. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 7168**]
Discharge Diagnosis:
1. Metastatic pancreatic cancer
2. Chronic pancreatitis
3. Pancreaticobiliary limb obstruction with closed loop
obstruction causing vena caval compression.
4. Post-op Hypoglycemia
5. Post-op Hypothermia
6. Pancreatic insufficiency
7. Hyponatremia
Discharge Condition:
Guarded
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* New chest pain, pressure, squeezing or tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
Continue to ambulate several times per day.
.
When you're resting, it is helpful to keep your legs elevated to
limit the swelling.
.
YOUR STAPLES CAN BE REMOVED ON [**2136-4-10**].
Followup Instructions:
You are scheduled to follow-up with Dr. [**Last Name (STitle) **] in the Deparment
of Surgery on [**2136-4-20**] at 9 a.m. His office is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building on the [**Hospital1 18**] [**Hospital Ward Name 516**]. Please
call ([**Telephone/Fax (1) 2828**] with any questions or concerns.
.
You are scheduled to follow-up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] and
Dr. [**First Name4 (NamePattern1) 5557**] [**Last Name (un) **] on [**2136-4-11**] at 1 p.m. Please call
[**Telephone/Fax (1) 22**] if you have questions.
|
[
"459.2",
"276.1",
"198.89",
"401.9",
"707.03",
"444.89",
"799.4",
"997.4",
"197.6",
"197.5",
"287.5",
"305.1",
"261",
"707.12",
"157.2",
"112.0",
"251.2",
"560.89",
"787.6",
"496",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.91",
"45.13",
"38.7",
"33.24",
"46.39",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12650, 12738
|
6578, 11141
|
341, 529
|
13029, 13039
|
4342, 6555
|
14170, 14822
|
3094, 3217
|
11348, 12627
|
12759, 13008
|
11167, 11325
|
13063, 14147
|
3232, 4323
|
277, 303
|
557, 1358
|
1380, 2913
|
2929, 3078
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
99
| 187,373
|
48110
|
Discharge summary
|
report
|
Admission Date: [**2184-7-29**] Discharge Date: [**2184-8-4**]
Date of Birth: [**2111-4-7**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
male admitted to [**Hospital1 69**] due to
new onset of angina and a positive stress test.
He was fine until approximately two weeks prior to
presentation when he started developing exertional chest
pain. The pain resolved with rest. He had a stress test
which showed inferolateral ST changes. An echocardiogram was
negative for ischemia. Ejection fraction was 60%. The
patient had a catheterization which showed 3-vessel disease.
He was referred to Cardiothoracic Surgery.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Basal squamous cell skin cancer.
3. Hemorrhoids.
PAST SURGICAL HISTORY:
1. Status post hemorrhoidectomy
2. Status post tonsillectomy and adenoidectomy.
3. Status post knee arthroscopy.
ALLERGIES: SULFA, SHELL FISH, and DYE.
MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o. q.d.,
Lopressor 25 mg p.o. b.i.d., Zestril 10 mg p.o. q.d., Centrum
p.o. q.d.
PHYSICAL EXAMINATION ON PRESENTATION: Blood pressure
was 155/76, heart rate was 48. Chest was clear to
auscultation bilaterally. Cardiovascular revealed a regular
rate and rhythm. Extremities were well perfused, no edema.
The abdomen was soft, nontender, and nondistended.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 13.3,
hematocrit was 46.2, platelets were 230. Sodium was 138,
potassium was 4.7, chloride was 101, bicarbonate was 26,
blood urea nitrogen was 19, creatinine was 1.2. INR was 0.9.
HOSPITAL COURSE: The patient was taken to the operating
room on [**2184-7-29**] where he had a coronary artery bypass
graft times three with left internal mammary artery to left
anterior descending artery, saphenous vein graft to obtuse
marginal, saphenous vein graft to ramus. The operation was
without complications. Pacing wires as well as chest tube
were placed intraoperatively. The patient was transferred to
the Surgical Intensive Care Unit in stable condition.
On postoperative day one, the patient was afebrile. Vital
signs were stable. He was extubated without complications.
His chest tube was removed successfully.
On postoperative day two, the patient remained afebrile.
Vital signs were stable. His intravenous line and Foley were
removed. The patient was transferred to the floor.
On postoperative day three, the patient remained afebrile.
Vital signs were stable. He started working with Physical
Therapy. He complained about pain and weakness in his left
arm. The patient reported it was worse immediately
postoperatively and slowly improved with time. On serial
examinations which were performed, the patient's strength had
improved over the preceding two days.
On postoperative day four, an Occupational Therapy
consultation was obtained who found that the patient did not
need immediate Occupational Therapy treatment at this time.
Their recommendation was to follow up on an outpatient basis
in two to three weeks if he did not recover significantly at
this time. The patient remained afebrile. Vital signs were
stable. He was exercising with Physical Therapy. No
concerns. No active issues.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was discharged to home without
[**Hospital6 407**].
DI[**Last Name (STitle) 408**]E FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (Prefixes) **] in four weeks for a postoperative check. The
patient was to follow up with his primary care physician in
two to three weeks for his left arm numbness and weakness; if
symptoms do not improve at that time, he may request referral
to the outpatient Occupational Therapy.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. b.i.d. (times seven days).
2. Potassium chloride 20 mEq p.o. b.i.d. (times seven days).
3. Zantac 150 mg p.o. b.i.d.
4. Enteric-coated aspirin 325 mg p.o. q.d.
5. Percocet one to two tablets p.o. q.4h. as needed.
6. Tylenol 650 mg p.o. q.4-6h. as needed.
7. Lopressor 25 mg p.o. b.i.d.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; stabilized.
2. Status post coronary artery bypass graft times three.
3. Hypercholesterolemia.
4. Hypertension.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 15509**]
MEDQUIST36
D: [**2184-8-3**] 18:32
T: [**2184-8-3**] 19:32
JOB#: [**Job Number **]
|
[
"V10.83",
"414.01",
"401.9",
"782.0",
"413.9",
"600.0",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.22",
"88.56",
"36.12",
"36.15",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
4180, 4582
|
3845, 4159
|
991, 1658
|
1677, 3304
|
806, 964
|
3319, 3819
|
178, 688
|
710, 783
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,416
| 108,341
|
44577
|
Discharge summary
|
report
|
Admission Date: [**2153-6-5**] Discharge Date: [**2153-6-8**]
Date of Birth: [**2071-9-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Dyspnea and fatigue
Major Surgical or Invasive Procedure:
Shocked x1 when in VT
History of Present Illness:
Pt. is an 81 yo female with pmh of diastolic HF, HTN, afib, and
tchy/brday syndrome s/p pacer placement [**2-20**] recently admitted
this month for dyspnea who comes in complaining of one week of
increasing fatigue, dyspnea, and productive cough. She reports
that she was improved upon last discharge last week, but since
has noted worsening SOB at rest and upon exertion, fatigue, and
productive cough. She reports that she has been taking her
medications as directed. She denies other upper respiratory
symptoms, PND, LE edema, CP, palpitations, abd pain, f/c, n/v,
other focal signs of infection. She chronically unable to lay
flat because of dizziness. She reports constipation with no BM
for the past week. Because of this her appetitie has been
decreased, though she is still taking PO fluid.
.
In the ED her CXR was unchanged. First set of CEs were flat. EKG
revealed baseline LBBB. She was seen by cardiology who requested
admission to check pacer.
.
ROS: Negative for fevers, chills, chest pain, shortness of
breath, cough, abdominal pain, nausea, vomiting, diarrhea,
dysuria. Otherwise negative in detail.
Past Medical History:
1. Chronic diastolic heart failure
2. Hypertension
3. Paroxysmal atrial fibrillation - on amiodarone treatment
between [**1-/2153**] and [**2-/2153**], then discontinued due to her
history of lung interstitial disease
4. Tachy-brady syndrome s/p dual chamber pacemaker placement
[**2-20**]
3. TIA 17 years ago
4. Hypercholesterolemia
5. Osteoporosis
6. Hypothyroidism (recently diagnosed)
7. Left cataract surgery in [**2149**]
8. Left ankle surgery status post fracture 20 years ago
9. S/p appendectomy
Social History:
Social history is significant for the absence of current tobacco
use. The patient had smoked previously and quit 24 years ago.
There is no history of alcohol abuse. The patient is retired and
lives in an independent living community. Had worked as a
bookkeeper.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her mother passed away at 88 years of age from
Alzheimer's disease. Father passed away at 88 years of age from
Parkinson's disease. Brother passed away at 60 years of age from
myocardial infarction. Brother passed away at 87 years of age
from a stroke.
Physical Exam:
VS: 98.3 104/48 65 18 93%RA
GEN: Well-appearing, NAD
HEENT: Sclera anicteric, PERRL, EOMI, OP clear, MMM
NECK: Supple, no LAD, no increased jvd
CV: RRR, distant, no M/G/R
PULM: CTAB, no W/R/R
ABD: Soft, distended, NT, ND, +BS
EXT: No C/C/E
NEURO: AAOx3, CN II-XII grossly intact, moving all extremities
well
Pertinent Results:
STUDIES:
CXR [**2153-6-5**]: (dictation). pacemaker with unchanged leads. minor
linear atelectasis. No acute cardiopulmonary abnormality
.
CXR [**2153-6-7**]:
FINDINGS: In comparison with the study of [**6-7**], there is a
somewhat better
inspiration but otherwise little change. Again there is evidence
of elevated pulmonary venous pressure with bilateral pleural
effusions and bibasilar atelectasis. The cardiac silhouette is
at the upper limits of normal in size and the pacemaker device
remains in place. Endotracheal tube and nasogastric tube are in
similar position.
.
Abdominal film [**2153-6-7**]:
IMPRESSION: Progressive distention of small and large bowel,
most likely
representing worsening ileus. However, given this interval
progression, close interval follow up is recommended, as a
mechanical bowel obstruction cannot be entirely excluded.
.
Cardiac cath [**2153-6-7**]:
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Reduced left ventricular function with apical hypokinesis.
3. Cardiogenic shock with cardiac index from 1.8-2.0 l/min/m2.
4. Slight improvement in pulmonary artery saturation and cardiac
index
with reduction of alpha pressor agents.
.
Echo [**2153-6-7**]:
IMPRESSION: Hyperdynamic biventricular systolic function with
moderate LVOT obstruction and moderate mitral regurgitation at
the pacing rate of 100 bpm. Lessened LVOT obstruction and mitral
regurgitation with pacing rate of 80 bpm.
Compared with the prior study (images reviewed) of [**2153-1-26**], LV
function is more hyperdynamic and LVOT obstruction is
identified. Mitral regurgitation is now more severe.
.
Labs
[**2153-6-5**] 06:00PM BLOOD CK-MB-6 proBNP-371
[**2153-6-5**] 06:10PM BLOOD cTropnT-<0.01
[**2153-6-6**] 01:15AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2153-6-6**] 10:25AM BLOOD CK-MB-5 cTropnT-<0.01
[**2153-6-5**] 06:00PM BLOOD CK(CPK)-138
[**2153-6-6**] 01:15AM BLOOD CK(CPK)-67
[**2153-6-6**] 10:25AM BLOOD CK(CPK)-65
.
[**2153-6-5**] 06:00PM BLOOD WBC-9.8# RBC-4.41 Hgb-13.0 Hct-39.1
MCV-89 MCH-29.4 MCHC-33.2 RDW-13.6 Plt Ct-279
[**2153-6-5**] 06:00PM BLOOD Glucose-69* UreaN-31* Creat-1.2* Na-129*
K-6.6* Cl-92* HCO3-22 AnGap-22*
[**2153-6-5**] 06:00PM BLOOD PT-38.0* PTT-44.9* INR(PT)-4.1*
.
[**2153-6-8**] 03:22AM BLOOD WBC-5.1# RBC-2.99*# Hgb-9.0* Hct-28.6*
MCV-96 MCH-30.1 MCHC-31.4 RDW-14.0 Plt Ct-94*#
[**2153-6-8**] 03:22AM BLOOD Glucose-266* UreaN-42* Creat-2.6* Na-140
K-4.4 Cl-102 HCO3-13* AnGap-29*
[**2153-6-8**] 03:22AM BLOOD Calcium-6.0* Phos-5.0* Mg-1.8
[**2153-6-8**] 03:22AM BLOOD PT-97.6* PTT-91.4* INR(PT)-12.9*
[**2153-6-8**] 03:22AM BLOOD ALT-[**Numeric Identifier 95461**]* AST-8452* LD(LDH)-9135*
AlkPhos-54 TotBili-0.7 DirBili-0.3 IndBili-0.4
[**2153-6-8**] 04:01AM BLOOD Lactate-13.3*
[**2153-6-8**] 04:01AM BLOOD Type-ART pO2-62* pCO2-25* pH-7.19*
calTCO2-10* Base XS--16
Brief Hospital Course:
The patient was an 81 yo female with h/o diastolic HF(EF 70%),
HTN, afib, and tachy/brady syndrome s/p pacer placement [**2-20**] who
was admitted for lethargy and SOB with plans to interrogate her
pacemaker to look for an arrhythmia. Her pacemaker was
interrogated and no abnormalities were found. She was ruled out
for an MI with 3 sets of negative cardiac enzymes. Her CXR was
negative for PNA. Her cough and SOB was thought to be secondary
to bronchitis. She complained of urinary frequency and
suprapubic tenderness and had a UTI with no signs of an upper
tract infection. Her UTI was treated with ciprofloxacin.
.
During her hospitalization she was constipated with abdominal
distention and a KUB revealed dilated loops of small bowel. She
had not had a bowel movement for one week prior to admission and
was started on colace, senna, miralax, and a bisacodyl
suppository. On the evening of the [**2153-6-6**] she complained of
nausea and on the morning of [**2153-6-7**] she had an episode of
straining in the bathroom and was found down in her room. Code
blue was called and she was coded for PEA arrest. She received
3mg epinephrine, 1 mg atropine, 3 amps of bicarb, dextrose,
insulin, calcium for a potassium of 5.7 which was 3.8 upon
rechecking. During her PEA arrest, she had an episode of VT
which was shocked x 1 to sinus rhythm. EP was called to bedside
and paced her at 110. After aproximately 15 minutes of CPR, she
regained her pulse. She was started on dopamine, levophed on the
floor. BP stabilized in the systolic 80-90s, she was intubated
on AC and requiring high levels of PEEP. She was transferred to
the CCU.
.
While in the CCU she was in NSR in the 80s and captured at 60.
Her abdomen was distended and she required multiple pressors.
The event precipitating the PEA arrest was unclear. [**Name2 (NI) **] shock
was treated with pressors and IVF. She was emprirically covered
with vancomycin, cipro, and flagyl. She also received a bicarb
drip for mixed acidosis. Her CXR showed fluid overload but she
continued to be given IVF aggresively due to her hypotension.
The patient was also in ARF in the setting of her shock. A KUB
showed dilated loops of small bowel with no clear evidence of
obstruction but it could not be excluded. Surgery was consulted
but the patient was not stable enough for any surgical
intervention. A CT scan of her abdomen was necessary to
evaluate her adominal process however despite frequent
re-evaluations the patient was never stable enough to tolerate
going for a CT scan.
.
We communicated with her daughter, [**Name (NI) **] [**Name (NI) **], throughout her
stay in the CCU and initially the patient was full code. During
the course of the evening and early morning the patient required
blood transfusions for a dropping HCT. In the early morning of
[**2153-6-8**] when the patient was requiring blood transfusions and
continuing to require pressors, the daughter told the team over
the phone that her mother would not want this and that she
wanted to change her mother's code status to CMO and DNR. The
daughter came into the hospital accompanied by other family
members. At that point the family requested we stop her
pressors and the blood transfusions. The patient remained
intubated. The patient expired shortly afterwords and the
family decided not to have an autopsy.
Medications on Admission:
1. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
5. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Calcium Oral
9. Vitamin D Oral
10. Disopyramide 100 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
11. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
12. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient Expired
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
Completed by:[**2153-8-6**]
|
[
"428.32",
"272.4",
"244.9",
"584.9",
"515",
"V45.01",
"733.00",
"V12.54",
"276.2",
"564.00",
"V58.61",
"518.81",
"427.1",
"599.0",
"427.31",
"428.0",
"496",
"401.9",
"785.51",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"88.56",
"89.45",
"88.53",
"37.23",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10256, 10265
|
5850, 9204
|
333, 356
|
10324, 10341
|
3010, 3897
|
10406, 10451
|
2326, 2666
|
10216, 10233
|
10286, 10303
|
9230, 10193
|
3914, 5827
|
10365, 10383
|
2681, 2991
|
274, 295
|
384, 1501
|
1523, 2028
|
2044, 2310
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,817
| 190,258
|
10354
|
Discharge summary
|
report
|
Admission Date: [**2153-12-19**] Discharge Date: [**2153-12-24**]
Date of Birth: [**2092-5-30**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: No medical history until
[**2153-9-15**] when she presented to her primary care
physician with complaints of right upper and lower extremity
weakness of approximately three weeks duration. An MRI done
at an outside hospital on [**2153-10-11**], reportedly
showed four enhancing lesions (lesion #1 is the largest
lesion, measuring approximately 14 mm X 14 mm X 8.0 mm in the
left thalamic region with surrounding edema extending to the
left mid brain with compression.)
At that time the patient had no pulmonary complaints, but a
chest x-ray on [**10-11**], demonstrated a right upper lobe
lesion with a question of mediastinal adenopathy and a chest
CT scan performed the next day revealed a 3.7 cm X 2.4 cm
right upper lobe mass with right hilar, precarinal
lymphadenopathy. Together these findings are suspicious for
a primary lung cancer. An initial bronchoscopy was
unsuccessful. On repeat bronchoscopy, there are clusters of
atypical glandular cells, suspicious for adenocarcinoma.
Mrs. [**Known lastname **] was administered approximately fourteen doses in
all. Her last dose was in late [**2153-10-15**].
She subsequently completed a Decadron prior to considering
chemotherapy. Mammography demonstrated two lesions on the
right breast. A chest CT scan demonstrated a right upper
lobe mass, but no mediastinal lymphadenopathy and low
attenuation lesions of the liver, suspicious for primary lung
carcinoma. CT scan guided biopsy of the chest lesion was
performed at [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] on
[**2153-12-18**]. The procedure was complicated by a small
persistent right apical pneumothorax. At the time of
admission, pathology was still pending.
On the day of admission, the patient was watching television
at home. She was in her usual state of health. She was
noted to be "zoned out" and staring blankly into space. Her
head turned to the right side and she had a generalized
tonoclonic seizure for at least several seconds. The
patient's husband could not recall the duration of seizure
activity. The patient and her husband, who witnessed the
seizure, denied any urinary or bowel incontinence.
The patient was taken to the Emergency Department where she
went for a head CT scan to evaluate. She apparently had a
second seizure while in the CT scan room. A medical
emergency was called, the patient was given 2.0 mg of IV
Ativan. She later received an additional 3.0 mg of IV
Ativan. After the head was examined, she was reported to be
somnolent with a respiratory rate ranging from 8 to 12
breaths per minute.
At that point, she was taken to the Medical Intensive Care
Unit for observation. In the Medical Intensive Care Unit,
her blood pressure responded to intravenous fluid
resuscitation. She had no further seizure activity while in
the Medical Intensive Care Unit.
PAST MEDICAL HISTORY: Metastatic cancer, brain and liver,
presumably from the right lung mass. Details described in
history of present illness.
ADMITTING MEDICATIONS: Formally on Decadron, tapered off in
mid [**Month (only) **]. No other medications.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is originally from County [**Doctor First Name **] in
[**Country 4754**]. She is married. She has a distant history of
tobacco use.
FAMILY HISTORY: No history of cancer.
PHYSICAL EXAMINATION: Temperature 98.6 F, blood pressure
124/70, heart rate 82 and regular, respiratory rate 18
breaths per minute. In general, she was somnolent, opens her
eyes to noxious, but not verbal stimuli. She does not follow
commands during the examination. Pupils are equal, round,
and reactive to light, extraocular movements are intact
without nystagmus. The trachea was midline. The neck was
supple without lymphadenopathy. The heart was regular in
rate and rhythm, there were normal first and second heart
sounds, no murmurs, rubs, or gallops. The lungs had
decreased breath sounds diffusely, but no crackles or wheezes
were appreciated. There was a poor inspiratory effort. The
abdomen was soft and nontender, there were normoactive bowel
sounds.
The extremities were warm with palpable peripheral pulses and
without edema. No lymph nodes were appreciated.
Neurologically she was not oriented to person, place, or
time. Cranial nerves II through XII are grossly intact. The
examination was limited due to lack of cooperation on the
patient's part. Muscle tone was markedly increased in the
right lower extremity. It was impossible to perform a
thorough motor / sensory examination secondary to patient's
inability to follow commands. Deep tendon reflexes were 2+
and symmetric.
LABORATORY DATA: Laboratory values on [**12-19**] were
notable for a white count of 9.1 with 89% neutrophils and 7%
lymphocytes, hematocrit 38.9%. PT 12.3, PTT 27. Sodium 137,
potassium 3.7, chloride 101, bicarbonate 24, BUN 11,
creatinine 0.7, glucose 151. ALT 15, AST 19, alkaline
phosphatase 81, albumin 4.0, amylase 43, total bilirubin 0.4,
lipase 37.
Laboratory values on [**12-20**] were notable for a white
count of 5.6, hematocrit 35.6, platelets 220,000. Sodium
137, potassium 3.7, chloride 101, bicarbonate 25, BUN 11,
creatinine 0.7, glucose 151. Dilantin 17.7 (normal value of
Dilantin is [**11-3**]).
The head without contrast on [**12-19**] demonstrated a 13 mm
X 18 mm mass with high attenuation in the left frontal lobe
with associated edema, extending to the cerebral peduncle.
No frank hemorrhage or midline shift was appreciated. X-ray
demonstrated a small apical pneumothorax post lung biopsy,
which is unchanged from the previous x-ray two days ago.
Pathology per the lung biopsy came back positive for a
non-small cell adenocarcinoma.
HOSPITAL COURSE: Mrs. [**Known lastname **] was transferred from the
Medical Intensive Care Unit to the OMED service for further
management of her adenocarcinoma. She was started on
Decadron and Dilantin for seizure prophylaxis and reduction
of cerebral edema associated with her metastatic disease.
She remained without seizure activity for the duration of her
stay on the OMED service. Her mental status gradually
cleared during the course of her stay on the OMED service.
It was thought that her initial decline in mental status was
due to the combination of the high dose of intravenous Ativan
she received immediately following her seizure and the
effects of cerebral edema. As the Decadron had a chance to
take effect and the Ativan had a chance to be metabolized,
her mental status improved.
At the time of discharge, her mental status was back to
baseline. Her neurological examination at the time of
discharge was notable for: alert and oriented to person,
place, and time with good naming and short-term and long-term
memory. Cranial nerves II through XII were intact. Motor
strength was [**4-19**] on the right side and [**5-19**] on the left side.
Her examination was grossly normal. Hemodynamically her
blood pressure remained stable throughout her admission on
the OMED service. She did not require any intravenous fluid
or medications.
DISCHARGE MEDICATIONS: Decadron 6.0 mg qid, Protonix 40 mg q
day, Dilantin 300 mg q HS.
DISCHARGE DIAGNOSIS:
Metastatic non-small cell adenocarcinoma.
FOLLOW UP: Mrs. [**Known lastname **] will follow up in the [**Hospital **] Clinic
on [**12-27**], with her oncologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3274**].
[**Name (STitle) 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3282**]
Dictated By:[**Last Name (NamePattern1) 7787**]
MEDQUIST36
D: [**2153-12-24**] 09:59
T: [**2153-12-24**] 10:32
JOB#: [**Job Number **]
|
[
"780.39",
"198.3",
"197.7",
"162.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.03",
"88.91"
] |
icd9pcs
|
[
[
[]
]
] |
3500, 3523
|
7289, 7355
|
7376, 7419
|
5920, 7265
|
7431, 7895
|
3546, 5902
|
162, 3032
|
3055, 3327
|
3344, 3483
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,867
| 104,935
|
50820+59286
|
Discharge summary
|
report+addendum
|
Admission Date: [**2130-5-23**] Discharge Date: [**2130-6-15**]
Date of Birth: [**2070-8-30**] Sex: F
Service: PLASTIC
Allergies:
Amoxicillin / aspirin / Tylenol / lisinopril / Augmentin
Attending:[**First Name3 (LF) 36263**]
Chief Complaint:
Suicide attempt with tylenol/benzo overdose and self inflicted
bilateral wrist lacerations
Major Surgical or Invasive Procedure:
[**2130-5-23**]
1. Exploration complex laceration left wrist.
2. Repair ulnar artery with reverse interposition vein graft
from dorsum left foot.
3. Repair complex laceration left wrist.
.
[**2130-6-6**]
1. Irrigation and debridement of skin, subcutaneous tissue,
flexor tendon.
2. Left open carpal tunnel release.
.
[**2130-6-12**]
1) Left below elbow amputation, left upper extremity.
2) Removed neuromas, removed nerve x6, left forearm.
History of Present Illness:
59F s/p suicide attempt with presumed Tylenol and Klonopin
overdose as well as wrist lacerations. Patient has history of
depression and anxiety but she stopped her medications about 3
weeks ago because she didn't think it was working and so she
weaned herself off. She was found by EMS at mid-day on [**5-22**] and
taken to [**Hospital **] Hospital. She was taken for surgical repair of her
wrist lacerations early in the morning of [**5-23**]. She was deemed
unfit to consent for the procedure by the psychiatry service.
She remained intubated following surgery for her mental status.
Per report, she was initially A&O x 3. Following surgery she was
obtunded. Her LFTs spiked significantly between her admission
and the following morning. Her acetaminophen level on admission
was 33, and 15 on redraw. She was transferred to the SICU at
[**Hospital1 18**] for evaluation of acute liver failure.
Past Medical History:
lupus
scleroderma
depression/anxiety (prior suicide attempt [**9-14**])
HTN
PUD prior GIB
endometriosis
Raynauds disease
.
PSH: unknown
Social History:
SH: Prior suicide attempts. [**Known firstname 4457**] owns her home and works FT for
a limo company making reservations. She is a former (25 years
ago) RN. [**Known firstname 4457**] has a
company vehicle. Her roommate [**Doctor First Name 4051**] doesn't drive and doesn't
have a vehicle. [**Known firstname 4457**] is single, has one son [**Doctor Last Name **] but there is
a restraining order against him because he is physically
abusive, her parents are deceased, and she has no siblings. [**Known firstname 4457**]
smokes "a lot" of cigarettes a day but doesn't use any other
drugs that her friends know of and she is not a drinker.
Physical Exam:
Vitals: 103.8 125 108/72 28 100% on AC 100/450 x 20/5 wt 72kg
General: intubated, sedated, opens eyes minimally to voice
.
RUE
Laceration over volar wrist closed with intact sutures.
Dopperable radial and ulnar pulses as well as superficial arch.
Arm, forearm and hand compartments soft. Digits warm and
well-perfused with cap refill < 2sec.
.
LUE
Laceration over volar wrist closed with intact sutures. No
dopperable ulnar pulse. Weak dopplerable superficial arch. Arm,
forearm and hand compartments soft. Index, long, ring, and small
fingers mottled to palmar crease. Poor cap refill >2sec.
Pertinent Results:
ADMISSION LABS:
[**2130-5-23**] 06:20PM GLUCOSE-150* UREA N-30* CREAT-2.3* SODIUM-141
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-18* ANION GAP-17
[**2130-5-23**] 06:20PM ALT(SGPT)-[**2041**]* AST(SGOT)-1337* ALK PHOS-56
TOT BILI-0.6
[**2130-5-23**] 06:20PM CALCIUM-8.0* PHOSPHATE-3.1# MAGNESIUM-1.6
[**2130-5-23**] 06:20PM ACETMNPHN-9*
[**2130-5-23**] 06:20PM WBC-17.0* RBC-2.88* HGB-8.6* HCT-26.7* MCV-93
MCH-29.9 MCHC-32.2 RDW-14.4
[**2130-5-23**] 06:20PM PLT COUNT-105*
[**2130-5-23**] 06:20PM PT-16.2* PTT-37.5* INR(PT)-1.5*
[**2130-5-23**] 06:20PM FIBRINOGE-338
[**2130-5-23**] 03:58PM TYPE-ART PO2-154* PCO2-33* PH-7.32* TOTAL
CO2-18* BASE XS--8
[**2130-5-23**] 03:58PM LACTATE-1.1
[**2130-5-23**] 03:58PM freeCa-1.07*
[**2130-5-23**] 03:36PM URINE HOURS-RANDOM UREA N-263 CREAT-140
SODIUM-28 POTASSIUM-96 CHLORIDE-<10 AMYLASE-427 TOT PROT-35
CALCIUM-6.4 PHOSPHATE-42.3 MAGNESIUM-5.8 URIC ACID-10.4 TOTAL
CO2-LESS [**First Name8 (NamePattern2) **] [**Doctor First Name 674**]/CREAT-3.1 PROT/CREA-0.3*
[**2130-5-23**] 03:36PM URINE OSMOLAL-374
[**2130-5-23**] 03:36PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2130-5-23**] 03:36PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2130-5-23**] 03:36PM URINE RBC-5* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
[**2130-5-23**] 03:36PM URINE GRANULAR-4* HYALINE-4*
[**2130-5-23**] 03:36PM URINE MUCOUS-RARE
[**2130-5-23**] 01:10PM TYPE-ART PO2-356* PCO2-30* PH-7.33* TOTAL
CO2-17* BASE XS--8
[**2130-5-23**] 01:10PM LACTATE-1.0
[**2130-5-23**] 12:56PM TYPE-[**Last Name (un) **] PO2-54* PCO2-40 PH-7.31* TOTAL
CO2-21 BASE XS--5
[**2130-5-23**] 12:56PM TYPE-[**Last Name (un) **] PO2-54* PCO2-40 PH-7.31* TOTAL
CO2-21 BASE XS--5
[**2130-5-23**] 12:56PM freeCa-1.10*
[**2130-5-23**] 12:40PM GLUCOSE-125* UREA N-32* CREAT-2.9* SODIUM-138
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-19* ANION GAP-15
[**2130-5-23**] 12:40PM estGFR-Using this
[**2130-5-23**] 12:40PM ALT(SGPT)-2376* AST(SGOT)-[**2124**]* LD(LDH)-2404*
ALK PHOS-54 AMYLASE-496* TOT BILI-0.4
[**2130-5-23**] 12:40PM LIPASE-66*
[**2130-5-23**] 12:40PM CK-MB-14* cTropnT-0.03*
[**2130-5-23**] 12:40PM ALBUMIN-2.5* CALCIUM-7.7* PHOSPHATE-1.2*
MAGNESIUM-1.7
[**2130-5-23**] 12:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-11 bnzodzpn-POS
barbitrt-NEG tricyclic-NEG
[**2130-5-23**] 12:40PM WBC-14.3* RBC-3.22* HGB-9.9* HCT-30.1* MCV-93
MCH-30.7 MCHC-33.0 RDW-14.0
[**2130-5-23**] 12:40PM NEUTS-87.5* LYMPHS-8.5* MONOS-3.7 EOS-0
BASOS-0.2
[**2130-5-23**] 12:40PM PLT COUNT-127*
[**2130-5-23**] 12:40PM PT-20.0* PTT-40.8* INR(PT)-1.9*
[**2130-5-23**] 12:40PM FIBRINOGE-281
[**2130-5-23**] 12:38PM URINE HOURS-RANDOM CREAT-137 SODIUM-29
POTASSIUM-96 CHLORIDE-<10 CALCIUM-6.7
[**2130-5-23**] 12:38PM URINE HOURS-RANDOM CREAT-137 SODIUM-29
POTASSIUM-96 CHLORIDE-<10 CALCIUM-6.7
[**2130-5-23**] 12:38PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
.
DISCHARGE LABS:
[**2130-6-11**] 05:40AM BLOOD WBC-15.2* RBC-3.21* Hgb-9.7* Hct-30.4*
MCV-95 MCH-30.1 MCHC-31.8 RDW-15.4 Plt Ct-594*
[**2130-6-11**] 05:40AM BLOOD Glucose-83 UreaN-4* Creat-0.6 Na-136
K-3.9 Cl-101 HCO3-24 AnGap-15
[**2130-6-8**] 02:04AM BLOOD ALT-63* AST-31 AlkPhos-68 TotBili-0.7
[**2130-6-11**] 05:40AM BLOOD Albumin-3.0* Calcium-9.2 Phos-3.5 Mg-1.5*
.
CARDIOLOGY;
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
75%). Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets (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 mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
.
RADIOLOGY
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2130-5-23**]
4:19 PM :
IMPRESSION:
1. No acute intracranial process.
2. Prominence of the ventricles and sulci, inappropriate for
the patient's age.
.
[**2130-5-27**] 12:51 am URINE Source: Catheter.
**FINAL REPORT [**2130-5-31**]**
URINE CULTURE (Final [**2130-5-31**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ 8 S <=2 S
AMPICILLIN/SULBACTAM-- 4 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 32 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 2 S
Brief Hospital Course:
She was admitted to the SICU at [**Hospital1 18**] on [**2130-5-23**]. The NAC drip
was continued and she was evaluated by transplant surgery and
hepatology. She was deemed not a transplant candidate given her
suicide attempts but aggressive supportive care was maintained.
Her course, by systems:
.
Neuro: Per reports, she was AAOx3 on presentation to the OSH
but became increasingly obtunded and especially after her radial
artery repair at the OSH. At [**Hospital1 18**], she became progressively
more responsive though demonstrated limited movement of her
extremities. She received flumazenil initially and was believed
to be improving; the flumazenil was therefore held. The tylenol
level was 11 on admission (33 at the OSH) and trended downward;
the NAC drip was dc'd on [**5-25**].
On [**5-27**] she was noted to be less responsive in the AM than prior
and a STAT Head CT demonstrated no changes. She gradually
improved over the course of the day into the next morning,
following commands and ultimately moving her extremities. She
was extubated on [**2130-5-29**] and was alert and interactive though
demonstrating slight confusion. Her confusion resolved and she
was alert and oriented x 3 for the rest of the hospitalization.
.
Psych: Consulted for evaluation after extubation. They
determined the pt to be unsafe for home discharge considering
her suicide attempt. She was placed under section 12, had 1:1
sitter at all times while an inpatient. She was discharged to
inpatient psych facility following this hospitalization.
.
CV: Baseline hypertension on home atenolol but allowed to be
hypertensive to the 160s (treated with metoprolol around the
clock/labetalol only for SBP>160) to allow for improved
perfusion to the extremities. She was ultimately transitioned
to nifedipine q8 during this hospitalization and her BP was
allowed to be mildly elevated w/ sbps in 140s-150s to allow for
better perfusion of her extremities during surgery. She was
discharged with orders to restart her atenolol dose.
.
Resp: She was weaned on the vent and tolerating CPAP 5/5 as of
[**5-28**]. She was noted to have a small left apical pneumothorax on
CXR [**5-25**]. It was followed by serial CXR and had decreased in
size on [**5-26**] and remained stable. She was extubated on [**5-29**].
She was weaned successfully to room air and remained that way
during the rest of this hospitalization.
.
GI: Her LFTs trended downwards during her admission. Initially
she presented with ALT 2376 AST [**2124**] AP 54 Tb 0.4 and a lipase
of 66. By [**5-28**] ALT/AST were 432/112.
Her Tb and AP remained within normal limits. Following
administration of NAC her LFTs normalized. She was tolerating a
regular diet and having normal Bowel movements at time of
discharge.
.
GU: She was in acute renal failure on admission with a Cr of
2.9. She was hydrated with progressive improvement. Cr was 0.6
as of [**5-28**]. She received lasix 10 IV BID to good effect on
[**5-31**]. Her kidney function remained normal throughout the
rest of the admission.
.
Endo: She was maintained on RISS and methylprednisolone 12 mg
daily (to account for her home prednisone) initially then
switched to Prednisone 15mg daily, her home dose.
.
Heme: LENIS on [**5-26**] due to perceived asymmetry of RLE vs. LLE
on exam (RLE>LLE), it was negative for DVT. She was started on
a heparin drip after her ulnar artery revision on [**5-23**] and this
was continued until [**5-31**]. Patient was then maintained on
subcutaneous heparin injections and encouraged to ambulate as
much as possible during the remainder of her inpatient stay.
.
ID: Febrile on admission to 103.8. She was pan cultured
(cultures did not grow anything) and continued to spike
low-grade fevers until [**5-27**] when she spiked a temperature of
102.0. She was re-cultured again, including sputum culture, and
was started empirically on vanc/cefepime. Her urine culture
returned positive for e.coli and enterococcus which were both
pan sensitive. She completed a five day course of Ceftriaxone.
The rest of her cultures were negative during this admission.
.
Upper Extremities: As noted, she had bilateral lacerations with
repair of the radial artery injuries at the OSH. At [**Hospital1 18**], she
was urgently taken back to the OR on [**2130-5-23**] for exploration and
repair of her left ulnar and radial arteries (thrombosed).
Post-operatively, she demonstrated ischemic gangrene of the left
hand along the ulnar artery distribution. She returned to the OR
on [**2130-6-6**] for surgical debridement for necrotic tissue of the
left hand. Patient had a wound vac in place to her left hand
wound but exhibited poorly healing granulation tissue, exposed
bone, tendon and nerve. She ultimately requested a left hand
amputation after lengthy discussion of poor healing and utility
prognosis for her left hand. Patient underwent a left below
elbow amputation on [**2130-6-13**] and tolerated this well. Her left
forearm stump sutures were clean and intact upon discharge. The
patient's right hand did not require any surgical intervention
on our part and continued to heal well and gain full function
after her reparative surgery at [**State 792**]Hospital.
Medications on Admission:
1. Atenolol 50 mg PO DAILY
2. PredniSONE 15 mg PO DAILY
3. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q4H:PRN pain
4. Klonopin
(clonazepam, alprazolam, ambien, and fluvoxamine in the past)
Discharge Medications:
1. PredniSONE 15 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 600 mg PO TID
4. Nicotine Patch 14 mg TD DAILY
5. OLANZapine 2.5 mg PO HS
6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
7. Pantoprazole 40 mg PO Q24H
8. Senna 1 TAB PO BID:PRN constipation
9. Atenolol 50 mg PO DAILY
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1) acute liver failure s/p suicide attempt (acetaminophen
overdose)
2) acute renal failure
3) left hand ischemia
4) right wrist laceration
Discharge Condition:
Alert and oriented x 3
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were recently admitted to the hospital for acute liver
failure and treatment for bilateral wrist lacerations. Your
liver function recovered well and is now normalized.
Unfortunately, the damage to your left hand was irreversible and
you required an amputation to the [**Last Name (un) **] of your mid-forearm. You
have sutures in place to that wound and these will need to be
removed in 2 weeks at your follow up visit to our Hand Clinic.
Your right wrist laceration, repaired at another hospital, has
healed well and your sutures have now been removed.
.
* Your left forearm sutures may be left open to air, without a
dressing.
* If you note swelling of your left arm, then you should elevate
it above the level of your heart to help alleviate this.
* You may shower.
* You should continue to increase your walking to increase your
stamina after your inpatient hospital stay.
* Monitor your left forearm suture site for any signs of
infection; redness, increased pain at site, swelling, and
drainage. Any evidence of infection should be reported to
Plastic/Hand surgery team: [**Telephone/Fax (1) 9986**] Pager [**Numeric Identifier 88994**]
Followup Instructions:
You should follow up with Primary Care Provider after discharge
to review the details of your recent hospitalization.
.
You will need to follow up in our hand clinic in two weeks to
remove the sutures from left arm.
DATE: Tuesday, [**2130-6-27**]
TIME: 9AM
LOCATION: Dept of Orthopaedics, [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building,
[**Location (un) **]
NUMBER: ([**Telephone/Fax (1) 2007**]
The clinic is open from 8-12pm most Tuesdays. The clinic is
located on the [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **]. Please
make sure that you obtain a referral from your insurance company
prior to your clinic appointment.
Completed by:[**2130-6-14**] Name: [**Known lastname **],[**Known firstname 356**] Unit No: [**Numeric Identifier 17193**]
Admission Date: [**2130-5-23**] Discharge Date: [**2130-6-15**]
Date of Birth: [**2070-8-30**] Sex: F
Service: PLASTIC
Allergies:
Amoxicillin / aspirin / Tylenol / lisinopril / Augmentin
Attending:[**First Name3 (LF) 17194**]
Addendum:
This is an addendum to the prior discharge summary dated [**2130-6-2**]
to [**2130-6-14**].
The patient required an additional day of hospitalization due to
a lack of inpatient psychiatric beds available. She remained
stable throughout this period of time, her pain was well
controlled, and she is discharged to [**Hospital1 **] 4 inpatient
psychiatric service.
Discharge Disposition:
Extended Care
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 462**] MD [**MD Number(2) 17195**]
Completed by:[**2130-6-15**]
|
[
"296.20",
"969.4",
"V58.65",
"E950.3",
"E950.0",
"991.6",
"041.04",
"710.0",
"733.00",
"584.9",
"710.1",
"301.81",
"276.2",
"790.92",
"305.1",
"444.21",
"V58.43",
"300.00",
"296.00",
"785.4",
"881.22",
"599.0",
"570",
"401.9",
"965.4",
"903.3",
"041.49",
"V12.71",
"E956",
"309.89",
"903.2",
"572.2",
"338.29",
"V70.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.45",
"84.05",
"96.72",
"38.91",
"83.64",
"77.64",
"82.36",
"39.56"
] |
icd9pcs
|
[
[
[]
]
] |
17478, 17650
|
8682, 13898
|
408, 850
|
14666, 14781
|
3228, 3228
|
15979, 17455
|
14139, 14445
|
14504, 14645
|
13924, 14116
|
14805, 15956
|
6253, 8659
|
2614, 3209
|
278, 370
|
878, 1776
|
3244, 6237
|
1798, 1936
|
1952, 2599
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,830
| 136,134
|
9369
|
Discharge summary
|
report
|
Admission Date: [**2190-9-8**] Discharge Date: [**2190-9-10**]
Date of Birth: [**2154-5-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Upper GI bleed, Melena
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
36 y/o with PMHx of liver fibrosis s/p schistosomiasis, known
varices and s/p splenectomy who presents with black stools and
light-headedness. She reports 4 dark BMs which began last night
but denies any BRBPR. She awoke this morning with nausea and
dizziness. She denied any chest pain, shortness of breath or
syncopal episodes.
.
In the ED, initial vs were: T 98.3 HR 98 BP 103/86 RR 16 100%
RA. Pt was noted to have guiac positive black stool and hct came
back at 30 down from 39. Pt underwent NG lavage which suctioned
out 450cc of coffee ground material. She had to 2PIVs placed and
was started on octreotide and PPI gtt. She was seen by liver,
gen [**Doctor First Name **] and was cross matched for 4units of RBCs before
transfer to ICU.
.
On arrival to ICU, pt was denying nausea, chest pain or
shortness of breath. She continues to have some lightheadedness
and epigastric pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied vomiting, diarrhea or
constipation. Denied arthralgias or myalgias.
Past Medical History:
- Schistosomiasis with bridging fibrosis, portal hypertension,
s/p splenectomy, recurrent upper GI bleed [**2-8**] esophageal varices
s/p banding and splenectomy.
- Recurrent UTIs
- Spontaneous abortion in [**2188**].
- Recurrent bronchitis.
.
Social History:
Patient moved to the United States from [**Country 4194**] approximately six
years ago. She lives in [**Location 583**] with her sister. She works as
a house cleaner. She reports no alcohol or tobacco use.
Family History:
She has one uncle who is status post splenectomy for unclear
reasons.
Physical Exam:
BP:117/83 P:104 R:21 O2: 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, NG in place-coffee grounds in
tubing aNeck: 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, mild tenderness over epigastrium, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2190-9-10**] 04:00PM BLOOD Hct-29.1*
[**2190-9-10**] 06:16AM BLOOD WBC-7.0 RBC-3.34* Hgb-9.7* Hct-30.3*
MCV-91 MCH-29.0 MCHC-32.0 RDW-14.7 Plt Ct-176
[**2190-9-9**] 05:44PM BLOOD Hct-30.2*
[**2190-9-9**] 12:01PM BLOOD Hct-31.0*
[**2190-9-9**] 04:02AM BLOOD WBC-8.7 RBC-3.63* Hgb-10.7* Hct-32.7*
MCV-90 MCH-29.6 MCHC-32.8 RDW-15.0 Plt Ct-172
[**2190-9-8**] 09:37PM BLOOD Hct-32.5*
[**2190-9-10**] 06:16AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-138
K-3.8 Cl-106 HCO3-27 AnGap-9
[**2190-9-9**] 04:02AM BLOOD ALT-17 AST-22 AlkPhos-46 TotBili-1.4
[**2190-9-8**] 10:53AM BLOOD ALT-18 AST-22 CK(CPK)-95 AlkPhos-52
TotBili-0.7
[**2190-9-10**] 06:16AM BLOOD Calcium-8.3* Phos-2.1* Mg-2.1
.
RUQ u/s [**2190-9-9**] IMPRESSION:
1. Heterogenous hepatic echotexture without focal mass lesion
identified.
2. Patent hepatic vasculature with normal directional flow.
.
EGD [**2190-9-9**] Impression
Nodules in the 30-35 cm
Varices at the upper third of the esophagus and middle third of
the esophagus
Patchy areas of erythema in the fundus and antrum compatible
with portal hypertensive gastropathy
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
36 y/o F with PMhx of liver fibrosis secondary to
schistosomiasis, portal hypertension and known varices who
presented with coffee ground emesis and upper GI bleed. She was
noted to have a hct drop from baseline of 37 to 30 and mild
tachycardia. Pt was admitted to the MICU and received a total of
2u prbcs and hct went from 28 to 32. She was hemodynamically
stable overnight without melena and underwent EGD on [**2190-9-9**]
which revealed portal gastropathy but no acute source for
bleeding. Pt was advanced po diet without complication and was
transferred to the floor on [**2190-9-9**]. Serial hematocrits were
stable on the floor and pt was discharged to home on [**2190-9-10**] with
plan for outpatient liver follow up.
Medications on Admission:
Protonix 40mg daily
Propanolol 20mg daily
Discharge Medications:
1. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed for portal hypertension.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Upper GI bleed secondary to portal hypertension caused
by schistosomiasis/liver fibrosis
Discharge Condition:
Vitals stable, hematocrit stable, asymptomatic.
Discharge Instructions:
You were admitted to the hospital because you developed dark
black stools, lightheadedness and nausea. When you arrived in
the hospital, you were found to have decreased amount of bed
blood cells (Hematocrit), which was caused by a bleed in your
stomach or esophagus. You were given IV fluids and Blood
Transfusions to correct your blood loss. You were given
medicines via IV to help stop the bleed and monitored closely in
the ICU. GI doctors performed a procedure called endoscopy,
where they looked inside your esophagus, stomach and small
intestine and determined that your bleed has stopped. After
that, you started feeling much better and have not have any more
symtpoms worrysome for a bleed. Your regular diet and your home
medications were re-started.
You should re-start all your outpatient medications. We made
one change - your dose of Protonix was increased to 40mg twice a
day.
You a follow-up appointment with Dr. [**Last Name (STitle) 497**] (see below).
Because of your liver disease, you are at increased risk of
bleeding from your stomach. If you feel nausea, vomiting,
lightheadedness, dizziness, shortness of breath, black or bloody
bowel movements, blood from your mouth or nose or any other
concerning symptoms, please IMMEDIATELY return to the Emergency
Department.
Followup Instructions:
You need to follow up with Dr. [**Last Name (STitle) 497**]:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD
Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2191-2-11**] 9:00
Location:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"572.3",
"471.9",
"285.1",
"530.89",
"599.0",
"491.9",
"578.0",
"571.5",
"537.89",
"785.0",
"278.00",
"120.9",
"456.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
4975, 4981
|
3840, 4572
|
336, 365
|
5123, 5173
|
2678, 3817
|
6521, 6860
|
2054, 2126
|
4665, 4952
|
5002, 5102
|
4598, 4642
|
5197, 6498
|
2141, 2659
|
1301, 1543
|
274, 298
|
393, 1282
|
1565, 1811
|
1827, 2038
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,790
| 156,299
|
18258
|
Discharge summary
|
report
|
Admission Date: [**2178-10-28**] Discharge Date: [**2178-11-9**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year-old man
who was found on the floor the morning of admission by his
family having fallen out of bed sometime during the night,
unclear if there was loss of consciousness. He states he
felt dizzy and could not get up off the floor. He was taken
to an outside hospital where a head CT showed a right sided
acute on chronic subdural hematoma 1 to 2 cm.
PHYSICAL EXAMINATION: Pleasant elderly gentleman in no acute
distress. His pupils are equal, round and reactive to light.
Extraocular movements intact. Neck was supple. He had no
midline tenderness. Chest was clear bilaterally. Cardiac S1
and S2. Abdomen soft, nontender, nondistended. Positive
bowel sounds. Extremities erythema and some edema
bilaterally of the lower extremities left greater then right.
Neurologically awake, alert and oriented. Cranial nerves II
through XII were intact. Pupils are 2 mm and reactive.
Extraocular movements intact. Face, he had a left facial
droop and a left drift. His strength was 5 out of 5 in all
muscle groups on the Right and 5-/5 on the Left. Reflexes are 2+
and symmetric. Sensation was
intact to light touch.
HOSPITAL COURSE: He was admitted to the Trauma CICU and was
taken to the Operating Room on [**2178-10-29**] after having some
neurological deterioration with a more pronounced left facial
droop and left side weakness. He tolerated the surgery well
without
complications. He had a right bur hole drainage times two
with placement of a JP drain. Postoperatively, he was awake,
alert and oriented to person, following commands with a left
facial droop, able to raise the left arm upward. His grasp
was 5 out of 5. His IPs on the right were 4+ on the left
were 4. He was somewhat agitated with elevated blood
pressures immediately postoperative. His vital signs
remained stable. On [**2178-10-30**] he had a repeat head CT,
which showed good evacuation of the subdural hematoma and
then around 2:00 p.m. on [**10-30**] the patient had an episode of
respiratory distress with supraventricular tachycardia and
question of seizure activity. The patient was immediately
intubated and sedated and had a femoral A line placed. He
was hemodynamically unstable with drop in blood pressure and
a Dopamine drip was started. The patient was also given
Metoprolol intravenously for his supraventricular
tachycardia, which dropped his heart rate. Cardiology was
consulted on [**2178-10-31**] for episodes of recurrent
supraventricular tachycardia. He was on a Diltiazem drip.
The patient underwent cardiac ablation for his
supraventricular tachycardia with good results and resolution
of his supraventricular tachycardia. The patient tolerated
the procedure well. He was extubated on [**2178-11-1**] following
commands times four with diffuse weakness. Pupils were 2
down to 1.5 and his incision was clean, dry and intact. He
moved his feet to command and withdrew to lower stimulation,
squeeze bilateral arm. He was transferred to the regular
floor on [**2178-11-5**] where he remained neurologically stable,
awake, alert and oriented times one to two, moving all
extremities with good strength following commands times four.
Episodes of some confusion requiring placement of a Posey
restraints _, which has now been discontinued. He is out of bed
to the chair, tolerating a regular diet. Physical therapy
and occupational therapy have seen him and felt he will
require a rehab prior to discharge to home.
MEDICATIONS ON DISCHARGE:
1. Tylenol 650 mg po q 4 hours prn.
2. Levofloxacin 500 mg po q 24 hours.
3. Famotidine 20 mg po b.i.d.
4. Heparin 5000 units subq q 12 hours.
5. Hydralazine 25 mg po q 8 hours hold for systolic blood
pressure less then 100.
6. Artificial tears one to two drops q 6 hours prn.
7. Insulin sliding scale.
DISCHARGE CONDITION: The patient's condition is stable at
the time of discharge. He will follow up with Dr.
[**Last Name (STitle) 739**] in one month with a repeat head CT.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D.
[**MD Number(1) 743**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2178-11-9**] 08:55
T: [**2178-11-9**] 09:14
JOB#: [**Job Number 50381**]
|
[
"852.22",
"427.89",
"518.5",
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"414.01",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"37.26",
"96.71",
"38.91",
"37.34",
"96.04",
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
3949, 4348
|
3616, 3927
|
1296, 3590
|
530, 1278
|
114, 507
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
805
| 152,905
|
9986
|
Discharge summary
|
report
|
Admission Date: [**2159-9-16**] Discharge Date: [**2159-10-5**]
Date of Birth: [**2110-12-5**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Morphine
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Chest pain, abdominal pain
Major Surgical or Invasive Procedure:
1. Left femoral line placement with Swan Ganz.
2. Right Midline placement by interventional radiology.
3. Arterial line placement.
History of Present Illness:
48 yo man with MMP including idiopathic dilated CM w/ end stage
CHF (EF 15-20%), s/p AICD on [**2159-8-7**], chronic chest/abd pain,
s/p recent admission to [**Hospital Unit Name 196**] and d/c on [**2159-9-13**] w/ lingular PE
and renal infarct who re-presents w/ c/o continued chest and abd
pain. States that both are his chronic pain. Describes Chest
pain as L sided, non-pleuritic, no radiation to arm or jaw, no
associated diaphoresis, SOB, N/V. States abd pain is diffuse
across entire abd. Pt states both of these are his chronic abd
pain that he's had for 3 mos, and chronic CP he's had for 6 mos.
Comes to ED b/c pain is too much. Pt initially presented to [**Hospital1 112**]
[**Hospital **] transferred to [**Hospital1 18**].
.
In [**Name (NI) **], pt afebrile, SBP 90's-100's (baseline), HR 110's
(baseline), labs WNL. EKG unchanged. Bedside ECHO w/ no
pericardial effusion or dilated aorta. D/w cardiology who do not
want pt admitted to them as no further cardiac issues. Plan to
admit to medicine for likely placement.
Past Medical History:
1. CHF: Idiopathic dilated cardiomyopathy. Echo [**6-2**] with LVEF
15-20%, mild-mod MR. [**Name14 (STitle) 33421**] [**4-30**] with global hypokinesis,
moderate dilation, no perfusion defects and normal EKG. Cath
[**8-2**] with no flow limiting coronary disease, elevated right and
left sided filling pressures consistent with biventricular
diastolic dysfunction (RVEDP = 16 mmHg, LVEDP = 31 mmHg),
moderate pulmonary arterial hypertension, markedly reduced
cardiac index, and markedly elevated SVR and PVR. Dry weight is
144lbs (65.5kg).
2. NSVT: Pt with several episodes during hospitalization in [**8-2**]
and underwent AICD placement.
3. h/o STDs: MSM. +gonorrhea [**2153**]. HBV core Ab+, sAb+. HIV neg
[**7-3**], HCV neg [**7-3**].
4. RUE DVT - on coumadin
5. ? Protein C and S deficient last admit
Social History:
The patient immigrated from [**Country 5976**] in [**2149**]. He currently lives
alone in [**Location (un) 686**]. He denies any use of alcohol, tobacco or
illicit drugs. He is a man who has sex with men (see above).
Family History:
CAD - Mother died of MI in her 50s. Brothers and sisters also
have "problems with their hearts." No known history of blood
clots.
Physical Exam:
VS: T 97.4, HR 113, BP 101/87, RR 24, O2 99% on 3L NC
GEN: NAD, comfortable, Spanish-speaking gentleman, breathing
comfortably.
HEENT: PERRL. MMM. OP clear. No JVD.
HEART: tachycardic, regular rhythm, no m/r/g. Defibrillator site
c/d/i without erythema or swelling.
LUNGS: CTA B/L
ABD: soft, nondistended. Hyperactive BS. Diffuse TTP throughout
abd, but no rebound/guarding.
EXT: No edema bilat.
NEURO: AO x 3. No focal deficits
Pertinent Results:
ADMISSION LABS:
[**2159-9-15**] 11:00PM PT-17.8* PTT-32.5 INR(PT)-1.7*
[**2159-9-15**] 11:00PM PLT COUNT-423
[**2159-9-15**] 11:00PM HYPOCHROM-2+ ANISOCYT-1+ MICROCYT-1+
[**2159-9-15**] 11:00PM NEUTS-66.1 LYMPHS-24.6 MONOS-6.4 EOS-2.2
BASOS-0.8
[**2159-9-15**] 11:00PM WBC-6.4 RBC-4.43* HGB-11.9* HCT-35.9* MCV-81*
MCH-26.8* MCHC-33.1 RDW-16.6*
[**2159-9-15**] 11:00PM DIGOXIN-0.5*
[**2159-9-15**] 11:00PM ACETONE-NEGATIVE
[**2159-9-15**] 11:00PM ALBUMIN-3.5 CALCIUM-8.6 PHOSPHATE-2.5*
MAGNESIUM-1.9
[**2159-9-15**] 11:00PM CK-MB-NotDone
[**2159-9-15**] 11:00PM cTropnT-<0.01
[**2159-9-15**] 11:00PM LIPASE-35
[**2159-9-15**] 11:00PM ALT(SGPT)-34 AST(SGOT)-24 CK(CPK)-45 ALK
PHOS-147* AMYLASE-43 TOT BILI-0.8
[**2159-9-15**] 11:00PM GLUCOSE-135* UREA N-13 CREAT-0.8 SODIUM-135
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-17* ANION GAP-16
[**2159-9-15**] 11:17PM LACTATE-2.1*.
.
DISCHARGE LABS:
[**2159-10-5**]: WBC 6.8, Hct 27.4, Hgb 8.9, Plt 486
[**2159-10-5**]: Na 129, K 5.4, Cl 102, CO2 20, BUN 19, Cr 1, INR 2.1, PT
21.1, PTT 32.5
.
IMAGING:
Chest X Ray [**9-15**]: IMPRESSION: PA and lateral chest compared to
[**9-15**]:
Interstitial abnormality in the lungs has cleared substantially
consistent with resolved edema. Severe cardiomegaly persists.
There is no pleural effusion or evidence of central adenopathy.
Transvenous right ventricular pacer defibrillator lead follows
the expected course.
.
Duplex Abd/Pelvis [**9-19**]: IMPRESSION:
1. Patent hepatic vasculature.
2. Moderate to large amount of sludge in the gallbladder, which
is not distended. Gallbladder wall edema, pericholecystic fluid
and ascites fluid likely relate to third spacing in this
patient.
.
Cardiac Cath [**9-21**]: COMMENTS:
1. Resting hemodynamics demonstrated normal pulmonary capillary
wedge
pressures (14mmHg mean PCWP) with moderate pulmonary
hypertension
(pulmonary artery pressures of 50/12 mmHg). Cardiac output was
above
normal with cardiac index of 3.8 L/min/m2.
2. Tailored therapy with dobutamine 20 mcg/kg/min and
ultimately
nitroprusside 1.5 mcg/kg/min improved cardiac index to 4.5
L/min/m2 with
simultaneous reduction of pulmonary vascular resistance to 1.8
Wood
units, which demonstrated adequate reversibililty of pulmonary
vascular
resistance to remain a viable candidate for cardiac
transplantation.
3. Left femoral pulmonary artery catheter was left in place at
65 cm
from the distal tip to the femoral sheath.
FINAL DIAGNOSIS:
1. Moderate pulmonary hypertension.
2. Above normal cardiac output and normal filling pressures at
baseline
on dobutamine 15 mcg/kg/min.
3. Adequate reduction of pulmonary vascular resistance on trial
of
dobutamine and nitroprusside to confirm that pulmonary
hypertension is
reversible.
.
ECHO [**9-26**]: Conclusions:
The left atrium is mildly dilated. The inferior vena cava is
dilated (>2.5 cm). Left ventricular wall thicknesses are
normal. The left ventricular cavity is mildly dilated. There is
severe global left ventricular hypokinesis. [Intrinsic left
ventricular systolic function is likely more depressed given
the severity of valvular regurgitation.] The right ventricular
cavity is mildly dilated. There is moderate global right
ventricular free wall hypokinesis. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are
structurally normal. Mild to moderate ([**1-29**]+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2159-9-3**],
right and left ventricular systolic function are slightly
improved. The severity of mitral regurgitation is reduced. Left
ventricular cavity size is also slightly smaller. The heart
rate has increased. Pulmonary artery systolic hypertension is
now present.
Brief Hospital Course:
A/P: 48 yo M with h/o idiopathic dilated cardiomyopathy (EF
15-20%) s/p AICD [**2159-8-7**] and RUE DVT who represents after d/c on
[**2159-9-13**] with c/o chest pain, now transferred for decompensated
CHF. Labs notable for hyperkalemia, and elevated INR and LFTs,
improved on inotrope therapy with milrinone, evaluated for
possible cardiac transplant.
.
1# Cardiac:
A. Pump: Pt w/ h/o idiopathic dilated cardiomyopathy, EF < 20%.
S/p AICD placement. On transfer was found to be in cardiogenic
[**Date Range **] (LFT's acutely rose to high thousands and had ARF, altered
MS). Treated with dobutamine and dopamine and clinically
improved and began diuresing. We stopped spironolactone,
valsartan, digoxin, lasix d/t rising Cr. Also stopped
metoprolol given decompensated CHF. A right heart cath [**9-21**]
with resting PCWP 14mmHg mean with moderate pulm HTN, CI 3.8.
Tailored therapy with dobutamine 20 and nitroprusside 1.5
improved CI to >4.5 with decreased Pulm vascular resistance to
1.8 Wood units ->pt is suitable candidate for heart transplant.
Milrinone was added to dobutamine. The dobutamine was titrated
down and stopped. On milrinone alone, his CI ranged from
2.23-3.07. his Aldactone and Valsartan were restarted at 25mg
and 160mg, respectively. He tolerated this change well. His
SVR on this regimen was in the 800s. His swan was D/C'd on
[**9-25**]. The patient went for IR guided PICC placement on [**9-25**],
but a midline was placed instead secondary to RUE clotting. He
was transferred to the floor in good condition. We tried to
increase his metoprolol from 12.5 to 25 without success due to
hypotension (SBP 70's). His metoprolol was stopped entirely.
He was on Aldactone 25mg PO qDay, which was held on discharge
due to hyperkalemia. He will be continued on a continuous
milrinone infusion indefinitely, as well as his valsartan 160mg
PO qDay. If his K normalizes, his aldactone can be re-started.
.
B. Rhythm: The patient initially had IVCD and 1st degree block
due to hyperkalemia. However, this resolved with his once his
potassium was improved. He remained in sinus rhythm, but was
tachycardic. His baseline HR is in the 110s. His metoprolol
was stopped initially per CHF given his decompensation. He also
experienced occational episodes of NSVT per telemetry. On [**9-28**]
his ICD discharged 5 times [**3-1**] sinus tachycardia. EKG was
unremarkable. EP evaluated the ICD and increased his HR
threshold from 160bpm to 180bpm, with pacing threshold at
200bpm. On [**10-3**] EP reverted his ICD to his old settings at
160bpm. He did experience NSVT for 18 beats on [**10-4**]. EP did not
make any changes. He remained asymptomatic. His metoprolol was
stopped due to hypotension. He will need to be followed by EP
with regards to his ICD.
.
C. Ischemia: Pt c/o ICD site chest pain, likely pt's chronic
chest pain. ICD site did not look inflamed or infected. No h/o
CAD. Ruled out for MI on the floor. A repeat troponin on [**10-4**]
was <0.01. His EKGs showed no changes. His pain improved on
oxycodone.
.
2# Elevated LFTs: Transaminases in the thousands, consistent
with [**Month/Day (4) **] liver from poor perfusion. As his perfusion was
improved, so did his LFTs. They trended down on a daily basis.
He continued to have vague abdominal discomfort. However, an
abdominal U/S was negative for any thrombosis.
.
3# Elevated INR: Thought likely due to liver failure as above.
Pt was anticoagulated as outpatient for DVT/PE. He was
initially treated with vit K and FFP to lower INR since was very
high when transfered to CCU. INR came down to 1.7. It
stabilized at 1.4. he was also restarted on a heparin gtt due
to his history of thromboses. They were still present on [**9-25**]
when he went for PICC placement. A midline was placed instead.
His coumadin was restarted on [**9-26**]. His most recent INR was 2.1
on [**10-5**]. His warfarin was 3mg PO qHS. His INR will need to be
watched.
.
4# ARF/hyperkalemia: Thought due to poor forward flow as above
with metabolic acidosis from uremia. Initially was treated with
calcium, insulin, D50 and responded well. Received kayexalate as
well. His hyperkalemia resolved, as did his ARF with improved
perfusion due to inotropes. His cr stabilized at his baseline
at 0.9 on transfer to the floor. He was transiently hypotense
once on the floor, causing his Cr to increase to 1.9. With
improved BP, his Cr returned to baseline. His K remained high
at 5-5.4. His EKG was unchanged.
.
5# Nausea and vomiting: Patient had intermittent nausea and
vomitting. He was given anzemet prn with good results.
.
6# Altered MS: Initially had MS changes thought due to initial
cardiogenic [**Month/Day (4) **] and poor perfusion. It resolved with
increased perfusion and inotropy. He was also treated for a
potential UTI. His mental status remained stable for the
duration of admission.
.
7# UTI: Pt did complain of some dysuria in days preceding
decompensation and initial Ua showed 21-50 WBCs. He was
initially treated with vancomycin and zosyn on [**9-22**] given acute
decompensation and concern for sepsis. However, he improved
clinically with treating cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] vancomycin and
zosyn were changed to cipro 500mg PO q12h. He was given a total
7 day course without incident. A urine culture from [**9-20**] was
negative for growth. A repeat culture on [**9-28**] grew resistant e
coli in the setting of fever to 101; therefore he was started on
cefazolin. It was stopped due to lack of symptoms and negative
UA and negative repeat urine culture. He remained afebrile and
did not complain of any further symptoms.
.
8# Anemia: On admission his Hct was 35. It remained in the low
30s throughout admission. Near the end of admission, his Hct
dropped to the high 20s. His labs did not fit with hemolysis.
He was guiac negative throughout admission. He had no signs or
symptoms of active bleeding and remained stable. His drop was
not related to any procedures. His MCV did hover around 77-82.
The patient was transferred before further work up could be
performed for iron /B12/folate deficiency vs. anemia of chronic
disease. He will need to have this work up prior to going home.
.
9# Chronic pain: Pt w/ chronic abd/chest pain. CT [**Last Name (un) 103**] on
[**2159-9-2**] showed hepatomegaly and right renal wedge shaped
infarct. Liver enzymes were normal except alk phos which
trended down. No etiology for pain found. Was on tramadol,
oxycodone, neurontin, lidocaine patch as outpt. Had no
insurance at that time. Said that Freecare pharmacy did not fill
the lidocaine patch scrips as they do not cover topical
anesthetics. Hence he was back to the hospital. His lidocaine
patch was changed to ointment. He was given oxycodone 15mg PO
QID/PRN for pain. His tramadol was initially stopped given his
ARF. However, it was restarted on a PRN basis once his ARF had
resolved. The chronic pain service that was initially following
him signed off. His pain remained well controlled on his
current regimen.
.
10# FEN: He was maintained on a heart healthy diet. He did have
mild hyponatremia which remained stable. He did not experience
any mental status changes with his levels.
.
11# Code status: He was full code during this admission
.
Medications on Admission:
Pantoprazole 40 mg PO Q24H
Digoxin 125 mcg PO DAILY
Docusate Sodium 100 mg PO BID
Senna 8.6 mg PO BID
Warfarin 3mg PO HS
Spironolactone 25 mg PO DAILY
Lovenox 60 mg/0.6 mL Syringe Sig SC BID (as bridge for
therapeutic INR)
Valsartan 40 mg PO QHS
Gabapentin 300 mg PO TID
Tramadol 50 mg PO q 4hr PRN
Toprol XL 50mg QD
Spironolactone 25 mg PO DAILY
Furosemide 80 mg PO once a day.
Lidocaine 5 %(700 mg/patch) Adhesive Patch QD - apply for 12
hours, and remove for 12 hours.
Oxycodone 15 mg PO q 6hr PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
3. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
4. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed.
8. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP <80.
9. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime):
Please monitor INR accordingly.
10. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day) as needed.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold for SBP <80.
14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
15. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Milrinone 0.38 mcg/kg/min IV INFUSION
18. Heparin Flush Midline (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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4415**]
Discharge Diagnosis:
Primary:
Congestive Heart Failure
.
Secondary:
Idopathic cardiomyopathy
Upper Extremity Deep Vein Thrombosis on Right
Anemia
Renal infarct
Urinary Tract Infection
Hyperkalemia
Hyponatremia
Discharge Condition:
Good. Hemodynamically stable. Afebrile.
Discharge Instructions:
Please tall medications as prescribed. Please keep all follow
up appointments. Please return to the hospital with any chest
pain, shortness of breath, fevers/chills, or any other symptoms
that concern you.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2159-10-29**]
11:00
.
Please follow up with Dr. [**First Name (STitle) 437**] as above.
|
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icd9cm
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icd9pcs
|
[
[
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16567, 16613
|
7112, 14438
|
317, 449
|
16846, 16890
|
3194, 3194
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2596, 2729
|
14990, 16544
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16634, 16825
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14464, 14967
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5653, 7089
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16914, 17123
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4109, 5636
|
2744, 3175
|
251, 279
|
477, 1512
|
3210, 4093
|
1534, 2342
|
2358, 2580
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,852
| 159,071
|
4006+4007
|
Discharge summary
|
report+report
|
Admission Date: [**2193-2-2**] Discharge Date: [**2193-2-12**]
Service: [**Doctor Last Name 1181**]/MEDICINE
CHIEF COMPLAINT: Dysphagia and urinary retention.
HISTORY OF PRESENT ILLNESS: This is an 81 year old man who
is status post [**2193-1-11**], three vessel coronary artery bypass
graft performed here at [**Hospital1 69**],
also with congestive heart failure with an ejection fraction
of 20 to 25%. He was sent to [**Hospital 38**] Rehabilitation post
coronary artery bypass graft for physical rehabilitation. He
developed the dysphagia at the rehabilitation center and
there was sent to an outside hospital where he underwent a
barium swallow which he failed. The patient also during his
rehabilitation stay developed urinary retention. A Foley was
placed but this was followed by hematuria. The Foley was
placed with a three-way Foley. Hematuria continued and
removal of the three-way Foley was difficult. The family
decided at that point to transfer the patient back to [**Hospital1 1444**] for workup of the dysphagia,
as well as the management of the three-way Foley by the
Department of Urology here at [**Hospital1 188**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Benign prostatic hypertrophy.
3. Coronary artery disease with three vessel coronary artery
bypass graft including the left internal mammary artery to
the left anterior descending, saphenous vein graft to
posterior descending artery, saphenous vein graft to OM1.
The patient also had prior myocardial infarctions in [**2170**],
[**2174**], [**2187**], and [**2190**]. Last recorded ejection fraction was 20
to 25%.
4. Hypercholesterolemia.
5. Gout.
6. Chronic obstructive pulmonary disease, asbestosis.
7. Prior history of depression.
8. New diagnosis of dysphagia.
ALLERGIES: Ambien for which he feels agitation. Ativan,
Haldol for which he also develops agitation and confusion.
MEDICATIONS ON TRANSFER:
1. Metoprolol 25 mg p.o. twice a day.
2. Pepcid 20 mg p.o. twice a day.
3. Senna two tablets p.o. q.h.s.
4. Proscar 5 mg p.o. once daily.
5. Captopril 25 mg p.o. q8hours.
6. Thiamine 100 mg p.o. once daily.
7. Remeron 15 mg p.o. q.h.s.
8. Tylenol 650 mg q8hours p.r.n.
9. Albuterol and Atrovent nebulizers.
SOCIAL HISTORY: The patient is widowed. He is a former
[**Location (un) 86**] [**Male First Name (un) 17703**] employee. He has a twenty pack year tobacco
history twenty years ago. He is not currently smoking. He
lives with his son.
FAMILY HISTORY: Notable for brother and sister who had
coronary artery disease, died very recently in their 70s. No
history of diabetes mellitus.
PHYSICAL EXAMINATION: The patient presented to the floor.
Temperature was 98.7, blood pressure 143/69, heart rate 66,
respiratory rate 20, oxygen saturation 100% on two liters.
On examination, he is a thin elderly man in mild discomfort.
The pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. Cranial
nerves II through XII are intact. Mouth is dry. Yellow
sputum was noted to be visible. The neck was supple with no
jugular venous distention. Lungs notable for bibasilar
crackles. The chest was notable for a midline scar. Cardiac
examination is notable for regular rate and rhythm, with a
II/VI systolic ejection murmur. The abdomen is soft,
nontender, positive bowel sounds present. Extremities
notable for saphenous vein graft scars on the calves but no
evidence of lower extremity edema. Neurologically, there are
no focal sensory or motor deficits noted.
HOSPITAL COURSE: The patient was reassessed by bedside video
swallow. The patient was noted to have marked difficulty
handling any sort of fluid bolus and thus was made NPO. At
that point, the patient was being evaluated for placement of
a percutaneous endoscopic gastrostomy tube by interventional
radiology to allow nutrition as well as continued
administration of p.o. medications. He was also evaluated by
ENT who found no anatomical abnormalities at the time.
Urology was also consulted who recommended a CT scan to rule
out a cerebrovascular accident. The CT was negative and also
follow-up evaluation with an EMG. EMG failed to find any
evidence suggestive of myasthenia [**Last Name (un) 2902**] which was the
working diagnosis at the time. In addition, a serum sample
for the presence of anti-acetylcholine receptor antibody was
also sent, the results of which are still pending at the time
of this dictation.
Given the patient's distress though for being continually
hospitalized, the patient was tried on a trial of 30 mg
q4hours of Mestinon p.o. Simultaneously, the patient's
three-way Foley was managed by urology. There were some
episodes of complications where both frank blood as well as
clots were noted coming out of the Foley, but after
continuous bladder irrigation, the three-way Foley was
discontinued by urology and the patient voided well without
indwelling catheter. After approximately 36 hours on
Mestinon, both the patient as well as family and the team
noted significant improvement in the strength of the
patient's voice, some sialorrhea was noted, believed a side
effect of the Mestinon. However, given the improvement, the
patient was reevaluated once again with a video swallow. The
repeat swallow was notable for the following: Significant
improvement from the initial study from [**2193-2-4**]. There was,
however, a continued delay in trigeminus swallow as well as a
reduced polypharyngeal excursion, some pharyngeal
constriction and some pharyngeal residue but no aspiration
occurred during this time. Recommendations from speech and
swallow included a diet of thin liquids, pureed solids, and
crush pills in apple sauce as well as maintain the patient in
a bold upright position for all meals.
The patient was reevaluated by physical therapy at the time
who felt that given the patient's willingness to accept round
the clock nursing at home that he would be safe for discharge
to home with visiting nursing care as well as home physical
therapy and occupational therapy.
Plan is to discharge the patient on continued tube feeds with
final recommendations to be recommended by nutrition and
Continued use of the p.o. Mestinon.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 25 mg p.o. twice a day.
2. Lisinopril 5 mg p.o. daily.
3. Protonix 40 mg p.o. once daily.
4. Proscar 5 mg p.o. three times a day.
5. Levofloxacin 250 mg p.o. times one additional day.
6. Trazodone 50 mg p.o. q.h.s.
7. Maalox 15 to 30 ccs q6hours p.r.n.
8. Mestinon 30 mg p.o. q4hours as per neurology
recommendations.
9. ProMod with fiber or equivalent at a rate of 75 cc/hour
with feeding bag and pump. Support materials including 60 cc
syringes as well as intravenous pole.
Additional details will be added on as an addendum to this
discharge summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 8442**]
MEDQUIST36
D: [**2193-2-11**] 17:33
T: [**2193-2-11**] 19:09
JOB#: [**Job Number 17706**]
Admission Date: [**2193-2-2**] Discharge Date: [**2193-4-18**]
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: Dysphagia, urinary retention, and failure
to thrive.
HISTORY OF PRESENT ILLNESS: Patient is an 81-year-old man
who underwent a CABG on [**2193-1-11**] at [**Hospital1 346**]. Patient was sent to [**Hospital 38**]
Rehabilitation Center postoperatively. At the center, he
developed dysphagia and difficulty swallowing. At that time,
the patient also retired acute urinary retention. Foley was
placed which subsequently resulted in hematuria. A three-way
Foley was then placed, and the patient was transferred here
to the [**Hospital1 69**] for evaluation of
dysphagia and the management of the hematuria through the
Urology Department.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Benign prostatic hypertrophy.
3. Coronary artery disease status post coronary artery bypass
graft. Ejection fraction 20-25%.
4. Hypercholesterolemia.
5. Gout.
6. Congestive obstructive pulmonary disease.
7. Asbestosis.
8. Prior history of depression.
9. Diagnosis of dysphagia.
ALLERGIES: Ambien, Ativan, Haldol, which all cause slight
agitation and confusion, question whether or not this is an
actual allergy.
MEDICATIONS:
1. Lopressor 25 mg po bid.
2. Pepcid 20 mg po bid.
3. Senna two tablets po q hs.
4. Proscar 5 mg po q day.
5. Captopril 25 mg po q8h.
6. Thiamine 100 mg po q day.
7. Remeron 50 mg po q hs.
8. Tylenol 650 mg q8h.
9. Albuterol and Atrovent nebulizers.
SOCIAL HISTORY: The patient is widowed. He is a former
[**Location (un) 86**] [**Male First Name (un) 17703**] employee. He has a 20 pack year history of
tobacco, currently does not smoke. He lived with his son
previous to his hospitalizations.
INITIAL PHYSICAL EXAMINATION: Temperature is 98.7, blood
pressure 143/68, heart rate 66, respiratory rate 20, and
oxygen 100% on 2 liters. On examination, the patient is an
elderly man. Pupils are equal and reactive. Extraocular
muscles were intact. Cranial nerves III through XII were
intact. Neck was supple. Lungs: Bilateral crackles in the
lower lobes. Cardiac: Regular, rate, and rhythm. Abdomen
was soft, nontender, nondistended.
INITIAL HOSPITAL COURSE: The patient was reassessed during
the hospitalization. Had a video swallow. The patient was
noted to have marked difficulty handling any sort of fluid
boluses, and thus was made NPO. At that point, the patient
was evaluated for placement of a percutaneous gastrostomy
tube by Interventional Radiology. Patient is also worked up
by ENT, and found to have no anatomic abnormalities, and the
CT scan was recommended of his head to evaluate for
cerebrovascular accident, which was subsequently negative.
Urology managed a Foley with a three-way catheter. Hematuria
resolved over time and the three-way catheter was then
changed to a standard Foley catheter. He was further
evaluated on [**2193-2-4**] by Speech and Swallow, which
recommended diet of thin liquids, solids, and crushed pills
with apple sauce.
Later in the patient's hospitalization stay, he became septic
and was transferred to the Intensive Care Unit. At that
time, Cardiothoracic Surgery took over the care of the
patient. General Surgery was asked to consult on the patient
as was Cardiothoracic Surgery due to an inflamed and
erythematous sternal wound.
On the [**1-13**], the patient was brought to the
operating room, and evaluated for the infection. The sternum
and xiphoid area was debrided, and it was noted that the G
tube passed through the sternal wound and into the stomach.
General Surgery recommended that the G tube be removed and a
second G tube be placed via an open incision.
Patient tolerated the procedure well, and was transported to
the CSRU in stable condition. The patient continued on
antibiotics and Intensive Care Unit management. On the [**1-20**], the patient was brought to the operating room by
Plastic Surgery for a sternal wound debridement and a right
pectoral advancement flap. Prior to the surgery, the patient
was treated with wet-to-dry dressing changes. Dr. [**Last Name (STitle) 13797**]
and Dr. [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **] debrided the sternal area, used a left
sided advancement flap and placed three [**Doctor Last Name 406**] drains. The
patient tolerated the procedure well. There was no
complications, and the patient was transferred to the CSRU in
stable condition.
Following the debridement and flap, the patient continued to
require ventilation. On the [**1-6**], Dr. [**Last Name (STitle) 952**] and Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] operated on the patient with their preoperative
diagnosis of postoperative respiratory insufficiency and
tracheobronchitis, wet secretions, and hemoptysis. The
patient had a percutaneous tracheostomy tube placed, and the
flexible bronchoscopy and tracheobronchial aspiration was
done at the same time. The patient tolerated the procedure
well.
Shortly thereafter, the patient became septic, required
pressors. Dr. [**Last Name (STitle) **], Dr. [**First Name (STitle) **], and Dr. [**Last Name (STitle) **] brought the
patient back to the operating room for an exploratory
laparotomy to rule out sepsis as a CT scan showed
inflammation of the colon. During the hospitalization, the
patient did suffer from Clostridium difficile and was treated
with Vancomycin and also Flagyl. It was thought that prior
to going to surgery, that this might be necrotic due to the
CT scan. Via a midline incision, the patient was explored.
The colon looked dusky and consistent with a colitis, but was
viable. The gallbladder was nondistended and appeared
normal. It was felt at that time that the patient's sepsis
was not due to abdominal source.
The patient was then closed with staples and returned to the
Cardiac Surgery Unit for ongoing therapy. During this time,
the patient was continued on Impact with fiber at 100 cc an
hour of tube feeds for nutritional support. Dr. [**Last Name (STitle) **]
consulted during the patient's hospitalization stay for
nutritional care.
On the [**1-7**], the patient had a bronchoscopy which
showed upper airway drainage with mucus with no major
abnormalities.
Renal was asked to see the patient for acute renal
insufficiency. They felt that the patient was prerenal, and
recommended renal dosing of medications and increased
titration. Plastic Surgery was reconsulted during the [**Month (only) 958**]
period for decubitus ulcer, which was debrided by them at the
bedside. Patient during this course was continued on
antibiotics to treat positive cultures.
On the [**1-13**], the patient was treated with Zosyn,
fluconazole, Vancomycin po and IV. At that time the patient
had MRSA in his wound, [**Female First Name (un) 564**] albicans in his wound, [**Female First Name (un) 564**]
parapsilosis in the sternum. The patient is also Clostridium
difficile positive and VRE positive in the stool.
During the end of [**Month (only) 958**], the patient stabilized and was
slowly taken off antibiotics. During that time the patient
was continued on tube feeds and was supported with Physical
Therapy. The patient also had a Psychiatry consult, and
their impression was he suffered from delirium which is
multifactorial with underlying dementia and depression. They
recommended minimizing the opiates and anticholinergics and
continue with general antidepressant medications.
At the beginning of [**Month (only) 956**], the patient was transferred to
the Surgical Intensive Care Unit service for further
management. At that time, the patient's antibiotics were
weaned off without spiking temperatures
On the [**1-10**], the patient became hyponatremic and had
his tube feeds and fluids adjusted appropriately. The
patient was also given sodium po until his sodium reached a
level greater than 130. During that time, it was decided
that the patient would be able to be discharged to
rehabilitation services. Plastic Surgery consulted to
evaluate the sacral decubitus ulcer. They recommended local
debridement as necessary, and to continue the Santyl.
During the beginning of [**Month (only) 547**], the patient increased stool
output. Clostridium difficile was negative and Imodium was
started with the Kaopectate. Before discharge, the patient's
diarrhea had decreased significantly.
DISCHARGE PHYSICAL EXAMINATION: Temperature max 100.6, 98.4,
130/66, 85, 17, and 97%, CVP was 20. Arterial blood gas:
CPAP pressure support 50% 10 and 10, 7.49, 54, 134, 40, and
14. His white blood cell count was 6.9, hematocrit was 29.3,
and platelets 243. Chem-7: 131, 4.5, 91, 33, 43, and 0.6.
DISCHARGE DIAGNOSES:
1. Sternal wound infection status post debridement.
2. Status post sternal wound debridement with right pectoral
flap by Plastic Surgery.
3. Status post takedown of transsternal gastrostomy with
surgical placement of a gastrotomy.
4. Status post percutaneous tracheostomy placement [**3-6**].
5. Status post exploratory laparotomy for sepsis.
6. Failure to thrive.
7. Severe deconditioning.
SECONDARY DIAGNOSES:
1. Hypertension.
2. Benign prostatic hypertrophy.
3. Coronary artery disease status post coronary artery bypass
graft in [**2193-1-2**].
4. Hypercholesterolemia.
5. Gout.
6. Congestive obstructive pulmonary disease.
7. Asbestosis.
8. History of depression.
9. History of dysphagia.
DISCHARGE MEDICATIONS:
1. Bumetanide 2 mg IV bid.
2. Loperamide 2 mg po q4h.
3. Zofran 2 mg IV q6h prn.
4. Kaopectin 30 mL po q8h.
5. Sertraline 50 mg po q day.
6. Santyl NF 1" topical [**Hospital1 **].
7. Lorazepam 0.5 mg IV q4h.
8. Digoxin 0.125 mg po q day.
9. Lopressor 12.5 mg po bid.
10. Morphine 4-6 mg IV q4h prn.
11. Oxybutynin 5 mg po tid.
12. Heparin 5,000 units subQ [**Hospital1 **].
13. Pyridostiginine 30 mg po q4h.
14. Tylenol 650 mg po q6h.
15. Percocet elixir [**5-11**] mL po q4-6h prn.
16. Lansoprazole 30 mg po q day.
17. Miconazole powder 2% topical qid prn.
18. Ipratropium two puffs q4-6h prn.
TREATMENT: The patient will need to continue with aggressive
Physical Therapy and conditioning. The patient will need
sacral decubitus ulcer care with prn debridement and also the
use of Santyl [**Hospital1 **] to the decubitus ulcer. Patient will need
G tube care with q6h flushing with 30 cc of normal saline.
Foley care. Patient will also need vent management currently
on CPAP with 10 of pressure support, 10 of PEEP, and 50%
FIO2. Patient will continue with Impact with fiber half
strength at 150 cc/hour. Patient's regular insulin-sliding
scale is 121-150 3 units, 150-200 6 units, 301-350 9 units,
250-300 12 units, 301-350 15 units, greater than 350, call
primary care physician.
CONDITION ON DISCHARGE: Stable condition to rehabilitation
services.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2193-4-18**] 09:56
T: [**2193-4-18**] 10:01
JOB#: [**Job Number 17707**]
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53,459
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Discharge summary
|
report
|
Admission Date: [**2148-10-21**] Discharge Date: [**2148-10-30**]
Date of Birth: [**2085-6-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lidocaine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
right upper quadrant pain
Major Surgical or Invasive Procedure:
[**2148-10-25**]: Right chest wall hernia repair with gortex mesh
History of Present Illness:
This is a 63 year old male with PMH significant for COPD,
obesity, and diabetes c/b peripheral neuropathy who was recently
discharged on a steroid taper and azithromycin for a COPD
exacerbation on [**10-20**] now presenting with RUQ abdominal pain that
has been increasing in severity since [**10-18**]. He says that he
first noted RUQ abdominal pain at the beginning of his COPD
exacerbation on [**10-18**], but felt like the pain was mild from
coughing and gasping for air. He was discharged on [**10-20**] and
developed increased pain at home to the point where he could not
even dress himself secondary to the pain. He describes the pain
as constant and it is difficult for him to find a comfortable
position. The pain sometimes feels like a burning sensation and
is often [**10-18**] when he positions himself in certain ways. The
pain is localized over the lower 2 ribs on his right side.
Placing a heating pad on the area helped somewhat at home. The
pain was so debilitating, he could not go to the pharmacy to
pick up his meds and therefore has not taken his steroids or
azithromycin today. He is intolerant to oral oxycodone,
Percocet, and Vicodin for pain control in the past namely
because he says it causes him to have a personality change.
Of note, the patient also mentions losing control of his bowels
for the first time ever today around noon. He felt that he
needed to have a bowel movement, but when he got up he had
already gone in his pants. He is not experiencing any increase
in his chronic back pain and has not noticed any urinary
incontinence. He has also not had any decreased motor strength.
At baseline he has severe peripheral neuropathy and describes
loss of sensation in his legs up to his mid-thighs, but this is
at baseline.
As far as his COPD exacerbation, the patient continues to
improve. However, he is having difficulty expectorating his
secretions secondary to the pain. He is also having difficulties
taking deep breaths with the pain. He also feels as though his
abdomen is more bloated tha usual.
.
In the ED, VS were: T=98.3, HR=79, BP=140/80, RR=22, POx=98% on
2L NC. He appeared uncomfortable secondary to pain and was given
12 mg of morphine as well as Toradol with moderate effect. He
was also noted to be 94% on RA and was therefore given 2L of NC.
.
On the floor, the patient continues to have RUQ pain with
difficulty taking deep breaths and clearing his secretions
secondary to the pain.
Past Medical History:
-COPD
-OSA
-Diabetes II, complicated by neuropathy
-Chronic Sinusitis
-Obesity
-BPH
-GERD
-Cold induced asthma
-OA
-Allergic Rhinitis
-HTN
-PTSD
-Hyperlipidemia (on simvastatin)
.
Past Surgical History:
The patient had previous L4-L5 microdiscectomy
in [**2142-4-9**]. He has had multiple discectomies in the past in
[**2118**], [**2124**], and [**2133**].
-Status post operative fusion of his left ankle following a
bimalleolar ankle fracture
-Cervical C3-4 spine fusion with persisting cervical cord
compression and plexopathy
-Lumbar laminectomy for spinal stenosis.
Social History:
He lives at home with his wife and his son [**Name (NI) **]. [**Name2 (NI) **] 4 adult
children who live away and are all described as healthy. He
does not smoke. He uses wine or beer occasionally, 2 cups of
coffee a day. He reports the use of a regular diet and sleeps 8
hours per night with nocturia interrupting his sleep every [**3-13**]
hours.
Family History:
He has a daughter today sutures old and two sons 19 and 33 years
old all of which are healthy. He denies family history of
neurologic disease.
Physical Exam:
On admission:
Vitals: T: 98.4, BP: 130/64, P: 82, R: 20, O2: 95% RA, blood
sugar=171
General: Alert, oriented, mild to moderate distress secondary to
pain in right flank
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation anteriorly as patient did not want
to sit up secondary to pain; no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, but moderately distended, bowel sounds present,
tender to light touch over RUQ; RUQ pain also reproduced with
palpation of epigastric region
Neuro: CN II-XII intact, motor strength and sensory at baseline,
at baseline he has decreased sensation up to mid thighs
bilaterally, weak left ankle flexors and extensors as a result
of several prior ankle surgeries. Upper extremity strength and
sensation equal and intact bilaterally.
Ext: Warm, well perfused, no clubbing or cyanosis, 1+ LLE edema
secondary to previous ankle surgeries
.
On discharge`
VS: 97.2, 121/66 70's SR (&% RA
General: Alert, oriented and in no apparent distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear bilateral no wheezes
CV: Regular rate and rhythm, normal S1 + S2, no m/g/r
Abdomen: soft, but distended with
Ext: Warm, well perfused. L ankle edema.
Incision: Right thoracotomy site clean dry intact with staples
no erythema
Pertinent Results:
On admission:
[**2148-10-20**]: WBC-8.9# RBC-4.15* Hgb-13.2* Hct-40.5 Plt Ct-230
[**2148-10-20**] Calcium-8.7 Phos-4.7* Mg-2.0
[**2148-10-21**] D-Dimer-549* [**2148-10-21**] K-3.9
[**2148-10-22**] Lactate-1.8
[**2148-10-21**] cTropnT-<0.01
[**2148-10-21**] ALT-24 AST-61* AlkPhos-55 TotBili-0.9
[**2148-10-21**] Lipase-46
On discharge:
[**2148-10-29**] WBC-12.7* RBC-3.74* Hgb-12.3* Hct-36.1 Plt Ct-313
[**2148-10-30**] Glucose-67* UreaN-25* Creat-0.7 Na-141 K-3.9 Cl-100
HCO3-32
[**2148-10-30**] Calcium-8.3* Phos-3.5 Mg-2.5
.
[**2148-10-21**], CTU Abd/pelvis, CTA chest:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. No evidence of renal calculi or appendicitis.
3. Herniation of the right lung through the right posterolateral
eighth and ninth ribs, may account for patient's symptoms of
right upper quadrant pain. Lucency along right inferior
hemithorax chest wall on chest radiograph performed same date is
new since prior chest radiograph of [**2148-10-18**] raising concern for
recent development. The findings are also new since CT abdomen
of [**2143-2-14**]
4. Outpouching of mesenteric fat through the esophageal hiatus
is unchanged since [**2143**].
.
[**2148-10-24**], CT torso, Preliminary Report !! WET READ !!
1. R lung herniation (between ribs 8 & 9), slightly increased
from prior CT & now includes a portion of liver
2. unchanged paraesophageal herniation of mesenteric fat
3. no hydronephrosis
4. R flank hematoma, new from [**2148-10-21**]
5. no rib fx
CXR:
[**2148-10-28**] A right chest tube is in place. The opacity projecting
over the right hemithorax is unchanged. Small amount of
subcutaneous air is unchanged. There is no change in the
pleural effusion .
Abdominal
[**2148-10-27**]: Mildly dilated loops of colon and non-specific small
bowel gas
pattern suggestive of probable post-operative ileus. No
definitive evidence of obstruction at this time.
[**2148-10-29**]: Left PICC terminates at the cavoatrial junction.
Brief Hospital Course:
This is a 63 year old male with PMH significant for COPD,
obesity, and diabetes c/b peripheral neuropathy who was recently
discharged on a steroid taper and azithromycin for a COPD
exacerbation on [**10-20**] now presenting with RUQ pain that has been
increasing in severity since [**10-18**].
.
#. Lower rib cage/RUQ pain: On imaging it appeared as though the
patient has herniation of his right lung through his posterior
chest wall. EKG without ischemic changes and cardiac bio
markers were negative. Pain control was initiated, but pt
reported a previous poor reaction to Vicodin, Percocet,
Oxycodone, including personality changes/agitation. Thoracic
surgery was consulted, and initial plan for conservative
management. Pain service consulted for pain recs, but pt
declined PCA, and pain team felt pt too high-risk for epidural
without concurrent surgical correction. No Tramadol given SSRI,
and no Ketorolac given hematoma. However, pain continued to
worsen, not controlled even with Lidocaine patches and IV pain
medications to extent that patient with desaturation on opioid
regimen. Repeat CT torso on [**10-24**] with worsened lung hernia, and
given worsening pain and discomfort.
#. COPD Exacerbation: No evidence of PNA on CXR. Poor cough and
inspiratory effort [**3-12**] splinting from pain. Prednisone taper
was continued in-house, and 7-day azithromycin course was
completed. Pt kept on standing nebs.
Thoracic surgery was consulted and on [**2148-10-25**] he was taken to
the operating room for
for right chest wall hernia repair with dual gortex mesh. He was
transferred to the SICU intubated, sedated and right chest tube.
Respiratory; he was successfully extubated on [**2148-10-26**],
continued on his home CPAP at night. He was followed by
pulmonology who recommended continue aggressive pulmonary
toilet, mucolytics, nebs, steroid taper and resume his home dose
Advair. On discharge his oxygen saturation was 97% RA and 93%
with activity.
Chest tube: right [**Doctor Last Name 406**] drain with moderate serous drainage was
removed on [**2148-10-29**] once output diminished.
Chest films: he was followed by serial chest films showed xxx
Cardiac: He was started beta-blockers for sinus tachycardia and
discharged on Toprol 50 mg [**Hospital1 **].
GI: abdominal distention noted [**2148-10-27**] x-ray showed
post-operative ileus. With ambulation and bowel regime it
resolved.
Nutrition: tolerated diabetic diet.
Endocrine: His blood sugars on admission were elevated 133-367
while on steroids. His home insulin was titrated with better
glucose control.
Renal: immediately postoperative he was found to [**Doctor First Name 48**] secondary
to low urine output, hypotensive and CRE elevated to 2.3. He
responded with fluid challenges with CRE return to baseline of
0.7-1.1 and good urine output.
Pain: Acute pain service followed the patient for difficult pain
management. Ketamine drip was started but was stopped due to
hallucinations and confusion. A Dilaudid PCA was started but
discontinued due to confusion. He was then started on MS Contin
with morphine immediate release with good control.
IV: access a 52 cm L brachial PICC line was placed for hydration
and access. This was removed prior discharge.
Neuro: Once confusion resolved he was back to his baseline,
awake alert and oriented.
Disposition: He was seen by physical therapy walks with a cane
and deemed safe for home. He was discharged on [**2148-10-30**] and
will follow-up with Dr. [**Last Name (STitle) **] and his pulmonologist as an
outpatient.
Medications on Admission:
1. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Oxybutynin Chloride 5 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
4. Paroxetine HCl 25 mg Tablet Sustained Release 24 hr Sig: Two
(2) Tablet Sustained Release 24 hr PO once a day.
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Cyanocobalamin (Vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation twice a day as needed for shortness of
breath or wheezing.
11. Glipizide 5 mg Tablet Extended Rel 24 hr Sig: 0.5 Tablet
Extended Rel 24 hr PO qAM.
12. Glipizide 5 mg Tablet Extended Rel 24 hr Sig: 1.5 Tablet
Extended Rel 24 hrs PO at bedtime.
13. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: 55-57
units Subcutaneous once a day.
14. Novolog 100 unit/mL Cartridge Sig: 25-27 units Subcutaneous
before dinner.
15. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
16. Prednisone 10 mg Tablets, Dose Pack Sig: dose pack, see
instructions Tablets, Dose Pack PO once a day for 6 days: take 4
tablets a day for 2 days, 2 tablets a day for 2 days, 1 tablets
a day for 2 days then stop.
Disp:*16 Tablets, Dose Pack(s)* Refills:*0*
17. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Medications:
1. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: 55-57
units Subcutaneous once a day.
2. Novolog 100 unit/mL Cartridge Sig: 25-27 units Subcutaneous
once a day.
3. Glipizide 5 mg Tablet Extended Rel 24 hr Sig: 0.5 Tablet
Extended Rel 24 hr PO each morning.
4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Oxybutynin Chloride 5 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
7. Paroxetine HCl 25 mg Tablet Sustained Release 24 hr Sig: Two
(2) Tablet Sustained Release 24 hr PO once a day.
8. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
SOB/wheezing.
12. Cyanocobalamin (Vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Glipizide 5 mg Tablet Extended Rel 24 hr Sig: 1.5 Tablet
Extended Rel 24 hrs PO at bedtime.
15. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
16. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
17. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours): Do not take more than 4000mg in a 24hr period.
18. Prednisone 10 mg Tablet Sig: As directed Tablet PO once a
day for 3 days: 20mg (2 tabs) for 2 day, then 10mg (1 tab) for 3
day, then 5 mg ([**2-10**] tab) for 3 days then none.
Disp:*7 Tablet(s)* Refills:*0*
19. Azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
20. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours): wean off as
tolerates.
Disp:*45 Tablet Sustained Release(s)* Refills:*0*
21. Morphine 15 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
22. Ipratropium Bromide 0.02 % Solution Sig: Three (3) mL
Inhalation four times a day.
Disp:*QS mL* Refills:*2*
23. Nebulizer Machine
24. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation four times a day.
Disp:*360 mL* Refills:*2*
25. Ipratropium Bromide 0.02 % Solution Sig: Three (3) mL
Inhalation four times a day: mix with albuterol.
Disp:*360 mL* Refills:*2*
26. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1)
Tab, Multiphasic Release 12 hr PO twice a day.
Disp:*60 Tab, Multiphasic Release 12 hr(s)* Refills:*2*
27. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO twice a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Lung herniation
Secondary:
-COPD
-OSA
-Diabetes II
-GERD
-HTN
-PTSD
-Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Incision develops drainage or increased redness.
-Staples will be removed on your follow-up visit
-Chest tube site cover with a clean dressing for 2 days then
cover with a bandaid until healed.
-You may shower. No tub bathing or swimming until all incisions
healed
-Continue to monitor fingerstick blood sugars keep a log and
cover as previous
Please call Dr. [**Last Name (STitle) **] your pulmonologist with shortness of
breath, increased sputum productions or concerns regarding your
CPAP
Albuterol and atrovent nebulizers 4 times a day
Mucinex 1200 mg twice daily to keep secretions loose
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3020**] [**2148-11-12**]:30 in the
[**Hospital Ward Name 121**] Building, West Procedure Specialities [**Hospital1 **] I
Chest X-Ray in the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **]
Radiology 30 minutes before your appointment
Staples removal at time of visit.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2148-12-2**] 3:10
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2148-12-2**] 3:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) **].
Completed by:[**2148-10-30**]
|
[
"301.9",
"403.90",
"458.29",
"276.52",
"250.00",
"E937.9",
"473.9",
"789.01",
"600.01",
"356.9",
"491.21",
"266.2",
"584.9",
"272.4",
"786.2",
"786.52",
"585.3",
"V15.82",
"309.81",
"788.21",
"338.19",
"530.81",
"327.23",
"799.29",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.79",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15707, 15713
|
7361, 10935
|
304, 372
|
15851, 15851
|
5365, 5365
|
16730, 17506
|
3820, 3964
|
12735, 15684
|
15734, 15830
|
10961, 12712
|
16002, 16707
|
3068, 3437
|
3979, 3979
|
5702, 7338
|
239, 266
|
400, 2843
|
5379, 5688
|
15866, 15978
|
2865, 3045
|
3453, 3804
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,891
| 111,619
|
50857
|
Discharge summary
|
report
|
Admission Date: [**2175-3-15**] Discharge Date: [**2175-3-21**]
Date of Birth: [**2109-5-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue. Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2175-3-17**]
Mitral valve repair with a quadrangular resection of the middle
scallop of the posterior leaflet (P2), and the mitral valve
annuloplasty with a 32-mm Physio II annuloplasty ring.
History of Present Illness:
This is a 65yo male with known mitral valve prolapse/mitral
regurgitation. Over the last year, he has complained of
worsening fatigue and shortness of breath with exertion. He
denies chest pain, orthopnea, PND, syncope, pre syncope and
pedal edema.
Past Medical History:
Chronic Atrial Fibrillation, last 10 years (coumadin)
Hypertension
Dyslipidemia
Carpal Tunnel Syndrome
Benign Prostatic Hypertrophy s/p Laser therapy
Hemorrhoids, s/p Banding
Insomnia
History of Basal Cell Carcinoma
Hematuria in [**2174-7-14**](normal CTA of abdomen and pelvis)
PSH: Vasectomy, Appendectomy
Social History:
Race: white
Last Dental Exam: [**2174-12-14**]
Lives with: Wife
Occupation: Photographer
Tobacco: non-smoker
ETOH: Occasional. No history of abuse
Family History:
Non-contributory
Physical Exam:
Pulse: 63 Resp: 18 O2 sat: 100%
B/P Right: 121/75 Left: 111/78
General: WDWN male in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur 3/6 systolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: None
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: groin site Left: groin site
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right: none Left: none
Pertinent Results:
Admission labs:
[**2175-3-15**] 10:36AM PT-15.2* PTT-30.5 INR(PT)-1.3*
[**2175-3-15**] 10:36AM PLT COUNT-263
[**2175-3-15**] 10:36AM WBC-8.0 RBC-5.16 HGB-14.9 HCT-44.7 MCV-87
MCH-29.0 MCHC-33.4 RDW-14.7
[**2175-3-15**] 10:36AM ALBUMIN-4.6
[**2175-3-15**] 10:36AM GLUCOSE-90 UREA N-28* CREAT-1.1 SODIUM-139
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15
[**2175-3-15**] 03:25PM %HbA1c-5.9 eAG-123
[**2175-3-15**] 03:25PM ALBUMIN-4.2 CHOLEST-142
[**2175-3-15**] 03:25PM ALT(SGPT)-30 AST(SGOT)-24 CK(CPK)-86 ALK
PHOS-60 AMYLASE-24 TOT BILI-0.9
Discharge labs:
[**2175-3-21**] 05:00AM BLOOD WBC-7.4 RBC-2.81* Hgb-8.5* Hct-24.1*
MCV-86 MCH-30.0 MCHC-35.1* RDW-14.8 Plt Ct-223
[**2175-3-21**] 05:00AM BLOOD Plt Ct-223
[**2175-3-21**] 05:00AM BLOOD PT-18.6* PTT-34.4 INR(PT)-1.7*
[**2175-3-21**] 05:00AM BLOOD Glucose-91 UreaN-24* Creat-0.9 Na-135
K-3.6 Cl-97 HCO3-31 AnGap-11
Radiology Report CHEST (PORTABLE AP) Study Date of [**2175-3-19**] 8:33
AM
Final Report:
Following removal of endotracheal tube and pleural drains and a
Swan-Ganz
catheter, moderate right pleural effusion is larger, severe left
lower lobe atelectasis and small left pleural effusion are
stable, large cardiac
silhouette is unchanged and there is no appreciable mediastinal
vascular
engorgement. There is no pulmonary edema or pneumothorax. Right
jugular line ends above the origin of the right brachiocephalic
vein.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *7.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% >= 55%
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Arch: 2.9 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.1 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Dilated LA. Dilated coronary sinus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV
cavity. Mildly depressed LVEF. [Intrinsic LV systolic function
likely depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Myxomatous mitral valve leaflets. Partial mitral leaflet flail.
Mitral leaflets fail to fully coapt. Eccentric MR jet. Severe
(4+) MR. [**Name13 (STitle) 15110**] to the eccentric MR jet, its severity may be
underestimated (Coanda effect).
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Resting tachycardia
(HR>100bpm). The rhythm appears to be atrial fibrillation.
patient.
Conclusions
Prebypass
The left atrium is dilated. The coronary sinus is dilated. The
right atrium is dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is severely dilated. Overall
left ventricular systolic function is mildly depressed (LVEF= 50
%). [Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular chamber size is normal with mild global free wall
hypokinesis. The mitral valve leaflets are moderately thickened
and myxomatous. There is posterior mitral leaflet flail
involving primarily the P2 scallop. The mitral valve leaflets do
not fully coapt. An eccentric, anteriorly directed jet of severe
(4+) mitral regurgitation is seen. Due to the eccentric nature
of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The tricuspid valve leaflets are
mildly thickened with mild tricuspid regurgitation. The degree
of tricuspid regurgitation did not increase in severity despite
administration of 1.5 Liters of crystalloid, giving a pressor to
increase afterload, and placing the patient in a Trendelenburg
position. There is no pericardial effusion.
Postbypass
The patient is in atrial fibrillation on an epinephrine
infusion. There is a new annuloplasty ring in the mitral
position. It appears well-seated. There is now only trace mitral
regurgitation. Gradients across the valve at a cardiac output of
6.5 L/min are peak/mean of [**10-17**] mmHg. Biventricular systolic
function appears unchanged. Tricuspid regurgitation is now
trace. The thoracic aorta is intact post decannulation.
Brief Hospital Course:
Mr [**Known lastname 3315**] was admitted to [**Hospital1 18**] for surgical repair of mitral
regurgitation on [**3-17**] by Dr [**Last Name (STitle) **]. Please see the operative
report for details, in summary he had:
Mitral valve repair with a quadrangular resection of the middle
scallop of the posterior leaflet (P2), and the mitral valve
annuloplasty with a 32-mm Physio
II annuloplasty ring. He tolerated the operation well and was
transferred from the operating room to the cardiac surgery ICU
in stable condition. He was hemodynamically stable in the
immediate post-operative period anesthesia was reversed he awoke
neurologically intact and he was extubated. He remained stable
and was transferred to the stepdown floor on POD1.
All tubes, lines, and drains were removed per cardiac surgery
protocol. Once on the stepdown floor he worked with physical
therapy to increase his strength and endurance. He remained in
atrial fibrillation and his coumadin was resumed.
The remainder of his post-operative course was uneventful. On
POD4 he was discharged home with visiting nurses. INR level and
Coumadin dosing will be followed by [**University/College **]
Vangaurd/ST-[**Last Name (LF) **],[**First Name3 (LF) **] F. [**Telephone/Fax (1) 105742**].
Medications on Admission:
HYDROCHLOROTHIAZIDE - 25 mg daily
SIMVASTATIN - 20mg daily
TRAZODONE - - 50 mg Tablet prn sleep
WARFARIN - 5 mg Tablet
DOCUSATE SODIUM -100 mg daily
MULTIVITAMIN 1 daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. 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*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 2 weeks.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
9. trazodone 50 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
10. warfarin 5 mg Tablet Sig: as directed Tablet PO once a day:
resume pre op coumadin schedule.
Target INR 2-2.5.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Mitral regurgitation s/p mitral valve repair(32 mm ring)
PMHx:Chronic Atrial fibrillation(coumadin), Hypertension,
Dyslipidemia, Carpal Tunnel Syndrome, Benign Prostatic
Hypertrophy s/p Laser therapy, Hemorrhoids, s/p Banding,
Insomnia, History of Basal Cell Carcinoma, Hematuria/[**Month (only) 205**]
[**2174**](normal CTA abdomen/pelvis), Vasectomy, Appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg 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 and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on [**4-13**] at 1:15PM
Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] :date and time to be determined
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (LF) 105743**],[**First Name3 (LF) **] F. [**Telephone/Fax (2) 105742**]in 4-5 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 ?????? for atrial fibrillation
Goal INR 2-2.5
First draw [**3-22**]
Results to phone fax: [**University/College **] Vangaurd/ST-[**Last Name (LF) **],[**First Name3 (LF) **] F.
[**Telephone/Fax (1) 105742**]
Completed by:[**2175-3-21**]
|
[
"416.8",
"443.0",
"998.2",
"427.31",
"443.22",
"272.4",
"600.00",
"424.0",
"401.9",
"V58.61",
"E879.0",
"V10.83",
"V26.52",
"780.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"39.61",
"88.56",
"35.12",
"00.46",
"37.21",
"39.90",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
9722, 9781
|
7046, 8303
|
339, 536
|
10191, 10365
|
2033, 2033
|
11206, 12023
|
1327, 1346
|
8529, 9699
|
9802, 10170
|
8329, 8506
|
10389, 11183
|
2612, 7023
|
1361, 2014
|
271, 301
|
564, 815
|
2049, 2596
|
837, 1147
|
1163, 1311
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,715
| 113,873
|
43605+43606
|
Discharge summary
|
report+report
|
Admission Date: [**2190-6-16**] Discharge Date: [**2190-6-18**]
Date of Birth: [**2119-8-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Aspirin / Augmentin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known lastname 93777**] is a 70 year old female with a history of DM 2, HTN,
breast CA, hypothyroid with a productive cough found to have a
left lower lobe pneumonia. The patient reports 2 days of
productive cough with associated headache, myalgias, and
dizziness. She has severe left shoulder pain for two days to the
point where she felt like she might be having an MI. The pain
radiated to her ears. Felt fine on Monday did water aerobics on
in the afternoon and then had a deep tissue massage. She was
very fatigued and had body aches worse in the shoulder region.
She finally came to the ED as she was not getting better.
.
Of note patient seen in clinic two to three weeks ago for a
persistent cold. She was given 10 days of azithromycin.
.
In the [**Hospital1 18**] ED, VS 99.6 127 134/70 16 98%RA. The patient had a
CXR notable for a left base conslidation. She received
levofloxacin 750 mg, had 1 set of blood cultures drawn, and was
admitted to Medicine for further management. On transfer her
vitals were: HR 106, 22, 98% RA
.
Currently, the patient is having some mild body ahces and just
generally feels unwell.
Past Medical History:
Past Medical History:
- Breast CA - diagnosed [**2169**] s/p left mastectomy
- Thyroid CA - diagnosed [**2185**] s/p thyroidectomy and I-125.
- DM 2
- Hypothyroid
- Migraines
- Hyperlipidemia
- HTN
- Chronic Pain
- 60%-69% stenosis of the internal carotid
Social History:
Social History:
No tob (quit 40yrs ago)
No EtOH
Family History:
Non-Contributory
Physical Exam:
Physical Exam:
VS: 98, 156/74, 107, 22, 97% RA
Gen: Uncomfortable, NAD
HEENT: MMM, OP clear
CV: s1+, s2+, RRR, No M/R/G
Pulm: Rhales on left side
Abd: Soft, NT, ND, +BS
Ext: No edema
Neuro:CN II-XII intact
Pertinent Results:
[**2190-6-16**] 06:30PM BLOOD WBC-12.8*# RBC-4.34 Hgb-10.0* Hct-32.1*
MCV-74* MCH-23.1* MCHC-31.2 RDW-14.9 Plt Ct-218
[**2190-6-17**] 06:20AM BLOOD WBC-7.6 RBC-3.90* Hgb-8.6* Hct-29.4*
MCV-75* MCH-22.0* MCHC-29.3* RDW-14.9 Plt Ct-182
[**2190-6-18**] 06:10AM BLOOD WBC-6.1 RBC-3.55* Hgb-7.9* Hct-26.9*
MCV-76* MCH-22.4* MCHC-29.5* RDW-15.0 Plt Ct-200
[**2190-6-18**] 12:30PM BLOOD Hct-27.5*
[**2190-6-16**] 06:30PM BLOOD Neuts-90.0* Lymphs-6.2* Monos-3.6 Eos-0.1
Baso-0.1
[**2190-6-18**] 06:10AM BLOOD Neuts-80.6* Lymphs-12.4* Monos-5.2
Eos-1.5 Baso-0.3
[**2190-6-16**] 06:30PM BLOOD Glucose-148* UreaN-12 Creat-0.6 Na-137
K-3.8 Cl-100 HCO3-25 AnGap-16
[**2190-6-17**] 06:20AM BLOOD Glucose-83 UreaN-11 Creat-0.5 Na-144
K-4.0 Cl-114* HCO3-21* AnGap-13
[**2190-6-17**] 06:20AM BLOOD ALT-17 AST-15 AlkPhos-65 TotBili-0.4
[**2190-6-16**] 09:13PM BLOOD Lactate-1.9
CXR: Left-sided pneumonia
Brief Hospital Course:
Assessment and Plan: [**Known lastname 93777**] is a 70 year old female with a
history of DM 2, HTN, breast CA, hypothyroid with a productive
cough found to have a left lower lobe pneumonia with recent
therapy for URI.
.
# CAP: Patient with evidence of LLL pneumonia. Patient with
antibiotic course (azithromycin) 2 weeks ago. No further risk
factors for HAP. However, given recent azithromycin therapy
broadened antibiotic coverage given potential for resistence. On
HD# 3, blood cultures were negative x 24 hours, patient remained
afebrile with improvement in symptoms and leukocytosis resolved.
Given this, the decision was made to narrow her antibiotics to
Levofloxacin. Of, note Legionella negative.
.
# Anemia: Slow decline in Hematocrit. No obvious source. Pt
denies any source of bleeding. HD stable and guaiac negative.
Hct stable at time of discharge. Iron studies sent for further
evaluation of anemia and can be followed up as an outpatient.
- Would consider repeating Colonoscopy as outpatient.
.
# DM 2: FS and ISS while inpatient. Restarted home meds upon
discharge.
.
# HTN: Continue Diltiazem and simvastatin.
.
# Carotid Stenosis: Patient with known 60-70% carotid stenosis.
On plavix and statin. Will continue.
.
# Hypothyroid: Cont thyroid replacement
.
# Anxiety: Continue Valium
.
# Chronic pain: Continue Gabapentin, Paroxetine, Percocet.
.
# FEN: Encouraged PO hydration, IV hydration PRN, replete
electrolytes PRN, regular
diet.
.
PPx: Heparin SQ, bowel regimen, On Omeprazole at home and
continued
Medications on Admission:
Plavix 75 mg daily
Valium 5 mg daily
Diltiazem XT 240 mg daily
Gabapentin 300 mg po bid
Glipizide ER 2.5mg daily
Hydrocodone-homatropine 5mg-1.5mg/5mL syrup - 1 tsp Q4H
Ibandronate 150 mg QMonthly
Levothyroxine 112 mcg daily
Metformin 500 mg QAM and 1500mg QPM
Paroxetine 30mg daily
Maxalt 10 mg prn
Simvastatin 40 mg qhs
Vitamin D
OM3FA
Omeprazole 40 mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for anxiety.
3. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Paroxetine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO QAM.
13. Metformin 500 mg Tablet Sig: Three (3) Tablet PO QPM.
14. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
15. Outpatient Lab Work
Recheck CBC on [**2190-6-22**]
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with a cough and muscle aches. You
were found to have a pneumonia. You were started on an
antibiotic. You should complete the entire course of the
medication.
Also, you were found to have anemia, but no evidence of
bleeding. We sent some blood work that Dr. [**Last Name (STitle) **] will follow-up
on. We will have you repeat blood work prior to your appointment
with Dr. [**Last Name (STitle) **].
You should call your doctor if you feel lightheaded, dizziness,
chest pain, shortness of breath, wheezing, abdominal pain,
vaginal bleeding or rectal bleeding.
Followup Instructions:
Appointment: Primary Care
When: THURSDAY, [**2190-6-24**], 2:15PM
With: [**Last Name (LF) **], [**First Name7 (NamePattern1) 2048**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL
GROUP
Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 133**]
Completed by:[**2190-6-18**] Admission Date: [**2190-6-19**] Discharge Date: [**2190-6-29**]
Date of Birth: [**2119-8-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Aspirin / Augmentin /
Azithromycin / Fentanyl / Paroxetine / Precedex
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Mechanical Ventilation
Endotracheal Intubation
Arterial line placement
Central venous line placement
Attempted left lung decortication
Placement of chest tube on the left
History of Present Illness:
[**Known lastname 93777**] is a 70 F w/ DM, HTN, Br Ca in [**2169**], thyroid ca in [**2185**]
who was d/c'd yest for CAP on levofloxacin. Today, the pt
presented to the ED with L sided CP. In the [**Hospital1 18**] ED, VS 97.4
103 157/69 24 96 RA. The patient was given zofran 2mg x1 and
morphine total 12mg IV and dailaudid 1mg IV. She never spiked a
temp in the ED. Her CXR looked worse so she was given
Vanc/Zosyn. She became tachypneic to mid 30s.
On arrival to the floor, [**Known lastname 93777**] reported being in [**10-22**] pain
which was most significantly located over left lateral ribs. She
states "I can't breathe." She received 0.25 IV Dilaudid x 2
doses with improvement of her pain to [**8-21**]. SL NTG x1 did not
relieve her pain. Given crackles on exam, patient received Lasix
20mg IV x 2. A CTA chest was ordered which showed preliminarily
LLL collapse but no PE. Her antibiotics were changed to
vanco/cefepime/azithro per ID. She was intolerant of NC so she
was placed on 4L by facemask with O2 sats 95-97%. She remained
tachypneic to the 30s, tachycardic to the 110s with SBPs
160-170s and was using accessory muscles to breath so an ICU
consult was called.
On ICU eval, she seemed to be tiring from her high RR. Pt c/o
left sided "rib" pain which is not TTP. She also states she is
SOB. Otherwise, she denies any other pain.
Review of systems:
(+) Per HPI
(-) Denies nausea, vomiting, abdominal pain, headache,
lightheadedness. Denies rashes or skin changes.
Past Medical History:
- Breast CA - diagnosed [**2169**] s/p left mastectomy
- Thyroid CA - diagnosed [**2185**] s/p thyroidectomy and I-125.
- DM 2
- Hypothyroid
- Migraines
- Hyperlipidemia
- HTN
- Chronic Pain
- 60%-69% stenosis of the internal carotid
Social History:
Pt lives in [**Location **] independently with daughter nearby. [**Name2 (NI) **] tob
(quit 40yrs ago). No EtOH . No drugs
Family History:
Non-Contributory
Physical Exam:
Vitals: 97 72 132/66 22 96%RA
General Appearance: AOx3, pleasant, appropriate, NAD.
Eyes / Conjunctiva: PERRL, anicteric
Head, Ears, Nose, Throat: Normocephalic, OP clear
Cardiovascular: RRR. No MRG
Respiratory / Chest: rhonchorous BS throughout, Diminished at R
base.
Abdominal: Soft, Non-tender, Bowel sounds present, Not Distended
Extremities: Right lower extremity edema: none, Left lower
extremity edema: none, No cyanosis
Pertinent Results:
Admission laboratories:
[**2190-6-18**] 06:10AM WBC-6.1 RBC-3.55* Hgb-7.9* Hct-26.9* MCV-76*
Plt Ct-200
[**2190-6-18**] 06:10AM Neuts-80.6* Lymphs-12.4* Monos-5.2 Eos-1.5
Baso-0.3
[**2190-6-19**] 04:04AM PT-12.1 PTT-22.9 INR(PT)-1.0
[**2190-6-19**] 04:04AM Glucose-193 UreaN-10 Cr-0.6 Na-137 K-3.2 Cl-101
HCO3-23
[**2190-6-21**] 08:22PM ALT-12 AST-16 LD-261* CK(CPK)-111 AlkPhos-94
TotBili-0.4
[**2190-6-19**] 08:12PM Calcium-7.6* Phos-3.2 Mg-1.7
-----------
MICRO:
[**6-19**] BCx ?????? negative
[**6-19**] UCx ?????? negative
[**6-20**] SputumCx ?????? rare yeast
[**6-20**] BCx ?????? negative
[**6-20**] UCx ?????? negative
[**6-20**] Pleural fluid Cx ?????? negative
[**6-20**] BAL ?????? negative
[**6-21**] Pleural fluid ?????? prelim negative
[**6-21**] UCx ?????? negative
[**6-21**] BCx ?????? negative
[**6-22**] BCx ?????? negative
[**6-22**] BAL ?????? negative
[**6-26**] UCx ?????? negative
[**6-26**] BCx ?????? NGTD
[**6-28**] Cdiff ?????? negative
----------
Imaging:
[**2190-6-29**] CT chest:
1)No pulmonary embolism to segmental level.
2) Near complete left lower lobe collapse and consolidation,
also involving the lingula, moderately large left pleural
effusion and left upper lobe consolidation is consistent with
pneumonia and has progressed since [**2190-6-16**]. The slightly
expansile appearance of the consolidations is associated with
pyogenic pneumonia with the differential including gram negative
organisms such as Klebsiella.
[**2190-6-21**] CT head:
No acute intracranial process.
[**2190-6-21**] CT Cspine:
No fractures noted. Unchanged mild degenerative changes of the
cervical spine with mild canal stenosis.
[**2190-6-22**] MRA neck:
1. Normal time-of-flight MRA with no evidence for carotid
dissection or hemodynamically significant stenosis within the
limitations of the examination.
2. Bilateral pleural effusions, left greater than right with
left-sided chest tube.
[**2190-6-23**] ECHO:
Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with akinesis of the mid to distal septum and severe hypokinesis
of the mid to distal inferior wall. Overall left ventricular
systolic function is mildly depressed (LVEF= 45-50%). The aortic
valve leaflets (?#) appear structurally normal with good leaflet
excursion. The mitral valve leaflets are structurally normal.
Compared with the findings of the prior report (images
unavailable for review) of [**2185-10-21**], there is new regional LV
dysfunction.
[**2190-6-24**] CT head:
No hemorrhage, edema, or evidence of acute process.
[**2190-6-28**] CXR:
No pneumothorax. Residual left lower lobe infection and/or
atelectasis and
small volume of loculated (non-dependent) pleural fluid.
1. Right PIC catheter terminates at or below the level of the
cavoatrial
junction.
2. Interval improvement in the left lower lobe opacity, likely
residual
infection or atelectasis. Unchanged mild asymmetric left
pulmonary edema and small left pleural effusion.
DISCHARGE LABS [**2190-6-29**]:
WBC 13 HCT 33.2 Plt 425
Na 143 K 3.8 Cl 107 HCO3 26 BUN 16 Cr 0.5 Glc 195
Ca 8.7 Phos 4.4 Mg 2.1
Brief Hospital Course:
70 F w/ DM, HTN, Br Ca in [**2169**], thyroid ca in [**2185**] who was d/c'd
the day prior to admission for CAP on levofloxacin who presented
again with CP and SOB, found to have parapneumonic effusion, s/p
chest tube.
# Respiratory failure with left sided pleural effusion/empyema:
The patient presented to the ICU with increased work of
breathing and chest pain. She was found to have a left sided
pleural effusion and LLL collapse. She was recently hospitalized
and discharged for community acquired pneumonia. The patient was
initally started on vanco/zosyn which was expanded to
vanco/cefepime/azithromycin. The patient was transferred to the
ICU for increased work of breathing and a pigtail catheter was
placed by IR. Pleural fluid was sent to pathology and for
cultures. The pH of the fluid was 6.8, so it was presumably an
empyema, though the cultures were negative. Cytology was also
negative for malignant cells. The patient was electively
intubated for procedures. The patient underwent an attempted
decortication of her left lung (since the pigtail did not fully
drain her pleural effusion), though there were problems in the
procedure because anesthesia was having difficulty ventilating
just her right lung. She was intubated and extubated multiple
times while in the operating room. Due to her ventilation
problems, the decortication procedure was not done and a chest
tube was placed for drainage. The chest tube drained
serosangious fluid. Initially, it was to suction and then to
waterseal. It was pulled prior to discharge. Her pleural
effusion improved.
After the operating room, the patient continued to be
ventilated. Multiple attempts were taken to wean the patient off
of the ventilator, though she became agitated with tachycardia
and hypertension. The patient's medications were switched from
fentanyl and versad to propofol, PRN ativan, and PRN morphine
with limited success. Precedex was tried, but the patient had
bradycardia during the infusion, so she was therefore continued
on the above regiment of propofol and PRN ativan/Morphine. The
patient was further diuresed with a lasix drip and was
successfully extubated after aggressive diuresis. She is now
satting 96-100% on RA.
# Muscle rigidity: The patient was noted to have muscle rigidity
and left sided ankle clonus after presenting from the operating
room. In the operating room, the patient received isoflurance
and sevoflurane as well as fentanyl. On return from the
operating room, the patient was noted to have tachycardia to
130s and BPs to ~200/110. Physical exam showed left sided ankle
clonus and muscle rigidity. Neurology was consulted who felt
that the patient's symptoms could be due to serotonin syndrome
(on paxil and fentanyl). A CT of the head ruled out ICH. A CT
and MRI of the spine ruled out any fracture or compression on
the spinal cord. A MRA of the neck ruled out carotid dissection.
Both fentanyl and paxil were immediately discontinued.
Anesthesiology was contact[**Name (NI) **] to ask about the possibility of
malignant hyperthermia. The patient received inhaled anesthetics
in the OR, though her CK was normal. About 11 hours post-op, the
patient spiked a fever to 101-102, so she was empirically given
one dose of dantrolene for the possibility of malignant
hyperthermia. The next documented examine after the dose of
dantrolene (5-6 hours after administration) showed a resolution
in her rigidity and clonus.
# Cardiac ischemia: The patient was noted to have persistent ST
depressions in her telemetry. Cardiology was consulted who
performed a stat echo showing mid-distal akinesis of the septum.
Her cardiac enzymes were trended and she did not have any
biomarker evidence of an acute thrombotic event. The patient was
re-started on her plavix and a beta blocker. Cardiology
recommended a catheterization when she is medically stable.
# Hypertension/tachycardia: The patient had multiple
hypertensive and tachycardic episodes while intubated. These
episodes took place during times of agitation and also during
perceived resting states. Since her blood pressures were so
labile, she was started on an esmolol drip. Post-extubation, she
required esmolol and a nitro gtt to control her blood pressures.
An NG tube was placed and she was given PO medications and the
drips were subsequently weaned. The patient is discharged on
Metoprolol and Captopril with better BP control, SBP 120-150s.
# Altered mental status: Post-extubation, the patient had
altered mental status, thought likely due to her prolonged
intubation and medications. Her mental status slowly cleared.
She was restarted on Valium qhs prn. MS currently is at baseline
- AOx3, pleasant, interactive. U/A was positive on [**6-29**], urine
culture from [**6-29**] is pending and should be followed up by rehab
MD.
# Contact: The PCP was notified via email of the patient's
admission. The ICU team also communicated with her daughter and
son.
# Speech/Swallow: The patient was noted to choke/cough while
drinking thin liquids on [**6-28**]. The patient underwent swallow
evaluation on [**6-29**] - she is able to tolerate a regular diet and
thin liquids. Pills to be taken whole with thin liquids. Oral
care three times a day.
# Urinary frequency and some mid urinary retension while at the
hospital. UA with moderate bacteria in setting of one epithelial
cell. Urine was nitrite and leukocyte negative. Urine with 3-5
WBCs. Cx was done and was pending at the time of discharge.
Medications on Admission:
Plavix 75 mg daily
Valium 5 mg daily
Diltiazem XT 240 mg daily
Gabapentin 300 mg po bid
Glipizide ER 2.5mg daily
Hydrocodone-homatropine 5mg-1.5mg/5mL syrup - 1 tsp Q4H
Ibandronate 150 mg QMonthly
Levothyroxine 112 mcg daily
Metformin 500 mg QAM and 1500mg QPM
Paroxetine 30mg daily
Maxalt 10 mg prn
Simvastatin 40 mg qhs
Vitamin D
OM3FA
Omeprazole 40 mg daily
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 11 doses: total 14 day
course
day 9 = [**2190-6-28**]
day 14 = [**2190-7-3**].
3. Diazepam 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for Anxiety.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
10. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
11. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
12. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Cefepime 2 gram Recon Soln Sig: Two (2) Recon Soln Injection
Q12H (every 12 hours) for 11 doses: total 14 day course day 9 =
[**2190-6-28**] day 14 = [**2190-7-3**]. .
14. 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.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation .
17. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
18. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
19. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
20. Ibandronate 150 mg Tablet Sig: One (1) Tablet PO once a
month.
21. Metformin 500 mg Tablet Sig: One (1) Tablet PO QAM.
22. Metformin 500 mg Tablet Sig: Three (3) Tablet PO at bedtime.
23. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO
once a day.
24. Tessalon 200 mg Capsule Sig: One (1) Capsule PO four times a
day as needed for cough.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Hypoxic Respiratory Distress
Lung Empyema
Possible Seratonin Syndrome
Benzodiazepine Withdrawal
Secondary Diagnosis:
Hypertension
Diabetes Mellitus
Hyperthyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the ICU with an infection of the lung known
as an abscess or 'empyema'. You were treated with a breathing
tube, and by having a catheter placed in your lung which drained
the infection. You were treated with antibiotics as well. Your
hospital course was also complicated by a possible damage to
your heart -- you were seen by cardiology, and you have been
started on medications to protect your heart. There was also
concern for a diagnosis known as 'seratonin' syndrome, for which
your paroxetine was stopped. The breathing tube was removed, and
you were no longer requiring oxygen on discharge. You are still
weak and needed rehabilitation on discharge.
Please take your medications as directed. The following changes
were made to your medications.
STOP Diltiazem, Paroxetine, Hydrocodone-Homatropine syrup.
START Metoprolol, Captopril
START Tessalon [**Doctor Last Name 6010**] for cough
START Colace, Senna, Bisacodyl as needed for stool softeners
START Trazodone as needed for sleep
START Miconazole powder
START IV Vancomycin and Cefepime for a total 14 day course (last
day = [**2190-7-3**])
INCREASE Simvastatin from 40 mg to 80 mg by mouth daily.
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] [**2-13**]
weeks of discharge from rehab. [**Last Name (LF) 2400**],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 133**].
Please call cardiology for an appointment for follow-up after
discharge from rehab. Phone #[**Telephone/Fax (1) 62**]
Other appointments:
Provider: [**First Name8 (NamePattern2) 3049**] [**Last Name (NamePattern1) 3050**], MD Phone:[**Telephone/Fax (1) 3051**]
Date/Time:[**2190-8-31**] 10:00
|
[
"788.20",
"V10.3",
"276.2",
"244.9",
"788.41",
"433.10",
"292.0",
"790.5",
"401.9",
"300.00",
"346.90",
"780.97",
"E944.4",
"V64.1",
"338.29",
"518.81",
"V10.87",
"E939.0",
"250.00",
"E935.2",
"E937.8",
"794.31",
"427.89",
"510.9",
"285.9",
"307.9",
"333.99"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.06",
"34.04",
"88.73",
"96.04",
"38.93",
"96.05",
"96.6",
"38.91",
"33.24",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
21712, 21782
|
13562, 17985
|
7815, 7987
|
22010, 22010
|
10401, 11878
|
23389, 23890
|
9917, 9935
|
19444, 21689
|
21803, 21803
|
19058, 19421
|
22186, 23366
|
9950, 10382
|
9387, 9504
|
7768, 7777
|
8015, 9368
|
12941, 13539
|
21940, 21989
|
21822, 21919
|
22025, 22162
|
9526, 9761
|
9777, 9901
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,116
| 174,797
|
21164
|
Discharge summary
|
report
|
Admission Date: [**2170-7-24**] Discharge Date: [**2170-7-29**]
Date of Birth: [**2096-8-13**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: On [**2170-7-12**] the patient
exercised for five minutes [**First Name8 (NamePattern2) **] [**Doctor First Name **] protocol and achieved 88
percent of his age-predicted heart rate. An
electrocardiogram was significant for 6-mm ST segment
depressions in leads II, III, aVF, V1, and V4 through V6.
Frequent premature ventricular contractions were noted.
Nuclear imaging revealed a dilated left ventricular cavity
with stress and mild inferoapical reversible defects. The
ejection fraction was 59 percent with no wall motion
abnormalities.
As a result of this, the patient was referred to the Cardiac
Surgery Service for a coronary artery bypass grafting.
PAST MEDICAL HISTORY: A cerebrovascular accident in [**2156**]-
[**2157**] with residual left hand swelling.
A myocardial infarction in [**2157**]; status post PPCA of the
right coronary artery in [**2153**].
Mitral regurgitation.
Carotid artery disease.
SOCIAL HISTORY: Right carotid endarterectomy and
appendectomy.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS AT HOME:
1. Lisinopril/hydrochlorothiazide 20/25 mg by mouth every day
2. Atenolol 100 mg by mouth once per day.
3. Lipitor 20 mg by mouth once per day.
4. Aspirin 81 mg by mouth once per day.
PHYSICAL EXAMINATION ON PRESENTATION: The patient is a 73-
year-old gentleman in no acute distress. Head, eyes, ears,
nose, and throat examination revealed the pupils were equal,
round, and reactive to light and accommodation. The
extraocular movements were intact. The oropharynx was
benign. Neck examination revealed the trachea was midline.
Pulmonary examination revealed the lungs were clear to
auscultation bilaterally. Cardiovascular examination
revealed a regular rate and rhythm. The abdomen was soft,
nontender, and nondistended. There were no masses.
Extremities revealed no cyanosis and no edema.
Neurologically, the patient was alert and oriented times
three.
SUMMARY OF HOSPITAL COURSE: The patient was admitted on [**2170-7-24**] and taken to the operating room where he underwent
coronary artery bypass grafting times two. The patient
tolerated the procedure well and received Novolin products in
the Operating Room and was admitted the Cardiac Surgery
Recovery Room after his procedure.
The patient was extubated the following day and transferred
to the floor. On [**2170-7-27**] his pacemaker wires were
discontinued.
DISCHARGE DISPOSITION: He was seen by Physical Therapy who
cleared him to go home.
CONDITION ON DISCHARGE: He was discharged on [**2170-7-29**]
in good condition.
DISCHARGE DIAGNOSES: Status post coronary artery bypass
grafting on [**2170-7-24**].
Status post cerebrovascular accident.
Status post myocardial infarction.
Mitral regurgitation.
Carotid disease.
Status post right carotid endarterectomy.
Status post appendectomy.
MEDICATIONS ON DISCHARGE:
1. Aspirin 81-mg tablets one tablet by mouth once per day.
2. Acetaminophen 325-mg tablets two tablets by mouth q.4h. as
needed (for pain).
3. Clopidogrel bisulfate 75-mg tablet by mouth once per day
(for three months).
4. Atorvastatin calcium 20-mg tablets one tablet by mouth
once per day.
5. Furosemide 20-mg tablets one tablet by mouth once per day
(for five days).
6. Atenolol 100-mg tablets one tablet by mouth once per day.
DISCHARGE FOLLOW-UP PLANS: The patient was instructed to
make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in five to six
weeks. The patient was also instructed to make a follow-up
appointment with is cardiologist.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 32536**]
MEDQUIST36
D: [**2170-7-29**] 17:52:20
T: [**2170-7-29**] 18:31:00
Job#: [**Job Number **]
|
[
"V45.82",
"414.01",
"412",
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] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"36.11",
"89.62",
"39.61",
"96.04",
"96.71",
"36.15",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
2583, 2644
|
2748, 3000
|
3026, 3484
|
1224, 2091
|
2120, 2559
|
3502, 4006
|
165, 824
|
847, 1084
|
1101, 1203
|
2669, 2726
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,286
| 196,933
|
21587
|
Discharge summary
|
report
|
Admission Date: [**2175-11-21**] Discharge Date: [**2175-12-4**]
Date of Birth: [**2097-7-24**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: Patient is a 78-year-old woman
transferred from home where she has 24 hour nursing care
after a fall. She had intermittent confusion and headache.
She also had nausea with dry heaves, but denied visual
changes, fever. Head CT showed a large subdural hematoma
with herniation.
PAST MEDICAL HISTORY: Scoliosis.
Left hip replacement.
Raynaud's syndrome.
Hypertension.
Polyneuropathy.
MEDICATIONS:
1. Celebrex 100 twice a day.
2. Trazodone 25 every evening.
3. Aspirin 81 by mouth every day.
4. Calcium 1500 mg every day.
5. Centrum every day.
6. Fosamax 70 every week.
7. Metoprolol 25 every day.
8. Lisinopril 25 twice a day.
PHYSICAL EXAMINATION: On exam, the patient was awake, alert,
and oriented times two. Pupils are equal, round, and
reactive to light. EOMs full. No nystagmus. Moving all
extremities with good strength with a left pronator drift,
slight. Strength was full throughout. Toes were downgoing
bilaterally.
Head CT shows right subdural hematoma with mass effect.
Dilated left lateral ventricle.
HOSPITAL COURSE: Patient was taken emergently to the OR for
a craniotomy on [**2175-11-21**] by Dr. [**First Name (STitle) 24425**]. She tolerated a right
frontal craniotomy for bur hole evacuation of subdural
hematoma without complication. Postoperatively, she was
admitted to the ICU. She was intubated and sedated, but
moving all extremities to pain. She had left eye lateral
deviation. Pupils are equal, round, and reactive to light.
Her trachea was midline. Postoperatively, she had a JP drain
that remained in place.
On postoperative day two, she had her C spine cleared. She
had a JP drain that was removed. She required some diuresis.
She was successfully extubated on [**2175-11-23**]. She was out of
bed with assistance keeping her blood pressure less than 160.
She had a head CT on [**11-21**], which showed improvement of the
mass effect on the right hemisphere and there remained some
right parietal-occipital blood and some air. Her TLS spine
was cleared. Her C spine, although the scans showed no
fractures, they were limited, and she remained in a hard
collar until flexion and extension films could be done.
On [**2175-11-25**], she was transferred to the Step Down Unit.
She remained neurologically awake, alert. Head CT on [**11-23**]
showed residual small intracranial hemorrhage in the lateral
ventricles and some subdural space, and no mass effect.
On [**11-26**], the patient had a bedside swallow evaluation, which
she passed. Although the following day, the nurse felt she
was coughing more frequently with taking fluids and a video
swallow study was ordered. The patient was found to be
aspirating all consistencies and she was kept NPO. On
[**2175-11-30**], the patient had PEG placed without complications.
Postoperatively, there was a small amount of bleeding,
however, it was felt to be no surgical issue. GI Surgery was
consulted and the patient's hematocrit was stable with no
further episodes of bleeding. Her G tube site is clean, dry,
and intact. She is started on her tube feedings. Her
dressing is clean, dry, and intact. She is arousable. Her
pupils are equal, round, and reactive to light. EOMs full.
She has no drift. She has got a weaker grasp on the left
than on the right and she has antigravity strength in her
lower extremities.
Her head CT remains stable. She remains in a hard collar
until she is able to flex and extend, which will be in about
two weeks. Her vital signs remained stable and she has been
afebrile.
MEDICATIONS:
1. Lisinopril 10 PEG twice a day.
2. Dilantin 100 mg per PEG three times a day.
3. Heparin 5000 units subcutaneously three times a day.
4. Levofloxacin 250 IV every 24 hours for a urinary tract
infection.
5. Pantoprazole 40 mg per her PEG every 24 hours.
6. Artificial Tears one application both eyes as needed.
7. Insulin-sliding scale.
8. Multivitamin one per PEG every day.
9. Alendronate sodium 70 mg by mouth every morning.
10. Calcium carbonate 500 four times a day as needed.
11. Senna one tablet by mouth twice a day.
12. Colace 100 by mouth twice a day.
13. Hydrocodone 1-2 tablets by mouth every four hours as
needed for pain.
CONDITION ON DISCHARGE: Patient's condition was stable at
the time of discharge.
FOLLOW UP: She will follow up with Dr. [**Last Name (STitle) 739**] in [**3-6**]
weeks with repeat head CT at that time.
[**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2175-12-4**] 10:53:05
T: [**2175-12-4**] 11:49:12
Job#: [**Job Number 56851**]
|
[
"348.4",
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"356.9",
"507.0",
"599.0",
"041.04",
"V43.64",
"342.82",
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icd9cm
|
[
[
[]
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] |
[
"87.61",
"99.04",
"39.98",
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"96.71",
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icd9pcs
|
[
[
[]
]
] |
1215, 4368
|
4463, 4811
|
824, 1197
|
166, 445
|
468, 801
|
4393, 4451
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,518
| 131,284
|
6749
|
Discharge summary
|
report
|
Admission Date: [**2122-9-19**] Discharge Date: [**2122-9-24**]
Date of Birth: [**2080-1-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Pt is a 42 yo W with PMH of COPD on home O2, OSA, pulm HTN and
prior PE who presented to ED with complaint of SOB and
productive cough with brown sputum. Cough worsening over last
few weeks. Also with chest tightness. Feels like "sucking air
through a straw." Spoke to primary care provider over phone and
was started on prednisone taper 2 weeks ago (can't recall dose,
10mg pred to start?). Symptoms persisted so pt was started on
azithromycin x 3 days ago by her PCP without improvement in
symptoms. On O2 at home, but increased requirements. Per pt,
O2sat normally 92-94% on 4L.
.
In the ED, VS: T99.6 BP 142/78 RR 28-36, 89O2 sat on RA. 92% on
NRB. She was tachypneic on exam. CXR with infiltrate vs soft
tissue, limited study. Received ceftriaxone 1g and levaquin
750mg IV x1. She received solumedrol 125mg IV x1 and nebs. EKG
with sinus tach at 104, TWI in V1,V2. D dimer was sent for
concern of possible PE as pt was unable to undergo CTA PE due to
size.
.
ROS: + knee pain
Past Medical History:
#. Morbid obesity
#. Obstructive sleep apnea
#. Reactive airway disease (COPD vs. Asthma) on 4L home O2
- no PFTs available for review
#. Presumed PE in '[**12**]
#. Pulmonary Hypertension
#. ? Hypertension
#. Joint disease
Social History:
The patient lives with her mother at home. No tobacco and no
alcohol use.
Family History:
HTN, breast cancer, and obesity (mother)
Physical Exam:
VS: T 97 BP 140/80 HR 98 91% on 50% face mask
GEN: Morbidly obese African american female in no acute distress
HEENT: EOMI, PERRL, anicteric
NECK: Obese, unable to assess [**Year (2 digits) 22116**]
CHEST: Clear anteriorly, distant breath sounds, no wheezes,
rales, rhonchi
CV: RRR, S1S2, iii/vi systolic murmur ar RUSB radiating to right
carotid
ABD: Soft, obese, nontender, nondistended
EXT: no clubbing, cyanosis, edema, DP/PT 2+
SKIN: hyperkeratotic, hyperpigmented crusting lesions on
bilateral lower extremities
NEURO:AAOx3, no focal deficits
Pertinent Results:
labs-
[**2122-9-19**] 06:25PM BLOOD WBC-6.4# RBC-4.68 Hgb-11.6* Hct-40.3
MCV-86 MCH-24.8* MCHC-28.9* RDW-16.7* Plt Ct-183
[**2122-9-19**] 06:25PM BLOOD Neuts-70.9* Lymphs-21.8 Monos-3.8 Eos-3.1
Baso-0.4
[**2122-9-19**] 06:25PM BLOOD PT-12.9 PTT-25.1 INR(PT)-1.1
[**2122-9-19**] 06:25PM BLOOD Glucose-96 UreaN-12 Creat-0.7 Na-139
K-4.6 Cl-94* HCO3-40* AnGap-10
[**2122-9-22**] 06:35AM BLOOD CK(CPK)-38
[**2122-9-22**] 06:35AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2122-9-19**] 06:25PM BLOOD proBNP-989*
[**2122-9-20**] 04:06AM BLOOD Calcium-9.3 Phos-4.5# Mg-1.9
[**2122-9-19**] 08:01PM BLOOD D-Dimer-654*
[**2122-9-19**] 08:18PM BLOOD Type-ART pO2-86 pCO2-76* pH-7.33*
calTCO2-42* Base XS-9
[**2122-9-19**] 06:28PM BLOOD Lactate-1.4
[**2122-9-20**] 05:28AM BLOOD O2 Sat-91
REPORTS:
CXR
FINDINGS: Single bedside upright radiograph of the chest is
notable for low lung volumes bilaterally. There is marked
cardiomegaly. The diaphragms are not optimally seen, presumably
related to confluence of overlying soft tissue, patient motion,
and possible pulmonary opacities which are not excluded on this
study and must be placed in clinical context. Possible right
lower lobe consolidation.
LENIs
IMPRESSION: Limited study with incomplete evaluation of the
proximal left
superficial femoral vein, otherwise, no evidence of DVT.
Echo
The left atrium is mildly dilated. The right atrial pressure is
indeterminate. There is moderate symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets are moderately thickened.
Significant aortic stenosis cannot be fully excluded. No aortic
regurgitation is seen. The mitral leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2113-8-9**], symmetric left ventricular hypertrophy
is more prominent and right ventricular enlargement with free
wall hypokinesis is now apparent. The aortic root is also now
dilated and moderate tricuspid regurgitation and mild pulmonary
artery systolic pressure are now present.
Brief Hospital Course:
42 y.o. F with PMH of COPD, OSA, morbid obesity here with
SOB/cough and increasing O2 requirement.
1. Shortness of breath: Worsening over past several weeks. No
improvement on low dose prednisone taper. Had not been using
inhalers as regularly as PCP [**Name Initial (PRE) 2875**]. Possible infiltrate on
CXR so the patient completed levofloxacin x 5 days. Also, PE
was considered given that she had a history in the past.
D-dimer was borderline elevated and had sinus tachycardia on
admission. However, due to body habitus, CTA could not be
obtained. LENIs were negative bilaterally. Given these
findings, she was empirically started on heparin gtt and
continues on this with coumadin bridge (currently, 10 mg / day).
INR 1.3 on discharge. She will need to have INR checked daily.
INR goal [**2-10**] and will need this for 6 months. Primarily, it was
felt that her shortness of breath is likely due to her morbid
obesity, causing obesity-hypoventilation syndrome. The patient
was maintained on 6 L NC while awake and on autoset Bipap when
sleeping. With this regimen, her O2 sats ranged between 89-95%.
Her goal O2 sat should be from 88-93%. There was one incidence
of hypercarbic respiratory failure that was due to malfunction
of her machine. She was rapidly corrected once her Bipap
machine was functioning properly. Albuterol and ipratropium
inhalers were given for reactive airway disease.
2. Pulmonary Hypertension: Likely secondary to obesity
hypoventilation syndrome, OSA. Maintained on O2 and Bipap as
noted above.
FEN: Heart Healthy low Na diet when tolerated.
Ppx: Coumadin, heparin gtt no PPI indicated
Code: FULL
CONTACT: [**Name (NI) **]# [**0-0-**] ([**Name2 (NI) **]r [**Doctor First Name 8513**]
Medications on Admission:
ASA
Advair 100-50 [**Hospital1 **]
Combivent q 6 hours
Atrovent MDI q 6hr PRN
Colace 100mg [**Hospital1 **]
Senna 1 tab [**Hospital1 **]
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. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for SOB.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: hold for rr<12 or oversedation.
8. Heparin (Porcine) in NS Intravenous
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary Diagnosis:
Obesity Hypoventilation Syndrome
Obstructive sleep apnea
Pulmonary embolism
Morbid obesity
Discharge Condition:
stable, on 6 liters NC oxygen
Discharge Instructions:
You were admitted to the hospital due to difficulty breathing.
You were found to have sleep apnea and low oxygen levels during
the day. You were treated with oxygen and a BIPAP mask. You will
be going to rehab in order to increase your strength and become
more comfortable with the BIPAP. You were also started on
medication to thin your blood in case you have a blood clot in
your lungs. You completed a full course of antibiotics for
possible pneumonia.
The following changes were made to your medications:
1. Your aspirin was stopped as you are now on coumadin.
2. You are on heparin IV for possible PE and will remain on this
until your INR is therapeutic.
3. Your Advair dose was changed to 250/50 instead of 100/50.
4. You will need to continue on coumadin for 6 months.
Please keep your follow up appointments. You have been
scheduled for a Sleep Clinic appointment. It is important that
you keep this appointment.
If you have worsening of your breathing, fevere, chills, chest
pain or other concerning symptoms please seek medical attention.
Followup Instructions:
Sleep Clinic: [**Telephone/Fax (1) 612**] [**10-13**] (Tuesday), 9:20 AM with Dr.
[**First Name (STitle) **]. [**Location (un) 8661**] Clinical Center, [**Location (un) **], Neurology.
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 10573**]
Completed by:[**2122-9-24**]
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
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7556, 7611
|
4874, 6604
|
335, 342
|
7765, 7797
|
2338, 4851
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8899, 9198
|
1710, 1752
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|
7632, 7632
|
6630, 6769
|
7821, 8876
|
1767, 2319
|
275, 297
|
370, 1353
|
7651, 7744
|
1375, 1601
|
1617, 1694
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,097
| 158,157
|
36841
|
Discharge summary
|
report
|
Admission Date: [**2195-4-19**] Discharge Date: [**2195-4-25**]
Service: MEDICINE
Allergies:
Sulfasalazine / Penicillins
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Nausea, abdominal pain
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **] [**4-19**] with sphincterotomy and stent placement
[**Month/Day (4) **] [**4-21**] with epinephrine injection and gold probe at
sphincterotomy stie
History of Present Illness:
On the morning of [**4-18**], Ms. [**Known lastname 83220**] was nauseous and unable to
ambulate. She was also lethargic, per her daughter. She
evidently complained of sharp upper abdominal pain when arriving
to the [**Hospital1 1562**] ED per their notes, and she also complained of
some rectal pain. (Her daughter, however, notes that she was
primarily complaining of nausea.) Evaluation at the [**Hospital 1562**]
Hospital included a CT abdomen/pelvis which showed likely
dilatation of the common bile duct and gallstones in the
gallbladder. She was eventually transferred to [**Hospital1 18**] for
evaluation for [**Hospital1 **].
.
Per daughter: The patient had been recovering from "broken
legs." Daughter reviews past history: about 15 years ago she had
bilateral knee replacements at the [**Hospital1 112**]; was fine until the end
of [**Month (only) 404**], her BP went up so high that the oncologist would not
give her Procrit. Once she took a new pill from the
cardiologist, she said she felt very dizzy. The next day she was
supposed to see the cardiologist, fell on her knees. Passed out
in the chair when sat up. Operated on left knee at [**Hospital1 112**]; the
prosthesis was pushed up into the femur; the other leg was
broken but not as bad as the left knee. Since then living at
daughter??????s house. Was doing well at rehab but couldn??????t live by
herself yet. VNA RNs see her twice a week for PT/OT.
.
Last couple of days has had very low blood pressure 90/50;
eating very little and was very lethargic, was complaining a lot
of not getting better and feeling depressed. Did have a visit
from a friend and was very cheerful and energetic. Went to bed;
but that next morning [**4-18**], she was sitting on the edge of the
bed and reported having vomited though none was apparent. Said
she felt very tired; couldn??????t move. Fell on top of daughter
trying to get to the bathroom. Sitting on the commode, putting
feet on bed trying to get back??????clearly confused. Was not
actually complaining of abdominal pain. Pulse was fine per
neighbor who was [**Name8 (MD) **] RN. Took her to the [**Hospital1 1562**] ER at 3:00 pm
[**4-18**]; WBC was high; they went looking for cause of this.
.
Reportedly has been having chronic renal failure and getting
Procrit in the past for anemia.
.
Has been having high blood pressure; has been on blood pressure
medication.
.
In the emergency department of the [**Hospital1 18**], having received her
from [**Hospital1 1562**], her vitals were T 98.0, HR 60, BP 139/66, RR 18,
O2 sat 100% RA. She was seen by surgery and [**Hospital1 **] in the ED. She
received zosyn although she had a stated PCN allergy; she had no
apparent adverse reaction to this.
.
Past Medical History:
Hypothyroidism
Hyperlipidemia
Hypercholesterolemia
Hypertension
Knee replacement in the past; bilateral knee injury earlier this
year, included need to reposition knee replacement
Had breast cancer in the past; got lumpectomy then had
recurrence and declined masectomy; has been cancer-free for five
years; has been on tamoxifen but now off it
h/o CABG [**2189**] x3; no history of heart valve problems
Social History:
Drugs: none
Tobacco: none
Alcohol: none
Lives with daughter; states she usually lives alone but on
further questioning reveals that nursing home would not allow
her to go home on her own and required d/c to daughter
Family History:
Likely non-contributory in this [**Age over 90 **] year old woman
Physical Exam:
T: 36.3 ??????C (97.4 ??????F)
HR: 70 bpm
BP: 181/60(91) mmHg
RR: 17 insp/min
SpO2: 95%
Heart rhythm: SR (Sinus Rhythm)
General Appearance: No acute distress, slumped to side of bed
while sleeping; easily aroused; appears to be hard of hearing
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous: )
Abdominal: Soft, Non-tender, No(t) Distended, seen
post-procedure
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis
Skin: Warm, No(t) Rash: in partial exam, No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): hospital, but names incorrect hospital;
date correct, Movement: Purposeful, Tone: Normal
.
Pertinent Results:
[**2195-4-19**] 03:45AM WBC-17.0* RBC-3.83* HGB-12.0 HCT-36.7 MCV-96
MCH-31.4 MCHC-32.7 RDW-14.2
[**2195-4-19**] 03:45AM NEUTS-84.4* LYMPHS-9.9* MONOS-5.6 EOS-0.1
BASOS-0.1
[**2195-4-19**] 03:45AM PLT COUNT-239
.
[**2195-4-19**] 08:05AM PT-15.9* PTT-29.1 INR(PT)-1.4*
.
[**2195-4-19**] 03:45AM GLUCOSE-83 UREA N-25* CREAT-1.6* SODIUM-132*
POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-25 ANION GAP-16
.
[**2195-4-19**] 03:45AM ALT(SGPT)-388* AST(SGOT)-638* ALK PHOS-295*
TOT BILI-4.0*
[**2195-4-19**] 03:45AM LIPASE-40
.
[**2195-4-19**] 03:45AM CK(CPK)-33 CK-MB-NotDone
[**2195-4-19**] 03:45AM cTropnT-0.04*
.
[**2195-4-19**] 03:58AM LACTATE-1.3
[**2195-4-19**] 03:29PM LACTATE-1.4
.
[**2195-4-19**] 06:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2195-4-19**] 06:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2195-4-19**] 06:50AM URINE RBC-0 WBC-0 BACTERIA-0 YEAST-MOD EPI-0-2
.
.
STUDIES:
.
RUQ ULTRASOUND [**Hospital1 18**] [**2195-4-19**]
FINDINGS: Overall evaluation is limited by bowel gas. Allowing
for this, no definite focal hepatic abnormality is identified.
The common bile duct measures 1.2 cm with limited evaluation of
the duct near the pancreatic head. The gallbladder is mildly
distended and contains sludge, with perhaps a minimally
thickenined wall. There is no pericholecystic fluid and
son[**Name (NI) 493**] [**Name2 (NI) 515**] sign is negative. No free fluid is seen in
the right upper quadrant. There is no right hydronephrosis.
IMPRESSION:
1. 1.2 cm CBD with limited evaluation of the duct near the
pancreatic head. Obstructive causes cannot be exlcuded and
correlation with recent outside imaging is recommended.
2. Distended, sludge- containing gallbladder. Findings may
represent early cholecystitis.
[**Name2 (NI) **] [**4-19**]:
Stones at the lower third of the common bile duct - full
cholangiogram was not perfomred due to suspicion of acute
cholangitis.
A sphincterotomy was performed.
A stent was placed.
[**Month/Day (4) **] [**4-21**]:
Fresh and old blood clots were seen in the body of stomach and
antrum.
A plastic stent placed in the biliary duct was found in the
major papilla.
Evidence of bleeding from the previous sphincterotomy was noted.
An epinephrine injection and a gold probe was applied at the
sphincterotomy site for hemostasis successfully.
Brief Hospital Course:
[**Age over 90 **] year old woman with past CABG now here w hx of abd pain, CBD
dilatation seen at OSH. Now s/p [**Age over 90 **] and sphincterotomy w stent.
CBD DILATATION AND LIVER ENZYME ABNORMALITIES/CHOLECYSTITIS
Consistent with cholelithiasis/choledocholithiasis; labs
consistent with ductal obstruction with elevated Alk phos,
elevated ALT/AST, high bilirubin. Had [**Age over 90 **], sphincterotomy,
stent placement [**4-19**]. Surgery discussed cholecystectomy but
given some reluctance by the patient and family, will not pursue
this admission. The patient had a large bloody bowel movement on
the medical floor [**4-21**], concerning for GIB related to
sphincterotomy. She was taken urgently to the GI suite for
repeat [**Month/Day (2) **] where bleeding was found at the sphincterotomy site.
Epinephrine was injected and a gold probe was applied with
resolution of the bleeding. She received 2 units PRBC after the
procedure and her Hct was stable at 28-31 afterwards. She should
continue on antibiotics to complete at 14-day course. She is
scheduled for [**Month/Day (2) **] for stent removal and stone extraction.
ST CHANGES
Non-diagnostic ST changes seen on EKG in setting of hypertension
and acute medical illness on admission. Diffuse non-diagnostic
abnormalities probably associated with demand and underlying
disease but baseline risk is significant given past CABG,
advanced age, HTN, hyperlipidemia. Repeat TnT was <0.01. She
was maintained on metoprolol and aspirin until she had GIB (see
above) for fear of worsening the bleeding and masking
tachycardia. Metoprolol was restarted on discharge after she had
been hemodynamically stable for three days. Statin was initially
held given elevated liver enzymes but may be restarted on
discharge.
HTN
Elevated systolic pressure, high pulse pressure, no physical
exam findings clearly assoc w AR, no known hx of valvular dz per
patient and patient??????s daughter. Calcified [**Name2 (NI) 83221**] aorta seen
on OSH CT. She was intermittently on hydralazine for blood
pressure control while her ramipril was held for acute renal
failure and metoprolol was held (see below). These were
restarted by discharge with improvement in her blood pressure.
RENAL FAILURE
Apparently a chronic issue, not clear what her baseline is, may
be close to baseline at this point. Improved with hydration to
1.2-1.3 and remained stable.
HYPOTHYROIDISM
Continued levoxyl.
DEPRESSION
Continued home dose of sertraline.
BREAST CANCER
Apparently was on tamoxifen (daughter unsure of med) for five
years until a few months ago; not now. No evident recurrence. No
need to pursue this in this setting; mets unlikely to be cause
of current problems given CT from OSH not showing lesions.
Medications on Admission:
(eventually confirmed with daughter's home list):
Levothyroxine 75 mcg daily
Metoprolol tartrate 12.5 mg daily
Ramipril caplets 5 mg daily
Simvastatin 20 mg nightly
Sertraline 50 mg HS
Prilosec
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO once
a day.
3. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 9 days.
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 24806**] Care Center - [**Hospital1 1562**]
Discharge Diagnosis:
Primary: cholelithiasis, bleeding from sphincterotomy site,
NSTEMI
Secondary: hypertension, hypothyroidism, hyperlipidemia,
hypercholesterolemia, coronary artery disease
Discharge Condition:
good, stable, hematocrit stable
Discharge Instructions:
You were evaluated for abdominal pain, found to have gallstones,
and transferred here for [**Hospital1 **]. You had another [**Hospital1 **] to correct
bleeding at the sphincterotomy site and remained stable
afterwards.
If you have worsening abdominal pain, blood in your stool, chest
pain, shortness of breath, call your doctor.
Followup Instructions:
You are scheduled for repeat [**Hospital1 **] on [**5-28**]:
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2195-5-28**] 11:00
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2195-5-28**] 11:00
Follow up with your primary care physician 1-2 weeks after
discharge from rehab
|
[
"E878.8",
"998.11",
"244.9",
"576.1",
"401.9",
"414.01",
"410.71",
"574.21",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"51.79",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
11034, 11116
|
7328, 10067
|
257, 430
|
11330, 11364
|
4896, 7305
|
11743, 12120
|
3850, 3917
|
10311, 11011
|
11137, 11309
|
10093, 10288
|
11388, 11720
|
3932, 4877
|
195, 219
|
458, 3173
|
3195, 3600
|
3616, 3834
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,389
| 175,065
|
24398
|
Discharge summary
|
report
|
Admission Date: [**2140-6-29**] Discharge Date: [**2140-7-12**]
Date of Birth: [**2060-12-13**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4277**]
Chief Complaint:
R calf pain
Major Surgical or Invasive Procedure:
Resection of neurofibrosarcoma R calf
History of Present Illness:
Mr. [**Known lastname 61773**] is a 79 year old gentleman with a history of
Neurofibromatosis. He presented to clinic with a painful right
calf mass. This mass was biopsied and proved to be a
neurofibrosarcoma. He underwent radiation therapy for this, but
unfortunately this did not significantly change his symptoms.
After a discussion of the risks and benefits of surgical
resection he elected to procede with surgery.
Past Medical History:
Neurofibromatosis
CAD w/CABG X2
Social History:
Lives alone.
Grandaughter in [**State 108**]
Pertinent Results:
[**2140-6-29**] 07:01PM TYPE-ART O2-100 PO2-100 PCO2-48* PH-7.36
TOTAL CO2-28 BASE XS-0 AADO2-588 REQ O2-93 COMMENTS-FACE MASK
Brief Hospital Course:
Patient was admitted through the same day surgery program. He
surgery was uneventful and he was extubated and came to PACU in
stable condition. Unfortunatlely while in pacu he began to have
respiratory difficulty and had to be intubated. He was admitted
to the ICU and a chest CT revealed a pulmonary embolus. He was
started on a heparin drip and given supportive care in the ICU.
Unfortunately he was unable to come off of the ventilator and
began to require more supportive care including pressor and
increasing ventilator support. After 13 days the granddaughter
elected to withdraw support and give comfort care only. Mr.
[**Name14 (STitle) 61774**] was extubated in the morning of [**7-12**] and expired
shortly therafter.
Discharge Disposition:
Expired
Discharge Diagnosis:
Pulmonary Embolus following resection of Neurofibrosarcoma R
calf.
Discharge Condition:
Deceased
Completed by:[**2140-7-14**]
|
[
"414.00",
"486",
"197.0",
"285.9",
"518.5",
"415.11",
"171.3",
"512.1",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"34.04",
"99.15",
"96.04",
"83.39",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
1871, 1880
|
1113, 1848
|
332, 371
|
1990, 2029
|
960, 1090
|
1901, 1969
|
281, 294
|
399, 824
|
846, 879
|
895, 941
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,582
| 152,643
|
2389+2454
|
Discharge summary
|
report+report
|
Admission Date: [**2119-6-5**] Discharge Date: [**2119-6-24**]
Service: GENERAL SURGERY GREEN
HISTORY OF THE PRESENT ILLNESS: The patient is an
88-year-old woman with 2 1/2 days of lower abdominal pain
with back pain. Her last bowel movement was on Sunday which
was hard and formed. She has noted severe nausea and bilious
vomiting. She has not passed any flatus. She reports
incontinence and a rectocele. She denied fevers or chills.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Glucotrol XL 5 mg p.o. q.d.
2. Spironolactone 25 mg p.o. q.d.
3. Quinine 260 mg p.o. q.d.
4. [**Doctor First Name **] 180 mg p.o. q.d.
5. Aspirin 81 mg p.o. q.d.
6. Norvasc 5 mg p.o. q.d.
PAST MEDICAL HISTORY:
1. Macular degeneration.
2. Diabetes mellitus.
3. Actinic keratosis.
4. Blindness.
5. Hypertension.
6. Osteoarthritis.
7. Venostasis.
8. Diverticulosis.
9. Gross hematuria.
10. Second-degree AV block.
11. History of endocarditis in [**2118**].
SOCIAL HISTORY: The patient is a former smoker and denied
alcohol use.
LABORATORY/RADIOLOGIC DATA: WBC 25.1, hematocrit 35.5,
platelets 370,000. Sodium 125, potassium 5.2, chloride 86,
C02 21, BUN 55, creatinine 3, glucose 235.
KUB revealed small bowel dilated. Air-fluid levels were
present.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
97, pulse 95, BP 144/52, respirations 16, 02 saturation 99%
on room air. General: The patient was in no apparent
distress. HEENT: The sclerae were anicteric. Heart:
Regular rate and rhythm. Lungs: Clear to auscultation
bilaterally. Abdomen: Soft, obese, nontender, with no
rebound or guarding. Extremities: With stasis disease,
palpable DP and PT pulses.
HOSPITAL COURSE: The patient was admitted to the Surgical
Service for aggressive hydration and electrolyte repletion.
NG tube and Foley catheter were placed. She was started on
antibiotic coverage with levofloxacin and Flagyl. CT
examination of the abdomen was performed which revealed small
bowel dilation to the ileum with no clear transition point.
Small bowel obstruction was evident and large bowel was
collapsed.
Given these findings, Ms. [**Known lastname 12367**] was taken to the Operating
Room on [**2119-6-5**] where she was found to have a left
incarcerated inguinal hernia. The hernia was reduced. The
procedure was performed without complication. The patient
was transferred to the floor after recovery in the PACU.
Postoperatively, Ms. [**Known lastname 12367**] [**Last Name (Titles) 12368**] to 84% on 100% face
mask. She was found to be hypoxic and acidotic on blood gas.
Chest x-ray at this time revealed massive atelectasis with
collapse of the left lower lobe.
Given the large AA gradient, Ms. [**Known lastname 12367**] was taken to CAT scan
for CTA to rule out pulmonary embolus. This examination was
negative. With oxygen and incentive spirometry, Ms. [**Known lastname 12369**]
oxygenation status progressively improved. This was followed
by respiratory failure which provided aggressive nebulizer
treatments. A NG tube was placed on [**2119-6-7**] due to
increasing gastric distention. Given her slow course, Ms.
[**Known lastname 12367**] was started on TPN for nutritional supplementation.
NG tube output progressively decreased and was discontinued
on [**2119-6-12**]. Her diet was slowly advanced; however, she
suffered from a prolonged ileus and with each diet
advancement began having nausea and vomiting, even after
return of bowel function she continued to have nausea and
vomiting and thus her diet was advanced very slowly and she
was continued on TPN.
On [**2119-6-20**], Ms. [**Known lastname 12367**] developed bradycardia down to the 30s
and 40s. She also felt short of breath at this time. She
was transferred to the Intensive Care Unit for close
monitoring. Cardiology consult was obtained and Ms. [**Known lastname 12367**]
was found to be in atrial fibrillation. It was decided at
this time that she would not necessarily need pacemaker
placement and that her bradycardia and hypotension was likely
a vagal response. All beta blockers and calcium channel
blockers were held at this time. The patient will follow-up
for further cardiology workup as an outpatient.
Her stay in the unit was unremarkable and cardiac and
pulmonary status remained stable. She was transferred back
to the floor on [**2119-6-21**]. She was doing well at this point.
Her diet was advanced to a diabetic diet which she tolerated
well. TPN was discontinued. She was working well with
physical therapy. She did develop a urinary tract infection
which was treated with Levaquin.
On [**2119-6-24**], she was felt stable to be discharged to a
rehabilitation facility.
PHYSICAL EXAMINATION AT DISCHARGE: Vital signs: Temperature
98.1, pulse 72, BP 150/70, respirations 24, 02 saturation 98%
on room air. Heart: Regular rate and rhythm. Lungs: Clear
to auscultation bilaterally with mild left lower lobe
coarseness. Abdomen: Soft, nontender, nondistended with
normoactive bowel sounds. The incision was clean, dry, and
intact. Extremities: Without clubbing, cyanosis or edema.
DISCHARGE MEDICATIONS:
1. Atrovent nebulizer, one neb q. six hours p.r.n.
2. Albuterol nebulizer, one neb q. six hours p.r.n.
3. Heparin 5,000 units subcutaneously q. 12 hours.
4. Protonix 40 mg p.o. q.d.
5. Tylenol 325 to 650 mg q. four to six hours p.r.n.
6. Aspirin, coated, 325 mg p.o. q.d.
7. Ambien 5-10 mg p.o. q.h.s.
8. Levaquin 250 mg p.o. q.d. times three days.
9. Coumadin 2.5 mg p.o. q.d.
10. Reglan 10 mg p.o. q.i.d.
11. Glucotrol XL 5 mg p.o. q.d.
12. Spironolactone 25 mg p.o. q.d.
13. Regular insulin sliding scale for glucose of 0-150, 0
units; 151-200, 3 units; 201-250, 5 units; 251-300, 7 units;
301-350, 9 units; 351-400, 11 units; greater than 400, 13
units.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Ms. [**Known lastname 12367**] should be discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Status post repair of incarcerated left inguinal hernia.
2. Status post massive postoperative atelectasis.
3. Prolonged ileus.
4. Second-degree heart block with intermittent bradycardia.
5. Atrial fibrillation/atrial flutter.
6. Urinary tract infection.
7. Diabetes mellitus.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Name8 (MD) 12370**]
MEDQUIST36
D: [**2119-6-23**] 01:25
T: [**2119-6-23**] 14:13
JOB#: [**Job Number 12371**]
Admission Date: [**2119-6-5**] Discharge Date: [**2119-6-29**]
Service: [**Hospital Unit Name 196**]
ADDENDUM: Transfer from General Surgery to the [**Hospital Unit Name 196**] Service.
The patient is an 88-year-old woman status post inguinal
hernia repair who had a [**Company 1543**] Sigma SDR 303B pacemaker placed
on [**2119-6-26**] after episodes of bradycardia and hypotension in
atrial fibrillation. At the time of pacemaker placement she also
underwent cardioversion. Atrial fibrillation was new this
hospitalization, and was first noted 1 day post op. A
Transesophageal echocardiogram was performed prior to
cardioversion, and revealed no left atrial or left atrial
appendage thrombus, but did reveal a 1 cm mass on the mitral
valve, felt to be a tumor. After discussion with the patient
and her daughter, as well as with the cardiac surgery service,
the decision was made not to pursue any workup of this finding.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Atrial fibrillation.
3. Hypertension.
4. Diverticulosis.
5. Hypercholesterolemia.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Coumadin.
2. Lisinopril.
3. Hydralazine.
4. Vancomycin.
5. Ampicillin as an inpatient.
6. Protonix.
HOSPITAL COURSE: During the hospital course from [**2119-6-26**] to
discharge on [**2119-6-29**], the patient was stable. The patient
was given 1 unit of blood for a crit of 27.2. The most
recent crit is in the 30s. The patient's INR is therapeutic
at 2.6. The patient will be discharged back to a
rehabilitation facility and will see Dr. [**Last Name (STitle) 284**] in one
week in the Electrophysiology Clinic. The patient is
discharged in good condition under the same discharge
medications as previously dictated.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Last Name (NamePattern1) 2584**]
MEDQUIST36
D: [**2119-6-29**] 12:47
T: [**2119-6-29**] 13:30
JOB#: [**Job Number 12572**]
|
[
"599.0",
"997.3",
"E849.7",
"E878.4",
"426.13",
"428.0",
"427.31",
"518.0",
"550.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"37.72",
"37.83",
"38.91",
"53.02",
"89.68",
"99.15",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
5188, 5856
|
6013, 7505
|
7835, 8623
|
7707, 7817
|
4782, 5165
|
1341, 1734
|
7527, 7684
|
1022, 1326
|
5881, 5992
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
924
| 150,035
|
14059+14120+14060+56502
|
Discharge summary
|
report+report+report+addendum
|
Admission Date: [**2127-1-23**] Discharge Date: [**2127-2-6**]
Date of Birth: [**2067-1-31**] Sex: F
Service: VASCULAR
CHIEF COMPLAINT: Discoloration and coolness of the left
foot.
HISTORY OF PRESENT ILLNESS: The patient was initially seen
in the Emergency Room. She had recently been discharged from
rehab after a long postoperative course after undergoing
coronary artery bypass graft requiring a tracheostomy. She
now presents with a left foot that is cold and painful over
the last 24 hours. She is now admitted for further
evaluation and treatment.
PAST MEDICAL HISTORY: Coronary artery disease, type 1
diabetes with triopathy, chronic renal insufficiency baseline
creatinine 2.0, peripheral vascular disease.
PAST SURGICAL HISTORY: Coronary artery bypass graft surgery
with saphenous vein graft to the right posterolateral
coronary, the obtuse marginal one in the left anterior
descending [**2126-12-10**]. Percutaneous tracheostomy with tube
placement and flexible sigmoidoscopy with aspiration of
tracheal broncho tree on [**2127-1-13**]. Cardiac catheterization on
[**2126-12-7**] demonstrated right coronary artery dominant system
with severe three vessel disease, left main trunk had 30%
stenosis at the ostium. The left anterior descending
coronary artery had diffuse disease with a mid 80% stenosis.
The diagonal one was occluded. The left circumflex main was
occluded. The right coronary artery had a mid 40% lesion
with diffuse disease into the posterior descending coronary
artery with an 89% stenosis of right coronary artery and
distal posterior descending coronary artery. Resting
measurements revealed pulmonary wedge pressure of 20, cardiac
index of 1.7. An attempt was made to try to stent the left
circumflex origin, but this was aborted. Echocardiogram done
on [**2127-1-13**] demonstrated left ventricular ejection fraction of
30% with severe inferior posterior hypokinesis and akinesis.
He is status post right femoral popliteal bypass graft.
ALLERGIES: No known drug allergies.
MEDICATIONS: Percocet tablets, Colace 100 mg b.i.d., Plavix
75 mg q day, Reglan 5 mg a.c. and h.s., aspirin 325 mg q day,
Vasotec dose not indicated, Lopressor 25 mg b.i.d., NPH
insulin 38 units q.a.m. and 28 units at h.s., Lasix 40 mg
b.i.d., Procrit 20,000 units q Friday.
PHYSICAL EXAMINATION: Vital signs were stable. Temperature
max was 98.7, 123/50, 93, 24, and 90% with a face mask.
Chest examination lungs showed coarse breath sounds
bilaterally. The heart was a regular rate and rhythm. The
abdominal examination was soft, nondistended, nontender.
Cholecystostomy tube was in place. Rectal examination was
guaiac negative. No masses. Peripheral vascular disease
pulses femorals palpable bilaterally. The left popliteal was
biphasic signal. The right popliteal was absent. The
dorsalis pedis pulse on the right was biphasic. The
posterior tibial pulse on the right was biphasic signals
only. The dorsalis pedis pulse on the right was palpable and
absent posterior tibial pulse. The right graft was palpable.
The forefoot was ischemic and cool to touch with diminished
sensation.
LABORATORIES IN THE EMERGENCY ROOM: White blood cell count
of 4.3, hematocrit of 30.6, BUN 66, creatinine 1.6, K 5.0,
PT/INR were normal. Electrocardiogram was without ischemic
changes.
HOSPITAL COURSE: The patient was seen by the Vascular
Service. Dr. [**Last Name (STitle) **] followed the patient for cardiac care.
[**Last Name (un) **] was involved regarding diabetic management. Initial
arteriogram planed for [**1-27**] was deferred secondary to the
patient's elevated BUN of 2.7. Her Lasix was held and serial
creatinines were obtained. Renal was consulted regarding her
acute renal failure. Recommendations they felt this was
secondary to hypovolemia both to poor oral intake and
diuretic use. Intravenous fluids were instituted. Her [**Last Name (un) **]
and ace inhibitors were held and diuretics were held and her
beta blockers were held for a systolic blood pressure less
then 100. Because of the patient's renal status she
underwent a bilateral MRA run off. The abdominal MRA showed
a mild and distal abdominal aorta appears to be within normal
limits. There is no significant stenosis. The proximal
celiac trunk or the proximal superior mesenteric artery with
a single right renal arteries bilaterally. On the right the
run off showed good in flow without significant stenosis of
the common iliac, external iliac, femorals, superficial
femoral artery and popliteals. A three vessel run off was
identified with poor quality proximal AT and posterior tibial
peroneal arteries. There were multiple foci of moderate
stenosis identified in the proximal half of each of the three
vessels. Anterior tibial and posterior tibial occluded at
the level of the mid calf and the peroneal occludes in the
distal one third of the calf. Bypass graft was identified
extending to below the popliteal artery with a good
anastomosis. There is good flow identified within the
dorsalis pedis artery. The bypass graft was patent. On the
left side there was no in flow disease. There is three
vessel run off. The anterior tibial provides flow to the
dorsalis pedis pulse. There are multiple areas of mild to
moderate stenosis along the AT length. The dorsalis pedis
pulse is diseased, but of good caliber. Posterior tibial
occludes at the distal one third of the calf, collateral
vessels are identified in the medial calf extending to the
level of the ankle, which reconstitutes at the plantar arch.
The peroneal occludes in the distal one third.
With intravenous hydration and holding her diuretics and ace
an ABRs the creatinine showed a significant improvement and
over the next 48 hours she returned to baseline. The patient
developed a total white blood cell count of 32.3. The
patient had blood urine sputum cultures obtained all which
were negative. The chest x-ray showed bilateral lower lobe
consolidation/collapse with worsening left sided pleural
effusion. White blood cell count over the next several days
improved after aggressive pulmonary care. Her white blood
cell count on [**2-4**] was 17.9, hematocrit 30.9, platelets
392K, BUN 90, creatinine 1.7, K 4.6. The patient underwent a
left leg arteriogram on [**2127-2-3**], which demonstrated patent
BK popliteal, diseased AT at the origin, tibial peroneal
trunk was diseased. There was a patent AT through the calf
with diffuse disease distally. The posterior tibial and
peroneal were occluded with reconstruction of the dorsalis
pedis at the foot that is patent and two tarsal branches in
the forefoot with incomplete arch.
Post angiogram the patient's renal function remained stable
without an increase in her creatinine. It was determined
that surgery would be deferred until the patient's
nutritional renal status were more stabilized. She will be
transferred to rehab for continued care and with follow up
with Dr. [**Last Name (STitle) 1391**] in two weeks. On discharge her white blood
cell count was 21.3, hematocrit 30.9, platelets 430K, sodium
144, potassium 5.2, chloride 109, CO2 23, BUN 88, creatinine
1.8.
DISCHARGE MEDICATIONS: Insulin fixed doses, NPH 34 units
q.a.m. and 18 units at bedtime with a Humalog sliding scale .
For breakfast, lunch, dinner and at bedtime please see
enclosed flow sheet. Flagyl 500 mg t.i.d., heparin 5000
units subQ b.i.d., Dulcolax suppositories 10 mg prn, Dulcolax
tablets prn, Trazodone 100 mg at h.s. prn, Colace 100 mg
b.i.d., Guaifenesin 5 to 10 cc q 6 hours prn, Tylenol 325 to
650 mg q 4 to 6 hours prn, Timolol ophthalmic drop 0.25% one
OS b.i.d., Alpidem 5 mg at h.s. prn, Epogen 20,000 units q
Friday subQ, Metoprolol 25 mg b.i.d. hold for systolic blood
pressure less then 100, heart rate less then 55, albuterol
nebulizers q 4 to 6 hours prn, Protonix 40 mg q day, and
Percocet tablets one to two q 4 hours prn for pain.
Dressings to the left foot is dry sterile dressing with a
multipodus splint placed at all times.
DISCHARGE DIAGNOSES:
1. Ischemic left foot secondary to tibial disease.
2. Type 1 diabetes with triopathy.
3. Status post tracheostomy, stable.
4. Bilateral lower lobe opacities, stable.
5. Hyperglycemia corrected.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2127-2-6**] 08:51
T: [**2127-2-6**] 09:28
JOB#: [**Job Number 41939**]
Admission Date: [**2100-4-5**] Discharge Date: [**2100-4-5**]
Date of Birth: [**2067-1-31**] Sex: F
Service:
ADDENDUM: This is an addendum to an initial Discharge
Summary which was dictated on [**2127-2-6**].
While awaiting rehabilitation bed placement, Psychiatry saw
the patient for management of anxiety attacks and sleep
depravation. Their impression was that the nightly episodes
of sleep depravation were most likely related to an anxiety
disorder secondary to her respiratory problems and a delirium
which might be caused by the presence of infection, hypoxia,
or metabolic. Their recommendations were to start Seroquel
12.5 mg p.o. q.h.s. which should help for the depression,
and anxiety, and sleep. Continue to treating her medical
problems.
The patient did not want to initiate medications at this
time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2127-2-7**] 11:07
T: [**2127-2-7**] 11:28
JOB#: [**Job Number 42077**]
Admission Date: [**2127-1-23**] Discharge Date: [**2127-2-19**]
Date of Birth: [**2067-1-31**] Sex: F
Service: [**Hospital1 **]
ADDENDUM: Please note that this is an Addendum to the
Discharge Summary dictated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who had
summarized the hospital course up to and including through
[**2127-2-14**]. Please see his Discharge Summary for
details of the hospital course.
HOSPITAL COURSE:
1. CARDIOVASCULAR SYSTEM: The patient was transferred to
the Medicine Service from the Vascular Surgery Service for
diuresis and management of her congestive heart failure. The
patient was started on Bumex and responded well to that and
was diuresing over one liter negative every day.
On the day of discharge, it was decided that the patient
would be sent back to the Community Hospital where she
initially presented from on Bumex 2 mg p.o. q.d.
2. PULMONARY SYSTEM: The patient's tracheostomy was removed
on [**2127-2-18**]. The patient tolerated the procedure
well and without complications, and the patient was also able
to maintain good oxygen saturations.
3. GASTROINTESTINAL SYSTEM: The patient's percutaneous
cholecystectomy tube was removed on [**2127-2-17**] without
any complications.
The patient was also found to have elevated
glutamyltransferase and alkaline phosphatase which were all
isolated, as all of her other transaminases were found to be
normal. At that time it was decided with they attending that
an ultrasound should be obtained. An ultrasound was done
that showed normal architecture with multiple small
gallstones. No gallbladder distention or dilatations, and no
signs of any obstruction. There were multiple hyperechoic
lesions which could likely represent hemangioma (as per the
radiology read).
At the time of this dictation the Gastroenterology team was
also consulted, but they had not seen the patient yet. The
patient was completely asymptomatic, so this may require
further followup in the outside Community Hospital.
MEDICATIONS ON DISCHARGE:
1. NPH 38 units subcutaneously q.a.m.
2. NPH 12 units subcutaneously q.p.m.
3. Losartan 25 mg p.o. q.d.
4. Diamox 250 mg p.o. b.i.d.
5. Bumex 2 mg p.o. q.d.
6. Amiodarone 400 mg p.o. b.i.d. for two more days; then
amiodarone 200 mg p.o. b.i.d. for seven days; then amiodarone
200 mg p.o. q.d. ongoing.
7. Metoprolol 25 mg p.o. b.i.d.
8. Heparin 5000 units subcutaneously b.i.d.
9. Timolol maleate 0.25% one drop left eye b.i.d.
10. Epogen 20,000 units subcutaneously every Friday.
11. Protonix 40 mg p.o. q.d.
12. Aspirin 325 mg p.o. q.d.
13. Colace 100 mg p.o. b.i.d. as needed.
14. Guaifenesin 5 mg to 10 mg p.o. q.4-6h. as needed.
15. Atrovent 1 to 2 puffs inhaled q.4-6h. as needed.
16. Seroquel 25 mg p.o. q.h.s.
CONDITION AT DISCHARGE: The patient was stable at the time
of discharge.
DISCHARGE STATUS: The patient was to be discharged back to
the Community Hospital. The attending, Dr. [**Last Name (STitle) **], has
already talked to her primary care physician who has accepted
her back to the Community Hospital.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to be seen
by her primary care physician in the outside Community
Hospital.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D.
[**MD Number(1) 7855**]
Dictated By:[**Name8 (MD) 14914**]
MEDQUIST36
D: [**2127-2-18**] 18:45
T: [**2127-2-18**] 19:00
JOB#: [**Job Number 41940**]
Name: [**Known lastname 7579**], [**Known firstname 1873**] Unit No: [**Numeric Identifier 7580**]
Admission Date: [**2127-1-23**] Discharge Date:
Date of Birth: [**2067-1-31**] Sex: F
Service: [**Hospital1 **]
ADDENDUM: Discharge date is still yet to be determined.
This is a dictation summary addendum to be addended to
dictation summary performed on report date [**2127-2-5**];
encompassing the course of this [**Hospital 1325**] hospital course
from [**2127-2-6**] through [**2127-2-14**].
HOSPITAL COURSE:
1. CONGESTIVE HEART FAILURE: The patient was transferred to
the Medicine Service for further management of her congestive
heart failure. It was noted that through her hospital course
she was receiving fluids for hydration for her kidneys for
anticipation of an angiogram to further examine the arteries
of her lower legs. However, during this time, it was noted
that she increasing shortness of breath as well as an
increasing renal insufficiency.
She was transferred to a cardiac floor and was begun on a
nesiritide drip; however, due to concomitant issues of
infection, her blood pressures often began hypotensive and
had difficulty tolerating the nesiritide drip. She then
experienced an episode of supraventricular tachycardia that
may be attributed to nesiritide, and her nesiritide was
discontinued. She was switched to Bumex 1 mg intravenously
b.i.d. and this was increased to 2 mg intravenously b.i.d.,
and the patient continued to have goo diuresis with greater
than one liter per day negative urine output.
A right-sided thoracentesis was performed which revealed a
transudative effusion that was felt to be secondary to her
congestive heart failure. Approximately four days later, a
left-sided thoracentesis was performed which also revealed a
transudative effusion that was also secondary to her
congestive heart failure.
2. SUPRAVENTRICULAR TACHYCARDIA: The patient was noted to
have episodes of supraventricular tachycardia noted on
telemetry with an unstable blood pressure with systolic blood
pressures dropping into the 60s. She was immediately
cardioverted at 200 joules; at which time she responded back
into a normal sinus rhythm.
She was then transferred to the Coronary Care Unit for
further observation after her cardioversion. It was felt
that her arrhythmia may be secondary to nesiritide, and this
drug was subsequently discontinued. She remained without
arrhythmia throughout her 2-day course in the Coronary Care
Unit and was transferred back to the floor.
Upon returning to the general medicine floor, she again
showed episodes of supraventricular tachycardia which was
characterized as atrial fibrillation with a rapid ventricular
response, and Electrophysiology was consulted for further
evaluation and recommended amiodarone. Amiodarone was
subsequently started, and at the time of this dictation the
patient was tolerating this without any complications. A
Holter monitor was ordered to have further evaluation of her
QTc interval and will continuing having this Holter monitor
for a total of two weeks.
3. TRACHEOBRONCHITIS: The patient was noted to have an
acute increase in her tracheal secretion, and a leukocytosis
sputum and blood cultures remained negative; however,
clinically, she seemed to be having more difficulty
breathing.
An Infectious Disease Service was consultation was obtained
and agreed with starting levofloxacin and vancomycin in
addition to her Flagyl and continued a course of seven days
of these antibiotics. She markedly improved with an abrupt
decrease in secretions. Her leukocytosis returned to within
normal limits and appeared much more comfortable clinically.
These antibiotics were discontinued, and the patient
continued in stable condition.
4. ASPIRATION: The patient was evaluated by bedside Speech
and Swallow Service who evaluated for possible aspiration.
They indicated that the patient had intact swallowing
function and aspiration precautions were not necessary.
[**Name6 (MD) 1662**] [**Last Name (NamePattern4) 4337**], M.D. [**MD Number(1) 4338**]
Dictated By:[**Name8 (MD) 1554**]
MEDQUIST36
D: [**2127-2-14**] 18:41
T: [**2127-2-14**] 23:35
JOB#: [**Job Number 7581**]
|
[
"276.5",
"428.0",
"584.9",
"482.41",
"707.19",
"250.71",
"519.01",
"440.24",
"250.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13",
"88.48",
"34.91",
"99.62",
"38.93",
"97.23"
] |
icd9pcs
|
[
[
[]
]
] |
8046, 10099
|
7190, 8025
|
11718, 12471
|
13705, 17422
|
12805, 13687
|
769, 2323
|
2346, 3338
|
12486, 12770
|
158, 204
|
233, 582
|
605, 745
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,490
| 127,622
|
12844
|
Discharge summary
|
report
|
Admission Date: [**2174-1-25**] Discharge Date: [**2174-2-9**]
Date of Birth: [**2105-4-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
68 year old male with cognitive difficulty, paranoid
schizophrenia, known
degenerative changes in lumbar/sacral spine presenting with 2-4
weeks of worsening back pain. Of note, two weeks prior to
admission he was able to walk independently and take the train
but he did have a weak left leg. Vitals on arrival to the ED
were 97.1 157/79 73 16 100% RA. No evidence of acute cord
compression on history or exam per ED physician. [**Name10 (NameIs) **] the floor,
the patient complained of [**7-13**] lower back pain. The patient was
noted to be falling asleep intermittently even as he was trying
to eat pretzels. A sodium returned as 116 (was 129 on the [**1-20**]).
He was then admitted to the ICU for further care.
Past Medical History:
HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR:
-Chronic paranoid schizophrenia
Psychiatrist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] @ MMHC [**Telephone/Fax (1) 39512**]
Therapist [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 39513**] [**Telephone/Fax (1) 39514**]
Last hospitalized @ [**Hospital1 18**] [**Date range (1) 39515**]
First psychiatrically hospitalized in the 7th grade
Multiple psychiatric admissions and was @ [**Hospital3 **] in [**2167**]
-Diabetes
-Hypertension
-Hyponatremia (Psychogenic polydypsia vs SIADH)
-Obesity
-BPH
Social History:
Social History:
-alcohol: hx of abuse quit in [**2143**] past hx of arrests around
alcohol use {public intoxication assault while drunk with fists
over 30 years ago}
-drugs: denies illicits: hx of inhaling [**Last Name (un) 39516**] vapor rub 10
years ago
-tobacco: past hx of swallowing cigarette butts to get a "buzz"
does not smoke cigarettes
-The patient was born and raised in So. [**State 4565**] and came to
[**Location (un) 86**] when he was hospitalized @ [**Doctor First Name **]. He is divorced with 3
chidren and has granchildren but has no contact with his family.
He now lives in [**Location 39517**] group home in [**Location (un) 86**] and has for a number
of years
He lives in a group home in [**Location (un) 583**]. At his group home he
furniture surfs. He is able to attend a day program. He is able
to go to BR independeently.
Family History:
Diabetes
Physical Exam:
Admission Physical Exam:
VS: T = 98.5 P = 75 BP = 154/73 RR 18 O2Sat = 100% on RA
GENERAL: Obese male, NAD, mildly unkept, at one point closing
his eyes during conversation
Mentation: Alert, speaks in full sentences. Repeatly says he
does not know or is unsure in response to my questions
Eyes: PERRL, EOMI grossly intact but pt not following direction
well, no scleral icterus noted
Ears/Nose/Mouth/Throat: [**Name (NI) 5674**], pt not opening his eyes completely
Neck: supple, unable to appreciate JVD due to body habitus
Respiratory: CTAB posteriorly
Cardiovascular: distant heart sounds, RRR, nl. S1S2, no M/R/G
noted
Gastrointestinal: obese, soft, NT/ND, normoactive bowel sounds,
no masses or organomegaly noted.
Rectum: Stage I decubitus. Normal rectal tone. No saddle
anesthesia. Was guaiac negative of brown stool in the ED
Extremities: Left quad weaker than right although may be limited
by pain 3+/5. Unable to lift left leg straight off bed
(secondary to pain) Plantar and dorsiflexion [**4-7**] bilaterally. +
edema bilaterally ? L mildly greater than right. UE strength
[**4-7**].
Neurologic:
-mental status: Alert, oriented x 3. Able to relate only some
history but then would say "I don't know."
-cranial nerves: II-XII intact, could not view back of mouth to
look for palate elevation as pt did not cooperate
-DTRs: 1+ biceps/tricepts b/l. Knee reflexes could not be
appreciated. Achilles reflexes +1.
Psychiatric: easily frustrated by questions.
Pertinent Results:
Admission Labs:
[**2174-1-25**] 09:20PM BLOOD WBC-7.6 RBC-3.54* Hgb-11.0* Hct-31.7*
MCV-90 MCH-31.1 MCHC-34.8 RDW-11.6 Plt Ct-239
[**2174-1-25**] 09:20PM BLOOD Glucose-88 UreaN-18 Creat-0.8 Na-116*
K-4.1 Cl-86* HCO3-24 AnGap-10
[**2174-1-25**] 09:20PM BLOOD Calcium-8.5 Phos-3.6 Mg-1.9 Iron-31*
Other Notable Studies:
Blood Culture, Routine (Final [**2174-1-31**]):
GRAM NEGATIVE ROD #1. CONSISTENT WITH MORPHOLOGY OF
ORGANISM #2..
PROTEUS MIRABILIS. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- 8 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
Blood Culture, Routine (Final [**2174-1-31**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
PIPERACILLIN/TAZOBACTAM : sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
PROTEUS MIRABILIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
316-6736R
[**2174-1-26**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 16 I
CEFTRIAXONE----------- 16 I
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Radiology:
- [**1-26**] MRI Lumbar Spine: IMPRESSION: 1. Stable superior
endplate loss of height of T11 level, likely representing a
Schmorl's node vs chronic compression deformity. No evidence of
significant thoracic spinal canal narrowing. No epidural abscess
is identified. 2. Unchanged moderate lumbar spondylosis as
described above.
- [**1-27**] TTE: IMPRESSION: Mild symmetric left ventricular
hypertrophy with normal cavity size and severely depressed
global left ventricular systolic function. Given suboptimal
image quality a focal wall motion abnormality cannot be fully
excluded. Elevated left ventricular filling pressures. Depressed
right ventricular systolic function. Mildly dilated ascending
aorta. Mild to moderate mitral regurgitation. At least mild to
moderate pulmonary artery systolic hypertension. Compared with
the prior study (images reviewed) of [**2173-6-1**], overall left
ventricular systolic function has decreased (LVEF 45-50%
previously, now 20-25%) and the focal wall motion abnormalities
appreciated previously appear to be more global, although a
focal wall motion abnormality cannot be fully excluded due to
suboptimal image quality. Mild to moderate mitral regurgitation
and mild tricuspid regurgitation are new. The pulmonary artery
pressures were not previously determined but are at least mild
to moderate.
.
[**1-27**] Chest/Abdomen/Pelvis CT: IMPRESSION: 1. Air within cervical
soft tissues, mediastinal and vasculature likely related to
intubation and central line placement. 2. No etiology for fever
identified.
.
[**1-31**] RUQ US: IMPRESSION: No evidence of biliary obstruction.
.
MRI L spine [**2-7**] IMPRESSION:
1. No definite evidence of discitis osteomyelitis. No evidence
of epidural
abscess.
2. Partially imaged and incompletely evaluated on this exam,
there is
stranding of the right perirenal fat. If clinically warranted,
CT or
ultrasound of the kidneys may be performed for further
characterization. It is noted that the patient underwent a renal
ultrasound on [**2174-1-27**] which did not show this
abnormality.
.
RUE U/S on [**2-8**] IMPRESSION:
No evidence of right upper extremity DVTs. PICC line is
visualized in the
right axillary vein.
.
Bilateral LE u/s on [**2-3**] IMPRESSION:
1. No evidence of DVT.
2. Bilateral [**Hospital Ward Name 4675**] cysts.
Brief Hospital Course:
68 y/o M with PMHx of chronic paranoid schizophrenia, DM, HTN
and chronic LLE weakness (unclear etiology) and low back pain
who presented for evaluation of worsening pain. He was noted to
be significantly weaker in proximal lower extremity muscles than
was noted in prior clinic notes and was hyponatremic with a Na
of 116. Pt was admitted to the ICU and was diagnosed with
primary polydipsia. While in the ICU being treated with
hypertonic saline, pt developped hypotension, syncope and apnea
requiring intubation. He was treated for severe sepsis from
gram negative rod bacteremia (EColi & proteus), acute kidney
injury, hypoxic respiratory failure, thrombocytopenia,
transaminitis, acute cardiomyopathy and new rash on distal
extremities.
.
Gram Neg Rod Bacteremia: Pt developped hypotension and sepsis
while in the ICU being treated for symptomatic hyponatremia.
Blood Cx returned positive for Ecoli and proteus sensitive to
ciprofloxacin. He underwent extensive imaging without a clear
source for the bacteremia. Suspect this was due to GU source
given urinary retention and perinephric stranding noted on
serial imaging. Pt underwent MRI L spine to rule out epidural
abscess given his LE weakness and it did not show any spinal
pathology. Echo did not show any vegetations and CT torso did
reveal any etiology for fevers/sepsis. MRI was repeated on [**2-7**]
due to recurrent low grade fevers and LE weakness, this did not
show any evidence of osteo/discitis or epidural abscess but did
show some residual perinephric stranding. Pt was noted to have
acute urinary retention that resolved after restarting
Doxazosin, this may have been contributing to low grade fevers
given likely UTI on admission. Pt was treated for a total of 14
days with IV Abx (cipro) and pt had one blood Cx return positive
for skin flora, otherwise all surveillance cultures and
infectious work up remained negative. The acute transaminitis
and thrombocytopenia improved with treatment of sepsis but will
need to be followed up as an outpt.
.
Acute systolic CHF(CMP): Pt was found to have a diffusely
depressed LVEF (20%) on echo performed [**1-27**] which was likely due
to sepsis. He was significantly volume overloaded after volume
resuscitation in the ICU and had anasarca. He was diuresed with
lasix and is currently close to euvolemic on lasix 40mg daily.
Pt will need ongoing volume assessment with daily weights and
currently tolerating Toprol 200mg daily and lisinopril 5mg
daily. I anticipate that this LVEF should improve over the next
[**12-5**] mths and he may not need lasix in the future. Pt should be
seen by his PCP after discharge from a rehab with repeat
echocardiogram in 8 weeks
.
Hyponatremia: Etiology was likely multifactorial and pt is
followed by nephrology for psychogenic polydypsia and likely
mild SIADH. Pt was being treated with demeclocycline 300mg TID
prior to admission but this was not continued in the ICU and he
has not had any issues with hyponatremia since that time. He is
currently being treated with lasix 40mg daily to maintain
euvolemia and has a 2L fluid restriction which should be
continued at rehab. Pt will need to follow up with his primary
nephrologist on [**2-24**] as he may develop recurrent issues with
hyponatremia and may need to restart the demeclocycline in the
future.
.
Bilateral extremity rash: Pt developped erythematous macules
over his hands and feet bilaterally while in the ICU.
Dermatology was consulted and performed a biopsy which did not
show any evidence of small vessel thrombosis. In addition, he
underwent hypercoag. work up which revealed a positive ACA IgM
and negative beta microglobulin. It was felt that this rash was
due to pressor related ischemia and it was not recommended that
he be treated with anticoagulation. This has been treated with
local wound care and has been improving while in house.
.
Bilateral Proximal Leg Weakness: Etiology remains unclear though
suspect ICU myopathy and lumbar imaging has been reassuring. Pt
will need ongoing rehab and primary care follow up for this
issue. Anticipate improvement over time.
.
Sacrum rash/Decub: Pt was noted to have desquamation over sacrum
that has been followed by wound care and dermatology. This will
need ongoing treatment at rehab.
.
BPH/Urinary retention: Pt developped acute urinary retention in
setting of doxazosin being held. Symptoms improved
significantly after this was restarted and post void residuals
returned to [**Location 213**].
.
Schizophrenia(Paranoid): stable on his current regimen but will
need follow up with his primary psychiatrist. HCP/Guardian:
[**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 39518**]
.
Medications on Admission:
Medications at home:
Taken from the patient's list of medications that comes with him
from the group home. He does not know the names of his
medications as they are given to him in the group home.
Abilify 20 mg qam
Glucotrol 10 mg T qam
Tenormin 50 mg 2 T qam
Lipitor 20 mg po T qam
Protonix 40 mg po T qd
Cogentin 1 mg T qam
Celexa 20 mg po qd
Proscar 5 mg po qd
Colace 100 mg [**Hospital1 **]
Risperdal 2 mg [**Hospital1 **]
Demeclocycline 300 mg T [**Hospital1 **]
Lisinopril 40 mg T qhs
Cadura 8 mg T qhs
Trazodone 50 mg T qhs
Vitamin D 50,000 T q week
Tylenol # 3 2 T for more severe pain
cortisone epidural injections q 4 months
Dr. [**Last Name (STitle) **] scheduled emergency cortisone injection [**1-25**] 1:45 pm
.
Meds on transfer:
-Acetaminophen 1000 mg PO/NG TID
-OxycoDONE (Immediate Release) 10 mg PO/NG Q4H:PRN pain
-traZODONE 50 mg PO/NG HS
-Doxazosin 8 mg PO/NG HS Pt is on this dose as an o/p and is not
delirious hence the dose is being continued.
-Lisinopril 40 mg PO/NG HS
-demeclocycline *NF* 300 mg Oral [**Hospital1 **]
-Risperidone 2 mg PO BID
-Docusate Sodium 100 mg PO BID
-Finasteride 5 mg PO DAILY
-Citalopram 20 mg PO/NG DAILY
-Benztropine Mesylate 1 mg PO/NG QAM
-Pantoprazole 40 mg PO Q24H
-Atorvastatin 20 mg PO/NG DAILY
-Atenolol 100 mg PO/NG DAILY
-Insulin SC (per Insulin Flowsheet)
Sliding Scale 02/22 @ 1844 View
-Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
-Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
-GlipiZIDE XL 10 mg PO DAILY
-Aripiprazole 20 mg PO/NG DAILY [**1-25**] @ 1844 View
-Heparin 5000 UNIT SC TID
.
Allergies:
Thiazide Diuretics
.
Discharge Medications:
1. aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Glucotrol 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. benztropine 1 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Risperdal 2 mg Tablet Sig: One (1) Tablet PO twice a day.
11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. doxazosin 8 mg Tablet Sig: One (1) Tablet PO at bedtime:
hold if SBP <100.
13. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): please check weight daily. [**Name6 (MD) **] rehab MD if weight
increases by >2-3lbs.
15. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for to feet and buttock wounds.
16. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for affected areas: groin.
17. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
18. Outpatient Lab Work
Please draw a basic metabolic panel every monday starting [**Month (only) 958**]
results to Dr. [**Last Name (STitle) 4090**] at ([**Telephone/Fax (1) 39519**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Hyponatremia
Severe Sepsis
Respiratory failure
Acute Systolic Heart failure
Acute renal failure
Bacteremia
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted with weakness and electrolyte abnormalities.
You were found to have bacteria in your blood and required
admission to the ICU for sepsis. Your hospital course was
complicated by multi-organ dysfunction due to severe infection
but you have improved significantly with antibiotics and
supportive care. You are still weak and will need aggressive
rehabilitation to get back to your baseline. You were found to
have congestive heart failure and will need follow up imaging in
3mths.
.
Please note the following changes to your medication regimen.
1. STOP Demeclocycline- pls discuss this with Dr. [**Last Name (STitle) 4090**] when
you see him in follow up on [**2-24**]
2. Start lasix 40mg daily
3. Stop Vitamin D
4. Stop Tylenol #3
5. Start Oxycodone 5-10mg as needed for pain
6. Stop Atenolol, Start Toprol 200mg daily
7. Decrease Lisinopril to 5mg daily
Followup Instructions:
IT IS IMPORTANT THAT YOU KEEP THIS APPOINTMENT WITH NEPHROLOGY
.
Department: WEST [**Hospital 2002**] CLINIC
When: THURSDAY [**2174-2-24**] at 2:00 PM
With: DR. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Please make sure that you schedule follow up with your PCP after
discharge from the rehab facility.
|
[
"995.92",
"038.42",
"295.32",
"272.4",
"E928.8",
"518.81",
"425.9",
"782.1",
"729.89",
"785.52",
"721.3",
"428.0",
"280.9",
"287.49",
"038.49",
"428.21",
"788.20",
"253.6",
"250.00",
"600.01",
"584.9",
"401.9",
"276.2",
"E849.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71",
"38.97",
"96.04",
"86.11",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
16554, 16615
|
8476, 13160
|
313, 339
|
16775, 16843
|
4099, 4099
|
17849, 18355
|
2587, 2597
|
14819, 16531
|
16636, 16754
|
13186, 13186
|
16951, 17826
|
13207, 13913
|
3843, 4080
|
2637, 3722
|
264, 275
|
367, 1085
|
4115, 8453
|
16858, 16927
|
1107, 1704
|
1736, 2571
|
13931, 14796
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,910
| 104,009
|
11221
|
Discharge summary
|
report
|
Admission Date: [**2107-9-2**] Discharge Date: [**2107-9-12**]
Date of Birth: [**2078-9-6**] Sex: F
Service: MEDICINE
Allergies:
Cephalexin / Optiray 300 / Nut Flavor / Fruit Flavor /
Erythromycin Base / Magnevist / Shellfish / iv contrast dye
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
EGD x 2
History of Present Illness:
28 yo F with a history of alcoholism, several episodes of acute
alcoholic pancreatitis, transferred from OSH with 3 days of
abdominal pain, nausea and vomiting. She reported that she had
been on an alcohol binge for several days, last drink was 3 days
prior. She had severe abdominal pain, worse than with prior
episodes of pancreatitis. She was vomiting blood tinged emesis.
Labs at OSH were notable for lipase of 1000. Patient had an
episode of 300 cc of emesis with red blood streaks. Later in the
evening, she vomited 1000cc of bright red blood with clots. Her
hematocrit dropped from 33.6-28.8 over 4 hours and she received
1U PRBC and was transferred to [**Hospital1 18**] for further management.
In the ED, initial vital signs were 97.7 79 123/80 16 97%. Labs
notable for hematocrit 32. KUB was negative for free air. She
was started on pantoprazole 80mg IV and given dilaudid for pain
control. She had an episode of hematemesis. NG tube was placed
and returned bright red blood. Patient was admitted to the MICU
for further management.
Vital signs prior to transfer were 98.2 104 142/98 18 98%.
On arrival to the MICU, vital signs were BP 128/78 HR 123 O2 99%
RA. Patient vomited 350cc of bright red blood with clots.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Past Medical History:
- Acute alcoholic pancreatitis [**6-2**], [**8-2**], [**2-2**]- No history of
pseudocysts
- Alcohol abuse
- Hematemesis- gastritis on EGD ([**7-/2105**], [**1-/2106**])
-HTN
Social History:
Lives in [**Location 3786**] with her mother.
Used to work at [**Hospital1 18**] as a clinical auditor.
- Tobacco: quit 2 years ago
- Alcohol: last drink 3 days ago, h/o abuse for many years, as
above
- Illicits: denies
Family History:
Parents - alive, both with DM and HTN
Both mother and father were alcoholics, her older brother is an
alcoholic.
Physical Exam:
ADMISSION EXAM
Vitals: BP 128/78 HR 123 O2 99% RA
General: Well nourished female, actively vomiting
HEENT: Sclera anicteric, NGT in place.
Neck: supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: diffusely tender to mild palpation with guarding.
GU: foley in place
Ext: WWP, 2+DP/PT pulses b/l, no edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred
DISCHARGE:
VS - 98 99/64 60 18 98 RA
GEN Alert, oriented, NAD
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD Nontender till sudden voluntary guarding at end of deep
palpation in all quadrants. soft, normoactive BS, ND, no
organomegaly noted, no ascites
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION LABS
[**2107-9-2**] 09:18PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2107-9-2**] 09:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2107-9-2**] 09:18PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2107-9-2**] 09:18PM URINE MUCOUS-RARE
[**2107-9-2**] 09:00PM GLUCOSE-86 UREA N-6 CREAT-0.5 SODIUM-144
POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-12* ANION GAP-25*
[**2107-9-2**] 09:00PM estGFR-Using this
[**2107-9-2**] 09:00PM ALT(SGPT)-23 AST(SGOT)-119* ALK PHOS-73 TOT
BILI-0.3
[**2107-9-2**] 09:00PM LIPASE-901*
[**2107-9-2**] 09:00PM ALBUMIN-4.2 CALCIUM-7.2* PHOSPHATE-3.3
MAGNESIUM-1.5*
[**2107-9-2**] 09:00PM WBC-6.4 RBC-3.28* HGB-10.3* HCT-32.2* MCV-98#
MCH-31.4 MCHC-31.9 RDW-14.7
[**2107-9-2**] 09:00PM NEUTS-85.9* LYMPHS-10.3* MONOS-3.2 EOS-0.4
BASOS-0.3
[**2107-9-2**] 09:00PM PLT COUNT-111*#
[**2107-9-2**] 09:00PM PT-13.5* PTT-29.3 INR(PT)-1.3*
DISCHARGE:
[**2107-9-12**] 07:50AM BLOOD WBC-7.2 RBC-3.24* Hgb-9.7* Hct-30.2*
MCV-93 MCH-30.0 MCHC-32.2 RDW-14.4 Plt Ct-613*
[**2107-9-12**] 07:50AM BLOOD Glucose-117* UreaN-11 Creat-0.5 Na-139
K-3.7 Cl-104 HCO3-24 AnGap-15
[**2107-9-12**] 07:50AM BLOOD Lipase-251*
[**2107-9-12**] 07:50AM BLOOD Calcium-9.4 Phos-4.9* Mg-1.9
IMAGING/STUDIES:
EGD [**2107-9-3**]: Impression: [**Doctor First Name **]-[**Doctor Last Name **] tear (injection,
endoclip)
Esophagitis
Granularity and erythema in the stomach body
Otherwise normal EGD to third part of the duodenum
CT ABD/PELVIS W/O CONTRAST:
1. No abdominal/retroperitoneal hemorrhage.
2. Ill-defined peripancreatic stranding is compatible with
patient's known history of pancreatitis. No peripancreatic
fluid or fluid collection to suggest peripancreatic hemorrhage
or pseudocyst formation. This unenhanced exam is limited for
the evaluation of necrotizing pancreatitis.
3. Hepatomegaly with diffuse hepatic steatosis.
4. Internal contents of the gallbladder measure 23 [**Doctor Last Name **],
intermediate density, and may represent sludge.
5. Normal caliber bowel loops and appendix. Normal terminal
ileum.
Brief Hospital Course:
28 yo F with h/o alcoholism, multiple episodes of acute
pancreatitis, presenting with acute pancreatitis and hematemesis
from two [**Doctor First Name 329**] [**Doctor Last Name **] tears.
# Hematemesis- On admission the patient was admitted to the
Medical ICU and underwent an emergent EGD which showed [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] tears likely secondary to profuse vomiting over last 3
days and no evidence of portal gastropathy. She continued to
have melenatotic stools with no evidence on CT scan of
retroperitoneal bleed and underwent a repeat EGD on [**9-5**] which
showed while one clip was intact, the other had come off and
there was a clot on that tear. She was treated with PPI drip x
24 hours and then switched to po BID. She received 5units of
pRBC between [**9-3**] and [**9-5**]. She was called out of the ICU and
remained stable on the med floor. However, she took a long time
before she started tolerating POs but was tolerating a regular
diet and her exam, while still tender, was back at baseline. The
pt refused both CT w/ contrast w/ premedication for her allergy
as well as MRI as did not believe they would be useful and did
not want to have her lip piercing taken out. She was counselled
to have the test done as an outpt.
# Alcoholic pancreatitis- BISAP score 0. Patient has a history
of 3 prior episodes of alcoholic pancreatitis requiring
hospitalization, last in 1/[**2106**]. Past imaging has been negative
for cholelithiasis and pseudocysts. She was treated with
aggressive IV hydration, vitamins and was NPO and diet was
advanced to clears and then to regular diet before dc. She
tolerated regular diet for several days prior to dc.
# Thrombocytopenia- Platelets drop >50% from last check in [**2106**].
In the ICU this was stable and was not further worked up. It is
likely due to her alcohol use.
Was 613 at time of dc.
# Alcohol abuse- she has significant alcohol abuse. She was
monitored on a CIWA scale for the first 3 days of her admission.
Social work was consulted and recommended rehab. The pt was set
up to see rehab as an outpt.
TRANSITIONAL ISSUES:
1. THE PT NEEDS [**Name (NI) 36068**] WITH OUTPT RESIDENT PCP (DR [**Last Name (STitle) **]); IS
SEEING NP THIS WEEK
2. DURATION OF PPI NEEDS TO BE READRESSED BY GI DOCTOR
3. ALCOHOL ABUSE COUNSELIING AND RESOURCES NEED TO BE PROVIDED
4. CT W/ CONTRAST OR MRI SHOULD BE CONSIDERED AS OUTPT IF STILL
HAVING PAIN
Medications on Admission:
none
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Q12 Disp #*60 Tablet
Refills:*0
2. Sucralfate 1 gm PO QID
Please start on [**2107-9-6**]
RX *Carafate 1 gram 1 tablet(s) by mouth four times a day Disp
#*80 Tablet Refills:*0
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN PAIN
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth Q8
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
[**Doctor First Name **] [**Doctor Last Name **] TEAR
ACUTE PANCREATITIS
ALCOHOL ABUSE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms [**Known lastname 36069**],
You were admitted to [**Hospital1 18**] for vomitting up blood which was
found to be due to a tear in your esophagus likely due to your
alochol intake. You got an endoscopy which clipped your
esophageal tears. You were treated medically and improved slowly
after several days of bowel rest and intravenous fluids.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2107-9-15**] at 10:20 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 15353**], NP [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2107-10-5**] at 8:30 AM
With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], 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
|
[
"577.0",
"530.7",
"276.2",
"564.00",
"790.4",
"291.81",
"305.01",
"276.52",
"285.1",
"785.0",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8490, 8496
|
5559, 7674
|
407, 416
|
8627, 8627
|
3385, 5536
|
9148, 9846
|
2233, 2347
|
8063, 8467
|
8517, 8606
|
8034, 8040
|
8778, 9125
|
2362, 3366
|
7695, 8008
|
1700, 1782
|
334, 369
|
444, 1681
|
8642, 8754
|
1804, 1980
|
1996, 2217
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,373
| 110,300
|
8702
|
Discharge summary
|
report
|
Admission Date: [**2204-8-13**] Discharge Date: [**2204-9-17**]
Date of Birth: [**2148-10-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Adhesive Tape
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 year old male with HCV cirrhosis s/p liver [**First Name3 (LF) **]
complicated by ascites/ encephalopathy/ varices (3 cords Grade I
varices)/ portal hypertensive gastropathy/chronic portal and
splenic venous thrombosis, recently discharged from [**Hospital1 18**] with a
GI bleed who presented on [**8-13**] with an HCT of 21.7, dizziness
and hypotension.
.
Pt has had a complicated history of recurrent GI bleeding with
no clear source being found after an extensive work up that
included:
[**2204-5-11**]: GI Bleeding study
[**2204-5-12**]: Sigmoidoscopy
[**2204-5-18**]: GI Bleeding study
[**2204-5-20**]: Colonoscopy and EGD
[**2204-5-21**]: Angiogram, no intervention
[**2204-5-24**]: Exploratory laparotomy, intraoperative endoscopy.
.
Pt was most recently admitted to [**Hospital1 18**] from [**8-1**] to [**8-9**] with
continued GI bleeding. Tagged RBC scan was negative. The result
of that admission was to manage his chronic GI bleeding as an
outpatient. He was undergoing twice weekly HCT checks, his HCT
was 30.9 four days prior to admission, and 21.9 on [**8-13**]. He also
had some associated lightheadedness at home. Over the weekend he
had been having [**4-26**] melanotic stools per day, that were streaked
with bright red blood. He was having his chronic abdominal pain,
but no changes from his baseline. After getting his HCT checked,
he was referred to the ER for further evaluation.
.
In the ED, initial BP-82/52. Patient was given 3L NS, 2 units of
PRBC's. Given his hypotension he was admitted to the ICU for
further monitoring.
.
Follow up HCT in the ICU 20.7 after 2u [**Last Name (LF) **], [**First Name3 (LF) **] 2 additional
units were given. Tagged red cell scan was negative. AM HCT was
27.8. He had 1 episode of melena on the morning of transfer. On
transfer patient is resting comfortably. He's quite worried
about where he might be bleeding from, but has no other
complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills. Denies headache. Denies cough,
shortness of breath. Denies chest pain. Denies nausea, vomiting.
Denies dysuria, frequency, or urgency.
Past Medical History:
PMH:
- Hepatitis C s/p liver Tx [**2198-5-20**], s/p revision [**12-27**];
complicated with rejection and steroid use since [**2199-4-20**] to
present; also complicated with Hep C recurrence and restarted
peg interferon [**2199-6-17**]. Hep C possibly contracted from tattoo
[**2171**]
- Chronic pancreatitis
- History of peripancreatic abscess [**8-/2203**]
- Diabetes: steroid induced, managed at [**Hospital **] Clinic, recent
HBA1C 5.1%
- ITP
- SVT last episode approximately [**1-30**], medically managed at this
time (atenolol)
- Secondary hyperparathyroidism due to CKD managed by Dr. [**Last Name (STitle) 4090**]
at [**Last Name (un) **]
- Depression/anxiety
- Primary hypogonadism
- Thoracic compression fractures ([**5-26**])
- H/o post hypoxic encephalopathy ([**2190**])
- Neutropenia and infections including c. diff x3, streptococcal
septicemia, anal fistula s/p fistulectomy([**11-24**])
- Left sided hydronephrosis due to obstruction from
splenomegaly, s/p left ureteral stent placement ([**5-28**])
- Chronic pain especially rectal pain
.
PSH:
- Cholecystectomy
- Appendectomy
- Splenectomy, distal pancreatectomy, c/w fistula, s/p stent and
then removal [**2201**]
- Bilateral inguinal hernia s/p hernia repair which has failed
- Umbilical hernia repair ([**11-22**])
- Tonsillectomy
Social History:
Pt was recently at rehab and was discharged home on [**7-26**]. He
lives with mother in [**Name (NI) 583**]. He has a sister who is a nurse
and is very involved in his care. Patient sates he smoked in
high school socially (only in parties), but quit since then.
Denies any current or past alcohol intake. Denies recreational
drug use.
Family History:
Mother has DM2 and HTN. Uncle with cancer in his 80s (unknown
site). Denies any family history of MI, sudden cardiac death,
stroke and lung diseases has DM2.
Physical Exam:
ON ADMISSION:
Vitals: Afebrile BP: 102/58 P: 56 R: 18 O2: 99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2204-8-13**] 09:50AM BLOOD WBC-7.4 RBC-2.06*# Hgb-7.1*# Hct-21.9*#
MCV-106* MCH-34.7* MCHC-32.6 RDW-23.0* Plt Ct-224
[**2204-8-13**] 09:50AM BLOOD Neuts-66 Bands-0 Lymphs-18 Monos-7 Eos-8*
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2204-8-13**] 09:50AM BLOOD Plt Smr-NORMAL Plt Ct-224
[**2204-8-13**] 09:50AM BLOOD UreaN-40* Creat-1.1 Na-139 K-5.4* Cl-111*
HCO3-19* AnGap-14
[**2204-8-13**] 09:50AM BLOOD ALT-26 AST-41* AlkPhos-211* TotBili-1.1
[**2204-8-13**] 09:50AM BLOOD Albumin-2.6* Calcium-8.5 Phos-3.9 Mg-2.3
[**2204-8-13**] 09:50AM BLOOD tacroFK-3.1*
.
DISCHARGE LABS:
.
MICRO: none
.
STUDIES:
Bleeding study ([**2204-8-13**]): No evidence for lower GI bleed.
.
Portable CXR ([**2204-8-13**]): Small bilateral pleural effusions with
associated atelectasis.
.
EGD:
.
Colonoscopy:
Brief Hospital Course:
55 y/o M with a h/o HCV cirrhosis, s/p liver [**Month/Day/Year **]
complicated by recurrence of HCV cirrhosis and ascites/
encephalopathy/ varices (3 cords Grade I varices)/ portal
hypertensive gastropathy/chronic portal and splenic venous
thrombosis, who presents with recurrence of GI bleed.
.
# GI bleed: Pt has a h/o GI bleeds of unknown etiology despite
numerous studies including EGDs, colonoscopies, bleeding
studies, and an intraoperative endoscopy. He was recently
admitted from [**Date range (1) 30471**], w/o identifying the bleeding source. He
was discharged with a plan to have twice weekly outpatient CBCs
with transfusions as needed. However, he continued to have
numerous large bloody stools and a large drop in Hct, so he was
again admitted to the hospital. A repeat tagged RBC scan failed
to show the source of the bleed. He was then challenged with
heparin, however he did not bleed and so he was reversed with
protamine. He then had a large melanotic stool, so he was taken
to angio and challenged with intra-artrial heparin to the SMA
and [**Female First Name (un) 899**]. Again, no source of bleeding was found. Colonoscopy and
EGD were performed with no bleeding source identified. He was
started on Amicar. He remained hemodynamically stable and was
transferred to the floor. On the floor, patient continued to
have intermittent episodes of bleeding requiring transfusions.
He underwent red blood cell scan which showed possible delayed
bleed around hepatic flexure. He subsequently underwent
colonoscopy which was essentially negative, showing one non
bleeding diverticulum. He had a brief trial of octreotide, which
was d/c-ed after one day secondary to cramping. He was finally
started on a trial of estrogen therapy. Underwent a capsule
study which was also negative. As of [**2204-8-25**] he had required 17
units of [**Date Range **] during this hospitalization. During this time he
was also treated for a complicated UTI with a course of cipro.
Pain and palliative care were consulted. Family meeting was
held with patient's three sisters, pain and palliative care,
outpatient hepatologist, attending on service, housestaff and
social work. Mr. [**Known lastname 4042**] expressed that he nolonger wished to be
intubated or recussitated and DNR/DNI status was initiated. On
[**9-15**], patient developed shortness of breath, chest discomfort
and continued to complain of abdominal discomfort. Throughout
the day, multiple discussions were held in the presence of the
family and the patient. Mr. [**Known lastname 4042**], stated that he nolonger
wanted any blood products. He also complained of discomfort
with taking in of medications. Comfort measures was initiated
and patient was placed on a morphine drip titrated to comfort.
Family support was provided. Mr. [**Known lastname 4042**] passed on [**9-17**], with
family present at his bedside.
Medications on Admission:
ALENDRONATE - 70 mg weekly
ATENOLOL - 50 mg once a day
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit weekly
LAMIVUDINE [EPIVIR HBV] - 100 mg once a day
LATANOPROST [XALATAN] - 0.005 % Drops - 1 Drops(s) in each eye
HS
LIPASE-PROTEASE-AMYLASE [PANCREASE] - 20,000 unit-[**Unit Number **],500
unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) - 2 Capsule(s)
by
mouth three times a day with meals
OMEPRAZOLE - 40 mg twice a day
SERTRALINE - 50 mg - 1.5 Tablet(s) by mouth once a day
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM DS] - 800 mg-160 mg
Tablet
- 1 Tablet(s) by mouth twice a day
TACROLIMUS - 0.5 mg Capsule - 1 Capsule(s) by mouth twice a day
TRAZODONE - 50 mg HS
URSODIOL - 300 mg twice a day
CALCIUM CITRATE-VITAMIN D3 - 315 mg-200 - 1 Tablet twice a day
FLUDROCORTISONE 0.1mg daily
FOLIC ACID 1mg daily
LACTULOSE 30mL daily
RIFAXIMIN 400mg TID
LASIX 20mg daily
SPIRONOLACTONE 25mg daily
MULTIVITAMIN 1 tablet daily
THIAMINE 100mg daily
Discharge Medications:
Pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Pt expired
Discharge Condition:
Pt expired
Discharge Instructions:
Pt expired
Followup Instructions:
Pt expired
Completed by:[**2204-9-18**]
|
[
"249.00",
"070.44",
"E932.0",
"427.89",
"996.82",
"577.1",
"571.5",
"458.9",
"578.1",
"518.0",
"572.3",
"E878.0",
"550.93",
"577.2",
"456.21",
"287.31",
"562.10",
"585.9",
"403.90",
"682.2",
"211.1",
"537.89",
"588.81",
"599.0",
"789.59",
"300.4",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"45.13",
"99.29",
"88.47",
"99.19",
"38.93",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
9614, 9623
|
5687, 8577
|
298, 304
|
9677, 9689
|
4864, 4864
|
9748, 9789
|
4135, 4294
|
9579, 9591
|
9644, 9656
|
8603, 9556
|
9713, 9725
|
5453, 5664
|
4309, 4309
|
2265, 2439
|
250, 260
|
332, 2246
|
4880, 5437
|
4323, 4845
|
2461, 3766
|
3782, 4119
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,417
| 152,762
|
32693
|
Discharge summary
|
report
|
Admission Date: [**2151-5-26**] Discharge Date: [**2151-6-3**]
Date of Birth: [**2096-6-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
CABG x 5 (LIMA>LAD, SVG>diag, SVG>OM1, SVG>OM2, SVG>PDA) [**5-26**]
History of Present Illness:
54 yo M who presented to cardiologists office with chest pain
and was subsequently admitted to OSH. Stress test was positive,
cath at [**Hospital1 18**] showed 3VD. Referred for surgery.
Past Medical History:
htn, dm, cad stents x 2, migraines
Social History:
Social history is significant for the absence of current tobacco
use; he quit 17 years ago. There is no history of alcohol abuse.
He moved to US from [**Country 2045**] in [**2124**]. He lives with wife; has three
children ages 12, 18, 26. Works part time driving children to
school in a [**Doctor Last Name **] ([**Location (un) **]).
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had MI in her 70s.
Physical Exam:
HR 60 RR 14 BP 121/72
NAD
Lungs CTAB
Heart RRR
Abdomen soft, NT, ND
Extrem warm, no edema
Pertinent Results:
[**2151-6-2**] 07:30AM BLOOD WBC-10.0 RBC-3.56* Hgb-10.1* Hct-31.1*
MCV-87 MCH-28.4 MCHC-32.5 RDW-15.6* Plt Ct-470*#
[**2151-6-2**] 07:30AM BLOOD Glucose-191* UreaN-11 Creat-0.8 Na-139
K-4.0 Cl-101 HCO3-28 AnGap-14
CHEST (PA & LAT) [**2151-6-2**] 10:09 AM
CHEST (PA & LAT)
Reason: evaluate rt ptx
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate rt ptx
HISTORY: Status post CABG, to evaluate right pneumothorax.
FINDINGS: In comparison with study of [**5-31**], there is little
change in the appearance of the right pneumothorax. The right
hemidiaphragm is much more sharply seen. Opacification at the
left base persists, consistent with some combination of
atelectasis, effusion, and possible pneumonia.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Name (NI) 76181**], [**Known firstname 76182**] [**Hospital1 18**] [**Numeric Identifier 76183**] (Complete)
Done [**2151-5-26**] at 10:59:17 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2096-6-20**]
Age (years): 54 M Hgt (in): 66
BP (mm Hg): 105/67 Wgt (lb): 160
HR (bpm): 69 BSA (m2): 1.82 m2
Indication: Intra-op TEE for CABG
ICD-9 Codes: 440.0, 414.8, 413.9
Test Information
Date/Time: [**2151-5-26**] at 10:59 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 35% to 40% >= 55%
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Mild-moderate regional LV systolic dysfunction. Moderately
depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Trivial MR.
TRICUSPID VALVE: Physiologic TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. See Conclusions for post-bypass data The
post-bypass study was performed while the patient was receiving
vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
There is mild to moderate regional left ventricular systolic
dysfunction with inferior, inferolateral and lateral apical to
mid hypokinesis. Overall left ventricular systolic function is
moderately depressed (LVEF= 35-40 %).
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. 5. Trivial
mitral regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine
1. Biventricular function is unchanged. Focal WMAs are unchanged
2. Aorta is intact post decannulation
3. Other findings are unchanged
Brief Hospital Course:
He was taken to the operating room on [**5-26**] where he underwent a
CABG x 5. He was transferred to the ICU in stable condition. He
was extubated the morning of POD #1. He was transferred to the
floor on POD #2. He had atrial fibrillation but converted to
NSR. He was lethargic and pain medications were discontinued. He
was seen by social work for ? of depression. He was followed by
[**Last Name (un) **] for his DM and started on insulin. He otherwise did well
postoperatively and was ready for discharge home on POD #8.
Medications on Admission:
plavix 75', asa 325' glipizide 5', metformin 1000'', lisinopril
10', metoprolol xl 200', pravastatin 80', colace 100', nitro sl
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. 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. Pravachol 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
6. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: 14 units in AM, 7 units in PM Subcutaneous twice a day.
Disp:*qs 1 month* Refills:*0*
7. Insulin Lispro 100 unit/mL Solution Sig: please see sliding
scale Subcutaneous four times a day.
Disp:*qs 1 month* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 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. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO
DAILY (Daily) for 5 days.
Disp:*5 Packet(s)* Refills:*0*
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H () as
needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD now s/p CABG
htn, dm, cad s/p stents x 2, migraines
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision, or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) 76184**] [**Last Name (NamePattern1) 76185**]/Dr. [**Last Name (STitle) **] (PCP) 2 weeks
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5686**] (cardiologist) 2 weeks
Dr. [**First Name (STitle) **] [**Name (STitle) **] 4 weeks
[**Hospital **] Clinic [**6-15**] at 2pm, 3pm and 4pm for MD, RN and Eye
appointments
Completed by:[**2151-6-3**]
|
[
"V45.82",
"411.1",
"780.79",
"414.01",
"428.23",
"401.9",
"250.02",
"285.9",
"427.31",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.61",
"36.14",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6986, 7044
|
4961, 5488
|
331, 401
|
7144, 7152
|
1279, 1581
|
7452, 7849
|
1045, 1153
|
5670, 6963
|
1618, 1648
|
7065, 7123
|
5514, 5647
|
7176, 7429
|
1168, 1260
|
281, 293
|
1677, 4938
|
429, 617
|
639, 675
|
691, 1029
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,510
| 181,737
|
53732
|
Discharge summary
|
report
|
Admission Date: [**2191-1-15**] Discharge Date: [**2191-1-28**]
Date of Birth: [**2128-5-7**] Sex: F
Service: MEDICINE
Allergies:
Tobramycin
Attending:[**First Name3 (LF) 16600**]
Chief Complaint:
Hypotension and Respiratory failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62 yr old female with complicated PMH including idiopathic
pulmonary fibrosis, Multi-drug resistant Pseudomonas PNA
sensitive only to Tobramycin, diastolic heart failure, OSA and
Type 2 DM recently discharged from [**Hospital1 18**] on [**2191-1-12**] after 17
day stay for lower back pain and PNA. She was found at home
[**1-15**] lethargic, hypoxic and hypotensive.
Past Medical History:
1. COPD/interstitial lung disease/IPF/bronchiectasis.
History of pan-resistant Pseudomonas colonization sensitive
only to Tobramycin.
2. CHF with diastolic dysfunction, EF 50%.
3. Obstructive sleep apnea, on home BIPAP.
4. History of ductal breast CA, status post resection.
5. Osteoporosis.
6. History of lumbar fracture.
7. History of DVT.
8. Hyperlipidemia.
9. Type 2 diabetes mellitus.
10. History of syncope, possibly medication related.
11. s/p hip fracture in [**2190-3-22**] with open reduction and
internal fixation.
Social History:
SOCIAL HISTORY: The patient quit tobacco many years ago.She
does not drink alcohol or use IV drugs. She lives alone.
Family History:
NC
Physical Exam:
G: Elderly female, edematous, intubated, sedated
HEENT: ETT in place, PERRL
Lungs: Crackles BL, No W/R
CV: Tachycardic, S1S2, No M/R/G
Abd: Soft, NT, ND, BS+
Ext: [**1-23**]+ pitting edema
Neuro: sedated, no gross deficits
Pertinent Results:
[**2191-1-15**] 11:41PM TYPE-ART TEMP-37.9 RATES-24/ TIDAL VOL-500
PEEP-5 O2-50 PO2-106* PCO2-62* PH-7.22* TOTAL CO2-27 BASE XS--3
INTUBATED-INTUBATED VENT-CONTROLLED
[**2191-1-15**] 11:41PM LACTATE-0.8
[**2191-1-15**] 11:41PM freeCa-1.14
[**2191-1-15**] 11:28PM GLUCOSE-129* UREA N-51* CREAT-3.0* SODIUM-138
POTASSIUM-5.0 CHLORIDE-104
[**2191-1-15**] 11:28PM CORTISOL-21.1*
[**2191-1-15**] 11:28PM WBC-24.1* RBC-3.10* HGB-8.2* HCT-26.5* MCV-85
MCH-26.3* MCHC-30.8* RDW-16.5*
[**2191-1-15**] 11:28PM PLT COUNT-482*
[**2191-1-15**] 09:50PM URINE HOURS-RANDOM UREA N-673 CREAT-84
SODIUM-31 POTASSIUM-33 CHLORIDE-25
[**2191-1-15**] 09:50PM URINE OSMOLAL-418
[**2191-1-15**] 08:48PM LACTATE-0.6
[**2191-1-15**] 08:48PM O2 SAT-86
[**2191-1-15**] 08:30PM GLUCOSE-159* UREA N-55* CREAT-3.6*#
SODIUM-138 POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
[**2191-1-15**] 08:30PM ALT(SGPT)-13 AST(SGOT)-24 LD(LDH)-255* ALK
PHOS-95 TOT BILI-0.1 DIR BILI-0.1 INDIR BIL-0.0
[**2191-1-15**] 08:30PM ALBUMIN-3.0* CALCIUM-8.5 PHOSPHATE-6.6*#
MAGNESIUM-2.2
[**2191-1-15**] 08:30PM WBC-25.1* RBC-3.14* HGB-8.4* HCT-28.4* MCV-91
MCH-26.7* MCHC-29.5* RDW-18.1*
[**2191-1-15**] 08:30PM PLT COUNT-490*
[**2191-1-15**] 08:30PM PT-13.4 PTT-28.4 INR(PT)-1.1
[**2191-1-15**] 07:37PM LACTATE-0.80
[**2191-1-15**] 07:14PM TYPE-ART PO2-136* PCO2-75* PH-7.16* TOTAL
CO2-28 BASE XS--3
[**2191-1-15**] 06:37PM LACTATE-0.8
[**2191-1-15**] 05:38PM LACTATE-0.9
[**2191-1-15**] 05:09PM TYPE-MIX
[**2191-1-15**] 05:09PM NA+-136 K+-5.3 CL--103 TCO2-26
[**2191-1-15**] 04:50PM TYPE-ART PO2-440* PCO2-78* PH-7.16* TOTAL
CO2-29 BASE XS--2
[**2191-1-15**] 04:42PM LACTATE-0.8
[**2191-1-15**] 04:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2191-1-15**] 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2191-1-15**] 04:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2191-1-15**] 02:32PM PO2-118* PCO2-81* PH-7.17* TOTAL CO2-31* BASE
XS--1
[**2191-1-15**] 02:00PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2191-1-15**] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2191-1-15**] 02:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2191-1-15**] 01:50PM LACTATE-1.9
[**2191-1-15**] 01:43PM TYPE-ART TEMP-37.4 O2-100 PO2-157* PCO2-77*
PH-7.16* TOTAL CO2-29 BASE XS--3 AADO2-487 REQ O2-81
INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2191-1-15**] 01:43PM LACTATE-1.8
[**2191-1-15**] 01:34PM GLUCOSE-174* UREA N-65* CREAT-4.8*#
SODIUM-134 POTASSIUM-6.0* CHLORIDE-97 TOTAL CO2-25 ANION GAP-18
[**2191-1-15**] 01:34PM CK(CPK)-71
[**2191-1-15**] 01:34PM cTropnT-0.04*
[**2191-1-15**] 01:34PM CK-MB-NotDone
[**2191-1-15**] 01:34PM CALCIUM-9.1 PHOSPHATE-9.4*# MAGNESIUM-2.6
[**2191-1-15**] 01:34PM CORTISOL-19.6
[**2191-1-15**] 01:34PM CRP-28.79*
[**2191-1-15**] 01:34PM WBC-24.7*# RBC-3.27* HGB-8.6* HCT-29.0*
MCV-89 MCH-26.4* MCHC-29.8* RDW-16.7*
[**2191-1-15**] 01:34PM NEUTS-93.9* BANDS-0 LYMPHS-4.1* MONOS-1.5*
EOS-0.5 BASOS-0.1
[**2191-1-15**] 01:34PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2191-1-15**] 01:34PM PLT SMR-HIGH PLT COUNT-467*
[**2191-1-15**] 01:43PM TYPE-ART TEMP-37.4 O2-100 PO2-157* PCO2-77*
PH-7.16* TOTAL CO2-29 BASE XS--3 AADO2-487 REQ O2-81
INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2191-1-15**] 01:43PM LACTATE-1.8
[**2191-1-15**] 01:34PM GLUCOSE-174* UREA N-65* CREAT-4.8*#
SODIUM-134 POTASSIUM-6.0* CHLORIDE-97 TOTAL CO2-25 ANION GAP-18
[**2191-1-15**] 01:34PM CK(CPK)-71
[**2191-1-15**] 01:34PM cTropnT-0.04*
[**2191-1-15**] 01:34PM CK-MB-NotDone
[**2191-1-15**] 01:34PM CALCIUM-9.1 PHOSPHATE-9.4*# MAGNESIUM-2.6
[**2191-1-15**] 01:34PM CORTISOL-19.6
[**2191-1-15**] 01:34PM CRP-28.79*
[**2191-1-15**] 01:34PM WBC-24.7*# RBC-3.27* HGB-8.6* HCT-29.0*
MCV-89 MCH-26.4* MCHC-29.8* RDW-16.7*
[**2191-1-15**] 01:34PM NEUTS-93.9* BANDS-0 LYMPHS-4.1* MONOS-1.5*
EOS-0.5 BASOS-0.1
[**2191-1-15**] 01:34PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2191-1-15**] 01:34PM PLT SMR-HIGH PLT COUNT-467*
[**2191-1-15**] 01:34PM PT-13.4 PTT-30.2 INR(PT)-1.1
CHEST (PORTABLE AP) [**2191-1-15**] 4:51 PM
Right subclavian line within the mid right atrium. No
pneumothorax or pleural effusion identified. Otherwise stable
exam when compared to previous studies from the same day.
CHEST (PORTABLE AP) [**2191-1-17**] 9:19 AM
Chronic bilateral lung process without significant interval
change since previous examination. Correction of central venous
line position has been performed.
Brief Hospital Course:
1. Respiratory Failure: Pt well-known to pulmonary clinic, has
baseline ILD/COPD with baseline pCO2 50. Pt was initially
started on broad-spectrum antibiotics including Zosyn, Levo,
Vanco, Azithro, and inhaled Tobra for her history of multiple
colonies of multi-drug resistent pseudomonas, atypicals, and
MRSA (given recent hospitalizations). Multiple sputum cultures
grew back Pseudomonas sensitive to everything but gent, and as
she had demonstrated clinical improvement on the zosyn, she was
continued on this and everything else was stopped. Despite her
extremely restrictive lung physiology, she was weaned off the
ventilator following diuresis to even I/O's for her ICU stay.
She was continued on Zosyn for 10 days, as well as
Albuterol/Ipratropium nebs, chest PT. She was restarted on
Mucomyst nebulizers. Her respiratory status continued to
improve. She was determined to be stable and discharged to
pulmonary rehab.
*
2. Hypotension/sepsis: Pt was started on the MUST protocol for
presumed sepsis, which included a negative response to [**Last Name (un) 104**] stim
test--started on hydrocortisone/fludrocortisone, as well as
being started on pressors and intially xigris (although this was
discontinued due to a decrease in Hct) Her blood pressure
gradually improved and she was weaned off of pressors.
Eventually, her blood pressure fully recovered and she was
started on an ACEI and diuresed back to her admission fluid
level. She was discharged on all of her pre-admission HTN
medications.
*
3. ARF: FENa demonstrated a pre-renal etiology, and the Cr
eventually returned to baseline with IVFs. Antibiotics were
initially renal-dosed, but with improved renal function, were
dosed at full doses.
*
4. CHF: A repeat Echo showed no obvious change from prior one in
[**12/2179**], EF 40-45%. Pt was started on ACEI and agressively
diuresed, upon transfer out of ICU her fluid status was negative
600cc. She remained euvolemic by exam.
*
5. Anemia: Underproduction according to RI. Fe studies in past
c/w chronic disease anemia. Repeat Hct were stable.
*
6. DM2: Pt was started on an Insulin GTT, which was then changed
to a sliding scale with clinical improvement.
*
7. Code status: Pt was kept full code throughout her ICU stay.
Per discussions with the family, should her prognosis change
such that she would need to be on a ventilator long term, she
may not desire to continue aggressive care.
Medications on Admission:
1. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO QD ().
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
5. Clonazepam 0.5 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)) as needed.
6. Venlafaxine HCl 37.5 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO BID (2 times a day).
7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
8. Mexiletine HCl 150 mg Capsule Sig: One (1) Capsule PO Q8H
(every 8 hours).
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
10. Nortriptyline HCl 50 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime).
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
14. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig:
Two (2) Spray Nasal [**Hospital1 **] (2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24HRS (): Please
wear for 12 hours on and then 12 hours off.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD PRN () as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
19. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: [**4-27**]
Puffs Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*0*
20. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QSAT
(every Saturday).
21. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q12HR: Take 20mg (2 tabs)
every morning and 10mg (1 tab) every evening.
Disp:*90 Tablet Sustained Release 12HR(s)* Refills:*0*
22. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig:
Three (3) Puff Inhalation [**Hospital1 **] (2 times a day).
23. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
24. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
25. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q1H (every
hour) as needed for constipation.
Disp:*500 ML(s)* Refills:*0*
26. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q3HR PRN as
needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
27. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
28. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
29. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: Start
on [**1-15**].
Disp:*30 Tablet(s)* Refills:*0*
30. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Start on [**1-15**].
31. Neurontin 600 mg Tablet Sig: One (1) Tablet PO four times a
day: Start on [**1-15**].
32. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day:
Start on [**1-15**].
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: 1-3 Tablets PO once a day: Take
3 tablets for 3 days, 2.5 tablets for 3 days, 2 tablets for 3
days, 1.5 tablets for 3 days, then take 1 tablet ongoing.
2. Insulin Regular Human 100 unit/mL Solution Sig: 1-12 units
Injection ASDIR (AS DIRECTED): If finger stick:
151-200 mg/dL give 2 Units If FS 201-250 mg/dL 4 If FS
251-300 mg/dL 6 Units If FS 301-350 mg/dL 8 Units If FS
351-400 mg/dL 10 Units .
3. Ipratropium Bromide 0.02 % Solution Sig: [**1-23**] Inhalation Q6H
(every 6 hours).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation [**Hospital1 **] (2 times a day).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed.
7. Nortriptyline HCl 25 mg Capsule Sig: Two (2) Capsule PO HS
(at bedtime).
8. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
10. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 2.5 MLs
Miscell. [**Hospital1 **] (2 times a day).
11. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Three
(3) Puff Inhalation [**Hospital1 **] (2 times a day).
12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
20. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
21. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
22. Mexiletine HCl 150 mg Capsule Sig: One (1) Capsule PO Q8H
(every 8 hours).
23. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
24. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
25. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
26. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QWED
(every Wednesday).
27. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] OF [**Location (un) **]
Discharge Diagnosis:
Pneumonia/sepsis
COPD/Interstitial lung disease
Secondary diagnosis
Acute renal failure
Anemia
Diabetes
Discharge Condition:
Continuing to require oxygen therapy.
Discharge Instructions:
Continue to take all medications as prescribed.
Return to the hospital with any increased shortness of breath,
productive cough, or increased wheezing.
Followup Instructions:
Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2191-2-17**]
9:30
Provider: [**Name Initial (NameIs) 36105**]CC5 BREAST SURGERY BREAST SURGERY (PRIVATE)
CC-5 (NHB) Where: BREAST SURGERY (PRIVATE) CC-5 (NHB)
Date/Time:[**2191-2-3**] 2:00
Call Dr.[**Name (NI) 110302**] office when you are discharged from Rehab to
make appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8273**] ([**Telephone/Fax (1) 1300**]
[**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 4200**] MD, [**MD Number(3) 16605**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,969
| 151,726
|
21685
|
Discharge summary
|
report
|
Admission Date: [**2110-4-30**] Discharge Date: [**2110-5-14**]
Date of Birth: [**2033-9-7**] Sex: F
Service: MEDICINE
Allergies:
Oxaliplatin
Attending:[**First Name3 (LF) 477**]
Chief Complaint:
CC:[**CC Contact Info 57025**]
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
76F with Stage IIB pancreatic cancer s/p whipple [**5-/2109**], DM II,
aortic stenosis currently C4 Day 14 of oxaliplatin given [**2110-4-18**]
and capecitabine (antimetabolite) [**Date range (1) 57026**] who felt lightheaded
and dizzy yesterday morning, with some abdominal cramping. Of
note she has had chronic diarrhea since her Whipple procedure,
her usual diarrhea is brown but for the last month she has had
"black tarry stools". Patient was seen in clinic on [**4-25**] with
HCT 24.2 and transfused 2 units of blood. Of note she did have
guiac + stool and Dr. [**Last Name (STitle) **] was to arrange for GI evaluation at
that time, last colonoscopy was 5 yrs ago and showed polyp per
patient, has never had EGD.
Of note recently admitted [**4-18**] for allergic response to
oxaliplatin but noted to have a decreasing hct, and coumadin for
her hx of PE was held. Received oxaliplatin [**4-18**] and was taking
capecitabine from [**Date range (1) 57026**] both of which cause anemia,
thrombocytopenia.
ED Course:
CT ABD/PELVIS
IMPRESSION: Interval development of a moderate amount of
ascites, without a clear identifiable cause. No abnormal soft
tissue density within the surgical resection bed in the pancreas
is identified.
Got 2 units RBC and admit to ICU for concern for decompensation,
pt. never tachycardic or hypotensive. Received 5mg oral vitamin
K. GI was made aware of patient.
ROS: + melena, abd pain improved since ER
Denies NSAIDS, ETOH
Past Medical History:
Oncologic History: Stage IIB pancreatic cancer, status post
Whipple surgery on [**2109-5-10**]. The patient is status post two and
a half cycles of adjuvant gemcitabine followed by CyberKnife
therapy. She then completed five weeks of external beam
radiation therapy overlapping with Xeloda 500 mg twice daily as
a radiosensitizer, which was completed on [**2109-9-18**]. Her dose
was eventually titrated up to 1000 mg twice a day during the
remaining half of her radiation treatment. She completed
radiation on [**2109-10-25**]. The decision was made to initiate
adjuvant chemotherapy following radiation therapy for an
additional two to three cycles. In total, she completed five
cycles of gemcitabine on [**2110-1-8**], complicated by the
development of febrile illnesses including hypotension requiring
ICU hospitalization. Her fifth cycle of chemotherapy was reduced
to 800 mg/m2; however, two days following treatment, she
required readmission to the hospital in the setting of
hypotension, tachycardia. She was discharged on [**2110-1-14**].
During that evaluation, CT of the abdomen and pelvis revealed
likely disease progression involving the porta hepatis in the
site of her pancreatic resection. There was no overt evidence of
hepatic metastases. Since that time-frame, we have initiated
capecitabine combined with oxaliplatin. She received her first
dose on [**2110-2-13**].
.
Past Medical History:
1. Aortic Stenosis (no echo on file)
2. Hypertension
3. Type II Diabetes
4. Glaucoma
5. h/o uterine mixed carcinoma endometrioid and clear cell:
stage Ib, grade III, s/p TAH-BSO [**9-13**]
6. history of PE at time of pancreatic cancer diagnosis,
formerly
on Coumadin which was stopped secondary to port hematoma. She
was treated with Coumadin for 10 months.
7. B12 deficiency, on oral B12.
Social History:
Lives alone in home in [**Location (un) 583**], but son or daughter stays with
her at night or checking in on her while she is taking
chemotherapy. Independent when well. She used to work as a
teacher's aid for special education. She has never smoked and
drinks occasional alcohol.
Family History:
daughter with endometrial carcinoma, sister with liver cancer,
father with lung cancer, no fam h/o blood clots
Physical Exam:
HR: 78 (77 - 83) bpm
BP: 127/57(75) {127/57(75) - 152/70(88)} mmHg
RR: 15 (13 - 19) insp/min
SpO2: 99%
Height: 63 Inch
T:97.3
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, Distended, +
fluid wave on exam
Extremities: Right: 1+, Left: 1+
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): x3, Movement: Purposeful, Tone: Normal
Pertinent Results:
EGD [**2110-5-1**]
Findings: Esophagus: Normal esophagus.
Stomach:
Other There was a small amount of red blood in the stomach but
no obvious abnormalities seen.
Duodenum: Normal duodenum.
Other
findings: The patient is s/p pylorus preserving whipple
procedure. The Afferent limb was normal without any blood. At
the initial portion of the efferent limb was blood and a 2.5 cm
linear ulcer in the setting of irregular, heaped up mucosa. This
occupied an approximately 6 cm area. The 10 cm of efferent limb
distal to this was normal. Cold forceps biopsies were performed
for histology at the Efferent Limb.
Impression: There was a small amount of red blood in the stomach
but no obvious abnormalities seen.
The patient is s/p pylorus preserving whipple procedure. The
Afferent limb was normal without any blood. At the initial
portion of the efferent limb was blood and a 2.5 cm linear ulcer
in the setting of irregular, heaped up mucosa. This occupied an
approximately 6 cm area. The 10 cm of efferent limb distal to
this was normal. (biopsy)
Otherwise normal EGD to approximately 10 cm into the afferent
and efferent limbs
Recommendations: Will rush the pathology results. Most
consistent with recurrence of her pancreatic adenocarcinoma.
Less likely a benign anastomotic ulcer.
Will initiate carafate qid while awaiting pathology results
----------------
CT [**4-30**]
CT OF THE PELVIS WITH IV CONTRAST: Multiple surgical clips are
seen within the pelvis. There is a tiny amount of air within the
bladder. Recommend correlation with history of
instrumentation/catheterization. Rectum is unremarkable. There
is no pelvic lymphadenopathy. There is a moderate amount of
fluid within the pelvis.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion
identified. Moderate degenerative changes of the lower lumbar
spine are identified. General anasarca of the soft tissue
structures is seen.
IMPRESSION: Interval development of a moderate amount of
ascites, without a clear identifiable cause. No abnormal soft
tissue density within the surgical resection bed in the pancreas
is identified.
--------------
Ultrasound:FINDINGS: There are innumerable anechoic and
hypoechoic lesions within the hepatic parenchyma, better
evaluated on the recent CT, largerst consistent with simple
cysts. The largest anechoic cyst is in the right liver lobe,
measuring 10.2 x 9.0 x 8.5 cm. Normal waveforms and appropriate
directionality of flow and appropriate waveforms are
demonstrated in the main portal, right anterior and posterior as
well as left portal veins. The IVC, right mid and left hepatic
veins were evaluated and demonstrate normal directionality of
flow as well as waveforms. The evaluation of the hepatic
arteries is suboptimal; however, normal flow and waveforms are
demonstrated in the left hepatic artery and main hepatic artery.
Splenic vein is patent.
IMPRESSION:
1. No evidence of portal vein thrombosis. Unremarkable
evaluation of liver vasculature.
2. Numerous hypo- and anechoic lesions within the hepatic
parenchyma, largest consistent with symple cysts, some are
suboptimally evaluated on this study.
.
Micro
Urine culture: + Ecoli, pan-sensitive
.
[**2110-5-4**] 9:15 pm BLOOD CULTURE Source: Line-poc.
**FINAL REPORT [**2110-5-10**]**
Blood Culture, Routine (Final [**2110-5-10**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
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
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Blood cultures [**Date range (1) 57027**] were negative.
.
CBC
[**2110-4-30**] 04:30PM BLOOD WBC-4.7 RBC-2.76* Hgb-9.0* Hct-24.8*
MCV-90# MCH-32.6* MCHC-36.2* RDW-20.6* Plt Ct-58*
[**2110-5-2**] 04:30AM BLOOD WBC-4.5 RBC-3.53*# Hgb-11.2*# Hct-31.2*
MCV-88 MCH-31.6 MCHC-35.8* RDW-18.6* Plt Ct-75*
[**2110-5-2**] 09:34AM BLOOD Hct-32.3*
[**2110-5-3**] 05:00AM BLOOD WBC-4.9 RBC-3.65* Hgb-11.1* Hct-31.3*
MCV-86 MCH-30.3 MCHC-35.3* RDW-17.7* Plt Ct-98*
[**2110-4-30**] 04:30PM BLOOD ALT-13 AST-31 AlkPhos-103 TotBili-0.8
[**2110-4-30**] 04:30PM BLOOD WBC-4.7 RBC-2.76* Hgb-9.0* Hct-24.8*
MCV-90# MCH-32.6* MCHC-36.2* RDW-20.6* Plt Ct-58*
[**2110-5-1**] 03:26AM BLOOD WBC-3.5* RBC-2.50* Hgb-8.1* Hct-22.9*
MCV-92 MCH-32.3* MCHC-35.2* RDW-18.6* Plt Ct-85*
[**2110-5-1**] 05:18PM BLOOD Hct-32.0* Plt Ct-94*
[**2110-5-1**] 10:47PM BLOOD Hct-31.0* Plt Ct-85*
[**2110-5-2**] 09:34AM BLOOD Hct-32.3*
[**2110-5-3**] 05:00AM BLOOD WBC-4.9 RBC-3.65* Hgb-11.1* Hct-31.3*
MCV-86 MCH-30.3 MCHC-35.3* RDW-17.7* Plt Ct-98*
[**2110-5-4**] 12:00AM BLOOD WBC-3.1* RBC-3.08* Hgb-9.9* Hct-27.5*
MCV-89 MCH-32.2* MCHC-36.0* RDW-19.2* Plt Ct-80*
[**2110-5-4**] 11:46AM BLOOD WBC-2.9* RBC-3.10* Hgb-10.1* Hct-26.4*
MCV-85 MCH-32.6* MCHC-38.4* RDW-18.9* Plt Ct-68*
[**2110-5-4**] 09:15PM BLOOD Hct-34.4*#
[**2110-5-5**] 12:00AM BLOOD WBC-4.6# RBC-3.56* Hgb-11.3* Hct-31.2*
MCV-87 MCH-31.7 MCHC-36.2* RDW-19.3* Plt Ct-57*
[**2110-5-5**] 11:44AM BLOOD WBC-5.3 RBC-3.38* Hgb-10.7* Hct-28.7*
MCV-85 MCH-31.5 MCHC-37.1* RDW-18.9* Plt Ct-54*
[**2110-5-6**] 12:00AM BLOOD WBC-5.4 RBC-3.50* Hgb-11.1* Hct-29.5*
MCV-84 MCH-31.7 MCHC-37.6* RDW-18.3* Plt Ct-94*
[**2110-5-7**] 12:00AM BLOOD WBC-6.4 RBC-3.97* Hgb-12.6 Hct-33.7*
MCV-85 MCH-31.7 MCHC-37.3* RDW-18.2* Plt Ct-71*
[**2110-5-7**] 01:00PM BLOOD Hct-35.3*
[**2110-5-8**] 12:00AM BLOOD WBC-6.4 RBC-3.85* Hgb-12.0 Hct-33.8*
MCV-88 MCH-31.1 MCHC-35.4* RDW-18.9* Plt Ct-56*
[**2110-5-9**] 12:01AM BLOOD WBC-5.5 RBC-3.63* Hgb-11.3* Hct-32.9*
MCV-91 MCH-31.0 MCHC-34.2 RDW-18.7* Plt Ct-54*
[**2110-5-9**] 12:53PM BLOOD Hct-34.1*
[**2110-5-10**] 12:01AM BLOOD WBC-6.2 RBC-3.53* Hgb-11.0* Hct-32.3*
MCV-92 MCH-31.1 MCHC-34.0 RDW-19.0* Plt Ct-56*
[**2110-5-11**] 12:00AM BLOOD WBC-6.2 RBC-3.49* Hgb-11.0* Hct-32.1*
MCV-92 MCH-31.5 MCHC-34.3 RDW-19.4* Plt Ct-54*
[**2110-5-12**] 12:00AM BLOOD WBC-5.9 RBC-3.54* Hgb-11.2* Hct-32.3*
MCV-91 MCH-31.6 MCHC-34.6 RDW-19.2* Plt Ct-56*
[**2110-5-13**] 12:01AM BLOOD WBC-6.2 RBC-3.50* Hgb-11.0* Hct-32.1*
MCV-92 MCH-31.3 MCHC-34.2 RDW-19.7* Plt Ct-61*.
.
Chem 7
[**2110-4-30**] 04:30PM BLOOD Glucose-175* UreaN-20 Creat-1.0 Na-137
K-3.5 Cl-106 HCO3-20* AnGap-15
[**2110-5-1**] 03:26AM BLOOD Glucose-98 UreaN-17 Creat-0.8 Na-136
K-3.1* Cl-107 HCO3-21* AnGap-11
[**2110-5-3**] 05:00AM BLOOD Glucose-129* UreaN-19 Creat-0.9 Na-134
K-3.8 Cl-106 HCO3-18* AnGap-14
[**2110-5-6**] 12:00AM BLOOD Glucose-67* UreaN-18 Creat-0.9 Na-135
K-3.6 Cl-108 HCO3-19* AnGap-12
[**2110-5-8**] 12:00AM BLOOD Glucose-104 UreaN-18 Creat-0.8 Na-134
K-3.8 Cl-111* HCO3-19* AnGap-8
[**2110-5-10**] 12:01AM BLOOD Glucose-111* UreaN-15 Creat-0.8 Na-133
K-3.7 Cl-109* HCO3-20* AnGap-8
[**2110-5-11**] 12:00AM BLOOD Glucose-96 UreaN-12 Creat-0.7 Na-133
K-3.7 Cl-107 HCO3-20* AnGap-10
[**2110-5-12**] 12:00AM BLOOD Glucose-89 UreaN-10 Creat-0.7 Na-133
K-3.7 Cl-108 HCO3-20* AnGap-9
[**2110-5-13**] 12:01AM BLOOD Glucose-102 UreaN-11 Creat-0.7 Na-134
K-3.8 Cl-107 HCO3-21* AnGap-10
.
Misc
[**2110-4-30**] 04:30PM BLOOD ALT-13 AST-31 AlkPhos-103 TotBili-0.8
[**2110-5-7**] 12:00AM BLOOD ALT-11 AST-33 AlkPhos-92 Amylase-10
TotBili-1.3
[**2110-5-10**] 12:01AM BLOOD Calcium-7.9* Phos-2.0* Mg-1.7
[**2110-5-11**] 12:00AM BLOOD Calcium-8.0* Phos-2.4* Mg-1.9
[**2110-5-12**] 12:00AM BLOOD Albumin-2.2* Calcium-8.1* Phos-2.6*
Mg-1.7
[**2110-5-13**] 12:01AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.9
Brief Hospital Course:
76-year-old female with stage II pancreatic adenocarcinoma, s/p
Whipple presented with melena in setting recent chemotherapy.
.
# Melena: The patient was initially admitted to the ICU for
observation. The patient underwent an EGD that revealed a 2.5-cm
ulcer at site of Whipple anastamosis, with no active bleeding,
concerning for pancreatic cancer recurrence. Biopsies were
taken. There was no other intervention performed. Patient
received a total of 4 units of PRBC and 1 bag plateletes during
her ICU stay. Patient was continued on IV protonix [**Hospital1 **] and was
started on caragate. Her capecitabine was held. Her HCT
stabalized, and she was transfered to the floor. On the floor,
she continued to have melena with slowly down-trending HCT. She
was transfused several times. Surgery, GI and Radiation-Oncology
were consulted, but all services recomended against
intervention. The GI team reported that due to the size and
shape of the ulcer and the lack of obvious vessels that
endoscopic cauterization would only damage more tissue. She
continued to have small amounts of melena which were thought to
be residual blood moving through the GI tract rather than new
bleeding. Her HCT was stable at 31-33 for 5 days prior to
discharge.
.
# Ecoli Bacteremia: The patient was found to have an Ecoli
bacteremia on [**2110-5-4**] senstive to Cipro and ceftriaxone. She was
started intially started on Flagyl and Cefepime prior to
speciation/sensitivities with the thought that she had a GI
source. She was also noted to to have an Ecoli UTI which could
also have been a source. She was then switched to Cipro for a 14
day course to end on [**2110-5-18**]. On day 9 of 14 day course, she was
found to have SBP and was switched from Cipro to Ceftriaxone.
She will finished Ceftriaxone on [**2110-5-18**]- which will be a
complete course of antibiotics for E.coli bacteremia/UTI and
SBP.
.
# Ascites: CT abdomen revealed a moderate amount of ascites that
was not new. On [**5-9**] the patient developed a rapidly enlarging
abdomen over one day. An U/S was performed showing ascites, no
portal vein thrombosis. A paracentesis was performed. WBC 1172,
segs 50% c/w SBP. The patient was switched from Cipro to
Ceftriaxone to complete a 5 day course. The patient never
developed fevers or chills.
.
# Pancreatic CA: The patient was followed by the inpatient
oncology service in conjunction with her outpatient team Dr [**Last Name (STitle) **]
and Dr. [**Last Name (STitle) **]. Chemotherapy including
capecitabine was held. She is to have no further chemotherapy
for the time being.
Medications on Admission:
Atenolol 50 mg Daily (never took)
Enalapril Maleate 10 mg Daily (never took)
Glyburide 2.5mg daily, sugars<200
Lorazepam 0.5 mg Tablet Sig: [**12-11**] Q4HR PRN
Cyanocobalamin 50 mcg Daily
Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet
Prochlorperazine Maleate 10 mg Q6H PRN
Loperamide 2 mg Capsule QID PRN
Xeloda [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 583**] House
Discharge Diagnosis:
Pancreatic Cancer
Ulcer at Whipple site with upper gastrointestinal bleeding
Ecoli Bacteremia
UTI
Ascites
Spontaneous Bacterial Peritonitis
Discharge Condition:
improved
Discharge Instructions:
You were admitted for melena and were found to have a bleeding
stomach ulcer. You were started on high dose antacids and
sucrulfate to help heal the ulcer. The bleeding eventually
stopped. You will need to have [**Hospital1 **]-weekly lab draws to monitor
your hematocrit and bleeding.
.
You were also found to have a urinary tract infection and blood
infection. You were treated with antibiotics.
.
You also had spontaneous bacterial peritonitis - an infection in
you abdomen related to the swelling (ascites). You were also on
antibiotics for this infection.
.
If you have any bleeding, worsening melena, dizziness, low blood
pressure, fevers or chills, you should go to the emergency room
[**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]
|
[
"276.2",
"157.9",
"534.40",
"250.00",
"041.4",
"401.9",
"782.3",
"197.6",
"266.2",
"599.0",
"287.5",
"790.7",
"567.89",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"99.05",
"92.29",
"99.04",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
15666, 15722
|
12689, 15272
|
301, 306
|
15906, 15917
|
4829, 12666
|
3937, 4049
|
15743, 15885
|
15298, 15643
|
15941, 16730
|
4064, 4810
|
231, 263
|
334, 1792
|
3226, 3618
|
3634, 3921
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,159
| 131,034
|
48076+48077
|
Discharge summary
|
report+report
|
Admission Date: [**2180-5-15**] Discharge Date: [**2180-6-8**]
Date of Birth: [**2117-1-6**] Sex: M
Service: BONE MARROW TRANSPLANT
male with a history of acute myelogenous leukemia diagnosed
in [**2180-1-8**] status post two cycles of Idarubicin and
ARA-C on [**2-22**] and [**3-21**], with consolidation
chemotherapy on [**2180-5-1**], who was admitted from the
vomiting, and neutropenia.
The patient has complained of feeling "terrible" since the
evening prior to admission. His only specific complaint was
low back pain radiating down both legs. He denied any cough,
shortness of breath, chest pain, abdominal pain, headache,
bright red blood per rectum, or melena.
The patient was given one dose of Ceftazidime in the clinic.
On transfer to the floor, he was noted to be increasingly
diffuse, confluent, erythematous papular rash over his
extremities, trunk, groin, and legs. He was noted to be
tachycardia to the 150s with a temperature of 102??????. The
patient complained of pruritus and was given Benadryl IV. He
continued to complain of low back pain, but did not have any
other complaints.
Given the patient's persistent hypotension despite
intravenous fluid, the MICU Team was called to evaluate him.
At this time, he was given a second dose of intravenous
Benadryl, Solu-Medrol 80 mg IV x 1, Vancomycin 1 g IV, and
was transferred to the MICU for further care.
PAST MEDICAL HISTORY: 1. Acute myelogenous leukemia
diagnosed in [**2180-1-8**], status post Idarubicin, and ARA-C
times two, with consolidation chemotherapy on [**2180-5-1**].
2. Hypertension. 3. Carotid stenosis. 4. History of
alcohol abuse. 5. Acoustic neuroma. 6. Benign prostatic
hypertrophy.
ALLERGIES: The patient on admission had no known drug
allergies but was found to be allergic to Ceftazidime.
MEDICATIONS ON ADMISSION: Zoloft 125 mg p.o. q.d., Norvasc,
Atenolol, Flomax, Lipitor.
SOCIAL HISTORY: The patient lives in [**Hospital3 4634**]. He
has been sober for the past six months. He has an 80
pack-year history of smoking. He is a retired electrician.
PHYSICAL EXAMINATION: Vital signs: Temperature 102??????, blood
pressure 70/40, pulse 130-150s, respirations 30, oxygen
saturation 94-99% on 5 L oxygen by nasal cannula. General:
He was awake, alert, and pale, but was noted to be
interacting appropriately. HEENT: Pupils equal, round and
reactive to light. Extraocular movements intact. Oropharynx
was dry. Neck: Supple. No lymphadenopathy or jugular
venous distention. Chest: He had wheezes bilaterally, right
greater than left. Cardiovascular: Sinus tachycardia with
no murmurs. Abdomen: Normoactive bowel sounds. Soft,
nontender, nondistended. No hepatosplenomegaly.
Extremities: Cool without cyanosis, clubbing, or edema. He
did not have any flank ecchymosis. Neurological: The
patient was interacting appropriately. He was seen to move
all four extremities. Ski: The patient was noted to have a
diffuse erythematous confluent papular rash over his
extremities, trunk, groin, and proximal legs.
LABORATORY DATA: The patient had a white blood cell count of
0.2, hematocrit 21.8, platelet count 15, 90% neutrophils, 0%
lymphs, 2% eosinophils; INR 1.2, PTT 27.5; fibrinogen 611;
sodium 133, potassium 3.9, chloride 98, CO2 18, BUN 25,
creatinine 1.4, glucose 270; AST 9, ALT 27, LDH 87, alkaline
phosphatase 103, total bilirubin 1.2, direct bilirubin 0.6,
magnesium 1.1, phosphate 2.7.
Electrocardiogram revealed sinus tachycardia at 150 beats per
minute. He had a normal axis and intervals without any overt
ischemic ST or T-wave changes.
On chest x-ray the patient was noted to have possible mild
congestive heart failure with small pleural effusions and
question of evolving pneumonia at the right lung base.
HOSPITAL COURSE: This is a 63-year-old male with a history
of acute myelogenous leukemia who is day 14 of consolidation
chemotherapy who presented with fever and neutropenia. The
patient developed a rash, tachycardia, and hypotension after
receiving one dose of Ceftazidime. Our initial suspicion was
that the hypotension was multifactorial, likely due secondary
to sepsis, as well as anaphylaxis to the Ceftazidime.
The patient was initially admitted to the MICU. Here, he was
started on an epinephrine drip. He was treated empirically
with Vancomycin and ................... and continued on
Solu-Medrol 80 mg q.8 for probable anaphylaxis.
The patient remained hemodynamically stable over night and
was called out to the Bone Marrow Transplant Unit on the
following day.
1. Anaphylaxis following Ceftazidime: Upon discharge from
the Medical Intensive Care Unit, the patient was noted to be
hemodynamically stable. At this time, he was switched to an
oral Prednisone at taper and was continued on Benadryl and
Zantac. An Allergy consult was obtained, and they concurred
that the anaphylaxis was most likely secondary to the
Ceftazidime. They recommended decreasing the patient's
steroids to Prednisone 60 mg q.d. and then discontinuing it
after 24 hours. They also instructed us to avoid to all
penicillins and cephalosporins, although Vancomycin and
.................... were thought to be appropriate.
2. Infectious disease: On hospital day #3, the patient had
2 out of 2 blood cultures grow gram positive cocci in pairs
and clusters. He was continued on his Vancomycin, as well as
.................. The organism was subsequently speciated
as MRSA. His urine culture subsequently grew coag-negative
staph as well. The patient subsequently was continued only
on Vancomycin, as well as Gentamicin times four days for
augmentation. The patient subsequently had a CT scan of his
chest which revealed multiple inflammatory foci within his
lungs, as well as bilateral small pleural effusions. These
results were discussed with both the pulmonary service, as
well as the Infectious Disease team. Their consensus was
that these nodules most likely represented infected foci with
MRSA. The initial plan was to continue to treat the patient
with Vancomycin and to subsequently reimage after a short
duration of antibiotic therapy.
The patient was subsequently noted to have diffuse erythema
and induration over his right deltoid. This was noted to be
distinct from the diffuse macular papular rash that he
presented with which was noted to be resolving.
The patient was seen by the Dermatology Service who obtained
a biopsy of his right deltoid for pathologic analysis and
culture. The patient subsequently had a CT of his right
shoulder which revealed .................. of his fat planes
with nearby inflammation and edema. The Dermatology Service
felt that these findings were most consistent with a drug
eruption, likely a residual response to the Ceftazidime.
Given his degree of MRSA bacteremia, the patient had a TTE to
rule out endocarditis. No vegetations were noted. The
patient subsequently had an MRI of his abdomen to rule out
hepatosplenic candidiasis after his liver function tests were
noted to be mildly elevated. This revealed a 5.2 x 4.5 cm
cystic lesion with rim enhancement over the right psoas.
This was felt to be consistent with abscess. The patient was
subsequently noted to have a tender, inflamed right calf.
The right deltoid edema and erythema that he had were noted
to be worse. These were all felt to likely represent
abscess. The patient subsequently underwent a CT-guided
placement of a pigtail catheter over the right psoas abscess.
He underwent ultrasound-guided aspiration of right shoulder,
as well as the left calf. Subsequent cultures from these
fluid collections grew MRSA. After the procedure, the
patient drained over 100 cc from the right psoas. His right
deltoid and left calf continued to be tender, indurated, and
erythematous.
We were concerned about probable reaccumulation. At this
point, we involved the General Surgery Service. The patient
underwent incision and drainage of the right deltoid and left
calf fluid collections. This procedure was done on [**6-1**]
by Dr. [**Last Name (STitle) **] from General Surgery. The patient tolerated
the procedure well. He did not have any reaccummulation in
either the deltoid or the calf. He subsequently had a repeat
CAT scan to evaluate for interval change in the pulmonary
nodules and psoas collection. The pulmonary nodules were
noted to be decreased in size but not number. This was still
felt to be consistent with a therapeutic response. Of note,
the psoas collection was noted to have resolved, and the
pigtail catheter was removed.
At the time of this dictation, the recommendation of the
Infectious Disease team is for a total of 12 weeks of
Vancomycin therapy. We will dose the Vancomycin only for
trough levels of under 20 given his acute on chronic renal
insufficiency.
3. Oncologic: The patient was initially noted to be
neutropenic. He was continued on Neupogen 480 mcg subcue
q.d. During his hospital course, his white blood cell count
returned to the normal range. Thus far, his platelets have
been somewhat slower to respond. They have remained in the
40,000 range. The patient underwent a repeat bone marrow
aspiration to evaluate for response after consolidation
chemotherapy. The bone marrow aspirate was consistent with
remission.
The patient will follow with his primary oncologist Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] for continuation of his chemotherapy.
4. Renal: After the patient's repeat chest and abdomen CT
scan, his creatinine increased to 2.0. This was felt to be
most consistent with contrast ATN. The patient had a FENa of
approximately 4% which was more consistent with an intrinsic
renal etiology. We hydrated the patient gently. We dosed
his Vancomycin only for trough levels of less than 20. We
anticipate that his creatinine will improve gradually.
DISPOSITION: The patient was seen by the Physical Therapy
Service who have recommended an acute inpatient
rehabilitation stay.
DISCHARGE DIAGNOSIS:
1. Anaphylactic reaction to Ceftazidime.
2. Methicillin resistant staphylococcus aureus sepsis with
multiple abscess foci status post drainage.
3. Acute myelogenous leukemia in remission.
4. Benign prostatic hypertrophy.
5. Hypertension.
6. Depression.
7. History of carotid insufficiency.
DISCHARGE MEDICATIONS: Pending at the time of this discharge
summary.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 11732**]
MEDQUIST36
D: [**2180-6-6**] 14:07
T: [**2180-6-6**] 14:13
JOB#: [**Job Number 101388**]
Admission Date: [**2180-5-15**] Discharge Date: [**2180-6-7**]
Date of Birth: [**2117-1-6**] Sex: M
DISCHARGE MEDICATIONS: The patient's discharge medications
are as follows:
1. Atenolol 25 milligrams po q day.
2. Zoloft 125 milligrams po q day.
4. Vancomycin 1 gram IV q day, dose only for a trough level
of less than 20. The patient will receive this through [**2180-8-14**].
5. Flomax 0.4 milligrams po q day.
6. Multi vitamin one po q day.
7. Reglan 10 milligrams po qid.
8. Oxycodone 5 to 10 milligrams po q four to six hours prn.
deltoid and left calf.
10. Protonix 40 milligrams po q day.
DISCHARGE CONDITION: Stable. Discharged to acute
rehabilitation facility.
DISCHARGE FOLLOW UP: The patient is to follow up with his
primary oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-438
Dictated By:[**Last Name (NamePattern1) 11732**]
MEDQUIST36
D: [**2180-6-7**] 09:55
T: [**2180-6-7**] 10:10
JOB#: [**Job Number **]
|
[
"790.7",
"E930.5",
"682.3",
"995.0",
"288.0",
"996.62",
"780.6",
"682.6",
"205.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"86.04",
"38.93",
"83.95",
"86.11",
"41.31"
] |
icd9pcs
|
[
[
[]
]
] |
11279, 11343
|
10777, 11258
|
10015, 10313
|
1849, 1911
|
3802, 9994
|
11354, 11713
|
2113, 3784
|
1424, 1822
|
1928, 2090
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,162
| 113,587
|
53672
|
Discharge summary
|
report
|
Admission Date: [**2190-4-5**] Discharge Date: [**2190-4-17**]
Date of Birth: [**2156-11-23**] Sex: M
Service: MEDICINE
Allergies:
morphine
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Infected ICD lead
Major Surgical or Invasive Procedure:
ICD removal and reimplantation
History of Present Illness:
This is a 33 yo male with PMHx of congenital heart defect s/p
ASD repair [**2159**], s/p MV repair [**2174**] and then mechanical MVR
(model number #[**2184-1-18**]),
complicated by complete heart block s/p pacemaker, developed
pacemaker-induced cardiomyopathy, upgraded to biventricular ICD
upgraded in [**2188**], who presents with an infected, eroded, exposed
lead to OSH this AM.
.
He initially noted a small pustule around the [**Year (4 digits) **] pocket 2
weeks ago. At that time, he had no fevers, chills, and denied
pain or drainage from the site. He visited his outpatient
cardiologist, Dr. [**First Name (STitle) **], 3 days prior to admission, and was
started on Keflex. He presented to OSH ED today after he noticed
that exposed leads after the pustule spontaneously drained. He
denied any recent fever (highest temp 99F on Friday), chills,
sweats, or pain or redness at site. Further denies trauma in the
area.
.
He was noted to be afebrile, HR 75 (paced), BP 129/81, satting
99% on RA. Prior to transfer, the patient was started on 1.25mg
vancomycin q12 and Ancef 1g q8. INR at the OSH was noted to be
3.0, with goal INR 2.5 to 3.5. Labs showed glucose of 136, BUN
of 13, creatinine of 0.69, sodium 139, potassium of 3.9,
chloride of 106, bicarb of 26, WBC of 10.4, hemoglobin of 14.3,
hematocrit of 41.5, platelets of 299,000. CXR showed no
subcutaneous air and pacerleads looked intact. He was
transferred to [**Hospital1 18**] on the same day for hardware removal and
reimplantation.
.
On arrival to the floor, patient was afebrile and comfortable,
VS were 98.2, 117/80, 86, 18, 100% RA. He denies chest pain and
shortness of breath.
.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia,
(-)Hypertension
2. CARDIAC HISTORY:
*Premium ASD repair [**2159**]
*MV repair [**2174**]
*H/o Afib
*MVR and Maze in [**1-/2184**] c/b CHB s/p PPM with pacemaker induced
CM s/p *BiV ICD upgrade (EP-Hx: [**2184-2-18**] PPM placement for CHB
post MVR; [**2184-10-29**] Upgrade to BiV ICD afer noted to have CM (EF
45--->17%); [**2188-4-8**], Generator change, RV PPM and Fidelis Lead
extraction)complicated by a hematoma
.
3. OTHER PAST MEDICAL HISTORY:
None
Social History:
Lives with parents. Works at Shaws. Independent of ADLs.
Family History:
Two sisters, both in good health. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory
Physical Exam:
VS- 98.3 101/66 83 20 93%
General- Well appearing, NAD.
Cardio- RRR, nl s1s2, +2/6 systolic murmur
Chest - Surgical dressings CDI, left arm in sling
Resp- CTAB anteriorly, no w/ra/rh, respirations unlabored.
Abd- S/NT/ND, NABS
Ext- No cce, DP 2+ b/l.
Pertinent Results:
[**2190-4-5**] 08:30PM WBC-9.9 RBC-4.90 HGB-14.8 HCT-43.8 MCV-90
MCH-30.2 MCHC-33.8 RDW-13.3
[**2190-4-5**] 08:30PM GLUCOSE-124* UREA N-11 CREAT-0.8 SODIUM-139
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-30 ANION GAP-10
[**2190-4-5**] 08:30PM CALCIUM-9.9 PHOSPHATE-3.4 MAGNESIUM-2.2
Chem
Admission: [**2190-4-5**] 08:30PM BLOOD Glucose-124* UreaN-11
Creat-0.8 Na-139 K-3.7 Cl-103 HCO3-30 AnGap-10 Calcium-9.9
Phos-3.4 Mg-2.2
.
Coag
[**2190-4-5**] 08:30PM BLOOD PT-22.1* INR(PT)-2.1*
[**2190-4-6**] 07:20AM BLOOD PT-18.2* INR(PT)-1.7*
[**2190-4-7**] 06:45AM BLOOD PT-14.1* PTT-150* INR(PT)-1.3*
.
LFTs:
[**2190-4-6**] 07:20AM BLOOD ALT-36 AST-39 AlkPhos-61 TotBili-0.5
.
Vanc:
[**2190-4-5**] 08:30PM BLOOD [**2190-4-5**] 08:30PM BLOOD Vanco-8.9*
[**2190-4-6**] 05:20PM BLOOD Vanco-5.9*
.
Digoxin
[**2190-4-6**] 07:20AM BLOOD Digoxin-0.6*
.
.
Imaging:
CXR ([**2190-4-5**])
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The lung volumes are normal. Moderate cardiomegaly,
status post
valvular replacement. Pacemaker in situ. No acute changes,
notably no
pulmonary edema, no pneumonia. No pleural effusions. The study
and the report were reviewed by the staff radiologist.
.
TTE ([**2190-4-6**]):
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is an inferobasal left ventricular aneurysm.
Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %) secondary to inferior and posterior
akinesis. The basal inferior and posterior walls are aneurysmal.
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 stenosis or aortic
regurgitation. A bileaflet mitral valve prosthesis is present.
At least moderate [2+] tricuspid regurgitation is seen. [Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion. No
valvular or wire-associated vegetation seen.
.
TEE ([**2190-4-8**]):
No mass/thrombus is seen in the left atrium or left atrial
appendage. No mass or thrombus is seen in the right atrium or
right atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is moderate regional
left ventricular systolic dysfunction with akinesis of the mid
anteroseptal wall. There is moderate global left ventricular
hypokinesis (LVEF = 30-35 %).
Right ventricular cavity size is normal with mild global free
wall hypokinesis. There are three aortic valve leaflets. There
is no aortic valve stenosis. Trace aortic regurgitation is seen.
A mechanical mitral valve prosthesis is present. The motion of
the mitral valve prosthetic leaflets appears normal.
Characteristic washing jets are seen. A mild paravalvular mitral
prosthesis leak is probably present.
Moderate to severe [3+] tricuspid regurgitation is seen. The
tricuspid regurgitation jet is eccentric and may be
underestimated. No masses or vegetations are seen on the
tricuspid valve. No masses or vegetations are seen on the
ICD/pacemaker leads in the right atrium and right ventricle.
There is no pericardial effusion.
.
[**2190-4-16**] CXR
Right ICD leads terminate in the right atrium and ventricle.
Again
seen is a tubular structure overlying the left hemithorax that
is presumably external to the patient. Median sternotomy wires,
and surgical clips are noted. The lungs are clear. There is mild
cardiomegaly.
Brief Hospital Course:
Patient is a 33yo M w/ PMHx of congenital heart defect, s/p ASD
repair at age 2, MVR, pacemaker induced cariomyopathy, s/p ICD
placement who presents with an infected, eroded, exposed [**Month/Day/Year **]
lead, s/p hardware removal and reimplantation.
.
ACTIVE PROBLEMS:
# [**Name2 (NI) 19721**] lead infection: Upon presentation, the patient was
afebrile with [**Name2 (NI) **] leads exposed in the left upper aspected of
the chest with no surrounding erythema, palpable fluctuance, or
purulence. The patient was started on IV cefepime and vancomycin
under the guidance of infectious disease consult service. Blood
cultures were drawn daily while the infected [**Name2 (NI) **] and generator
were in place. TTE did not show evidence of valvular vegetations
given the concern of wire-associated endocarditis. The patient
was taken to the operating room [**2190-4-7**] for [**Year (4 digits) **] lead
and generator extraction. Blood cultures remained negative.
Cultures of the pocket grew PROPIONIBACTERIUM ACNES. His [**Year (4 digits) **]
pocket was closed by plastic surgery on [**2190-4-13**] without
complication. He then underwent a pacemaker replacement on his
right anterior chest on [**2190-4-14**] with removal of the temporary
pacing device. He is to continue antibiotic thearpy for 10 days
following his new pacemaker placement, with linezolid and
moxifloxacin.
.
# [**Date Range 19721**]-induced cardiomyopathy: ICD exchanged in [**2188**]. Patient
with an EF of 35%. Followed by an outpatient cardiologist. His
outpatient medications of lisinopril, metoprolol, and digoxin
were initially held due to concern of hypotension. They were
restarted at lower doses, including lisinopril 5mg daily and
metoprolol tartrate 12.5mg [**Hospital1 **]. The patient's digoxin level was
therapeutic when checked during admission.
.
# Status post mechanical MVR: Model number #[**Serial Number **]. Patient's
goal INR 2.5-3.5. The patient was stopped on coumadin in the
setting of intiating antibiotics (anticipate elevated INR) and
started on a heparin drip. Coagulation studies were followed
through the admission, and the heparin drip was adjusted
accordingly. His INR was 2.2 on day of discharge and heparin was
stopped. He was discharged on 7.5mg warfarin daily.
.
TRANSITIONAL ISSUES
- He needs close monitoring of INR due to antibiotic use. He
will have his INR checked at Dr.[**Name (NI) 220**] office on Monday.
- He should followup with device clinic this week for
interrogation and to have stitches removed.
Medications on Admission:
Coumadin 5-7.5mg qday (INR goal 2.5-3.5)
Lisinopril 10mg [**Hospital1 **]
Digoxin 250mcg [**Hospital1 **]
Metoprolol succinate 100mg [**Hospital1 **]
No longer takes ASA
Discharge Medications:
1. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
2. digoxin 250 mcg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
6. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. [**Hospital1 19721**]-pocket infection
2. s/p ASD repair
3. s/p MVR
4. [**Hospital1 19721**] induced cardiomyopathy
5. sCHF
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 to care for you at [**Doctor First Name **]-[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. You
were transferred to us for a [**Last Name (NamePattern1) **]-pocket infection. You were
treated with antibiotics. You device was replaced. You will be
on the antibiotics for 10 days after implantation.
Please note these medication changes to your medication:
Linezolid 600mg twice daily for 8 more days for infection
Moxifloxicin 400mg daily for 8 more days for infection
Reduce lisinopril to 5mg daily (this can be further discussed
with Dr. [**First Name (STitle) **]
Reduce metoprolol succinate to 25mg daily (this can be further
discussed with Dr. [**First Name (STitle) **]
Followup Instructions:
Name: DREW,[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Location: [**State **]CARDIOLOGY CENTER
Address: [**Location (un) **], [**Apartment Address(1) 77647**], [**Hospital1 **],[**Numeric Identifier 91109**]
Phone: [**0-0-**]
Appointment: Thursday [**2190-4-22**] 10:20am
Department: CARDIAC SERVICES
Please call to make an appointment on Thursday or Friday.
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: NP [**Location (un) 3230**] [**Location (un) 110215**]
Address: 450 VETERANS [**Hospital1 **] PKWY [**Apartment Address(1) **], EAST [**Hospital1 **],[**Numeric Identifier 110216**]
Phone: [**Telephone/Fax (1) 110217**]
Appointment: Friday [**2190-4-23**] 1:00pm
Department: INFECTIOUS DISEASE
When: FRIDAY [**2190-4-30**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SPINE CENTER
When: FRIDAY [**2190-4-30**] at 2:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD [**Telephone/Fax (1) 39347**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"041.84",
"458.9",
"428.22",
"428.0",
"425.4",
"426.0",
"E878.1",
"427.1",
"V43.3",
"996.61",
"285.1",
"998.12",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.94",
"37.79",
"86.59",
"89.49",
"83.45",
"37.78",
"88.72",
"37.77"
] |
icd9pcs
|
[
[
[]
]
] |
10126, 10132
|
6739, 9257
|
286, 319
|
10302, 10302
|
3064, 6716
|
11226, 12784
|
2630, 2778
|
9477, 10103
|
10153, 10281
|
9283, 9454
|
10452, 11203
|
2793, 3045
|
2117, 2501
|
229, 248
|
347, 2004
|
10317, 10428
|
2532, 2539
|
2026, 2097
|
2555, 2614
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,496
| 179,138
|
14889
|
Discharge summary
|
report
|
Admission Date: [**2150-6-16**] Discharge Date: [**2150-6-22**]
Date of Birth: [**2092-1-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
58 F c hepatitis C cirrhosis, hepatocellular carcinoma, with
recent admission for esophageal variceal [**First Name3 (LF) **] s/p banding
who presents with hematemesis. She was recently admitted to
[**Hospital1 18**] in [**5-14**] for large volume hematemesis requiring intubation
and 4 units pRBC transfusion. EGD revealed 4 cords of grade 3
varices that were oozing and were [**Date Range 43652**] x 5. A repeat EGD
approximately 2 weeks ago revealed 4 non-[**Date Range **] grade 3
varices that were again [**Date Range 43652**] X 3. The day of admission patient
again had hematemesis x 2 with 300 cc each time. Complained of
weakness, lethargy, chronic abdominal pain. Presented to ED.
.
In the ED, T 98.4, BP 134/82, HR 62, RR 14, 100% RA. There was
no further episode of hematemesis. Hct was 28.9, similar to 28.8
on most recent admission. Twi large bore PIVs were placed and
the pt was given octreotide 50 mcg IV X 1 and started on a drip
at 25 mcg/hr, protonix 40 mg IV X 1, ceftriaxone 1 gm IV X 1,
and zofran 4 mg IV X 1. NGL lavage deferred. Liver fellow was
contact[**Name (NI) **] for emergent EGD. Transferred to MICU for further
management.
Past Medical History:
- Hepatocellular ca (3.8x3.0x3.0 cm lesion in dome of the liver)
- Hepatitis C - diagnosed in [**2141**], underwent tx c pegylated
interferon and ribavirin in [**2144**] with sustained virologic
response. Had a stable 1 cm hepatic dome nodule until [**3-/2150**]
when nodule noted to be 3.8 cm on MRI with associated probable
tumor thrombus of side branch L portal vein. AFP [**2142**]. Underwent
selective chemo-embolization from the R hepatic artery.
- Cirrhosis - liver bx showed mild portal
predominantly mononuclear cell infiltrate with minimal
periportal
extension (Grade 1). No steatosis or necrotic hepatocytes.
Moderate to focally marked portal fibrosis on trichrome stain,
with focal bridging and bile duct proliferation (Stage 2-3).
Complicated by portal HTN and extensive esophageal varices
Social History:
No tobacco, alcohol, or illicit drug use.
Family History:
N/C
Physical Exam:
VS - T 98.4, BP 103/60, HR 71, 94% 2L NC
GEN - elderly woman looking anxious, speaking Arabic,
interpreted by son
[**Name (NI) 43653**] anicteric sclerae
[**Name (NI) 43654**] CTA bilaterally
HEART- regular rate, [**3-12**] early systolic murmur best heard at
LUSB without radiation to carotids
ABDOM- soft, tender at LUQ and LLQ, no rebound tenderness, bowel
sounds present
EXTRE- no edema
NEURO- oriented x 3
Pertinent Results:
[**2150-6-17**]: CXR
IMPRESSION:
1. Volume overload.
2. No focal opacity worrisome for aspiration, hemorrhage or
infection.
3. Calcified opacity corresponds to hepatocellular carcinoma
treated with
chemoembolization.
[**2150-6-17**]: EGD
Erythema and atrophy in the lower third of the esophagus and
gastroesophageal junction
Varices at the lower third of the esophagus and middle third of
the esophagus (ligation)
Varices at the fundus
Normal mucosa in the duodenum
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
58 F c HCC, HCV cirrhosis p/w GIB.
The patient was intially admitted to the MICU. Emergent EGD in
the MICU revealed 4 cords of grade 3 varices, 3 gastric ulcers,
and gastric varices; banding x 5. HCT was 28.9 last night to
25.1 am of procedure, and 24 post procedure. She remained
hemodynamically stable and was transferred to the floor for
further management.
.
Upper GI Bleed: Patient had a bleed secondary to known
esophageal and gastric varices with history of portal
hypertension from cirrhosis and hepatocellular carcinoma.
Emergent EGD in the MICU [**2150-6-17**] revealed 4 cords of grade 3
varices, 3 gastric ulcers, and gastric varices; banding x 5. Sge
was treated with Octreotide gtt x72 hours, had 2 large bore
peripheral IVs maintained. She was intially on IV PPI [**Hospital1 **]
intially, and then transitioned to PO. She was continued on
carafate. She had post bleed Ceftriaxone 1gm IV daily x5 days
([**Date range (1) 32263**]). Nadolol 20mg daily was initially held for
hypotention, but restarted on floor. Patient intially had [**Hospital1 **]
Hcts which remained stable but slowly trended down. She was
transfused 1 unit PRBCs prior to discharge with plan to follow
up Hct 1 week after discharge. She likely has slow oozing from
varices and hypertensiv gastropathy. The patient is planned to
have a repeat EGD 2 weeks from last one, likely 1 week after
discharge.
.
HCV with HCC: Chronic, not candidate for transplant given
worsening of hepatocellular carcinoma. S/p recent
chemoemobolization. Also has portal vein thrombosis. MELD 11. on
transplant list.
- monitor coags
- further management of HCC to be deferred to outpatient
oncologist Dr. [**Last Name (STitle) **]
.
Dispo: patient has been DNR/DNI since last admission. There was
a question as to if the family wanted her to go home with
Hospice. A palliative care consult was called and there was a
family meeting with Dr. [**Last Name (STitle) 497**], Dr. [**First Name (STitle) **], social worker and a
translater with the family. The meaning of hospice was clarified
and at this time are NOT interested in hospice care. They do
agree with her being DNR/DNI, but do want intervention done if
she bleeds.
Medications on Admission:
Nadolol 20 mg daily
Omeprazole 20 mg [**Hospital1 **]
Carafate 1 gm tid
Compazine 10 mg q6h prn
Docusate 100 mg daily
Senna 1 tab [**Hospital1 **] prn
Oxycodone [**1-7**] tab q 4-6h prn
Caltrate 1 tab [**Hospital1 **]
Lorazepam 0.5 mg qhs prn
Lactulose 15 ml [**Hospital1 **] prn
Citalopram 10 mg daily
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Compazine 10 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for nausea.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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. Lactulose 10 gram/15 mL Solution Sig: One (1) PO twice a day
as needed for constipation.
Disp:*450 mL* Refills:*3*
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Citalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Simethicone 80 mg Tablet, Chewable Sig: [**1-7**] Tablet, Chewables
PO QID (4 times a day) as needed for GI upset.
10. Outpatient Lab Work
Hct check [**6-25**]. Please fax results to Dr. [**Last Name (STitle) **] at fax [**Telephone/Fax (1) 43655**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Upper GI bleed
Esophageal varicies
hep C cirrhosis
Hepatocellular carcinoma
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital after vomitting blood. You
were initially admitted to the ICU and had an EGD where they
[**Hospital 43652**] the [**Hospital **] vessels.
Your blood level was also trending down, so you recieved a blood
transfusion. You should have your blood level checked again on
[**2150-6-25**].
You should have a repeat EGD next week as an outpatient. The
Liver office will call you with the information regarding this
sometime this week. Please call them if you dont hear from them
by wednesday.
Please call your doctor or return to the hospital if you have
vomit blood or have blood in your stool, lightheadedness,
fainting, or have any other concerning symptoms
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2150-7-9**] 2:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2150-7-9**]
2:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2150-8-5**] 3:00
Completed by:[**2150-6-26**]
|
[
"285.1",
"456.8",
"571.5",
"155.0",
"531.90",
"070.54",
"572.3",
"456.20",
"452"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7018, 7076
|
3423, 5610
|
325, 337
|
7196, 7206
|
2880, 3400
|
7944, 8304
|
2428, 2433
|
5964, 6995
|
7097, 7175
|
5636, 5941
|
7230, 7921
|
2448, 2861
|
274, 287
|
365, 1523
|
1545, 2351
|
2367, 2412
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,363
| 125,496
|
44117
|
Discharge summary
|
report
|
Admission Date: [**2142-9-25**] Discharge Date: [**2142-11-2**]
Date of Birth: [**2091-11-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Odynophagia
Major Surgical or Invasive Procedure:
[**2142-9-26**]- Exploratory Laparotomy, Nonocclusive mesenteric
ischemia
with compromise segment of the mid small bowel.
[**2142-9-27**]- Exploratory Laparotomy, closure of abdominal fascia,
Nonocclusive mesenteric ischemia,no necrotic bowel found, portal
pylephlebitis.
[**2142-10-3**] Exploratory laparotomy, peritoneal toilet, reclosure of
the abdomen with drains.
[**2142-10-12**] Tracheostomy, Percutaneous endoscopic gastrostomy
History of Present Illness:
Pt [**Name (NI) 94690**] is a 50 yo F that presented to [**Hospital1 18**] ED in the late
evening f [**2142-9-25**] with complaint of dysphagia x 2days. Pt was
admitted to medical service and on [**2142-9-26**] general surgery was
consulted due to pt complaint of abdominal distention and emesis
x 2. A nasogastric tube was placed which decompressed 1500ml of
bilious fluid. A CT scan was obtained which was concerning for
ischemic bowel, the patient was promptly taken to the operating
room for exploratory laparotomy by the general surgery team
under the guidance of Dr. [**Last Name (STitle) **].
Past Medical History:
Hepatitis C
CAD
GERD
CRI
hypercholesteremia
Bipolar, Schizoeffective d/o
Social History:
lives in [**Location **] with son
h/o tobacco use 1ppd, unk number of years
Family History:
father: lung cancer
Physical Exam:
Alert and oriented
PERRLA, EOMI
Neck supple, no addenopathy, tracheostomy site c/d/i
RRR
nild b/l rhonchi
abd soft, distended, +BS, approp tender, wounds C/D/I with good
granulation
Mild UE/LE edema +1, +sensation, FROM, [**4-20**] MS
Pertinent Results:
[**2142-9-25**] WBC-8.3 Hgb-11.1* Hct-31.6* MCV-95 RDW-14.6 Plt Ct-175
[**2142-9-25**] Neuts-61 Bands-2 Lymphs-15* Monos-19* Eos-0 Baso-0
Atyps-0 Metas-1* Myelos-1* Promyel-1* NRBC-1*
[**2142-10-31**] WBC-14.7 Hgb-9.7 Hct-28.6* MCV-93 RDW-17.8 Plt Ct-327
[**2142-9-26**] PT-13.4* PTT-24.1 INR(PT)-1.2*
[**2142-10-13**] Ret Aut-2.7
[**2142-9-25**] Glucose-210* UreaN-67* Creat-2.1* Na-133 K-3.0* Cl-101
HCO3-15*
[**2142-9-27**] Glucose-180* UreaN-46* Creat-1.4* Na-142 K-3.9 Cl-111*
HCO3-22
[**2142-9-28**] Glucose-74 UreaN-44* Creat-1.9* Na-137 K-4.1 Cl-108
HCO3-20*
[**2142-9-29**] Glucose-100 UreaN-57* Creat-2.6* Na-137 K-3.7 Cl-107
HCO3-19*
[**2142-10-3**] Glucose-139* UreaN-60* Creat-2.2* Na-156* K-3.9 Cl-124*
HCO3-22
[**2142-10-4**] Glucose-180* UreaN-45* Creat-1.9* Na-160* K-3.8 Cl-129*
HCO3-23
[**2142-10-7**] Glucose-100 UreaN-37* Creat-1.6* Na-153* K-3.4 Cl-124*
HCO3-20*
[**2142-10-14**] Glucose-60* UreaN-51* Creat-1.1 Na-147* K-4.5 Cl-116*
HCO3-22
[**2142-10-18**] Glucose-95 UreaN-43* Creat-0.8 Na-142 K-4.1 Cl-105
HCO3-27
[**2142-10-31**] Glucose-160 UreaN-85 Creat-1.2* Na-143 K-4.8 Cl-108
HCO3-22
[**2142-9-25**] ALT-42* AST-67* CK(CPK)-176* AlkPhos-89 TotBili-0.6
[**2142-10-31**] ALT-59* AST-51*
[**2142-9-25**] Albumin-2.7->3.2
[**2142-9-26**] Calcium-6.8* Phos-3.8 Mg-2.2 Iron-29*
[**2142-9-26**] calTIBC-200* VitB12-1489* Folate-12.9 Ferritn-199*
TRF-154*
[**2142-10-4**] BLOOD Osmolal-340*
[**2142-10-9**] BLOOD Osmolal-312*
[**2142-10-20**] BLOOD Osmolal-327*
[**2142-10-22**] BLOOD Osmolal-322*
[**2142-10-4**] Lithium-LESS THAN
[**2142-9-25**] BLOOD ASA-4 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2142-9-27**] BLOOD Type-ART pO2-305* pCO2-43 pH-7.34* calTCO2-24
Base XS--2
[**2142-9-25**] URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006 Blood-SM
Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-1 pH-5.0 Leuks-NEG RBC-0-2 WBC-0-2 Bacteri-RARE
Yeast-NONE Epi-0-2
[**2142-10-3**] URINE Hours-RANDOM UreaN-255 Creat-21 Na-33
[**2142-10-5**] URINE Hours-RANDOM UreaN-240 Creat-21 Na-26
[**2142-10-10**] URINE Hours-RANDOM Na-21 K-6 Cl-21
[**2142-10-3**] URINE Osmolal-201
[**2142-10-7**] URINE Osmolal-146
[**2142-10-10**] URINE Osmolal-116
Upright KUB ([**10-1**]): Diffusely dilated small bowel with
moderately dilated and air-filled proximal colon and a question
of obstruction at the splenic
flexure.
Abd/pelvis CT ([**10-1**]): 1. Small bowel obstruction with ischemia
as indicated by diffuse jejunal and ileal small bowel dilatation
measuring up to 4.5 cm with distal jejunal/proximal ileal
pneumatosis, mesenteric and portal venous air and intraabdominal
ascites(Ascite may be realted to liver disease).
2. Probable foci of free air within a small pocket of ascites
within the
pelvis seen best on series 2, image 81. Clinical correlation is
recommended.
3. Transition point identified in the region of the terminal
ileum.
4. Lipomatous mass within the right atrium only partially
imaged, and better characterized on the cardiac MRI of [**2136**].
5. Heterogeneous liver with a low density focus within the left
lobe,
incompletely characterized on this non-contrast examination.
Similar focus within the spleen. These can be further evaluated
with a contrast-enhanced study after the acute issues are
resolved.
Portable abdomen ([**10-3**]): Dilated loops of large and small
bowel. These findings could represent ileus versus early
small-bowel obstruction. Clinical correlation and close
followup recommended. CT could be helpful for further
evaluation if clinically indicated.
Abd U/S ([**10-7**]): 1. Normal direction of flow seen within the
portal vein.
2. Heterogeneous appearing liver, with suggestion of portal
venous air, as seen on prior CT.
3. Small amount of perihepatic ascites.
CTA Abd/Pelvis ([**10-11**]): 1) Patent mesenteric and hepatic
vasculature. 2) Interval development of multiple rounded
non-enhancing areas in the pancreas consistent with pancreatitic
necrosis. 3) Ascites. Additional abdominal collections with
hematocrit effect consistent with hematomas. The largest is
located in the left lower quadrant and measures 11 x 5 cm. 4)
Development of mild left hydronephrosis and hydroureter.
Diminished contrast excretion from the kidneys suggestive of
renal dysfunction. Bulky calcifications at ostium of left renal
artery could represent renal artery stenosis. 5)
Re-demonstration of right interatrial lipoma.
Abd U/S ([**10-25**]): 1. No biliary ductal dilatation, as clinically
questioned.
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. No focal hepatic lesions.
Brief Hospital Course:
Pt [**Name (NI) 94690**] is a 50 yo F who presented to [**Hospital1 18**] ED in the late
evening of [**2142-9-25**] with complaint of dysphagia x 2days. Pt was
admitted to medical service and on [**2142-9-26**] general surgery was
consulted due to pt complaint of abdominal distention and emesis
x 2. A nasogastric tube was placed which decompressed 1500ml of
bilious fluid. A CT scan was obtained which was concerning for
ischemic bowel, the patient was promptly taken to the operating
room for exploratory laparotomy by the general surgery team
under the guidance of Dr. [**Last Name (STitle) **].
[**2142-9-26**] pt underwent exploratory laparotomy which revieled
Nonocclusive mesenteric ischemia with compromise segment of the
mid small bowel. Using sterile dopplers and then fluorescence.
The perfusion was noted to be quite generous And there was
sufficient perfusion all the way to the antimesenteric border.
The fascia was left open, but the skin closed for planned return
to the OR within 24 hours.
On [**2142-9-27**] pt [**Name (NI) 94690**] again returned to OR for exploratory
laparotomy, the diagnosis was again Nonocclusive mesenteric
ischemia, no necrotic bowel was found. The abdomen was now
suctioned free of any fluid and the viscera were returned to
their anatomic locations. The abdominal wall the subcutaneous
tissues were irrigated with copious normal saline and the skin
was closed with surgical staples. The patient was returned to
the SICU and monitored. Over the next subsequent days the
patient was extubated. Enteral feedings were started using a
nasogastric tube. Electrolytes were monitored and it was noted
that the patients sodium and calcium were increasing and the
patient had a significant increase in urine output. Urine and
plasma sodium and osm were evaluated. After DDAVP test failed to
increase urine osm the diagnosis of nephrogenic diabetes
insipidus was formed. Nephrology was consulted and determined
that teh patients prolonged use of Lithium for BPD prior to
admission may have initailly damaged the renal tubules. The
additional onset of non obstructive mesenteric ischemia in
combination of surgery likely caused a degree of ATN which
ultimately led to her DI. The patient was started on D5W at
300ml/hr and urine and plasma osms measured routinely. The
nephroglogy team was concerned that the patients renal function
would not return to baseline.
Due to the patients increase in abdominal distention and
increasing WBC count and fever the decision was made to take Ms.
[**Known lastname 94690**] for Exploratory laparotomy on [**10-3**] with suspicion for
ascitic leak. During teh exploration teh patient underwent
peritoneal toilet and reclosure of the abdomen with drains. No
active leak was visualized, and teh abdomen was closed.
Once again the patient was returned to the SICU and
monitored. The patient was continued on D5W ranging between 200
and 300ml/hr. The patient was repeatedly attemped to be
extubated but failed from respiratory failure likely due to
metabolic acidosis from diabetes insipidus. On [**10-12**] the patient
underwent open tracheostomy and percutaneous endoscopic
gastrostomy. Teh patient returned to [**Location 4171**] SICU and was again
closely monitored. Free water fluid boluses were initiated via
the PEG Tube and IV D5W was decreased. Pt tolerated tube feeds
at goal as well as free water boluses. Pt was eventaully weened
to Trach Mask and was doing well working with physical therapy
taking steps daily.
Floor course:
This is an unfortunate 50 year old woman with bipolar d/o, HCV,
CAD, who presented with odynophagia, developed abdominal
distention and N/V, and is now s/p ex lap x3 for mesenteric
ischemia as well as trach and PEG placement. Course complicated
by nephrogenic diabetes insipidus.
## Diabetes insipidus: Likely secondary to lithium treatment as
she failed ddAVP trial. Initially managed with D5W IV. Now
tolerating free water boluses via PEG tube and HCTZ 25 mg [**Hospital1 **]
and amiloride 5 mg qd. Her urine output will need to be
monitored as her nephrogenic DI resolves over time, and her free
water boluses will have to be managed accordingly.
## Acute renal failure: Patients Creatinine bumped to 1.4 on the
floor from a nadir of 0.9. This was felt to be [**1-18**] intravascular
volume depletion and resoved with mild fluid resuscitation. Her
BUN and Cr will have to be followeed in order to ensure she is
receiving adequate hydration.
## DM2: Patient required insulin drip when on large volumes of
D5W. Now on long-acting insulin with aggressive sliding scale.
Sugars reasonably well-controlled. Likely DM2 induced by chronic
pancreatitis. She should be continued on insulin glargine 28 mg
qhs and her aggressive sliding scale with close monitoring of
her insulin requirements, as she is likely to need less insulin
as her inflammatory state improves.
## Respiratory failure: Had trach for short time (~14 days).
Pulled on day prior to discharge. Satting fine on room air
without trach.
## Fever/leukocytosis: Spiked fevers in unit. Treated with vanco
for MRSE wound infxn and fluconazole for yeast growing in urine
and sputum. Not on any antibiotics on the floor. Her WBC count
was increased, but her U/A was clean and she was not febrile.
This is likely stress-induced leukocytosis.
## Mesenteric ischemia: No abdominal pain on the floor.
Recovering well post-op. No evidence of ischemia currently, pt
asymptomatic. She should have her dressing changed twice daily.
## Acute on chronic pancreatitis: Surgery commented that
pancreas felt as though it was nodular and burnt out. Her
amylase and lipase were followed, but she had noi clinical
evidence of pancreatitis or pancreatic insufficiency (other than
the aforementioned diabetes mellitus)
## Elevated LFTs: RUQ u/s unremarkable other than fatty liver.
Likely related to her chronic Hepatitis C infection.
## Odynophagia: was presnting complaint, but not currently a
problem for her.
## CAD: s/p failed PCI of RCA. No CP, no evidence of active
ischemia currently. She was continued on her beta-blocker,
aspirin after surgery and simvastatin.
## HCV: Likely the cause of increased LFTs
## Bipolar and schizoaffective d/o: Transitioned to her home
dose of risperidone. Still holding seroquel and lamictal.
## FEN/Lytes: Tolerating tube feeds
Medications on Admission:
risperdal 2mg po qhs
seroquel 200mg po qhs
clonazepam 0.25po qday prn anxiety
lamictal 100mg po bid
(confirmed with Dr. [**Last Name (STitle) 724**] of Mass Mental Health)
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
2. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
4. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
5. Senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
6. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
7. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
9. Amiloride 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
10. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
11. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Risperidone 0.5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: Four (4)
Tablet, Rapid Dissolve PO HS (at bedtime).
14. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
15. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Lorazepam 2 mg/mL Syringe [**Last Name (STitle) **]: One (1) Injection Q4H (every
4 hours) as needed for agitation.
17. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Twenty Eight (28)
Units Subcutaneous at bedtime.
18. Insulin Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Non-occlusive mesenteric ischemia s/p resection
Nephrogenic diabetes insipidus
Respiratory failure s/p trach and subsequent trach removal
S/p G-tube placement
Secondary:
Coronary artery disease
Chronic kidney disease
Hypercholesterolemia
Bipolar d/o
Schizophrenia
Chronic Hepatitis C infection
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
Please keep all of your follow-up appointments.
Please take all of your medications as prescribed.
Please return to the hospital if you experience fevers,
abdominal pain, chest pain or shortness of breath.
Please monitor potassium, sodium, BUN and creatinine every other
day.
Followup Instructions:
Provider: [**Name10 (NameIs) 2194**],[**Name11 (NameIs) 900**] [**Name Initial (NameIs) **]. TRAUMA LMOB (SB) Date/Time:[**2142-11-13**]
1:00
Provider: [**Name10 (NameIs) **] FERN, RNC Date/Time:[**2142-11-15**] 9:40
|
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"572.1",
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"998.59",
"272.0",
"305.1",
"557.1",
"250.00",
"789.5",
"787.2",
"585.9",
"V58.67",
"572.3",
"276.2",
"414.01",
"584.5",
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icd9cm
|
[
[
[]
]
] |
[
"54.11",
"38.93",
"54.23",
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"97.37",
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"96.6",
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icd9pcs
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[
[
[]
]
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15217, 15283
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6682, 13030
|
327, 764
|
15631, 15666
|
1890, 6659
|
15993, 16213
|
1599, 1620
|
13252, 15194
|
15304, 15610
|
13056, 13229
|
15690, 15970
|
1635, 1871
|
276, 289
|
792, 1393
|
1415, 1489
|
1505, 1583
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,910
| 147,257
|
54736
|
Discharge summary
|
report
|
Admission Date: [**2197-11-26**] Discharge Date: [**2198-1-10**]
Date of Birth: [**2129-5-28**] Sex: M
Service: MEDICINE
Allergies:
Ultram / IV Dye, Iodine Containing Contrast Media / Dilaudid /
Zosyn / morphine / morphine
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Back pain with infection of surgical site
Major Surgical or Invasive Procedure:
-[**11-26**] Incision and drainage, Debridement and Fusion exploration
of laminectomy wound
-[**2197-12-3**]
1. Incision and drainage of back wound.
2. Debridement.
3. Fusion exploration.
-[**12-15**] IR-guided drainage of paraspinal hematoma
-[**12-19**] debridement of sacral ulcer
-[**12-26**] bedside debridement of sacral ulcer
-[**1-1**] removal of infected laminectomy instrumentation and soft
tissue debridement, as well as sacral ulcer debridement
History of Present Illness:
68yo male with PMH significant for polio with residual RLE
paralysis and atrophy, DMII, HTN, [**Month/Year (2) 9215**], CAD with angina, and
recent T9-S1 laminectomy on [**10-18**] (with Dr. [**Last Name (STitle) 363**] for severe
spinal stenosis. Post laminectomy, patient had hypoxemia and was
treated with nebs, antibiotics and with diuresis. He was
discharged to rehab without O2 requirement and on home dose of
PO Lasix 40.
Later seen at clinic and noted to have some serosanginous
drainage, but no erythema or sign of infection. He was given IV
ceftaz [**Hospital1 **]. He returned to [**Location **] on [**11-26**] septic - with fevers,
white count of 27, neck pain, and pus from operative site.
Intubated for MRI and airway protection. MRI showed no definite
focal collection in the soft tissues or epidural space, although
it was a poor study. Nonetheless, emergent I&D was performed
with 6 L washout of infected lumbar wound, wound cultures sent
which later grew out MRSA, no CSF taken as dura was intact, and
two lumbar drains placed and hemovac applied. BCx also drawn
which later grew out MRSA.
After I+D, he was admitted to TSICU. Briefly on a pressor (neo)
and had initial 4L O2 requirement after extubation. Antibiotics
switched to vanc/zosyn (starting on [**11-26**] and [**11-27**]
respectively) with improvement in WBC (27->20->12->normal on
transfer to floor today). Afebrile and subsequently narrowed
down to vancomycin per ID given culture of GPC in pairs and
clusters (likely MRSA) for a planned total course of antibiotics
of 8 weeks (from day 1 [**2197-11-26**]). PICC Line was placed on
[**2197-11-29**].
[**2197-11-28**], patient developed increased difficulty breathing
attributed to fluid overload. He was diuresed with two doses of
IV lasix 20mg and then switched to 40mg PO lasix [**Hospital1 **] for [**11-30**].
On this ICU stay he was net positive 700ccs. On transfer he is
saturating 97% on 3L NC.
On [**11-29**] prior to initial effort to transfer to [**Doctor Last Name **] A, had a
30 beat run of V-tach in context of K+ of 3.2. Asx. EKG at the
time showed JP elevations in V1-V3 with poor R wave progression.
Otherwise patient was in normal sinus rhythm with PACs.
Potassium was repleted. First troponin was negative.
Initially on Fentayl PCA for control of back pain and neck
stiffness. Has been weaned down to oxycodone/tylenol/neurontin
over ICU stay with good tolerance on transfer.
Past Medical History:
- Diastolic Heart Failure with preserved EF - recently started
on Lasix by his PCP. [**Name Initial (NameIs) **] [**10-16**] with LVH and preserved EF.
- Hypertension c/b LVH
- CAD c/b angina, unknown history of MI, caths
- Type 2 DM
- BPH
- Polio
- H/O measels, mumps, whooping cough
- Hemorrhoids
- Cervical laminectomy and fusion
- Ulnar nerve decompression
Social History:
He's from [**Hospital1 189**]. He has residual weakness on the right side
from Polio and has been unable to ambulate on the left secondary
to pain and spinal disease for which he was operated on this
admission. He is a 1ppd smoker since age 12. He drinks 6-8
drinks per week. He denies any IVDU. He drinks socially, denies
any drug use.
Family History:
Heart disease, diabetes, and arthritis.
Physical Exam:
ADMISSION PE (per ortho note)
99.1F 136 107/87 22 99%
UE C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R intact intact intact intact intact
L intact intac intact intact intact
T2-L1 (Trunk) intact
LE L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
L intact intac intact intact intact intact
Motor:
UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8) FinAbd(T1)
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
LE Flex(L1) Add(L2) Quad(L3) TA(L4) [**Last Name (un) 938**](L5) Per(S1) GS(S1-2/T)
L 5 5 5 5 5 5 5
unable to assess tenderness to palpation due to total global
pain
upon any manipulation, pt appeared to have meningismus with
nuchal rigidity
perianal sensation intact, decreased but present rectal tone
No clonus
Prior surgical site inflamed, with pus present from mid lumbar
surgical wound
PHYSICAL EXAM UPON TRANSFER TO FLOOR FROM ICU
VS - 142/56 83 12 97 on 3L
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - Anterior auscultation: good air movement, soft left
sided wheezing, bibasilar crackles, resp unlabored, no accessory
muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - Atrophic LE, +1 pitting edema on feet, +
pneumoboots
LYMPH - no cervical, axillary, or inguinal LAD
DISCHARGE PE
VS - 99.3 124-168/59-66 58-75 18 93-94%RA
GENERAL - paraplegic middle aged male, NAD
CV - RRR, [**3-13**] apical systolic murmur
LUNGS - Breathing is comfortable, CTAB, No accessory muscles of
respiration used.
ABDOMEN - obese, distended, soft, +bowel sounds, non-tender
GU - foley with yellow output, scrotum quite swollen
EXTREMITIES - 2+ pitting LE Edema b/l to knees
SKIN: Large sacral ulcer (stage 4) with surrounding erythematous
macules but no induration or cellulitic areas. granulation
tissue present.
Pertinent Results:
ADMISSION LABS
[**2197-11-26**] 06:20PM BLOOD WBC-27.2*# RBC-4.36* Hgb-10.7* Hct-34.3*
MCV-79* MCH-24.6* MCHC-31.2 RDW-15.7* Plt Ct-721*
[**2197-11-26**] 06:20PM BLOOD PT-14.4* PTT-28.7 INR(PT)-1.3*
[**2197-11-26**] 06:20PM BLOOD Glucose-196* UreaN-15 Creat-0.7 Na-132*
K-4.8 Cl-92* HCO3-26 AnGap-19
[**2197-12-2**] 05:37AM BLOOD ALT-12 AST-18 AlkPhos-126 TotBili-0.2
[**2197-11-27**] 02:04AM BLOOD Calcium-7.5* Phos-4.2 Mg-1.6
[**2197-11-26**] 06:29PM BLOOD Lactate-2.7*
INFLAMMATORY MARKERS
[**2197-12-5**] 09:33AM BLOOD ESR-139*
[**2197-11-28**] 06:19AM BLOOD CRP-GREATER THAN 300
[**2197-11-28**] 04:22PM BLOOD CRP-GREATER THAN 300
[**2197-12-5**] 05:47AM BLOOD CRP-167.6*
MICRO DATA
[**2198-1-7**] 5:20 am URINE Source: Catheter.
URINE CULTURE (Preliminary):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
[**2197-12-26**] 8:02 pm URINE Source: Catheter.
**FINAL REPORT [**2197-12-29**]**
URINE CULTURE (Final [**2197-12-29**]):
ENTEROCOCCUS FAECIUM. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 256 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
[**2197-11-26**] 6:20 pm BLOOD CULTURE
**FINAL REPORT [**2197-11-30**]**
Blood Culture, Routine (Final [**2197-11-29**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
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.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
LINEZOLID CIPROFLOXACIN AND TETRACYCLINE REQUESTED PER
DR
[**Last Name (NamePattern4) 111915**] [**2197-11-30**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CIPROFLOXACIN--------- =>8 R
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final [**2197-11-27**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**Last Name (un) **] [**Doctor Last Name 12729**] [**2197-11-27**]
12:15PM.
Anaerobic Bottle Gram Stain (Final [**2197-11-27**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**2197-11-26**] 3:35 pm SWAB Source: Spine.
**FINAL REPORT [**2197-11-30**]**
GRAM STAIN (Final [**2197-11-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Final [**2197-11-30**]):
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE
GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
LINEZOLID REQUESTED BY DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23870**] [**2197-11-30**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2197-11-30**]): NO ANAEROBES ISOLATED.
[**2197-11-26**] 7:00 pm BLOOD CULTURE
**FINAL REPORT [**2197-11-29**]**
Blood Culture, Routine (Final [**2197-11-29**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 111916**] FROM
[**2197-11-26**].
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
Anaerobic Bottle Gram Stain (Final [**2197-11-27**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**Last Name (un) **] [**Doctor Last Name 12729**] [**2197-11-27**] 2:35PM.
Aerobic Bottle Gram Stain (Final [**2197-11-27**]):
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
[**2197-11-26**] 9:40 pm SWAB LUMBAR WOUND.
GRAM STAIN (Final [**2197-11-27**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
WOUND CULTURE (Final [**2197-11-29**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 356-7394M
[**2197-11-26**].
ANAEROBIC CULTURE (Final [**2197-12-1**]): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final [**2197-11-27**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
POTASSIUM HYDROXIDE PREPARATION (Final [**2197-11-27**]):
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(KOH).
BLOOD CULTURES 10/21 - [**12-6**]: NGTD
STOOL [**2197-12-6**] 3:51 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2197-12-8**]**
C. difficile DNA amplification assay (Final [**2197-12-7**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final [**2197-12-8**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2197-12-8**]): NO CAMPYLOBACTER
FOUND.
[**2197-12-6**] 6:30 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2197-12-6**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. HEAVY GROWTH.
[**2197-12-6**] 5:23 pm URINE Source: Catheter.
**FINAL REPORT [**2197-12-7**]**
URINE CULTURE (Final [**2197-12-7**]):
PROBABLE ENTEROCOCCUS. ~[**2185**]/ML.
GRAM POSITIVE BACTERIA. ~[**2185**]/ML.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
[**2197-12-7**] 9:47 am URINE Source: Catheter.
**FINAL REPORT [**2197-12-7**]**
Legionella Urinary Antigen (Final [**2197-12-7**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
IMAGING
T-SPINE XRAY [**11-22**] These two exams consist of AP and lateral
probable standing views of the thoracic and lumbar spine. There
is partially visualized anterior and posterior fusion of the mid
and lower cervical spine. There is posterior fusion extending
from T9-S1 with corresponding pedicle screws at all levels and
two vertical posterior metallic rods. There is disc narrowing
and associated osteophytes at most of the fused levels as well
as at T7-T8 and T8-9. Slight angular kyphosis centered at T8-9.
The visualized medial lung is clear with slightly tortuous
aorta. The hips and SI joints are WNL. There is a moderate
amount of stool in the right and transverse colon. There is
morselized bone graft around the posterior fusion. Overall
appearance is little changed from [**2197-10-31**].
PATHOLOGY
LUMBAR WOUND [**11-26**]: Acute osteomyelitis.
MRI TOTAL SPINE [**11-26**]:
1. Limited examinations due to artifact from hardware and lack
of contrast.
2. Extensive post-operative changes in the posterior soft
tissues with foci of signal hypointensity which may reflect air.
However, no definite focal collection in the soft tissues or
epidural space is identified on this limited exam.
3. Bibasilar lung consolidation, left greater than right.
[**Month/Year (2) **] [**11-28**]
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. No valvular pathology or pathologic flow identified.
CT ABD/PELV [**12-4**]
1. No acute intra-abdominal process. No evidence of
obstruction.
2. Foley catheter balloon is inflated within the prostate.
3. Nonobstructing 2 mm right renal calculus.
4. Postoperative changes from T9 through S1 laminectomies.
U/S RUE [**12-6**]
1. Partial nonocclusive thrombus involving the right brachial
vein containing the PICC. No evidence of DVT within the
remaining veins.
CXR [**2197-12-7**] (after L PICC placement)
A left-sided PICC line terminates in the right atrium. The
cardiac silhouette is enlarged. The mediastinal silhouette and
hilar contours are normal. There is a moderate left and small
right pleural effusion. Left lower lobe atelectasis is noted,
unchanged.
There are mild interstitial opacities consistent with edema.
Note is made of anterior and posterior cervical fusion devices,
unchanged. Thoracic fusion devices are also partially imaged.
KUB (there are a series of these that are unchanged: latest on
[**12-8**])
Multiple air-filled dilated loops of large and small bowel
compatible with ileus. The appearance has not changed
significantly from yesterday's examination.
Renal ultrasound [**12-13**]: 1. Small nonobstructing left renal
stone.
2. No evidence of hydronephrosis.
3. No renal vein thrombosis visualized on limited Doppler
evaluation.
CT of thoracic and lumbar spine [**2197-12-14**]: 1. Large fluid
collection with surrounding calcification extending from the
surgical site to the level of L5, noted to have increased in
size since prior examination.
2. Increased bone destruction with associated lucencies which
are likely
representative of an infectious process.
3. Breached screw through the intervertebral disc at the level
of T9.
4. Multilevel degenerative changes.
MRI of thoracic and lumbar spine [**2197-12-15**]:
1. Significantly limited study
2. Large posterior paraspinal fluid collections, significantly
increased in size from the prior MRI two weeks ago, but similar
to the CT one day ago. Within the limits of a non-contrast
study, irregular rim around the large collection is in keeping
with superimposed infection, and cannot exclude a developing
abscess.
3. Segmental cord deformity at T7-8 with anterior displacement
of the cord secondary to a posterior epidural collection,
uncertain if it was already present in the prior MRI study.
4. Please refer to the recent CT study for assessment of the
fusion hardware and interval bony destruction.
5. Bilateral pleural effusions, left greater than right.
RUE LENI [**2198-1-2**]: IMPRESSION: Resolution of right upper
extremity DVT
LUE ultrasound [**2198-1-8**]: No evidence of deep vein thrombosis of
the bilateral lower extremities.
MUDDY BROWN CASTS SEEN ON URINE MICRO
Discharge labs:
[**2198-1-10**] 05:30AM BLOOD WBC-8.8 RBC-3.05* Hgb-7.8* Hct-24.8*
MCV-81* MCH-25.7* MCHC-31.7 RDW-17.8* Plt Ct-381
[**2198-1-10**] 05:30AM BLOOD Glucose-85 UreaN-21* Creat-0.9 Na-138
K-3.7 Cl-104 HCO3-24 AnGap-14
[**2198-1-10**] 05:30AM BLOOD Calcium-7.7* Phos-3.8 Mg-1.7
Brief Hospital Course:
BRIEF HOSPITAL COURSE
68yo male with PMH significant for polio with residual RLE
paralysis and atrophy, DMII, HTN, [**Month/Day/Year 9215**], angina, and recent T9-S1
laminectomy on [**10-18**] with complicated hospital course. He
presented [**11-26**] with sepsis and neck pain and was found to have
MRSA wound infection at laminectomy site and MRSA bacteremia
requiring ICU admission and pressors. Started on vancomycin.
Course complicated by decompensated [**Month/Year (2) 9215**], 30 beat run of V-tach
in context of K+ of 3.2, anemia requiring transfusion of PRBCs,
staph aureus pneumonia, bowel pseudoobstruction/ileus, PICC
associated DVT, ATN. Also s/p drainage of paraspinal
MRSA-infected hematoma [**12-15**] and debridement of sacral ulcer
first in OR on [**12-19**] and then at bedside on [**12-26**]. On [**1-1**]
instrumentation removed in the OR and thorough soft tissue
debridement performed. Debridement of sacral ulcer performed
again at that time.
ACTIVE ISSUES:
# Wound infection and MRSA bacteremia:
Patient has a spinal hardware infection s/p T9-S1 laminectomies.
Washout of wound was performed on [**11-26**], dura was intact and
wound cultures grew staph aureus sensitive to vanc and
corynebacterium. Blood cultures were positive for MRSA. There
was no sign of epidural abscess on MRI. He currently has PICC
and initially thought to need 8 week course of vancomycin
starting from [**2197-11-26**]. On [**12-15**] noted on imaging to have
paraspinal fluid collection so this was drained by IR with
finding of infected hematoma with MRSA. JP drain was left in.
Decision was made with orthopedics to remove infected hardware
and to definitively drain paraspinal abscess in OR on [**1-1**].
Will need 6 week course of vancomycin with start date of [**1-1**]
(to finish [**2198-2-12**]). Will be followed by spine and ID.
# Intermittent fevers:
The patient began spiking intermittent fevers up to 101.2 on
[**12-4**] and his antibiotic regimen was broadened by adding
cefepime and flagyl to his vancomycin. The patient's sputum
culture grew out coag + staph aureus, and he was treated for
presumed MRSA pneumonia. A urine culture came back positive for
[**Month/Year (2) **] with 10k - 100k organisms / ml; however upon changing the
foley the enterococcus bacterial count decreased to [**2185**]
organisms/ml without treatment indicating bacterial colonization
with [**Year (4 digits) **] and not true UTI. Azithromycin was added to the
patient's regimen per ID recs for possible COPD exacebration.
Last day of azithromycin was [**12-10**]. Last day of Cefepime was to
be [**12-11**]. However, given new O2 requirement on [**12-20**] was started
on another course of Cefepime ending on [**12-27**].
# Hypoxia:
Patient had 3 liter O2 requirement with O2 sats in the mid to
high 90s. His hypoxia was likely multifactorial and due to
pulmonary edema from [**Month/Year (2) 9215**] and volume overload, presumed MRSA
pneumonia, atelectasis, and COPD exacerbation. Repeated CXRs
shows bilateral pleural effusions, worse on the left, left lower
lobe atelectasis and pulmonary edema. His sputum culture grew
coag + staph aureus, presumed MRSA pneumonia is adequately
covered by vancomycin. The patient is volume overloaded on exam
and has [**Last Name (LF) 9215**], [**First Name3 (LF) **] he was diuresed with good effect on respiratory
status, although diuresis was limited by kidney function.
Incentive spirometry encouraged. The patient does not have a
previous diagnosis of COPD, but he has an extensive smoking
history and his exam is concerning for underlying COPD. He was
started on continuous albuterol and ipratropium nebulizers on
[**12-6**], and a five day course of azithromycin starting on [**12-6**],
which improved his breathing. Underwent thoracentesis on [**12-18**]
on the left side. Concurrently began aggressive course of
diuresis starting [**12-18**] with up to 160mg IV lasix daily. Hypoxia
improved and creatinine trended down. He is currently on room
air and not requiring IV lasix. We placed him on standing lasix
20mg PO qd for peripheral edema. Would recommend daily weights.
# Pseudobstruction:
Abdominal pain, distention, constipation and intermittent nausea
developed after TSICU call-out. On exam his abdomen was tense,
distended and tympanic throughout with hyperactive bowel sounds.
The patient had only mild rectal tone and was unable to feel
when he passes gas or stool. Serial KUBs showed distended loops
of colon. GI was consulted and was concerned about ileus vs
pseudobstruction. A rectal tube was placed but did not relieve
the pressure, or lead to increased passage of stool, and no
change was seen on KUB. GI recommended electrolyte repletion and
serial rectal exams with stimulation to produce BMs. This was
continued until resolution of abdominal distension and return of
spontaneous stooling. Diet was titrated up to regulars as
tolerated. The patient still intermittently complains of
abdominal cramping and fullness, and requires multiple bowel
medications.
# Anemia:
Patient with gradual hemoglobin drop requiring transfusion of 7
units of PRBCs through course of hospitalization ([**12-5**], [**12-6**],
[**12-9**], [**12-20**], [**12-31**] x2, [**1-4**]). There were no signs of hemolysis
and no active source of bleeding was found on examination,
serial guaics, or CT abdomen / pelvis. Hct has been stably low
for over a week now.
# [**Month/Year (2) 9215**] and hypervolemia:
Hx of diagnosed [**Month/Year (2) 9215**], with volume overload leading to pleural
effusions and pulmonary edema on this admission. IV lasix used
to remove fluid as tolerated by his kidneys. Due to hypoxia from
pleural effusions on [**12-18**] began aggressive course of diuresis
starting [**12-18**] with up to 160mg IV lasix daily. Hypoxia improved
and creatinine trended down. He is currently on room air and
not requiring IV lasix. We placed him on standing lasix 20mg PO
qd for peripheral edema. Would recommend daily weights.
# [**Last Name (un) **]/ATN:
Baseline creatinine 0.4-0.6. Creatinine elevated from his
baseline starting hospital day 5. Urine electrolytes consistent
with pre-renal failure, likely due to decreased effective
circulating volume due to [**Last Name (un) 9215**]. Diuresis attempted, however his
Cr increased from 1.1 to 1.3 and his BUN increased to 29. Muddy
brown casts seen on light microscopy on [**12-10**] suggestive of ATN.
Renal U/S showed no hydronephrosis. UPEP negative, SPEP
abnormal. Due to hypoxia from pleural effusions on [**12-18**] began
aggressive course of diuresis starting [**12-18**] with up to 160mg IV
lasix daily. Hypoxia improved and creatinine trended down.
Creatinine 0.9 on discharge.
# Catheter associated DVT:
Patient had a PICC line in his right arm and was noted to have
swelling of his right hand and forearm. RUE ultrasound revealed
a catheter-induced thrombus associated with the PICC line in his
right brachial vein. His RUE PICC was removed. A new PICC line
was placed in his left arm given necessity for continued
antibiotic administration. He was started on heparin gtt and his
PTT on [**12-9**] was 73.3. He showed some LUE swelling on [**12-8**], but a
LUE ultrasound showed no evidence of thrombus. Warfarin 5mg
started [**12-11**] but then discontinued due to need for OR
interventions. Subsequently maintained on heparin gtt. RUE was
rechecked after patient had been on anti-coagulation for one
month, and showed interval clot resolution. Decision made to
stop anticoagulation at that time given patient's bleeding risk
and lack of data to support continued anticoagulation for PICC
related clot in brachial vein only.
# Sacral deep tissue injury:
The patient has a sacral deep tissue injury with friable, deep
tissue involvement. He has been seen by wound care regularly.
Noted to be necrotic and debrided first in OR on [**12-19**] and then
at bedside on [**12-26**], then again in OR on [**1-1**]. He has been
continued to be seen by wound care. Wound care recs included in
this discharge summary.
# Episode of ventricular tachycardia:
30 beat run on [**11-29**] in context of low K of 3.2. SBP during
episode held in 150s and he was asymptomatic. EKG showed normal
sinus rhythm with PACs afterwards without intervention. He was
continuously monitored on telemetry after this episode and
remained in normal sinus rhythm.
# Back and Neck pain:
Acute on chronic pain secondary to nerve compression due to
spinal stenosis, multiple surgeries, and recent infection. The
patient was initially on a fentanyl PCA, but on the floor was
weaned to oral oxycodone, acetaminophen and gabapentin 100 TID.
Pain was well controlled on this regimen. Increased amounts of
opioids were avoided due to abdominal pain and ileus vs
pseudobstruction. Ortho spine advises the patient be in a TBSO
when out of bed.
# Chest pain:
Transient episode of pleuritic chest pain on the night of [**1-7**].
There were no significant EKG changes and trop t was 0.12 and
0.13. PE unlikely given lack of tachycardia, hypoxia, EKG
changes and negative LENIs. Troponin negative on admission, was
0.11-0.16 on [**11-15**] (likely secondary to demand ischemia in
setting of acute infection), with no subsequent troponins drawn
since until this episode so elevation may be residual.
Cardiology consulted, recommended optimizing medical management.
Patient on aspirin, beta blocker, [**Last Name (un) **], statin.
# Enterococcus in urine: Patient found to have [**Last Name (un) **] in urine with
10k - 100k organisms / ml; however upon changing the foley the
enterococcus bacterial count decreased to [**2185**] organisms/ml
without treatment indicating bacterial colonization with [**Year (4 digits) **] and
not true UTI. Repeat culture showed continued enterococcus
colonization, but patient without signs of active infection at
that point. Foley changed by urology, repeat culture at time of
discharge was positive for enterococcus. Given we believe this
is chronic colonization, we did not treat. Enterococcus was
[**Last Name (LF) **], [**First Name3 (LF) **] if patient becomes symptomatic, the organism is
linezolid and that would be the logical antibiotic choice.
INACTIVE ISSUES:
# DMII: Patient's home metformin was held and he was put on FSS
and insulin sliding scale. No standing insulin. FSBGs were well
controlled.
# HTN: Patient was continue on home amlodipine. His losartan was
initially discontinued due to his acute kidney injury, but was
restarted prior to discharge.
# BPH: Patient was continued on home finasteride and tamsulosin
with no issues on this admission.
# Polio with residual RLE paralysis: Stable on this admission
with no issues.
TRANSITIONAL ISSUES
# Last vancomycin trough was 19.3 ([**2198-1-6**]) on dose of 1000 mg
IV Q48h. Last day of vancomycin will be [**2198-2-12**].
# Titrate diuretic dose: patient started on furosemide 20mg
daily on [**2198-1-9**]. He should be weighed daily, and furosemide
dose increased by 20mg if patient's weight goes up by more than
2lbs. BUN/Cr should be checked weekly or after any significant
dose changes. Downtitrate furosemide accordingly if renal
function deteriorates.
# Urine grew [**Date Range **], thought to be colonization rather than true
infection. Foley changed, repeat urine culture at discharge
still positive for enterococcus. Electing not to treat as no
clinical signs of UTI and we believe this is chronic bladder
colonization
# Consider changing labetalol to cardioselective beta blocker
such as metoprolol
# If worsening abdominal pain and distension and patient not
stooling, GI recommends:
- Serial rectal exams with stimulation to produce BMs, patient
should be rolled on left side for this
- Electrolye repletion
# Sacral ulcer, continue wound care as follows:
Cleanse ulcer with wound cleanser set to "stream"
pat dry, use cotton tip swab as needed to remove excess cleanser
Prep periwound tissues with No Sting Barrier Wipe and miconazole
powder
fill ulcer with slightly moistened AMD Kerlix
Cover with softsorb dressing
Secure with Medipore H soft cloth tape and pink Hy tape to
inferior edge
change [**Hospital1 **]
# Per ortho: TBSO when out of bed.
# UPEP normal, but SPEP showed abnormal band in the gamma region
identified as monoclonal IgG kappa. This should be followed up
with hematology as an outpatient.
# Code status: full
# Contact: sister [**Female First Name (un) 111917**] (HCP): [**Telephone/Fax (1) 111918**]
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Aspirin 81 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. meloxicam *NF* 7.5 mg Oral daily
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Senna 1 TAB PO BID
11. Docusate Sodium 100 mg PO BID
12. Bisacodyl 10 mg PR HS:PRN constipation
13. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
14. Polyethylene Glycol 17 g PO DAILY
15. MetFORMIN (Glucophage) 500 mg PO DAILY
16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheeze
17. Ipratropium Bromide Neb 1 NEB IH Q6H wheeze, sob
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheeze
2. Amlodipine 5 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Ipratropium Bromide Neb 1 NEB IH Q6H wheeze, sob
7. Senna 1 TAB PO BID
8. Tamsulosin 0.4 mg PO HS
9. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN
heartburn
10. Heparin 5000 UNIT SC TID
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
12. Labetalol 200 mg PO TID
13. Lorazepam 0.5 mg PO Q8H:PRN anxiety
14. Miconazole Powder 2% 1 Appl TP TID:PRN groin rash
15. Multivitamins 1 TAB PO DAILY
16. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
hold for sedation, RR<12
17. Pantoprazole 40 mg PO Q24H
18. Sarna Lotion 1 Appl TP QID:PRN itching
19. Sertraline 25 mg PO DAILY
20. Vancomycin 1000 mg IV Q48H
21. Furosemide 20 mg PO DAILY
22. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
23. Losartan Potassium 100 mg PO DAILY
hold for SBP<100
24. Polyethylene Glycol 17 g PO DAILY:PRN constipation
25. Benzonatate 100 mg PO TID
26. Guaifenesin [**6-15**] mL PO Q6H
27. Gabapentin 100 mg PO TID
28. Diazepam 5 mg PO HS:PRN anxiety/muscle cramps
29. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
30. OxycoDONE (Immediate Release) 5-10 mg PO Q8H:PRN
breakthrough pain
31. Simethicone 40-80 mg PO QID gas/distention
32. Sodium Chloride Nasal [**2-6**] SPRY NU TID:PRN nasal dryness
33. Aspirin 81 mg PO DAILY
34. Nitroglycerin SL 0.4 mg SL PRN chest pain
35. Ascorbic Acid 500 mg PO DAILY Duration: 10 Days
36. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days
37. Outpatient Lab Work
-Check CBC with differential, BUN/Cr and vancomycin trough
weekly and fax to the Infectious Disease R.N.s at ([**Telephone/Fax (1) 4591**].
All questions regarding outpatient parenteral antibiotics should
be directed to the Infectious Disease R.N.s at ([**Telephone/Fax (1) 21403**]
-Also check Chem 7 in [**3-11**] days and after any changes in Lasix
dose. send results to facility MD
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
MRSA wound and spinal hardware infection
MRSA sepsis
Diastolic heart failure exacerbation
Acute tubular necrosis
PICC associated RUE DVT (brachial vein)
Ileus, possibly [**Last Name (un) 3696**] Syndrome
Bilateral lower extremity paresis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 111914**],
Thank you for choosing [**Hospital1 18**] for your care. You were admitted
with a surgical site infection of your back. On [**11-26**], you went
to the operating room where infected tissue and pus were
removed. On [**2198-1-1**] you went for surgery again, at which point
your infected spinal hardware was removed. You will need to
follow up with your orthopedic surgeon, Dr. [**Last Name (STitle) 363**], for
management of your spinal incision.
Your course was complicated by bacteria in your bloodstream,
kidney injury and pulmonary edema (fluid in your lungs) due to
your heart failure. You were started on the IV antibiotic called
vancomycin, which you will need to continue through [**2-12**].
You have follow up appointments at infectious disease clinic in
3 weeks, and again in 8 weeks. You will need to have your labs
checked weekly.
Over your hospital stay, you developed abdominal distention from
a condition we call ileus, which can happen after surgery or
severe infection. We have been giving you strong laxatives to
help you move your bowels and your distension has been slowly
getting better.
It was a pleasure taking care of you during your hospitalization
and we wish you the best going forward.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2198-1-17**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23870**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2198-2-14**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23870**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27362**], PA
Location: [**Hospital1 **]
Address: [**Last Name (LF) **], [**First Name3 (LF) **] BLDG. RM 239, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3573**]
Appt: [**1-24**] at 11am
Completed by:[**2198-1-11**]
|
[
"348.31",
"707.03",
"E879.8",
"600.00",
"V02.59",
"560.89",
"584.5",
"401.9",
"453.82",
"038.12",
"138",
"998.12",
"E878.1",
"491.21",
"707.24",
"285.1",
"276.1",
"275.3",
"250.00",
"324.1",
"995.92",
"263.9",
"996.67",
"428.33",
"344.1",
"996.74",
"411.89",
"482.42",
"518.0",
"320.3",
"V45.4",
"997.49",
"781.6",
"730.08",
"427.1",
"V09.80",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.69",
"34.91",
"54.0",
"86.22",
"83.95",
"86.28"
] |
icd9pcs
|
[
[
[]
]
] |
34701, 34775
|
19491, 20460
|
393, 852
|
35057, 35057
|
6266, 7012
|
36471, 37486
|
4066, 4107
|
32678, 34678
|
34796, 35036
|
31960, 32655
|
35192, 36448
|
19194, 19468
|
4122, 6247
|
12313, 12581
|
12617, 13943
|
13984, 19178
|
312, 355
|
20475, 29672
|
7047, 12274
|
880, 3312
|
29689, 31934
|
35072, 35168
|
3334, 3696
|
3712, 4050
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,619
| 110,324
|
9787
|
Discharge summary
|
report
|
Admission Date: [**2190-10-4**] Discharge Date: [**2190-10-7**]
Date of Birth: [**2112-6-26**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
gentleman with coronary artery disease, diabetes mellitus,
and chronic renal insufficiency who presented with a chief
complaint of shortness of breath.
The patient presented to the Emergency Department and was
found to be bradycardia to the 20s. Per the patient's
family, the patient had complained of shortness of breath for
the past two days prior to admission. He was becoming
dyspneic with walking across the room.
On the day of admission, the patient had decreased oral
intake and one episode of vomiting. His wife his finger
blood sugar level to be 400 and called his primary care
physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) who advised the patient to go to
the [**Hospital1 69**] Emergency
Department.
In the Emergency Department, the patient's heart rate was in
the 20s with a stable blood pressure. Electrocardiogram
showed complete heart block. According to his wife, the
patient does not have any recent history of chest pain,
orthopnea, or paroxysmal nocturnal dyspnea. The patient did
complain of some lightheadedness earlier on the day of
presentation. He denies any recent history of fevers or
chills.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post coronary artery
bypass graft in [**2181**] with stents times five in [**2189**].
2. Diabetes mellitus.
3. Hypercholesterolemia.
4. Hypertension.
5. Benign prostatic hypertrophy.
6. Congestive heart failure with left ventricular systolic
dysfunction.
7. Chronic renal insufficiency.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg by mouth once per day.
2. Lasix 80 mg by mouth once per day.
3. Hydralazine 25 mg by mouth four times per day.
4. Isordil 20 mg by mouth three times per day
5. Toprol-XL 100 mg by mouth once per day.
6. Zantac 150 mg by mouth twice per day.
7. Zestril 40 mg by mouth once per day.
8. Zocor 80 mg by mouth once per day.
9. Flomax 0.4 mg by mouth once per day.
10. Proscar 5 mg by mouth once per day.
11. Insulin (70/30) 40 units subcutaneously in the morning
and 35 units subcutaneously in the evening.
12. Procrit 7500 units subcutaneously every other week.
ALLERGIES: An allergy to PENICILLIN.
SOCIAL HISTORY: The patient is married. He denies any
history of alcohol, tobacco, or drug use.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient was afebrile, his blood
pressure was 164/58, his heart rate was in the 70s (following
temporary pacemaker placement), his respiratory rate was 20,
[**Hospital1 **]-level positive airway pressure [**6-22**] with an FIO2 of 60%,
and saturating 100%. The physical examination was notable
for an irregular rhythm with normal first heart sounds and
second heart sounds. No murmurs, rubs, or gallops were
appreciated. Extremity examination revealed no lower
extremity edema was present on examination. Chest
examination revealed crackles in the lungs bilaterally.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram on admission
revealed complete heart block with a rate of 30 and possible
anterior fascicular block.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
were notable for a creatinine of 4 and a potassium of 6.2.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was admitted to the Coronary Care Unit.
In the Emergency Department, prior to transfer to the
Coronary Care Unit, a temporary pacemaker was placed. The
patient was also placed on [**Hospital1 **]-level positive airway pressure
to assist with ventilation.
The following morning, the patient was taken for pacemaker
placement. The patient received a [**Company 1543**] SDR 303B
dual-chamber rate-responsive pacemaker. The patient
tolerated the procedure well.
Following the procedure, the patient was sent back to the
Coronary Care Unit for further monitoring. Following
pacemaker placement his heart rate remained stable in the 60s
with a systolic blood pressure ranging from the 120s to the
140s.
Due to his congestive heart failure and mild left ventricular
systolic dysfunction, the patient was diuresed with Lasix.
The patient required multiple blood pressure medications to
control his hypertension. He was also continued on aspirin,
statin, and beta blocker due to his history of coronary
artery disease. The patient was not placed on an ACE
inhibitor due to his elevated creatinine over his baseline.
His creatinine remained stable between 3.7 and 4 throughout
his hospitalization. However, his creatinine was elevated
from his previous known baseline of 3.
Following the pacemaker placement procedure, the patient was
restarted on his home insulin scheduled of 70/30. It was
found to cause excessive nocturnal hypoglycemia. His evening
insulin dose was decreased, and he had no further problems
with his blood sugars.
On hospital day four, the patient was found to have an
episode of shaking chills. He was afebrile, and his white
blood cell count was elevated. Blood cultures and urine
cultures were obtained but did not grow anything. Due to
concern for possible pacemaker pocket infection, the patient
was started on intravenous vancomycin; however, there were no
signs of infection at pacemaker site. Prior to discharge,
the patient was switched to a by mouth antibiotic.
Prior to discharge, the patient was given an injection of
Epogen 7500 units for anemia of chronic disease and chronic
renal insufficiency.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient's discharge status was to home
with home physical therapy.
DISCHARGE DIAGNOSES:
1. Complete heart block.
2. Status post pacemaker placement.
3. Congestive heart failure.
4. Systolic dysfunction.
5. Coronary artery disease; status post coronary artery
bypass graft and stent from prior hospitalization.
6. Hypertension.
7. Insulin-dependent diabetes mellitus.
8. Chronic renal insufficiency.
9. Benign prostatic hypertrophy.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg by mouth once per day.
2. Zantac 150 mg by mouth twice per day
3. Toprol-XL sustained release 100 mg by mouth once per
day.
4. Hydralazine 50 mg by mouth q.6h.
5. Amlodipine 5 mg by mouth once per day.
6. Isosorbide dinitrate 20 mg by mouth three times per day.
7. Furosemide 80 mg by mouth twice per day.
8. Docusate 100 mg by mouth twice per day as needed (for
constipation).
9. Insulin (70/30) 40 units subcutaneously in the morning
and 25 units subcutaneously in the evening.
10. Tamsulosin sustained release 0.4 mg by mouth at hour of
sleep.
11. Finasteride 5 mg by mouth once per day.
12. Zocor 80 mg by mouth once per day.
13. Clindamycin 150 mg by mouth q.6h. (times five days).
DISCHARGE INSTRUCTIONS/FOLLOWUP: (The patient's was
scheduled to follow up as follows)
1. The patient was instructed to follow up with the [**Hospital1 1444**] Cardiology Device Clinic on
[**2190-10-12**].
2. The patient was instructed to follow up with his primary
cardiologist (Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 32963**]) at the [**Hospital6 4193**] Cardiovascular Division.
3. The patient was instructed to follow up with his primary
nephrologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25699**]) at the [**Hospital6 15291**].
4. The patient was instructed to follow up with his primary
care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) on [**10-12**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Name8 (MD) 32964**]
MEDQUIST36
D: [**2190-10-12**] 15:35
T: [**2190-10-14**] 11:39
JOB#: [**Job Number 32965**]
|
[
"593.9",
"424.0",
"250.00",
"272.0",
"426.0",
"600.00",
"401.9",
"414.01",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"37.72",
"37.78",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
2482, 3465
|
5826, 6180
|
6207, 6934
|
1730, 2366
|
6969, 7961
|
3499, 5664
|
5679, 5805
|
156, 1351
|
1373, 1703
|
2383, 2465
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,666
| 187,016
|
19926
|
Discharge summary
|
report
|
Admission Date: [**2147-4-6**] Discharge Date: [**2147-4-12**]
Date of Birth: [**2090-7-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
epigastric discomfort
Major Surgical or Invasive Procedure:
[**2147-4-7**] Pericardiectomy
History of Present Illness:
56 yo F with epigastric pain who ws found in [**12-21**] to have new
afib. Later found to have pericardial effusion, tapped for
bllody fluid, felt to be from coumadin or pericarditis. Studies
since pericardiocentesis showed pericardial constriction.
Past Medical History:
htn
hypercholesterolemia
possible TIA in past
afib
h/o viral pericarditis c/b effusions s/p pericardiocentesis
[**12-21**]
s/p tubal ligation
s/p right heel surgery
s/p T&A
Social History:
No tobacco, occ ETOH, no drugs. Pt lives at home with husband
and is a decorative painter.
Family History:
grandmother RA, aunt with breast ca, CAD father with first MI
late 40s, died at 83.
Physical Exam:
WDWN female in NAD
Lungs CTAB
CV Irreg at times, no M/R/G
Abd protuberent
Extrem 1+ edema
Pertinent Results:
[**2147-4-12**] 06:09AM BLOOD Hct-30.8*
[**2147-4-11**] 08:16PM BLOOD WBC-8.9 RBC-3.81* Hgb-11.0* Hct-33.1*
MCV-87 MCH-28.8 MCHC-33.2 RDW-15.1 Plt Ct-226
[**2147-4-12**] 06:09AM BLOOD PT-30.5* INR(PT)-3.2*
[**2147-4-11**] 08:16PM BLOOD PT-28.0* INR(PT)-2.9*
[**2147-4-11**] 06:50AM BLOOD PT-26.3* INR(PT)-2.7*
[**2147-4-12**] 06:09AM BLOOD K-4.2
[**2147-4-11**] 08:16PM BLOOD Glucose-92 UreaN-27* Creat-1.2* Na-134
K-4.6 Cl-102 HCO3-22 AnGap-15
[**2147-4-11**] 06:50AM BLOOD Glucose-91 UreaN-26* Creat-1.2* Na-133
K-3.9 Cl-101 HCO3-23 AnGap-13
Brief Hospital Course:
Surgery was planned for [**4-6**], preop labs included an INR of 1.7.
Surgery was cancelled and she was admitted to the floor for
vitamin K and heparin gtt.
She was taken to the operating room on [**2147-4-7**] where she
underwent a perciardiectomy. She was extubated later that same
day. Her vasoactive drips were weaned to off by POD #2. She was
transferred to the floor on POD #3. Her chest tubes were dc'd on
POD #4, and she was ready for discharge home on POD #5.
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).
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: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200 mg [**Hospital1 **] x 5 days then 200 mg daily ongoing.
Disp:*60 Tablet(s)* Refills:*0*
6. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day.
Disp:*60 Capsule, Sustained Release(s)* Refills:*0*
9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
TBA
Discharge Diagnosis:
pericardial restriction
HTN
lipids
AF
viral perciarditis c/b pericardiocentesis
s/p tubal ligation
s/p right heel surgery
s/p T&A
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one dya or five in one week.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) 32848**] 2 weeks
Dr. [**Last Name (STitle) 914**] 4 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Completed by:[**2147-4-12**]
|
[
"401.9",
"272.0",
"V58.61",
"423.2",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3469, 3503
|
1754, 2224
|
341, 374
|
3677, 3685
|
1186, 1731
|
3984, 4137
|
975, 1060
|
2247, 3446
|
3524, 3656
|
3709, 3961
|
1075, 1167
|
280, 303
|
402, 653
|
675, 850
|
866, 959
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,858
| 130,611
|
36191
|
Discharge summary
|
report
|
Admission Date: [**2121-11-25**] Discharge Date: [**2121-11-27**]
Date of Birth: [**2056-1-9**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Septic shock
Major Surgical or Invasive Procedure:
Mechanical Ventilation
History of Present Illness:
Ms. [**Known lastname 10168**] is a 65 year old female with type 2 DM, HTN,
alcoholism who was at day 4 of detox. Per detox staff, she was
complaining of weakness and lethargy and had poor PO intake. She
was noted to be more confused yesterday and her son questioned
if she was drinking. SHe was found this evening in the bathtub
with altered mental status but was arousable. She was note
dinitiallly to have BP 82/40, RR 20, HR 70, 97% on RA by EMS.
She was given 500 cc of fluid.
.
She was taken to [**Hospital 26580**] Hospital. She was found to have
leukocytosis (19.1) and hypothermia (T 92.6). She had acute
renal failure (Cr 9.9) and hyperkalemia (7.7). She had profound
acidosis (pH 6.89/22/102/5) with bicarb of less than 5. She was
intubated for airway protection. She was then started on
Levophed 10 mcg/hour and Dopamine 20 mcg/keg/min due to
hypotension. She was given vancomycinand ceftriaxone. For her
hyperkalemia, she was given 5IV insul, 1 amp dextrose, and 1
gram of calcium gluconate, and kayexalate. There was concern for
a guiaic positive NG return, so started on protonix drip. She
was then trasported to [**Hospital1 18**] by [**Location (un) **].
.
In th ED,she arrive intubated and sedated. She remained
hyperkalemic and acidotic. She was given an amp of bicarb, 1
gram of calcium gluiconate and remained on the dopamine and
levophed drips. She got a total of 7L IVF and remained anuric. A
CT abdomen pelvis showed pancreatitis and her lipase was
elevated to >[**2112**]. Renal was consulted and recommended CVVHD.
She was not given any further antibiotics. SHe had a bedside
ultrasound that was fast negative and no pericardial effusion
seen. In the ED, right femoral line was placed.
.
Patient arrived in the MICU intubated. She denied pain
Past Medical History:
HTN
Type 2 DM
Hypercholesterolemia
Social History:
Historically heavy EtOH use, but currently at a detox facility
with reportedly little supervision. Per medical records from
detox facility, last drink [**2121-11-20**]. Denies drug use.
Family History:
Non-Contributory
Physical Exam:
VS: HR 87, BP 97/34, RR 29, 96% on
Gen: Intubated, Sedated
HEENT: Edematous, Pupils sluggish
CV: Tachy, No MRG
Pulm: Coarse BS Anteriorly
Abd: Firm, BS+
Ext:2+ edema
Pertinent Results:
Admission Labs:
[**2121-11-25**] 08:20PM WBC-12.4* RBC-2.58* HGB-9.4* HCT-30.5*
MCV-119* MCH-36.4* MCHC-30.7* RDW-14.6
[**2121-11-25**] 08:20PM NEUTS-86.6* LYMPHS-9.5* MONOS-2.7 EOS-1.0
BASOS-0.2
[**2121-11-25**] 08:20PM PLT COUNT-164 LPLT-1+
[**2121-11-25**] 08:20PM PT-20.9* PTT-64.4* INR(PT)-2.0*
[**2121-11-25**] 08:20PM SED RATE-6
[**2121-11-25**] 08:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2121-11-25**] 08:20PM TSH-1.2
[**2121-11-25**] 08:20PM OSMOLAL-327*
[**2121-11-25**] 08:20PM ALBUMIN-3.0* CALCIUM-7.0* PHOSPHATE-9.1*
MAGNESIUM-1.9
[**2121-11-25**] 08:20PM LIPASE-2678*
[**2121-11-25**] 08:20PM ALT(SGPT)-23 AST(SGOT)-29 ALK PHOS-72 TOT
BILI-0.4
[**2121-11-25**] 08:20PM GLUCOSE-266* UREA N-66* CREAT-8.5*
SODIUM-131* POTASSIUM-7.1* CHLORIDE-99 TOTAL CO2-5* ANION
GAP-34*
[**2121-11-25**] 08:38PM LACTATE-10.6*
.
CT Head: No Hemorrhage
.
CT Abdomen, Pelvis:
1. Extensive stranding and fluid surrounding the pancreas and
extending into
the transverse mesocolon, the appearance of which is most
compatible with
acute pancreatitis. Correlate with lipase and amylase.
Non-contrast technique
limits evaluation for pancreatic necrosis and vascular
complications.
2. Diffuse low attenuation of the liver consistent with fatty
infiltration.
.
IMPRESSION: New discrete multiple lung opacities could be due to
pneumonia,
but hemorrhage related to vasculitis can also be considered due
to patient's
history of renal failure.
Brief Hospital Course:
65 year old female with type 2 diabetes, HTN, HL, admitted with
shock of unclear etiology -- septic shock (leukocytosis,
hypothermia), distributive shock secondary to pancreatitis
(lipase >2500, radiographic evidence of pancreatitis), and toxic
ingestion (?ethylene glycol -- elevated osmolar gap).
.
# Acute Pancreatis: The patient presented in shock. Etiology of
shock in this complicated patient was not immedicately clear.
The differenital included septic shock (leukocytosis,
hypothermia), distributive shock secondary to pancreatitis
(lipase >2500, radiographic evidence of pancreatitis), and toxic
ingestion (?ethylene glycol -- elevated osmolar gap).
Leukocytosis and hypothermia were suggestive of septic shock,
though there is no clear source of infection. The patient had a
lactate of 10 on admission. The patient was intubated for airway
protection initially but developed increasing 02 requirements.
CXR showed no infection initially, and the patient was anuric so
we were unable to send urine. There was no evidence of
cellulitis. History limited but no localizing symptoms per
family. Patient's osmolar gap was suggestive of a toxic
ingestion such as ethylene glycol or methanol. Her history of
?intoxication per son yesterday in spite of being at rehab in
addition to acidosis and renal failure may support ethylene
glycol ingestion. The patient was placed on levo, neo, dopa,
vasopressin to maintain MAPs>65. She was treated empirically
with vanco and cefepime; hold off on empiric c. diff treatment
or antifungal therapy given lack of risk factors. The patient
was given IVF boluses in addition to 10L the patient received at
the OSH. The patient presented with a Cr of 10. Urgent CVVH was
attempted, however the patients blood pressure would not
tolerate dialysis. Ethylene glycol and methanol levels were sent
out and found to be negative. Thus given a lipase 0f 2500,
radiographic evidence of acute pancreatitis, a strong personal
history of heavy alcohol abuse, a diagnosis of Acute Pancreatis
was made for the etiology of the patients septic shock.
Following a family discussion, a decision was made to make the
patient comfortable. The patient expired shortly after withdrawl
of pressors and extubation. A most mortem examination was
declined by the family.
.
Medications on Admission:
Lovastatin 20 mg daily
Metoprolol 50 mg [**Hospital1 **]
Lisinopril 20 mg daily
HCTZ 25 mg daily
Metformin 1000 [**Hospital1 **]
Prilosec 20 mg daily
Celexa 10 mg daily
Naproxen 500 PO BID
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"785.52",
"584.9",
"250.00",
"276.7",
"401.9",
"995.92",
"276.2",
"038.9",
"577.0",
"518.81",
"303.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
6700, 6709
|
4147, 6433
|
310, 334
|
6760, 6765
|
2628, 2628
|
6817, 6823
|
2409, 2427
|
6672, 6677
|
6730, 6739
|
6459, 6649
|
6789, 6794
|
2442, 2609
|
258, 272
|
362, 2132
|
3530, 4124
|
2644, 3521
|
2154, 2190
|
2206, 2393
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,040
| 107,281
|
24125
|
Discharge summary
|
report
|
Admission Date: [**2174-3-29**] Discharge Date: [**2174-4-15**]
Service: MEDICINE
Allergies:
Heparin Sodium
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
[**Age over 90 **] year old with hx of HTN, DM, CHF, s/p pacemaker for
bradycardia, and high cholesterol who presented to [**Hospital 61311**] this morning after he experienced a loss of
conciousness. He was in his USOH until 8:30AM today when he had
brief loss of conciousness. Though he was not aware of it, he
was told that his speech was slurred and that his face was
asymmetric. He did not notice any weakness or numbness, denies
difficulty with speech, no vision changes. He did complain of
right arm pain. Denied CP, +mild SOB, An ambulance was called
and brought him to [**Location (un) **].
On arrival to OH ED, VS: 97.2 HR 60 BP 154/35 RR16 O2 Sat 95% on
room air. He was evaluated by neurology who found him to have a
"left homonymous hemianopsia" and "left hemiparesis". NCHCT was
done and was negative. While in the OH ER, he was found to have
positive troponin trop 1.13, CK 56 with EKG changes and was also
noted to have a BP discrepency between the right and left arm
with right arm being roughly 50mm mercury less than BP in left
arm. He was transfered here for cardiology workup and evaluation
for subclavian steal.
According to his family, his mental status has waxed and waned
throughout the day with periods of alterness and lethargy. He
has always been arousable and has been able to communicate a
coherent history at all times. They do note, however, that he
seems to be improved over the last several hours. They have also
noticed that his speech is slurred, he has a tendancy to look
only to the right, and has decreased spontaneous movement of his
left side (though they note that he has been able to move the
left side purposefully).
CT: Mild atrophy, ? hyperdense right MCA, but images out of
focus on re-prints.
At [**Hospital1 18**] ED, no CTA secondary to ARF. He was unable to do MRI
2/s pacemaker. Neurology :?right MCA territory(most likely
embolic vs Sc steal). Repeat NCHCT negative for bleed/edema. He
should have his BP kept in 200s and received 2u PRBC. EKG with
persistent lateral ST depression
On arrival to the floor, he was in respiratory distress
unresponsive to lasix and nitro gtt. He became unresponsive and
respiratory code was called. His initial ABG showed 7.18/67/67.
He was intubated and his BP was in 210/100 and P120. He was
given 10mg IV lopressor and nitro gtt.
Past Medical History:
#CHF
#HTN
#s/p PM [**2-12**] for symptomatic bradycardia
#DM2
#hyperlipidemia
#gout
#h/o BPH
#s/p TURP
#CRI
#CAD
cath 98-?stent [**19**]% LAD, 90%circ
90% LCX
#anemia
Social History:
retired wood worker
remote tobacco
lives alone in NH
3 children
no ETOH
Family History:
no CAD/CVA
Physical Exam:
The patient was unresponsive and found to be breathless,
pulseless, and without heart tones, blood pressure, and corneal
reflexes. The patient was pronounced dead. The patient's
physician and family were notified. They refused anatomic gifts
and autopsy.
Pertinent Results:
Admission Labs [**2174-3-28**]:
WBC-7.8 RBC-3.27* Hgb-9.8* Hct-30.4* MCV-93 MCH-29.9 MCHC-32.2
RDW-15.4 Plt Ct-137* Neuts-79.2* Lymphs-16.1* Monos-3.4 Eos-1.2
Baso-0.2
0PT-13.6 PTT-28.4 INR(PT)-1.2
[**2174-3-28**] 11:50PM BLOOD Glucose-103 UreaN-38* Creat-1.7* Na-144
K-4.2 Cl-106 HCO3-29 AnGap-13 Calcium-8.6 Phos-3.3 Mg-2.1
CK-MB-NotDone cTropnT-0.40* CK(CPK)-62
calTIBC-270 Hapto-199 Ferritn-112 TRF-208
Micro:
No growth/negative: urine cx, blood cx, bile cx, stool for
c.diff
Sputum: MRSA+
EKG on admission:SR 70bpm PR 200ms, nml axis, STD I, AVL, V4-V6,
LVH, QTC 447
CXR on admission -mild CHF, right pleural effusion, no focal
consolidation
CXR [**4-12**] -Worsening congestive heart failure.
Head CT [**3-29**]: Mild atrophy, ? hyperdense right MCA, but images
out of
focus on re-prints.
repeat Head CT [**3-31**]: R occip.parietal hypoattenuation, R
capsular attenuation.
non-invasive head studies: severely stenotic R and L ICA's;
severe vertebrobasilar stenosis
Renal u/s [**4-10**]: No hydronephrosis in either kidney. Left renal
calculus, which is nonobstructing. Slight increase in
echogenicity of both kidneys consistent with underlying renal
parenchymal disease. Small amount of free fluid in the abdomen
as well as a small right pleural effusion.
GB DRAINAGE,INTRO PERC TRANHEP BIL US [**4-8**]: Successful placement
of a percutaneous cholecystostomy tube. A sample of the bile was
immediately sent to microbiology for Gram stain and culture.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**4-7**]:Acute
cholecystitis, with distended, sludge and stone-filled
gallbladder and wall edema.
[**Month/Day (4) **] [**4-5**]: No masses or thrombi are seen in the left ventricle
(evaluated with Definity). The apex is hypokinetic and the
basal inferior/inferoseptal segments are aneurysmal. Compared to
the prior study of [**2174-4-4**], left ventricular systolic function
appears similar.
[**Date Range **] [**4-4**]: 1. The left atrium is mildly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed. Resting regional
wall motion abnormalities include inferobasal aneurysm with
inferolateral akinesis and apical akinesis.
3.Right ventricular chamber size is normal. Right ventricular
systolic function is normal. 4.The aortic valve leaflets (3)
are mildly thickened. Trace aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Mild mitral
regurgitation seen. 6.There is no pericardial effusion. 7.
There appears to be a circular mass in the LV, consistent with
an LV thrombus. Would recommend Definity contrast to beeter view
the mass. Compared with the findings of the prior tape of
[**2174-3-29**], images were equally limited but appears unchanged,
though LV mass not previously seen.
[**Date Range **] [**3-29**]: 1. The left atrium is mildly dilated. 2. There is
mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. There is mild global left ventricular
hypokinesis.
Overall left ventricular systolic function is mildly depressed.
3. The aortic valve leaflets are mildly thickened. 4. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
5. There is mild pulmonary artery systolic hypertension.
CT ABDOMEN W/O CONTRAST 03/29:1. No evidence of retroperitoneal
hematoma.
2. Moderate bilateral pleural effusions.3. Two small
high-attenuation foci in the right kidney which may represent
hyperdense cysts. 4. Tiny nonobstructing left renal calculus.
Carotid u/s [**3-30**]:On the left, there is significant plaque with
an 80% to 99% cervical carotid stenosis. On the right, there is
evidence of an intracranial carotid artery occlusion. In
addition, there is a significant disease in the right subclavian
artery, based on waveforms.
C.CATH Study Date of [**3-29**]: 1. Coronary angiography of this
right dominant circulation demonstrated three vessel coronary
artery disease. The LMCA had no angiograpically apparent
disease. The LAD had an origin 70% stenosis with moderate
calcification. There were serial 50% stenosis through out the
vessel with total occlusion in the apical segment. There was
diffuse diagonal disease with 60-70% stenosis. The LCX had a
widely patent stent proximally with 30% instent restenosis.
Major OM had 60% stenosis prior to bifurcation. The RCA was
totally occluded proximally with left to right collaterals
filling the distal vessel. 2. Left ventriculography was
deferred. 3. Resting hemodynamics demonstrated mildly elevated
left and right sided pressures with mRAP of 11 mmHg and mPCWP of
14 mmHg. There was mild pulmonary hypertension with PASP of 36
mmHg and mPAP of 24 mmHg. Cardiac output and cardiac index were
preserved at 5.9 L/min and 3.4 L/min/M2, respectively. 4. Due to
blood pressure discrepancy in the right arm, subclavian
angiography was performed to determine if vertebral
insufficiency was present. Via access in the right common
femoral artery, a catheter was placed in retrograde fasion
seletively into the right and then left subclavian. Selective
imaging of bilateral subclavians and nonselective imaging of the
bilateral vetebrals were performed. 5. The right subclavian was
widely patent and then occluded at the axillary segment with
what appeared to be atherothrombotic material.
The right vertebral had 95% stenosis. The left subclavian was
widely
patent. The left vertebral had 95% stenosis. 6. During the
procedure, the patient developed atrial tachycardia/atrial
flutter with pacemaker tracking at 2:1 with HR in the 130s. SBP
dropped from 150 to 110 mmHg. The magnet was placed and BP
increased to 140 mmHg with VVO pacing. The EP service was
consulted and reprogrammed the pacemaker to DDI mode without
rate adaption.
Brief Hospital Course:
[**Age over 90 **] yo male h/o HTN, DM, CHF s/p pacemaker for bradycardia, and
high cholesterol p/w CVA, vertebral insufficiency, and demand
ischemia in respiratory distress requiring intubation. The
patient expired after a prolonged cardiac ICU course involving
multiorgan failure (cardiac, pulmonary, renal, stroke, acute
cholecystitis) that was ultimately irreversible in spite of the
maximum medical measures.
Cardiovascular: Patient underwent cardiac cath [**2174-3-29**]
revealing 3 vessel disease (LAD 50% diffuse, Diagonal 60%
diffuse, LCx 30%, OM 60%), right subclavian occlusion, bilateral
vertebral stenosis, PCWP 14, CVP 11, and CO/CI 5.9/3.4. No
intervention was performed as the patient had not ruled in for
MI at that time and there was no culprit lesion. He was
continued on BB, ASA, lipitor, and plavix as possible. While the
goal for beta blockade was titration for HR~60 from a cardiac
standpoint, this goal was not often met due to limitations from
blood pressure that was required to be elevated for preservation
of brain perfusion, considering the patient's severe bilateral
vertebral artery stenosis and recent stroke. Patient's cardiac
enzymes and ECG in setting of flash pulmonary edema [**4-4**] were
suggestive of demand ischemia, considered likely due to the
narrowed circumflex artery. Patient was determined to have an
NSTEMI with increased TnT [**4-5**] thought secondary to pulmonary
edema and HTN. The patient's cardiac enzyems remained elevated
until patient expired. Optimization of medical management was
attempted but limited by increased blood pressure required for
brain perfusion. Patient received blood transfusions to maintain
goal HCT>30.
CHF/pulmonary edema: Patient was initially intubated on
admission for flash pulmonary edema in setting of hypertension
and was successfully extubated. However, on [**2174-4-3**], patient
again went into flash pulmonary edema and required reintubation
likely in the setting of hypertension that was required to
maintain cerebral perfusion. He temporarily required levophed
and nitro gtt for BP control for goal SBP 120-160 determined
with consultation by the neurology service. Echocardiogram [**3-29**]
revealed EF 50%, global LV HK, and 1+MR. [**First Name (Titles) 907**] [**Last Name (Titles) 113**] raised a
question of a mural thrombus; however, echocardiogram [**4-5**] with
definity contrast was negative for thrombus yet revealed EF
35-40%, apical HK, and inferobasal/septal aneurysm. Serial CXR
showed worsening pulmonary edema over time while patient
appeared intravascularly volume depleted (FeUrea 12%) and
received blood products and gentle fluids to maintain blood
volume.
Valves: 1+MR, 1+TR
Rhythm: During the hospital course, patient's pacemaker was
interrogated by the EP service and determined to be functional.
It was set at DDI post cath. Overnight on [**4-9**], patient converted
from NSR to AF and was not paced. Subsequently, patient variably
shifted in and out of AF. He was monitored continuously on
telemetry.
Neuro: Patient presented having had recent right temporal stroke
complicated by ICH that did not progress upon repeat head CT
imaging (MRI contraindicated due to PM). The patient's blood
pressure at first was recommended to be maintained between
140-160 per neurology stroke team recommendation; however, this
was liberalized to >120 as the patient's hemodynamic status
became further compromised due to evolving NSTEMI, worsening
CHF, atrial fibrillation, and renal failure. Nevertheless, when
awake, the patient was responsive to questions and communicative
with the SBP in the 120s. He was able to communicate his wishes
to his family/HCP. On exam, patient had left-sided
hemiparesis/neglect. The hemiparesis improved slightly over
time. He was noted to have vertebral insufficiency from severe
bilateral vertebral stenosis. Per carotid U/S [**2174-3-30**], there was
right total occlusion and left 90% occulsion. Neurosurgical or
endovascular intervention was deferred as patient was not
determined to be an appopriate candidate due to the several
comorbidities and complicating factors. While anticoagulation
with heparin was attempted, it was discontinued as the patient's
HCT and platelets dropped. He was noted to be positive for
heparin-induced thrombocytopenia. He temporarily received
argatroban. Plavix was started for stroke prevention and patient
took aspirin as able.
Respiratory: Patient's respiratory distress requiring intubation
[**4-3**] was likely pulmonary edema in the setting of hypertension
(higher BP needed for cerebral perfusion) vs aspiration
pneumonia since patient has to remain flat for cerebral
perfusion. After successful extubation, patient was reintubated
[**4-4**] for suspected aspiration in setting of heart failure. The
patient's blood pressure was required to be elevated for the
cerebral perfusion, but it was an additional stress to his heart
function, which made the patient's pulmonary edema more
difficult to control. The pulmonary edema persisted and worsened
as the patient underwent NSTEMI; diuresis was limited by renal
failure; the patient was unable to be safely extubated; thus,
per family meeting a tracheostomy was placed for continued
intubation and to help limit aspiration risk. Patient developed
ventilator associated MRSA PNA after being on levoquin and
flagyl x4d. He then started vanco/zosyn/flagyl/cipro on [**4-6**] for
MRSA and cholecystitis. Zosyn was d/c'd [**4-10**] for ? renotoxicity.
Intubation with AC/PS was continued due to infection and
difficulty to diurese. Patient was unable to be successfully
extubated due to worsening pulmonary edema and also required
gentle hydration and blood products for intravascular volume
depletion as well as hypernatremia.
Renal: Patient developed acute renal failure in setting of
chronic renal insufficiency. Patient was intravascularly
depleted and was given gentle hydration blood products to
support HCT>30 for CAD. Suspicion was low for ATN/AIN as the
urine was negative for eosinophils and the sediment was normal.
No hydronephrosis was seen per renal u/s [**4-10**]; however, there was
bilateral echogenicity suggestive of chronic parenchymal
disease. Metabolic acidosis was likely related renal loss as the
renal failure worsened. Renal service consultation raised
concern for irreversible cholesterol embolic renal disease due
to the patient's low C3 level. Medications were renally dosed.
Endocrine: Diabetes was managed with subcutaneous insulin.
Heme: Patient presented with anema and was documented to be
guaiac negative in the ED. He received blood products to keep
his HCT>30 and for iron repletion as iron studies were
concerning for iron deficiency and possible acute phase reactant
in setting of chronic disease: iron 44->20, transferrin
208->139, & TIBC 270->181 all trending down, but ferritin
increasing 112->241. Labs were negative for hemolysis and
abdominal CT [**4-5**] showed no evidence of hematoma or
retroperitoneal bleeding. After worsening thrombocytopenia,
patient was found to be positive for heparin induced
thrombocytopenia and all heparin per IV was discontinued.
Patient was started on argatroban for increased thrombotic risk
in AF rhythm in setting of known SC occluding thrombus, LV
aneurysm, and h/o stroke; however, it was then held for
procedure and discontinued altogether on [**4-14**] after patient made
CMO per family decision.
GI: Patient found to have elevated transaminases, AP, and GGT
but normal amylase and lipase. Abdominal exam evolved to have
RUQ guarding and u/s revealed cholecystitis for which the
patient received a gallbladder drain placed by IR. IR
recommended continuation of the drain until cholecystectomy;
however, the patient was too systemically ill to undergo
surgical intervention. Due to this and risk of aspiration, oral
nutrition including tube feeding, was held. The family did not
decide to proceed with PEJ placement as a goal of care and PICC
placement for TPN was contraindicated given the patient's
infections. Patient had poor gag reflex and required sedation
for comfort on the ventilator.
ID: Patient's temperature was 99 [**4-3**] and he was pancultured and
started on IV levoquin and flagyl. Infectious sources were
determined to be MRSA ventilator associated pneumonia and
evolving acute cholecystitis. He developed fever (102PR) [**4-6**]
that resolved after gallbladder drain placement and treatment
with vancomycin/zosyn/flagyl started [**4-6**]. Ciprofloxacin was
added 3/31 per ID consultation. Zosyn was d/c'd [**4-10**] for
renotoxicity concerns. The patient's fever resolved and
leukocytosis improved. All antibiotics were discontinued [**4-13**]
after family decision was made for CMO given patient's
irreversible multiorgan failure.
Access was per PIVs and central line.
Code on admission was full then the family, with patient's
daughter as HCP, decided to change the code status to DNR/DNI.
Palliative care consultation was assisting. As the [**Hospital 228**]
medical status worsened and became grave, the family decided to
pursue comfort measures as the primary goal of care and the
patient expired while family was present.
Medications on Admission:
asa 325
lasix 40
imdur 60
norvasc 5
catapres 0.1
zocor 20
acebutol 200mg
KCL
Starlix 120 mEQ
flomax 0.4
NKDA
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"435.2",
"V53.31",
"507.0",
"584.5",
"428.0",
"410.71",
"287.5",
"482.41",
"250.40",
"433.31",
"038.9",
"434.11",
"575.0",
"518.84",
"995.92",
"274.9",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.01",
"31.1",
"00.13",
"88.56",
"96.72",
"96.71",
"96.6",
"00.17",
"88.44",
"96.04",
"99.07",
"99.04",
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] |
icd9pcs
|
[
[
[]
]
] |
18445, 18454
|
9082, 18253
|
230, 255
|
18505, 18514
|
3210, 3710
|
18570, 18580
|
2905, 2917
|
18413, 18422
|
18475, 18484
|
18279, 18390
|
18538, 18547
|
2932, 3191
|
183, 192
|
283, 2609
|
3723, 9059
|
2631, 2800
|
2816, 2889
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,712
| 187,891
|
30060
|
Discharge summary
|
report
|
Admission Date: [**2113-6-14**] Discharge Date: [**2113-6-16**]
Date of Birth: [**2061-10-24**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Hydrocephlus
Major Surgical or Invasive Procedure:
[**6-14**] Proxima revision of VP Shunt
History of Present Illness:
The patient is a 51 year old man with a history of traumatic
brain injury s/p ventriculoperitoneal shunt who suffered a fall
ten days ago and has had subacute on chronic worsening of his
gait. He has a poor baseline level of neurologic functioning, in
particular his mental status (disoriented, poor attention). He
had an episode of stiffening last night and initially was found
to have a mild right facial weakness and right arm drift,
possibly secondary to [**Doctor Last Name 555**] Paralysis from a seizure. However,
on imaging, he has been found to have an interval increase in
ventricular size suggestive of hydrocephalus.
Past Medical History:
1. TBI (left temporal skull fracture) w/ resultant seizure d/o
2. History of status epilepticus
3. Anemia
4. former EtOH abuse
5. chronic cholecystitis
Social History:
The patient is divorced. He currently resided at [**Location (un) **] Neuro
Rehab Center/Chip's House. He is a former computer programmer
and has 2 teenage children (Son and daughter)
EtoH: former significant abuse per wife
[**Name (NI) 1139**]: 1ppd since a teenager; stopped after injury
Family History:
Father had Pick's Disease and Mother died of a glioma
Physical Exam:
General: Awake, NAD, lying in bed comfortably.
Head: NC/AT, no scleral icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilateraly, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulse
Psych: Inattentive, occasionally laughs inappropriately and says
"true but false"
Neurologic Examination:
- Mental Status - Awake, alert, oriented x name but not month,
year, place or situation (near baseline, per wife). Cannot
recall
a coherent story. Recall 0/3. Attention moderately difficult to
attain and maintain. Follows simple one step commands, midline
and appendicular, but does so sporadically. Language volume
decreased, repetition intact. No dysarthria. No neglect.
Perseverative with words and actions.
- Cranial Nerves - [II] PERRL 4->2 brisk. VF full to number
counting. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without
deficits to light touch bilaterally. [VII] No facial asymmetry.
[VIII] Hearing intact to finger rub bilaterally. [IX, X] Palate
elevation symmetric. [[**Doctor First Name 81**]] SCM/Trapezius strength 5/5
bilaterally.
[XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift. No
tremor
or asterixis.
=[Delt] [Bic] [Tri] [ExD] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[[**Last Name (un) 938**]]
L 5 5 5 5 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 bilaterally.
- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger/foot mirrored
movements.
- Gait - Slow initiation. Wide base. Short stride length.
Present
Romberg.
Pertinent Results:
[**2113-6-15**] 06:05AM BLOOD WBC-10.1 RBC-3.90* Hgb-12.5* Hct-37.3*
MCV-96 MCH-32.1* MCHC-33.5 RDW-13.5 Plt Ct-284
[**2113-6-14**] 01:45PM BLOOD Neuts-71.3* Lymphs-19.6 Monos-5.6 Eos-2.9
Baso-0.6
[**2113-6-15**] 06:05AM BLOOD Plt Ct-284
[**2113-6-15**] 06:05AM BLOOD Glucose-108* UreaN-8 Creat-0.5 Na-139
K-3.6 Cl-109* HCO3-22 AnGap-12
[**2113-6-15**] 06:05AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.7
[**2113-6-14**] 01:45PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
CT brain [**6-14**] - Mild ventricular enlargement in a stable and
symmetric fashion compared to the prior exam. Findings suggest a
communicating hydrocephalus, possibly due to shunt failure.
Slightly more conspicuous hypoattenuation in a confluent nature
throughout the periventricular white matter may simply reflect a
progression of small vessel ischemic disease, although given the
periventricular distribution, an element of transependymal CSF
flow cannot be entirely excluded.
Ct brain [**6-15**] - 1. Right ventriculostomy catheter terminating in
the frontal [**Doctor Last Name 534**] of the right lateral ventricle at the septum
pellucidum, stable in position from prior study. Clinician to
review images to see if positioning is desired.
2. Minimally decreased ventricular size by 1-2 mm.
3. Encephalomalacia involving primarily the right temporal lobe
and left
frontal lobe, stable from prior study. Prominent extra-axial CSF
space in the left middle cranial fossa, compatible with a
preexisting arachnoid cyst.
Brief Hospital Course:
Mr [**Known lastname 20663**] was admitted to the neurosurgery service and
emergently was taken to the OR and changed the proximal valve as
the old one was fractured right before the valve. Post
operatively he was neurologically at his baseline, orientated
X2, he was perseverative with poor comprehension. Neurology was
consulted given his seizure history and recent seizures. They
recommended an EEG, and UA and tox screen. On post op day one
his CT scan showed stable placement of RVP shunt catheter with
slight improvement of dilated ventricles.
On [**6-16**] patient had an EEG for which full report was pending.
Pt was consulted and they recommend rehab vs. home. Now DOD,
patient is afebrile, VSS, and neurologically stable. Patient's
pain is well-controlled and the patient is tolerating a good
oral diet. Pt's incision is clean, dry and inctact without
evidence of infection. He is set for discharge back to his
group home in stable condition and will follow-up accordingly
with neurology and neurosurgery.
Medications on Admission:
Lacosamide, Lamotrigine, Lorazepam, Clonazepam,
Ibuprofen, Diphenhydramine, Phenytoin, Quetiapine, Zonisamide,
Docusate, Sennosides, Acetaminophen
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. lacosamide 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. lamotrigine 100 mg Tablet Sig: Five (5) Tablet PO BID (2
times a day).
5. phenytoin sodium extended 100 mg Capsule Sig: Two (2) Capsule
PO QHS (once a day (at bedtime)).
6. phenytoin sodium extended 30 mg Capsule Sig: One (1) Capsule
PO BREAKFAST (Breakfast).
7. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for severe agitation.
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO NOON (At
Noon).
10. clonazepam 0.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
11. zonisamide 100 mg Capsule Sig: One (1) Capsule PO BREAKFAST
(Breakfast).
12. zonisamide 100 mg Capsule Sig: Six (6) Capsule PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
Group home
Discharge Diagnosis:
Hydrocephlus
S/P Traumatic brain injury,
Status epilepticus
Anemia
Chronic cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**] to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
- Neurology f/u
[**2113-8-21**] 10:30a [**Last Name (LF) **],[**First Name3 (LF) **] L.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
NEUROLOGY UNIT CC8 (SB)
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2113-6-16**]
|
[
"345.40",
"331.4",
"781.2",
"V15.52",
"E878.1",
"996.2",
"342.90",
"V15.88"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.42"
] |
icd9pcs
|
[
[
[]
]
] |
7241, 7278
|
5033, 6055
|
322, 363
|
7411, 7411
|
3500, 5010
|
8459, 9102
|
1522, 1578
|
6253, 7218
|
7299, 7390
|
6081, 6230
|
7562, 8436
|
1593, 2012
|
270, 284
|
391, 1022
|
7426, 7538
|
2037, 3481
|
1044, 1198
|
1214, 1506
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,882
| 185,959
|
8865
|
Discharge summary
|
report
|
Admission Date: [**2141-4-28**] Discharge Date: [**2141-5-6**]
Date of Birth: [**2083-2-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
IR drainage of Appendiceal Abscess
History of Present Illness:
This is a 58 year old gentleman with 2-3 weeks of increasing
abdominal pain. He characterizes the pain as sharp, located in
his right lower quadrant, and non-radiating. In addition he has
had fevers , chills, dark urine, decreased appetite, nausea, and
increased belly girth. He has not head emesis, melena, bright
red blood per rectum. He has not had any abdominal surgeries.
Past Medical History:
Insulin-dependent Diabetes Mellitus
COPD
Peripheral vascular disease
Hypercholesterolemia
Obstructive Sleep Apnea
S/P CVA [**2-23**] - very mild dysarthria/mild left facial weakness
[**2115**]'s right fem-[**Doctor Last Name **] bypass graft x 2
Hepatomagaly
Social History:
The patient is happily married. He is a former smoker. He admits
to drinking [**1-26**] drinks a day.
Physical Exam:
On admission:
vitals: 95.0, 115, 144/90, 70, 86% on 3 liters
Gen: alert, awake, oriented, toxic-appearing
Neuro: CN 2-12 grossly intact
CV: sinus tachycardia, no murmur
Chest: decreased breath sounds at bases
Abd: tense, distended, quiet bowel sounds, focal right lower
quadrant tenderness, palpable mass at Mcburney's point
Rectal: guaic negative
Pertinent Results:
SEROLOGIES:
[**2141-4-28**] 11:10AM BLOOD WBC-19.7*# RBC-3.77*# Hgb-11.2*#
Hct-34.1*# MCV-91 MCH-29.8 MCHC-32.9 RDW-12.8 Plt Ct-589*#
[**2141-4-28**] 09:44PM BLOOD WBC-19.1* RBC-3.55* Hgb-10.6* Hct-31.3*
MCV-88 MCH-29.8 MCHC-33.8 RDW-12.7 Plt Ct-495*
[**2141-4-29**] 04:42AM BLOOD WBC-20.9* RBC-3.42* Hgb-10.2* Hct-30.6*
MCV-89 MCH-29.8 MCHC-33.3 RDW-13.0 Plt Ct-515*
[**2141-4-29**] 06:49PM BLOOD WBC-22.6* RBC-3.06* Hgb-9.5* Hct-27.9*
MCV-91 MCH-31.2 MCHC-34.3 RDW-12.8 Plt Ct-461*
[**2141-4-30**] 02:29AM BLOOD WBC-19.2* RBC-3.07* Hgb-9.3* Hct-27.6*
MCV-90 MCH-30.3 MCHC-33.7 RDW-12.9 Plt Ct-482*
[**2141-5-1**] 03:38AM BLOOD WBC-13.2* RBC-3.15* Hgb-9.2* Hct-27.9*
MCV-89 MCH-29.4 MCHC-33.1 RDW-12.5 Plt Ct-482*
[**2141-5-2**] 03:52AM BLOOD WBC-9.9 RBC-2.84* Hgb-8.6* Hct-25.8*
MCV-91 MCH-30.4 MCHC-33.4 RDW-12.6 Plt Ct-515*
[**2141-5-3**] 07:46AM BLOOD WBC-11.1* RBC-3.46* Hgb-10.6* Hct-30.9*
MCV-89 MCH-30.5 MCHC-34.2 RDW-13.7 Plt Ct-513*
[**2141-5-4**] 04:52AM BLOOD WBC-9.7 RBC-3.52* Hgb-10.6* Hct-31.3*
MCV-89 MCH-30.0 MCHC-33.7 RDW-13.6 Plt Ct-520*
[**2141-5-5**] 05:30AM BLOOD WBC-11.3* RBC-3.79* Hgb-11.2* Hct-34.4*
MCV-91 MCH-29.5 MCHC-32.5 RDW-13.5 Plt Ct-492*
[**2141-5-6**] 05:45AM BLOOD WBC-10.6 RBC-3.63* Hgb-10.8* Hct-32.8*
MCV-90 MCH-29.8 MCHC-33.0 RDW-13.4 Plt Ct-472*
[**2141-4-28**] 11:10AM BLOOD Neuts-86.3* Lymphs-7.8* Monos-5.5 Eos-0.3
Baso-0.1
[**2141-4-28**] 09:44PM BLOOD Neuts-88.1* Lymphs-5.3* Monos-6.0 Eos-0.4
Baso-0.1
[**2141-4-29**] 04:42AM BLOOD Neuts-85* Bands-3 Lymphs-1* Monos-10
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2141-4-28**] 08:15PM BLOOD PT-39.0* PTT-54.2* INR(PT)-10.1
[**2141-4-28**] 09:44PM BLOOD PT-38.7* PTT-58.7* INR(PT)-9.9
[**2141-4-29**] 04:42AM BLOOD PT-20.2* PTT-36.3* INR(PT)-2.7
[**2141-4-29**] 11:42AM BLOOD PT-16.3* INR(PT)-1.8
[**2141-4-30**] 02:29AM BLOOD PT-14.9* PTT-25.4 INR(PT)-1.5
[**2141-5-2**] 03:52AM BLOOD PT-14.4* PTT-23.4 INR(PT)-1.4
[**2141-5-3**] 07:46AM BLOOD PT-14.8* PTT-24.8 INR(PT)-1.5
[**2141-5-5**] 05:00PM BLOOD PT-14.0* PTT-60.5* INR(PT)-1.3
[**2141-5-5**] 09:21PM BLOOD PT-14.0* PTT-61.6* INR(PT)-1.3
[**2141-5-6**] 05:45AM BLOOD PT-14.3* PTT-72.8* INR(PT)-1.4
[**2141-4-28**] 11:10AM BLOOD Glucose-351* UreaN-29* Creat-1.2 Na-135
K-4.5 Cl-91* HCO3-33* AnGap-16
[**2141-4-28**] 09:44PM BLOOD Glucose-235* UreaN-29* Creat-1.3* Na-135
K-4.4 Cl-94* HCO3-32* AnGap-13
[**2141-4-29**] 04:42AM BLOOD Glucose-103 UreaN-27* Creat-1.2 Na-140
K-4.2 Cl-95* HCO3-31* AnGap-18
[**2141-4-29**] 06:49PM BLOOD Glucose-200* UreaN-31* Creat-1.3* Na-143
K-4.8 Cl-96 HCO3-28 AnGap-24*
[**2141-4-30**] 02:29AM BLOOD Glucose-153* UreaN-34* Creat-1.2 Na-144
K-4.1 Cl-100 HCO3-34* AnGap-14
[**2141-5-1**] 03:38AM BLOOD Glucose-100 UreaN-23* Creat-0.9 Na-141
K-3.9 Cl-96 HCO3-39* AnGap-10
[**2141-5-1**] 03:33PM BLOOD Glucose-118* UreaN-24* Creat-0.9 Na-141
K-4.3 Cl-95* HCO3-35* AnGap-15
[**2141-5-2**] 03:52AM BLOOD Glucose-224* UreaN-25* Creat-0.9 Na-141
K-4.3 Cl-98 HCO3-36* AnGap-11
[**2141-5-3**] 07:46AM BLOOD Glucose-178* UreaN-17 Creat-0.9 Na-143
K-3.9 Cl-100 HCO3-37* AnGap-10
[**2141-5-5**] 05:30AM BLOOD Glucose-121* UreaN-11 Creat-0.8 Na-141
K-4.1 Cl-102 HCO3-33* AnGap-10
[**2141-4-28**] 09:44PM BLOOD ALT-58* AST-15 AlkPhos-207* Amylase-20
TotBili-0.3
[**2141-4-29**] 04:42AM BLOOD ALT-52* AST-19 AlkPhos-194* TotBili-0.6
[**2141-4-29**] 06:49PM BLOOD CK(CPK)-64
[**2141-4-29**] 11:58PM BLOOD CK(CPK)-122
[**2141-4-30**] 02:29AM BLOOD ALT-44* AST-21 AlkPhos-188* Amylase-29
TotBili-0.6
[**2141-4-28**] 09:44PM BLOOD Lipase-10
[**2141-4-29**] 06:49PM BLOOD CK-MB-CK-MB NOT cTropnT-0.03*
[**2141-4-29**] 11:58PM BLOOD CK-MB-5 cTropnT-0.04*
[**2141-4-28**] 09:44PM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.5 Mg-1.9
[**2141-4-30**] 02:29AM BLOOD Albumin-3.6 Calcium-9.3 Phos-3.7 Mg-2.1
[**2141-5-1**] 03:33PM BLOOD Albumin-3.2* Calcium-8.9 Phos-2.9 Mg-1.9
Iron-36*
[**2141-5-3**] 07:46AM BLOOD Calcium-8.4 Phos-2.1* Mg-2.0
[**2141-5-5**] 05:30AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.0
[**2141-5-1**] 03:33PM BLOOD calTIBC-230* TRF-177*
[**2141-5-4**] 04:52AM BLOOD CEA-2.0
MICROBIOLOGY:
[**2141-4-29**] Abscess aspirate: E. coli (pan-sensitive)
RADIOLOGY:
[**2141-4-28**] CT: There are no stones in the ureters or urinary
bladder. The prostate and seminal vesicles appear unremarkable.
There is a 7.3 x 5.4 cm fluid collection inferior to the cecum,
with adjacent fat stranding. The appendix is not visualized.
These findings likely represent ruptured appendicitis and
periappendiceal abscess. Small bowel loops are normal in
caliber.
[**2141-4-29**] CT: Successful placement of an 8-French self-locking
pigtail catheter within the periappendiceal abscess. The
catheter is open to drainage.
[**2141-5-6**] CT: drainage from JP
Brief Hospital Course:
This is a 58 year old male who was admitted on [**2141-4-28**] with
several weeks of abdominal pain and a CT scan revealing an
appendiceal abscess. This was drained by interventional
radiology on [**2141-4-29**] and an 8-french catheter was left in place.
The patient was toxic-appearing on admission with tachycardia
and low oxygen saturation. He also had an INR of 10 and was on
coumadin at home for peripheral vascular disease, but hadn't had
this checked regularly. He also had an elevated blood sugar of
500. He was admitted to the intensive care unit for management
of these multiple issues . His pain was well controlled with prn
morphine. From a respiratory standpoint, he was well-managed
with nasal cannula oxygen and did not require intubation but was
treated with nebulizers. His blood sugars were managed
initially with an insulin drip which was then converted to
sliding scale insulin. He was started on empiric levoquin and
flagyl. Prior to the IR drainage, FFP was used to reverse his
elevated INR. He remained stable after his procedure and had no
bleeding complications. On hospital day three he was started
back on a clear diet which he tolerated well. He received lasix
diuresis for congestion in his lungs and edema with good
response. [**Last Name (un) **] was consulted for diabetes control and assisted
with transition to a sliding scale insulin. He was transfered to
the floor on hospital day 5 and started on a regular diet which
he tolerated well . His hematocrit trended downward although
there was no evidence of an active bleed and he was supported
with 2 units of packed red blood prodcuts on hospital day 5.
Pulmonology consult was obtained and assessed the patient as
having chronic obstructive pulmonary disorder and felt he should
continue his home oxygen treatment and transition from
nebulizers here to combivent at home. He was restarted on his
home coumadin on hospital day 6 and was started on a heparin
drip. His INR level was 1.4 on day of discharge and he was
discharged with 5 mg QHS coumadin with planned blood level check
2 days after discharge and appropriate adjustment per PCP. [**Name Initial (NameIs) **] CT
scan was obtained on day of discharge which revealed no
remaining undrained abscesses, but his drain was left in place
with planned repeat CT scan within 2 weeks for assessment of any
new fluid collections before removal. He was transitioned off of
IV pain medications to oral pain medications as a discharge
regimen. A visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 25472**] to assist with home drain
teaching. Cultures from his fluid aspirate revealed
pan-sensitive E. coli and he was discharged on a 10 day course
of augmentin. He will have follow-ups with Dr. [**Last Name (STitle) 468**] as well
as [**Last Name (un) **] Diabetes and his PCP. [**Name10 (NameIs) **] questions were answered to
his satisfaction upon discharge.
Medications on Admission:
Insulin
Home Oxygen
Lipitor
Coumadin
Lasix
Atenolol
Pulmicort
Folate
Discharge Medications:
1. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): You should have your INR checked at [**Company 191**] on [**2141-5-7**] and
follow-up your levels with Dr. [**Last Name (STitle) **] . .
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
5. Budesonide 200 mcg/Inhalation Aerosol Powdr Breath Activated
Sig: Two (2) Aerosol Powdr Breath Activated Inhalation [**Hospital1 **] () as
needed for copd.
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-25**]
Puffs Inhalation Q6H (every 6 hours) as needed.
7. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
You should have your INR, PT, PTT (coags) checked on [**2141-5-7**].
This should be faxed to Dr. [**First Name4 (NamePattern1) 915**] [**Last Name (NamePattern1) 29958**] at Health Care
Associated. [**Telephone/Fax (1) 250**]
9. Home Oxygen Therapy
Home Oxygen via Nasal Cannula 2L/min titrate to O2 sat > 95%
10. Insulin
Please administer NPH Insulin and Humalog per the Sliding Scale
printed out for you
11. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary: Appendiceal Abcess
Secondary: Hypertension, history of DVTs, peripheral vascular
disease, hsitory of a stroke, COPD
Discharge Condition:
Stable
Discharge Instructions:
You should keep your drain attached to the bag as taught to you
here in the hospital. A visiting nurse [**First Name (Titles) 767**] [**Last Name (Titles) 1519**]
will come to your house starting on [**5-8**] to assist with this.
You should return to the ER or call the office with any
worsening fevers, abdominal pain, or significant increase in
daily drain outputs. You should take all medications as
prescribed. You should return for an abdominal CT scan on [**5-13**].
Followup Instructions:
An Abdominal CT scan has been scheduled for you for [**5-13**].
You should call [**Telephone/Fax (1) 16718**] on Monday [**2141-5-8**] to arrange for a
time for this appointment.
You should follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] after you have your
abdominal CT scan on [**5-13**]. Please call [**Telephone/Fax (1) 2835**] to
schedule for this appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 30886**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-5-10**] 2:00
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-8-3**]
8:45
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-8-3**] 9:00
Completed by:[**2141-5-6**]
|
[
"V58.61",
"491.21",
"272.0",
"362.01",
"357.2",
"583.81",
"250.51",
"250.61",
"540.1",
"416.8",
"780.57",
"250.41",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"47.2"
] |
icd9pcs
|
[
[
[]
]
] |
10813, 10862
|
6280, 9189
|
326, 363
|
11031, 11039
|
1554, 6257
|
11560, 12582
|
9308, 10790
|
10883, 11010
|
9215, 9285
|
11063, 11537
|
1185, 1185
|
272, 288
|
391, 769
|
1200, 1535
|
791, 1051
|
1067, 1170
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,651
| 188,162
|
48719
|
Discharge summary
|
report
|
Admission Date: [**2141-2-3**] Discharge Date: Pending
Date of Birth: [**2076-4-27**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 953**] is a 64 year old
male who was transferred from an outside hospital to a
Medical Intensive Care Unit at the [**Hospital1 190**] after frontal lobe watershed infarction during
a right sided carotid endarterectomy on [**1-31**]. The
patient had carotid Dopplers in [**2140-2-11**], showing total
occlusion of his left carotid artery and 70% stenosis of his
right carotid artery which, on repeat Doppler, showed 80 to
99% stenosis, per his daughter's report.
The patient woke up from anesthesia in the outside hospital
and was found to have a right gaze preference and an
attention to the left hemi-space. Serial CT scans of his
head demonstrated bilateral frontal infarcts presumed to be
watershed infarcts sustained during cross-clamping of the
right carotid artery during surgery with a totally occluded
left carotid artery. An embolic source of his infarction was
not completely ruled out.
The patient had a transthoracic echocardiogram at the outside
hospital which was suboptimal with poor visualization of the
apex. The patient's blood pressure became hard to control
post operation requiring nitroprusside drip. He was also
found to have a low grade fever and chest x-ray showed
atelectasis with a question of early infiltrate in the
outside hospital. At this point, his daughter requested
transfer to [**Hospital1 69**].
The patient was transferred to [**Hospital1 188**] Medical Intensive Care Unit on [**2141-2-3**]. He
was evaluated with MRI and MRA which demonstrated anterior
and posterior watershed distribution infarcts plus small
emboli, likely from the occlusion of the internal carotid
artery during surgery. The patient initially required a
Nitroglycerin drip in the Intensive Care Unit to control his
blood pressure and maintain the systolic blood pressure at a
range from 140 to 150 mm of Mercury. This was the
recommendation of the stroke team. The patient was
eventually weaned off of Nitroglycerin drip on [**2141-2-5**], and was transferred to Medicine Service.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
3. Type 2 diabetes mellitus.
4. Coronary artery disease with a myocardial infarction 20
years ago. The patient is status post coronary artery bypass
graft in [**2140-2-11**], for five-vessel disease.
5. History of gastrointestinal bleed.
MEDICATIONS AT HOME:
1. Aspirin 325 mg p.o. q. day.
2. Glyburide.
3. Gemfibrozil.
4. Analopril.
MEDICATIONS UPON TRANSFER:
1. Atenolol 75 mg p.o. q. day.
2. Captopril 6.25 mg p.o. three times a day.
3. Protonix 40 mg p.o. q. day.
4. Regular insulin sliding scale.
5. Norvasc 10 mg p.o. q. day.
6. Aggrenox one tablet p.o. twice a day.
7. Gemfibrozil, 600 mg p.o. twice a day.
8. Glyburide 5 mg p.o. twice a day.
ALLERGIES: The patient has reported allergies to statins.
SOCIAL HISTORY: The patient lived alone and worked part time
at a court house as a security guard prior to his surgery.
The patient was completely independent prior to this event.
The patient's daughter is an Emergency Department nurse who
works at the [**Hospital1 69**].
PHYSICAL EXAMINATION: On admission, the patient's
temperature was 97.8 F.; heart rate was 68; blood pressure
131/78; respiratory rate of 24 and oxygen saturation of 94%
on room air. The patient was alert, awake, oriented, in no
acute distress. His Head, Eyes, Ears, Nose and Throat
examinations revealed mucous membranes that were moist.
There is a right carotid endarterectomy scar which is well
healed. Cardiovascular system revealed normal S1 and S2.
There was a faint I/VI systolic murmur. The patient had a
regular rate and rhythm. Presternal scar was well healed.
Pulmonary examination revealed mild tachypnea. The patient
had bilateral crackles in the lower third of his chest.
There was no wheezing and no stridor. Abdominal examination
revealed a large obese normal abdomen with normoactive bowel
sounds. His abdomen was nontender with no
hepatosplenomegaly. Extremities examination revealed a mild
non-pitting edema in the lower extremities. There was no
erythema or tenderness in his lower extremities. Neurologic
examination revealed an awake and alert individual who was
oriented to place and people. His face was symmetric. The
patient manifested some mild left hemi-space neglect. The
patient had normal extraocular movements except for lack of
left gaze, question neglect. The patient had increased tone
in bilateral upper extremities. The patient had a negative
glabellar tap, negative grasp and negative [**Doctor Last Name 937**] sign.
The patient's strength is four plus to five over bilateral
lower extremities. The patient had upper extremity
paraplegia, both upper extremities. In the right upper
extremity, he had distal greater than proximal weakness. In
the left upper extremity, he had proximal greater than distal
weakness. The patient follows commands inconsistently.
LABORATORY: On admission revealed a hematocrit of 33.1,
white count of 12.2 and a platelet count of 301. His MCV was
84, red cell distribution was 13.7. Chemistry on admission
revealed a sodium of 138, potassium of 4.1, chloride of 100,
bicarbonate of 17, BUN of 30 and creatinine of 1.7 with a
glucose of 188. His magnesium was 2.0, phosphate was 4.0,
calcium 9.6 and albumin was 4.2.
COURSE IN THE HOSPITAL: The patient was transferred from the
Medical Intensive Care Unit after controlling his blood
pressure to the Medical Service. Issues by systems were as
follows:
1. Neurologic Issues: The patient sustained embolic
infarction in a watershed distribution bilaterally. This is
likely due to ischemia and distal embolization during
cross-clamping of his right carotid artery during surgery.
The patient received a transthoracic echocardiogram on
[**2141-2-6**]. This transthoracic echocardiogram revealed
a normal ejection fraction of 45 to 55%. The patient had
mildly dilated left atrium with a mild symmetric left
ventricular hypertrophy. There was no severe valvular
pathology. There were septal and inferior hypokinesis noted.
This was a limited study but did not demonstrate any
concerning cardiac source for embolization.
After much discussion between Neurology, Stroke Team and
Cardiology, it was determined that the patient did not need
to go on to a transesophageal echocardiogram for further
evaluation of his stroke. The source of his embolic stroke
was pretty clearly his recent carotid endarterectomy surgery
and likely following the cross-clamping of his carotid
artery.
The patient received Physical Therapy and Occupational
Therapy evaluation and was determined to require a [**Hospital 878**]
Rehabilitation Center.
For his stroke risks, the patient is put on Aggrenox 1 tablet
twice a day. Per stroke team recommendation, the patient's
blood pressure was maintained in a range of 140s to 150s
systolic within the first week of stroke to maintain cerebral
perfusion. Seven days post-stroke, the stroke team has
recommended controlling his blood pressure to be below 140.
The patient is on Gemfibrozil and Aggrenox for reduction of
his stroke risks.
2. Cardiovascular: The patient is on Aggrenox, Atenolol and
an ACE inhibitor for his coronary artery disease risk
factors. He is status post coronary artery bypass graft with
a 45 to 55% ejection fraction. His rate and rhythms were
regular and he does not have any inherent need for diuretics.
In terms of the patient's blood pressure control, he is
currently maintained on Atenolol, Captopril and Norvasc.
There is a plan to change him from Captopril to Analopril
which he was on as an outpatient at home prior to his current
admission.
3. Endocrine: The patient has known type 2 diabetes
mellitus and is on p.o. Glyburide. He has been requiring his
regular insulin sliding scale.
4. Pulmonary: The patient was found to be mildly tachypneic
ever since arrival to the [**Hospital1 188**]. Repeated chest x-rays reveal no clear evidence of
infiltrates or congestive heart failure. The patient likely
has a degree of atelectasis.
5. Renal: The patient likely has chronic renal
insufficiency with a baseline creatinine between 1.4 to 2.2.
Given his history as a type 2 diabetic, the patient should be
maintained on an ACE inhibitor.
6. In terms of feeding and nutrition, the patient was
evaluated by Speech and Swallow to have no aspiration risks.
It was recommended that the patient go on a soft diet and can
tolerate thin liquids. It was recommended that the patient
sit upright while being fed for further prevention of
aspiration. The patient has a strong cough. He is
recommended to have a p.o. diabetic, low cholesterol and low
salt diet.
There will be an addendum to this Discharge Summary.
DR.[**Last Name (STitle) 2400**],[**First Name3 (LF) **] 12-875
Dictated By:[**Doctor Last Name 37523**]
MEDQUIST36
D: [**2141-2-8**] 14:51
T: [**2141-2-8**] 15:00
JOB#: [**Job Number 93957**]
|
[
"518.0",
"414.01",
"997.02",
"276.5",
"401.9",
"434.11",
"593.9",
"433.10",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2512, 2977
|
3275, 9109
|
161, 2188
|
2210, 2491
|
2994, 3252
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,466
| 165,091
|
10663+56169
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-9-5**] Discharge Date: [**2181-10-11**]
Date of Birth: [**2106-1-8**] Sex: M
Service: VSU
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
male with a past medical history significant for long
standing diabetes mellitus, hypertension, coronary artery
disease. He is status post myocardial infarction and
extensive peripheral vascular disease, and is status post
multiple peripheral bypasses. The patient had been recently
admitted to [**Hospital6 34976**] in [**Location (un) 5503**] for five
days due to bacteremia and was discharged on Augmentin. He
was seen in clinic on the day of admission for bilateral leg
ulcers and referred to the hospital for admission. He denies
any history of nausea, vomiting, fevers or chills, but does
report having diarrhea four to five days prior to admission.
No chest pain or shortness of breath.
PAST MEDICAL HISTORY: Past medical history is significant
for diabetes mellitus, coronary artery disease, history of
myocardial infarction, congestive heart failure, atrial
fibrillation and chronic renal insufficiency.
PAST SURGICAL HISTORY: Past surgical history is significant
for a right TMA, a right STSG of the right ankle, venous
bypass graft from previous right popliteal to dorsalis pedis
and cephalic vein bypass; another STSG for the right foot;
right dorsalis pedis to distal bypass graft, a left TMA, a
left superficial femoral artery to popliteal bypass graft.
MEDICATIONS: Medications on admission included Megace,
Prozac, insulin, Darvocet, Neurontin, Protonix, Reglan,
aspirin and Duragesic patch.
ALLERGIES: He had no known drug allergies.
PHYSICAL EXAMINATION: On examination on admission, the
patient's vital signs included a temperature of 96.2 F.;
pulse of 95; blood pressure 129/63; O2 saturation is 96
percent and his respiratory rate was 18. He was in no acute
distress. His pupils were equally round and reactive.
Extraocular movements intact. Sclerae were white, no
conjunctival injection. His neck was supple; no carotid
bruits. His heart rate was irregularly irregular. His lungs
were clear to auscultation bilaterally. His abdomen was
soft, nontender, nondistended. Extremities: He had an ulcer
at the lateral aspect of the left lower extremity. He was
status post TMA. He had an ulcer on the lateral aspect of
the leg and also on the anterior aspect of the TMA. He had
Doppler able posterior tibial and dorsalis pedis pulses.
Right lower extremity revealed multiple ulcers on the calf
and Doppler able dorsalis pedis and posterior tibialis
pulses.
LABORATORY DATA: His labs on admission included a white
blood cell count of 9.8, hematocrit of 36.8, platelets of
737. His chemistry revealed a sodium of 137, potassium 5.7,
chloride 102, bicarbonate 23, BUN and creatinine 9 and 0.9.
Glucose was 62.
He had an EKG which showed no change from his examination in
[**Month (only) 205**] but irregular rhythm. Chest x-ray showed a mild
pulmonary edema with a right pleural effusion.
HOSPITAL COURSE: He was admitted to the Vascular Surgery
Service and placed on intravenous antibiotics and was preoped
for a bilateral lower extremity debridement of ulcers. The
patient tolerated the procedure well. He was placed on
antibiotics, Vancomycin, Levofloxacin and Flagyl. He was
given a Fentanyl patch for pain control and was treated with
intravenous fluids. Nutrition was involved in his care
postoperatively. He also received a cardiac evaluation and
the [**Last Name (un) **] Diabetes Center was involved. On the [**9-14**], he underwent a right above the knee amputation. He
tolerated the procedure well. His blood sugars were
monitored closely throughout his stay. He was treated
primarily in the Surgical Intensive Care Unit and in the
Vascular Intensive Care Unit throughout his stay.
On the [**9-18**], the patient was found to be
increasingly somnolent and it was determined that he was in
respiratory failure with acidosis. He was intubated at this
time and his vital signs were monitored closely. It was
thought that he had aspirated during a meal. He was
transferred from the Vascular Intensive Care Unit to the
Medical Intensive Care Unit at that time. He was sedated
appropriately with Propofol and a Swan-Ganz catheter was
placed. He was started on a Dopamine drip. A Dobhoff
feeding tube was placed and he was initiated on tube feeds.
His Infectious Disease issues were dealt with by the
Infectious Disease Service. Multiple cultures were obtained
which showed gram negative rods consistent with enterococcus
from his left heel wound along with Pseudomonas. A lavage
revealed Citrobacter which is resistant to multiple agents
and his right stump revealed a Citrobacter also resistant to
multiple agents along with Methicillin resistant
Staphylococcus aureus. He was on Meropenem and Vancomycin
for his pneumonia and these agents covered his stump
infection as well.
A Dermatology consultation was also obtained due to a rash
which had been noted for the last few days by the primary
team, that began at his right forearm and appeared
morbilliform in character and non itchy. Dermatology
recommended Triamcinolone ointment to the arms and
Dermatology Service also followed him throughout the
remainder of his course at the hospital.
The patient had a tracheostomy during his stay; this was done
on [**10-9**] when a percutaneous tracheostomy was placed
due to chronic respiratory failure. The patient was
discharged to a rehabilitation facility on [**10-11**]. At
that time, he was receiving tube feeds at 85 cc an hour.
Tube feeds were ProMod with fiber. He had a trache in place.
He was on Vancomycin, Levofloxacin and Flagyl and his
diabetes mellitus was being managed by the [**Hospital **] [**Hospital 982**]
Clinic. His Lantus was at 26 units and he had a regular
insulin sliding scale as well.
DISCHARGE DIAGNOSES:
1. Status post incision and drainage of leg ulcers.
2. Status post right above the knee amputation.
3. Citrobacter pneumonia.
4. Status post PEG tube placement.
5. Status post percutaneous tracheostomy tube placement.
DISCHARGE MEDICATIONS:
1. Lorazepam 0.5 to 1 mg intravenously q. Four hours p.r.n.
2. Furosemide 20 mg intravenously three times a day.
3. Lactulose 30 cc p.o. or NG tube twice a day p.r.n.
4. Insulin sliding scale.
5. Non-formulary Lantus 20 units subcutaneously daily.
6. Fluoxetine hydrochloride 20 mg p.o. q. Day.
7. Gabapentin 200 mg p.o. twice a day.
8. Methadone 20 mg p.o. or NG twice a day.
9. Famotidine 20 mg p.o. q. 12 hours.
10. Albuterol nebulizers, one nebulizer inhaled q. Six
hours p.r.n.
11. Vancomycin 1000 mg intravenously q. 24.
12. Meropenem 1000 mg intravenously q. Eight.
13. Metoprolol 12.5 mg p.o. or NG twice a day.
14. Milk of Magnesia 30 cc p.o. or NG q. Six hours
p.r.n.
15. Bisacodyl 10 mg p.o. or p.r. q. Day.
16. Colace 100 mg p.o. twice a day.
17. Aquaphor Ointment, one application topically twice a
day to arms and trunk.
18. Triamcinolone acetonide 0.1 percent cream, one
application topically twice a day to be placed on arms and
trunk of affected area, avoiding the face, groin and
axillae.
19. Dakens quarter strength, one application topically
as directed.
20. Miconazole powder, two percent, one application
topically four times a day p.r.n.
21. Heparin flushes to his lines, subcutaneous heparin
5000 units three times a day.
Other medications will have to be added in a Discharge
Addendum.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7258**], [**MD Number(1) 7263**]
Dictated By:[**Last Name (NamePattern1) 15009**]
MEDQUIST36
D: [**2181-10-11**] 17:15:45
T: [**2181-10-11**] 18:14:51
Job#: [**Job Number 34977**]
Name: [**Known lastname 6215**],[**Known firstname 6216**] Unit No: [**Numeric Identifier 6217**]
Admission Date: [**2181-9-5**] Discharge Date: [**2181-10-22**]
Date of Birth: [**2106-1-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3717**]
Addendum:
please see remainig addendum
Major Surgical or Invasive Procedure:
Debridement bilateral heels
Right AKA
Percutaneous tracheostomy
Percutaneous G-J tube placement (tube now in 2nd portion of
duodenum)
Brief Hospital Course:
Mr. [**Name14 (STitle) 6218**] was maintained on meropenem and vancomycin to
cover multi-resistant citrobacter koseri and MRSA that grew from
both BAL and the right AKA stump. He has a VAC dressing in
place that is changed every 3 days. He is currently still
ventilator dependent, tolerating trach collar trials on a daily
basis, but needing venitlator assistance at night. He is
tolerating enteral feeding via a percutaneously placed
transgastric jejunostomy tube. On [**10-18**] his feeding tube was
pulled out 5cm. An x-ray performed with contrast via the tube
revealed the tip in the 2nd portion of the duodenum. HE IS AT
RISK FOR PULLING THE TUBE OUT! On [**2181-10-21**] the antibiotics were
discontinued as he had been afebrile and completed a 30 day
course. He lasted on trach collar for longer periods, and on
the day of discharge had been on trach collar for 30 hours.
Discharge Medications:
1. Triamcinolone acetonide 0.1%, apply TP [**Hospital1 **]
2. Milk of magnesia 30cc NG q6h prn
3. Miconazole powder 2% to groin folds
4. Methadone 10mg NG [**Hospital1 **]
5. Lopressor 25mg NG [**Hospital1 **]
6. Ativan 0.5-1mg IV q4h prn
7. Lactulose 30ml PO/NG, [**Hospital1 **] prn
8. Lantus 20u SC qhs
9. Regular insulin sliding scale
10. Heparin 5000u SC tid
11. Neurontin 200mg PO/NG [**Hospital1 **]
12. Prozac 20mg PO/NG qd
13. Colace (liquid) 100mg PO/NG [**Hospital1 **]
14. Dulcolax 10mg PO/PR qd prn
15. Aquaphor ointment TP [**Hospital1 **] to arms, trunk
16. Albuterol 1-2 puffs q4h prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 6219**] - [**Location (un) 2653**]
Discharge Diagnosis:
Gangarenous ulcers bilateral legs/heels
Aspiration pneumonia
Respiratory failure with ventilator dependence
Status post placement percutaneous transgastric jejunostomy tube
Discharge Condition:
Good
Discharge Instructions:
VAC dressing to right AKA stump with 125 mmHg suction. Change
every 72hours (last changed [**10-19**])
Tracheostomy care
Ventilator support with weaning as tolerated
GJ-tube feedings: respalor at goal rate 60/hour
Followup Instructions:
With Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 162**] two weeks after discharge ([**Telephone/Fax (1) 6220**]
[**First Name11 (Name Pattern1) 798**] [**Last Name (NamePattern4) 3683**] MD [**MD Number(1) 3724**]
Completed by:[**2182-1-1**]
|
[
"V58.67",
"482.83",
"707.12",
"278.01",
"707.03",
"997.62",
"507.0",
"518.84",
"707.14",
"731.8",
"730.07",
"428.0",
"440.24",
"250.80",
"682.6",
"250.70",
"682.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.72",
"86.22",
"84.17",
"46.32",
"89.64",
"93.59",
"33.24",
"99.04",
"96.6",
"34.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9966, 10040
|
8430, 9317
|
8271, 8407
|
10256, 10262
|
10525, 10819
|
5903, 6123
|
9340, 9943
|
10061, 10235
|
3044, 5882
|
10286, 10502
|
1137, 1657
|
1680, 3026
|
164, 892
|
915, 1113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,411
| 139,010
|
20375
|
Discharge summary
|
report
|
Admission Date: [**2101-11-3**] Discharge Date: [**2101-11-8**]
Date of Birth: [**2023-3-13**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
78 year old woman with history of MI, RHD, HTN and elevated
cholesterol presented to outside hospital with a chief complaint
of sharp SSCP (~[**7-6**]) that radiated up her neck at 0530 on [**11-3**].
The event began after an episode of coughing. At this time, she
also began to experience palpitations. The pain was not
associated with N/diaphoresis/dyspnea. She states that this pain
was different from the dull chest pain that she had 1.5 years
ago when she had her first MI. She took two SL NG with minimal
relief. She called the ambulance and states that her pain began
to dissipate during the ambulance ride.
At [**Hospital3 **], she was found to be in AFib with RVR at rate
of approx 124bpm at 730am. STD in I, II, AVF, V4-V6 and STE in
V1 and AVR. She was also hypotensive. She was started on a nitro
gtt, lopressor 5mg IV x 1, and dopamine drip. The dopamine was
subsequently changed to a levophed drip before transfer to
[**Hospital1 18**].
Past Medical History:
# Cardiac Hx:
Rheumatic Heart Disease - as a child
Myocardial Infarction: [**2099**]
A Fib: had a few episodes after MI in [**2099**] - but not known to
have AFib since
OSteoporosis
Hypothyroidism (THyroid nodule removed)
HTN
Hypercholesterolemia
Appendectomy
Breast Lumpectomy x 4
B/L LE vein stripping
# Baseline Hct: 30 ([**2-28**]
Social History:
Retired school teacher
No tobacco, No EtOH
Family History:
NC
Physical Exam:
ADmission Physical Exam:
T: 98 BP: 85/55 HR: 70s
HEENT: PERRL EOMI. OP clear
Neck: JVD: 12-14cm. No bruits
Resp: Good anterior air movement (patient seen after cath and
with femoral sheath)
CV: Normal S1, soft S2. III/VI systolic murmur radiating to R
carotid and heard well at RUSB and LUSB. II/VI rumble at RLSB
Abd: Benign. Guaiac +, but pt has hemorrhoids
Ext: good distal pulses. 1+ edema
Pertinent Results:
ECHO: [**2101-11-3**]:
- LVEF: 70%
- Marked LA enlargement
- Mild symmetric LVH
- Severely thickened/deformed aortic valve leaflets. Severe AS
- Moderate to severe (3+) MR. [Due to acoustic shadowing, the
severity of MR may be significantly UNDERestimated.]
- Aortic Valve - Peak Velocity: *4.2 m/sec (nl <= 2.0 m/sec)
.
Cath [**2101-11-3**]:
- 0.9cm^2 aortic valve area with 60mmHg peak aortic valve
gradient - consistent with aortic valve stenosis
- 50% mid LAD
- R dominant circulation
- unchanged from [**2100-3-5**]
.
[**2101-11-4**]:
CT Chest, Abdomen and Pelvis:
INDICATION: Asymmetric hilum on chest x-ray. The patient to go
to operating room tomorrow for CABG and aortic valve
replacement. Evaluate hilar mass. Also exclude retroperitoneal
hemorrhage. Patient cannot receive IV contrast secondary to
renal failure and recent cardiac catheterization.
No prior studies are available for comparison.
TECHNIQUE: Contiguous axial images through the chest, abdomen,
and pelvis were obtained without IV contrast.
CT OF THE CHEST WITHOUT IV CONTRAST: There are heavy aortic
calcifications and coronary artery calcifications. There are
small bilateral pleural effusions. No pericardial effusion.
There are multiple mediastinal lymph nodes, in the prevascular,
peritracheal, and subcarinal regions. The largest discrete lymph
node appreciated is in the subcarinal region, measuring 1.1 cm
in short axis dimension. There is lymphadenopathy of the right
hilum, which is not well evaluated due to the lack of IV
contrast. The lungs are difficult to evaluate due to the degree
of respiratory motion and patchy ground-glass opacity. However,
a few peripheral nodular densities are appreciated bilaterally.
There is a 3-mm nodule within the right mid lung, as is seen on
series 2, image 29. There is a 3-mm nodule within the right
middle lobe, as seen on image 38. There is a 5-mm nodule within
the left mid lung, as seen on image 26. Ground glass opacity in
the lungs bilaterally may represent edema. The central airways
are patent. No significant axillary adenopathy. Within the left
breast, there is a rounded soft tissue density lesion measuring
0.9 x 1.3 cm.
CT OF THE ABDOMEN WITHOUT CONTRAST: The liver, gallbladder,
spleen, pancreas, and adrenal glands are normal. There is a
large soft tissue density lesion on the left kidney, measuring
9.7 x 8.5 cm in greatest axial dimensions. Some areas of this
lesion measure roughly 20 Hounsfield units, of simpler
proteinaceous fluid attenuation. Other areas are higher in
attenuation, consistent with soft tissue or blood. The mass is
extremely suspicious for renal cell carcinoma. There is
enlargement of the central left renal vein, which raises the
possibility of involvement. There are enlarged retroperitoneal
lymph nodes. Within the mid portion of the right kidney, there
is a low attenuation lesion consistent with a cyst. Contrast is
being excreted from the kidneys bilaterally, likely from the
recent cardiac catheterization. The aorta is of normal caliber
and is calcified, its branches are calcified as well. No free
air or free fluid within the abdomen. Stomach and small bowel
loops are unremarkable. Colonic diverticula are seen.
CT OF THE PELVIS WITHOUT CONTRAST: There is residual contrast
within the bladder. There is a Foley catheter within the
bladder, and air, which likely is related to instrumentation.
The rectum, and uterus are unremarkable. There is sigmoid
diverticulosis, without evidence of diverticulitis. No free
pelvic fluid, and no pathologically enlarged pelvic or inguinal
lymph nodes. There is a right femoral venous catheter in place.
BONE WINDOWS: There is likely a hemangioma within the L1
vertebral body. There is a bone island within the left inferior
pubic ramus. There are degenerative changes of the spine.
IMPRESSION:
1. Left renal mass, incompletely characterized on this study is
indicative of renal cell carcinoma.
2. Mediastinal, hilar, and retroperitoneal lymphadenopathy.
3. Small bilateral pleural effusions.
4. Coronary artery calcifications.
5. Ground glass opacity within the lungs bilaterally, possibly
representing pulmonary edema.
5. At least three nodular opacities within the lungs bilaterally
and peripherally. The lungs are otherwise not well evaluated,
however, due to respiratory motion.
6. Soft tissue density rounded lesion within the left breast.
Correlation with mammogram is suggested.
.
[**2101-11-5**]: MRI Abdomen:
FINDINGS: There is an 11.0 x 11.7 x 10.4 cm heterogeneously
enhancing mass arising from the mid left kidney. This mass has a
large necrotic center. It demonstrates regions of signal drop
out on out-of-phase sequences, suggesting intravoxel fat.
Findings are consistent with a renal cell carcinoma, likely a
clear cell given the presence of intravoxel fat. This mass is
multilobated with probable invasion of the perirenal fat. In
addition, there is possible extension to the posterior flank
wall. There is no evidence for renal vein invasion. Of note,
there is a large retroaortic left renal vein, which is formed by
the confluence of 2 large extra-pelvic renal veins approximately
3.5 cm proximal to the IVC. No renal vein tumor. Large
retroperitoneal collateral veins were seen as well. Single renal
arteries are identified bilaterally.
Lung bases show small bilateral effusions and bibasilar
atelectasis. No focal liver lesions are identified. The
gallbladder, pancreas, spleen, and adrenal glands are
unremarkable. The visualized bowel is normal, and there is no
significant free fluid or lymphadenopathy. Several hemangiomas
are incidentally noted throughout the lumbar spine and sacrum.
IMPRESSION: 11.0 x 11.7 x 10.4 cm heterogeneous mass arising
from the left kidney. Findings consistent with a renal cell
carcinoma, likely clear cell type given its signal
characteristics. Probable extension into the perirenal fat and
possible extension to the left posterior flank wall. No evidence
for renal vein invasion or significant lymphadenopathy.
Retroaortic renal vein fed by 2 large renal veins extending
beyond the left renal pelvis. No renal vein tumor.
.
[**2101-11-6**]: CT Head w/ contrast
- NO intracranial hemorrhages or masses
.
[**2101-11-6**]: CT chest w/ contrast:
IMPRESSION: 1) Multiple lung nodules smaller than 5 mm. Lung
nodules of this appearance and size in patients without
malignancy generally represent benign findings; however, in the
presence of a large left renal mass, the nature of these lesions
are indeterminate.
2) 11 cm extremely vascular left renal mass. This study was not
performed for the purposes of staging an intra-abdominal mass.
3) Borderline mediastinal lymph node enlargement. No hilar
adenopathy.
4) 1.7 cm wide aspiration or pneumonia, right lung apex.
4) Heavily calcified aortic valve and mitral annulus, coronary
atherosclerosis. Stable cardiomegaly
.
[**2101-11-8**]:
STORY: PT WITH L RENAL MASS ,CONCERNING FOR RCC ,ASSESS FOR
METASTATIC LESIONS
INTERPRETATION:
Whole body images of the skeleton were obtained in anterior and
posterior
projections.
Increased tracer uptake is seen approximately at T1, which is
consistent with a collapsed vertebra as seen on a recent CT
examination. Scoliosis and
degenerative changes are seen along the spine.
The kidneys and urinary bladder are visualized, the normal route
of tracer
excretion.
IMPRESSION: No definite evidence of osseous metastatic disease
Brief Hospital Course:
78 year old female with history of MI, rheumatoid heart disease
presented with aortic stenosis in AFib who was found to have a
newly discovered renal mass on AbdCT.
.
# Cardiac:
On admission from OSH, patient was sent for cardiac cath which
revealed:
1. Moderate one vessel coronary artery disease.
2. Elevated right and left sided filling pressures.
3. Severe aortic stenosis.
4. Normal ventricular function.
5. 2+ mitral regurgitation.
.
She also had an Echocardiogram which demonstrated:
The left atrium is markedly dilated. No atrial septal defect is
seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function
is normal (LVEF 70%). Right ventricular chamber size and free
wall motion are
normal. The ascending aorta is mildly dilated. There are focal
calcifications
in the aortic arch. The aortic valve leaflets are severely
thickened/deformed.
There is severe aortic valve stenosis. Mild (1+) aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve
prolapse. There is severe mitral annular calcification. There is
moderate
thickening of the mitral valve chordae. Moderate to severe (3+)
mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
.
This coronary anatomy was not significantly different from
[**2100-3-5**]. She was then admitted to the CCU on levophed and
transfused for a Hct goal of 28. Cardiac surgery was consulted
for AVR/CABG. However, with the finding of her renal mass, her
surgery was postponed. Urology was consulted and she had staging
of her mass with Chest, Abdomen and Pelvis imaging. She also had
an MRI to better delineate the mass. It was felt that she had a
renal cell carcinoma. Urology felt that her aortic stenosis
needed to be fixed before any abdominal resection of the mass
could be attempted. Hence, follow up was arranged for her with
Dr. [**Last Name (STitle) **] as an outpatient. In addition, GU oncology would have
to be consulted regarding her lung masses (i.e., re: the
potential of metastatic RCC).
# Rhythm:
She was placed on amiodarone for AFib. Anticoagulation was held
for surgery and [**12-29**] renal mass and question of bleeding into
mass (as patient had a small Hct drop). Her ASA was increased to
325 daily for some anticoagulation
.
#Ischemia:
- No significant ischemia by cath on [**11-3**]
- 50% occ of LAD
- on ASA, Statin, BB
.
#Pump:
- Patient wanted to wait until after [**Holiday **] to undergo
surgery for her aortic stenosis.
.
# Renal Mass:
- 9.8 x 8 cm mass - contrast flowing through kidney per CT
report. Urology input as above. Bone Scan for metastasis work up
was negative.
.
# Fever/UTI:
PAtient was found to have a temp to 101.6 via rectum -> culture
x 2 sent
She was found to have a UTI and was started on Levaquin. Blood
cultures were negative, but urine cultures eventually grew out E
Coli, which was sensitive to Levoquin. Afebrile for 72 hours
prior to discharge. Finished 5 day course of levoquin.
.
# Respiratory Distress:
- This was likely a mixture of poor forward flow and fluid
overload. She responded to Lasix and diuresed well with
improvement in her symptoms. Atrovent nebs.
.
# Anemia:
- Hct 28 at OSH. Hct stable from [**Date range (1) 54629**] after transfusion.
.
.
# Hypothyroidism:
- cont synthroid
.
# CODE: Full
.
# Dischrage: She was discharged with the plan of following up
with HemeOnc and Urology regarding her renal mass. She also
wanted to delay her surgery. Date to be planned between patient
and CT surgery. Patient was HD stable on discharge.
Medications on Admission:
Synthroid 75mcg daily
Plavix 75mg daily
ASA 81mg daily
Fosamax 70mg q Sunday
Vitamin E
Lipitor: 80
Furosemide
Metoprolol
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
Disp:*4 Tablet(s)* Refills:*2*
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO TID, the
[**Hospital1 **], then daily for 2 weeks: On [**11-9**]: Take 400mg every 8 hours
(3 doses total for the day)
--------
from [**Date range (1) 54630**]: Take 400mg at 8 AM and at 8 PM (or at times
that are 12 hours apart)
------
From [**Date range (1) 54631**]:
Take 400mg once daily
---------.
Disp:*24 Tablet(s)* Refills:*0*
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start on [**2101-11-24**]
keep taking until instructed to stop per cardiologist.
Disp:*30 Tablet(s)* Refills:*2*
13. 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*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary Diagnosis:
Critical Aortic Stenosis
.
Secondary Diagnosis:
Renal Mass 11x10cm
Discharge Condition:
Chest pain free
Afebrile
AAOx3
Discharge Instructions:
Please contact your PCP or call the emergency room if you
develop chest pain, shortness of breath, fevers or other
concerning symptoms.
.
Please keep the follow up appointments listed below
.
Please follow the medication regimen that we have listed below.
.
You surgery has been scheduled for the [**3-23**]. Please
follow the instructions of the Heart surgeons. Please call them
(Dr. [**Last Name (STitle) **] - see number below if you need to speak with them.
.
Please stop taking the plavix(clopidogrel) in preparation for
your surgery.
Followup Instructions:
If you have Questions for Dr. [**Last Name (STitle) **] (the heart surgeon)
regarding your Aortic Valve surgery, his office # is
[**Telephone/Fax (1) 170**].
.
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**]
Date/Time:[**2101-12-9**] 10:00
.
You have the following appointment with the oncologist regarding
the Kidney mass: (the two people are the renal attending and the
fellow)
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2101-11-14**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2101-11-14**] 3:00
.
Please call your PCP for [**Name Initial (PRE) **] follow up appointment in the next
7-10 days.
Completed by:[**2102-4-15**]
|
[
"401.9",
"414.01",
"244.9",
"733.00",
"593.9",
"599.0",
"396.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"37.23",
"88.56",
"88.53",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15329, 15400
|
9587, 13365
|
289, 315
|
15530, 15563
|
2168, 9564
|
16151, 16999
|
1731, 1735
|
13537, 15306
|
15421, 15421
|
13391, 13514
|
15587, 16128
|
1775, 2149
|
239, 251
|
343, 1296
|
15488, 15509
|
15440, 15467
|
1318, 1655
|
1671, 1715
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,097
| 169,453
|
1445
|
Discharge summary
|
report
|
Admission Date: [**2172-7-24**] Discharge Date: [**2172-9-22**]
Date of Birth: [**2115-9-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Intubation
Multiple lumbar punctures
Gastro-jejunal feeding tube placement
History of Present Illness:
The patient is a 56M w/ HIV/AIDS, h/o cryptococcal meningitis
who presents with 5 days of headache and photophobia as well as
intermittent nausea/vomiting over the past 2 days. He feels the
headache is very similar to his symptoms when he was diagnosed
with cryptococcal meningitis in [**10-13**], with generalized pain over
the crown of his head that has been persistent and accompanied
occasionally by nausea and vomiting. He was referred to the ED
by his PCP where an LP was done with an opening pressure of 21,
215 WBC with 25% neutrophils, 67% lymphs, protein 101, glucose
59. Gram stain did not show any organisms but CSF cryptococcal
antigen waws positive. Non-contrast head CT was unremarkable. He
did not note fevers at home but had a fever to 101. ID was
consulted and recommended covering for bacterial meningitis as
well as for Listeria, HSV, and cryptococcal meningitis. He was
admitted to medicine for further management.
ROS:
-Constitutional: []WNL []Weight loss [x]Fatigue/Malaise []Fever
[]Chills/Rigors []Nightsweats []Anorexia
-Eyes: []WNL []Blurry Vision []Diplopia []Loss of Vision
[x]Photophobia
-ENT: [x]WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose
[]Tinnitus []Sinus pain []Sore throat
-Cardiac: [x]WNL []Chest pain []Palpitations []LE edema
[]Orthopnea/PND []DOE
-Respiratory: [x]WNL []SOB []Pleuritic pain []Hemoptysis []Cough
-Gastrointestinal: [x]WNL []Nausea []Vomiting []Abdominal pain
[]Abdominal Swelling []Diarrhea []Constipation []Hematemesis
[]Hematochezia []Melena
-Heme/Lymph: [x]WNL []Bleeding []Bruising []Lymphadenopathy
-GU: []WNL []Incontinence/Retention []Dysuria []Hematuria
[]Discharge []Menorrhagia
-Skin: [x]WNL []Rash []Pruritus
-Endocrine: [x]WNL []Change in skin/hair []Loss of energy
[]Heat/Cold intolerance
-Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain
-Neurological: []Numbness of extremities []Weakness of
extremities []Parasthesias []Dizziness/Lightheaded []Vertigo
[]Confusion [x]Headache
-Psychiatric: [x]WNL []Depression []Suicidal Ideation
-Allergy/Immunological: [x] WNL []Seasonal Allergies
Past Medical History:
1. HIV/AIDS: Dx ~16 years ago. Resumed ARVs in [**10-13**], followed by
Dr. [**Last Name (STitle) **] at [**Hospital6 **]
2. Hodgkin's lymphoma (stage IV); Dx [**2165**], treated with
Adriamycin, bleomycin, vinblastine, and dacarbazine x6 months
without any relapse.
3. Asthma.
4. Syphilis s/p rx with penicillin
5. High-grade anal squamous lesions/dysplasia s/p resection in
[**2167**].
6. cryptococcal meningitis [**10-13**], treated with Ambisome and
flucytosine (2 weeks) followed by fluconazole x 10 weeks
Social History:
Works as a handyman/carpenter. Lives with his dog on a boat on
Naponset River near [**Location (un) 686**]. Lives in an apartment [**Location (un) 8608**] during winter.
Tobacco: smokes 1ppd, approximately 30 pack-year history, has
only been able to quit for a few months at a time occasionally
Alcohol: consumes occasionally
No drugs
Family History:
No Fhx of brain cancer.
Father ?????? passed away from GI malignancy NOS.
Mother ?????? alive, healthy
3 healthy sisters; no children
Physical Exam:
Physical Exam:
Appearance: NAD
Vitals: T: 99.1 BP: 126/63 HR: 74 RR: 18 O2: 99% RA
Eyes: EOMI, PERRL, conjunctiva clear, noninjected, anicteric, no
exudate
ENT: MMM, scattered white spots in oropharynx
Neck: No JVD, no LAD, full range of motion
Cardiovascular: RRR, nl S1/S2, no m/r/g
Respiratory: CTA bilaterally, comfortable, no wheezing, no
ronchi, no rales
Gastrointestinal: soft, non-tender, non-distended, no
hepatosplenomegaly, normal bowel sounds
Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint
swelling, no edema in the bilateral extremities
Neurological: Alert and oriented x3, fluent speech, no pronator
drift, no asterixis, sensation WNL, CNII-XII intact
Integument: warm, no rash, no ulcer
Psychiatric: appropriate, pleasant
Hematological/Lymphatic: No cervical, supraclavicular, axillary,
or inguinal lymphadenopathy
Pertinent Results:
IMAGING
MRI OF SPINE [**8-20**]- Diffuse leptomeningeal enhancement throughout
the cord and cauda equina keeping with patient's known history
of meningitis. No other focal lesions or extramedullary fluid
collections identified. No findings of discitis/osteomyelitis.
MRI OF HEAD [**8-20**]- New abnormal perivascular (early pseudocysts)
and leptomeningeal enhancement involving the left internal
capsule, cerebellar folia, bilateral internal auditory canals,
and bilateral trigeminal nerves. Given clinical history this is
consistent with cryptococcal meningeal inflammation. No focal
mass lesion identified.
Repeat MRI head [**9-12**]
1. New moderate edema in the right frontal lobe surrounding the
ventriculostomy catheter. Only minimal linear contrast
enhancement along the ventriculostomy catheter, which is
nonspecific. However, early cerebritis in this immunocompromised
patient cannot be excluded, as discussed above.
2. Decreased extent and intensity of preexisting leptomeningeal
enhancement, including cranial nerve enhancement, and
perivascular space enhancement.
3. Stable size of the ventricles without evidence of dilatation.
No evidence of periventricular or intraventricular blood
products.
CSF STUDIES
POSITIVE FOR CRYPTOCOCCAL ANTIGEN. [**2172-8-15**]
The following is his LP history since admission:
[**7-24**] OP 21; WBC 215 (25P/67L); prot 101; crypto antigen +, cx
neg
[**7-27**] Failed LP
[**7-28**] OP 38. WBC 185 (49P/33L); prot 145; cx neg
[**7-29**] OP 41; WBC 255 (23P/57L); prot 145; cx neg
[**7-30**] OP 45; WBC 17; cx neg (8P/82L); cx neg
[**7-31**] WBC 140; prot 104; CoNS 1 colony
[**8-1**] OP 40; WBC 340; cx neg
[**8-2**] WBC 98
[**8-3**] WBC 120; cx neg
[**8-6**] OP 37; WBC 170; prot 223; cx neg
[**8-8**] OP 39; WBC 250; prot 178; cx neg
[**8-9**] OP 42; WBC 220; prot 175; cx neg
[**8-10**] WBC 260 (48P/45L); prot 183; cx neg
MICRO
POSITIVE FOR CRYPTOCOCCAL ANTIGEN. SERUM [**8-18**]
RPR [**8-20**] negative
[**9-8**]: HIV VL undetectable
[**9-15**]: CMV VL negative
CMV IGG positive, IGM negative
[**2172-9-5**] 1:42 am URINE Source: Catheter.
**FINAL REPORT [**2172-9-7**]**
URINE CULTURE (Final [**2172-9-7**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
LABS AT DISCHARGE
133 / 94 / 27
-------------112
4.7 \ 33 \ 1.4
Ca: 9.1 Mg: 2.3 P: 3.4
.
WBC 8.3 N:67.8 L:22.2 M:5.5 E:4.0 Bas:0.4
Plt 226
Hct 26.5
[**2172-9-21**]
UA
Source: CVS
Color
Yellow Appear
Clear SpecGr
1.014 pH
8.0 Urobil
Neg Bili
Neg
Leuk
Sm Bld
Neg Nitr
Neg Prot
Neg Glu
Neg Ket
Neg
RBC
0-2 WBC
21-50 Bact
Few Yeast
None Epi
[**4-9**]
Brief Hospital Course:
Pt is a 56 yo M with HIV and recurrent cryptococcal meningitis
on fluconazole complicated by continued nausea, vomiting,
headaches. Now s/p lumbar drain placement on [**8-28**] with long
complicated medical course including MICU stay and now stable
for rehab s/p G-J placement for medication administration of HIV
medications and nutrition.
MICU COURSE
On the morning of [**2172-8-11**], the patient had an unsuccessful LP and
worsening mental status. Because of this, he had another lumbar
drain placed and was transfered to MICU. There was concern
about his need for close nurse monitoring, his intractible
nausea/vomiting, and his need for frequent potassium
supplementation. On his admission to the MICU, the patient was
oriented but had some slurring of speech. Based on his previous
failed attempts to get an MRI, it was decided to electively
intubate the patient for an MRI of his brain and spine. In the
MICU he was intubated for airway protection/MRI from [**Date range (1) 8609**].
He had MRI head and spine which showed leptomeningeal
involvement. His LP drain broke and the patient was febrile,
thus preventing a new one from being placed. ID recomended
starting acyclovir and vancomycin prophylaxis given staph epi
positive cultures in CNS. His abx treatment for meningitis was
also modified to ambisome and flucoazole, while flucytizine was
d/cd. Initially a NG tube was placed but he self removed. CT abd
was negative. Patient was successfully extubated and transferred
back to medical floor on [**8-16**].
# Cryptococcal meningitis: Pt was found to have recurrence of
cryptococcal meningitis by positive CSF cryptococcal antigen
test at a titer of >1:64. Gram stain was negative. Pt previously
admitted for cryptococcal meningitis in [**9-12**] and treated for 9
days with Ambisome and Flucytosine (14 days) followed by
Fluconazole for >10 weeks. On this admission the patient was
seen by ID and was empirically started on vancomycin,
ceftriaxone, azithromycin, and Ambisome to cover for bacterial
meningitis, Listeria, HSV, and cryptococcus. Other cultures were
found to be negative including HSV, so the patient was continued
only on Ambisome. Flucytosine was held intially given the
patient's ARF (worst Cr 1.9 on [**7-29**]). ARF improved and switched
to Flucytosine [**2163**] mg PO q8h and Ambisome 400 mg IV q24h -
finished 2 week course for induction therapy. However,
administration of Flucytosine has proven to be difficult
secondary to the patient's frequent emesis and overall poor
toleration for PO intake. The patient's course has further been
complicated by persistently elevated ICP. Serial LPs have
attempted to remove 20cc/day of CSF fluid. Has been on
Fluconazole 800mg IV daily rom [**Date range (1) 8610**] for consolidation
phase and then switched to maintenance dose Fluconazole at 400
mg PO q24h for the next 4 weeks ([**9-10**] - [**10-7**]). Then plan is to go
to 200mg Fluconazole daily for life for ppx/suppression, per ID
recs. Patient on IV morphine and fentanyl patch for pain
control. He has follow up with [**Hospital 8611**] clinic for repeat LP and
follow up of his cryptococcal meningitis.
# CMV detectable in CSF: Patient with positive CMV in CSF with
negative VL in serum and no active evidence of CMV encephalitis
by exam, quantitative levels, and per discussion at ID HIV
multidisciplinary rounds. During hospital stay had 2 ophtho
exams negative for retinitis. MRI with new moderate edema in R
frontal lobe around ventriculostomy cath, and nonspecific
minimal linear contrast along the cath; no periventricular blood
products. Plan to follow up in [**Hospital **] clinic. Baseline mental
status is AOx2 (not to date) with appropriate answers with
slightly slow speech.
.
#FEN: PICC line / In terms of nutrition, patient unable to take
consistent PO due to nausea and vomiting from meningitis. s/p
Dobhoff placement [**2172-9-8**]; expelled [**2172-9-10**]. Fluids were given;
TPN started at beginning of [**Month (only) 205**] until G-J tube placement by IR
on [**2172-9-16**].
Per neurosurgery, patient had vanc/zosyn x 3 days periprocedure
with first dose within 2 hours prior to incision. Per ID,
vancomycin is reasonable for coverage of skin flora for
procedure. Prior to discharge, patient was able to tolerate tube
feeds and administration of medications by G-J tube without
problems. Tube feeds at: Fibersource HN Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q6h Goal rate: 75
ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 150 ml water q6h
.
Of note, prior to discharge, the patient's free water boluses by
TF were increased to 150cc to increase hydration as BUN/Cr
slightly trending upwards to BUN 27/ Cr 1.4. Please recheck
lytes and give IV fluids or increase hydration through TF to
keep patient at baseline BUN low 20s and Cr 1.1-1.3.
.
# s/p low grade temperature: Patient with low grade temp to max
100.3 on [**9-20**] overnight but temperature has decreased without
treatment (at discharge has been ranging 98-99) with no overt
signs of infection. No leukocytosis or left shift. Increased eos
[**3-9**] possible drug reaction. UA obtained on [**9-21**] with epis, some
leuks, WBCs, UCx pending. Patient without suprapubic tenderness
or dysuria. BCx taken are pending with NGTD. Would recommend
repeating UA at rehab and send for UA/UCx and Ueos. If patient
with evidence of UTI, would start 4th generation cephalosporin
to cover for pseudomonal coverage (has been colonized in past).
Also, if spikes temperature, would consider sending patient for
abd CT to r/o abcess, collections given 2 foreign bodies in
abdomen but currently no increased pain or evidence of infection
at VP-shunt or G-J sites.
.
# HIV: During hospital course, the patient was followed by the
ID service. Most recent CD4 count- 164, viral load undetectable
([**9-8**]). Pt was continued on his ARV regimen initially, but it was
discontinued on [**8-4**] secondary to persistent nausea and vomiting
to PO intake per ID. HAART was held until G-J tube placement on
[**9-16**] when it was restarted by G-J tube as concern that
inadequate absorption of medication would lead to resistance.
Patient was continued on bactrim and acyclovir prophylaxis by IV
dosing while unable to administer PO medications. Plan to
continue HAART regimen: darunavir, truvada, enfuvirtide,
raltegravir, ritonavir by G-J tube and prophylactic medications
also by G-J tube. patient has follow up with ID.
***Your antiretroviral medications for the evening of Tuesday
[**9-22**] were given prior to transfer to [**Hospital 8612**] rehab and the
medications will be delivered by UPS by the 8:30am or 10:30am
delivery of Wednesday [**9-23**]. Please call [**Hospital1 778**] pharmacy at
[**Telephone/Fax (1) 8613**] if you have any questions with this medication
delivery.
.
# Anemia: Has been stable between 23-24. Retic count depressed
at 0.8. Vitamin B12 was 264 and folate 6.6 on [**2172-8-3**].
Low Hct likely due to repeated needle sticks over course of
prolonged hospitalization and also anemia of chronic disease.
Patient was started on B12 repletion and Hct remained stable
throughout hospital stay. Please guaic all stools.
.
# Depression: Patient has reported feeling down and depressed
and was started on Remeron on [**9-9**]. No side effects thus far.
Dose increased to 30mg daily on [**9-13**], and patient reports
sleeping well. Patient discharged on 30mg PO remeron at night.
#Access: double lumen PICC line in right arm
# Contacts: [**Name (NI) 8614**] [**Name (NI) 8615**] [**Name (NI) **] [**Telephone/Fax (1) 8616**], [**Name2 (NI) 2808**]
[**0-0-**]
Mom- [**Telephone/Fax (1) 8617**]
Medications on Admission:
Fuzeon 90mg SC q12h
Prezista 600mg po q12h
Isentress 400mg po q12h
Truvatda 1 tab po daily
Norvir 100mg po q12h
Bactrim 1 DS tab po daily
albuterol inh 2puffs q4-6h prn
Atrovent 2 puffs q6-8h prn
Valtrex 500mg 1 tab daily
atovaquone 1500mg daily
oxycodone 5-10mg 30mg prior to Fuzeon injection, up to twice
daily
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Telephone/Fax (1) **]:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for
sob/wheezing.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Telephone/Fax (1) **]: Two (2)
Puff Inhalation Q6H (every 6 hours) as needed for sob/wheezing.
3. Acetaminophen 325 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
4. Lidocaine HCl 2 % Gel [**Telephone/Fax (1) **]: One (1) Appl Mucous membrane PRN
(as needed) as needed for pain.
5. Loperamide 2 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
6. Fentanyl 25 mcg/hr Patch 72 hr [**Telephone/Fax (1) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. Polyethylene Glycol 3350 100 % Powder [**Telephone/Fax (1) **]: One (1) dose PO
DAILY (Daily) as needed for constipation.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Miconazole Nitrate 2 % Powder [**Telephone/Fax (1) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
10. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
injection Injection TID (3 times a day).
11. Dronabinol 2.5 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
12. Cyanocobalamin 500 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
13. Mirtazapine 15 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime) as needed for depression.
14. Ritonavir 80 mg/mL Solution [**Hospital1 **]: One Hundred (100) mg PO BID
(2 times a day): via G-J tube .
15. Enfuvirtide 90 mg Kit [**Hospital1 **]: One (1) Kit Subcutaneous [**Hospital1 **] (2
times a day).
16. Emtricitabine-Tenofovir 200-300 mg Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily): please crush and put in via G-J tube .
17. Raltegravir 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day): please crush and put in via G-J tube .
18. Darunavir 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day): please crush and put in via G-J tube .
19. Acyclovir 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every
12 hours): please crush and put in via G-J tube .
20. Heparin, Porcine (PF) 10 unit/mL Syringe [**Hospital1 **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush: PICC,
heparin dependent: Flush with 10mL Normal Saline followed by
Heparin as above daily and PRN per lumen.
21. Promethazine 12.5 mg IV Q6H
22. Morphine Sulfate 2-4 mg IV Q2H:PRN pain
hold for signs of oversedation or RR<12
23. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension [**Hospital1 **]:
Ten (10) ml PO once a day: per G-J tube.
24. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day: Please mix with water,
and administer by G-J tube.
25. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q24H (every
24 hours): Please crush and administer per G-J tube. Please give
400mg until [**10-7**], then switch to 200mg daily (ongoing for
lifetime ppx) .
26. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: Ten (10) ml PO BID (2
times a day) as needed for constipation.
27. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Month/Day (2) **]: Eight (8) mg
Injection Q8H (every 8 hours).
28. Zolpidem 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary diagnosis
Recurrent cryptococcal meningitis
Secondary diagnosis
Human immunodeficiency virus
Acute renal failure
Anemia
Depression
Discharge Condition:
Stable, feeding tube in place, afebrile.
Discharge Instructions:
You were treated in the hospital for recurrent cryptococcal
meningitis with antibiotics and anti-fungal agents. Because of
persistently elevated intracranial pressures, you had a lumbar
drain placed on [**2172-8-30**], and a ventriculoperitoneal shunt
placed by Neurosurgery on [**2172-9-4**]. You required total
parenteral nutrition due to nausea and vomiting, and on [**9-16**], [**2172**], a feeding tube was placed, allowing enteral
administration of nutrition and medications.
Please continue all your medications except for the following
additions and changes:
- You will need to take fluconazole (anti-fungal) 400mg daily
until [**10-7**], then 200mg daily for lifetime prevention of
cryptococcal meningitis
- You were also started on Remeron for depression, and on
cyanocobalamin (Vitamin B12) supplementation.
In addition to antimicrobial agents, you were treated with
anti-nausea medication and pain medications, with some
improvement in your symptoms.
Your antiretroviral medications for the evening of Tuesday [**9-22**]
were given prior to transfer to [**Hospital 8612**] rehab and the
medications will be delivered by UPS by the 8:30am or 10:30am
delivery of Wednesday [**9-23**]. Please call [**Hospital1 778**] pharmacy at
[**Telephone/Fax (1) 8613**] if you have any questions with this medication
delivery.
Please call your physician if you notice any changes in your
mentation, increased confusion, increased headache, fever,
chills, abdominal pain.
Followup Instructions:
Please see your primary care physician, [**Name10 (NameIs) **],[**Name11 (NameIs) **]
[**Telephone/Fax (1) 798**] on Monday [**10-5**] at 2:40pm.
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**Last Name (STitle) 8618**] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2172-10-7**] 1:00
- you will need a repeat lumbar puncture during this appointment
You have an appointment with Dr. [**First Name (STitle) **] from neurosurgery on
[**10-22**], 2:15 for CT scan in [**Hospital Ward Name 517**] Clinical Center
on [**Location (un) **], then at 3:00pm you have an appointment with Dr.
[**First Name (STitle) **] in [**Hospital Ward Name **] 3rd Fl 3B. ([**Telephone/Fax (1) 8619**]
You have an outpatient follow-up appointment scheduled with Dr.
[**First Name (STitle) **] (Infectious Diseases) at the [**Hospital1 18**] on [**2172-10-2**] at
10:00am.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
|
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icd9cm
|
[
[
[]
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[
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|
[
[
[]
]
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19172, 19246
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7568, 15250
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324, 400
|
19430, 19472
|
4427, 7545
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15614, 19149
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15276, 15591
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19496, 20971
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3574, 4408
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276, 286
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428, 2505
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2527, 3039
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3055, 3393
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,577
| 157,115
|
51378
|
Discharge summary
|
report
|
Admission Date: [**2180-3-14**] Discharge Date: [**2180-4-4**]
Date of Birth: [**2123-11-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
s/p vfib arrest
Major Surgical or Invasive Procedure:
1. Intubation
2. Mechanical Ventilation
3. Femoral line
4. Cardiac catheterization with stenting to LAD
5. Right radial arterial line
History of Present Illness:
Mr. [**Known lastname 3694**] is a 57 year old male with history of mild
hyperlipidemia who presents s/p VF arrest. Pt was playing
basketball, and his legs buckled, and he fell to the ground, and
hit his head. CPR was started at the scene until the EMS
arrived, ~7-10mins per report. When EMS arrived, CPR was
continued, and he was shocked x3, subsequent asystole, and then
into PEA. CPR was continued until he arrived at the [**Hospital1 18**] ED. In
the ED, she was given Epi, Atropine, and Bicarb with return of
pulse. ECG demonstrated STE in V2-V3, aVL...
Placed on arctic sun after CT head negative for ICH and sent to
cath lab. Urine tox positive for opioids, but negative
otherwise. Serum tox negative.
.
In the cardiac cath lab, he was found to have a mid-LAD
completely occluded, with DES x1 placed, with return of good
flow. LCx was without disease, and RCA with 40-50% disease. He
required Levophed on low dose continued during the cath. He was
loaded with Prasugrel in the lab, and continued on Integrillin
for 1 hr.
.
Unable to obtain complete ROS given pt intubated and sedated.
Per his wife, prior to this, he was in his usual state of
health. She denied him reporting and chest pressure, pain, or
SOB. His only recent complaints were a mild knee injury.
Otherwise he had been feeling well. He is quite active and uses
an arc trainer at home. He also plays with his 6 year old son.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- Torn medial meniscus on Right knee
- Elbow injury
Social History:
He lives at home with his wife and 6 year old son. [**Name (NI) **] is
self-employed full-time.
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
Father with CABG at 74 or 75yo, Paternal GF with heart disease
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=34.2C BP=127/83 HR=73 RR=14 O2 sat=98% on ventilator
GENERAL: intubated, sedated, not responding to any commands or
stimuli
HEENT: large L frontal laceration, no active bleeding. Sclera
anicteric. Pupils 1mm, reactive.
NECK: Supple, unable to appreciate JVP given body habitus
CARDIAC: RRR, nl S1 S2, unable to appreciate murmurs over breath
sounds
LUNGS: Intubated, bilateral breath sounds anteriorly, coarse
breath sounds, no wheezes
ABDOMEN: +BS, distended, but soft. Arctic sun pads in place.
EXTREMITIES: cool at distal extremities, arctic sun pads in
place
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
Neuro: intubated, sedated, not responding to painful stimuli,
pupils 1mm, symmetric, reactive; 2-3 beats of clonus
bilaterally, downgoing toes, lipsmacking movements, posturing of
right arm
.
DISCHARGE
Patient died on [**2180-4-4**] in early afternoon.
Pertinent Results:
ADMISSION LABS:
.
DISCHARGE LABS:
.
PERTINENT LABS:
CARDIAC ENZYMES:
A1c 5.8
Lipid Panel: LDL 109 Total 184 TG 135 HDL 48
.
STUDIES:
CARDIAC CATH [**2180-3-14**]:
COMMENTS:
1. Coronary angiography in this left dominant system
demonstrated severe single vessel disease. The LMCA had no
angiographically apparent disease. The LAD had an eccentric 50%
proximal stenosis followed by a mid-occlusion after the 1st
setpal and
diagonal. The 1st diagonal had 50% origin and mid stenoses.
The LCx
was a large, dominant vessel without angiographic CAD. The RCA
was
non-dominant and had a 50% mid-stenosis.
2. Limited hemodynamics revealed a central aortic pressure of
117/82
mmHg while the patient was on 0.03 mcg/kg/min of Levophed.
3. Successful Export Thrombectomy and direct stenting of mid LAD
with
3.0 X 18 mm ENDEAVOR DES at 12 atms, post dilated with 3.0 mm NC
balloon
at 16 atms. Final angiogram showed 0% residual stensosis, no
dissection
and normal flow.
FINAL DIAGNOSIS:
1. Severe one vessel coronary artery disease.
2. Coma post cardiac arrest.
3. Cardiogenic shock.
4. Successful [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAD
FINAL DIAGNOSIS:
1. Severe one vessel coronary artery disease.
2. Coma post cardiac arrest.
3. Cardiogenic shock.
.
CT HEAD W/O [**2180-3-14**]:
IMPRESSION: No acute intracranial process; specifically no
intracranial
hemorrhage.
.
CXR [**2180-3-14**]:
IMPRESSION: Limited study. Probable retrocardiac atelectasis.
ETT in standard position.
.
CXR [**2180-3-15**]:
FINDINGS: As compared to the previous radiograph, the
endotracheal tube might have been minimally advanced. Otherwise,
the radiograph is unchanged, with borderline size of the cardiac
silhouette, partial right upper lobe atelectasis and bilateral
perihilar opacities suggesting mild-to-moderate pulmonary edema.
.
EEG: IMPRESSION: This prolonged continuous EEG showed an
extremely
suppressed background rhythm early on [**2180-3-15**] during
hypothermia treatment. Over the day, the background improved in
voltage
and frequency. By the end, it showed an encephalopathic pattern
with
slow frequencies in all areas. There were no prominent focal
abnormalities. There were no clearly epileptiform features.
.
TTE [**2180-3-15**]:
Conclusions
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
severe regional left ventricular systolic dysfunction with mid
to distal septal, anterior, distal/apical akinesis. The basal
lateral wall moves best. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size is normal. with focal hypokinesis of
the apical free wall. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
MRI [**2180-3-19**]:
IMPRESSION:
Diffusion abnormalities in the biparietal cortex, predominantly
in the medial parietal lobes, compatible with ischemic injury or
post-ictal state.
.
MRI [**2180-3-25**]:
IMPRESSION: Bilateral parietal cortical and subcortical
diffusion
abnormalities are noted which indicate progression to white
matter of the
previously noted ischemic lesions secondary to hypoxic injury.
Bilateral
globus pallidi lesions are also noted. No hemorrhage, mass
effect or
hydrocephalus.
.
CTAP [**2180-3-20**]:
IMPRESSION:
1. 5.8 x 3.2 cm hematoma within the right pelvis may be related
to recent
catheterization procedure. Bilateral fat stranding within the
groins
compatible with instrumentation.
2. Areas of hypodensity and hyperdensity within the left iliacus
and psoas
muscles bilaterally and expansion of the left iliacus. The
increased density suggests this is atleast mostly hemorrhage,
however, given multifocal findings, septic emboli/abscesses are
a consideration.
3. New hyperdense foreign body within the stomach. In a patient
intubated
with feeding tube, foreign body from dental origin is a
possibility.
.
Brief Hospital Course:
HOSPITAL COURSE:
56 yo M with Hx of mild HLD who presents s/p VF arrest, now s/p
cardiac cath with DES to LAD and therapeutic cooling. Pt treated
with AED??????s for seizing s/p re-warming, and found to have anoxic
brain injury. Course complicated by spiking fevers, growing
Haemophilus and E. coli from sputum with concern for aspiration
pneumonia and sinusitis. Pt continued to spike fevers and
antibiotics were broadened. Hospital course also complicated by
anemia multifactorial in origin, s/p 4 units PRBC??????s. Pt then
developed [**Last Name (un) **] [**3-1**] pre-renal etiology. Second neurology opinion
was obtained per family request, and prognosis by two neurology
teams were conflicting. His AED's were temporarily discontinued
due to concern that they may be causing sedation. Keppra was
restarted as pt was having seizures. He continued to demonstrate
poor chance of a meaningful neurologic recovery. On [**2180-4-4**],
Mr. [**Known lastname 103420**] family elected to extubate him and focus on
comfort care.
.
ACTIVE ISSUES:
# S/P VF ARREST, STEMI: Most likely [**3-1**] STEMI and active
ischemia. ECG demonstrating diffuse ST elevations in
inferolateral leads. Pt required several cycles of CPR, shocks
x3, and epi, atropine. Pt s/p DES to mid-LAD as below. He was
placed on arctic sun with q4hr lytes for neuroprotection. He was
managed for STEMI.
Per the wife's report, pt had no previous symptoms to suggest
angina, and had been very active. Received 600mg ASA in ED. Pt
requiring levophed on presentation from cath lab. Pt loaded with
Prasugrel in lab and integrillin. Pt's risk factors included
hyperlipidemia only, on no home meds. Started on Atorvastatin
80mg po daily, Prasugrel 10mg daily, ASA 325mg daily. ACEI and
beta blocker were initially held given hypotension initially
requiring low doses of Levophed. Captopril was started for
afterload reduction; as his BP's tolerated this he was switched
to Lisinopril 2.5 daily. Beta blockade with metoprolol 12.5mg
[**Hospital1 **] was started. A1c was checked for risk stratification and was
5.8; lipids were checked and showed LDL 109. He was continued on
Atorvastatin 80mg daily. His cardiac function appeared to have
recovered appropriately; unfortunately he continued to
demonstrate poor chance of a meaningful neurologic recovery. On
[**2180-4-4**], Mr. [**Known lastname 103420**] family elected to extubate him and
focus on comfort care.
.
# Hypoxic Brain Injury: Review of MRI by both radiology and
neurology concerning for extensive hypoxic injury. MRI
demonstrated diffusion abnormalities in the biparietal cortex,
predominantly in the medial parietal lobes, that were compatible
with ischemic injury or post-ictal state. Family requested
second neurology opinion, and per Dr. [**Name (NI) 1693**], pt??????s prognosis may
not be as poor as initially thought. Per Dr. [**Last Name (STitle) 1693**], possibly
that AED??????s could be contributing to pt??????s mental state. AED's
were then held, temporarily, but restarted given continued
seizure activity. Repeat MRI revealed progression of ischemic
damage. He continued to demonstrate poor chance of a meaningful
neurologic recovery. On [**2180-4-4**], Mr. [**Known lastname 103420**] family elected
to extubate him and focus on comfort care.
.
# Seizures: Pt was found to have seizure activity on EEG after
re-warming. Neurology and Epilepsy were consulted. He was loaded
with Keppra; however, he continued to seize and was loaded with
Fosphenytoin. Dilantin levels were checked. MRI was done, which
showed diffusion abnormalities in the biparietal cortex,
predominantly in the medial parietal lobes, compatible with
ischemic injury or post-ictal state.
As above, AED's were briefly held, and then restarted given
continued seizure activity. Rest as noted above.
.
# Respiratory distress: Pt intubated for inability to protect
airway in setting of VF arrest. He was kept on mechanical
ventilation with settings titrated based on ABG's. His seizure
activity and myoclonus would trigger breaths on the mechanical
ventilator this he required propofol to facilitate ventilation.
On [**2180-4-4**], Mr. [**Known lastname 3694**] was extubated in keeping with his
living will and his family's wishes.
.
# Fevers, Leukocytosis: During re-warming, pt had elevated
temperature. Pt was cultured. He eventually spiked a fever, and
cultures were re-sent. Sputum cultures grew out Haemophilus.
MRI also suggested sinusitis as possible source. He was treated
with IV Zosyn. He continued to spike fevers, and WBC climbed
from 10, to 16 to 27. Likely pulmonary source, possibly
aspiration given now speciation of E. coli from sputum. Pt also
growing Haemophilus, and likely sinusitis by MRI. The CT scan
from [**3-20**] also suggestive of possible septic emboli, but thought
to be unlikely. Concern for C. diff given sig leukocytosis, but
negative. He was treated with Vanc/Zosyn/Gent to cover for VAP.
Other possible sources included abdominal given question of
septic embolic on CTAP. ID was consulted. Gent was dc'd given
worsening renal function, and Cipro was started. Zosyn was
switched to Cefepime given MIC of 8 to Unasyn. ID signed off
after goal of care transitioned to comfort care.
.
# Anemia: Multifactorial [**3-1**] UGIB on admission, possibly
continued gastritis given guaiac positive stools (though no
frank blood), phlebotomy, and inadequate production of RBC??????s
with low retic count. Pt also had a CTAP to look for bleed,
which showed small hematomas. Pt had also been on multiple
myelosuppressive medications including zosyn and phenytoin.
Hemolysis labs were negative. Heparin gtt was dc??????d [**3-22**]. Hct
continued to drop, and he was transfused 2 units PRBC??????s [**3-22**],
with appropriate bump in Hct. Concern for continued bleeding
into abdomen given significant cont??????d drop in Hct. Serial Hct's
showed drop, with no further clear source. He was transfused an
add'l 2 units of PRBC's, for a total of 4 units. His Hct
remained stable.
.
# PUMP: Pt presented in VF arrest. Unknown prior EF, though pt
with no symptoms per his wife of orthopnea, SOB, etc. CXR looked
like fluid overload, which would not be surprising given STEMI
in LAD region. TTE showed severely depressed EF of 15% with
severe LV dysfunction. Pt had been s/p several cycles of shocks,
and was thought to at least in part have stunned myocardium. He
was started on heparin gtt given apical akinesis and concern for
stroke. Captopril was started, which he tolerated, and was
switched to Lisinopril 2.5mg daily. Metoprolol 12.5mg [**Hospital1 **] was
started as above. Pt auto-diuresed initially, but required IVF
given fevers as above. Repeat TTE showed improved LVEF of 50%.
.
# RHYTHM: As above, presented s/p VF arrest. Pt in sinus with
prolonged PR interval s/p cath. Pt intermittently going into
Vtach after cath. However, rhythm switched to afib on repeat ECG
overnight. On morning of hospital day 1, pt continued to be in
Afib with hypotension, cardioverted with conversion to sinus.
However, pt was then bradycardic, likely [**3-1**] cooling. EP was
consulted. He was started on Lidocaine and Amiodarone gtt.
However, Lidocaine was discontinued given that Amiodarone was
preferred in the context of reperfusion. He was switched to po
amiodarone load. Dopamine was initially given for bradycardia
and hypotension, but weaned off.
He continued on po Amiodarone and remained in sinus rhythm.
.
# [**Last Name (un) **]: Pt??????s Cr bumped from 1.1 to 1.6 on the morning of [**3-23**]
after continued fevers. Thought to be pre-renal in etiology
given diaphoresis and fevers. Ulytes showed FeNA <1%. His UOP
was monitored, and he continued to put out good urine. His
creatinine improved. Gentamycin was dc'd as above. His Cr was
trended and remained stable.
.
# UGIB: Pt had 150cc dark red blood coming up from OGT on
admission, concerning for UGIB. Most likely [**3-1**] to integrillin,
prasugrel and possible gastritis. GI was consulted. Pt had NG
lavage with clearing of blood. Hct's were checked frequently,
and remained stable. He was placed on PPI drip initially, which
was switched to IV BID PPI once Hct stable. H. pylori was sent,
and was negative. GI was consulted prior to starting heparin
gtt. Given that he was not stable for endoscopy, recommended
proceding with heparin as long as pt didn't rebleed. Rest as
above under "Anemia."
.
# HEAD LACERATION: The patient sustained a head laceration on
his original fall prior to admission. Plastics was consulted,
and placed several deep and superficial sutures. Bacitracin was
applied for one day and then dry dressing applied. Sutures were
removed.
Medications on Admission:
- Glucosamine
- Chondroitin
- Mucinex
- Advil prn
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient Expired
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
|
[
"276.2",
"427.1",
"873.42",
"V49.86",
"V66.7",
"285.1",
"276.0",
"790.01",
"348.1",
"E888.9",
"410.91",
"785.51",
"570",
"584.9",
"414.2",
"414.01",
"578.9",
"414.8",
"427.5",
"E007.6",
"482.82",
"427.31",
"272.4",
"518.81",
"780.39",
"275.41",
"507.0",
"E934.8",
"780.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"96.72",
"00.66",
"37.22",
"88.56",
"00.40",
"96.04",
"38.91",
"96.6",
"36.07",
"38.93",
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
16642, 16651
|
7851, 7851
|
319, 454
|
16710, 16727
|
3516, 3516
|
16791, 16809
|
2344, 2522
|
16602, 16619
|
16672, 16689
|
16528, 16579
|
7868, 8880
|
4690, 7828
|
16751, 16768
|
3551, 3553
|
2562, 3497
|
1991, 2067
|
3587, 4482
|
264, 281
|
8895, 16502
|
482, 1881
|
3533, 3535
|
3569, 3569
|
2098, 2151
|
1903, 1971
|
2167, 2328
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,776
| 126,824
|
14588
|
Discharge summary
|
report
|
Admission Date: [**2129-11-29**] Discharge Date: [**2129-12-7**]
Date of Birth: [**2057-10-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tegretol / Spironolactone
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Fever
Reason for MICU transfer: AMS
Major Surgical or Invasive Procedure:
CVVHD
History of Present Illness:
This is a 72 year-old male with PMH of diastolic heart failure
with an EF=65%, AS s/p mechanical AVR, AF on coumadin, CAD s/p
CABG, pulmonary hypertension, 3rd degree heart block s/p PPM,
severe COPD, with recent prolonged hospitalization for MRSA
bacteremia who was sent in from [**Hospital **] clinic with fevers.
His most recent medical course dates back to [**Month (only) 359**]/ [**2129**] when
the patient was admitted with MRSA bacteremia secondary to a
PICC line. Hospital course complicated by left prostethic hip
seeding requiring OR washout and prolonged post-op course of
intubation that was complicated by several infections:
Pseudomonal pneumonia +/- upper resp tract infection; Prevotella
bacteremia; and tunneling sacral wound. Hospital course also
c/b ARF with Cr peaking at 3.9. Eventually the patient was
extubated and d/ced to LTAC with plan to continue vancomycin IV
x 6weeks and then a prolonged oral course of antibiotics.
Rehab course was c/b worsening L hip pain with evidence of
dislocation on an X-ray taken at his LTAC. He was hospitalized
again briefly for relocation of hip with recommendations to
continue an abduction pillow between his legs until his follow
up appointment on [**12-6**].
The patient was at a routine follow up appointment at [**Hospital **] clinic
when found to have fever, tachypnea and AMS. Per ID fellow,
vancomycin should be changed to linezolid with addition of
colisitin and Doripenem. In the ED, initial VS 100.5 HR:88
BP:115/44 Resp:24 O(2)Sat:98. CXR showed volume overload and
worsening b/l patchy infiltrates c/w volume overload vs.
infection.
Past Medical History:
-CAD s/p 2V CABG
-HTN
-HLD
-Severe diastolic CHF (EF >60% [**2129-2-7**])
-Pulmonary Hypertension
-A fib on coumadin
-Hx of 3rd degree block s/p PPM, currently V-paced
-Hx of AS s/p AVR with [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] Mechanical Valve ([**2116**])
-COPD
-Hx of CVA c/b seizure DO, on lamictal
-Diet-controlled DM
-Chronic Kidney Injury
-Chronic lethargy and confusion with concern for Dementia
-Focal disection of abd aorta - noted CT abdomen [**2126-10-16**]-
unchanged from [**2124**]
-BPH (no difficulty voiding)
-s/p L ORIF and THR [**9-/2128**]
Social History:
Prior to [**2130-10-7**] admission he lived with wife and youngest
son, [**Name (NI) 43025**] [**Name (NI) **], in a two story home. He is a retired newpaper
journalist and English professor; He moved to the U.S.A. in
[**2098**], but returned to [**Country 11150**] to work. He returned here
permanently in [**2120**]. He does not currently smoke, but quit 10
years ago with an 80 pack year history.
Family History:
Per OMR. There is a family history of CAD. All sisters and
brothers are deceased.
Physical Exam:
Physical Exam on Arrival to [**Hospital Unit Name 2112**]: Temp: 98.9 BP: 102/44 HR: 81 RR:29 O2sat 99%
GEN: cachectic,
HEENT: PERRL, EOMI, anicteric, very dryMM, poor dentition, no
supraclavicular or cervical lymphadenopathy, neck vein engorged
but flatten with inspiration,
RESP: no accessory muscle use, mildly tachypneic, good air
movement throughout, rhonchi laterally at R base
CV: mechanical heart sounds, regular rate, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: warm, no clubbing or edema
SKIN: tunneling sacral ulcer, venous stasis changes on bilateral
distal legs
NEURO: Drowsy, arousable to verbal stimuli, follows commands
slowly, inattentive, is oriented to person and hospital, Cn
II-XII intact. 5/5 strength throughout. No sensory deficits to
light touch appreciated. No pass-pointing on finger to nose.
2+DTR's-patellar and biceps
RECTAL: Guaiac negative
Pertinent Results:
[**2129-11-29**] 06:20PM BLOOD WBC-10.8 RBC-2.40* Hgb-7.0* Hct-22.7*
MCV-95 MCH-29.3 MCHC-31.0 RDW-19.7* Plt Ct-324
[**2129-11-29**] 06:20PM BLOOD Neuts-85.5* Lymphs-8.5* Monos-3.7 Eos-2.0
Baso-0.3
[**2129-11-29**] 06:20PM BLOOD PT-18.4* PTT-64.5* INR(PT)-1.7*
[**2129-11-29**] 06:20PM BLOOD Glucose-165* UreaN-86* Creat-2.6* Na-143
K-5.3* Cl-102 HCO3-31 AnGap-15
[**2129-11-29**] 06:20PM BLOOD ALT-23 AST-47* AlkPhos-176* TotBili-1.1
[**2129-11-29**] 06:20PM BLOOD Lipase-69*
[**2129-11-29**] 06:20PM BLOOD cTropnT-1.58*
[**2129-11-30**] 03:26AM BLOOD CK(CPK)-36*
[**2129-11-30**] 03:26AM BLOOD CK-MB-3 cTropnT-1.63*
[**2129-11-30**] 04:49PM BLOOD CK(CPK)-34*
[**2129-11-30**] 04:49PM BLOOD CK-MB-4 cTropnT-1.67*
[**2129-11-29**] 06:20PM BLOOD Calcium-9.2 Phos-3.4 Mg-2.9*
[**2129-11-29**] 07:04PM BLOOD Type-ART pO2-65* pCO2-38 pH-7.53*
calTCO2-33* Base XS-8
[**2129-11-29**] 06:41PM BLOOD Lactate-2.2* K-5.3
[**2129-11-29**] 07:04PM BLOOD Lactate-1.5
[**2129-11-29**] 06:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2129-11-29**] 06:20PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2129-11-29**] 06:20PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0-2
=============
MICROBIOLOGY
=============
[**2129-11-29**]
- Blood cx [**2-8**]
- Urine cx: negative
- Urine legionella: negative
=============
IMAGING
=============
[**2129-11-29**]
- CXR: SEMI-UPRIGHT AP VIEW OF THE CHEST: The patient is status
post median sternotomy and aortic valve repair. Left-sided
single-lead pacemaker device is noted with lead terminating in
the region of the right ventricle. A left PICC tip terminates
within the left distal subclavian/brachiocephalic vein. The
heart remains moderately enlarged. Worsening perihilar opacities
with vascular indistinctness is again noted compatible with
congestive heart failure, moderate in severity. Worsening
bibasilar opacities are also noted with small bilateral pleural
effusions. No pneumothorax is present. There are no acute
osseous findings.
IMPRESSION:
1. Worsening congestive heart failure.
2. Worsening bibasilar airspace opacities which may reflect
atelectasis but infection is not excluded.
3. Small bilateral pleural effusions.
4. Left PICC tip terminates within the distal left
subclavian/proximal brachiocephalic vein, unchanged.
Brief Hospital Course:
72 year-old male with PMH of diastolic heart failure
with an EF=65%, AS s/p mechanical AVR, AF on coumadin, CAD s/p
CABG, pulmonary hypertension, 3rd degree heart block s/p PPM,
severe COPD, recent MRSA bacteremia, prolonged post-surgical
intubation presents after recent discharge with persistent
fevers and altered mental status. He was admitted to the ICU
for these symptoms. His heart failure continued to worsen while
in the ICU, and he began to undergo multiorgan failure. As his
condition was refractory to treatment, his family decided to
place Mr. [**Known lastname 43019**] on a morphine drip. He expired on the morning
of [**2129-12-7**].
Medications on Admission:
PATIENT EXPIRED
Discharge Medications:
PATIENT EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
PATIENT EXPIRED
Discharge Condition:
PATIENT EXPIRED
Discharge Instructions:
PATIENT EXPIRED
Followup Instructions:
PATIENT EXPIRED
|
[
"272.4",
"403.90",
"276.2",
"707.24",
"496",
"428.33",
"345.90",
"416.8",
"V58.61",
"285.9",
"486",
"707.03",
"427.31",
"V49.86",
"570",
"038.9",
"428.0",
"441.4",
"250.00",
"780.09",
"995.91",
"511.9",
"438.89",
"V45.81",
"585.9",
"V43.3",
"584.9",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"00.11",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7197, 7206
|
6435, 7091
|
337, 344
|
7265, 7282
|
4055, 6412
|
7346, 7364
|
3035, 3119
|
7157, 7174
|
7227, 7244
|
7117, 7134
|
7306, 7323
|
3134, 4036
|
262, 299
|
372, 1989
|
2011, 2601
|
2617, 3019
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,029
| 156,954
|
44672
|
Discharge summary
|
report
|
Admission Date: [**2160-2-15**] Discharge Date: [**2160-3-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82 yo female with hx of afib s/p ablation x2 on amiodarone and
coumadin, CAD, HTN, hyperthyroidism, chronic cough who presents
with cough and SOB. Pt was recently hospitalized [**Date range (1) 2953**] for
rapid afib suspectedly due to hyperthyroidism induced by
amiodarone toxicity. She was started on methimazole, prednisone
and metoprolol and completed 2 wks of methimazole but was
continued continued on a prednisone taper although increased
back to 15mg from 10mg due to climbing freeT4. She presented to
her PCP [**Last Name (NamePattern4) **] [**2-13**] for increase in her baseline cough and change in
the quality of her sputum to thick and green but no fever or
chills. He held on antibiotics and obtained a CXR which revealed
blunted CP angles with interstitial prominence but no
infiltrate. This am she noticed irregular pulse so called her
endocrinologist Dr. [**Last Name (STitle) 7852**] who consulted with her cardiologist
Dr. [**Last Name (STitle) **] and told her to go to the ED. Her irregular pulses
lasted 2 hours and resolved spontaneously before getting to the
ED. She denied CP, CT, PND, orthopnea but did have increasing
DOE. She also reports for the last 2 wks some nocturia with
incontinence, but no frequency, urgency or dysuria during the
day.
In the ED, she was afebrile and VS were stable with CXR
revealing RML opacity so she was given 750mg of levofloxacin,
tessalon pearles and tylenol with codeine and admitted for PNA.
Past Medical History:
1. CV:
---Atrial fibrillation, status post two ablations last in '[**52**] on
amiodarone chronically as well as coumadin. ECG in [**2156**] with
sinus bradycardia.
---Pump: Echo from [**2150**] with mild AR, mild MR, preserved LV
function.
---CAD: Stress ECG in [**June 2157**] with borderline EKG evidence of
myocardial ischemia in the absence of anginal symptoms with 6min
on [**Doctor First Name **].
2. Hypertension
3. Hypercholesterolemia
4. Status post total abdominal hysterectomy
5. Chronic cough followed by Dr. [**Last Name (STitle) 575**]
6. Anxiety
7. Back pain - DJD of L4-L5 and L5-S1 and spondylolisthesis
followed by Dr. [**First Name (STitle) 4223**] of Ortho.
.
Social History:
She lives alone but in the same building that
her son. She has never smoked, does not drink alcohol and had
her flu shot in 11/[**2158**]. She also denies any TB contacts.
Family History:
Positive for migraines, no heart disease, no lipid disorders,
sister died of lung cancer, mother with breast cancer
Physical Exam:
T 100.1 HR 70 BP 112/60 RR 20 O2Sat 89% RA 96% 2L NC
Gen-mild resp distress
HEENT-PERRLY, OP clear, MMM, overiding V waves
Hrt-RRR nS1S1 [**1-22**] HSM at LUSB and LLSB, [**12-25**] SM at apex rad to
axilla
Lungs-rt ant crackles but otherwise no crackles or wheeze
Abd-soft, tympanitic, NT, mod distended, no CVA tenderness
Extrem-1+ dp pulses, 2+ rad pulses, chronic venous stasis changs
of shins bilat, no LE edema
Neuro-A and O x3, CN II-XII intact, [**3-22**] UE and LE strength
Skin--mild erthema of upper chest and back without rash
Pertinent Results:
K:5.1
T3: Pnd
Chem &
129 97 24 185 AGap=16
6.4 22 1.0
.
MCV 79 WBC 18.7 Hgb 11.6 Plt 239 Hct 33.9
N:94.2 L:2.9 M:2.5 E:0.3 Bas:0.2
.
PT: 20.4 PTT: 32.5 INR: 2.0
.
ECG-brady SR at 55, nl axis, LVH, Q in III, TWI III, 0.[**Street Address(2) **]
dep in v4-6 which is old
.
CXR-1. Ill-defined right middle lobe opacity may represent early
pneumonia. Clinical correlation recommended.
2. No evidence for pulmonary edema.
.
TTE-no recent
.
[**6-21**] ETT-equivocal ST dep inferiorly and v5-6 w/o symtoms
.
[**2-13**] TSH <.02 T4 2.1
Brief Hospital Course:
1) Respiratory Failure: Patient was admitted for suspected
pneumonia with positive rhinovirus by bronchoscopy BAL and
presumed bacterial superinfection. This escalated to ARDS
requiring MICU admission and intubation. She was treated with
steroids, fluconazole, cefepime/flagyl for a 10 day course.
Shortly after tapering steroids she developed increased
dependence on the ventilator and so steroids were increased.
She was shortly thereafter given a tracheostomy and PEG due to
inability to wean from vent. Within the first few days she was
improving, able to breath at trach mask only for several hours
per day, however, over [**3-9**]-23 she had increased secretion
and difficulty weaning pressure support with increasing
leukocytosis. On [**2160-3-10**] she was restarted on Vancomycin and
Cefepime for planned 10 day course. Sputum has only ever grown
yeast. As of [**2160-3-15**] she had increased secretions and underwent
another bronchoscopy. This confirmed that the trach was
mechnically intact.
In review of her respiratory failure, the MICU team also
considered amiodarone toxicity, although seemed unlikely given
acute time frame. She had a bronchoscopy on [**2-19**], PCP was
negative but rhinovirus positive.
Patient was placed on assist-control at night for comfort while
sleeping, and pressure support during the day, and may continue
this at rehab.
.
2) Afib- tachy/brady symdrome: Followed in house by patient's
cardiologist Dr. [**Last Name (STitle) **]. Through course pt had several episodes
of afib/aflutter with additional episodes of RVR with aberrancy.
Best controlled on Metoprolol 25 mg po BID. Decision was made
to discontinue her amiodarone early in the hospital course as
this was causing hyperthyroidism which was exacerbating her
afib, aflutter. When on smaller doses of metoprolol, pt
developed tachycardia with hypotension and increased work of
breathing. She had been on digoxin briefly but this was
discontinued in the setting of bradycardic episodes to the 30's.
Prior to hospitalization she was on coumadin 1 mg po qd.
Patient with heart rate in the 40s intermittently, but remains
hemodynamically stable.
.
She has been maintained well on Metoprolol 25 mg Q6H. When she
does not take her Metoprolol, her heart rate goes into the range
of 130-140. When she is given metoprolol and she is resting, her
heart rate will suddenly decrease dramatically to 30's. She was
asymptomatic with a HR 30s.
.
3) Amiodarone induced secondary hyperthyroidism: Improved to
normal function on steroids. Endocrine team suggests slow taper
of prednisone and she is currently at prednisone 15 mg po qd.
Goal dose is to get her off of steroids over the next 1-1.5
months. She will need [**Hospital1 **]-weekly TFTs and to follow up with her
outpatient endocrinologist by [**2160-4-13**]. Family can schedule
appointment.
.
4) Hyperglycemkia: Pt required sliding scale regular insulin
while on steroids.
.
5) GERD: cont protonix and prm reglan
.
6)Tube feeds given through PEG tube.
.
7) Prophylaxis: Pt does not need heparin SC while INR on
coumadin > 2.0. She does require a proton pump inhibiotor.
.
8) Access: A PICC line was placed and confirmed by X ray on
[**2160-3-11**], this unfortunattely clotted off and a new PICC was
placed on the left side that is functional.
.
9) Code: Full code - should be re-discussed with patient at
rehab.
.
10) Contact is health care proxy: daughter
Medications on Admission:
1. Warfarin 1 mg qd
2. Pantoprazole 40 mg qd
3. Amlodipine 2.5 mg qd
4. Amiodarone 200 mg qod
5. Amiodarone 300 mg qod alternating with 200mg
6. Prednisone 15mg qd just increased 1 wk ago
8. Metoprolol Tartrate12.5 [**Hospital1 **]
9. MVI
10. Actonel 1x/wk
11. Ca and glucosamine
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
3. Alprazolam 0.25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day) as needed for anxiety, insomnia.
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
6. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6)
Puff Inhalation Q4H (every 4 hours).
7. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6
hours) as needed for thick secretions.
10. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: Three (3)
Tablet, Chewable PO BID (2 times a day).
11. Omega-3 Fatty Acids 550 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
BID (2 times a day).
12. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed for rash.
13. Fentanyl 25 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
14. Clonazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
15. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
16. Metoclopramide 5 mg/mL Solution [**Last Name (STitle) **]: Ten (10) mg Injection
Q6H (every 6 hours) as needed.
17. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours).
18. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
19. Prednisone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily)
for 14 days.
20. Prednisone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day for
14 days: Start: [**Date range (1) 66813**].
21. Prednisone 2.5 mg Tablet [**Date range (1) **]: One (1) Tablet PO once a day
for 14 days: Start: [**4-16**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Pneumonia
-rhinovirus with secondary bacterial
Atrial fibrillation/ Tachy-brady syndrome
Hyperthyroidism
Discharge Condition:
Out of bed in chair
Spending several hours per day on trach mask
Discharge Instructions:
Please follow plan of care as determined by physician at rehab.
You will be sent back to the emergency room with new chest pain,
shortness of breath, persistent fever, or low blood pressure.
Patient may be placed on ventilator settings of assist-control
at night to allow her to sleep more comfortably.
Patient with heart rate in the 30s with blood pressure in the
80s at times from her tachy-brady syndrome, but remains
asymptomatic with quick return to normal HR and blood pressures.
Patient should always be on telemetry.
Patient cannot be on amiodarone or digoxin. Amiodarone causes
thyroid problems.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2160-4-29**] 10:50
Patient should follow up with her endocrinologist.
Completed by:[**2160-3-20**]
|
[
"401.9",
"428.0",
"482.9",
"275.41",
"242.80",
"V58.65",
"E932.0",
"427.31",
"038.9",
"E942.0",
"276.0",
"995.92",
"079.3",
"707.8",
"518.81",
"112.2",
"785.52",
"530.81",
"251.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"99.04",
"31.1",
"99.07",
"33.21",
"33.24",
"38.93",
"43.11",
"93.90",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10174, 10253
|
3927, 7354
|
281, 287
|
10402, 10469
|
3375, 3904
|
11126, 11364
|
2683, 2800
|
7684, 10151
|
10274, 10381
|
7380, 7661
|
10493, 11103
|
2815, 3356
|
222, 243
|
315, 1772
|
1794, 2477
|
2493, 2667
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,009
| 183,327
|
22827
|
Discharge summary
|
report
|
Admission Date: [**2133-7-4**] Discharge Date: [**2133-7-9**]
Date of Birth: [**2075-3-5**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Xanax
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p Left distal femur hardware failure
Major Surgical or Invasive Procedure:
[**2133-7-4**]: Revision of left distal femur ORIF
History of Present Illness:
Ms. [**Known lastname 17025**] is a 58 year old female who had a left
supradcondylar femur fracture repair on [**2133-6-4**]. On [**2133-6-30**] she
heard a [**Doctor Last Name **] while seated. She was taken to the [**Hospital3 3583**]
and then to [**Hospital1 18**] on [**2133-7-4**] with increasing pain and found the
the plate had pulled off the bone proximally.
Past Medical History:
Anemia, CAD, CHF, HTN, DM1, GERD, hx of VRE
Social History:
40 pack year hx, quit 23 yrs ago
no EtOH
Family History:
Father: died from CHF age 58
Physical Exam:
Upon admission
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender non-distended
Extremities: LLE, skin intact, + TTP no notable swelling,
ecchymosis, + pulses
Upon discharge
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender non-distended
Extremities: LLE, staples intact, SILT DP/SP/T, intact GS/TA,
cap refill 2 seconds
Pertinent Results:
FEMUR (AP & LAT) LEFT [**2133-7-4**] 11:01 AM
IMPRESSION: Fracture and failure of the fixation plate from the
fixation screws with impaction at the original fracture site and
displacement of the pre- existing comminuted fractures. The
fixation screws through the femoral condyles remain intact.
CHEST (PORTABLE AP) [**2133-7-6**] 4:20 AM
FINDINGS: In comparison with study of [**2133-6-6**], there is again
enlargement of the cardiomediastinal silhouette, accentuated by
the portable AP technique.
FEMUR (AP & LAT) LEFT [**2133-7-8**] 12:55 PM
FINDINGS: In comparison with study of [**8-3**], there is little
change in the appearance of the new fixation plate of the distal
left femur with screws fixing the comminuted fracture of the
distal femur. As on the previous study, the screw that is
closest to the top does not appear to be seated within the
femoral plate.
[**2133-7-9**] 06:00AM BLOOD Hct-32.2*
[**2133-7-4**] 10:27AM BLOOD PT-12.3 PTT-27.4 INR(PT)-1.0
[**2133-7-7**] 05:40AM BLOOD PT-12.7 PTT-29.9 INR(PT)-1.1
[**2133-7-8**] 05:30AM BLOOD Plt Ct-289
[**2133-7-4**] 10:27AM BLOOD Glucose-119* UreaN-38* Creat-1.0 Na-134
K-5.7* Cl-100 HCO3-25 AnGap-15
[**2133-7-4**] 07:21PM BLOOD Calcium-8.3* Phos-3.8 Mg-2.0
[**2133-7-8**] 05:30AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0
Brief Hospital Course:
Ms. [**Known lastname 17025**] presented to the [**Hospital1 18**] on [**2133-7-4**] after transfer
from [**Hospital3 3583**] with increasing left leg pain after hearing
a "[**Doctor Last Name **]" 4 days prior. She was evaluated by the orthopaedic
surgery service and found that the left distal femur plate
pulled off the bone proximally. She was admitted, consented,
and prepped for surgery. Later that day she was taken to the
operating room and underwent a revision ORIF of her left distal
femur. She was transfused with 2 units of packed red blood
cells due to acute blood loss anemia. She was transferred to
the ICU post operatively due to hypovolemia and was treated with
a Neo-Synephrine drip. On [**2133-7-5**] she was weaned off the
Neo-Synephrine drip and was seen by physical therapy to improve
her strength and mobility. On [**2133-7-6**] she was again transfused
with 2 units of packed red blood cells due to acute blood loss
anemia. She was transferred out of the intensive care unit on
[**2133-7-7**] to the orthopaedic floor. On the floor she was seen by
physical therapy to improve her strength and mobility. The
patient experied some nausea on [**2133-7-8**]. EKG performed on
[**2133-7-8**] demonstrated no acute ST changes.
The rest of her hospital stay was uneventful with her lab data
and vital signs within normal limits and her pain controlled.
She is being discharged today in stable condition.
Medications on Admission:
[**Last Name (un) 1724**]: Furosemide 40', Zolpidem 5 QHS, Aspirin 325', Hexavitamin
1', Becaplermin 0.01 % Gel Q24, Citalopram 20', Carvedilol 12.5
'', Simvastatin 80', Oxycodone 5-10 mg Q4-6 prn, Colace 100'',
Albuterol 90 mcg 2 Puff Q6 prn, Acetaminophen 325-650 Q6H prn,
Lisinopril 5'', Nitroglycerin 0.3 prn chest pain, Enoxaparin 30
mg'', insulin Glargine 44 QAM, Glargine 30 QPM, Insulin SC
Sliding Scale
Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours).
8. Becaplermin 0.01 % Gel Sig: One (1) Appl Topical DAILY
(Daily).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
10. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
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 for constipation.
14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever or pain.
18. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
19. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection qACHS.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at Silver [**Doctor Last Name **]
Discharge Diagnosis:
s/p L femur fracture hardware failure
Acute blood loss anemia
Discharge Condition:
Stable
Discharge Instructions:
Continue to be non weightbearing on your left leg
Continue your lovenox injections for a total of 4 weeks after
surgery
Continue your home medications as prescribed by your doctor
Keep incision clean and dry
If you notice any increaed redness, drainage, or swelling, or if
you have a temperature greater than 101.5 please call the office
or come to the emergency department.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Physical Therapy:
Activity: Out of bed w/ assist
Left lower extremity: Non weight bearing
Hinge Knee brace to left leg at all times, may come off for
daily care.
Treatment Frequency:
Staples/sutures out 14 days afer surgery
Dry sterile dressing daily or as needed for drainage or
comfortSite: L femur
Description: Staples clean/dry/intact
Care: Change DSD QD and inspect daily.
Site: L heel
Description: 2mm round pinpoint stage I pressure ulcer.
Care: Continue to monitor. Keep heel elevated for pressure
relief. Apply Aloe vista barrier cream daily & prn.
Site: R lateral ankle
Description: Dime sized round stage II pressure ulcer. Wound bed
pink & yellow. Periwound skin intact, pink, blanchable. Small
amt yellow drainage, no odor noted.
Care: Cleanse with NS or wound cleanser, apply gel to wound bed.
Apply moistened gauze w/NS with DSD overlay.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2
weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2133-8-11**] 9:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2133-8-11**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14839**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2133-8-31**] 8:40
|
[
"996.49",
"707.06",
"788.5",
"458.29",
"428.0",
"V45.81",
"E878.8",
"285.1",
"401.9",
"V49.73",
"707.07"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.55"
] |
icd9pcs
|
[
[
[]
]
] |
6168, 6252
|
2710, 4143
|
306, 359
|
6358, 6367
|
1403, 2687
|
7754, 8366
|
900, 931
|
4605, 6145
|
6273, 6337
|
4169, 4582
|
6391, 6870
|
946, 1384
|
6888, 7036
|
228, 268
|
387, 757
|
7057, 7731
|
779, 825
|
841, 884
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,582
| 101,422
|
54763
|
Discharge summary
|
report
|
Admission Date: [**2100-7-16**] Discharge Date: [**2100-7-24**]
Date of Birth: [**2024-1-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2100-7-20**] Aortic Valve Replacement with 23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue valve
History of Present Illness:
76 year old man with history of coronary artery disease,
diabetes, hypercholesterolemia, and aortic stenosis who was
admitted to [**Hospital6 3105**] with two days of
intermittent dyspnea, and malaise. A subsequent cardiac
catheterization revealed patent left anterior descending artery
and severe aortic stenosis. He was then referred to [**Hospital1 18**] for
AVR
Past Medical History:
Coronary artery disease(s/p stent x3)last stent spring [**2099**],
diabetes mellitus, dyslipidemia, aortic stenosis
Past Surgical History: none
Past Cardiac Procedures: PTCA-stent LAD spring [**2099**]
Social History:
Race: Caucasian
Last Dental Exam: none recently
Lives with: alone in [**Male First Name (un) 1056**]-staying w/ daughter(recently
widowed)
Contact: [**Name (NI) 111955**] [**Last Name (NamePattern1) 13621**]-daughter Phone # [**Telephone/Fax (1) 111956**]
[**Name2 (NI) **]ation:
Cigarettes: Smoked no [x]
Other Tobacco use: Pipe [] Cigars [] Smokeless []
ETOH: denies
Illicit drug use: denies
Family History:
Family History: Sister in 50's with heart disease-unspecified
Father died in 90's Mother died in 60's of "smoking"
Physical Exam:
Admission:
Pulse: 75 B/P 145/66 Resp: 18 O2 sat:97%RA
Height: 63in Weight: 175 lbs
General: NAD
Skin: Warm [x] Dry [x] intact [x]
HEENT: NCAT[x] PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit: none
Pertinent Results:
[**2100-7-24**] 06:45AM BLOOD WBC-7.7 RBC-3.62* Hgb-10.1* Hct-29.9*
MCV-83 MCH-28.0 MCHC-33.8 RDW-13.2 Plt Ct-184#
[**2100-7-23**] 04:57AM BLOOD WBC-7.7 RBC-3.76* Hgb-10.6* Hct-31.9*
MCV-85 MCH-28.2 MCHC-33.2 RDW-13.4 Plt Ct-118*
[**2100-7-22**] 04:58AM BLOOD WBC-6.5 RBC-3.80* Hgb-10.4* Hct-32.2*
MCV-85 MCH-27.5 MCHC-32.4 RDW-13.3 Plt Ct-100*
[**2100-7-24**] 06:45AM BLOOD UreaN-30* Creat-1.1 Na-129* K-4.7 Cl-94*
[**2100-7-23**] 04:57AM BLOOD Glucose-129* UreaN-24* Creat-1.0 Na-131*
K-4.8 Cl-97 HCO3-30 AnGap-9
[**2100-7-22**] 04:58AM BLOOD Glucose-185* UreaN-19 Creat-1.0 Na-130*
K-5.2* Cl-97 HCO3-29 AnGap-9
[**2100-7-21**] 11:01PM BLOOD Na-130* K-5.1 Cl-98
[**2100-7-20**] 06:30PM BLOOD Na-137 K-4.3 Cl-108
TTE [**2100-7-20**]
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Low normal LVEF.
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
A TEE was performed in the location listed above. I certify I
was present in compliance with HCFA regulations. The patient was
under general anesthesia throughout the procedure. No TEE
related complications.
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 borderline normal free wall function. There are
simple atheroma in the descending thoracic aorta.
The aortic valve leaflets are severely thickened/deformed.
There is critical aortic valve stenosis (valve area <0.8cm2).
Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is AV-Paced, on no inotropes.
Unchanged biventricular systolic fx.
There is a bio-prosthetic valve in the aortic position with no
leak and no AI.
Residual mean gradient = 11 mmHg.
Aorta intact. Trace MR.
Brief Hospital Course:
The patient was admitted to the hospital, completed a
unremarkable pre-operative workup and was brought to the
operating room on [**2100-7-20**] where the patient underwent an Aortic
valve replacement (23 St. [**Male First Name (un) 923**] tissue). Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. Vanco was used for surgical antibiotic
prophylaxis. POD 1 found the patient extubated, alert and
oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued without
complication. He did have less than 24 hours of rapid atrial
fibrillation but converted to sinus rhythm with Amiodarone and
increased Lopressor. He was in sinus rhythm at the time of
discharge. The patient failed to void when his Foley was
removed and was found to have 800cc in his bladder via bladder
scan and the Foley was re-inserted. A repeat voiding trial was
done and the patient was able to void successfully. The patient
was evaluated by the physical therapy service for assistance
with strength and mobility. By the time of discharge on POD #4
the patient was ambulating freely, the wound was healing and
pain was controlled with oral analgesics. The patient was
discharged home in good condition with appropriate follow up
instructions via the Spanish interpreter.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. GlipiZIDE 10 mg PO BID
3. Enalapril Maleate 20 mg PO BID
4. Doxazosin 2 mg PO HS
5. Clopidogrel 75 mg PO DAILY
6. Simvastatin 20 mg PO DAILY
7. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. GlipiZIDE 10 mg PO BID
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Acetaminophen 650 mg PO Q4H:PRN pain/fever
7. Amiodarone 400 mg PO TID
RX *amiodarone 400 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
8. Aspirin EC 81 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Metoprolol Tartrate 50 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
11. Milk of Magnesia 30 ml PO HS:PRN constipation
12. Oxycodone-Acetaminophen (5mg-325mg) [**1-11**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**1-11**] tablet(s) by mouth
four times a day Disp #*30 Tablet Refills:*0
13. Bisacodyl 10 mg PR DAILY:PRN constipation
14. Potassium Chloride 20 mEq PO Q12H
Hold for K+ > 4.5
RX *potassium chloride 20 mEq 1 tablet by mouth once a day Disp
#*7 Tablet Refills:*0
15. Ranitidine 150 mg PO DAILY
RX *Acid Reducer (ranitidine) 150 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
16. Doxazosin 2 mg PO HS
17. 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:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
aortic stenosis s/p AVR(StJude tissue)[**7-20**]
PMH: coronary artery disease(s/p stent x3)last stent spring
[**2099**],
diabetes mellitus, dyslipidemia, PSH: none
Past Cardiac Procedures: PTCA-stent LAD spring [**2099**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema: Trace lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on in the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **] [**2100-8-25**] at 1:15p
Cardiologist: [**Doctor Last Name 29070**] (office will call patient with appt)
Wound check on [**2100-8-3**] at 10:00a [**Hospital **] medical office building,
[**Doctor First Name **], [**Hospital Unit Name **]
Please obtain a primary care physician as soon as possible
and see your primary Care Doctor in [**4-15**] 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:[**2100-7-24**]
|
[
"250.00",
"414.01",
"424.1",
"272.4",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
7975, 8050
|
4625, 6278
|
331, 460
|
8316, 8517
|
2301, 4602
|
9321, 10058
|
1531, 1634
|
6649, 7952
|
8071, 8295
|
6304, 6626
|
8541, 9298
|
1017, 1082
|
1649, 2282
|
271, 293
|
488, 856
|
878, 994
|
1098, 1499
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,607
| 126,571
|
47503
|
Discharge summary
|
report
|
Admission Date: [**2139-11-11**] Discharge Date: [**2140-2-26**]
Date of Birth: [**2083-9-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Found down at nursing home, hypercarbic respiratory failure.
Major Surgical or Invasive Procedure:
Intubation
Mechanical Ventilation
History of Present Illness:
52 y.o. M with h/o HTN, chronic renal disease thought secondary
to HTN, schizoaffective DO, bipolar DO, presents from home after
having been found down by Baycove workers (psych in home
services) this morning. Baycove workers generally check in at
patient's home several times a week and reportedly he did not
return phone calls beginning 1 day PTA. On the day of
admission, he was still not returning phone calls and a Baycove
employee went to check in on him at his apartment. At this
time, he was found down and EMS was called. It is unclear when
he was last well and awake.
In the ED, initial vitals were T 85.1 (forehead) HR 53 BP
127/75 RR 29 O2sat 96%NRB. He was noted to be somnolent and
difficult to arouse. Initial ABG was 6.98/98/156 and he was
intubated at which time BP reportedly dropped to 50s systolic
and he was transiently on pressors, until BP quickly returned to
that of presentation. A femoral line was placed. As he was
noted to be hypothermic and bear hugger was placed. He received
3L warm NS and additionally received 1g IV vancomycin and 4.5g
IV zosyn. A CXR was performed which showed diffuse bilateral
haziness c/w pulmonary edema w/o clear e/o infiltrate. A head
CT was ordered, but they were unable to perform as he became
bradycardic requiring atropine. Additionally at that time his
blood pressures again dipped to 50s-60s systolic and he was
started on levophed; dopamine was added.
Additionally, creatinine was elevated to 5.2 (BL most recently
[**12-27**]). Potassium was 6.8 although hemolyzed and repeat was 5.6.
He is now being transferred to the MICU for further management
of his hypercarbic respiratory failure, hypothermia and
hypotension.
Past Medical History:
-HTN
-Renal disease, thought to be [**12-26**] to HTN
-Schizoaffective disorder
-Bipolar disorder
-Morbid obesity
-Probable gout, given med list
-Chronic LE edema
-Dyslipidemia
Social History:
Sees social worker [**Name (NI) 57756**] [**Name (NI) **] (Phone [**Telephone/Fax (1) 100427**]). Lives by
himself in the Trilogy building in [**Hospital1 778**], [**Location (un) 86**]. Baycove
services check in on him several times weekly. Is followed by
psychiatrist Dr. [**Last Name (STitle) **]. Walks with walker/cane at baseline.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: Temp: 87.4->93.2 BP: 144/88 (73-144 systolic) HR: 58-74 AC
600/18 PEEP 5 FiO2 50%
GEN: Intubated and sedated, opens eyes and tracks prior to CVL
insertion, but does not follow commands, morbidly obese
HEENT: [**Last Name (un) **] minimally reactive to light, EOMI, anicteric, MMM,
op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, unable to
assess jvd [**12-26**] to habitus, no carotid bruits, no thyromegaly or
thyroid nodules
RESP: Clear anteriorly with upper airway sounds
CV: RRR, S1 and S2 distant [**12-26**] habitus, no m/r/g appreciated
ABD: +b/s, soft, obese, protruberant, does not respond to deep
palpation, no palpable masses
EXT: 2+ b/l LE edema, left great toe distally with increased
redness, warmth, no skin breakdown/purulent drainage
SKIN: no rashes/no jaundice
NEURO: Neuro exam unable to fully assess given
intubated/sedated. Downgoing toes b/l.
PHYSICAL EXAM UPON TRANSFER:
============================
VS: 97.2 82 152/88 20 95% 3L
GEN: Morbidly obese, pleasant, speaks in full sentences,
tangential
HEENT: PERRL, EOMI, OP Clear, MMM, supple, Obese neck
RESP: CTA [**Last Name (un) **]
CV: distant HS, RRR no mrg
ABD: +b/s, protuberant, nontender
EXT: 2+ b/l LE edema, L great toe with swelling, erythema,
R toe nail with evulsion
NEURO/PSYCH, Awake alert, orientated to month/day/year, believes
he is in [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], president is his excellence [**Known firstname **] W
[**Last Name (un) 2450**]
Pertinent Results:
ADMISSION LABS:
================
[**2139-11-11**] 12:10PM WBC-4.0 RBC-3.49* HGB-11.0* HCT-34.0* MCV-98
MCH-31.6 MCHC-32.4 RDW-17.2*
[**2139-11-11**] 12:10PM NEUTS-70.3* LYMPHS-23.9 MONOS-4.4 EOS-1.1
BASOS-0.2
[**2139-11-11**] 12:10PM GLUCOSE-86 UREA N-58* CREAT-5.1*# SODIUM-145
POTASSIUM-6.8* CHLORIDE-116* TOTAL CO2-19* ANION GAP-17
[**2139-11-11**] 12:30PM TYPE-ART PO2-156* PCO2-98* PH-6.98* TOTAL
CO2-25 BASE XS--11
[**2139-11-11**] 12:10PM CK(CPK)-2138*
[**2139-11-11**] 12:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2139-11-11**] 12:10PM CK-MB-269* MB INDX-12.6* cTropnT-0.10*
[**2139-11-11**] 02:18PM PO2-149* PCO2-58* PH-7.14* TOTAL CO2-21 BASE
XS--10
[**2139-11-11**] 02:18PM LACTATE-0.9 K+-5.6*
PERTINENT LABS DURING HOSPITALIZATION:
===================================
Prot. Electrophoresis, Urine +/-
MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING BASED ON
IFE (SEE SEPARATE REPORT), NO MONOCLONAL IMMUNOGLOBULIN SEEN.
NEGATIVE FOR BENCE-[**Doctor Last Name **] PROTEIN
INTERPRETED BY [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19695**], MD
Immunofixation, Urine
NO MONOCLONAL IMMUNOGLOBULIN SEEN. NEGATIVE FOR BENCE-[**Doctor Last Name **]
PROTEIN.
INTERPRETED BY [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19695**], MD
MICROBIOLOGY:
=============
[**11-11**] Blood Cultures x 2: negative
[**11-11**] Urine Culture: negative
[**11-12**] Blood Culture x 1: negative
[**11-20**] Blood Culture x 2: negative
[**11-21**] Blood Culture x 1: negative
[**2139-11-13**] 2:24 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2139-11-13**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS.
RESPIRATORY CULTURE (Final [**2139-11-16**]):
RARE GROWTH OROPHARYNGEAL FLORA.
YEAST. SPARSE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
PENICILLIN------------ =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2140-1-7**] 1:34 pm SWAB Source: right arm.
M4 MEDIA RECEIVED FOR CULTURE, NO SLIDE RECEIVED FOR VZV DFA
STAIN.
VARICELLA-ZOSTER CULTURE (Final [**2140-1-13**]):
VARICELLA-ZOSTER VIRUS.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY.
STUDIES:
========
EKG [**2139-11-11**]
Sinus rhythm with prolonged P-R interval at approximately 280
milliseconds.
Left ventricular hypertrophy. Diffuse non-diagnostic
repolarization abnormalities. Compared to previous tracing of
[**2139-4-27**] multiple abnormalities
as noted persist without major change.
TRACING #1
EKG [**2139-11-11**]
Sinus bradycardia. Compared to previous tracing no major change.
TRACING #2
CHEST (PORTABLE AP) [**2139-11-11**]
FINDINGS: Single bedside AP examination labeled" "upright at
12:10 hours" is compared with study dated [**2139-6-22**]. Allowing for
the significantly lower lung volumes, there is further
cardiomegaly with pulmonary vascular congestion, interstitial
and early alveolar edema and probable bilateral pleural
effusions, left greater than right. No definite focal
consolidation is seen. There is prominence of the right
paratracheal soft tissues, more evident than on the earlier
study (perhaps related to degree of patient rotation), likely
representing ectatic brachiocephalic vessels.
IMPRESSION: CHF, new since [**2139-10-23**].
FOOT AP,LAT & OBL LEFT PORT [**2139-11-12**]
IMPRESSION: Erosive change at the first MTP joint and
interphalangeal joint of the left great toe. Appearance is
somewhat nonspecific, but could be consistent with gout or
inflammatory arthropathy.
CT HEAD W/O CONTRAST [**2139-11-12**]
IMPRESSION:
1. No hemorrhage or mass effect.
2. Mild stable ventriculomegaly.
EEG [**2139-11-12**]
IMPRESSION: This is an abnormal portable EEG due to the frequent
spike and sharp wave discharges seen in the frontal regions
bilaterally and over the central midline. While no clear
spike/slow wave or sharp/slow wave complexes were noted, the
findings raise concern for an area of potential epileptogenesis.
In addition, the background was disorganized, slow, and
interrupted by bursts of generalized mixed frequency slowing,
consistent with a moderate encephalopathy. This suggests
dysfunction of bilateral subcortical or deep midline structures.
Medications, metabolic disturbances, and infection are among the
common causes of encephalopathy. There were no areas of
prominent focal slowing, although encephalopathic patterns can
sometimes obscure focal findings. There were no repetitive or
sustained discharges and no electrographic seizures were noted.
Portable TTE (Complete) Done [**2139-11-12**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Compared to the last study (images reviewed) of [**2139-8-13**], the
findings are similar.
EEG [**2139-11-13**]
IMPRESSION: This 24-hour video EEG telemetry captured two sitter
pushbuttons for unclear reasons which were not associated with
any significant change on the patient's EEG or any significant
change in the patient's appearance on video. No electrographic
seizures were seen; however, interictal epileptiform discharges
were seen independently from both hemispheres and from the
bifrontal region simultaneously at times, but these never
progressed to [**Hospital1 2824**] electrographic seizures. The background was
slow and disorganized throughout the recording suggestive of a
moderate to severe encephalopathy.
EEG [**2139-11-14**]
IMPRESSION: This telemetry captured no pushbutton activations.
Routine sampling shows a normal background with bursts of
generalized slowing and particularly prominent slowing over the
right hemisphere. This suggests a focal subcortical abnormality
on the right side. Nevertheless, the background remained normal
in other areas and at other times. There were no epileptiform
features or electrographic seizures.
EEG [**2139-11-15**]
IMPRESSION: This is a mildly abnormal 24 hour video EEG
telemetry in the waking and sleeping states due to the bursts of
generalized delta frequency slowing. This is a nonspecific
finding suggestive of deep subcortical midline dysfunction.
There were no epileptiform discharges, no lateralized findings,
and no electrographic seizures noted.
ANKLE (AP, MORTISE & LAT) LEFT [**2139-12-29**]
IMPRESSION:
1. No fracture or dislocation.
2. Degenerative changes of the foot.
Brief Hospital Course:
Mr. [**Known lastname 13175**] is a 56 y.o. M with schizophrenia, bipolar disorder,
HTN, CKD thought [**12-26**] to HTN who presented to [**Hospital1 18**] after having
been found down by Baycove Social Work at home and then found to
be hypothermic, hypercarbic, and hypotensive in the ED and
subsequently admitted to the MICU for further care.
# Hypercarbic respiratory failure: Etiology is not entirely
clear. He is obese and likely has some element of OSA vs.
hypoventilation syndrome but the degree seems more extensive to
be explained by this alone. Although serum and urine tox were
negative for illicits, there is the possibility of overdose on
psychiatric medication. As he was found down, trauma is another
possible cause of his depressed mental status and
hypoventilation, although no evidence of this on physical exam.
Head CT was negative for acute process. During MICU course, the
patient was successfully extubated and breathing comfortably
before being called out to the medicine floor. On the floor,
sleep medicine was consulted to help evaluate the patient for
possible OSA and to titrate nighttime BiPAP. He did well with
this when agreeable to wearing it (he frequently refused). The
patient's respiratory status rapidly improved on the floor, and
he was oxygen saturation was in the mid-90's on room air.
# Acute on chronic renal failure: (Stage IV CKD) Creatinine
elevated from previous baseline of high 2-low 3. Given that he
was found down, likely poor PO, + rhabdomyolysis, likely
ischemic ATN. No problems with volume status and making good
urine. Renal followed him initially and considered possible
FSGS secondary to obesity or hypertension nephrosclerosis. He
had large proteinuria of unknown origin upon admission that
continued during his stay. SPEP was negative. UPEP showed
predominance of albumin. Hyperkalemia was intermittently a
concern; received Kayexalate as needed. Renal was reconsulted
for evaluation of worsening renal status, chronic kidney
disease. He is to follow up with his outpatient nephrologist
about possible future hemodialysis. He was started on phosphate
binders and Vitamin D.
# Altered mental status: As above, the differential was broad,
but likely is a reflection of hypercarbia. Given the degree of
hypercarbia and having been found down, likely altered mental
status even prior to this possibly secondary to ingestion of
higher dose of his own meds vs. psychosis and subsequent fall,
although no clear evidence of trauma. Head CT negative and EEG
without seizure activity. At the time of admission to the MICU,
his psychiatric medications were held. Psychiatry was consulted
and at time of floor transfer suggested adding back risperidone.
This was done gradually, but on the second day on the floor,
the patient again became somnolent. This was felt due to CO2
narcosis (with a contribution from medications as well). This
prompted the sleep medicine consult as noted above, and BiPAP
was begun. Following this, there were no further problems with
somnolence. The patient frequently refused BiPAP while on the
medical floor.
# Hypotension: Was normotensive upon presentation to ED
(probable relative hypotension for him given h/o poorly
controlled HTN), but then required Levophed in ED and upon
presentation to MICU. Etiology not entirely clear and may have
been some contribution from med effect w/sedation for
intubation, but seems only partially contributing. Met SIRS
criteria w/hypothermia and RR >20 and concerning for sepsis
although truly no clear source of infection (CXR with clear
pulmonary edema, but w/o clear infiltrate however at risk for
aspiration given AMS/found down), UA negative. Cardiac etiology
was also a possibility given increased CEs and new pulmonary
edema (no EKG changes). Echo was unchanged without new wall
motion abnormalities. Cortisol stimulation test was not
suggestive of adrenal insufficiency. In the MICU, the patient
became hypertensive. His home meds were restarted. These meds
were titrated for better blood pressure control on the floor.
The patient's BP was stable on clonidine patch, metoprolol, and
amlodipine.
# Elevated cardiac enzymes: CK elevated secondary to
rhabdomyolysis; however MB also up with positive MBI (trending
down slightly). Troponin was also up and was likely
multifactorial given hypotension and likely demand, also with
worsened renal function. No clear EKG changes c/w ischemia. TTE
without focal wall motion abnormalities.
# Schizoaffective & Bipolar disorder with h/o psychosis: H/o
psychosis in the past on multiple occasions. Events surrounding
his having been found down are not entirely clear. Psych
restarted risperidone with gradual titration to 2 mg daily.
Aripiprazole also started with plan to increase as tolerated.
On the medical floors, he was often hyperreligious, grandiose,
and delusional. Does not have capacity to make decisions;
therefore, the process of guardianship was pursued. The
patient's legal hearing for guardianship occurred on [**2140-2-23**], and a guardian was appointed.
# Hypertension: BPs stable after resolution of hypotension.
Normotensive while on Clonidine patch, lisinopril, amlodipine,
and metoprolol.
# Dyslipidemia: Continued statin.
# Left ankle pain: History of gout, elevated uric acid. Ankle
film showed degenerative changes without fracture. Improved
with tylenol. Renally dosed allopurinol was begun.
# Pancytopenia: Hemolysis was considered as an etiology, but
peripheral smear appears WNL. HIT antibody negative. Improved
during hospitalization. CKD also contributing to anemia, so
epogen was started and then stopped after resolution of his
anemia.
# Herpes zoster: The patient was noted to have a herpetic rash
on right shoulder, which was culture positive for herpes zoster.
He was treated with valtrex for 5 days with resolution of his
symptoms and improvement in the rash.
# Access: poor peripherals, lost IV access after transfer to
medicine floor. We repeatedly recommended a PICC line, which he
repeatedly refused. Given the overall situation (lack of
capacity to make decisions and frequent refusal of PICC line,
occasional labs, some meds) ethics consult was obtained.
# Dispo: Home with maximum services, including VNA, PACT team,
and guardian to help assist with medical decision making.
Medications on Admission:
Medications per [**2139-8-13**] d/c summary
1. Aspirin 81 mg daily
2. Oxybutynin Chloride 5 mg PO HS
3. Colchicine 0.6 mg PO q3days
4. Psyllium 1.7 g Wafer daily
5. Calcitriol 0.25 mcg qod
6. Benztropine 1 mg PO HS
7. Allopurinol 100 mg PO DAILY
8. Divalproex 250 mg Delayed Release PO daily
9. Metoprolol Tartrate 50 mg PO BID
10. Colace 100 mg PO bid
11. Senna 8.6 mg PO daily prn
12. Risperdal 4 mg daily
.
Medications per Baycove med list (not clear when last updated):
Sodium bicarbonate 650mg tid
ASA EC 81mg
Colace 100mg [**Hospital1 **]
Haldol 25mg IM q3weeks
Hectorol 0.1mg qam
Lasix 20mg qam
Lopid 600mg [**Hospital1 **]
Lopressor 100mg PO bid
Norvasc 10mg qam
Omega 3 1000mg PO bid
Prilosec 20mg PO qam
Seroquel 12.5mg qam
Seroquel 800mg qhs
Simvastatin 10mg qam
Terazosin 1mg qhs
.
Medications on Tx from ICU ([**11-16**])
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, SOB, wheezing
Albuterol [**11-25**] PUFF IH Q6H:PRN
Insulin SC (per Insulin Flowsheet)
Amlodipine 10 mg PO DAILY
Metoprolol 100 mg PO BID
Aspirin 325 mg NG DAILY
Ondansetron 4 mg IV Q8H:PRN
Docusate Sodium (Liquid) 100 mg PO BID
Quetiapine Fumarate 25 mg PO ONCE
Doxercalciferol 2.5 mcg PO DAILY
Risperidone 0.5 mg PO BID
Epoetin Alfa 8000 UNIT SC QMOWEFR Start: HS
Senna 1 TAB PO BID
Famotidine 20 mg PO Q24H
Simvastatin 10 mg PO DAILY
Furosemide 20 mg IV ONCE Duration: 1 Doses Order date: [**11-16**]
Sodium Bicarbonate 650 mg PO BID
HydrALAzine 25 mg PO Q6H
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 capsules* Refills:*2*
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*2 inhaler* Refills:*4*
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*30 Tablet(s)* Refills:*2*
8. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Sodium Citrate-Citric Acid 500-300 mg/5 mL Solution Sig:
Sixty (60) ML PO TID (3 times a day).
Disp:*5400 ML(s)* Refills:*2*
12. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QFRI (every Friday).
Disp:*4 Patch Weekly(s)* Refills:*2*
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
15. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a
day).
Disp:*60 Wafer(s)* Refills:*2*
16. Risperidone 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
17. Sevelamer HCl 800 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*360 Tablet(s)* Refills:*2*
18. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (ONCE PER WEEK) for 7 weeks.
Disp:*7 Capsule(s)* Refills:*0*
19. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO TID W/MEALS.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
1. Hypercarbic Respiratory Failure
2. Obstructive Sleep Apnea
3. Hypertension
4. Chronic Kidney Disease, Stage IV
5. Schizoaffective disorder
Discharge Condition:
Stable. Afebrile. With legal guardian appointed.
Discharge Instructions:
You were admitted to the hospital because you were found at home
and were difficult to arouse. This was likely due to a
combination of factors, including obstructive sleep apnea,
hypoventilation syndrome, and medications. You were intubated
and placed on a mechanical ventilator and admitted to the ICU.
In the ICU, you were quickly off the ventilator and then
transferred to the medical floor. On the medical floor, you
continued to do well and used BiPAP infrequently. Your oxygen
saturations remained in the mid 90's on room air. You were also
seen by psychiatry and the renal doctors.
Please continue to take all your medications as prescribed. You
have been given prescriptions for all of them. Please keep all
your medical appointments.
If you have any of the following symptoms, please call your
doctor or go to the nearest ER: fever>101, chest pain, shortness
of breath, altered mental status, abdominal pain, or any other
concerning symptoms.
Followup Instructions:
Dr. [**First Name (STitle) **] [**Name (STitle) **] (Primary Care): Thursday, [**3-3**] at 4:10
PM. If you cannot make this appointment, please call
[**Telephone/Fax (1) 47783**] to reschedule.
Dr. [**First Name8 (NamePattern2) 6930**] [**Last Name (NamePattern1) 72152**] (Kidney): [**Last Name (LF) 766**], [**3-21**] at 11:30 AM. If
you cannot make this appointment, please call [**Telephone/Fax (1) 100430**] to
reschedule.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2140-2-26**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,083
| 140,076
|
50086
|
Discharge summary
|
report
|
Admission Date: [**2120-3-1**] Discharge Date: [**2120-3-5**]
Date of Birth: [**2051-4-24**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Chief Complaint: Confusion, difficulty breathing
Reason for MICU transfer: Hypotension
Major Surgical or Invasive Procedure:
[**2120-3-1**] - Central line placement in IJ, removed [**2120-3-4**]
[**2120-3-4**] - PICC line placement
History of Present Illness:
Ms. [**Known lastname 104573**] is a 68 year-old woman with extensive stage small
cell lung cancer with a painful, large R abdominal mass causing
T12-L3 neurologic symptoms s/p palliative chemotherapy with
Carboplatin/Etoposide and recent initiation of radiation to the
abdominal mass presenting with altered mental status, fever, and
difficulty breathing. Patient reports cough over the past few
months and had recent admission for pneumonia on [**2120-2-7**]. She does not remember what happened at home today, but
believes she was confused prior to presentation. Per report,
patient's husband went to work today and was unable to get in
touch with patient by telephone. [**Name (NI) **] son went to her home
and found her confused, but alert. Yesterday morning, patient
had some emesis but then tolerated lunch and dinner. She last
had chemotherapy one week ago, and is due for chemotherapy again
today.
.
In the ED, initial VS were: 99.7 133 153/83 20 99% 2L NC. On
arrival to the ED patient was tachypnic with increased work of
breathing. She was dehydrated on arrival and IV access was
initially difficult to obtain. Patient was found to have a
peri-hilar pneumonia on chest x-ray. She received acetaminophen
1000 mg PO x1, vancomycin, ceftriaxone, and levofloxacin.
Antibiotics were chosen prior to return of labs, which revealed
neutropenia. During ED stay, pt became tachycardiac to 140s and
blood pressure dropped to 80/40. This initially improved with
4L IVF and patient was going to be admitted to the floor.
However, blood pressure dropped to 80/40 and patient required
right IJ placement and neosynephrine to maintain blood pressure.
Vitals on transfer: Temperature 98.2, Pulse 81, Respiratory
Rate 16, Blood Pressure 99/60, O2 Saturation 96 on 4L. Prior to
arrival to the MICU, patient had head CT for AMS. DNR/DNI code
status was confirmed with patient and husband in [**Name (NI) **], but
noninvasive ventilation and pressors are acceptable. Prior to
transfer patient received a total of 6.3L of IVF during ED
course.
On arrival to MICU, patient feels slightly better. She
continues to complain of cough, but does not feel short of
breath. She denies headache and visual changes, but does
endorse some neck stiffness after having central line placed.
No abdominal pain, nausea, vomiting, diarrhea, melena, or
hematochezia. No dysuria. Pt does endorse back pain, which is
consistent with her chronic back pain.
Past Medical History:
-Small cell lung cancer with a painful, large R abdominal mass
causing T12-L3 neurologic symptoms currently on palliative
chemotherapy with taxol and recent initiation of radiation to
the abdominal mass.
- HTN
- Anxiety
- COPD
- GERD
Social History:
Married, lives with husband, retired from State Department
processing tax forms. Continues to smoke [**1-15**] pack per day. No
etoh or illicits.
Family History:
No known fhx of lung cancer
Physical Exam:
Admission exam:
Vitals: T: 99.4, BP: 117/62 P: 110 R: 19 O2: 100% on 2L
General: Alerted to [**Month (only) 956**], "hospital" but not [**Hospital1 18**], self,
sleeping in bed, but arousable to voice
HEENT: Sclera anicteric, EOMI, PERRLA, dry mucus membranes, oral
thrush
Neck: supple, JVP not elevated, no LAD, no nuchal rigidity
CV: Tachy, S1, S2, no murmurs/rubs/gallops
Lungs: Diffuse rhonchi bilateral, coarse breath sounds, no
wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley in place
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Os2, CNII-XII intact
Discharge exam - unchanged from above, except as below:
General: Awake and alert, comfortable and conversive
HEENT: moist MM, no thrush
CV: RRR, no m/r/g, nl S1/S2
Lungs: CTAB aside from some slightly bronchial breath sounds at
the lung bases bilat
GU: No Foley
Neuro: A&Ox3, no focal defecits
Pertinent Results:
Admission labs:
[**2120-3-1**] 01:45PM BLOOD WBC-1.1*# RBC-3.66* Hgb-10.9* Hct-31.0*
MCV-85 MCH-29.7 MCHC-35.1* RDW-15.9* Plt Ct-156
[**2120-3-1**] 01:45PM BLOOD Neuts-26* Bands-43* Lymphs-21 Monos-8
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2120-3-1**] 01:45PM BLOOD Glucose-95 UreaN-12 Creat-0.9 Na-129*
K-6.1* Cl-97 HCO3-23 AnGap-15
[**2120-3-1**] 01:45PM BLOOD Albumin-3.3* Calcium-8.1* Phos-2.7 Mg-1.6
[**2120-3-1**] 02:02PM BLOOD Type-[**Last Name (un) **] pO2-39* pCO2-40 pH-7.38
calTCO2-25 Base XS-0 Comment-GREEN TOP
[**2120-3-1**] 02:10PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2120-3-1**] 02:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2120-3-1**] 02:10PM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
Discharge labs:
[**2120-3-5**] 06:03AM BLOOD WBC-2.4* RBC-3.06* Hgb-8.9* Hct-25.6*
MCV-84 MCH-29.0 MCHC-34.7 RDW-16.3* Plt Ct-110*
[**2120-3-5**] 06:03AM BLOOD Neuts-61 Bands-1 Lymphs-18 Monos-15*
Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-2*
[**2120-3-5**] 06:03AM BLOOD Glucose-92 UreaN-7 Creat-0.7 Na-132*
K-3.6 Cl-100 HCO3-26 AnGap-10
[**2120-3-5**] 06:03AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.9
Micro:
-BCx ([**2120-3-1**]): No growth at discharge
-UCx ([**2120-3-1**]): No growth
-C. diff ([**2120-3-2**]): Positive for C. diff toxin
Imaging:
-CXR ([**2120-3-1**]):
1. Findings suggesting slight pulmonary congestion.
2. Focal right infrahilar opacity of recent onset which may
reflect
atelectasis or potentially early pneumonia in the appropriate
setting; if
pulmonary symptoms are present then short-term follow-up
radiographs,
preferably with PA and lateral technique if feasible, are
suggested.
-CXR ([**2120-3-1**]):
1. Worsening interstitial abnormality suggesting
mild-to-moderate pulmonary
vascular congestion. More confluent right perihilar opacity.
Although an
asymmetric pattern of pulmonary congestion could be considered
particularly
given rapid onset in the same timeframe, coinciding pneumonia
should also be considered.
2. Satisfactory placement of central venous catheter.
-CT head ([**2120-3-1**]): No acute intracranial hemorrhage or mass
effect. If clinical suspicion for an intracranial mass is high,
MRI is the recommended study of choice if not contra-indicated.
-CXR ([**2120-3-2**]): Right internal jugular central line with its tip
in the proximal SVC. More confluent airspace consolidation in
the right lower lobe which is concerning for pneumonia.
Pulmonary venous hypertension without evidence of overt
pulmonary edema. No large left effusion. No pneumothorax.
Overall, cardiac and mediastinal contours are stable.
-CXR ([**2120-3-4**]): Interval placement of a left subclavian PICC
line which has its tip in the
distal SVC. Right internal jugular central line has its tip in
the
proximal-to-mid SVC, unchanged. There continue to be streaky
opacities at the left base which may reflect subsegmental
atelectasis, although pneumonia or aspiration cannot be
excluded. The airspace consolidation at the right base has
significantly improved, and given the interval change, this
would favor resolving atelectasis rather than an acute
infectious process. Clinical correlation is advised. No
pneumothorax is seen. No evidence of pulmonary edema. Overall
stable cardiac and mediastinal contours given patient rotation
on the current study.
Brief Hospital Course:
68 year-old woman with extensive stage small cell lung cancer,
COPD, HTN presenting with fever, dyspnea, and altered mental
status, found to have pneumonia and C.Diff infection.
# Sepsis and pneumonia: Ms. [**Name13 (STitle) 104577**] presented with fever,
altered mental status, cough, tachycardia, hypotension,
leukopenia, She was found to have right lower lobe pneumonia on
chest x-ray at presentation. She remained hypotensive despite
6L of IVF and initially required pressors in the emergency room,
she was subsequently admitted to the ICU. Pressors were weaned
off overnight on first night of admission. In the ICU, she was
started on vancomycin, zosyn, and levofloxacin to cover for HCAP
given that she was recently admitted in [**1-/2120**] and received a 5
day course of levofloxacin at that time. Antibiotics were
changed to vancomycin, cefepime and levofloxacin upon transfer
to the floor. She received 5 days of levofloxacin during her
admission. A PICC line was placed and she will complete an 8
day course of vancomycin/cefepime as an outpatient. At
discharge, she was breathing comfortably on room air and mental
status was back to baseline.
#C. diff colitis: On hospital day #2, patient developed diarrhea
which was shown to be C.diff positive. She was started on PO
vancomycin which she will continue for a total of 2 weeks after
her 8 day course of HCAP antibiotics is completed.
# Hypoxia: Pt with known small cell lung cancer and recent
admission for pneumonia in [**2120-1-14**]. Also with history of
COPD but no wheezing. Presented with cough, fever, and evidence
of pneumonia on examiation. Patient requires coverage for HCAP
given recent admission. There was evidence of pulmonary edema
on CXR after aggressive volume resuscitation in the ED, however
her hypoxia resolved after the first day of admission. As
mentioned above, she was satting in the high 90s on room air at
discharge.
# Neutropenic fever: ANC was 286 at admission to [**Hospital1 18**], she was
placed on neutropenic precautions. She was febrile at admission
and was covered broadly as described above, she received
vanc/Zosyn/levofloxacin in the MICU and vanc/cefepime/levofloc
upon transfer to the floor. Her neutropenia improved at the
time of discharge, her ANC was 1464.
# Chronic pain: Related to her extensive metastases, especially
her large ambominal mass which extends from her liver to the
upper pole of her right kidney. She was continued on her home
dose of gabapentin 600 mg Q8H. She was continued on a lower dose
of oxycontin given her initial altered mental status. At
discharge, she will resume her home doses of pain medications.
#Extensive stage metastatic SCLC: She had been receiving
palliative chemotherapy and radiation at the time of
presentation. She did not receive any chemo or radiation during
this admission and will follow-up with her oncologist as an
outpatient.
#COPD: Continued on home dose of tiotropium. As described
above, her respiratory status was stable after her pneumonia was
treated and she was breathing comfortably on room air with no
wheezing on exam at discharge.
# GERD: Continued on home omeprazole.
# Code status this admission: DNR/DNI was confirmed with patient
her husband.
TRANSITIONAL ISSUES
-Will continue vanc/cefepime for 3 days after discharge via PICC
line
-PICC line to be removed by VNA after last dose of antibiotics
-Should follow-up with her oncologist after discharge regarding
management and palliation of her metastatic SCLC
Medications on Admission:
Amlodipine 2.5 mg daily
Hydormorphone 2 mg Q3H PRN
Lorazepam 0.5 mg Q6H PRN
Omeprazole 20 mg daily
Zofran 8 mg PO Q8H
Oxycodone ER 20 mg Q12H
prochlorperazine maleate 10 mg Q6H PRN nausea
tiotropium bromide 18 mcg inh daily
senna 8.6 mg [**Hospital1 **] PRN
docusate sodium 100 mg [**Hospital1 **]
simethicone 80 mg QID
gabapentin 600 mg Q8H
Discharge Medications:
1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO q3h as
needed for pain.
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
6. OxyContin 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO every twelve (12) hours.
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) capsule Inhalation once a day.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
11. simethicone 80 mg Tablet Sig: One (1) Tablet PO four times a
day.
12. gabapentin 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
13. cefepime in D5W 2 gram/50 mL Piggyback Sig: Two (2) gram
Intravenous every twelve (12) hours for 3 days: Lase dose on
afternoon of [**3-8**].
Disp:*3 days* Refills:*0*
14. vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
every twelve (12) hours for 3 days: Last dose on afternoon of
[**3-8**].
Disp:*3 days* Refills:*0*
15. vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 17 days: Last dose on [**2120-3-22**].
Disp:*68 Capsule(s)* Refills:*0*
16. sodium chloride 0.9 % 0.9 % Syringe Sig: One (1) syringe
flush Injection four times a day as needed for line flush per
protocol for 3 days: Line flushes per protocol.
Disp:*15 syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
Primary diagnoses:
Healthcare associated pneumonia (HCAP)
Clostridium difficile infection
Sepsis
Neutropenic fever
Secondary diagnoses:
Small cell lung cancer
Chronic obstructive pulmonary disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 104573**],
It was a pleasure taking care of you during your admission to
[**Hospital1 18**] for pneumonia, C. diff (stool infection) and sepsis. You
were initially admitted to the ICU and received IV antibiotics
as well as fluids. Your condition improved and were transferred
to the floor. After discharge, you will continue to receive IV
antibiotics.
You were also found to have C. diff which caused your diarrhea.
You will continue to take oral vancomycin for 2 weeks after
stopping the IV antiotics.
The following changes were made to your medications:
START vancomycin 1000mg by PICC every 12 hours (last dose 2/24)
START cefepime 2g by PICC every 12 hours (last dose 2/24)
START oral vancomycin 125mg by mouth every 4 hours (last dose
[**2120-3-22**])
Followup Instructions:
Name: [**Month/Day/Year **],[**Last Name (un) 104572**] M.
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 26 CITY [**Doctor Last Name **] MALL, [**Location (un) **],[**Numeric Identifier 6086**]
Phone: [**Telephone/Fax (1) 6087**]
When: Monday, [**2119-3-12**]:00 AM
You have an appointment with Dr. [**Last Name (STitle) **] ([**Location (un) 2274**] Oncology) on
[**2120-3-15**] at 2:30pm. Please be sure to keep this
appointment.
Department: PAIN MANAGEMENT CENTER
When: FRIDAY [**2120-3-29**] at 2:40 PM
With: [**Name6 (MD) 12672**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
|
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,752
| 148,439
|
22224
|
Discharge summary
|
report
|
Admission Date: [**2168-4-27**] Discharge Date: [**2168-5-7**]
Date of Birth: [**2137-3-18**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 32198**]
Chief Complaint:
abdominal pain and fever
Major Surgical or Invasive Procedure:
paracentesis
History of Present Illness:
Mr. [**Known lastname 57978**] is a 31 y/o man with a history metastatic, poorly
differentiated adenocarcinoma with squamous differentiation,
likely gallbladder primary who presents with abdominal pain and
fevers.
Was recently admitted to the OMED service [**Date range (1) 10649**]/[**2167**] for
hematemesis. Had EGD which showed non-bleeding duodenal masses
likely malignant in nature. They were not intervened upon. The
plan was to start him on xeloda as an outpatient. He had a
paracentesis with removal of 2.5L fluid on [**2168-4-11**] and then
was seen in Heme/[**Hospital **] clinic on [**4-15**] when the ascites fluid had
reaccumulated. There was a long family meeting at that time and
the decision was made to NOT proceed with Xeloda chemotherapy,
and to focus on pain control, however the patient??????s code remains
full.
He has had diffuse abdominal pain since [**4-15**] and then on the
evening prior to admission developed fevers and nausea with
non-bloody vomiting today. He complains of diarrhea x 2 days
after taking Fleet??????s enema. Pain generalized, dull [**8-3**]. No
radiations. He otherwise describes some mild dysuria and left
inguinal/scrotal pain associated with walking. Denies SOB or
cough, sinus pressure or pain, dysphagia, chest pain. No sick
contacts, no travel history.
In the ED, VS T103; HR 122 BP 175/87 18 99%RA. WBC was 19.1.
Lactate was 4.2. He was enrolled in sepsis protocol. A central
venous line was placed and paracentesis was performed removing
1L of ascites. Ascites fluid showed WBC 385 ( 20PMNs, 40L,
18Mono, 5meso, 17mac); RBC 2340; tpro 0.7; glu 153; LD 57; [**Doctor First Name **]
75; alb <1. He was given Vancomycin 1g , Flagyl 500iv x 1,
Unasyn 3 g, Dilaudid 8 mg and 8L NS with repeat WBC 26 with 10%
bands . RUQ U/S showed no obstruction. CT abdomen showed diffuse
colitis new from CT scan 2 days prior . Surgery was consulted
and felt that the patient was not a surgical candidate,
recommended antibiotic treatment. Admitted to the [**Hospital Unit Name 153**] for
further workup and management.
Past Medical History:
1. Metastatic GB cancer as above, with mets to liver,
retroperitoneal lymph nodes. With metal stent in CBD.
Complications of esophageal varices, s/p multiple bandings (most
recently [**2168-1-21**]). On Gemcitabine/Cisplatin, most recent chemo
[**2168-2-4**]
2. Malaria in past
3. s/p Appendectomy
4. H. Pylori, treated
5. UTI [**2163**]
6. HBV, low viral load, with varices in lower 1/3 esophagus
Social History:
Originially from [**Country **], moved to [**Location (un) **] 5 years ago, worked at
[**7-4**] (not currently). Denies tobacco/etoh (for many
months)/drugs. Living with his brothers
Family History:
DM in both parents, no cad, cancer. 10 siblings, none with
cancer
Physical Exam:
PE: VS: 98.9 HR 99 BP 106/48 RR 25 %Sat 99 CVP 9 ScvO2 77
Gen: Tired, jaundiced, flat affect otherwise NAD
HEENT: Mild icterus bilateral, O/P dry
Neck: Supple, no cervical LAD, RIJ in place
Chest: Decreased breath sounds on right halfway up and crackles
left base
Cor: Tachy no rubs/m/g
Abd: Distended, bandage on right side, generalized TN on deep
palp
Ext: 1+ pitting edema to knee
Neuro: A+O x 3, grossly non-focal
Pertinent Results:
CXR: Right effusion, cannot rule-out PNA
CT Chest/Abdomen [**2168-4-25**]: 1) Interval progression of disease with
new pulmonary nodules and increased size and number of multiple
hepatic metastasis when compared to prior studies from
[**2167-11-20**] as well as [**2168-2-26**]. 2) Occlusion of the portal vein
as well as the superior mesenteric vein at its confluence with
the splenic vein. 3) Increased intraabdominal ascites when
compared to [**2168-2-26**]. 4) The lesion within the gallbladder
fundus that measured 3.0 x 2.5 cm on [**2168-2-26**], measures 2.7 x
2.5 cm.
RUQ U/S [**4-27**]:
1. Ascites and right pleural effusion.
2. Gallbladder with sludge, not distended. There is some minimal
gallbladder
wall edema, though to be expected in the setting of high fluid
states.
CT Abdomen [**4-27**]: Thickened Colon. No perforation. Unchanged
pancreas. Unchanged bilateral pleural effusions.
Brief Hospital Course:
31 yo M with metastatic gallbladder cancer who presented to the
ED with fever, abdominal pain and sepsis; found to have
enterococcal bacteremia and endocarditis
.
1. Entercoccal bacteremia, endocarditis
He met criteria for sepsis by fever, tachycardia, elevated white
count, and elevated lactate. He has had early
intervention/aggressive volume resuscitation and broad spectrum
abx. His infectious work up to date significant for pan-colitis
on CT with c. diff negative, clean UA, clear CXR, and [**1-27**]
bottles bloood cultures on [**4-27**] with gram + cocci/enterococcus,
and paracentesis with no evidence of SBP. RUQ US with no
evidence of cholecystitis.
He clinically improved and remained stable; continued broad
spectrum abx with Linezolid to cover for potential MRSA or VRE,
levo for SBP prophylaxis, and po flagyl for empiric c. diff
coverage.
Ultimately, he was maintained on Penicillin and gentamycin for
treatment of his enterococcal bacteremia with TTE evidence of
endocarditis - had valvular thickening and inferior wall
hypokinesis. TEE was considered, but was deemed too risky in the
setting of known esophageal varices. Plan is for 4-6 weeks of
these antibiotics.
2. cholestasis/liver failure
Complicated by recurrent ascites and h/o esophageal varices s/p
repeat banding
- EGD in [**2-27**] with grade I varices
- s/p paracentesis on admission with no evidence of SBP
His ascites, peripheral edema was manged with lasix/aldactone,
and repeat
paracentesis. His nadolol was continued for secondary variceal
bleeding prophylaxis.
.
3. Metastatic cholangiocarcinoma of the GB
With mets to liver and lungs, retroperitoneal lymph nodes. With
metal stent in CBD. Discussion was held with Dr. [**Last Name (STitle) 27538**],
patient, and family. It was discussed that these is no further
role for chemotherapy, and also code status was discussed.
.
5. Microcytic, hypochromic anemia
History of past GI bleeding from esophageal varices. These have
been
monitored by repeated EGD with banding. GI was involved in his
care during
this hospitalization; no further EGD or banding done at this
time. Last EGD
in [**2-27**] with Grade I varices.
6. Pan-colitis
Seen by abdominal CT; was c. diff negative x 3. Diarrhea only
once, thereafter resolved and clincally stable. Tolerated po
diet well.
.
Medications on Admission:
Ciprofloxacin 500 mg po qd
Aldactone 50 mg po qd
Dilaudid 16 mg po q6-8h prn
Neurontin 300 mg po tid
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Nadolol 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Fentanyl 100 mcg/hr Patch 72HR Sig: 2.5 patches Transdermal
Q72H (every 72 hours): total dose of 250mcg patch q72h.
13. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: Four
(4) MU Injection Q4H (every 4 hours) for 4 weeks.
14. Gentamicin in Normal Saline 100 mg/50 mL Piggyback Sig: One
Hundred (100) mg Intravenous Q8H (every 8 hours) for 4 weeks.
15. Hydromorphone HCl 4 mg/mL Syringe Sig: Four (4) mg Injection
Q3-4H () as needed.
16. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg
Injection Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. metastatic cholangiocarcinoma
2. enterococcal bacteremia/endocarditis
3. liver metastases/failure/coagulopathy/h/o variceal bleeding
4. anemia
5. ascites, s/p paracentesis
6. pan-colitis, c. diff negative x 3
Discharge Condition:
stable
Discharge Instructions:
Call your doctor for any worsening abdominal pain,
nausea/vomiting,
blood in your stool, or any fevers.
Followup Instructions:
Keep your follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 150**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 32201**]
|
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icd9cm
|
[
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8419, 8498
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4505, 6830
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293, 307
|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,242
| 149,651
|
1556
|
Discharge summary
|
report
|
Admission Date: [**2107-12-19**] Discharge Date: [**2108-1-5**]
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 9055**] is an 86 year old
gentleman with known coronary artery disease with recent
increase in dyspnea and fatigue. He was admitted on the [**11-19**] from the emergency room. His primary care
physician referred him due to his worsening dyspnea. His
electrocardiogram had no new ischemic changes.
PAST MEDICAL HISTORY:
1. Cervical spondylosis.
2. Spinal stenosis.
3. Status post bilateral total hip replacement.
4. Status post hernia repair.
5. Status post back surgery many years ago.
PREOPERATIVE MEDICATIONS: Include Zocor and aspirin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with his wife. Denies
tobacco use and admits to one alcohol drink per day.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] where he underwent an echocardiogram
which showed an ejection fraction of 60 to 70 percent with
severe aortic stenosis with an aortic valve area of 0.7 cm
sq, a dilated ascending aorta, mild mitral regurgitation. He
underwent VQ scan to rule out pulmonary embolism which showed
low suspicion. The patient underwent a stress MIBI which the
patient stopped due to fatigue and chest pressure, a mild
inferior wall reversible defect and mild septal akinesis with
an ejection fraction of 67 percent. The patient was taken
for cardiac catheterization on [**12-23**] which showed
pulmonary capillary wedge pressure of 7 and pulmonary artery
pressure of 21/5, 20 to 30 percent calcified left main
lesion, 60 percent mid left anterior descending coronary
artery lesion, 70 percent left circumflex lesion, 70 percent
mid to distal right coronary artery lesion. Patient was
referred to the cardiac surgery service and as part of the
work up an oral and maxillofacial consult was obtained to
rule out any evidence of dental disease and their diagnosis
was chronic apical periodontitis of tooth number 20 and 24
with generalized periodontitis. Initially the oral and
maxillofacial team had recommended extraction of teeth
numbers 23 and 24. However, on further evaluation they felt
that there were no signs of acute infection and patient was
cleared for surgery and patient was taken to the operating
room with Dr. [**Last Name (STitle) **] on [**2107-12-27**] where he underwent
a coronary artery bypass graft times three with left internal
mammary artery to left anterior descending coronary artery,
saphenous vein graft to obtuse marginal and saphenous vein
graft to right coronary artery as well as aortic valve
replacement with a 23 mm [**Last Name (un) 3843**] [**Doctor Last Name **] bovine
pericardial valve. The patient tolerated the procedure well
and was transferred to the Intensive Care Unit in stable
condition.
The patient remained intubated and overnight on his first
postoperative night and was weaned and extubated from
mechanical ventilation without difficulty. It was noticed
that patient had an irregular rhythm with some element of
block and required some ventricular pacing. The patient
began to have some ventricular ectopy and was started on an
amiodarone infusion. Electrophysiology Service was
consulted. It was felt that service that postoperatively the
patient had a new right bundle branch block with some
preoperative sinus node dysfunction and a postoperative
tachyarrhythmia. It was felt that the patient would benefit
from a pacer. It was recommended to discontinue the
amiodarone and continue to evaluate the patient over the next
several days. On postoperative day number two it was noted
the patient's platelet count had dropped to 84,000. A
heparin antibody was sent which was subsequently negative.
Electrophysiology service subsequently felt that the
irregular heart rhythm was due to complete heart block and
was evidence of AV nodal dysfunction or HIS disease. The
patient continued to be paced intermittently with atrial
sensing and ventricular pacing. He was started on Lasix with
good diuresis. By postoperative day number four the patient
was consistently in first degree AV block. Patient was
transferred from the Intensive Care Unit to the regular part
of the hospital on postoperative day number 5. On
postoperative day number seven the patient was taken to the
electrophysiology laboratory where it was determined that
patient would benefit from implanted pacemaker. Patient
received a [**Company 1543**] Dual Chamber rate responsive pacemaker.
He tolerated this procedure well and he was transferred back
to Far 2.
On postoperative day number eight the patient underwent
evaluation of the pacemaker by the Electrophysiology team
which showed that it was working appropriately. He underwent
a chest x-ray which showed no pneumothorax and good aeration,
mild pulmonary edema and he was started on a low dose beta
blocker. At that time it was decided patient was cleared for
discharge to rehabilitation.
CONDITION ON DISCHARGE: Temperature 97.6, pulse 74 and in
sinus rhythm. Blood pressure 108/58, respiratory rate 18,
oxygen saturation 95 percent on room air. Patient's weight
is 63.4 kilograms, patient was 65 kilograms preoperatively.
Laboratory data: Hematocrit 32.3, sodium 137, potassium 5.2,
chloride 100, bicarb 29, BUN 38, creatinine 1.6, glucose of
86. Physical examination - patient is awake, alert,
oriented, nonfocal. Breath sounds are coarse bilaterally.
Heart is regular rate and rhythm. Extremities show clean,
dry and intact with no erythema or drainage. Abdomen is
soft, nontender, nondistended. Positive bowel sounds.
Extremities were warm without edema. The left leg incision
is clean and dry without edema.
DISCHARGE MEDICATIONS:
1. Colace 100 mg P.O. B.I.D
2. Enteric coated aspirin 81 mg P.O. daily
3. Percocet 5/325 1 to 2 P.O. q 4 hours PRN
4. Zantac 150 mg P.O. daily
5. Atenolol 25 mg P.O. daily
6. Lasix 20 mg P.O. q day times five days.
7. Potassium chloride 10 mEq P.O. q day times five days.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft aortic valve
replacement.
2. Status post permanent pacemaker insertion.
3. Renal insufficiency.
4. Status post bilateral total hip replacement.
5. History of cervical spondylosis.
6. Status post hernia repair.
7. Status post back surgery.
Patient should follow up with Dr. [**Last Name (STitle) 9056**] his primary care
physician in one to two weeks. He should follow up with Dr.
[**Last Name (STitle) 284**] with electrophysiology in three to four weeks. He
should follow up with Dr. [**Last Name (STitle) **] in four weeks. He should
be seen in the device clinic in the [**Hospital Ward Name 23**] Center [**1-10**] at 10 A.M. for check on his pacemaker. He is to be
discharged to rehabilitation in stable condition.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2108-1-4**] 17:28:42
T: [**2108-1-4**] 18:20:20
Job#: [**Job Number 9057**]
|
[
"593.9",
"997.1",
"427.31",
"424.1",
"522.6",
"272.0",
"414.01",
"401.9",
"426.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"36.12",
"37.26",
"37.83",
"35.21",
"88.56",
"37.23",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6022, 7031
|
5727, 6001
|
855, 4968
|
659, 725
|
118, 441
|
463, 632
|
742, 837
|
4993, 5704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,426
| 143,342
|
34366+57917
|
Discharge summary
|
report+addendum
|
Admission Date: [**2125-8-26**] Discharge Date: [**2125-8-30**]
Date of Birth: [**2064-1-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Lethargy/fever
Major Surgical or Invasive Procedure:
PICC line placement.
EGD.
History of Present Illness:
61 y/o Haitian speaking M with complicated PMHx including CVA,
neurogenic bladder s/p suprapubic cath, lymphoma, SLE and
partial bowel obstruction s/p colostomy who was transferred from
NH due to lethargy, mental status change and fever to 104. Per
EMS, pt was found febrile to 104, tachycardic and hypoxic with
room air sat in the 80s. Pt was transferred to [**Hospital1 18**] (though
receives most of his care at [**Hospital1 2177**]).
.
On arrival to ED VS:T 103.5, HR 128, BP 125/63, RR 22 Sats 97%
[**Name (NI) 597**]
Pt received 4L of IVF, blood & urine Cx sent. He received Vanc &
Cefepime for +UA. CXR showed bibasilar atelectasis vs
infiltrate. Pt was persistently febrile and was transferred to
ICU for tachycardia.
.
On arrival to ICU VS: pt was feeling tired but denying
CP/SOB/Abd pain. He was complaining of acute on chronic left
lower extremity pain, otherwise, no complaints.
.
ROS: Pt was not oriented but denied fevers, nausea, vomiting,
abdominal pain, diarrhea, chest pain, shortness of breath or
cough
Past Medical History:
s/p CVA
Neurogenic bladder s/p suprapubic cath
Recurrent UTIs with Klebsiella/Pseudomonas
Non-hodgkins Marginal Zone Lymphoma of the left orbit Dx in 03
(s/p R-CHOP x 6 cycles)
Bells Palsy
BPH
Hypertension
Partial Bowel obstruction s/p colostomy
Hepatitis C
Cryoglobulinemia
SLE with transverse myelitis, anti-dsDNA Ab+
Insulin Dependant Diabetic
Fungal Esophagitis Stage IV?
Urinary Tract Infections-pseudomonas & enterococcus
Social History:
Pt has been residing in nursing home since [**3-9**] but speaks to
sister regularly and is alert & oriented x 3 at baseline.
Family History:
non-contributory
Physical Exam:
T-100.1 HR 109 BP 160/57 RR 17 Sats 97% on 2L
GEN: WDWN, no acute distress, oriented to person & med center
only
HEENT: Residual left facial droop and right lid lag (not new per
pt) [**Name (NI) 22031**], sclera anicteric, EOMI, MMM.
NECK: supple, no lymphadenopathy
COR: RRR, no M/G/R, prominent S2
PULM: subtle inspiratory crackles at right lower lung base,
otherwise clear to auscult bilaterally, no wheeze
ABD: Soft, NT, active BS, mildly distended but non-tender, stoma
from colostomy beefy red and nontender, formed green stool in
bag
EXT: chronic venous stasis changes, +1 pitting edema
bilaterally, tender to palp over left lower extremity, decreased
hair/sensation, poor nail hygiene/onychomycosis. No erythema or
warmth.
NEURO: alert, oriented to person/medical center, not oriented to
time/place. CN II ?????? XII grossly intact, residual left sided
facial droop. Moves upper extremities well, moves distal right
lower extremity-strength 3/5, residual left lower extremity
weakness since CVA per pt report, strength 1/5
Brief Hospital Course:
61 y/o haitian male with complicated PMHx including CVA with
residual neurogenic bladder s/p suprapubic cath who is
presenting with fever, lethargy and positive UA. Was initially
admitted to the ICU for management of infection and tachycardia.
.
.
# Septic shock due to pneumonia, aspiration: He was admitted
with tachycardia, leukocytosis, and encephalopathy with fever,
and was admitted to the ICU. The patient had mild opacities on
his CXR. Pt received Vanc/Cefepime in ED, and this was
continued while awaiting culture results. We checked CXR daily
and bolused LR to maintain MAP>65 and urine output >30cc. Chest
CT done to evaluate for PE revealed bilateral lower lobe
opacities and right upper lobe opacities, consistent with
aspiration or multifocal pneumonia. He was treated empirically
for aspiration pneumonia with vancomycin and cefepime, and was
improved, with decreased leukocytosis and no fever. He was
initially hypoxic, but this resolved with treatment. He will
need repeat Chest xray in 4 weeks to verify resolution.
.
#Chronic suprapubic catheter: Patient's UA on admission from
suprapubic cath concerning for infection, UA+ with 21-50 WBCs
and h/o Pseudomonas UTI sensitive to Cefepime, though chronic
colonization was also considered. Urology was consulted to
change out suprapubic cath and changed this on [**8-27**] without
complications. Initial urine culture was contaminated, repeat
done after change of suprapubic catheter also negative. His
suprapubic catheter was draining a small amount of bloody urine
due to manipulation, but his hematocrit remained stable.
.
# Elevated CK/Trop: Pt EKGs show sinus tachycardia with LVH and
likely strain. Suspect the elevated CK/Trop is due to ARF vs
demand ischemia from tachycardia given that MB fraction was
normal and CE did not increase. He received Aspirin 325 and was
asymptomatic.
.
# Acute encephalopathy: Per family, pts baseline is
alert/oriented x 3. However, pt was confused and only oriented
to place and person. Neuro exam was assessed q4h and remained
non-focal. This was acute toxic metabolic encephalopathy due to
infection, and returned to baseline by HD #2.
.
# PPD reaction: Mr. [**Known lastname **] had a PPD placed at his nursing
facility. While here, approximately 10 days after placement, he
had an indurated area in the location of the PPD injection.
This was discussed with ID, who recommended repeat PPD after the
resolution of the current reaction, given the delayed reaction.
It is possible that the recent discontinuation of prednisone
permitted reaction.
.
#Acute gastritis: He had a CT scan to evaluate for PE, this
revealed possible gastric wall thickening. He was seen by Dr.
[**First Name (STitle) 10113**] of GI and underwent endoscopy. This revealed a normal
esophagus and duodenum, and mild gastritis. He was started on
[**Hospital1 **] protonix, and should get a repeat CT in [**6-10**] weeks to
evaluate for changes. He also has outstanding biopsies, which
will be sent to Dr. [**Last Name (STitle) **] when they are available. ASA was held,
and heparin was discontinued prior to biopsies.
.
# ARF: Creatinine of 2.0 on admission and decreased to 1.0 after
fluid resuscitation. Last cr 1.0.
.
# Left lower extremity pain: Is a chronic problem but acute
worsening on admission. Extremity does not appear cellulitic.
LENIs negative. Gabapentin was increased to 1200 mg po TID.
Lyrica could be added if still significantly painful on higher
dose of neurontin. Oxycodone 10 mg po tid also continued.
.
# Diabetes: Continued home regimen of Lantus 8u qhs, and
diabetic diet with ENSURE.
.
# Lupus: No active issues addressed during hospitalization.
.
# Code: Full per HCP & NH records. Jehova's witness, no
transfusions.
Medications on Admission:
Lactulose 30ml TID
Ensure TID
Celexa 20mg daily
Folic Acid 1mg daily
Multivitamin/Vitamin B-1/Thiamine daily
Aspirin 81mg daily
Simvastatin 10mg daily
Prilosec 20mg daily
Calcium tab [**Hospital1 **]
Ferrous Sulfate 325mg TID
Gabapentin 900mg TID
Oxycodone 10mg TID (5mg prn)
Lantus 8u qhs
Humalog 5u qam, 6u qnoon, 6u qdinner
Prednisone 1mg daily (d/c'd on [**2125-8-22**])
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO TIW as needed for
constipation.
2. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Tablet PO three times a day.
10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for breakthrough pain.
14. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
15. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in
Packet Sig: One (1) Powder in Packet PO TID (3 times a day) for
3 days: Through tomorrow.
16. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Five (5) ML
Injection PRN (as needed) as needed for line flush.
17. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours): through [**9-1**].
18. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours): through [**9-1**].
19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
20. Insulin Regular Human 100 unit/mL Solution Sig: Five (5)
units Injection QAC: 5 units before, breakfast, 6 units before
lunch, dinner.
21. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day: start in 1 week post EGD.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] care center
Discharge Diagnosis:
Pneumonia, likely aspiration.
Acute renal failure.
Septic shock.
Gastritis.
Lupus.
?positive PPD.
Suprapubic tube infection.
Elevated troponin.
Diabetes mellitus, Insulin dependent.
Neuropathic leg pain.
Discharge Condition:
Improved, tolerating oral diet, suprapubic catheter with small
amount of blood due to trauma, not ambulatory.
Discharge Instructions:
You were admitted with an infection, likely pneumonia. You were
rehydrated and treated with IV antibiotics, and improved
significantly. You also had an endoscopy to look at your
stomach, which showed gastritis.
Return to the emergency room if you develop worsening abdominal
pain, leg pain, inability to eat, high fevers, or confusion.
You should follow up with Dr. [**Last Name (STitle) **] in 1 week.
You will need a repeat PPD in 1 month.
Followup Instructions:
You should see Dr. [**Last Name (STitle) **] after returning to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
You need a repeat CT scan of the abdomen in [**6-10**] weeks.
Repeat PPD in 4 weeks (reaction in area of injection, but 10
days post injection)
Name: [**Known lastname **],[**Known firstname 12722**] Unit No: [**Numeric Identifier 12723**]
Admission Date: [**2125-8-26**] Discharge Date: [**2125-8-30**]
Date of Birth: [**2064-1-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4842**]
Addendum:
Attached are important studies, not included in prior discharge
summary.
Pertinent Results:
Chest CT [**8-28**]
Final Report
REASON FOR EXAM: 61-year-old man with complicated medical
history including
stroke, neurogenic bladder status post suprapelvic cath,
lymphoma, SLE who
presented with fever, tachycardia and hypoxia. Rule out PE.
No prior exam for comparison.
This study is slightly suboptimal. Inspiration and contrast
enhancement in
pulmonary arteries is suboptimal.
There is no pulmonary embolism.
PICC ends in low right atrium. Small bilateral pleural effusions
are
associated with peribronchial ground-glass opacity and alveolar
consolidation
in right upper lobe and both lower lobes, consistent with
multifocal pneumonia
or aspiration, mostly in dependent regions. Mediastinum is
shifted to the
right associated with pleural fat thickening without
calcification, could be
due to noncalcified fibrothorax.
Prominent mediastinal lymph nodes are seen, the most prominent
in the
subcarinal region measures 4 mm. Calcified lymph node is in the
prevascular
region. Other lymph nodes are not enlarged. Right subclavian
lymph node
measures 7 mm and multiple axillary lymph nodes are not
enlarged. Right hilar
lymph nodes are up to 9 mm.
The pulmonary artery is mildly enlarged up to 3.1 cm. Bilateral
gynecomastia
is symmetrical.
This study was not tailored for subdiaphragmatic evaluation
except to note
gastric distention and a normal-sized spleen. The anterior
stomach wall is
thickened, could be only gastric adherent, gastric content or
gastric wall
thickening.
Lucent well-defined 19 x 9 mm left clavicular bony lesion has
sclerotic
borders, presumably benign.
IMPRESSION:
1. No PE.
2. PICC ends in low atrium.
3. Small bilateral pleural effusion associated with
peribronchial ground-
glass opacity and alveolar consolidation in right upper lobe and
both lower
lobes consistent with multifocal pneumonia versus aspiration.
4. Right pleural fat thickening with shift of the mediastinum to
the right
consistent with noncalcified fibrothorax.
5. Multiple mediastinal lymph nodes, one is enlarged and one is
calcified.
6. Bilateral gynecomastia.
7. Enlarged pulmonary artery consistent with pulmonary
hypertension.
8. Gastric distention with thickening of the anterior wall of
the stomach up
to 25 x 22 mm. Giving the knowp prior diagnosis of MALT
lymphoma, endoscopy
with further evaluation of the stomach is recommended.
9. Well-defined clavicular lesion with sclerotic borders, could
be fibrous
dysplasia. If of clinical concern, bone scan could further
characterize this.
Results were discussed on the phone at the time of [**Location (un) **] with
the treating
team.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 1236**] [**Name (STitle) 12724**]
DR. [**First Name4 (NamePattern1) 10279**] [**Last Name (NamePattern1) 12407**]
Approved: TUE [**2125-8-28**] 4:28 PM
EGD results [**8-29**]:
Impression: Normal mucosa in the esophagus
Erythema and granularity in the stomach compatible with
gastritis (biopsy)
Normal mucosa in the duodenum
Recommendations: Follow-up biopsy results
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 84**] [**Last Name (NamePattern1) **] care center
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4843**] MD [**MD Number(2) 4844**]
Completed by:[**2125-8-31**]
|
[
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"995.92",
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"459.81",
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icd9cm
|
[
[
[]
]
] |
[
"59.94",
"45.16",
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] |
icd9pcs
|
[
[
[]
]
] |
14118, 14381
|
3111, 6860
|
330, 358
|
9654, 9766
|
11027, 14095
|
10261, 11008
|
2022, 2040
|
7286, 9279
|
9427, 9633
|
6886, 7263
|
9790, 10238
|
2055, 3088
|
276, 292
|
386, 1411
|
1433, 1863
|
1879, 2006
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
902
| 143,497
|
44539
|
Discharge summary
|
report
|
Admission Date: [**2171-12-21**] Discharge Date: [**2172-1-10**]
Date of Birth: [**2111-12-6**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Penicillins / Zinc Oxide
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Transferred to [**Hospital1 18**] for possible endocarditis, transfer to ET
for work up of cirrhosis
Major Surgical or Invasive Procedure:
Transesophageal Echocardiogram
History of Present Illness:
Patient is a 60 yo M with HCV, cirrhosis, h/o poly substance
abuse currently on a Methadone program, trasnfusion dependent
anemia, chronic renal isufficiency, CAD, h/o cardiac arrest s/p
ICD who was initially transferred to [**Hospital1 18**] CCU for enterococcus
bacteremia and concern for endocarditis given new murmur and
persistant bacteremia. He was initially treated with Vancomycin
and Gentamicin but Gent discontinued for [**Last Name (un) **]. TEE and TTE
negative for vegetation but given high pre-test probability and
possible infected pacer wires ID has consulted on patient and
recommended Cipro and Vancomycin for prolonged course. Patient
has never had an outpatient work up for cirrhosis in the past
and his MELD was >20 and so patient transferred to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**]
for further management of his acute on chronic kidney injury in
addition to work up for Cirrhosis and initiation of transplant
evaluation.
.
Review of Systems:
Patient is somnolent, is arousable and oriented so ROS is unable
to be completed.
Past Medical History:
-?Cirrhosis
-Hepatitis C
-Polysubstance abuse - IVDU, now on methadone, EtOH, MJA
-HLD
-HTN
-ICD/dual chamber pacemaker
-[**Last Name (LF) 9215**], [**First Name3 (LF) **] 70%
-CAD distant MI
-Recurrent VT, VF arrest s/p Guidant ICD [**2165-4-22**] prolonged QT
-GERD s/p partial gastrectomy in [**2138**] for gastric ulcer
-Hypothyroidism
-Peripheral Vascular Disease
-Right hip fracture s/p multiple surgical revisions
-Chronic pain (hip and back)
-Appendectomy in [**2138**]
Social History:
The patient is on disability.
- IVDU with heroin (last use "years ago").
- MJA use
- He formerly drank a 6 packs/day and now cut back to [**3-29**]
beers/day.
- He is currently on methadone.
- He is married and lives with his wife.
Family History:
Sister died [**2165**] from "blood clot" with sudden death. Had
not been hospitalized or with recent trauma/surgery. No other
family history of blood clots/bleeding disorders. No family
history of heart problems, [**Name (NI) 2320**] or cancer.
Physical Exam:
Admission Exam:
Vitals: AV paced at 80bpm, 110/47 16 95%RA
General: Patient is somnolent but arousable, he is when aroused
he is AOx3 but he quickly closes eyes and has to be rearoused.
He is chronically ill appearing. NAD. Does not appear grossly
jaundiced
HEENT: Normocephalic, atraumatic, no scleral icterus
Neck: Supple, NT, No [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3495**]: S1 S2 clear and of good quality, 2/6 Systolic murmur RUSB
Lungs: Patient unable to take deep breaths for exam but clear to
asucultation on anterior exam
Abdomen: Soft, Obese, ecchymoses, NTTP, distended, palpable
hepatosplenomegaly.
Extremities: Bilateral [**Location (un) **] 3+ up to thigh with also scrotal
edema present. Chronic LE skin changes hyperpigmentation of skin
without evidence of cellulitis. Diminished pulses but also with
severe edema
Neurological: Somnolent but arousable, Ox3 when aroused
Discharge Exam:
General: Patient is alert and oriented x3, chronically ill
appearing. NAD. Does not appear grossly jaundiced, wanting to go
home, does not want further treatment
HEENT: Normocephalic, atraumatic, no scleral icterus
Neck: Supple, NT, No [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3495**]: S1 S2 clear and of good quality, 2/6 Systolic murmur LUSB
Lungs: Patient clear to asucultation on anterior exam
Abdomen: Soft, Obese, ecchymoses, NTTP, distended.
Extremities: Bilateral [**Location (un) **] 3+ up to hips also with scrotal edema
present. Chronic LE skin changes c/w venous stasis.
Pertinent Results:
Admission:
[**2171-12-21**] 07:48PM BLOOD WBC-21.0*# RBC-2.52*# Hgb-7.9*#
Hct-23.5*# MCV-93 MCH-31.4 MCHC-33.7# RDW-19.2* Plt Ct-58*
[**2171-12-21**] 07:48PM BLOOD Neuts-77* Bands-13* Lymphs-5* Monos-2
Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2171-12-21**] 07:48PM BLOOD PT-17.0* PTT-40.2* INR(PT)-1.5*
[**2171-12-21**] 07:48PM BLOOD Fibrino-133*
[**2171-12-21**] 07:48PM BLOOD ESR-81*
[**2171-12-21**] 07:48PM BLOOD Ret Aut-1.8
[**2171-12-21**] 07:48PM BLOOD Glucose-97 UreaN-61* Creat-3.2*# Na-139
K-3.3 Cl-109* HCO3-24 AnGap-9
[**2171-12-21**] 07:48PM BLOOD Albumin-1.4* Calcium-7.7* Phos-3.8 Mg-2.2
[**2171-12-21**] 07:48PM BLOOD ALT-33 AST-128* LD(LDH)-335* AlkPhos-46
TotBili-2.0* DirBili-0.9* IndBili-1.1
[**2171-12-21**] 07:48PM BLOOD Hapto-<5*
[**2171-12-23**] 08:00PM BLOOD Hapto-<5*
[**2171-12-21**] 07:48PM BLOOD CRP-55.9*
[**2171-12-21**] 08:08PM BLOOD Type-[**Last Name (un) **] Temp-35.6 pO2-59* pCO2-39
pH-7.43 calTCO2-27 Base XS-1
[**2171-12-21**] 08:08PM BLOOD Lactate-2.6*
[**2171-12-21**] 08:08PM BLOOD freeCa-1.11*
Hemolysis work up:
[**2171-12-21**] 07:48PM BLOOD Hapto-<5*
[**2171-12-23**] 08:00PM BLOOD Hapto-<5*
[**2171-12-26**] 04:11AM BLOOD calTIBC-146 Ferritn-906* TRF-112*
[**2171-12-21**] 07:48PM BLOOD Ret Aut-1.8
[**2171-12-21**] 07:48PM BLOOD Fibrino-133*
[**2171-12-23**] 08:00PM BLOOD Fibrino-113*
[**2171-12-24**] 03:45AM BLOOD Fibrino-77*
[**2171-12-25**] 04:30AM BLOOD Fibrino-117*#
[**2171-12-25**] 04:30AM BLOOD FDP-40-80*
[**2171-12-28**] 03:00PM BLOOD Fibrino-101*
[**2171-12-21**] 07:48PM BLOOD PT-17.0* PTT-40.2* INR(PT)-1.5*
[**2171-12-21**] 07:48PM BLOOD Plt Smr-VERY LOW Plt Ct-58*
Difficult Cross Match:
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [**Known lastname 95409**] has a
new diagnosis of an anti-K (prior diagnosis of anti-c, anti-E
and anti-Sda at [**Hospital1 18**]). K is a member of the [**Doctor Last Name **] blood group
system. Anti-K is
clinically significant and is capable of causing hemolytic
transfusion
reactions. In the future, Mr. [**Known lastname 95409**] should receive K, c and
E
antigen negative products for all red cell transfusions.
Approximately
13% of ABO compatible blood will be K, c and E antigen negative.
In addition, Mr. [**Known lastname 95409**] has an anti-Sda. Although usually
not
considered clinically significant these antibodies can
complicate blood
bank workups. Therefore, please notify the blood bank as soon as
possible if transfusion is being considered.
Reports:
TEE [**2171-12-22**]: The left atrium is normal in size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The 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 masses or
vegetations are seen on the mitral valve. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
CT Head [**12-22**] IMPRESSION: No CT evidence for acute intracranial
hemorrhage or mass effect. Correlate clinically to decide on the
need for further workup/followup.
RUQ US [**2171-12-23**]
1. Coarsened heterogeneous hepatic echotexture without focal
lesion. Small volume of ascites and borderline splenomegaly
noted.
2. Bilateral pleural effusions.
3. Prominent CBD at 8 mm.
CXR [**12-25**] Right PICC tip is in the right atrium, can be
withdrawn approximately 4 cm for more standard position. There
are low lung volumes. Moderate cardiomegaly is stable. Left
transvenous pacemaker leads are in a standard position. Moderate
pulmonary edema has minimally increased. Small left pleural
effusion has increased. Left lower lobe retrocardiac atelectasis
has worsened.
Micro:
HCV VIRAL LOAD (Final [**2171-12-27**]):
192,129 IU/mL.
BCx x6 Negative
C.Diff Negative
UCx negative x 1, GNRs ~5000/ml x1
Catheter tip Cx negative
Brief Hospital Course:
Patient is a 60yo M with IVDU, polysubstance abuse on Methadone,
HCV, ?Cirrhosis based on biopsy per report who was initially
admitted to CCU for ?endocarditis/pacemaker wire infection,
transferred to ET for management of cirrhosis and acute kidney
injury.
# Goals of Care: It is clear thats patient's goal is to be
discharged home regardless of prognosis. He is aware that his
liver will continue to deteriorate and he does not want to
continue aggressive measures to improve his hepatic function. He
is a not a transplant candidate, both from pre-hospitalization
EtOH intake and because patient not interested in evaluation,
without a transplant his prognosis is poor. Palliative care
consulted. After in depth discussion between patient, his wife,
[**Name (NI) 55745**] and with Pal Care team the decision was made to transition
patient to home hospice care. Patient's ICD was turned off and a
home hospital bed was delivered to patient's home. He was
discharged in stable condition to home hospice care with minimal
medications.
# Hepatitis C: End Stage Liver Dysfunction possibly complicated
by Cirrhosis, ascites and hepatic encephalopathy though
cirrhosis not confirmed. This has been untreated as an
outpatient and has not seen a hepatologist. LFTs began improving
in the CCU and continued to during ET admission but albumin
remained <1.5 and INR 1.5. MELD=22 on ET transfer. He was
encephalopathic on transfer. Transplant work up was initiated
though not completed as patient expressed his desire to not be
treated. [**Doctor First Name **]/AMA negative, HBsAb+ but HBsAg-, HCV load 192,000.
His Cirrhosis was treated with Lactulose and Rifaximin. He
continued to refuse his lactulose yet his mental status improved
in clarity, hepatic encephalopathy likey the result of
bacteremia. He was treated with spironolactone: 50mg for
anasarca and hypokalemia and Furosemide 20mg daily. Creatinine
remained stable at new baseline of 1.4 despite diuretics.
# Acute Kidney Injury: Acute on Chronic Renal Insufficiency.
FeUrea was 48% and urinalysis showed muddy brown casts
suggesting ATN. Episode of hypotension may have precipitated ATN
in addition to Gentamicin related nephrotoxicity. Creatinine
continued to improve during admission with clearing of
bacteremia, improvement in LFTs and with avoiding hypotension
and Gentamicin. Renal initially consulted, did not feel it was
HRS but rather ATN. Lasix did not exacerbate renal function
# Bacteremia: At OSH, he had BCx positive for Enterobacter and
Enterococcus. All BCx drawn at [**Hospital1 18**] were negative. He was
treated with vanc and gent at the OSH, which was changed to vanc
and cipro after consult with ID at [**Hospital1 18**]. Patient with prior
enterococcal UTI/bacteremia without definitive evidence of
endocarditis found on TEE. He was treated for Endocarditis
despite negative TEE given high suspicion and pacer wire high
risk infection. He was treated with IV Vanco and Cipro for a 6
week course. A TTE and TEE showed no vegetations and no sign of
infection on the pacer/ICD wire. The lead was not removed per ID
recommendations.
#Anemia - He has a known history of anemia which is transfusion
dependent. The etiology is thought to be hemolytic given low
haptoglobin, elevated LDH and tbili. Repeat work-up here showed
anti-C, anti-E, anti-sda and anti-[**Doctor Last Name **] antibodies. Heme/onc was
consulted did not feel this was DIC but rather transfusion
hemolysis. However, after bacteremia was treated hct remained
relatively stable with uptrending platelets. INR remained
elevated and continued to rise somewhat in the setting of low
fibrinogen and elevated FDPs. Upper and Lower endoscopies were
deferred given goals of care discussion with patient and his
wife. [**Name (NI) **] did require multiple PRBC transfusions, he
remained HD stable during Hct drops without e/o bleeding.
#Thrombocytopenia and concern for DIC - Thrombocytopenia was
thought to be primarily from liver disease. There was initially
some concern for DIC. Fibrinogen was low, fibrin split products
were elevated, and INR was somewhat elevated (which may have
been partially from liver disease). He did not receive any
blood products in the CCU and there was no evidence of bleeding.
Heme/onc was following and thought that if there were e/o
bleeding then we could consider FFP or cryoprecipitate.
Platelets continued to rise after bacteremia treated. Anemia
treatment as above with PRBCs
#H/o substance abuse - Continued on home methadone dose, it was
divided into 3 doses at one point to treat pain and patient
tolerated this dosing regimen well. Discharged on
pre-hospitalization 140mg daily
#Chronic Venous stasis - No s/s infection, chronic, stable.
TRANSITIONAL ISSUES:
- Patient discharged to home hospice care
Medications on Admission:
Medications: Unclear home medications but based on transfer
list:
-Methadone
-Epoetin
-Oxazepam 15 mg daily
-digoxin 0.125
-Folic acid
-Levothyroxine 0.088
-phytonadione 2.5 mg dily
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*90 Doses* Refills:*0*
2. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
5. methadone 40 mg Tablet, Soluble Sig: 3.5 Tablet, Solubles PO
once a day.
Disp:*105 Tablet, Soluble(s)* Refills:*0*
6. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
5-20 mg PO Q2Hrs as needed for Pain or SOB.
Disp:*30 mL* Refills:*0*
7. hyoscyamine sulfate 0.125 mg/mL Drops Sig: One (1) mL PO
every four (4) hours as needed for Upper Respiratory Congestion.
Disp:*15 mL* Refills:*0*
8. lorazepam 0.5 mg Tablet Sig: 0.5-2 mg PO every four (4) hours
as needed for anxiety.
Disp:*30 tabs* Refills:*0*
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
old colony hospice
Discharge Diagnosis:
Active:
- End Stage Liver Disease
- Hepatitis C
- Alcohol
- Polysubstance abuse now on Methadone
Chronic:
-HLD
-HTN
-ICD/dual chamber pacemaker
-[**Last Name (LF) 9215**], [**First Name3 (LF) **] 70%
-CAD distant MI
-Recurrent VT, VF arrest s/p Guidant ICD [**2165-4-22**] prolonged QT
-GERD s/p partial gastrectomy in [**2138**] for gastric ulcer
-Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 95409**],
It was a pleasure treating you during this hospitalization. You
were transferred to [**Hospital1 69**] with
bacteria in your blood and the concern that you developed an
infection on one of your heart valves. You had an echocardiogram
completed of your heart which did not show infection on your
heart valve. You were treated with IV antibiotics. You were also
found to have dropping blood levels requiring multiple
transfusions. Your kidneys were damaged when you were admitted
but began improving after your blood pressure was improved and
an antibiotic called Gentamicin was stopped. Your kidney, liver
and blood counts all improved and you were discharged in
improved condition. Your liver disease is end stage and after
discussion it was clear you did not want to be evaluated for a
transplant. In keeping with your goals of care and after
discussion with your wife, [**Name (NI) 55745**], it was decided to send you
home with hospice care. Prior to your discharge the implanted
ICD was turned off. It was a pleasure treating you at [**Hospital1 18**].
The following changes to your home medications were made:
- START Lactulose 30ml three times per day
- START Rifaximin 550mg twice daily
- START Pantoprazole 40mg Daily
- Pain and breathing control with Morphine, Ativan and
Oxycodone.
- No other changes to your home medications were made, please
continue as previously prescribed
Followup Instructions:
None
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,976
| 196,153
|
30772
|
Discharge summary
|
report
|
Admission Date: [**2175-5-13**] Discharge Date: [**2175-6-22**]
Date of Birth: [**2136-2-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Transfer from OSH for liver and renal failure
Major Surgical or Invasive Procedure:
Liver biopsy
Dialysis catheter placement
History of Present Illness:
This is a 39 yo male with HIV diagnosed in [**2164**] but was only
recently started on HAART therapy about 2 months ago in [**Month (only) **]
[**2175**]. He also has HepC and disseminated MAC with liver biopsy
in [**2174-11-16**] demonstrating AFB positive granulomas and was
subsequently started on ethambutol/azithro/rifabutin. He has
had several recent admissions this past month at OSH for PNA,
neutropenia and left renal calculus with hematuria.
.
His current course started on [**2175-4-29**] when he presented to
[**Hospital 189**] [**Hospital 107**] Hospital with fever, left flank pain and RUQ
pain. The workup for his pain was difficult because he has
chronic abdominal pain requiring narcotics. Workup includes
multiple problems: increased LFTs, pericholecystic fluid,
coagulopathy, hyperkalemia and ARF. The differential for his
liver failure at this time included HIV cholangiopathy vs. drug
induced hepatitis vs. reactivation MAC infection from starting
HAART therapy. The differential for his renal failure included
HIV nephropathy vs. membranoproliferative glomerulonephritis [**2-17**]
Hepc vs. chronic renal calculi vs. reconstition syndrom from
HAART therapy.
.
Because of the concern for reconstitional syndrome, his HAART as
well as MAC therapy were stopped. He was put on Ceftriaxone for
unclear reasons.
.
His potassium was as high as 7.2 and there were reports of a
pericardial rub. He was urgently dialyzed on [**5-11**] and [**5-12**] with
resolution of hyperkalemia.
.
Given his liver failure, renal failure and complex infectious
history including HIV, HepC and disseminated MAC, he was
transferred to [**Hospital1 18**] for tertiary care.
.
Currently his chief complaint is left sided abdominal pain and
RUQ pain. He denies fevers currently but reported having fevers
at OSH. He denies chest pain or shortness of breath. He has
been passing gas and moving his bowels. He is making urine and
has no dysuria.
Past Medical History:
# HIV/AIDS, diagnosed in [**2164**], off HAART "on religious grounds",
CD4 count 2 and VL 350,000 on [**2174-11-1**].
# HCV with cirrhosis, (?)genotype 1, viral load 7 million
# Liver biopsy [**11-21**]: AFB positive granulomas, started on
ethambutol/azithro/rifabutin for MAC (rifabutin later d/c'd for
unclear reasons)
# Longstanding right-sided abdominal pain of unclear etiology:
distended [**Name (NI) **] with pericholecystic fluid, however HIDA normal,
surgeons do not feel this is cholecystitis
# Prior CT demonstrating hypoechoic splenic lesions, (?)lymphoma
vs infection
# Admitted [**1-22**], found to be in new renal failure secondary to
glomerulonephritis (?)HIV/HCV-associated. At that time started
on anti-retrovirals - kaletra and trizivir.
# Bilateral renal stones
# Polysubstance abuse
# Penile warts and perianal warts
Social History:
Lives in [**Doctor First Name **] home called New Challenge (home for rehab for
polysubstance abusers with other residents). He contracted HIV
from a woman in [**Male First Name (un) 1056**]. Moved from [**First Name9 (NamePattern2) 8880**] [**Country **] 1.5 years
ago but frequently returns for visits. Has extensive history of
illicit drug use for 20 years in the past that included cocaine,
heroine, LSD, marijuanna, tobacco and alcohol. He is married
with 2 children in [**Male First Name (un) 1056**].
Family History:
Father died of colon cancer. Mother died with diabetes and
depression.
Physical Exam:
VITALS: 99.0 145/80 100 16 95%RA
GEN: A+Ox3, NAD, coughing, no respiratory distress, well
nourished male
HEENT: PERRL, EOMI, sclera icteric, MMM, OP clear
NECK: no LAD
CV: tachycardic, regular, pericardial rub heard best at LRSB, no
murmurs or gallops, PMI at left nipple
PULM: scattered rhonchi with bilateral faint crackles, no
wheezes, good air movement
ABD: soft, tender at epigatrum, nondistended, +BS. No
costovertebral tenderness. + warts on penis
EXT: 2+ pedal edema up to lower legs bilaterally
NEURO: grossly nonfocal, mobilizes all extremities
Pertinent Results:
OSH [**4-28**]:
-- BUN 18, Cr 1.2.
-- AST 265, ALT 108, Alk phos 188, TB 1.6
-- UA: 2+ protein, 3+ blood, 250 RBC per HPF
.
OSH [**5-8**]:
-- BUN 70, Cr 3.3
-- TB 16.7, DB 13.7
.
OSH [**5-11**]:
-- Cr 3.3
-- INR 6.0
.
OSH [**5-13**]:
-- CHEM 7 134, 4.7, 101, 22, 58, 2.8
-- Tprot 5.6, alb 1.8
-- Cal 7.9
-- Tbili 8.3, AP 153, AST 152, ALT 87
-- CBC: 3.1, 2.73, 24.8, 75, MCV 91
-- INR 2.3 (down from 3.4 yesterday)
.
STUDIES:
# OSH CT ABD [**4-29**]: 2-3mm stone at ureterovesicular junction.
.
# OSH MRI [**5-3**]: hepatosplenomegaly
.
# OSH CT ABD C CONTRAST [**5-7**]:
Liver pancreas normal contours. Spleen slightly enlarged.
Gallballder NL in diameter, however an attenuated ring surrounds
the gallbladder. No intraluminal stones. Kidneys normal in
size shape and positive. No hydronephrosis. No stones.
Adrenal glands normal. No Retroperitoneal adenopathy. No upper
abd areas of ascites.
IMPRESSION:
1. Splenomegaly
2. Pericholecystic fluid suggestive of acalculus cholecystitis.
.
.
[**2175-5-13**] CXR: No acute cardiopulmonary process.
.
[**2175-5-14**] RUQ USN: Minimal gallbladder wall edema, without
significant distension, or evidence of cholelithiasis.
Acalculous cholecystitis cannot be excluded. If there is
concern for cholecystitis, further evaluation with a HIDA scan
could also be considered.
.
[**2175-5-14**] RENAL USN: No hydronephrosis. Medical renal disease.
.
[**2175-5-15**] TTE:
The left atrium is normal in size. The estimated right atrial
pressure is
0-5mmHg. Left ventricular wall thicknesses and cavity size are
normal.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%).
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. No mitral
regurgitation is seen. There is normal pulmonary artery systolic
pressure. There is no pericardial effusion.
.
IMPRESSION: No pericardial effusion. Preserved global and
regional
biventricular systolic function.
.
[**2175-5-15**] CT CHEST:
1. Mild dependent peribronchial ground-glass opacities are
suggestive of
aspiration, either subclinical or due to early aspiration
pneumonitis
2. Minimal right upper lobe bronchiolitis may be due to
aspiration or focal small airways infection. Localized
distribution is not typical of MAC, which is usually more
diffuse. Follow-up CT after treatment for bacterial infection
may be considered, if warranted clinically.
3. Trace ascites
4. Probable splenomegaly and 4 mm nonobstructing right renal
stone.
.
.
[**2175-5-15**] CT SINUS:
Mild-moderate degree of mucosal thickening is seen within the
maxillary sinuses bilaterally, sphenoid sinuses, and ethmoid
sinuses, with
aerosolized secretions in the left maxillary sinus. Minimal
mucosal thickening noted within the frontal sinus. Right
ostiomeatal complex appears patent. Left ostiomeatal complex is
opacified by mucosal thickening. Nasal septum is midline. Right
cribriform plate is approximately 1-2 mm lower than the left. No
evidence of osseous destruction seen. Likely 3mm bone island is
noted in
the left orbital roof.
.
.
[**2175-5-16**] CT ABD/PELVIS:
1. Enlarged liver with perihepatic ascites. Nonspecific fat
stranding along the anterior right retroperitoneum and right
pericolic gutter extending about the cecum is nonspecific, may
be related to hepatic dysfunction.
2. Distended gallbladder without disproportionate surrounding
fat stranding. If there is clinical concern for acute
cholecystitis, hepatobiliary nuclear medicine scan could be
performed.
3. Bilateral nonobstructing renal calculi.
4. Appendix not definitely visualized. Fat stranding and fluid
along the
right pericolic gutter extends from the liver edge into the
pelvis obscures its visualization. If there is clinical concern
for acute appendicitis, MRI could be performed in this patient
who cannot have intravenous contrast.
5. Splenomegaly. No lymphadenopathy.
.
.
[**2175-5-17**] HIDA:
1. Limited study. 2. No evidence of acute cholecystitis. 3.
Normal biliary to bowel transit time. 4. Poor hepatic tracer
uptake,
compatible with the stated history of MAC hepatitis.
.
.
[**2175-5-17**] ERCP:
Four fluoroscopic spot images were obtained during ERCP
procedure
by gastroenterologist without a radiologist present.
Cholangiogram
demonstrates opacification of a mildly dilated biliary tree. A
filling defect is seen within the distal CBD consistent with
stone. Final image demonstrates placement of a biliary stent.
.
.
[**2175-5-23**] transjugular liver biopsy:
1. Marked lobular regeneration with scattered apoptotic
hepatocytes and moderate cholestasis.
2. Localized areas of bile duct proliferation surrounded by
fibrosis, highly suggestive of cirrhosis.
3. Trichrome stain shows prominent sinusoidal fibrosis (see
note).
4. No granulomas are seen.
5. No stainable iron seen.
.
.
[**2175-5-22**] bone marrow biopsy:
FLOW CYTOMETRY REPORT:
FLOW CYTOMETRY IMMUNOPHENOTYPING:
The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, Lambda, and CD antigens: 2, 3, 5, 7, 10, 19, 20, 23, 45.
.
RESULTS:
Three-color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
.
B-cells are scant in number (4% of lymphoid gated events), and
do not express aberrant antigens. Clonality could not be
reliably assessed due to scant numbers and cytophilic staining.
.
T-cells comprise 47% of lymphoid gated events and express mature
lineage antigens.
.
INTERPRETATION:
Non-specific lymphoid profile; B-cells are scant in number and
clonality could not be reliably assessed. T-lymphocytes do not
show any antigenic aberrancy.
.
Correlation with clinical findings and morphology (see separate
report) is recommended. Flow cytometry immunophenotyping may
not detect all lymphomas due to topography, sampling or
artifacts of sample preparation.
.
.
[**2175-5-26**] USN GUIDED PARACENTESIS:
Successful 1 liter diagnostic paracentesis via the right lower
quadrant under ultrasound guidance. negative for SBP.
.
.
[**2175-5-27**] RUS USN:
Gallbladder wall thickening is secondary to contracted
state and third-spacing.
.
[**2175-6-1**] VEIN MAPPING UPPER EXTREMITIES:
Thrombophlebitis in right cephalic vein. Patent bilateral
basilic with diameters as noted. There is no left cephalic
vein. Patent
bilateral subclavian veins and brachial arteries.
.
.
[**2175-6-3**] CT ABD/PELVIS:
1. Small nonobstructing renal calculi bilaterally.
2. No dilated loops of small bowel seen. Evaluation of the
colon is limited as it is not filled with oral contrast, and
surrounding pericolonic fat is obscured by ascites.
3. Interval development of large amount of ascites.
4. Hepatosplenomegaly unchanged.
.
.
Brief Hospital Course:
# Comfort measures only. This is a 39 yo man with HIV/AIDS and
hep C cirrhosis not a candidate for interferon or HAART with
progressive liver and renal failure. In accordance with the
patient's and his family's wishes, the patient is comfort care
only.
.
Below is a detailed history of his recent hospitalization.
.
# ID. The patient has hep C and HIV not previously on medication
until late [**2174**] (per conversation with Dr. [**Last Name (STitle) 72851**], ID at
OSH). Upon admission to OSH, he was noted to have CD4=4, VL
undetectable, (CD4=2, VL 350,000 in [**2174-10-16**]). Hep C viral load
55,000,000. per OSH records, his HAART was held upon admission
to OSH [**2-17**] concern for reconstitution syndrome in addition to
concern that HAART regimen could be causing liver failure (pt
was briefly treated with solumedrol for reconstitution at OSH,
but this was discontinued upon his admission). His PCP
prophylaxis and MAC treatment were also held because of concern
that these could be causing his elevated LFTs.
.
Upon presentation, the patient was febrile daily with temps
100-102, however serial blood, urine, sputum and stool cultures
were generally unremarkable, with the exception of sputum
culture [**2175-5-18**] which showed 2+ GPC, GPR, however sample quality
was poor, and culture was negative. The patient was ruled out
for TB with sputum cx x 3. PCP smears were negative. CMV and
EBV viral load were negative. HepC viral load was 55 million.
.
The patient was treated with a 7 day course of zosyn [**Date range (1) 72852**]
upon presentation because of coarse breath sounds, and fever,
however CT CHEST revealed only ground glass opacification at
bases, but no clear infiltrate.
.
ID consult was obtained. given his elevated bilirubin and
alkaline phosphatase, concern was for a biliary source of
infection, however RUQ USN [**2175-5-14**] showed minimal gallbladder
wall edema, without significant distension, or evidence of
cholelithiasis. The patient underwent HIDA [**2175-5-17**] which showed
no evidence of acute cholecystitis. Given a high concern for
biliary infection (RUQ pain, fever, elevated tbili), the patient
undwerwent ERCP on [**2175-5-17**], at which time mildly dilated biliary
tree was visualized with filling defect in distal CBD consistent
with a stone, thus stent was placed.
.
The patient's LFTs continue to rise after stent placement, and
give his immunocomprimized state, fungal etiologies were
considered. Liver biopsy was performed on [**2175-5-23**] via
transjugular approach. KOH prep revealed budding yeast, and
pathology specimens demonstrated yeast, however culture data was
unremarkable. Given elevated LFTs, and clinical suscpicion for
fungal infection, the patient was started on ambisome on [**5-27**].
.
Bone marrow biopsy was obtained on [**2175-5-22**] which was
unremarkable. Serum crypto, urine histo, and fungal blood
cultures were negative. Galactomannan and beta glucan were
negative.
.
LFTs began improving on [**5-21**]. He was without elevated wbc
throughout admission (indeed was neutropenic as below). He
continued to have low grade temperatures (99-100.6) until [**5-31**].
he was restarted on azithromycin for PCP prophylaxis on [**5-31**]
(dosed qweekly), however his tbili began rising again, and this
was discontinued on [**6-2**].
.
The patient was not felt to be a candidate for hep C treatment
given his comborbidities. On [**6-2**] repeat HIV viral load was
>100,000, decision was made to continue to defer restarting
HAART, while awaiting HIV genotype information (pt's prior HIV
regimen of trisovir/kaletra was felt to be atypical). In close
consultation with the infectious disease team, the patient was
ultimately felt to not be a candidate for HAART therapy out of
concern for further liver toxicity and inability to tolerate the
therapy. After the patient's decision to be comfort only, all
antibiotics were discontinued.
.
# GI/LIVER. The patient presented to an OSH with fever and RUQ
pain. The patient had known hepatitis C, viral load on this
admission was 55,000,000. The patient had been started on MAC
treatment [**2-17**] liver biopsy in [**11-21**] which was AFB positive on
smear, however no cultures had been sent. MAC treatment
(ethambutol, rifabutin, azithromycin) were held upon admission
at OSH. Upon admission to OSH, pt had AST 265, ALT 108, AP 188,
TB 1.6. His LFTs continued to rise, and peaked after transfer
to [**Hospital1 18**] on [**5-15**] ALT 150 AST 223, but then trended down ALT 50s,
AST 120s by [**5-23**]. TBil peaked on [**2175-5-21**] @ 22.1, s/p ERCP with
stent placement on [**5-17**]. Upon presentation, to [**Hospital1 18**] his INR was
2.0.
.
Presentation was primarily a cholestatic picture. RUQ USN, HIDA
scan and ERCP were as above. There was no evidence of HIV
cholangiopathy.
.
Hepatitis serologies were hepBsAg, hepBsAb negative, BepBcAb
positive. ANCA negative. [**Doctor First Name **] weakly positive (1:40), C3 43, C4
10. HepC viral load 55 million. HSV IgG and IgM positive.
.
Given elevated LFTs after ERCP with stent placement, pt
underwent liver biopsy on [**2175-5-23**] which revealed fibrosing
cholestatic hepatitis, with cirrhosis. LFTs began trending down
shortly after biopsy, however, thus pt's hepatic failure was
felt more likely to be the result of medication (most likely
azithromycin or HIV medications), superimposed upon hepatitis C
infection and underlying fibrosing cholestatic hepatitis.
.
On [**6-5**], pt's HCT droped from 22-24 ->20 -> 17 requiring
transferred to the ICU.
.
# RENAL. The patient presented without a history of renal
disease, however creatinine 1.2 upon presentation to OSH up to
3.3 upon transfer to [**Hospital1 18**]. His OSH course was complicated by
hyperkalemia for which he underwent hemodialysis on [**5-11**] and
[**5-12**].
.
Upon presentation to [**Hospital1 18**] pt was not felt to require urgent
dialysis. renal consult was obtained. His temporary dialysis
catheter was discontinued on [**5-24**], the tip was sent for culture
which was unremarkable.
.
The patient did apparently have complicated history of bilateral
renal calculi and he was admitted at OSH recently for renal
calculi and hematuria. Abd CT at OSH [**2175-5-7**] showed no
hydronephrosis. UA and UCx were unremarkable, and CT ABD/PELVIS
this admission was negative for calculi, or hydronephrosis.
.
The patient developed progressive renal failure. Etiology was
ultimately felt most likely to be [**2-17**] hepC induced MGPN. Biopsy
was deferred as he was relatively high risk for the procedure
and the relevance to management options in this patient (as he
was already known to not be a candidate for interferon therapy)
were limited. The patient's renal failure continued to progress
and in accordance with the patient's wishes he had a temporary
dialysis catheter placed and 2 cycles of hemodialysis in able to
prolong his life to allow his family to see him. After his
family's arrival - and in accordance with the patient's and his
family's wishes - his dialysis catheter was removed and the
patient had no further dialysis.
.
# HEME/ONC. The patient presented with anemia and
thrombocyopenia. The etiology was initially felt most likely [**2-17**]
HIV, HepC, renal disease. Bone marrow biopsy was performed which
revealed hypercellular marrow with mild erythroid and
megakaryocytic hyperplasia and left-shifted myelopoiesis.
.
Medications on Admission:
MEDICATIONS AT HOME:
# Mepron
# Zithromax
# Ethambutol
# Diflucan
# Kaletra
# Triziver
.
MEDICATION ON TRANSFER:
# Reglan PRN
# Flonase
# Protonix
# Zofran PRN
# Ambien PRN
# MS [**First Name (Titles) **] [**Last Name (Titles) **] 30mg [**Hospital1 **]
# Oxycodone IR 15mg q6PRN
# Morphine 5mg IV q4H PRN
# Solumedrol 40mg IV BID
# Tylenol PRN
# Procrit40,000 quweek starting [**5-13**]
# Ceftriaxone 1gram q24 (last dose 4/28)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: [**1-17**] PO twice a day as
needed for constipation.
4. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
5. Lorazepam 1 mg Tablet Sig: 0.5-1.0 Tablet PO Q4-6H (every 4
to 6 hours) as needed for Nausea or anxiety.
6. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed for pain.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 36748**] Radius
Discharge Diagnosis:
PRIMARY:
AIDS
Hepatitis C
Disemminated MAC
Acute renal failure
Acute liver failure
SECONDARY:
Longstanding right-sided abdominal pain of unclear etiology
Bilateral renal stones
Polysubstance abuse
Penile warts and perianal warts
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were admitted because of liver and kidney failure secondary
to HIV, hepatitis C and complications of these diseases. The
goals of care are your comfort. You will be further cared for at
a hospice facility in [**Hospital1 189**], [**State 350**].
Followup Instructions:
A hospice nurse will be available to answer any questions for
you and to obtain and provide medical care.
|
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61,012
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55094
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Discharge summary
|
report
|
Admission Date: [**2158-4-14**] Discharge Date: [**2158-4-20**]
Date of Birth: [**2095-12-5**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
speech difficulty, weakness
Major Surgical or Invasive Procedure:
[**2158-4-14**] intra-arterial therapy, mechanical thrombectomy
History of Present Illness:
Mr. [**Known lastname 17025**] was transferred to [**Hospital1 18**] from [**Location (un) **] after he
received intravenous tPA there. On arrival at [**Hospital1 18**], he was
aphasic and unable to provide any history. Initially his history
obtained
from transfer notes and prior medical records provided with
transfer paperwork.
Mr. [**Known lastname 17025**] is a 62 year-old man with PMH notable for
seizure seizures and HLD who developed right sided weakness and
aphasia while at work today. He was reportedly at work and said
hello to co-workers at the desk. Last known well time 8:45. He
was then unable to talk. He must have gotten into his car and
drove himself to [**Location (un) **] ED,
where he was noted to be nonverbal with right face, arm and leg
weakness. NCHCT was performed and there was concern for M1/M3
occlusion as there was hyperdense left MCA. He received
intravenous tPA at
10:30 AM; 9 mg bolus followed by continuous infusion of 81 mg.
He
was then transferred to [**Hospital1 18**] for post-tPA management and
potential further intervention.
On presentation to the ED at [**Hospital1 18**], he continued to have a
global aphasia with significant impairment of comprehension and
he had a 4/5 weakness pattern mainly involving his right UE.
Past Medical History:
-cirrhosis? Fatty? (this is listed on problem list but no other
info.
regarding this currently known)
-seizure d/o (was treated with DIlantin 400mg po QD for many
decades; last generalized seizure has been at least one decade
ago)
-hx optic neuritis
-HLD
-obesity
-OSA
-BPH
Social History:
He is married. He works as a
sports writer at [**Location (un) **] Publishing. No smoking or ETOH use.
Family History:
Mother deceased age 82, father
deceased age 72.
Physical Exam:
ADMISSION EXAM:
Physical Exam:
Vitals: T: 98.4 P: 56 R: 56 BP: 174/86 SaO2: 95% on 2L O2 via NC
General: Awake
HEENT: NC/AT, no scleral icterus noted, MMM, dried blood in
mouth
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: lcta anteriorly b/l
Cardiac: RRR, S1S2
Abdomen: obese, soft, nondistended, +BS
Extremities: warm, well perfused
Neurologic:
NIH Stroke Scale score was: 15
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 2
4. Facial palsy: 2
5a. Motor arm, left: 0
5b. Motor arm, right: *4-->1
6a. Motor leg, left: 0
6b. Motor leg, right: *3-->1
7. Limb Ataxia: 0
8. Sensory: 2
9. Language: 2
10. Dysarthria: 1
11. Extinction and Neglect: 2
Of note, on first arrival, he was plegic in the right upper
extremity and was able to move the right lower extremity in the
plane of the bed but not antigravity. Shortly thereafter, he was
able to maintain both the right upper and lower extremity
antigravity with only some drift.
Mental Status: Awake, alert, global aphasia limiting remainder
of
mental status testing. He is unable to produce any intelligible
speech; occasionaly mumbles but incomprhensible. Did say "no"
one
time. He was intermittently able to follow simple commands such
as "close your eyes", "squeeze my hand" or "wiggle your toes."
In
addition to not always being able to follow these commands,
there
seems to have been some perseveration with the previous
commands.
Cranial Nerves: PERRL 3-->2. Blinks to threat on left but not on
right (unable to assess visual fields by confrontation). EOMI.
Right lower facial droop. Palate elevates symmetrically.
Motor: Decreased tone on right. Initially plegic RUE and no
antigravity right lower extremity but this improved to being
able
to maintain both right upper and lower extremity antigravity
with
drift. Left sided strength grossly full. Unable to perform
formal
strength testing due to aphasia.
Sensory: Grimmaces to noxious stimuli on left but not right
upper
and lower extremities.
DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 3 0
R 2 2 2 3 0
Plantar response was flexor on left and extensor on right.
Coordination: No clear dysmetria but was not able to comprehend
and perform finger-nose testing.
Gait: deferred
---
Discharge Exam:
Awake, alert, follows some midline commands but poor
comprehension and minimal verbal output. PERRL, EOMI, right
facial droop, right hemiparesis (mild).
Pertinent Results:
[**2158-4-14**] 12:00PM BLOOD WBC-7.3 RBC-4.75 Hgb-15.2 Hct-44.4 MCV-93
MCH-32.0 MCHC-34.3 RDW-13.1 Plt Ct-159
[**2158-4-14**] 12:00PM BLOOD PT-10.8 PTT-25.6 INR(PT)-1.0
[**2158-4-14**] 07:36PM BLOOD Glucose-143* UreaN-16 Creat-1.0 Na-138
K-4.6 Cl-104 HCO3-26 AnGap-13
[**2158-4-14**] 12:00PM BLOOD ALT-26 AST-25 AlkPhos-94
[**2158-4-14**] 12:00PM BLOOD cTropnT-<0.01
[**2158-4-14**] 07:36PM BLOOD cTropnT-<0.01
[**2158-4-14**] 07:36PM BLOOD Calcium-8.3* Phos-3.5 Mg-2.0 Cholest-199
[**2158-4-14**] 12:00PM BLOOD %HbA1c-6.8* eAG-148*
[**2158-4-14**] 07:36PM BLOOD Triglyc-306* HDL-39 CHOL/HD-5.1
LDLcalc-99
[**2158-4-14**] 07:37PM BLOOD Phenyto-<0.6*
[**2158-4-16**] 02:11AM BLOOD Phenyto-1.9*
[**2158-4-14**] CTA/CTP
IMPRESSION:
1. CT head demonstrates a subtle area of hypodensity in the
left posterior
insular region.
2. CT perfusion demonstrates increased transit time and
decreased blood flow
in the posterior division of the left middle cerebral artery
with subtle
decrease in blood volume indicating an area of ischemia with a
small area of
infarction.
3. Suboptimal visualization of the neck arteries, which appear
patent without
high-grade stenosis.
4. CTA of the head demonstrates occlusion of the inferior
division of the
left middle cerebral artery. The remaining arteries in the
anterior and
posterior circulation are patent.
[**2158-4-14**] Intraarterial therapy/Angiogram
IMPRESSION:
Preprocedure angiogram demonstrates total occlusion of an M2
segment of the left middle cerebral artery.
Intra-arterial thrombolysis in the form of 3 mg of
intra-arterial TPA.
Intra-arterial thrombectomy using Merci device x2 passes.
Solitaire stent retriever was used.
Post-procedure angiogram demonstrates recanalization of the
previously
occluded left M2 segment branch.
No complications.
[**2158-4-15**] MRI Head
FINDINGS: Correlation was made with the CT examination and
cerebral
angiography of [**2158-4-14**].
There is a middle cerebral artery infarct identified involving
the basal
ganglia posterior insular region as well as in the
parietooccipital region.
There is a small area of susceptibility seen in the left
parietal region
indicative of petechial hemorrhage. The vascular flow void in
the region of
middle cerebral artery is seen. There is no midline shift or
hydrocephalus.
Soft tissue changes in the sinus are likely related to
intubation.
IMPRESSION: Acute left middle cerebral artery infarct with
predominance in
the posterior division, but also involvement of the basal
ganglia and several
small foci in the anterior division of the left middle cerebral
artery. A
small area of susceptibility in the left parietal region within
the infarct
indicates petechial hemorrhage. No mass effect or
hydrocephalus.
[**2158-4-17**] TTE
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild concentric LVH with
normal chamber size and normal global systolic function. Cannot
exclude inter-atrial shunt as suboptimal image quality limits
interpretation of bubble study.
[**2158-4-20**] ECG - atrial fibrillation
Brief Hospital Course:
Admitted [**2158-4-14**]:
Mr. [**Known lastname 17025**] is a 62 year-old man with PMH notable for
seizures and HLD who developed right sided weakness and aphasia
while at work today and received tPA at OSH (infusion completed
en route)and was then transferred to [**Hospital1 18**] for further
management.
Neuro exam was significant for aphasia (productive greater than
receptive though still made numerous errors on following simple
commands), had right lower facial droop and initially had right
upper extremity hemiplegia with lower extremity able to move in
plane of bed but subsequently right sided strength improved to
where he had antigravity strength with drift in right upper and
lower extremities (NIHSS 14).
.
He completed his infusion of IV tPA and then underwent [**Doctor First Name 10788**]
procedure.
.
[**Doctor First Name 10788**] procedure ([**2158-4-14**]):
An 18 L catheter and a Synchro wire was used and occluded left
M2 segment was
selectively catheterized. Approximately 3 mg of intra-arterial
TPA was
administered. Two passes of Merci device V 2mm soft device were
used.
Solitaire stent retriever was also used.
Post-procedure angiogram demonstrated recanalization of the
superior segmental
branch of the left middle cerebral artery.
ICU course ([**2158-4-14**]- [**2158-4-18**]):
# NEURO:
Aspirin 325mg, Lipitor 80mg were started in addition to
Fosphenytoin 150mg TID. Given his Lipid profile (HgbA1c 6.8;
FLP: TC 109; TG 306; HDl 39; LDL 99) lipitor was decreased to
20mg daily.
Although his phenytoin was confirmed to be a home med, his level
was very low on admission and he was switched to Keppra 500mg
[**Hospital1 **] instead.
TTE did not show clot but was limited by body habitus. Given the
difficulty with intubation, body habitus, a TEE was considered
but ultimately not attempted. The patient demonstrated several
arrhythmias on tele/EKG including PACs and possible runs of
afib. Cardiology was consulted and recommended anticoagulation
for now and possible holter monitor on discharge to confirm
paroxysmal afib.
He was started on heparin gtt with goal 50-70, but his IV access
failed so he was switched to Aspirin 325 mg daily. Atrial
fibrillation was not confirmed at that time, but overnight on
[**4-19**] to [**4-20**], he had atrial fibrillation with rapid ventricular
rate on telemetry which was confirmed by ECG. He was started on
Warfarin 5 mg daily with an Enoxaparin bridge (120 mg SC BID) as
well as Metoprolol tartrate for rate control.
.
# RESP: Extubated, increased secretions and difficult intubation
baseline. He was kept in the ICU for respiratory monitoring
given that he had a difficult airway, was receiving keppra and
had a failed attempt at NGT placement with some bloody
secretions. However over the next two days, his resp status
improved, as did his level of arousal.
.
# CARDS: Goal BP <160 w/ hydral prn, paroxysmal afib on tele
(likely), started lisinopril 5mg daily for HTN. This was
increased to Lisinopril 15 mg daily for improved blood control.
.
# Nutrition: NGT tube placed on 2nd attempt, tube feeds were
started, Speech reevaluated him on the floor and he passed. He
was advanced to a regular diet and thin liquids and the NGT was
removed.
.
# PPx: pneumoboots for DVT ppx, H2 blocker for GI ppx
.
# Code status: FULL code
.
PENDING STUDIES: None
.
TRANSITIONAL CARE ISSUES:
[ ] PCP [**Name Initial (PRE) **] [**Name10 (NameIs) 357**] follow the patient's INR and continue warfarin
therapy for PAF and stroke prevention.
[ ] Rehab - Please check the patient's INR daily and stop the
Enoxaparin when the warfarin is therapeutic (INR [**1-6**] for atrial
fibrillation). PLEASE GIVE THE FIRST DOSE OF WARFARIN AND
ENOXAPARIN UPON ARRIVAL.
[ ] Rehab - Please adjust the patient's Metoprolol tartrate as
needed to control his heart rate and prevent RVR.
[ ] Please continue PT, OT, and Speech therapy for maximal
functional recovery for his motor/sensory aphasia and right
hemiparesis.
[ ] PCP/Neurology - If he displays any seizure activity, please
consider increasing his Levetiracetam dose.
[ ] PCP/Rehab - Please titrate his Lisinopril for adequate blood
pressure control.
[ ] ? Sinusitis - He was started on Amoxicillin briefly for some
nasal drainage, but this was later thought to be possible viral
sinusitis in the absence of fever or leukocytosis. If he
displays signs of sinus infection, consider restarting
antibiotics.
[ ] Rehab - Tamsulosin - Consider restarting his tamsulosin.
.
[ AHA/ASA Core Measures for Ischemic Stroke ]
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 99) - () No
5. Intensive statin therapy administered? (for LDL > 100) () Yes
- (x) No (if LDL > 100, Reason Not Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - () unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No (if LDL >100,
Reason Not Given: )
10. Discharged on anti-thrombotic therapy? (x) Yes (Type: ()
Antiplatelet - (x) Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No
Medications on Admission:
Per med list from [**2156**]-
Dilantin 400-500 mg daily, Viagra 50 mg prn, Flomax 0.4 mg qhs
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
7. lisinopril 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: goal
INR [**1-6**]. Check daily INR until within therapeutic range.
Indication: AF, stroke.
10. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous twice a day: bridge anticoagulation until warfarin
therapeutic (INR [**1-6**]), then discontinue.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Acute Ischemic Stroke
SECONDARY DIAGNOSIS: Atrial Fibrillation, Hypertension, Seizure
disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic Exam: Awake, alert, minimal speech output, poor
comprehension, can sing along, right-sided hemiparesis (face and
arm worse than leg).
Discharge Instructions:
Mr. [**Known lastname 17025**],
You were hospitalized due to symptoms of SPEECH DIFFICULTY
(APHASIA) and RIGHT-SIDED WEAKNESS due to an ACUTE ISCHEMIC
STROKE. You were treated with intravenous tPA and intra-arterial
therapy. Your risk factors for stroke were assessed. You have a
condition called PAROXYSMAL ATRIAL FIBRILLATION where one of the
top [**Doctor Last Name 1754**] of your heart does not beat/contract well,
sometimes causing the formation of small clots that can travel
to the brain. We would like to help you prevent further stroke.
We are changing your medications as follows:
1. We have started WARFARIN 5 MG one tablet daily for stroke
prevention. Another medication, ENOXAPARIN will be injected
twice daily until your warfarin is therapeutic (a blood INR
level will be drawn, and it should be between [**1-6**]). This will be
followed by your PCP.
2. We have started ATORVASTATIN 20 MG one tablet daily to
control your cholesterol.
3. We have started LISINOPRIL 15 MG daily to control your blood
pressure.
4. We have changed your Dilantin/phenytoin to LEVETIRACETAM 500
MG one tablet TWICE DAILY for seizure prevention.
5. We have started METOPROLOL TARTRATE 12.5 MG three times daily
to control your heart rate for your atrial fibrillation.
6. Please continue other medications as prescribed.
Please followup with Dr. [**Last Name (STitle) **] in Neurology as listed below
for further management of stroke prevention.
If you experience any of the symptoms below, please seek medical
attention.
It was a pleasure providing you with medical care during this
hospitalization.
Followup Instructions:
NEUROLOGY Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2158-6-6**] 3:00pm, [**Hospital1 69**],
[**Hospital Ward Name 516**] ([**Hospital Ward Name 23**] building [**Location (un) **]), [**Location (un) 830**],
[**Location (un) 86**], MA
Please followup with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] within 3-6 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"327.23",
"781.94",
"600.00",
"345.90",
"787.20",
"401.9",
"427.31",
"784.3",
"250.00",
"461.9",
"434.11",
"342.90",
"278.00",
"272.4",
"427.32",
"V45.88"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"39.74",
"00.40",
"88.41",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
15165, 15212
|
8615, 11953
|
332, 397
|
15370, 15370
|
4715, 8592
|
17287, 17820
|
2131, 2181
|
14119, 15142
|
15233, 15233
|
14001, 14096
|
15666, 17264
|
2228, 3214
|
4542, 4696
|
265, 294
|
11979, 13975
|
425, 1696
|
3689, 4526
|
15295, 15349
|
15252, 15274
|
15385, 15495
|
15512, 15642
|
1718, 1994
|
2010, 2115
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,677
| 159,991
|
5685
|
Discharge summary
|
report
|
Admission Date: [**2122-12-30**] Discharge Date: [**2123-1-7**]
Date of Birth: [**2058-3-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain, DOE
Major Surgical or Invasive Procedure:
MVR (31mm [**Company **] mosaic porcine valve), LAA resection, and
MAZE [**12-31**]
History of Present Illness:
64 yo F s/p RCA stent and CVA, with 3+MR followed by echo,
referred for surgery.
Past Medical History:
1. Prior stroke: [**2106**], with right facial droop and speech
arrest,
found to have anti-cardiolipin ab and vegetations, started on
Coumadin
2. Atrial fibrillation - s/p cardioversion and unsuccessful
ablation [**4-23**] now maintained in sinus rhythm with flecainide
3. CAD s/p RCA stent [**1-24**]
4. moderate MR
5. HTN
6. Diastolic CHF
7. Dyslipidemia
8. Anti-cardiolipin antibody
9. Asbestos exposure with pleural plaque
10 Vein ligation and stripping x 2.
Social History:
Married, lives with husband. [**Name (NI) 1403**] as a registered nurse [**First Name (Titles) **] [**Last Name (Titles) **]
[**Location (un) 620**]. Smoked 1 [**1-20**] ppd x 30 years, quit 16 years ago. 1 glass
red wine/day
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother - deceased age 76 DM, CAD. Father -
deceased age 84, CAD. Two brothers s/p CABG. Daughter -
deceased age 36, leukemia.
Physical Exam:
NAD
Lungs CTAB
Heart irreg rhythm, 2/6 SEM,
Abdomen benign
Extrem warm, no edema
No varicosities
No carotid bruits
Pertinent Results:
[**2123-1-7**] 06:35AM BLOOD WBC-7.5 RBC-2.95* Hgb-9.1* Hct-26.1*
MCV-89 MCH-30.7 MCHC-34.7 RDW-15.0 Plt Ct-120*
[**2123-1-6**] 12:40PM BLOOD WBC-6.7 RBC-3.02* Hgb-9.5* Hct-26.9*
MCV-89 MCH-31.3 MCHC-35.2* RDW-14.8 Plt Ct-97*
[**2123-1-7**] 06:35AM BLOOD Plt Ct-120*
[**2123-1-7**] 06:35AM BLOOD PT-42.7* PTT-52.8* INR(PT)-4.7*
[**2123-1-6**] 12:40PM BLOOD PT-44.6* INR(PT)-5.1*
[**2123-1-6**] 06:45AM BLOOD PT-65.8* INR(PT)-8.3*
[**2123-1-5**] 03:21PM BLOOD PT-57.2* INR(PT)-6.7*
[**2123-1-5**] 06:15AM BLOOD PT-40.9* PTT-52.9* INR(PT)-4.5*
[**2123-1-4**] 05:35AM BLOOD PT-24.2* PTT-60.4* INR(PT)-2.4*
[**2123-1-3**] 07:00AM BLOOD PT-17.6* PTT-53.5* INR(PT)-1.6*
[**2123-1-2**] 11:08PM BLOOD PT-15.8* PTT-58.2* INR(PT)-1.4*
[**2123-1-7**] 06:35AM BLOOD Glucose-115* UreaN-15 Creat-1.3* Na-135
K-4.0 Cl-101 HCO3-26 AnGap-12
[**2123-1-5**] 06:15AM BLOOD Glucose-109* UreaN-14 Creat-1.1 Na-137
K-4.6 Cl-100 HCO3-28 AnGap-14
CHEST (PA & LAT) [**2123-1-4**] 10:22 AM
CHEST (PA & LAT)
Reason: evaluation of effusion
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with s/p MVR LAA resection maze
REASON FOR THIS EXAMINATION:
evaluation of effusion
TWO-VIEW CHEST, [**2123-1-4**]
COMPARISON: [**2123-1-1**].
INDICATION: Status post mitral valve surgery.
There has been prior median sternotomy and mitral valve surgery.
Improving bibasilar atelectasis is present. Persistent small
pleural effusions, left greater than right, as well as multiple
calcified pleural plaques. Small air-fluid level in the
retrosternal region is likely related to recent sternotomy.
IMPRESSION: Improving bibasilar atelectasis. Persistent small
pleural effusions.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 539**] [**Hospital1 18**] [**Numeric Identifier 22715**] (Complete)
Done [**2122-12-31**] at 2:00:02 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2058-3-31**]
Age (years): 64 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraop MVR Maze
ICD-9 Codes: 394.0, 394.1, 440.0
Test Information
Date/Time: [**2122-12-31**] at 14:00 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Aortic Valve - Valve Area: *2.2 cm2 >= 3.0 cm2
Mitral Valve - MVA (P [**1-20**] T): 2.0 cm2
Findings
LEFT ATRIUM: Moderate LA enlargement. Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Overall normal LVEF (>55%). [Intrinsic LV systolic function
likely depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending aorta. Normal aortic arch diameter. Simple atheroma in
aortic arch. Mildly dilated descending aorta. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Mild valvular MS (MVA 1.5-2.0cm2). Moderate to
severe (3+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications.
Conclusions
Pre Bypass: The left atrium is moderately dilated. The left
atrium is elongated. 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%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the aortic arch.
The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. There is mild valvular mitral stenosis
(area 1.5-2.0cm2). Moderate to severe (3+) mitral regurgitation
is seen. There is no pericardial effusion.
Post Bypass: Perservered Biventricular function LVEF >55%. There
is a bioprosthetic mitral valve insitu. Peak gradient 10, mean 8
mmHg with cardiac output 5.2. There was initally a tiny
perivavluar leak which resolved completely with protamine
administration. Aortic Contours are intact. Remaining exam is
unchanged. All finidings dicussed with surgeons at the time of
the exam.
Brief Hospital Course:
She was admitted preoperatively for IV heparin. She was taken to
the operating room on [**12-31**] where she underwent a MVR, MAZE and
LAA ligation. She was transferred to the ICU in stable
condition. She was given 48 hours of vancomycin as she was in
the hospital preoperatively. She was extubated later that same
day. She was restarted on IV heparin and coumadin. She was
transferred to the floor on POD #1. She did well
postoperatively. She awaited therapeutic INR and 24 hours of
overlap with IV heparin before discharge however her INR became
supratherapeutic and she remained in the hospital. She developed
a rash on her back that seemed to improve once her lasix was
discontinued. Her INR continued to rise and she was given FFP.
She went in to atrial fibrillation and was seen by EP who
planned for cardioversion but she returned to sinus rhythm. Her
INR began to improve and she was ready for discharge on POD #7.
Spoke to [**Doctor Last Name **] at [**Location (un) 620**] anticoagulation, Dr. [**First Name (STitle) **] will
follow her coumadin as prior to surgery, anticoag will assume
management once VNA services are stopped.
Medications on Admission:
ASA 325, toprol 100, flecanide 100 ", zetia 10, crestor 20,
ativan, coumadin 10 Mon, 7.5 on other days, MVI, colace 100",
oscal-D
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. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Flecainide 50 mg Tablet Sig: Three (3) Tablet PO Q12H (every
12 hours).
Disp:*180 Tablet(s)* Refills:*0*
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily): 150
mg Daily.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*0*
8. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime for
1 doses: 5 mg [**1-7**], then check INR [**1-8**] with results to Dr.
[**First Name (STitle) **] for further dosing.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
MR, PAF now s/p MVR, MAZE [**2122-12-31**]
CAD s/p RCA stent, CVA [**2066**], recent TIA, MR, HTN, hyperchol,
PAF, hypercoaguable state, s/p vein stripping, s/p appy, chronic
diastolic CHF.
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**First Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) 914**] 4 weeks
Dr. [**Last Name (STitle) **] or [**Doctor Last Name **] 2 weeks
[**Location (un) 620**] anticoagulation
Already scheduled appointments:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2123-2-9**] 4:10
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2123-3-10**] 3:40
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5250**], M.D. Phone:[**Telephone/Fax (1) 7612**]
Date/Time:[**2123-3-12**] 10:00
Completed by:[**2123-1-7**]
|
[
"782.1",
"501",
"272.4",
"428.0",
"427.31",
"438.9",
"414.01",
"424.0",
"V15.82",
"428.30",
"710.0",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"35.23",
"39.61",
"37.33",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
9309, 9358
|
6850, 7991
|
292, 379
|
9592, 9600
|
1597, 2613
|
9899, 10648
|
1237, 1447
|
8171, 9286
|
2650, 2700
|
9379, 9571
|
8017, 8148
|
9624, 9876
|
1462, 1578
|
237, 254
|
2729, 6827
|
407, 489
|
511, 977
|
993, 1221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,225
| 115,814
|
4298
|
Discharge summary
|
report
|
Admission Date: [**2175-9-1**] Discharge Date: [**2175-9-22**]
Date of Birth: [**2147-8-13**] Sex: F
Service: SURGERY
Allergies:
Demerol / Unasyn / Cephalosporins / Levaquin
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
End stage renal disease
Major Surgical or Invasive Procedure:
Cadaveric kidney transplant [**2175-9-1**]
Right retroperitoneal exploration with washout of hematoma and
transplant kidney biopsy [**2175-9-8**]
Post-op bleeding necessitating re-exploration of transplant
kidney and hematoma evacuation [**2175-9-11**]
History of Present Illness:
Ms. [**Known lastname 14323**] is a 28-year-old female with end-stage renal disease
secondary to lupus. She underwent pre transplant evaluation as
a suitable candidate for kidney transplantation. A donor organ
became available. Crossmatch was negative. She now presents for
kidney transplantation.
Past Medical History:
- SLE - diagnosed in [**2166**]. Complicated by lupus, nephritis,
anemia, serositis, and ascites. Currently in remission.
- ESRD on HD (M/W/F), [**1-11**] lupus
- h/o VSD - s/p ocrrective surgery at age 13
- Hypertension
- ITP
- MSSA endocarditis
- [**Month/Day (2) 14165**] cell trait
- s/p L oophorectomy - related to IUD-associated infection
- restrictive lung dz noted on PFTs from [**2166**]. In [**2173**] chest CT
w/ diffuse ground glass opacity w/ paratracheal adn, persistent
on repeat in [**2-10**]. +peripheral adn ? sarcoid. echo c/w pulm htn.
ACE level low. Referred to pulm.
- GERD since [**2172**]
- domestic violence
Social History:
Patient immigrated from [**Country **] and lives at home with her
mother, husband, and 11 year old son. Past episodes of
physical/verbal abuse from husband. Denies etoh, smoking, or
drugs.
Family History:
Mother with diabetes, [**Country 14165**] cell traint. Sister deceased at age
33 from SLE. Has 7 siblings. Maternal grandmother died of
diabetes at age 56. Grandfather otherwise healthy. No h/o CA,
hypercholesterolemia, stroke, lupus.
Physical Exam:
Physical Exam upon admission
T 98.6 HR 64 BP 114/82 RR 20 SaO2 99RA
Gen: Alert and oriented x3, no acute distress
HEENT: PERRLA, EOMI, anicteric sclerae, mucus membranes pink,
moist
Neck: no JVD, no bruits, well healed scars on neck from previous
HD catheters
Lungs: faint rales in left lower lobe
CV: Regular rate and rhythm, S1 S2, 3/6 systolic ejection [**Country 9413**]
Abd: soft, non-distended, non-tender, no hepatosplenomegaly,
small umbilical hernia, well healed midline scar
Ext: no edema or cyanosis
Skin: well demarcated dark round flat lesions on legs
Pertinent Results:
[**2175-9-1**] 12:30PM WBC-6.5 RBC-4.76 HGB-15.0 HCT-43.6 MCV-92
MCH-31.5 MCHC-34.4 RDW-19.9* PLT COUNT-44*
[**2175-9-1**] 12:30PM UREA N-27* CREAT-6.3*# SODIUM-141
POTASSIUM-5.1 CHLORIDE-94* TOTAL CO2-33* ANION GAP-19
[**2175-9-1**] 12:30PM CALCIUM-10.8* PHOSPHATE-4.7*# MAGNESIUM-2.1
CHOLEST-147
[**2175-9-1**] 12:30PM ALT(SGPT)-23 AST(SGOT)-20 LD(LDH)-238
[**2175-9-1**] 12:30PM PT-12.3 PTT-28.3 INR(PT)-1.0
Please see electronic record for detailed results of radiology
and laboratory studies.
Brief Hospital Course:
28-year-old female with end-stage renal disease secondary to
lupus admitted for a cadaveric renal transplant. The patient
underwent the surgery on the day of admission. She was given
the standard perioperative immunosuppressant regimen of
anti-thymocyte globulin, solumedrol, and cellcept. She was also
given lamivudine and HBIG for a donor kidney with positive
hepatitis B core antibody. Please see operative note for
details. She was noted to have bleeding from the biopsy site on
the donor kidney intraoperatively and had an EBL of 1000cc and
was given FFP, PRBCs, and platelets in the OR. Post-op she was
given 2units PRBCs for blood loss anemia. She initially made
670cc of urine but then became gradually oliguric in the PACU.
An ultrasound was obtained showing normal vascular flow and
resistive indices. A tiny post-operative perinephric fluid
collection was noted. She remained intubated and was kept in
the PACU for close observation. She was extubated the morning
of POD1. She had a pressor requirement and also became
hyperkalemic while still in the PACU. She underwent urgent HD
for hyperkalemia and was transferred to the surgical ICU.
She remained in the SICU until POD4. She was on pressor support
until POD3 and was dialyzed again for hyperkalemia. She
received another 2U PRBCs for low hematocrit and was maintained
on the standard protocol for immunosuppressants along with HBIG
and lamivudine. She remained in ATN/DGF with minimal urine
output. She had a fever spike on POD3 =101.9 and was noted to
have a positive U/A at that time. Levofloxacin was started.
She was transferred to the floor on POD4. Her platelets had
dropped and a HIT panel later was negative. Heparin was changed
to fondaparinux in the interim until the results of the HIT were
found to be negative. She had a significant amount of pain and
her abdomen was distended. She was started on labetolol and
nifedipine for hypertension. She was passing some flatus but
was slow to have a return of bowel movements. She was
maintained on a regular dialysis schedule and remained oliguric
with UOP 80-200cc per day. On POD6 her hematocrit decreased and
her pain and distension were more prominent. She was taked back
to the OR for a washout and hematoma evacuation. A biopsy of
the kidney was also done which revealed acute tubular necrosis.
She continued to have abdominal pain post-operatively. On
POD1/8 she had a KUB that was consistent with post-op ileus.
She moved her bowels following this with some relief of her
pain. She required 4units of PRBC on POD [**1-18**] for continuing
anemia. She was again taken back to the OR on POD3/10 for
exploration due to a continuing low hematocrit and persistent
pain. Additional PRBCs were given in the OR. A hematoma was
evacuated and the retroperitoneum washed-out. She was extubated
in the PACU and did well following this final surgery.
She was admitted to the surgical ICU for observation post-op.
She remained on dialysis. Hematology was consulted for her
coagulopathy and thrombocytopenia. A bleeding time was elevated
at >15minutes. She remained under observation in the SICU until
POD3/6/13. Her hematocrit remained stable and she had no
further bleeding.
The patient did well on the floor and was able to tolerate a
regular diet and was seen by physical therapy who worked with
her daily. She continued on dialysis and continued to make
approximately 150-200cc of urine per day. Her blood pressure
medication regimen was optimized and she remained stable on an
immunosuppressant regimen of Tacrolimus, Cellcept, and
Prednisone. Her JP drain was removed on POD7/10/17 and her
bowel function returned on a bowel regimen although she remained
intermittently constipated with the need for additional bowel
medication. Her kidney function gradually improved and she went
without dialysis during the last few days leading up to
discharge. Her pain was controlled. She was able to ambulate
on her own and walk stairs. She was discharged to home with
services on [**2175-9-22**]. She will follow-up closely with the
transplant center to monitor her progress and her medications.
Medications on Admission:
prednisone 5', protonix 40', nifedipine SR 60', minoxidil 2.5',
labetolol 800", clonidine 0.6", nephrocaps', renagel 1600'''
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
Disp:*30 Tablet(s)* Refills:*2*
3. Lamivudine 10 mg/mL Solution Sig: Five (5) PO DAILY (Daily).
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*15 Tablet(s)* Refills:*0*
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*140 * Refills:*2*
6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*64 Tablet(s)* Refills:*2*
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*64 Capsule(s)* Refills:*2*
9. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*84 Tablet(s)* Refills:*2*
10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
Disp:*84 Tablet(s)* Refills:*2*
11. Clonidine 0.2 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*42 Tablet(s)* Refills:*1*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
13. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*1*
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
15. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day): take with 3-one mg cap for total of 8mg twice a day.
Disp:*64 Capsule(s)* Refills:*0*
16. Prograf 1 mg Capsule Sig: Three (3) Capsule PO twice a day:
take with a 5mg capsule for total dose of 8mg twice a day .
Disp:*180 Capsule(s)* Refills:*1*
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*40 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
End stage renal disease secondary to lupus s/p cadaveric kidney
transplant
Secondary diagnoses:
hypertension
pulmonary hypertension
gerd
post-op ileus
Discharge Condition:
stable
Discharge Instructions:
Call [**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, inability
to take medications, decreased urine output, weight gain of 3
pounds in a day, leg edema, bleeding/pus or redness of incision
or inability to eat.
No heavy lifting
[**Month (only) 116**] shower
No driving if taking pain medications
Labs every Monday & Thursday for cbc, chem 7, calcium,
phosphorus, ast,t.bili, albumin, urinalysis and trough prograf
level. Results to be fax'd to [**Telephone/Fax (1) 697**]
Followup Instructions:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2175-9-22**] 9:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2175-9-25**] 11:00
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2175-10-2**] 3:30
|
[
"584.5",
"996.81",
"710.0",
"998.12",
"780.57",
"998.11",
"599.0",
"564.00",
"403.91",
"582.81",
"560.1",
"285.1",
"286.9",
"282.5",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.12",
"99.07",
"55.69",
"99.15",
"99.04",
"99.05",
"00.93",
"55.24",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9556, 9614
|
3165, 7320
|
326, 581
|
9809, 9818
|
2632, 3142
|
10354, 10775
|
1792, 2028
|
7495, 9533
|
9635, 9710
|
7346, 7472
|
9842, 10331
|
2043, 2613
|
9731, 9788
|
263, 288
|
609, 910
|
932, 1567
|
1583, 1776
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,661
| 155,397
|
30326
|
Discharge summary
|
report
|
Admission Date: [**2188-7-30**] Discharge Date: [**2188-8-14**]
Date of Birth: [**2145-2-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3619**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Epidural catheter placement
History of Present Illness:
43 yo female with metastatic breast ca with mets to pleural
space as well as t4 and t10 spine s/p xrt and a trial of
Enzasataurin who presented to the clinic today for a follow up
appointment and was found to be hypoxic with O2Sats of 84% on
RA. Other vital signs were as follows BP 98/54, Heart Rate: 120,
Temperature: 98.3, Resp. Rate: 20. She reports a dry cough that
has been ongoing for the last week, but denies fever, chills,
night sweats, SOB, productive sputum, and CP. She also reports
an fall yesterday on transfer from the bedside commode to her
bed, landing head first. She denies LOC, lightheadedness,
nausea, diaphoresis at the time of the fall.
.
On review of systems she also reports recent nausea and vomiting
that improved with Zofran. She also felt increasingly tired over
the last weeks and only was minimally active at home. Her po
intake has been limited and she reports occasional episodes of
lightheadedness and dizziness.
.
ROS: no fevers or chills at home, + occasional hot flashes, no
cold sx or cough, no CP, + fatigue and states that she has had
to slow down over the past couple of weeks, no dysuria, no calf
pain, no LE edema, no sensory or motor changes.
Past Medical History:
no medical problems prior to dx of br ca
.
ONCOLOGICAL HISTORY (PER OMR): [**Known firstname **] was diagnosed with a
right-sided
breast cancer in [**2186-7-5**]. The initial biopsy results
showed
her tumor to be ER and PR negative and HER-2/neu overexpressing
by report sent to us from Dr.[**Name (NI) 30616**] office. She was treated
with neoadjuvant FAC x1 followed by 4 cycles of dose-dense AC
and
four cycles of dose-dense Taxol. Because it was this time
believed her tumor was overexpressing HER-2, she was given an
approximately 5-week course of Herceptin. At some point,
shortly
thereafter, it was determined that her tumor was indeed not
overexpressing of HER-2/neu. In [**2187-3-7**], [**Known firstname **]
underwent a right-sided modified radical mastectomy. Per notes
from her oncologist that time, the past showed 2.3 cm triple
negative lesion. Five of 11 lymph nodes were positive. [**Known firstname **]
then underwent chest wall radiation. In [**2187-12-5**]
metastases to the spine as well as some soft tissue lesions were
noted. A pathology report of these lesions confirmed a triple
negative status. She was treated with Taxotere and Xeloda as
well as pamidronate. Upon progression is when she presented to
us for a second opinion. She is also just recently treated with
radiation to T10. There is a compression fracture or
dislocation. Please see Dr. [**First Name (STitle) **] and Dr.[**Name (NI) 72168**] note for
further details regarding her oncology history.
Social History:
She is married. She used to work at [**Company 72169**]. She has four
children aged 18, two 15-year-old twins, and age 13 (all of whom
live at home with her). She does not smoke cigarettes nor has
she in the past. She does not drink alcohol except for rarely.
Family History:
Mother is alive at age 63. Her father is alive at age 65. She
has four half siblings, two maternal aunts had cancers, one who
had breast cancer in her 70s and one with some type of cancer in
her back, in her 60s. A paternal aunt also had breast cancer in
her 70s and a paternal aunt had some type of cancer.
Physical Exam:
VS: as above
comfortable at rest, with no apparent distress, speaking in full
sentences
neck supple, no jvd, no nodes
rrr, nl s1+s2, no m/r/g
Coarse breath sounds throughout, more decreased sounds on right
upper quadrant, left with expiratory rhonchi
abdomen soft, non tender, non extended, nl bs,
no c/c/e
a&ox3, cns [**3-17**] intact, nl strength and reflex in all four
limbs, nl sensation.
Pertinent Results:
[**2188-7-30**]
WBC-5.4 HGB-9.9* HCT-29.5* MCV-80* MCHC-33.6 RDW-19.6* PLT
COUNT-180
NEUTS-81* BANDS-3 LYMPHS-9* MONOS-3 EOS-2 BASOS-0 ATYPS-1*
METAS-1*
MYELOS-0 BLASTS-0 NUC RBCS-2*
GLUCOSE-94 SODIUM-138 POTASSIUM-3.1* CHLORIDE-91* TOTALCO2-37*
ANION GAP-13
UREA N-9 CREAT-0.7
ALBUMIN-3.0* CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-1.5* URIC
ACID-5.6
ALT(SGPT)-51* AST(SGOT)-56* LD(LDH)-2429* ALK PHOS-115 TOT
BILI-0.4
.
CXR: 1. Interval new pulmonary edema, with atypical infection
felt less likely.
2. Perhaps increased loculated fluid associated with the
dominant right upper lobe mass.
.
CT with contrast: 1. New right upper lobe consolidation,
possibly post-obstructive in the setting of narrowing of the
right apical segmental bronchus adjacent to lymphadenopathy.
However, if the patient has been undergoing radiation therapy to
this region, radiation pneumonitis is an additional
consideration. Correlation with timing and port of radiation
therapy would be helpful.
2. Continued rapid progression of multifocal metastatic disease
within the lymph nodes and pleura, as well as probable
progressive lymphangitic carcinomatosis in the right lung.
3. Extensive hepatic disease likely due to widespread
metastases, although infection is an additional consideration
given the rapid development since [**2188-6-3**].
4. Extensive skeletal metastasis with compression deformity at
the T10 vertebral body with further slight decrease in height
since recent chest CT.
5. Supraclavicular and retroperitoneal lymphadenopathy
Brief Hospital Course:
Assessment and plan: 43 yo female with metastatic breast cancer
to pleural space and to spine presented with hypoxia. Found to
have findings on CT consistent with lymphangetic carcinomatosis
of the right lung. Patient with extensive disease including mets
to pleural space, T4 and T10 spine, diffuse metastatic disease
of pelvis, lumbar spine, proximal femurs and lesion of posterior
aspect of right ischial tuberosity s/p xrt and chemotherapy.
.
1. Dyspnea and hypoxemia: Based on CT findings of RUL infiltrate
she was thought to have post-obstructive pna vs. radiation
pneumonitis vs. lymphangitic carcinomatosis. She was treated
with 7 day course of levofloxacin with no improvement in O2
requirement. She was also treated with carboplatin [**8-1**] also
with questionable improvement in symptoms. Bronchoscopy and BAL
were also performed on this date: infectious workup was negative
for PCP, [**Name10 (NameIs) 72170**] viruses, legionella; AFB smear was negative
with pending culture; some yeast were present. She remained on
supplemental oxygen. On [**8-10**], she became tachypneic with
respiratory rates in the 40's to 50's; this was also accompanied
by tachycardia and intermittent desaturations to the 80's. Some
component of this episode was thought to be due to anxiety. The
episode prompted transfer to the ICU where she remained until
[**8-12**]. She was transferred back to the floor with 2-3 L oxygen
requirement. She has remained stable on the current settings on
the floor. Her anxiety has been treated with ativan.
.
2. Breast cancer, metastatic: As described above, her disease
was extensive with diffuse metastatic disease and rapid
progression. See oncologic history for pre-admission details.
She was also treated with carboplatin as noted above. Given the
extent and progression, discussions were had with the patient
and her family regarding goals of care. She was full code at
admission but then became DNR/DNI. At this time she is wanting
mainly comfort care; labs are still being drawn at this time in
preparation for possible intrathecal pump insertion. More
discussion will need to be had with the family regarding blood
draws, transfusions if needed. Hospice should be involved with
the patient upon her plans of discharge.
.
3. Pain control: Initially having a great deal of difficulty
with pain control, and patient had nausea/vomiting and altered
mental status thought in part to be due to systemic narcotics
and other pain medications. An epidural catheter was placed
which improved pain control and mental status. Placement of
intrathecal pump is highly desired by the family and patient for
longer term pain control. Intrathecal permanent pump to be
placed by pain anesthesia service at [**Hospital1 112**] by Dr. [**First Name8 (NamePattern2) 1116**] [**Last Name (NamePattern1) **] and
his team.
.
4. Nausea: This improved with decrease in systemic narcotic
doses and other medications (including Zofran, compazine, and
lorazepam).
.
5. Depression and anxiety: We started her on Paxil and lorazepam
with good effect.
.
6. Altered mental status: This improved greatly with changes in
pain management as above.
.
7. Anemia: Likely due to myelosuppression from chemotherapy.
Received PRBC transfusions as needed.
.
8. Dispo - patient is being transfered to [**Hospital1 112**] for placement of
permanent epidural pump. She is to be transferred to oncology
service with anesthesia following. After anesthesia
observational period, patient may warrant hospice discharge
instructions. She wishes to return home under hospice care.
Medications on Admission:
Docusate Sodium 100 mg PO BID
Senna 8.6 mg PO BID as needed for constipation.
Lactulose 10 g/15 mL PO Q8H as needed for constipation.
Albuterol 90 every 4-6 hours as needed for shortness of breath
Prochlorperazine 10 mg PO Q6H as needed.
Fentanyl 275 mcg/hr Patch Q72 hr
Bisacodyl 10 mg PO BID
Dronabinol 2.5 mg PO BID
Gabapentin 300 mg PO HS
Ibuprofen 600 mg PO Q8H as needed for pain.
Folic Acid 1 mg PO DAILY
Hydromorphone 4 mg PO Q3 HRS as needed for pain.
Zofran 8mg as needed for nausea
Ativan 0.5mg po prn q4h for anxiety
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
3. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO Q8H (every
8 hours) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-5**] Sprays Nasal
QID (4 times a day) as needed.
9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation every four (4) hours as needed for wheezing.
10. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for SOB.
12. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety or nausea.
13. Ondansetron 4 mg IV Q8H:PRN
14. Prochlorperazine 10 mg IV Q6H:PRN nausea
15. Pantoprazole 40 mg IV Q24H
16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
17. epidural
Epidural care per protocol
Bupivicaine 0.1% with Fentanyl citrate 2 micrograms/ml: Infuse
at 8 ml/hour
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Metastatic breast cancer
Hypoxemia
Chronic pain
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with uncontrolled pain and low blood oxygen.
As many of your medical problems are related to your advanced
cancer, we have begun discussions with you and your family
regarding hospice care. We are transferring you to another
hospital so that you may get a device to help with pain control.
.
You will get further discharge instructions after leaving
[**Hospital6 1708**].
Followup Instructions:
Followup as per [**Hospital6 1708**].
[**First Name8 (NamePattern2) 1116**] [**Last Name (NamePattern1) **] (anesthesia attending) for pump insertion.
Hospice consult.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**]
|
[
"197.1",
"300.00",
"338.3",
"285.22",
"197.0",
"287.5",
"518.82",
"112.0",
"197.2",
"311",
"V10.3",
"787.02",
"198.5",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"99.04",
"99.05",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
11324, 11339
|
5676, 8762
|
323, 353
|
11431, 11440
|
4129, 5653
|
11879, 12172
|
3390, 3700
|
9840, 11301
|
11360, 11410
|
9287, 9817
|
11464, 11856
|
3715, 4110
|
276, 285
|
381, 1571
|
8777, 9261
|
1593, 3096
|
3112, 3374
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,808
| 188,064
|
44734
|
Discharge summary
|
report
|
Admission Date: [**2176-9-4**] Discharge Date: [**2176-9-10**]
Date of Birth: [**2099-1-25**] Sex: F
Service: [**Company 191**] MED
HISTORY OF PRESENT ILLNESS: This is a 77-year-old woman with
achalasia, status post esophageal pneumatic dilation on [**9-4**]
that was complicated by an esophageal tear. She had several
episodes of hematemesis post procedure accompanied by melena
with a hematocrit dropped to 21. An esophageal contrast
study showed a question of an intramural perforation of the
esophagus posteriorly without leakage of contrast into the
mediastinum or the pleural space. There was also marked
dilation of the esophagus consistent with her diagnosis of
achalasia.
She was originally admitted to the A-Cove service, but then
was transferred to the ICU. Surgery was consulted and she
was being managed conservatively. She was started on
levofloxacin and metronidazole prophylactically on [**9-4**]. She
received six units of packed red blood cells, as well as four
units of FFP on [**9-6**] with an appropriate rise in her
hematocrit to 36. Her ICU course was significant for low
grade temperatures (approximately 100?????? Fahrenheit), as well
as sundowning. She remained NPO and was transferred to the
[**Company 191**] medicine service on [**9-8**].
PAST MEDICAL HISTORY:
1. Achalasia.
2. Hypertension.
3. Hypercholesterolemia.
4. Anxiety.
MEDICATIONS: Her medicines at home include:
1. Toprol XL, 100 q a.m. and 550 q p.m..
2. Mavik, 4 mg q day.
3. Lipitor, 10 q day.
4. Aspirin.
5. Xanax, 0.25 b.i.d..
6. Prilosec, 20 q day.
Her medicines on transfer from the ICU were:
1. Levofloxacin, 500 mg IV q day.
2. Flagyl, 500 mg t.i.d. IV.
3. Protonix, 40 IV b.i.d..
4. Captopril, 6.25 t.i.d. PO.
5. With p.r.n. ordered for droperidol, Compazine, and
Haldol.
ALLERGIES: Penicillin, reaction unknown.
SOCIAL HISTORY: The patient lives alone. She was recently
widowed and she has no children.
FAMILY HISTORY: Significant for hypertension and CAD.
REVIEW OF SYSTEMS: Patient denied fevers and chills, cough,
shortness of breath, chest pain, palpitations, nausea,
vomiting, diarrhea, constipation or dysuria. She reports her
weight has been stable.
PHYSICAL EXAMINATION: Vitals: Temperature 98.6, heart rate
86, blood pressure 180/85, respiratory rate of 20, and 96% on
room air. General: She is a pleasant, elderly, white female
in no acute distress and appeared comfortable. Skin: Warm,
dry, anicteric, and there is no rash. HEENT: Positive for
temporal wasting. Oropharynx is clear and mucous membranes
are slightly dry. Neck: Supple. There is a right internal
jugular triple lumen central line in place. Lungs: Clear to
auscultation bilaterally. No wheezes, rales or rhonchi.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2.
No murmurs, rubs or gallops. Abdomen: Bowel sounds are
present. Soft, nontender, nondistended. No organomegaly.
Extremities: No cyanosis, clubbing or edema.
LABORATORY DATA: On [**9-8**] - white count of 10.3, hematocrit
36.4, platelets of 84. PT of 14.4 and INR of 1.4. Albumin
2.9. Potassium 3.8, sodium 137, BUN 18, creatinine 0.8,
glucose 87.
ASSESSMENT: This is an 77-year-old female with hypertension,
hypercholesterolemia, and achalasia status post balloon
dilation complicated by an esophageal tear. Hematocrit has
been stable with no evidence of continued bleeding for
greater than 36 hours by the time of transfer to the [**Company 191**]
medicine service on [**9-8**].
HOSPITAL COURSE: Since her admission to the floor on [**9-8**] -
1. GI - Diet: Patient was kept NPO during the admission
until [**9-8**] when her diet was advanced slowly and, by the time
of discharge, she was tolerating solids without difficulty.
Her hematocrit was stable for greater than 72 hours by the
time of discharge. Nutrition was consulted and Boost was
recommended. High dose proton pump inhibitor (40 mg of
Protonix b.i.d.) was continued during the admission.
2. Heme - 1. Thrombocytopenia (a low of 73 from 220 on
admission). This was initially thought to be dilutional and
she received three units of FFP. By discharge, her platelets
were up to 149. 2. Increased PT - PT was found to be 4.2 and
malnutrition was highly suspected. Vitamin K was
administered and it had decreased to 1.3 by the time of
discharge.
3. Hypertension - Her hypertensive medications were held
while she was NPO and she occasionally received 5 mg of IV
Lopressor p.r.n. for hypertension. Captopril was begun in
the ICU and was quickly titrated up. She was restarted on
Toprol XL by the day of discharge.
4. Infectious Disease - The patient had had low grade
temperatures in the 100's during her course. This may have
represented an inflammatory response secondary to esophageal
injury. However, by the time of discharge, she had a
temperature around 98 for greater than 24 hours. The
esophageal tear was treated conservatively with IV
antibiotics (Levaquin and Flagyl).
4. Psych - Sundowning was noted in the ICU and the patient
was treated with IV Haldol as needed, as well as avoidance of
medications that could trigger this like benzodiazepines.
Also, the patient has been depressed as she recently lost her
husband and a nephew of hers is currently dying from
pancreatic cancer. Social Services was consulted, but the
patient declined to see them as she wanted to deal with it
"on her own." She may benefit from some
therapy/antidepressant medications and will be followed by
her primary care physician on this matter.
5. FEN - Potassium phosphorus, and magnesium were repleted
p.r.n. during this admission.
6. Code status - DNR/DNI, per patient's stated wishes.
7. Access - A right internal jugular central line was
placed without incident in the ICU. It was removed upon
discharge without complications.
DISCHARGE STATUS: Patient was discharged to home with a home
PT evaluation. She will be following up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 349**] in his office in about one week and she was given
the phone number to make that appointment. She will also be
following up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at [**Hospital 1459**] Medical.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Achalasia status post esophageal tear on [**9-4**] during a
balloon dilation.
2. Hypertension.
3. Hypercholesterolemia.
4. Anxiety/depression.
DISCHARGE MEDICATIONS:
1. Toprol XL, 100 mg q a.m., 50 mg q p.m..
2. Mavik, 4 mg q day.
3. Lipitor, 10 mg q day.
4. Xanax, 0.25 b.i.d..
5. Protonix, 40 mg b.i.d..
6. Levaquin, 50 mg q day PO for a total of four days.
7. Flagyl, 500 mg q 8 hours PO for a total of four days
after discharge.
8. Note, she was told to continue to hold her aspirin until
it would be safe for her to restart it at a later date.
[**First Name11 (Name Pattern1) 870**] [**Last Name (NamePattern4) 80703**], M.D. [**MD Number(1) 95700**]
Dictated By:[**Name8 (MD) 210**]
MEDQUIST36
D: [**2176-9-10**] 20:41
T: [**2176-9-16**] 14:26
JOB#: [**Job Number 95701**]
|
[
"998.2",
"530.0",
"401.9",
"300.00",
"272.0",
"293.0",
"998.11",
"276.5",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.92"
] |
icd9pcs
|
[
[
[]
]
] |
1988, 2027
|
6377, 6528
|
6551, 7209
|
3541, 6324
|
2253, 3523
|
2047, 2230
|
178, 1296
|
1318, 1877
|
1894, 1971
|
6349, 6356
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,921
| 177,024
|
31746+57763
|
Discharge summary
|
report+addendum
|
Admission Date: [**2121-3-26**] Discharge Date: [**2121-4-1**]
Date of Birth: [**2042-11-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2121-3-26**] 1. Aortic valve replacement with a 23-mm [**Doctor Last Name **] Magna
aortic valve bioprosthesis. 2. Coronary artery bypass grafting
x3 with left internal mammary artery to left anterior descending
coronary artery; reverse saphenous vein single graft from the
aorta to the first obtuse marginal coronary artery; reverse
saphenous vein single graft from the aorta to the distal right
coronary artery.
History of Present Illness:
78 year old russian speaking female with history of coronary
artery disease s/p stent placement to LAD in [**2120-9-12**].
She was feeling well until 2 months ago when she started
experiencing chest tightness. This is associated with dyspnea,
as well as several episodes of nocturnal and rest angina. She
underwent a cardiac cath at [**Hospital3 **] on [**2121-3-4**] which
revealed severe left main and three vessel disease. Based on
these findings, she was admitted and bypass surgery was
recommended. However, she did not want to pursue surgery and
wanted a second opinion (specifically to pursue minimally
invasive and off-pump). Since discharge from [**Hospital3 **],
she has had several episodes of chest pain at rest.
Past Medical History:
Coronary artery disease s/p LAD DES [**9-20**]
Hypertension
Hyperlipidemia
Spinal stenosis
Social History:
Lives: alone
Occupation: -
Tobacco: denies
ETOH: denies
Family History:
non-contributory
Physical Exam:
Pulse: 61 Resp: 20 O2 sat: 99%
B/P Right: 160/69 Left: 163/68
Height: 5'2" Weight: 165 lbs
General: well-developed elderly female 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
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema: - Varicosities:
small right calf
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Pertinent Results:
Intra-op Labs
[**2121-3-26**] 09:36AM HGB-8.7* calcHCT-26
[**2121-3-26**] 09:36AM GLUCOSE-90 LACTATE-0.9 NA+-138 K+-3.8 CL--104
[**2121-3-26**] 02:42PM FIBRINOGE-284
[**2121-3-26**] 02:42PM PT-15.3* PTT-28.8 INR(PT)-1.3*
[**2121-3-26**] 02:42PM PLT COUNT-149*
[**2121-3-26**] 02:42PM WBC-14.6*# RBC-2.83*# HGB-7.0*# HCT-21.8*#
MCV-77* MCH-24.9* MCHC-32.3 RDW-16.2*
[**2121-3-26**] 02:42PM HGB-7.3* calcHCT-22
Discharge labs:
[**2121-3-31**] 06:30AM BLOOD WBC-7.7 RBC-3.98* Hgb-10.5* Hct-32.2*
MCV-81* MCH-26.4* MCHC-32.7 RDW-18.8* Plt Ct-81*
[**2121-3-31**] 06:30AM BLOOD Plt Ct-81*
[**2121-3-29**] 04:54AM BLOOD PT-11.9 PTT-26.8 INR(PT)-1.0
[**2121-3-30**] 06:30AM BLOOD Glucose-86 UreaN-26* Creat-0.9 Na-139
K-3.5 Cl-104 HCO3-25 AnGap-14
[**2121-3-26**] Echo: PRE BYPASS The left atrium is mildly dilated. The
left atrium is elongated. Mild spontaneous echo contrast is seen
in the body of the left atrium. No mass/thrombus is seen in the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild to moderate ([**12-14**]+), bordering on moderate aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). Moderate [2+] tricuspid regurgitation is seen.
Dr. [**Last Name (STitle) 914**] was notified in person of the results in the
operating room at the time of the study. POST BYPASS The patient
is being AV paced. There is normal biventricular systolic
function. There is a bioprosthesis in the aortic position. It
appears well seated. Leaflet function appears normal. There is
very trace aortic insufficiency the origin of which can not be
determined. The maximum gradient across the aortic valve is 17
mmHg with a mean of 9 mmHg at a cardiac output of 6
liters/minute. The effective orifice area of the valve is 1.8
cm2. The tricuspid regurgitation is improved and is now mild to
moderate. The thoracic aorta appears intact.
Radiology Report CHEST (PA & LAT)[**2121-3-31**] 11:37 AM
[**Hospital 93**] MEDICAL CONDITION: 78 year old woman s/p cabg
REASON FOR THIS EXAMINATION: eval for effusion
Final Report
Mild-to-moderate postoperative enlargement of the
cardiomediastinal silhouette has been stable since [**3-27**].
Small bilateral pleural effusions are unchanged since [**3-28**].
There is no pneumothorax or pulmonary edema.
Moderately severe bibasilar atelectasis is stable on the left,
worsened on the right.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Brief Hospital Course:
Ms. [**Known lastname 74551**] was a same day admit after undergoing pre-operative
work-up as an outpatient. On [**3-26**] she was brought directly to
the operating room where she underwent a coronary artery bypass
graft x 3 and aortic valve replacement. Please see operative
report for surgical details. In summary she had: Aortic valve
replacement with a 23-mm [**Doctor Last Name **] Magna aortic valve
bioprosthesis.
Coronary artery bypass grafting x3 with left internal mammary
artery to left anterior descending coronary artery; reverse
saphenous vein single graft from the
aorta to the first obtuse marginal coronary artery; reverse
saphenous vein single graft from the aorta to the distal right
coronary artery. Her bypass time was 130 minutes with a
crossclamp of 108 minutes. She tolerated the operation well and
following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. She was somewhat labile
hemodynamically on the day of surgery requiring volume overnight
herand hemodynamics had improved on post operative day 1 she
woke and was extubated. A heparin induced antibody test was
done on post operative day 1 due to falling platelets, which was
negative. Her home dose of Plavix was restarted for a history
of LAD stent in [**9-20**]. Chest tubes and pacing wires were
removed per cardiac surgery protocol. She remained
hemodynamically stable and was transferred to the step down unit
on post operative day 3. Once on the floor, beta blockers were
titrated up and an ACE-I was started for better blood pressure
control. She was tolerating a full oral diet, continued to be
gently diuresed and her incisions were healing well. She had
generalized weakness preoperatively and required assistance for
transfers. She was transfered to rehabilitation at [**Hospital 7137**] in [**Location (un) **] on post operative day 6.
Medications on Admission:
Metoprolol 100mg qd
Plavix 75mg qd
Simvastatin 40mg qd
Aspirin 81mg qd
Hydrochlorothiazide 25mg qd
Nitro 2.5mg prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day): total 75mg three times a day .
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Aortic insufficiency s/p Aortic valve replacement
Past medical history
s/p LAD DES [**9-20**]
Hypertension
Hyperlipidemia
Spinal stenosis
Discharge Condition:
Alert and oriented x3 nonfocal - Russian speaking
Ambulates with walker, minimal distance
Sternal pain managed with Ultram prn
Sternal wound healing well, no eryhtema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
***If there are any questions or concerns please call the
cardiac surgery office [**Telephone/Fax (1) 170**]. The answering service will
contact the [**Name2 (NI) 24140**] person during off hours.***
Followup Instructions:
Appointments already scheduled
Surgeon Dr [**Last Name (STitle) **] - Thrusday [**5-1**] at 1:30 pm [**Telephone/Fax (1) 170**]
Please call to schedule appointments
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**12-14**] weeks [**Telephone/Fax (1) 589**]
Cardiologist Dr.[**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] in [**12-14**] weeks
Completed by:[**2121-4-1**] Name: [**Known lastname 12287**],[**Known firstname 12288**] Unit No: [**Numeric Identifier 12289**]
Admission Date: [**2121-3-26**] Discharge Date: [**2121-4-1**]
Date of Birth: [**2042-11-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine
Attending:[**First Name3 (LF) 1543**]
Addendum:
correction on follow up appointment
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 901**] - [**Location (un) 382**]
Followup Instructions:
Appointments already scheduled
[**First Name8 (NamePattern2) 33**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1477**] Date/Time:[**2121-4-29**] 2:45
Please call to schedule appointments
Primary Care Dr. [**First Name8 (NamePattern2) 12290**] [**Name (STitle) 902**] in [**12-14**] weeks [**Telephone/Fax (1) 903**]
Cardiologist Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-14**] weeks
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2121-4-1**]
|
[
"293.0",
"724.00",
"518.5",
"287.5",
"414.2",
"401.9",
"414.01",
"V45.82",
"413.9",
"272.4",
"424.1",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"36.15",
"36.12",
"39.61",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10333, 10405
|
5362, 7244
|
283, 701
|
8567, 8748
|
2356, 2779
|
10428, 11028
|
1658, 1676
|
7409, 8232
|
4834, 4861
|
8346, 8546
|
7270, 7386
|
8772, 9479
|
2795, 4797
|
1691, 2337
|
233, 245
|
4890, 5339
|
729, 1455
|
1477, 1569
|
1585, 1642
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,745
| 145,057
|
25802
|
Discharge summary
|
report
|
Admission Date: [**2156-12-23**] Discharge Date: [**2156-12-29**]
Date of Birth: [**2094-3-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
62 year old male with ETOH cirrhosis/HCC with diuretic-resistant
ascites despite placement of a TIPS shunt and resultant
significant hydrocele and possible inguinal hernia status post
orthotopic liver transplant. He presents with one day history
of chest pressure. He felt tired and lethargic in the morning
even after a good night sleep. He then experienced chest
pressure
which he has been experiencing intermittently since surgery but
it was worse this AM. The pain did radiate to both of his
shoulders and down his elbows. The pressure was relieved
slightly by nitro and felt better after passing gas. He is
trembulous but he says that he feels that this is better today.
No fever, chills or night sweats. No nausea or vomiting. He did
have shortness of breath with the chest pressure. He went to
OSH where EKG showed afib and he was given digoxin and
lopressor. He converted to sinus and was transferred here.
Past Medical History:
1. Alcohol-related cirrhosis status post TIPS placement
[**2154-10-8**]
requiring dilatation [**2154-10-15**]
2. Upper GI bleeding in [**2152**]. Patient was treated at an
outside
hospital and it is unclear whether his upper GI bleed was
secondary to esophageal varices or peptic ulcer disease.
3. Coronary artery disease status post angioplasty in the
[**2129**].
4. Diabetes mellitus type 2 diagnosed in [**2152**]. Hemoglobin A1c
[**2154-10-4**] was 6.3
5. Umbilical hernia status post repair [**2154-11-3**]
6. Right knee surgery
7. Depression
8. HCC, growth [**Last Name (un) 64259**] 2.5x2.5cm confirmed on [**2156-9-8**] at the dome
of the liver
9. Recurrent recent paracentesis due to refractory ascites
Social History:
Married with two adult sons. Formerly worked as a vice
president
of a trucking company. Drank from the age of 20 until [**2154-9-19**]. He never smoked. Denies IV drug use.
Family History:
Father and brother died of MI at the age of 52. His mother and
sister have diabetes.
Physical Exam:
T 97.7 HR 68 BP 122/74 RR 20 99% on 3L NC 104.8kg
General: NAD, alert and oriented x 3. tremlous
anicteric sclerae, upper dentures
Luns: clear to ausculation bilaterally
Cor: RRR, no murmur
Abd: soft, slightly distended, appropriately tender around the
incsion. Incision is intact with staples
Pertinent Results:
[**2156-12-27**] 05:43PM BLOOD WBC-7.5 RBC-3.28* Hgb-10.0* Hct-30.2*
MCV-92 MCH-30.5 MCHC-33.1 RDW-17.1* Plt Ct-187
[**2156-12-29**] 05:34AM BLOOD WBC-6.0 RBC-2.96* Hgb-9.0* Hct-26.1*
MCV-88 MCH-30.4 MCHC-34.5 RDW-17.1* Plt Ct-154
[**2156-12-23**] 05:24PM BLOOD PT-13.4 PTT-23.7 INR(PT)-1.1
[**2156-12-28**] 06:07AM BLOOD PT-13.5* PTT-25.8 INR(PT)-1.2*
[**2156-12-23**] 05:24PM BLOOD Glucose-193* UreaN-29* Creat-1.7* Na-136
K-5.9* Cl-111* HCO3-19* AnGap-12
[**2156-12-29**] 05:34AM BLOOD Glucose-58* UreaN-24* Creat-1.8* Na-131*
K-4.2 Cl-100 HCO3-26 AnGap-9
[**2156-12-23**] 05:24PM BLOOD ALT-33 AST-18 CK(CPK)-21* AlkPhos-153*
Amylase-44 TotBili-0.6
[**2156-12-29**] 05:34AM BLOOD ALT-21 AST-18 CK(CPK)-27* AlkPhos-151*
TotBili-0.6
[**2156-12-27**] 03:31AM BLOOD Triglyc-163* HDL-39 CHOL/HD-4.9
LDLcalc-119
[**2156-12-27**] 03:31AM BLOOD TSH-2.0
[**2156-12-28**] 06:07AM BLOOD FK506-9.8
[**2156-12-27**] 03:31AM BLOOD FK506-8.2
[**2156-12-26**] 06:05AM BLOOD FK506-10.2
[**2156-12-25**] 05:50AM BLOOD FK506-10.5
[**2156-12-24**] 04:30AM BLOOD FK506-16.7
[**2156-12-23**] 05:24PM BLOOD cTropnT-<0.01
[**2156-12-24**] 12:30AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2156-12-27**] 02:08AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2156-12-27**] 05:43PM BLOOD CK-MB-NotDone cTropnT-0.26*
[**2156-12-28**] 06:07AM BLOOD CK-MB-NotDone cTropnT-0.24*
Brief Hospital Course:
62 year old male with ETOH cirrhosis/HCC POD #19 s/p liver
transplant initially presented on [**12-23**] with chest pain. He was
fatigued, lethargic then had chest pain relieved by nitro and
passing flatus. At OSH, EKG showed afib with RVR and received
digoxin and lopressor. He had TWI anterolaterally during afib
which persisted while in sinus. He converted to sinus and was
transferred here to the xplant service. Cards was consulted. His
enzymes cycled and Trop peaked at 0.03 with negative CKs.
Treated with ASA and metoprolol. Stress on [**12-24**] showed mild
fixed apical defect and decreased EF so he was planned for cath
on [**12-27**]. Precath hydration performed. Cath on [**12-27**] showed prox
LAD calcification with occlusion of D2 and occluded mid RCA.
During intervention on the D2, the guidewire appeared to cause
dissection of the artery and there was extravasation of blood
seen on cath. The patient experienced CP so was started on nitro
gtt. Echo was perfomed which showed no effusion. CP improved
from [**9-27**] to [**5-27**] and he was transferred to CCU for closer
monitoring. The following day the chest pain had completely
resolved and a repeat Echo showed only physiologic effusions.
He was transferred back to [**Hospital Ward Name 121**] 10 on the transplant service.
He was stared on metoprolol, aspirin, and isosorbide
mononitrate. Because of a hematocrit of 26.1 and his recent
cardiac events he was transfused with 1 unit of blood. He was
discharged in good, stable condition.
Medications on Admission:
1. Fluconazole 400 mg PO Daily
2. Prednisone 20 mg PO Daily
3. Docusate Sodium 100 mg PO BID
4. Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY
5. Valganciclovir 450 mg PO Daily
6. Mycophenolate Mofetil 1000 mg PO Daily
7. Citalopram 40 mg PO Daily
8. Senna 8.6 mg PO BID: prn
9. Pantoprazole 40 mg PO Daily
10. Metoprolol Tartrate 25 mg PO BID
11. Oxycodone 5-10 mg PO prn
12. Tamsulosin 0.4 mg PO QHS
13. Insulin Glargine 18 units SC QHS
14. Tacrolimus 2.5 mg PO BID
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours) for 2 doses.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed. Tablet(s)
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
chest pain with cath
Discharge Condition:
good, stable
Discharge Instructions:
You were started on a statin to lower your cholesterol. Your PCP
should titrate this dose to get your LDL ("bad cholesterol")
down to less than 70.
Your aspirin was increased to 325mg daily.
You were also started on isosorbide mononitrate daily.
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] (cardiology). Please
call ([**Telephone/Fax (1) 7236**] to confirm an appointment for this week.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2157-1-5**] 9:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2157-1-5**]
9:30
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2157-1-13**]
8:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
[
"411.1",
"998.2",
"V10.07",
"V42.7",
"427.31",
"414.01",
"E879.0",
"414.12",
"250.00",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"88.56",
"99.20",
"00.66",
"00.40",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
7635, 7709
|
4065, 5582
|
326, 352
|
7774, 7789
|
2705, 4042
|
8083, 8841
|
2279, 2367
|
6102, 7612
|
7730, 7753
|
5608, 6079
|
7813, 8060
|
2382, 2686
|
276, 288
|
380, 1307
|
1329, 2068
|
2084, 2263
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,564
| 118,586
|
16305
|
Discharge summary
|
report
|
Admission Date: [**2159-10-21**] Discharge Date: [**2159-10-25**]
Date of Birth: [**2076-10-24**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Motrin / Penicillins
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82 yo male with a history of lower GI bleed in [**2-22**] and [**9-22**]
thought to be related to his diverticulosis. Over the past few
days he had dark maroon stool and thought maybe he was having
some GI bleeding as he had in the past. On the day of
presentation [**2159-10-21**] he had a large amount of blood in his stool
with blood clots as well lightheadedness which caused him to
fall. He states he hit his L side of his body and his head and
he does not believe he lost consciousness. He then called to
the person who lives across the [**Doctor Last Name **] to call 911 and then got up
on his own and continued to feel lightheaded. No abdominal
pain, no F/C, no N/V. No black stool. No other bleeding. No
Urinary symptoms, no SOB, cough, chest pain or any other
symptoms.
In the ED, initial vs were: T 98.3 P 58 BP 136/59 R 20 O2 sat
96% RA. Patient was given protonix 40mg IV x 1, tylenol 500mg po
x 1, 2L IVF he underwent an NG lavage that was negative and had
a rectal exam with maroon stool that was guaiac negative. Prior
to transfer to the ICU his vitals were HR 56 BP 117/65 RR 19 96%
on RA.
Past Medical History:
1)hx of LGIB in [**2-22**] and [**9-22**]
2)Sick sinus syndrome s/p pacemaker
3)Hyperlipidemia
4)GERD
5)Asthma
6)Wilson's disease carrier
Social History:
lives alone in [**Location (un) 3146**] Beach, widowed, 2 children (live in
[**Hospital1 **] and [**Location (un) **]), 4 grandchildren (ages 15-24); formerly
worked in real estate and bartending; denies tobacco and drug
use, occ alcohol.
Family History:
4 of 6 sibs with pacemakers, brother died of stroke at 81yo,
father w/ stroke at 62yo, brother w/ CAD and colon ca, mother w/
cancer, father w/ wilson's disease
Physical Exam:
Vitals: T: 97.2 BP: 146/61 P: 61 R: 21 O2: 92% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM slightly dry, oropharynx clear
Neck: supple, JVP 7cm, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2159-10-21**] 05:35PM WBC-4.8 RBC-3.53* HGB-9.8*# HCT-30.9*#
MCV-88#
[**2159-10-21**] 05:35PM PT-13.2 PTT-27.7 INR(PT)-1.1
[**2159-10-23**] 06:05AM BLOOD WBC-5.4 RBC-3.18* Hgb-9.2* Hct-28.0*
MCV-88 MCH-
[**2159-10-25**] 06:25AM BLOOD WBC-5.6 RBC-3.92* Hgb-11.2* Hct-33.9*
MCV-86 MCH-28.6 MCHC-33.1 RDW-14.2 Plt Ct-244
[**2159-10-21**] X-ray HIP UNILAT MIN 2 VIEWS LEFT: IMPRESSION: No
traumatic injury. Mild degenerativedisease of the underlying
left hip noted.
[**2159-10-21**] CT HEAD W/O CONTRAST: IMPRESSION: No acute
intracranial hemorrhage or fracture. Interval small lacunar
infarct in the left centrum semiovale.
Brief Hospital Course:
The patient is an 82 yoM w/ SSS s/p pacer and a h/o recurrent
lower GI bleeds thought to be due to diverticulosis presents
with BRBPR and presyncope.
1) Lower GI bleed: likely related to diverticulosis given
previous history of bleeds and history of diverticulosis. He
had a colonoscopy in [**2-22**] and [**9-22**] and a bleeding scan in [**2-22**]
as well as an angio that was unable to localize bleeding. His
bleeding previously on bleeding scan was localized to the
hepatic flexure, he has diverticulosis of the entire colon
making diverticular bleed most likely. He has a history of
polyps so a poly bleed is also possible but less likely, he also
has internal hemorrhoids however this is also lower on the
differential given the presence of clots. No fever,
leukocytosis or anything else to suggest inflammatory or
infectious cause of bleeding. In the hospital, hct remained
stable at 28 to 30. He continued to have small amounts of blood
when wiping which resolved by [**2159-10-23**] The patient was given IV
fluid. He was given a red cell transfusion to improve
phsyiologic reserve given his multiple bleeding episodes. He did
not bump appropriately to the transfusion and therefore an
additional 2 units of packed red blood cells were given. GI was
consulted who recommended holding off on colonoscopy given
recent study in [**9-22**]. Surgery was consulted and did not feel
that surgical intervention was warranted at this time given the
cessation of acute bleeding and that a complete colectomy would
be necessary. He should have follow-up hematocrit (serially,
likely on a weekly basis) given his recurrent lower GI bleeds.
At time of discharge, his hematocrit was stable at 33.9.
2) s/p Fall: no LOC, likely from volume depletion and possible
vagal stimulus after visualization of blood +/- micturation /
BM. No prodromal symptoms, urinary/fecal incontinence, or
tongue biting to suggest seizure. Sick sinus syndrome may have
contributed however this is less likely given the previously
placed pacemaker. CT head and hip films were negative for bleed
or fracture. The patient was not orthostatic prior to discharge.
3) Sick Sinus Syndrome: Questionable brief period of heart rate
in 30s-40s without triggered pacing, however appeared
functioning appropriately on review of multiple days of
telemetry. He also recently had his pacer interrogated in [**7-24**].
Should follow-up outpatient with cardiology for pacemaker
maintenance.
4) Conversion reaction: Stable. Continued celexa.
5) Hyperlipidemia: Stable. Continued lovastatin.
6) Code: Full (discussed with patient)
Medications on Admission:
Citalopram 10mg daily
Simvastatine 20mg daily
Omeprazole 20mg daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Lower GI bleed [**3-19**] diverticulosis,
Pre-syncope
Secondary Diagnoses: Sick Sinus Syndrome, Hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with a lower GI bleed,
light-headedness, and a fall. The lower GI bleed was most
likely due to diverticulosis, a condition in which blood vessels
can bleed into outpouchings in your colon. The light-headedness
that caused your fall was due to your blood loss. You were
given IV fluids, and blood transfusions. Your blood levels
remained stable in the hospital. Surgery was consulted but did
not feel that your bleeding warranted surgical evaluation at
this time. To evaluate your injuries from the fall, you had a
head CT and a hip X-ray, both of which were negative. You
should follow-up your recurrent lower GI bleed with your primary
care physician with regular checks of your hematocrit.
-------------------
No changes were made to your medications
-------------------
If you experience any of the following symptoms you should
contact your primary care physician or go to the emergency room:
Grossly bloody or tarlike stools, abdominal pain, fevers or
chills, diarrhea, nausea, vomiting, chest pain, shortness of
breath, weakness, dizziness or light-headedness.
Followup Instructions:
PCP: [**Name10 (NameIs) **] to [**Name (NI) 46496**] office for a blood draw on monday
[**2159-10-29**] to access your level of blood cells.
[**2159-11-1**] @ 2:50 p.m. with DR. [**Last Name (STitle) 1576**]. [**Telephone/Fax (1) 1579**]
|
[
"300.11",
"780.2",
"578.9",
"272.4",
"V45.01",
"427.81",
"V15.88",
"562.13",
"285.1",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6270, 6276
|
3287, 5890
|
322, 328
|
6452, 6461
|
2631, 3264
|
7618, 7860
|
1910, 2072
|
6008, 6247
|
6297, 6297
|
5916, 5985
|
6485, 7595
|
2087, 2612
|
6393, 6431
|
255, 284
|
356, 1475
|
6317, 6371
|
1497, 1637
|
1653, 1894
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,840
| 138,367
|
15209+15210
|
Discharge summary
|
report+report
|
Admission Date: [**2162-8-10**] Discharge Date: [**2162-8-17**]
Date of Birth: [**2097-5-20**] Sex: M
Service: CARDIOVASC
HISTORY OF THE PRESENT ILLNESS: This is a 65-year-old male
who only past medical history consisted of tobacco abuse, who
was complaining of substernal chest pressure with
diaphoresis, while working at his autobody shop the day of
admission, which is [**2162-8-10**]. He presented to the
primary care physician office that day, where he was found to
have inferolateral ST elevations. He was treated with
sublingual nitroglycerin and heparin, as well as receiving 40
mg of ....................at 6:20 PM that day. The patient
had no evidence of chest pain since he arrival to our
hospital at 8 PM.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS PRIOR TO ADMISSION: Occasional aspirin for
degenerative joint disease.
The patient underwent cardiac catheterization on
[**2162-8-11**], which revealed three-vessel coronary artery
disease with preserved ejection fraction. The patient
underwent coronary artery bypass grafting times four on
[**2162-8-12**] with left internal mammary artery to the
left anterior descending; left radial artery to the posterior
descending coronary artery and saphenous vein graft to the
OM1 and OM2 sequential. The patient was transferred to the
Cardiac Surgery Recovery Unit on Nitroglycerin at 0.5 mcg per
kilo per minute in stable condition being A-V paced with an
underlying sinus bradycardia. The patient was extubated the
same day as the surgery. A low dose of Neo-Synephrine was
started for his persistent systolic blood pressure being in
the low 90s. The left hand remained well perfused with a
normal plus wave. The plan was to have the patient
transferred to the floor.
On postoperative day #1, the patient remained afebrile.
Vital signs were stable with heart rate of 89 in sinus
rhythm. The patient had been extubated the prior day. The
labs revealed the following: White count of 12.2, hematocrit
25.2, platelet count 214,000, sodium 137, potassium 4.6, BUN
11, creatinine 0.8, glucose 104 on Neo-Synephrine at 2 and
nitroglycerin at 0.5.
The physical examination was benign Plan was to start Imdur
and to wean the nitroglycerin, as well as the Neo-Synephrine
as tolerated; Imdur for the radial artery harvest and to
transfer to the floor when off the drip.
On postoperative day #2, the patient had no complaints
overnight with a low-grade fever of 99.6, somewhat
tachycardiac with a heart rate ranging from 105 to 140. The
patient was saturating at 99% on two liters. The heart rate
was irregularly irregular on physical examination with an
otherwise, unremarkable physical examination. Amiodarone
bolus was given and the plan was to started on Amiodarone
400 mg PO t.i.d. for the atrial fibrillation.
The patient was noted to be somewhat pleasantly confused all
night the prior evening. The atrial fibrillation was
documented as beginning around 5 o'clock that morning,
postoperative day #1 with ventricular rates in the 120s. The
patient was given 5 mg IV push of Lopressor times two, as
well as the Amiodarone bolus. He was converted to normal
sinus rhythm that morning at 8 AM.
On postoperative day #3, the patient had no complaints
overnight. The patient remained with a low-grade fever of
99.2. Vital signs were stable. He was in sinus rhythm with
a heart rate of 84 in stable condition. However, the patient
continued to remain confused and received a 1:1 sitter for
the confusion and for fall precautions.
On postoperative day #4, the patient had no complaints
overnight. The patient was afebrile, vital signs were
stable. The patient was still in sinus rhythm. Plan was to
discontinue the sitter and to plan for a potential discharge
date of [**2162-8-17**].
LABORATORY DATA: Current labs revealed the following: White
count of 7.7, hematocrit of 23.9, platelet count 256,000,
sodium 139, potassium 4, BUN 16, creatinine 0.9, glucose 105.
Anticipated discharge medications: Imdur 60 mg PO q.d. for
three months; Aspirin 325 mg q.d.; Amiodarone PO 400 mg q.d.;
Metoprolol 50 mg PO b.i.d.; Lasix 40 mg PO q.d. for ten days;
potassium chloride 20 mg PO q.d. for ten days; Tylenol 650 mg
PO q.6h.p.r.n.; Ibuprofen 400 mg PO q.6.p.r.n.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES: Coronary artery disease.
FOLLOW-UP CARE: The patient is to visit Dr. [**Last Name (STitle) 1537**] in four
weeks and his primary care physician in three to four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 30647**]
MEDQUIST36
D: [**2162-8-16**] 11:34
T: [**2162-8-17**] 16:02
JOB#: [**Job Number 44276**]
Admission Date: [**2162-8-10**] Discharge Date: [**2162-8-17**]
Date of Birth: [**2097-5-20**] Sex: M
Service: CARDIOVASC
HISTORY OF THE PRESENT ILLNESS: This is a 65-year-old male
who only past medical history consisted of tobacco abuse, who
was complaining of substernal chest pressure with
diaphoresis, while working at his autobody shop the day of
admission, which is [**2162-8-10**]. He presented to the
primary care physician office that day, where he was found to
have inferolateral ST elevations. He was treated with
sublingual nitroglycerin and heparin, as well as receiving 40
mg of ....................at 6:20 PM that day. The patient
had no evidence of chest pain since he arrival to our
hospital at 8 PM.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS PRIOR TO ADMISSION: Occasional aspirin for
degenerative joint disease.
The patient underwent cardiac catheterization on
[**2162-8-11**], which revealed three-vessel coronary artery
disease with preserved ejection fraction. The patient
underwent coronary artery bypass grafting times four on
[**2162-8-12**] with left internal mammary artery to the
left anterior descending; left radial artery to the posterior
descending coronary artery and saphenous vein graft to the
OM1 and OM2 sequential. The patient was transferred to the
Cardiac Surgery Recovery Unit on Nitroglycerin at 0.5 mcg per
kilo per minute in stable condition being A-V paced with an
underlying sinus bradycardia. The patient was extubated the
same day as the surgery. A low dose of Neo-Synephrine was
started for his persistent systolic blood pressure being in
the low 90s. The left hand remained well perfused with a
normal plus wave. The plan was to have the patient
transferred to the floor.
On postoperative day #1, the patient remained afebrile.
Vital signs were stable with heart rate of 89 in sinus
rhythm. The patient had been extubated the prior day. The
labs revealed the following: White count of 12.2, hematocrit
25.2, platelet count 214,000, sodium 137, potassium 4.6, BUN
11, creatinine 0.8, glucose 104 on Neo-Synephrine at 2 and
nitroglycerin at 0.5.
The physical examination was benign Plan was to start Imdur
and to wean the nitroglycerin, as well as the Neo-Synephrine
as tolerated; Imdur for the radial artery harvest and to
transfer to the floor when off the drip.
On postoperative day #2, the patient had no complaints
overnight with a low-grade fever of 99.6, somewhat
tachycardiac with a heart rate ranging from 105 to 140. The
patient was saturating at 99% on two liters. The heart rate
was irregularly irregular on physical examination with an
otherwise, unremarkable physical examination. Amiodarone
bolus was given and the plan was to started on Amiodarone
400 mg PO t.i.d. for the atrial fibrillation.
The patient was noted to be somewhat pleasantly confused all
night the prior evening. The atrial fibrillation was
documented as beginning around 5 o'clock that morning,
postoperative day #1 with ventricular rates in the 120s. The
patient was given 5 mg IV push of Lopressor times two, as
well as the Amiodarone bolus. He was converted to normal
sinus rhythm that morning at 8 AM.
On postoperative day #3, the patient had no complaints
overnight. The patient remained with a low-grade fever of
99.2. Vital signs were stable. He was in sinus rhythm with
a heart rate of 84 in stable condition. However, the patient
continued to remain confused and received a 1:1 sitter for
the confusion and for fall precautions.
On postoperative day #4, the patient had no complaints
overnight. The patient was afebrile, vital signs were
stable. The patient was still in sinus rhythm. Plan was to
discontinue the sitter and to plan for a potential discharge
date of [**2162-8-17**].
LABORATORY DATA: Current labs revealed the following: White
count of 7.7, hematocrit of 23.9, platelet count 256,000,
sodium 139, potassium 4, BUN 16, creatinine 0.9, glucose 105.
Anticipated discharge medications: Imdur 60 mg PO q.d. for
three months; Aspirin 325 mg q.d.; Amiodarone PO 400 mg q.d.;
Metoprolol 50 mg PO b.i.d.; Lasix 40 mg PO q.d. for ten days;
potassium chloride 20 mg PO q.d. for ten days; Tylenol 650 mg
PO q.6h.p.r.n.; Ibuprofen 400 mg PO q.6.p.r.n.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES: Coronary artery disease.
FOLLOW-UP CARE: The patient is to visit Dr. [**Last Name (STitle) 1537**] in four
weeks and his primary care physician in three to four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 30647**]
MEDQUIST36
D: [**2162-8-16**] 11:34
T: [**2162-8-17**] 16:02
JOB#: [**Job Number 44277**]
|
[
"272.0",
"305.1",
"410.21",
"414.01",
"427.31",
"401.9",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"89.68",
"36.15",
"88.53",
"99.29",
"37.22",
"88.56",
"99.69"
] |
icd9pcs
|
[
[
[]
]
] |
9144, 9605
|
8830, 9088
|
5635, 8806
|
9113, 9122
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,379
| 186,358
|
35676
|
Discharge summary
|
report
|
Admission Date: [**2181-2-24**] Discharge Date: [**2181-3-2**]
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Percutaneous transhepatic cholecystostomy
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **] yo female with PMH of AS, DM who was diagnosed
last month with adenocarcinoma of her pancreatic head causing
post-obstructive dilation. She underwent ERCP at that time
after presenting with painless jaundice, which showed a long
stricture in the common bile duct in the region of the
intrapancreatic portion of common bile duct consistent with
pancreatic cancer. Cytology was obtained from this area which
has subsequently returned as positive for adenocarcinoma. A
wall stent was placed for longterm palliation of her obstructive
jaundice.
While she was in the hospital, she also underwent a CT angiogram
of the pancreas with pancreas protocol. This demonstrated a 3
cm mass in the head of the pancreas with obstruction of the
pancreatic duct. The mass encased the gastroduodenal artery, no
definitive metastasis was seen. She was seen by Dr. [**Last Name (STitle) **]
from sugery and was thought not a surgical candidate due to
multiple comorbidities and age.
Today, she presented to [**Hospital3 3583**] with abd pain and fever
and was found to have acute cholecystitis. Her WBC was 26 and
AP 358. She received 3.375 zosyn and fluid before being
transferred to [**Hospital1 18**].
In the ED, initial vs were: 102.4 rectally. HR 140s-160s (afib,
RVR), BP 80s-100s. RR 20. 97% RA. She was reportedly not
responding much, so her head was scanned which was unremarkable.
She had diffuse abd TTP, mostly in RUQ. She was given flagyl
and another dose of zosyn (no cipro b/c of a fluoroquinolone
allergy. She received 4.5L of IVF and tylenol for pain with
improvement in her MS. She was seen by surgery who again felt
she was not an operative candidate in addition to her not
wanting a large surgery, so she was admitted to [**Hospital Ward Name **] ICU
with recommendations to undergo IR-guided percutaneous chole
tube. VS before being sent to ICU: 100.2 rectal. HR 113.
94/59. RR 23. 100% 4L. She has one 18g and one 20g IV. She
is DNR/DNI.
Upon arrival to the ICU, she reports the abdominal pain is
improved but still present. She denies n/v, CP, SOB.
Past Medical History:
hypercholesterolemia
diabetes mellitus type II
glaucoma
aortic stenosis
heel ulcers
Social History:
No tobacco, EtOH, Lives at Life Care Center of [**Location (un) 3320**],
generally uses wheelchair but can use a walker.
Family History:
Noncontributory
Physical Exam:
Vitals: T: 98.5 BP: 89/48 P:113 R: 25 O2: 97% 2L NC
General: Alert but sleepy, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral basal rales. no wheezes, ronchi
CV: tachy, irregular, normal S1 + S2. 2/6 SEM throughout
precordium. no rubs, gallops
Abdomen: soft, non-distended, bowel sounds present. TTP
diffusely, > RUQ. + murphys. no rebound tenderness or
guarding.
Ext: no c/c/e. Large right heel ulcer.
neuro: aox2
Pertinent Results:
Admission labs:
[**2181-2-24**] 08:20PM BLOOD WBC-12.4* RBC-3.87* Hgb-10.4* Hct-32.0*
MCV-83 MCH-27.0 MCHC-32.6 RDW-14.9 Plt Ct-324
[**2181-2-24**] 08:30PM BLOOD PT-15.0* PTT-30.5 INR(PT)-1.3*
[**2181-2-24**] 08:20PM BLOOD Glucose-258* UreaN-54* Creat-2.0*# Na-137
K-4.5 Cl-100 HCO3-23 AnGap-19
[**2181-2-24**] 08:20PM BLOOD ALT-26 AST-27 LD(LDH)-316* AlkPhos-393*
TotBili-1.9*
[**2181-2-25**] 01:40AM BLOOD Albumin-2.7* Calcium-7.3* Phos-3.3 Mg-2.0
[**2181-3-2**] 05:15AM BLOOD WBC-16.4* RBC-3.04* Hgb-8.4* Hct-24.6*
MCV-81* MCH-27.7 MCHC-34.1 RDW-16.0* Plt Ct-498*
.
Discharge labs:
[**2181-3-2**] 05:15AM BLOOD PT-14.9* PTT-29.1 INR(PT)-1.3*
[**2181-3-2**] 05:15AM BLOOD Glucose-75 UreaN-11 Creat-1.0 Na-138
K-3.2* Cl-106 HCO3-25 AnGap-10
[**2181-3-2**] 05:15AM BLOOD ALT-10 AST-16 AlkPhos-280* Amylase-44
TotBili-0.9
[**2181-3-2**] 05:15AM BLOOD Albumin-2.5* Calcium-8.0* Phos-2.9
Mg-1.5*
[**2181-2-25**] 9:39 am BILE
.
Microbiology:
**FINAL REPORT [**2181-3-1**]**
GRAM STAIN (Final [**2181-2-27**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2181-3-1**]):
ENTEROBACTER SAKAZAKII. HEAVY GROWTH.
sensitivity testing confirmed by Microscan.
LACTOBACILLUS SPECIES. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
ENTEROBACTER SAKAZAKII
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Imaging:
ERCP [**2-6**]:
IMPRESSION: Severe post-obstructive dilatation of the proximal
CBD and intrahepatic biliary ducts with severe narrowing of the
distal CBD with a shelf-like transition concerning for malignant
lesion. Placement of a Wallstent catheter at the site of
narrowing.
.
RUQ U/S [**2181-2-24**]:
IMPRESSION:
1) Distended gallbladder with wall thickening and edema and
pericholecystic fluid consistent with acute cholecystitis.
Irregular mucosa is worrisome for gangrenous cholecystitis.
2) Stable dilatation of the pancreatic duct and intrahepatic
bile ducts. Pancreatic head mass is not well seen. Stent within
the common bile duct.
.
Non-contrast head CT [**2181-2-24**]:
IMPRESSIONS:
1. No acute intracranial abnormality.
2. Chronic small vessel ischemia.
3. Right thalamic lacune
.
CXR [**2181-2-24**]:
IMPRESSION: Patchy bibasilar opacities likely reflect
atelectasis. Low lung volumes. Probable mild volume overload.
.
[**2181-2-26**] LENIS: no DVT.
.
EKG: sinus tach at 110. Nl axis, nl intervals. TWF II/aVF,
q-wave in III/aVF.
Brief Hospital Course:
[**Age over 90 **]F with pancreatic adenocarcinoma with entrapment of the
hepatoduodenal artery and obstruction of the CBD s/p ERCP
stending admitted with cholecystitis and sepsis. She was
initially treated in the MICU and stabilized. She improved from
an infectious point of view. She will need a 14 day course of
antibiotics. She is refusing surgery for her malignancy. She was
DCed back to her [**Hospital1 1501**] with PT, PO cipro for her infection, RN
care of her perc chole, and close follow up. She will follow up
with oncology as an outpatient.
.
# Cholecystitis: Was initally febrile, hypotensive, and with
altered mental status. Not a surgical candidate. Now s/p
percutaneous transhepatic cholecystostomy with ongoing drainage.
Bile culture grew ENTEROBACTER SAKAZAKII with HEAVY GROWTH and
LACTOBACILLUS with SPARSE GROWTH. Initially on
Piperacillin-Tazobactam, but discontinued after sensitivies for
the Enterbacter sp. came back as sensitive to ciprofloxacin.
Conitnue Ciprofloxacin HCl 500 mg PO Q24H for a total of 14 days
to DC on [**2181-3-9**]. Bcx and Ucx negative to date.
.
# Sinus tachycardia with intermitent atrial fibrillation with
rapid ventricular response: LENIs negative for DVT. Started
Metoprolol Tartrate 12.5 mg PO BID with excellent effect.
Holding off on uptitrating dose given aortic stenosis and
tachycardia is the only mechanism to increase cardiac output.
.
# Pancreatic cancer: Not an acute issue. Pt refusing surgery,
which seems reasonable given the clinincal picture. Pt may opt
for palliative chemotherapy. Will F/U as an outpatient with
oncology. Pt. was offered palliative care consult and hospice
care, she stated that she was "not ready for hospice yet", so
this was deferred.
.
# ARF: likely secondary to hypotension. Improving now.
.
# DM: chonic issue, on insulin.
.
# Aortic stenosis: no echocardiogram in the system, unclear
severity. Low dose Bblocker as above.
.
# Glaucoma: Continue Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT
EYE HS, Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H,
Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
Medications on Admission:
MVI
potassium 10 mEQ qday
alphagan P 0.15% drops one drop each eye tid
humalog 50-50 28 unis sc qAM
lumigan 0.03% one drop left eye qhs
NPH 15U qAM
NPH 6U qPM
albuterol/atrovent q 4hrs prn
tylenol 650mg q 4hrs
imodium
cosopt eye drops one drop both eyes [**Hospital1 **]
lasix 20mg qday
colace 100 [**Hospital1 **]
zofran 4mg q 6hrs prn nausea
Discharge Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-22**]
Puffs Inhalation Q4H (every 4 hours) as needed.
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: as
directed U Subcutaneous twice a day: NPH 15U qAM
NPH 6U qPM .
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): DC on [**2181-3-9**] . Tablet(s)
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Morphine 10 mg/5 mL Solution Sig: 1-2 mg PO Q6H (every 6
hours) as needed for pain.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U
Injection TID (3 times a day).
13. Colace 50 mg Capsule Sig: [**12-22**] Capsules PO twice a day.
14. Insulin Lispro 100 unit/mL Insulin Pen Sig: as directed U
Subcutaneous four times a day: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 3320**]
Discharge Diagnosis:
Primary: cholecystitis complicated by sepsis, acute renal
failure
.
Secondary: Adenocarcinoma of the head of the pancreas, aortic
stenosis, diabetes, glaucoma
Discharge Condition:
Stable vital signs, afebrile, tolerating POs
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital3 **] Medical
Center.
.
You were admitted with a severe infection of your gall bladder.
This is a complication of your pancreatic cancer and the stent
we placed to open up your bile duct. We placed a tube into your
gall bladder to drain the infection and treated you with
antibiotics. You will need to keep taking these antibiotics for
several days.
.
Please take your medications as ordered.
.
Please attend your follow up appointments.
.
Please call your doctor or come to the emergency room if you
experience fevers, chills, nausea and vomiting, diarrhea, chest
pain, shortness of breath, bleeding, loss of consciousness, or
other concerning symptoms.
Followup Instructions:
[**2181-3-14**] 01:00p [**Last Name (LF) **],[**First Name3 (LF) **] M.F. [**Telephone/Fax (1) 22**]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
.
Please see Dr. [**Last Name (STitle) **] in clinic in three weeks his number is
([**Telephone/Fax (1) 2363**]
Completed by:[**2181-3-2**]
|
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41,976
| 145,024
|
35281
|
Discharge summary
|
report
|
Admission Date: [**2202-5-1**] Discharge Date: [**2202-5-4**]
Date of Birth: [**2136-7-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 7835**]
Chief Complaint:
GJ tube needing exchange, UTI, need for trach exchange
Major [**Last Name (un) 2947**] or Invasive Procedure:
Tracheostomy exchange
PICC placement
GJ tube unclogging X2
History of Present Illness:
Mr. [**Known lastname 8182**] is a Spanish-comprehending 65M with complicated
PMH including CVA (nonverbal and does not move arms or legs at
baseline), AFib on warfarin, h/o chronic aspiration and multiple
PNA (s/p trach/PEG [**3-/2200**]), multiple prior episodes of
urosepsis with drug-resistant organisms (VRE), C diff s/p
colectomy, DM2, PVD, and multiple admissions (most recently
[**2-/2202**]) for GJ tube replacement presenting today from nursing
home with concern that GJ tube is not working. En route with
EMS, patient developed desaturations down to 80%s. BLS was
unable to suction.
In the ED, initial VS were 98.8F 80 130/70 98% on trach mask.
Repiratory therapy was able to succion with rapid improvement in
respiratory status. Labs in the ED were notable for WBC 16.1
78%N, lactate 1.8, Cr 0.5, Na 141, K 4.2. UA was notable 25
RBCs, 136 WBCs, nitrite postitive and many bacteria.
A cuff [**Year (4 digits) 3564**] was noted and replacement was not possible in the
ED. CXR did not reveal evidence of PNA. Clearance of J tube was
attempted with coke that was unsuccessful and imaging of J tube
was not possible given obstruction. IR was consulted for J tube
replacement and advised admission for replacement. Surgery was
also consulted for replacement of trach and J tube and advised
admission to MICU for trach replacement. The patient receive 4.5
g Zosyn for UTI and admitted to the MICU for further management.
Vitals on transfer were 98F 82 119/79 21 98% on trach mask.
On arrival to the MICU, the patient appeared comfortable and was
hemodynamically stable. Surgery evaluated Pt for trach exchange,
but part was apparently not availble. Pt remained very stable,
with O2 sat > 98% on trach mask and Pt was called out to the
medical floor for further management.
.
Past Medical History:
- Hypertension
- Hypothyroidism
- H/o CVA (bilateral embolic cerebellar [**2188**], hemorrhagic left
thalamic [**2190**])
- Type 2 Diabetes mellitus
- Peripheral neuropathy
- Depression
- h/o DVT (? - no [**Hospital1 18**] records)
- Atrial fibrillation (on coumadin)
- Peripheral vascular disease
- Hyperlipidemia
- Tracheostomy and GJ tube for chronic aspiration
([**3-/2200**])-Portex Bivono, Size 6.0
- C.diff colitis in [**1-29**] requiring total abdominal colectomy
with end ileostomy [**1-29**], repeat positive C diff toxin
[**2200-5-20**](outside facility, [**12/2198**] here)
Social History:
Resident of [**Hospital 16662**] Nursing Home, previously at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
Family very involved in care. Patient does not take anything by
mouth due to history of aspiration. Spanish-speaking. Patient is
a former 60 pack year smoker but quit in [**2183**].
Family History:
Patient has a mother with diabetes and brother with heart
disease
.
Physical Exam:
Initial physical exam:
VITALS: 98.8F 80 130/70 98% on trach mask
GENERAL: non-verbal but can nod/shake head in response to
questions, patient denies pain. Also denies cough.
HEENT: EOMI and making good eye contact, sclera anicteric
NECK: [**Year (4 digits) **], trach in place
LUNGS: Coarse breath sounds bilaterally, no wheezing, good air
movement, respirations unlabored, no accessory muscle use
HEART: distant heart sounds but Reg nl S1-S2,
ABDOMEN: Soft but scar tissue palpated, non-tender,
non-distended. PEG in place. Midline scar. no guarding or
rebound tenderness or suprapubic tenderness
EXTREMITIES: warm, well-perfused, no edema, contractions. Some
mild bleeding at midline insertion site with pressure dressing
placed.
NEURO: awake, non-verbal but can nod or shake head in response
to Y/N questions. Cannot move legs or feet/toes; can move both
arms slightly L>R (contracted hands b/l).
Discharge exam:
GENERAL: non-verbal but can nod/shake head in response to
questions in Spanish, patient reports pain in lower extremities.
Denies cough, denies respiratory problems.
VITALS: 98.1, 92-100/53-56, 63-79, 20, 98% on trach mask
HEENT: EOMI and making good eye contact, sclera anicteric
NECK: [**Year (4 digits) **], trach in place
LUNGS: Coarse breath sounds bilaterally, no wheezing, good air
movement, respirations unlabored, no accessory muscle use. Thick
but clear phlegm expectorated from trach.
HEART: distant heart sounds but regular rate and rhythm, nl
S1-S2, no m/r/g
ABDOMEN: Soft but scar tissue palpated, non-tender,
non-distended. PEG in place. Midline scar. no guarding or
rebound tenderness or suprapubic tenderness
EXTREMITIES: warm, well-perfused, no edema, contractions. Legs
atrophied but no visible lesions, no erythema. Reports severe
pain in lower extremities, mostly calves and thigh, seems to
worsen with palpation.
NEURO: awake, non-verbal but can nod or shake head in response
to Y/N questions. Cannot move legs or feet/toes; can move both
arms slightly L>R (contracted hands b/l).
Pertinent Results:
Admission labs:
[**2202-5-1**] 07:50PM BLOOD WBC-16.1* RBC-5.49 Hgb-11.7* Hct-39.4*
MCV-72* MCH-21.2* MCHC-29.6* RDW-16.1* Plt Ct-240
[**2202-5-1**] 07:50PM BLOOD Neuts-78.0* Lymphs-15.7* Monos-4.8
Eos-1.1 Baso-0.4
[**2202-5-1**] 07:50PM BLOOD Glucose-100 UreaN-13 Creat-0.5 Na-141
K-4.2 Cl-99 HCO3-32 AnGap-14
[**2202-5-1**] 07:50PM BLOOD Lactate-1.8
[**2202-5-1**] 08:50PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.014
[**2202-5-1**] 08:50PM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
[**2202-5-1**] 08:50PM URINE RBC-25* WBC-136* Bacteri-MANY Yeast-NONE
Epi-0
Discharge labs:
[**2202-5-4**] 07:00AM BLOOD WBC-11.2* RBC-4.48* Hgb-9.7* Hct-33.1*
MCV-74* MCH-21.7* MCHC-29.4* RDW-16.2* Plt Ct-216
[**2202-5-4**] 07:00AM BLOOD Glucose-86 UreaN-12 Creat-0.5 Na-141
K-3.6 Cl-105 HCO3-27 AnGap-13
[**2202-5-4**] 07:00AM BLOOD Calcium-9.3 Phos-2.5* Mg-1.7
CK: 506
Micro:
[**2202-5-1**] 8:50 pm URINE
URINE CULTURE (Preliminary):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
WORKUP REQUESTED BY DR. [**Last Name (STitle) **] [**Numeric Identifier 17776**].
GRAM NEGATIVE ROD #1. 10,000-100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD #3. UNKNOWN AMOUNT.
GRAM NEGATIVE ROD #4. UNKNOWN AMOUNT.
Imaging:
[**2202-5-3**]:
FINDINGS: A single portable AP chest radiograph was obtained and
is limited by portable technique and patient rotation. Focal
opacity at the left base appears more conspicuous compared with
prior studies dating back to [**Month (only) 404**]. No other distinct
consolidation is identified. There is no effusion or
pneumothorax. Mild cardiomegaly is unchanged. Tracheostomy tube
remains in unchanged position. Right upper quadrant [**Month (only) **]
clips and a percutaneous gastrostomy tube are in appropriate
positions. IMPRESSION: Increased conspicuity of left lower lobe
opacity could represent developing consolidation and/or
aspiration or atelectasis.
[**2202-5-4**] [**Month/Day/Year **] CHEST PORT. LINE PLACEM
FINDINGS: AP single view of the chest has been obtained with
patient in semi-upright position. Comparison is made with the
next preceding similar study obtained two and a half hours
earlier during the same day. The previously identified
right-sided PICC line has been withdrawn by a few centimeters
and terminates now in a location 3 cm below the carina. This is
compatible with the lower third of the SVC. No other significant
interval change can be identified. As identified on previous
examinations the patient has a tracheoscopy cannula in place.
Brief Hospital Course:
65M with history CVA c/b anoxic brain injury (non-verbal at
baseline), paraplegic, bedbound, able to shake head and move
upper extremities slightly, s/p trach/PEG admitted with UTI,
occluded GJ tube and trach [**Month/Day/Year 3564**].
#Urinary tract infection: Patient has a history of UTIs with
urosepsis notable for resistant organisms including proteus,
pseudomonas and VRE now presenting with elevated WBC and pyuria
on UA, concerning for UTI. Patient received zosyn in the ED for
possible UTI. Most recent UTI [**1-/2202**] grew proteus species that
intermittently sensitive to unasyn but sensitive to cefepime and
ceftazidime. Prior UTI in [**12/2201**] grew pseudomonas and VRE. Pt's
urine culture grew > 3 different colonies suggestive of
contamination. Given history of urosepsis with resistant
organsims, Pt will need broad antibiotic coverage. Pt was thus
treated with cefepime 1g iv q12h and daptomycin 450mg iv q24,
and received a PICC line to continue antibiotics until [**2202-5-17**]. His blood culture remained without growth during this
admission, and his leukocytosis resolved from 16k to 11k on
discharge. Pt was not febrile. While taking daptomycin, Pt will
need weekly creatinine kinase (CK) checks; his baseline CK is
~500 on discharge.
# GJ tube obstruction: Patient has had multiple ED visits and
admissions for occlusion of GJ tube since placement, most recent
replaement was 2/[**2201**]. Patient sent today from nursing home for
evaluation of occluded GJ tube that was not cleared using coke
in the ED. IR was consulted and advised admission with inpatient
replacement. Pt was taken to IR today but apparently, GJ tube
was reportedly working well and flushed both water and contrast
w/out issue. Pt was then returned to floor and tube feeds
restarted per nutrition recs. Pt's tube reclogged temporarily on
[**2202-5-4**], but was easily opened by flushing the J tube with a 5
cc syringe full of diet coke. A 5 CC SYRINGE MUST BE USED in
order to generate the force necessary to clear any blockages. Pt
was tolerating tube feeds well and may need to receive
supplementation with neutra-phos to keep phos between 2.7 - 4.5.
# Trach/respiratory: Patient was succioned by respirtory with
rapid improvement in respiratory status in the ED. Low suspicion
for PNA with patient has been afebrile and CXR did not show
evidence of PNA. Nursing home did not report worsening
respiratory status prior to presentation. Initial hypoxia
probably due to Pt having some mucus plug during transport,
which subsequently resolved w/ suctioning in ED. CXR suggests
probably L basilar atelectasis. Pt originally supposed to have
trach exchange, but part was initially not available. Pt had
trach part successfully replaced by respiratory therapist on
[**2202-5-3**]. Pt w/ copious but clear sputum. Pt had a repeat CXR,
which showed a possible focal opacity in left lung base,
possibly developing consolidation, aspiration, or atelectasis
and bibasilar atelectasis. Since Pt was at baseline respiratory
status and did not have any additional respiratory complaints or
fever, Pt was felt not to have a pneumonia.
#Type 2 Diabetes mellitus: Patient is on [**Date Range **] and SSI at home.
continued prior insulin scale after unclogging tube.
# Atrial fibrillation: Patient is on warfarin as an outpatient.
Pt's warfarin was held given elevated INR. Home dose 4mg po
daily, should be restarted on [**2202-5-5**] and have INR recheck daily
until it stabilizes.
# Hypothyroidism: levothyroxine 25 mcg daily
# Spasticity: Continue baclofen 15 mg QID
# C.diff colitis in [**1-29**] requiring total abdominal colectomy
with end ileostomy [**1-29**]. Received colostomy care.
# Peripheral neuropathy / Leg pain: doubled gabapentin to 600mg
po tid, increased Pt's fentanyl to 200mcg/hr patch, q72hr, and
started Capsaicin 0.025% cream tid to lower extremities.
# Depression: Continued duloxetine and mirtazapine.
TRANSITIONAL ISSUES:
-recheck INR [**2202-5-5**], restart warfarin 4mg daily when INR is <
3.0, with goal 2.0-3.0
-A 5 CC SYRINGE MUST BE USED in order to generate the force
necessary to clear any J tube blockages. He may need a
prophylactic flush every day with diet coke.
-Pt will need to have CK checked weekly while on daptomycin.
Medications on Admission:
- Acetaminophen 650 mg Q6H
- Ascorbic acid 500 mg [**Hospital1 **]
- Baclofen 15 mg QID
- Bisacodyl 10 mg [**Hospital1 **]
- Duloxetine 30 mg daily
- Fentanyl 150 mcg Q72H
- Gabapentin 300 mg TID
- Insulin aspart sliding scale
- Insulin glargine 32 units at bedtime
- Albuterol sulfate 2.5 mg/3 mL Q6H:PRN SOB or wheezing
- Ipratropium bromide 0.02% Q6H:PRN SOB or wheezing
- Lansoprazole 30 mg PO daily
- Furosemide 20 mg PO daily
- Mirtazapine 15 mg PO HS
- Morphine 10 mg Q6H:PRN pain
- Warfarin 4 mg daily
- Nystatin 5 ML PO QID:PRN thrush
- Levothyroxine 25 mcg daily
Discharge Medications:
1. levothyroxine 25 mcg Capsule [**Hospital1 **]: One (1) Capsule PO once a
day.
2. nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
3. Coumadin 4 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day:
Resume [**2202-5-5**].
INR to be checked by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 11041**] on [**2202-5-6**].
4. baclofen 10 mg Tablet [**Year (4 digits) **]: 1.5 Tablets PO QID (4 times a
day).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Year (4 digits) **]: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
6. duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Year (4 digits) **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. morphine 10 mg/5 mL Solution [**Year (4 digits) **]: Five (5) mL PO every six
(6) hours as needed for severe pain.
8. mirtazapine 15 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO HS (at
bedtime).
9. fentanyl 100 mcg/hr Patch 72 hr [**Year (4 digits) **]: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. gabapentin 300 mg Capsule [**Year (4 digits) **]: Two (2) Capsule PO Q8H (every
8 hours).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Year (4 digits) **]: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for SOB or wheeze.
12. ipratropium bromide 0.02 % Solution [**Year (4 digits) **]: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for SOB or wheezing.
13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. capsaicin 0.025 % Cream [**Last Name (STitle) **]: One (1) Appl Topical TID (3
times a day): Apply thin layer to bilateral lower extremities
(calves and thights).
15. daptomycin 500 mg Recon Soln [**Last Name (STitle) **]: Four [**Age over 90 1230**]y (450)
mg Recon soln Intravenous Q24H (every 24 hours) for 14 days: To
end on [**2202-5-17**].
16. cefepime 1 gram Recon Soln [**Year (4 digits) **]: One (1) gram Recon Soln
Injection Q12H (every 12 hours) for 14 days: To end on [**2202-5-17**].
17. insulin glargine 100 unit/mL Solution [**Year (4 digits) **]: Thirty Two (32)
units Subcutaneous at bedtime.
18. insulin regular human 100 unit/mL Solution [**Year (4 digits) **]: Per sliding
scale Injection qACHS.
19. ascorbic acid 500 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO twice a
day.
20. Tylenol 325 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
clogged J tube
urinary tract infection
tracheostomy [**Hospital6 3564**]
Secondary:
- Hypertension
- Hypothyroidism
- H/o CVA (bilateral embolic cerebellar [**2188**], hemorrhagic left
thalamic [**2190**], baseline averbal, paraplegic)
- Type 2 Diabetes mellitus
- Peripheral neuropathy
- Depression
- Atrial fibrillation
- Peripheral vascular disease
- Hyperlipidemia
Discharge Condition:
Mental Status: Averbal but responsive to questions in Spanish.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 8182**],
You were sent to the hospital because your J tube was clogged.
During transport, your oxygen level was low, but they had
trouble providing suctioning. Your tracheostomy was leaking, and
you were admitted to the hospital. Your breathing improved
rapidly, your tracheostomy was exchanged successfully, your J
tube was unclogged, and you were treated for a urinary tract
infection. You will need to continue your antibiotics for 2
weeks to treat this infection, so you received a special
tunneled IV line (PICC) for this. You also had severe leg pain,
which we felt was neuropathic (related to your nervous system)
and we increased your pain medications.
We have made the following changes to your medications:
INCREASE Fentanyl patch to 200mcg/hr patch, 1 patch every 72
hours
INCREASE Gabapentin to 600mg by mouth three times daily
START Capsaicin 0.025% cream, apply to lower extremities three
times daily
START Daptomycin 450 mg IV every 24 hrs, stopping on [**2202-5-17**].
START Cefepime 1g IV every 12 hrs, stopping on [**2202-5-17**].
** Your J tube was flushed successfully with diet coke in a 5cc
syringe. (You MUST use a 5 cc syringe to generate the necessary
force,.)
We have not made any other changes to your medications. Please
continue to take them as previously prescribed.
Followup Instructions:
Department: [**Year (4 digits) 706**] CARE UNIT
When: THURSDAY [**2202-5-13**] at 8:30 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Street Address(1) 706**]
When: THURSDAY [**2202-5-13**] at 10:00 AM
With: [**Year (4 digits) 6122**] WEST [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2202-5-4**]
|
[
"311",
"443.9",
"599.0",
"V58.67",
"357.2",
"E879.8",
"V58.61",
"427.31",
"536.42",
"244.9",
"250.60",
"401.9",
"438.53",
"519.09",
"344.1",
"V49.84",
"438.10",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"97.02",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15517, 15583
|
8062, 11985
|
16006, 16006
|
5332, 5332
|
17516, 18103
|
3207, 3276
|
12945, 15494
|
15604, 15985
|
12347, 12922
|
16169, 16881
|
5990, 6313
|
3314, 4192
|
4208, 5313
|
12006, 12321
|
16910, 17493
|
261, 434
|
6348, 8039
|
462, 2249
|
5349, 5974
|
16021, 16145
|
2271, 2859
|
2875, 3191
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,293
| 127,220
|
42212
|
Discharge summary
|
report
|
Admission Date: [**2130-7-22**] Discharge Date: [**2130-7-30**]
Date of Birth: [**2062-11-30**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headaches x 1 week
Major Surgical or Invasive Procedure:
[**2130-7-28**]: Right parietal craniotomy for tumor resection
History of Present Illness:
This is a 67 year old female with 55 year history of smoking
1 pack of cigarettes a day who presents with a week of headaches
and difficulty "putting thoughts together". A head ct was
performed consistent with significant right hemispheric edema
and
possible right sided brain mass. There was a chest xray that was
consistent with a possible mass in the left lower lobe. The
patient was transferred here for further treatment and
evaluation.
The patient states she has been experiencing headache a level
[**4-11**] on a [**12-12**] pain [**Last Name (un) **] that is on the right side and radiates
posteriorly to the base of the skull.She states that she has
been
having difficulty with coordination and difficulty organizing
her
thoughts. The patient denies weakness, numbness, tingling,
vision
or hearing deficit, bowel or bladder dysfunction, nausea or
vomiting.
She states that she is not followed by a primary care physician
and has no prior medical history.
At the time of the consult that patient had received Decadron 4
mg IV per the ED physician.
Past Medical History:
None
Social History:
She Lives with husband has five children. She is working
part-time.
Smoked 1 ppd x 55 years, no alcohol or drug use.
Family History:
Denies family history of malignancy. Reports that her siblings
died from heart attacks.
Physical Exam:
On Admission:
O: T:97.1: 132/60 HR:110 R : 16 O2Sats: 97% room air
Gen: comfortable, NAD.
HEENT: Pupils: 4-3mm EOMs:intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-2**] objects at 5 minutes.
Language: Speech is slow with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-6**] RUE, LLE, RLE- LUE limited due
to fractures- deltoid [**4-6**] otherwise unable to challenge the left
grip/biceps/triceps . No pronator drift
Sensation: Intact to light touch, proprioception bilaterally.
Toes mute bilaterally
Coordination: normal on finger-nose-finger on RUE, rapid
alternating movements on RUE, heel to shin
At discharge:
Exam in nonfocal.
Pertinent Results:
[**2130-7-23**] MRI Head
Right parietal mass in the subcortical region with extensive
surrounding edema with the appearance most suggestive of
metastatic disease. The post-gadolinium images are motion
degraded and no obvious other lesions are seen. No acute
infarcts.
[**2130-7-23**] CT Torso
IMPRESSION:
1. Left lower lobe superior segment mass and a smaller left
lower lobe
spiculated-appearing lesion may represent synchronous or
metachronous
bronchogenic carcinomas or metastases in the proper clinical
setting.
2. Metastatic necrotic-appearing lymph nodes in the right
paratracheal
region.
3. Right lower lobe superior segment 4 mm nodule likely
represents a small
metastasis.
4. No lytic, blastic or aggressive-appearing osseous lesions are
appreciated.
[**2130-7-23**] Xray Left wrist and forearm:
FINDINGS: Comparison is made to previous study from [**2130-7-22**].
There is an overlying cast which limits fine bony detail. There
is again seen a fracture involving the distal radius with
intra-articular extension. There is neutral alignment of the
radial articular surface. Degenerative change of the first CMC
joint is noted. Images of the forearm do not show any injury of
the proximal radius or ulna. The elbow joint is grossly intact.
[**2130-7-25**] chest Xray: FINDINGS: In comparison with the outside
study of [**7-22**], there is little overall change in the appearance
of the large left lower lung mass laterally consistent with the
opacification seen on the CT that was felt to represent both a
left lower lobe superior segment and left lower lobe mass
representing either bronchogenic carcinoma or metastases.
[**2130-7-26**] L wrist xray:
IMPRESSION: Nondisplaced distal radial fracture with largely
unchanged from prior study. Degenerative changes at 1st CMC and
IP joints.
[**2130-7-28**] CT Head:
IMPRESSION:
1. Expected post-surgical changes seen post right
parieto-occipital
craniotomy and tumor resection.
2. Minimal blood within the surgical bed. Expected amount of
pneumocephalus is seen. Persistent edema unchanged from before.
Stable minimal right-to-left shift of midline structure is seen.
[**2130-7-29**] MRI BRAIN:
IMPRESSION: No evidence of residual mass in the right parietal
surgical bed. Continued follow-up is recommended when blood
products resolve.
Brief Hospital Course:
Pt was admitted to the neurosurgery service for further workup
of Right parietal brain mass seen on CT scan. An MRI was
obtained and this showed an enhancing R parietal mass with
surrounding vasogenic edema. A CT torso was obtained for further
metastatic workup that demonstrated bilateral lung lesions, two
in the left lower lobe and one small lesion in the right lower
lobe, as well as necrotizing right paratracheal nodes.
Neuro-oncology, radiation oncology, hematology/oncology and
Thoracic surgery were consulted due to her metastatic disease.
Final tissue pathology is pending thus final recommendations
from these teams are pending.
Orthopedics was consulted for a known left forearm fracture and
she was recasted on [**7-25**] and she will be non-weight bearing in
Left upper extremity. She will follow in hand clinic with Dr.
[**Last Name (STitle) **] in [**12-4**] weeks for this fracture. For a left 5th toe
fracture she was put in a Hard-sole shoe, weight bearing as
tolerated.
On [**7-26**], pt was scheduled for elective surgical resection,
however, pt had blood that was difficult to crossmatch. As a
result, surgery was postponed until [**7-28**] in order to allow for
optimum time to obtain appropriate blood products.
Patient was taken to the OR on [**7-28**] for a right parietal
craniotomy for tumor resection. Operative details can be found
in the OP note. Operative course was uncomplicated, post
operatively patient was extubated and transfered to the ICU for
observation. Post operative CT revealed no hemorrhage, moderate
post op pneumocephalus and moderate edema. She remained in the
ICU for monitoring and was transferred to the floor on [**7-29**].
Physical therapy evaluated the patient and cleared her for home.
On [**7-30**] she was discharged home.
Medications on Admission:
none
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO every
eight (8) hours: 3 tabs every 8hrs for 2 days then 2 tabs every
8hrs for 2 days then 2 tabs every 12hrs until follow-up.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right parietal brain mass
Cerebral edema
Bilateral lung masses
Left wrist fracture
Left 5th toe fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed LeVETiracetam (Keppra) for
anti-seizure medicine, take it as prescribed and follow up with
the Brain [**Hospital 341**] Clinic.
?????? 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 will be addressed at your post-operative
office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
**** Your Steroid Taper:
- Dexamethasone 3 mg (3 tabs) every 8 hrs for 2 days then;
- 2 mg (2 tabs) every 8 hrs for 2 days then;
- 2 mg (2 tabs) every 12 hrs until follow-up with the BTC.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in 10 days (from your date of
surgery) for removal of your sutures. Please make this
appointment by calling [**Telephone/Fax (1) 1669**].
??????You will need to be seen in The Brain [**Hospital 341**] Clinic. They will
call you to make this appointment. 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**].
- F/u in Ortho Hand Clinic, Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 1228**] in 2
weeks. Please call to make this appointment.
- You will need Oncology follow-up to be scheduled once
pathology has been finalized. The Brain [**Hospital 341**] Clinic can help
coordinate this.
Completed by:[**2130-7-30**]
|
[
"813.42",
"348.5",
"162.5",
"198.3",
"305.1",
"E885.9",
"197.0",
"196.1",
"825.25"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
8219, 8225
|
5512, 7305
|
326, 391
|
8374, 8374
|
3186, 5003
|
10070, 10915
|
1659, 1750
|
7360, 8196
|
8246, 8353
|
7331, 7337
|
8525, 10047
|
1765, 1765
|
3147, 3167
|
268, 288
|
419, 1481
|
2245, 3133
|
5012, 5489
|
1779, 1952
|
8389, 8501
|
1503, 1509
|
1525, 1643
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,660
| 134,321
|
52040+59393
|
Discharge summary
|
report+addendum
|
Admission Date: [**2111-8-6**] Discharge Date: [**2111-8-25**]
Date of Birth: [**2033-11-9**] Sex: F
Service: SURGERY
Allergies:
Percocet / Codeine / Hydrochlorothiazide / Percodan / Cardizem
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
midsternal chest pain
Major Surgical or Invasive Procedure:
[**8-14**]: Extended right hemicolectomy
History of Present Illness:
Ms. [**Known lastname 8260**] is a 77 y/o F with PMH of CAD s/p CABG in [**2098**] (LIMA to
LAD, SVG to PDA, SVG to OM, SVG to diag), ESRD s/p renal
transplant ([**2100**]), and IDDM who presents in transfer from [**Hospital **]. The patient has felt quite tired for the past several
days while visiting her daughter; on routine labs (due for INR),
the patient was found to have a Hct of 18 with INR of 6. She was
admitted to [**Hospital3 8544**] for further evaluation; there, she
received 3 U PRBCs (by report). Hematocrit after her 2nd unit of
PRBCs was 21.9. Her INR was reversed with FFP and vitamin K with
repeat INR 2.6 from 6. Overnight, the patient had the acute
onset of midsternal chest pain with radiation to the back at the
OSH. This was not associated with diaphoresis, shortness of
breath, or palpitations. The patient was nauseous and vomited
once. The pain is a "steady, sharp" pain per her report; at its
worst, the pain was [**5-5**]. Now, the pain is [**2114-2-28**] and actually
resolved completely. She noted some improvement with
administration of labetalol gtt; she also received morphine and
nitroglycerin without much relief. She states that the pain is
improved with sitting up. It is not pleuritic. She has no cough.
She denies orthopnea and PND. She has left > right lower
extremity edema which is chronic.
.
She tells me that she had a low blood count one month ago that
required a transfusion of 1 U PRBCs; she subsequently was placed
on aranesp. At that time, she also experienced substernal chest
pain, much like her current pain, for which an answer was not
found (per her report). At the current time, she is on a
nitroglycerin gtt and without pain. Her stool is trace guaiac
positive.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
PMH: Renal artery stent on [**2110-12-27**]; surveillance U/S [**4-23**]
(+)in-stent stenosis/hydronephrosis; ESRD s/p CRT'[**99**], RUE AVF,
CAD s/p CABGx4(LGSV)'[**98**], cAF, HTN, IDDM2, gout, CCY, zoster
Social History:
Widowed and lives with her son. She is a nonsmoker. She denies
alcohol use.
Family History:
No hx of premature coronary artery disease
Physical Exam:
VS: T 96.9, BP 144/42, HR 66, RR 12, O2 100% on 4L NC
Gen: WDWN elderly woman in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate. Pleasant and able to speak in full
sentences.
HEENT: NCAT. Left conjunctiva injected. PERRL, EOMI. MM somewhat
dry.
Neck: Supple with JVP of 8 cm.
CV: Irregularly irregular rhythm, normal S1, S2. No S4, no S3.
2/6 systolic murmur at the apex.
Chest: Prior CABG sternotomy scar. No chest wall deformities,
scoliosis or kyphosis. Resp were unlabored, no accessory muscle
use. Occasional crackles at the bases; no wheezes or rhonchi.
Abd: soft, hypoactive bowel sounds, NTND, No HSM or tenderness.
No abdominial bruits.
Rectal: firm stool in the vault, trace guaiac positive
Ext: 1+ left lower extremity edema with overlying erythema.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+; DP dopplerable
Left: Carotid 2+ without bruit; Femoral 2+; DP dopplerable
Pertinent Results:
On admission, Hg 7.7, Hct 23.5.
[**2111-8-6**]. AXR. moderate-to-severe amount of stool within the
descending colon and rectal vault consistent with
constipation/impaction.
.
[**2111-8-6**]. Conclusions:
The left atrium is elongated. The right atrium is markedly
dilated. The
estimated right atrial pressure is 0-5mmHg. There is mild
symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Cannot exclude mild focal distal septal hypokinesis.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue
velocity imaging are consistent with Grade II (moderate) LV
diastolic dysfunction. Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is a trivial/very small
pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2110-12-25**],
previously
noted regional wall motion is now improved.
.
[**2111-8-6**]. CXR. No evidence of acute change.
[**2111-8-6**] 10:23PM HCT-29.1*
[**2111-8-6**] 07:50AM GLUCOSE-434* UREA N-95* CREAT-1.7* SODIUM-139
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-22 ANION GAP-13
[**2111-8-6**] 07:50AM ALT(SGPT)-22 AST(SGOT)-20 LD(LDH)-238
CK(CPK)-47 ALK PHOS-96 TOT BILI-0.4
[**2111-8-6**] 07:50AM CK-MB-NotDone cTropnT-0.06*
[**2111-8-6**] 07:50AM ALBUMIN-2.9* CALCIUM-7.2* PHOSPHATE-3.5
MAGNESIUM-2.4 CHOLEST-135
[**2111-8-6**] 07:50AM HAPTOGLOB-155
[**2111-8-6**] 07:50AM %HbA1c-6.1*
[**2111-8-6**] 07:50AM TRIGLYCER-179* HDL CHOL-48 CHOL/HDL-2.8
LDL(CALC)-51
[**2111-8-6**] 07:50AM FK506-4.9*
[**2111-8-6**] 07:50AM WBC-11.1*# RBC-2.57* HGB-7.7* HCT-23.5*
MCV-91 MCH-30.0 MCHC-32.8 RDW-17.0*
[**2111-8-6**] 07:50AM PT-27.1* PTT-39.9* INR(PT)-2.8*
Brief Hospital Course:
In summary, Ms. [**Known lastname 8260**] is a 77 y/o F with ESRD s/p renal
transplant, CAD s/p CABG, and IDDM admitted with demand ischemia
and profound anemia from likely GI bleed.
.
Chest pain. Initially concerning for aortic dissection because
report from outside hospital stated that there was unequal blood
pressures in L and R arms, though patient has an AV fistula on
the right which ws clotted. The chest pain was thought to be due
to demand ischemia from profound anemia. Cardiac enzymes were
negative. She reports three prior episodes of chest pain over
the past two years that resolved with blood transfusions. She
was treated with a nitroglycerin drip and had resolution of
chest pain. Also given aspirin, statin, metoprolol. An echo
showed an EF of 55%. Uremic pericarditis may also have
contributed to chest pain, as patient was found to have elevated
BUN and pericardial friction rub.
.
Anemia. Her hematocrit was 18 with INR of 6 at an outside
hospital. She was transfused at the outside hospital. Upon
arrival, her Hct was 23.5, but rose to 29.1 with transfusion of
two units of PRBCs on [**8-6**]. There is concern GI blood loss
given trace guaiac positive stools with supratherapeutic INR. GI
team was consulted on [**8-6**] and an EGD was done - mucosal
biopsies of antrum and duodenum revealed no diaagnostic
abnormalities in fundic mucosa and chronic inactive duodenitis
in duodenum. Next, she underwent 2 tagged red blood cell scans
which both showed active bleeding localized to the hepatic
flexure of the colon. Both of the scans were followed by an
angiogram which was negative on 2 occasions. She underwent
colonoscopy which again showed bright red blood in the right
colon and diverticula throughout the entire colon. The
colonoscopy failed to localize the site of bleeding and the
patient was taken to the operating room where an extended right
hemicolectomy was done. Hemicolectomy pathology revealed a
single tiny area of dilated venules in the mucosa, consistent
with vascular ectasia (angiodysplasia), and no erosion and
multiple diverticula of the colon. Post-operatively, staples
were removed from a 2x2 cm area of inferior wound due to
fluctuance and erythema. Wet to dry dressing changes were
started, and erythema since decreased. She received 1U pRBCs on
[**8-18**] and [**8-24**] for Hct<30%, asymptomatic.
.
Constipation. KUB showed stool in colon and rectum. Was
started on Milk of magnesia in addition to senna, colace and prn
Dulcolax and lactulose.
.
L LE edema: Problem appears chronic (mentioned in last renal
note from [**Month (only) 547**]) and likely due to prior vein harvesting for
CABG. L femoral US on [**8-11**] revealed L inguinal hematoma. No
pseudoaneurysm or fistula involving the left common femoral and
iliac arteries.
.
L UE erythema: patient was noted to have L arm swelling /
erythema at PICC site which prompted LUE U/S on [**8-15**] - found 6x4
fluid collection, no DVT. Double lumen PICC line via left
basilic venous approach by placed by IR on [**8-12**] due to poor
peripheral access.
.
CRI s/p renal transplant: The patient's creatinine appears to be
at baseline. Tacrolimus level was 4.9 on admission. Discharge
dose 1mg po q12h. Lasix was administered during hospital stay to
regulate fluid balance. Patient will be discharged on Lasix 40mg
po daily.
.
Hypertension: Holding home antihypertensives while in CCU. While
in the CCU, patient was on a nitroglycerin drip initially, but
weaned off after a couple of hours with plans to restart
antihypertensives slowly. Her blood pressure was monitored and
remained stable. Upon transfer to the floor she was placed on
Metoprolol 12mg po bid.
.
IDDM: Outside regimen unclear. [**Name2 (NI) **] verify with patient this
morning. SSI for now. HgA1c found to be 6.1 on admission. She
was followed by [**Last Name (un) **] during her stay, was continued on SSI.
.
UTI: Urine culture on [**8-15**] revealed >100,000 EColi. Cefepime was
started and then changed to Ceftriaxone for total of 7day of
antiobiotic therapy. ID was consulted for recommendations
regarding therapy.
.
Hypothyroidism. Continue levothyroxine 100 mcg daily
.
Gout. Renally-dosed allopurinol.
.
Dispo VNA services arranged for wound cares. PT cleared patient
for stair climbing. Patient was determined stable to be
discharged home vs rehabilitation center.
.
Proph: INR therapeutic was therapeutic on admission, so heparin
SQ was initally not started, but began post-operatively on [**8-14**].
She was given a PPI due to concern for upper GI bleed.
Medications on Admission:
Home MEDICATIONS (per recent nephrology note, patient unsure of
medications)
coumadin
norvasc 10 mg daily
diovan 80 mg [**Hospital1 **]
prednisone 5 mg daily
clonidine 0.1 mg [**Hospital1 **]
Labetalol 50 mg [**Hospital1 **]
colace 100 mg daily
amiodarone 100 mg every other day
lasix 60 mg [**Hospital1 **]
lipitor 20 mg daily
calcitriol 0.25 mcg daily
allopurinol 100 mg every other day
aspirin 81 mg daily
prograf 2 mg [**Hospital1 **]
levothyroxine 100 mcg daily
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO Q48H (every 48
hours).
4. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) Injection
QMOWEFR (Monday -Wednesday-Friday).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours) for 2 doses.
7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eighteen
(18) units Subcutaneous once a day.
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous at bedtime.
9. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day.
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-27**]
Drops Ophthalmic PRN (as needed).
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO BID (2 times a day).
Discharge Disposition:
Home With Service
Facility:
Community VNA
Discharge Diagnosis:
ESRD h/o renal transplant, s/p extended right hemicolectomy for
diverticular bleed
Discharge Condition:
stable
Discharge Instructions:
Please call Dr[**Name (NI) 4838**] office at [**Telephone/Fax (1) 673**] if you experience
fever > 101.5, chills, nausea, vomiting diarrhea, constipation,
blood in stool, inability to take or keep down medications.
Monitor wound for redness, swelling, tenderness, or drainage
No heavy lifting
Stay on Lasix 40mg po daily until told otherwise
Wet to dry dressings twice daily on open wound site with home
nursing.
Continue Colace and do NOT drive as long as you are taking
narcotics
Followup Instructions:
[**Name6 (MD) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2111-8-31**] 10:20
[**Name6 (MD) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2111-9-1**] 10:50
Name: [**Known lastname **],[**Known firstname 6310**] J. Unit No: [**Numeric Identifier 17582**]
Admission Date: [**2111-8-6**] Discharge Date: [**2111-8-25**]
Date of Birth: [**2033-11-9**] Sex: F
Service: SURGERY
Allergies:
Percocet / Codeine / Hydrochlorothiazide / Percodan / Cardizem
Attending:[**First Name3 (LF) 852**]
Addendum:
Patient initially scheduled for discharge on [**8-24**], but stayed
overnight due to complaints of nausea. She will be discharged
[**8-25**]. She is tolerating a regular diet and denies nausea. No
changes from previous discharge summary dated [**2111-8-24**].
Discharge Disposition:
Home With Service
Facility:
Community VNA
[**Name6 (MD) **] [**Last Name (NamePattern4) 853**] MD [**MD Number(2) 854**]
Completed by:[**2111-8-25**]
|
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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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14265, 14446
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6240, 10787
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343, 386
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12793, 12802
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2996, 3040
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11304, 12599
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12687, 12772
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10813, 11281
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12826, 13310
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3055, 4017
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282, 305
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414, 2656
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2678, 2887
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2903, 2980
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,828
| 136,152
|
42130
|
Discharge summary
|
report
|
Admission Date: [**2147-12-22**] Discharge Date: [**2148-1-5**]
Date of Birth: [**2082-1-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
T12-L2 anterior fusion with instrumentation
History of Present Illness:
Mr. [**Known lastname 91386**] was in his usual state of health until until
[**12-10**] when he fell from the second rung of a ladder at his home.
He had immediate and severe pain in his lower back at that time.
He says there was one moment where he was put in a chair by
first-responders and he sensed that he couldn't feel or move his
legs, but this resolved quickly on being put on a board by EMS.
He was taken to [**Hospital3 **] Hospital, had his C-spine cleared for
trauma, but was found to have an unstable burst fracture of L1,
and was transferred to [**Hospital1 18**]. He underwent transpedicular
decompression of L1, laminectomies of T11 and 12, and L2 and L3,
fusion of T10-L3, instrumentation T10-L3, and autograft on
[**12-11**].
He was discharged to rehab on [**12-16**] with weakness in his lower
extremities R>L per discharge summary, as well as some weakness
in his bilateral upper extremities. The patient reports he was
able to feel people touching his feet/legs at that time and was
able to move his toes. On [**12-18**] he was being repositioned at
rehab and heard a snapping sound in his back followed by intense
pain in his back and across his abdomen. He did not have any
loss
of sensory or motor function. He also notes an episode at rehab
where his blood pressure might have been slightly low on getting
out of bed but he says this resolved rapidly on sitting back
down.
He was readmitted to [**Hospital1 18**] on [**12-22**] because of persistent pain.
He
had an MRI at that time which revealed recurrent instability, so
he was taken back to the OR for T12-L2 reconstruction of
ankylosing spnodylitis type fracture with a lateral
trans-diaphragmatic approach. On [**12-28**] he was being positioned
for
a CXR and he heard a snap and noticed that the pain he had been
having in his back since the operation disappeared. Upon
returning to his room he noticed that he couldn't feel the nurse
touching his feet and he couldn't move his lower extremities.
Past Medical History:
PMH:
- Obesity, 300 lbs, 66 inches tall
- Chronic pain in neck, per patient [**2-22**] to arthritis
- Burst fracture of L1, s/p transpedicular decompression of L1,
laminectomies of T11 and 12, and L2 and L3, fusion of T10-L3,
instrumentation T10-L3, and autograft on [**12-11**]
- Renal cancer, s/p unilateral nephrectomy,
- IDDM, poorly controlled per patient
- HTN, poorly controlled per patient
- R knee replacement in [**5-21**] DJD
- S/p thyroid surgery for goiter 10 years ago
Social History:
Married with 2 kids, lives in [**Location 7658**] with his wife.
[**Name (NI) 1403**] in tech support. Denies tobacco or drug use with
occasional EtOH.
Family History:
Dad - CAD
[**Name (NI) 21206**] - CAD, CVA from DVT that left her comatose for several years
Physical Exam:
On Admission to [**Hospital1 18**]:
A&O X 3; uncomfortable appearing in a stretcher
RRR
CTA B
Abd soft NT/ND; obese
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension; ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL slugish but present; sensation intact L1-S1 dermatomes;
- clonus, reflexes symmetric at quads and Achilles
Prior to discharge:
98.1 100/52 62 18 93% on 2L
General: Calm, obese man lying in bed, stated age, NAD, with a
foley catheter in place.
HEENT: NC/AT, no scleral icterus noted, MMM, limitation of
rotation, flexion, and extension of neck, left more limited than
right.
Pulmonary: CTAB
Cardiac: Heart sounds distant, RRR, S1/S2 poorly differentiated
with unspecified murmur heard throughout precordium.
Abd: Obese habitus, NT.
Extremities: wwp, no clubbing or cyanosis. Trace pitting edema
in
bilateral feet, non-pitting edema in bilateral arms and hands
Skin: No rashes appreciated.
Neuro: Mental status is normal. Pupils are symmetric and
reactive
bilaterally. EOM conjugate and full, face symmetric with normal
sensation. Hearing is mildly reduced on the right compared to
the
left. Cough, voice are normal. Shoulder shrug is full and tongue
moves normally. Tone is flaccid in his legs, near normal in his
arms. Power is absent in his legs, completely. He is able to
lift
both arms against gravity and some resistance (deltoids 4-/5 on
right, [**4-25**] on left), biceps 4 on right, 4+/5 on left, triceps
[**3-25**]
on right, [**4-25**] on left, finger extension is [**2-25**] on right and 4-/5
on left, grip strength 4/5 on right and 4+/5 on left. Reflexes
are absent throughout. He has a sensory level at t10 on right
and
t11 on left. He perceives vibration in his toes, but cannot
localize this (refers to left ear).
Pertinent Results:
Admission Labs:
===============
[**2147-12-22**] 05:15PM BLOOD WBC-12.9* RBC-3.72* Hgb-10.7* Hct-34.2*
MCV-92 MCH-28.9 MCHC-31.4 RDW-13.7 Plt Ct-339#
[**2147-12-22**] 05:15PM BLOOD PT-12.6* PTT-32.2 INR(PT)-1.2*
[**2147-12-22**] 05:15PM BLOOD Glucose-156* UreaN-36* Creat-1.2 Na-140
K-4.7 Cl-104 HCO3-29 AnGap-12
[**2147-12-22**] 05:15PM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1
Prior to discharge:
===================
[**2148-1-3**] 07:45AM BLOOD WBC-6.2 RBC-3.23* Hgb-9.3* Hct-29.0*
MCV-90 MCH-28.7 MCHC-32.0 RDW-13.7 Plt Ct-401
[**2148-1-2**] 10:10AM BLOOD Glucose-181* UreaN-19 Creat-0.8 Na-137
K-4.8 Cl-94* HCO3-36* AnGap-12
.
Imaging:
========
MRI Thoracic and Lumbar spine [**2147-12-29**]:
1. New horizontal fracture through T10 vertebral body. The
possibility of
instability at that level cannot be ruled out. Correlate
clinically.
2. Hyperintense signal in the thoracic spinal cord at T9-T10
level which is likely due to cord infarct or progression of cord
edema.
3. Post-operative changes in the form of posterior fusion
hardware from
T10-L3 level with interbody cage at L1 level.
.
CT lumbosacral myelogram [**12-28**]: Per radiology report, evaluation
is limited from T10-T12 level. Particularly, somewhat distorted
appearance of the spinal canal and spinal cord at T9-10 level
appears to be secondary to artifacts, but given the appearance
on
axial T2 images, an actual narrowing in the region cannot be
completely excluded. If the patient's clinical and neurologic
findings correlate with the abnormality, consider CT myelography
for better assessment.
.
CT T/L spine [**12-27**]: Per radiology report, very limited study due
to streak artifact from the orthopedic hardware. There are
postsurgical changes status post T10 to L3 fusion, resection of
posterior elements and spacer. There is contrast in the
subarachnoid space extending from S1 to T6. There is no evidence
of new fracture or retropulsion. The evaluation of the spinal
canal from T8 to T10 is very limited, otherwise there no gross
evidence of cord compression at other levels. There are stable
multilevel degenerative changes. Postsurgical changes in the
posterior soft tissues. There are surgical clips in the abdomen.
There are bilateral lung infiltrates and a right pleural
effusion. MRI is recommended to evaluate for cord infarct and to
try to better visualize the T8 to T10 levels.
.
MR thoracic and lumabr spine w/o contrast [**12-22**]: Per radiology
report, evaluation is limited from T10-T12 level. Particularly,
somewhat distorted appearance of the spinal canal and spinal
cord
at T9-10 level appears to be secondary to artifacts, but given
the appearance on axial T2 images, an actual narrowing in the
region cannot be completely excluded.
.
CXR [**12-28**]: No evidence of pneumothorax. Small-to-moderate
layering
right pleural effusion.
.
CT Thoracolumbar spine [**2148-1-2**]:
Again fixation hardware is redemonstrated consistent with
transpedicular screws at T10, T11 and T12 vertebral bodies with
a cage at the level of L1 and transpedicular screws in the upper
lumbar spine at L2 and L3 levels. In comparison with the most
recent CT examination, the previously noted new fracture at the
level of T10 on the right appears more conspicuous; however, the
remainder levels are intact. Persistent anterior displacement of
the cage at L1 with areas of low attenuation in the surgical
region, difficult to assess due to metal artifacts. Multilevel
ankylosing spondylitis is redemonstrated.
The prevertebral soft tissues are otherwise unremarkable,
persistent right
pleural effusion and consolidation on the right lung base with
air
bronchogram.
Multiple clips are redemonstrated anteriorly in the abdomen.
IMPRESSION: The fracture identified at the right side of the T10
vertebral
body appears more conspicuous, the other levels are unchanged
since the most recent examination.
Brief Hospital Course:
Primary Reason for Hospitalization:
===================================
65 yo man with h/o DM type 2, HTN, hyperlipidemia, morbid
obesity, ankylosing spondylitis, renal cell carcinoma s/p
nephrectomy, and L1 burst fracture after falling off step stool
s/p T11-12 and L2-3 laminectomies on [**2147-12-11**] who was admitted
for fusion of T12-L2 with instrumentation on [**12-25**] who on POD #3
developed numbness and paraplegia in his bilateral lower
extremities from an apparent anterior spinal artery infarction.
.
ACTIVE ISSUES:
==============
# Acute Lower Extremity Paraplegia: He has no motor function in
his lower extremities and a pinprick/light touch deficit level
at T12, with a temperature deficit level at T9. There is
relatively preserved vibration in his lower extremities, with
absent proprioception in his toes. Given lack of external
compression of the thoracic cord on imaging these deficits
correspond with a likely anterior spinal artery infarction of
unclear etiology at about [**Name (NI) 91387**]. Presumably related to fracture at
T10 although this is not certain as it was not seen on CT on
[**2147-12-28**] and not seen on initial read of MRI on [**2147-12-29**]. There
are significant limitations to imaging due to nearby hardware
and extensive soft tissue making clear diagnosis difficult. He
does not have any obvious risk factors for an embolic etiology
and this would also be a very rare presentation. BP was
initially allowed to autoregulate 130-160 to maintain cord
perfusion.
- PT with ROM exercises to prevent frozen joints
- AFO's to prevent foot drop
- Monitor for pressure sores
- Discharge to Acute rehab for intensive therapy
- Patient needs repeat CT of thoracolumbar spine ~7 days after
discharge. This should be done within [**Hospital1 18**] system with Dr.
[**Last Name (STitle) 363**] following up the results. Follow-up after that with Dr.
[**Last Name (STitle) 363**] or colleague.
.
# Cervical Spinal disc disease: Patient had cervical cord
impingement noted on CT from OSH. This is a chronic issue but
continues to be a major source of discomfort and disability for
the patient. This is likely the cause of his effort-related
bilateral arm weakness and neck pain. He was advised to wear a
soft cervical collar however he did not because of discomfort.
He may benefit from wearing the collar during movements and
transfer to decrease pain related to transfer.
- Patient will need ortho follow-up with possible surgery in the
future after recovery from his more acute injury.
- Shoulder pain treated with lidocaine patches, gabepentin, and
oxycodone
.
# Hypertension: Patient on Diovan/HCTZ 160/25 at home.
- home meds were held initially to allow BP to autoregulate.
- Patient was normotensive prior to discharge to rehab. Rehab MD
will re-initiate anti-hypertensive therapy if neccessary.
.
# Type 2 Diabetes, uncontrolled with comps: Patient on high
doses of insulin at home (levemir 80 [**Hospital1 **] plus intensive humalog
sliding scale ranging from 20-30 units of humalog). Blood sugars
at [**Hospital1 18**] were reasonably well controlled with significantly
lower doses of insulin. This was presumed to be because of
decreased PO intake.
- Lantus 12u [**Hospital1 **] plus Humalog sliding scale with uptitration at
rehab as neccessary as PO intake increases.
.
# Asymptomatic Pyuria: discovered incidentally when looking for
proteinuria. No treatment indicated. Foley changed [**2148-1-4**].
.
CHRONIC ISSUES:
==============
# Normocytic Anemia: Appears to be chronic with some
superimposed blood loss from surgery.
.
# Hyperlipidemia:
- continue home atorvastatin and gemfibrozil
.
# Gout:
- continue allopurinol
.
# Morbid Obesity:
- This may complicate [**Hospital 228**] rehab course
.
# Ankylosing Spondylitis: Likely this is responsible for the
severe nature of his initial fractures on [**12-10**] which were out
of proportion to the expected injury from a fall from the second
rung of a ladder.
.
Transitional Issues:
====================
- Patient needs repeat CT of thoracolumbar spine ~7 days after
discharge. This should be done within [**Hospital1 18**] system with Dr.
[**Last Name (STitle) 363**] following up the results. Follow-up after that with Dr.
[**Last Name (STitle) 363**] or colleague.
- Home BP meds held at hospital because patient normotensive.
Rehab MD will re-initiate anti-hypertensive therapy if
neccessary.
- Home insulin regimen decreased while inpatient due to poor
appetite. It will need to be uptitrated as neccessary at rehab
as PO intake increases.
- Foley catheter changed [**2148-1-4**]
- Workup for osteoporosis or other causes of pathologic fracture
if indicated when patient follows-up with PCP
Medications on Admission:
- Levemir 'pen' 80 units [**Hospital1 **] (breakfast and dinner)
- Novolog 'pen' 20-30 units per sliding scale at meals
- Allopurinol 100 mg QD
- Diovan HCTZ 160/25 QD
- Lipitor 10 mg QD
- Gemfibrozil 600 mg QD
- Previously taking ASA 325 mg - no longer taking, stopped in
[**Month (only) 547**] for knee surgery and did not restart.
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
6. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain or prior to transfers.
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to affected areas on shoulders.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 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. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
15. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal
DAILY (Daily) as needed for No BM in 48 hr.
16. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-22**] Sprays Nasal
TID (3 times a day) as needed for congestion or dryness.
17. insulin glargine 100 unit/mL Cartridge Sig: Twelve (12)
units Subcutaneous twice a day: With breakfast and dinner.
18. insulin aspart 100 unit/mL Cartridge Sig: per sliding scale
Subcutaneous four times a day.
19. heparin (porcine) 5,000 unit/mL Solution Sig: 7500 (7500)
units Injection TID (3 times a day): subcutaneous.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
L1 burst fracture
T10 anterior spinal cord infarction
Paraplegia
Secondary Diagnoses:
Ankylosing Spondylitis
Diabetes Mellitus Type 2
Hyperlipidemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for pain control and spinal
instability after an L1 burst fracture. You underwent an
operation called anterior thoracolumbar stabilization. Several
days later, you developed a fracture of the T10 vertebral body
and infarction of the spinal cord at that level. This resulted
in paraplegia, with loss of the sensation and movement in your
legs. Further imaging did not show a likely benefit from
additional surgery or procedures at this time.
Your ongoing neck, back, and shoulder pain was managed with a
new oral pain control regimen. You were discharged to rehab for
aggressive physical therapy. Your pain control regimen may need
to be adjusted further while at rehab.
Brace: You have been given a brace. This brace is to be worn
when you are active. You may take it off when sitting in a
chair or while lying in bed.
Wound Care: Your surgical wounds will be managed at rehab. 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, you may bathe the area. Do
not soak the incision. If the incision starts draining at
anytime after surgery, do not get the incision wet. Cover it
with a sterile dressing.
Medications:
Several changes were made to your medications. Please see the
attached list.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27362**] in [**7-30**] days. You will need to
have another CT scan of your spine prior to that appointment.
You will need to see your primary care doctor after you are
discharged from rehab.
|
[
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"E849.8",
"403.10",
"720.0",
"278.01",
"285.1",
"285.29",
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] |
icd9cm
|
[
[
[]
]
] |
[
"87.21",
"81.04",
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"84.51",
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] |
icd9pcs
|
[
[
[]
]
] |
16029, 16099
|
9098, 9615
|
314, 360
|
16325, 16325
|
5211, 5211
|
17879, 18177
|
3063, 3157
|
14181, 16006
|
16120, 16205
|
13822, 14158
|
16501, 17364
|
3172, 5192
|
16226, 16304
|
13082, 13796
|
265, 276
|
9630, 12550
|
17376, 17856
|
388, 2370
|
5227, 9075
|
16340, 16477
|
12566, 13061
|
2392, 2877
|
2893, 3047
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,665
| 126,151
|
2746
|
Discharge summary
|
report
|
Admission Date: [**2131-3-20**] Discharge Date: [**2131-3-30**]
Date of Birth: [**2093-1-14**] Sex: F
Service: NEUROLOGY
Allergies:
Demerol / Ciprofloxacin / Bacitracin / Neosporin / Adhesive Tape
/ Latex / Optiray 300
Attending:[**First Name3 (LF) 13565**]
Chief Complaint:
Dystonia
Major Surgical or Invasive Procedure:
G-J tube replacement
History of Present Illness:
Mrs. [**Known lastname 13556**] is a 38 year old woman with longstanding dystonia
and autonomic dysfunction who develpoed a full body dystonic
reaction following IR guided replacement of her granulated G-J
tube on [**2130-3-20**]. At baseline she is wheelchair bound since [**2122**]
with severe dystonia of her lower extremities, but is able to
use her upper extremities to transfer by herself. She also has
laryngeal dystonia which has worsened over the past 6 months
causing her to speak in a whisper. She has the G-J for
gastroparesis which she uses for decompression and receives her
nutrition via TPN 5 days per week. She is also s/p pacemaker
placement for neurocardiogenic syncope and s/p urostomy for
bladder areflexia.
Prior to the G-J tube replacement on [**2131-3-20**] she was at her
baseline and received her daily doses of Artane and Baclofen and
was given midazolam by anesthesia (due to prior dystonic
reaction with propofol). Following the case she developed a
full body dystonic reaction and anesthesia felt she was not safe
to go home despite diazepam 10 mg x 2, diphenhydramine 50 mg x
2. She was initially admitted to medicine for observation and
spent the night in the MICU. In the MICU, she had one more
episode of dystonia, where she received 20mg IV valium and 50 mg
IV benadryl. Since she has been heavily sedated and hypotensive
with SBP in the 70s (baseline 80s). She was initially responding
to questions by blinking once for yest and twice for no, but
eventually began to whisper.
Neurology was consulted and she was transferred to the general
neurology service on [**2131-3-21**].
Review of systems is notable for chills, constipation, headaches
since last night, and intermittent lightneadedness. She denies
fevers, nausea, vomiting, or abdominal pain.
Past Medical History:
- dystonia involving mainly her lower extremities and
intermittently her arms, laryngeal dystonia worse over past 6
months; provoked exacerbations of the symptoms without a clear
direct inducer [seen by Dr. [**Last Name (STitle) 13551**] at [**Hospital1 2025**] and Dr. [**Last Name (STitle) 13552**] at
[**Hospital1 1774**]]
- dysautonomia with orthostasis, baseline SBP 80s-90s - followed
by Dr. [**First Name (STitle) **]
- neuro-cardiogenic syncope s/p pacer in [**12/2120**] (current
pacemaker detects low-BP and increases HR to 130 for 5min)
- Parkinsonism - occasional adventitious choreiform movements in
both upper extremities induced by action; takes Artane
- gastric dysmotility s/p g-tube placement and recently on TPN
- bladder areflexia s/p bladder stimulator implant and urostomy
- depression with h/o suicide attempt
- peripheral neuropathy
- chronic pupillary dilation
- s/p lap CCY
- Chronic anemia and intermittent low platelets
- EGD with gastritis ([**2127**])
- colonoscopy with friability ([**2122**])
Social History:
Lives with husband in [**Name (NI) **], Mass. ([**First Name8 (NamePattern2) 3613**] [**Known lastname 13556**]: cell
[**Telephone/Fax (1) 13557**], home [**Telephone/Fax (1) 13558**], work [**Telephone/Fax (1) 13566**]). Not
working, receives disability payments.
Family History:
Grandfather with frequent sycnope; 3 deceased paternal uncles
with [**Name (NI) 5895**] Disease. No family history of seizures or
strokes.
Physical Exam:
On admission:
Vital signs:
Afebrile; HR: 80 --> 130 x 5min (pacemaker setting for HR < 70,
per husband); BP: 82/60 (baseline SBP 80-90, per husband); RR:
[**9-25**]; SaO2 98% RA
General: Awake, NAD, frowning, eyes closed, face fixed in frown.
HEENT: Normocephalic and atraumatic. No scleral icterus. I
cannot open the mouth.
Neck: Stiff, turned to left. No carotid bruits appreciated. No
lymphadenopathy was appreciated.
Pulmonary: Lungs CTA bilaterally. Slow, non-labored breathing
(post-morphine, BDZ).
Cardiac: RRR, normal S1/S2, no M/R/G appreciated.
Abdomen: G-tube/dressing and ileostomy/bag. Mildly tender near
G-tube site. No BS appreciated. Soft, non-distended, +
normoactive bowel sounds.
Extremities: Warm and well-perfused, no clubbing, cyanosis, or
edema. 2+ radial, DP pulses bilaterally.
Neurologic examination:
Mental Status exam:
Patient responds to my questions with eyeblinks only -- one
blink
for yes; two for no. She answers appropriately, but does not
(?cannot) speak. She does not follow any commands that do not
involve simply answering with eye-blink.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL, 4 to 2.5mm and brisk.
III, IV, VI: Eyes are midposition, and when I ask her to move
them she looks up slightly, nothing else. +strong corneal/blink
reflexes.
V: +corneals. Pt. blinks "yes" to can you feel this the same (lt
touch)
VII: No apparent asymmetry.
VIII: Pt. blinks "yes" to can you hear this on L/R.
IX, X: cannot open mouth to assess
[**Doctor First Name 81**]: cannot assess
XII: cannot assess
-Motor:
Face fixed in a grimace/frown. Head/neck turned down and to the
left. Hypertonic x all four limbs. Hands are fisted and do not
relax. Feet are inverted with toes curled under, fixed. When I
try to relax toes or move/relax feet/legs, she kicks/flexes knee
back and forth (and flexes hip / elevates leg) a few times, but
not like typical clonus. When I try to test tone/spasticity of
hand, she kicks legs and arms/torso/neck lurch a bit. No
tremor/fasciculations. Normal muscle bulk.
-Sensory:
No gross deficit to light touch -- Pt (with eyes closed)
endorses me touching her feet/legs/hands/arms with appropriate
eye-blink.
-Reflex examination:
No clonus or hyperreflexia (already hypertonic); could not
really elicit any reflexes on either side, UE/LE. and toes were
stuck in contracted position.
-Coordination/Gait: could not assess
Neurologic exam at discharge: Patient can open left eye with
much strain, and is unable to open right eye, but when lid is
passively opened, both eyes are midline. Horizontal movements
intact, but patient intermittently refuses to gaze upward.
Patient speaks in a soft whisper and makes intermittent audible
groaning sounds. Tongue and facial muscles with full strength
and sensation, palate elevates symmetrically.
Lower extremities are flexed at hip joints and flexed at knee
joint. Feet are inverted with toes curled and fixed. When
attempting to passively move arms or legs she kicks and flexes
her lower extremities. No tremor/fasciculations. Normal muscle
bulk and tone. Right arm flexed at elbow and wrist and tone
increases when arm is touched.
Pertinent Results:
On admission:
[**2131-3-21**]:
CBC:
4.4 > 9.0 / 26.5 < 93
PT:14.5 PTT:33.0 INR:1.3
138 | 109 | 8 / 76
4.0 | 24 | 0.7 \
Ca:7.7 P:3.4 Mg:1.8
CK:375
ALT:19 AST:26 LDH:219 AP:110 TBili:0.3
On discharge:
ALT:24 AST:35 LDH:238 AP:112 TBili:0.4 Alb:3.9
CBC:
4.7 > 10.3 / 30.4 < 110
135 | 101 | 19 / 91
4.1 | 27 | 0.7 \
Ca:8.9 P:4.3 Mg:2.0
CK:175
[**2131-3-28**] 11:09AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.009
[**2131-3-28**] 11:09AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2131-3-28**] 11:09AM URINE RBC-2 WBC-101* Bacteri-MANY Yeast-RARE
Epi-0
[**2131-3-28**] 11:09AM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2131-3-30**] 05:19AM BLOOD WBC-3.4* RBC-3.14* Hgb-9.6* Hct-27.4*
MCV-87 MCH-30.7 MCHC-35.1* RDW-14.2 Plt Ct-86*
[**2131-3-29**] 03:04AM BLOOD WBC-5.6 RBC-3.09* Hgb-9.4* Hct-26.9*
MCV-87 MCH-30.5 MCHC-35.0 RDW-14.2 Plt Ct-100*
[**2131-3-30**] 05:19AM BLOOD Glucose-97 UreaN-20 Creat-0.7 Na-137
K-4.3 Cl-104 HCO3-27 AnGap-10
[**2131-3-29**] 11:23AM BLOOD CK(CPK)-342*
[**2131-3-29**] 03:04AM BLOOD CK(CPK)-143
[**2131-3-28**] 11:09AM BLOOD ALT-35 AST-46* LD(LDH)-239 CK(CPK)-113
AlkPhos-117* TotBili-0.3
[**2131-3-29**] 11:23AM BLOOD CK-MB-8 cTropnT-<0.01
[**2131-3-29**] 03:04AM BLOOD Calcium-8.6 Phos-4.2 Mg-1.9
[**2131-3-28**] 10:03AM BLOOD Type-ART pO2-307* pCO2-42 pH-7.40
calTCO2-27 Base XS-1
Brief Hospital Course:
Ms [**Known lastname 13556**] is a 38 year old female with longstanding
dystonia/autonomic syndrome of unknown etiology who presents
with an episode of post procedural dystonia, s/p high doses of
benadryl and valium.
Medical ICU course: Following the onset of dystonic reaction
after G-tube replacement, Ms. [**Known lastname 13556**] was transferred from the
PACU to the medical ICU. There, she was noted to have blood
pressures stable in the SBP 80s-100s and heart rate was 80 with
occasional episodes of paced tachycardia to 130 (pacemaker
programmed to respond to drop in heart rate to less than 70 by
pacing at 130 for 5 minutes). She was evaluated by the neurology
consult team and transferred onto the neurology service.
On the neurology service, no clear etiology for her symptoms of
dystonia was discovered. According to prior notes, she has
experienced post procedure dystonia in the past and would often
require prolonged hospital stays with large amounts of IV
morphine, benadryl, and valium. On initial examination she had
increased tone in all four extremities with flexion at hips,
knees, curled toes, flexion at the elbow, wrist and clenched
fists. She was also able to speak only in a soft whisper and
could not open her eyes despite normal movements of facial
muscles such as brow wrinkling, raising brows, orofacial
movements. She was continued on her home regimen of Baclofen
and Artand and adamantly requested high doses of IV morphine,
valium, benedryl as she felt this is the only way to break her
dystonia. She triggered multiple times while on the floor for
low blood pressure (has low BP at baseline) and for "marked
nursing concern" because as her heart rate drops, her pacer is
set to respond with tachycardia to 130 for 5 minutes. She was
unwilling to transition to PO or G-tube medications as she felt
the IV formulations worked better. Ultimately, her doses were
weaned given the recurrent questionable cardiovascular
depression. Over several days, her dystonia was moderately
improved from admission and she was able to move her left arm,
and slightly open her left eye.
# Code blue: On the day of her proposed discharge to the
rehabilitation facility, within an hour of discharge, a code
blue was called on Mrs. [**Known lastname 13556**]. She was found unresponsive and
tachycardic without clear pacer spikes, and ventricular
tachycardia was suspected at the time. Initially, a pulse was
not felt and she was having poor respiratory effort. Chest
compressions were started and a pulse was subsequently felt.
She was intubated due to the poor respiratory effort and
transferred to the intensive care unit. The ICU/code team noted
that she was fighting and grabbing as the tube was actually
inserted. ABG showed no evidence of hyercarbia. She was promptly
extubated and spent one night in the ICU before being
transferred back to the neurology service. She was discharged
to a rehabilitation facility the following day to further manage
her dystonia where her expected length of stay is less than 30
days. She should be progressively weaned off IV pain
medications and back onto her PO home regimen.
There is a strong belief that much of her presentation is
consistent with a psychodynamic process manifesting as
neurological complaints. Factitious disorder cannot be ruled
out as there are many elements of her neurologic presentation
that are inconsistent. We extensively counseled her on the
risks of sedative medications, particularly IV, given the
multiple episodes of bradycardia triggering her pacer.
# Nutrition: She is s/p G-tube placement. She is on TPN at home
since [**2122**] and uses her G-tube for decompression only, and takes
medications by mouth at home and food by mouth for pleasure. In
the hospital she was started TPN and outpatient TPN was set-up
by nutrion.
Autonomic dysfunction: She has neurocardiogenic syncope s/p
pacemaker placement which activates when her heart rate falls
below 70. It responds by increasing the HR to 130 for 5
minutes. She is on nadolol at home and was continued on her
home dose of 80 mg daily.
Urinary Tract Infection:
She was found to have a positive UA. URINE CULTURE (Final
[**2131-3-29**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION. She was placed on
Ceftriaxone for 2 days and switched over to cefpoxidime to
complete a 3 day course.
Medications on Admission:
1. baclofen 20mg tid
2. diazepam (Valium) 5mg tid PRN for anxiety
3. nadolol 80mg daily
4. omeprazole (Prilosec) 20mg [**Hospital1 **] PRN(?)
5. sertraline (Zoloft) 50mg daily
6. trihexyphenidyl (Artane) 3mg qAM / 3mg q1pm / 4mg qhs
Discharge Medications:
1. baclofen 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day).
2. nadolol 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
3. sertraline 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. trihexyphenidyl 2 mg Tablet [**Hospital1 **]: 0.5 Tablet PO QHS (once a
day (at bedtime)).
5. trihexyphenidyl 2 mg Tablet [**Hospital1 **]: 1.5 Tablets PO TID (3 times
a day).
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. DiphenhydrAMINE 25 mg IV Q4H:PRN anxiety/dystonia
8. Diazepam 5 mg IV Q6H:PRN pain
9. Morphine Sulfate 2-4 mg IV Q4H:PRN pain
10. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
11. cefpodoxime 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every
12 hours) for 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Primary diagnoses:
- Granulated G-J tube
- Full body dystonia (arms, legs, larynx, eyelids)
Secondary diagnoses:
- Autonomic dysfunction (s/p pacemaker, urostomy, G-J tube
- Depression
- Peripheral neuropathy
- Chronic anemia and intermittent low platelets
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic exam at discharge: Patient can open left eye with
much strain, and is unable to open right eye, but when lid is
passively opened, both eyes are midline. Horizontal movements
intact, but patient intermittently refuses to gaze upward.
Patient speaks in a soft whisper and makes intermittent audible
groaning sounds. Tongue and facial muscles with full strength
and sensation, palate elevates symmetrically.
Lower extremities are flexed at hip joints and flexed at knee
joint. Feet are inverted with toes curled and fixed. When
attempting to passively move arms or legs she kicks and flexes
her lower extremities. No tremor/fasciculations. Normal muscle
bulk and tone. Right arm flexed at elbow and wrist and tone
increases when arm is touched.
Discharge Instructions:
Dear Mrs. [**Known lastname 13556**]
You were admitted to the hospital because you developed a severe
full body dystonic reaction following surgery for replacement of
a G-J tube. You were initially admitted to the medical
intensive care unit and were eventually transferred to the
neurology service for management of your dystonia. Following the
surgery, you were having symptoms of dystonia in your legs,
arms, voice box, and eyelids. Your dystonia symptoms improved
over several days while you were in the hospital, and you were
able to speak in a whisper, open one eye, and move your arms.
You were transferred to a rehabilitation facility for further
management of your remaining dystonia symptoms.
Estimated length of stay less than 30 days.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2131-4-11**] 10:00
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 8914**] Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2131-4-16**] 10:00
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2131-7-23**] 11:15
Neurology with Dr. [**First Name (STitle) 951**]: If an appointment is needed sooner
please call.
Provider: [**Name Initial (NameIs) 1220**].[**First Name (STitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 13567**]
Date/Time:[**2131-5-11**] 4:00
Completed by:[**2131-3-30**]
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137
| 151,583
|
13802
|
Discharge summary
|
report
|
Admission Date: [**2191-11-10**] Discharge Date: [**2191-11-24**]
Date of Birth: [**2117-2-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Coumadin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2191-11-16**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to
Diag, SVG to OM)
History of Present Illness:
74 y/o male with 1 year of dyspnea on exertion which has been
worsening over the past couple of months. Underwent cardiac cath
at OSH which revealed 50% LMCA and 3 vessel disease. He was then
tranasferred to [**Hospital1 18**] for surgical intervention.
Past Medical History:
Cornary Artery Disease s/p PTCA/stent [**82**], Atrial Fibrillation,
Hyperthyroidism, Diabetes Mellitus, Hyperchoelsterolemia, s/p
hernia repair, eczema, neuropathy, ?TIA
Social History:
Retired. Quit smoking after 12yrs x 1ppd. Denies ETOH.
Family History:
Non-contributory
Physical Exam:
General: NAD
Skin: Bilat. soles with eczema. Neck with 1" scar secondary to
cyst removal
Lungs: CTAB -w/r/r
Heart: Irreg. rate and rhythm -murmur
Abd: Soft, NT/ND, +BS
Ext: Brown discoloration b/l LE, -varicosities
Neuro: Non-focal, MAE, A&O x 3
Pertinent Results:
Vein Mapping [**11-11**]: Duplex evaluation was performed of bilateral
lower extremity veins. Greater saphenous vein is patent
bilaterally from the groin to the ankle. On the right, vein
diameters range from .24-.46 cm. On the left, vein diameters
range from .20-.5 cm to .62 cm.
Echo [**11-16**]: PRE-BYPASS: Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). Right
ventricular systolic function is normal. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. Mild(1+) mitral
regurgitation is seen. There is no mitral valve prolapse. The
left atrium is normal in size. No atrial septal defect is seen
by 2D or color Doppler. There are simple atheroma in the
descending thoracic aorta. No thoracic aortic dissection is
seen. POST-BYPASS: Preserved [**Hospital1 **]-ventricular systolic function.
No evidence of aortic dissection post decannulation. The mitral
regurgitation may have been slightly improved. CXR [**11-22**]:
[**2191-11-10**] 04:44PM BLOOD WBC-9.5 RBC-4.32* Hgb-12.8* Hct-36.7*
MCV-85 MCH-29.7 MCHC-35.0 RDW-14.8 Plt Ct-250
[**2191-11-18**] 01:57AM BLOOD WBC-17.4*# RBC-3.77* Hgb-10.7* Hct-32.6*
MCV-86 MCH-28.4 MCHC-32.9 RDW-15.3 Plt Ct-205
[**2191-11-21**] 02:44AM BLOOD WBC-13.6* RBC-3.53* Hgb-10.5* Hct-30.0*
MCV-85 MCH-29.8 MCHC-35.0 RDW-15.3 Plt Ct-363
[**2191-11-10**] 04:44PM BLOOD PT-12.2 PTT-24.7 INR(PT)-1.0
[**2191-11-22**] 06:45AM BLOOD PT-16.1* PTT-28.4 INR(PT)-1.5*
[**2191-11-10**] 04:44PM BLOOD Glucose-349* UreaN-13 Creat-1.1 Na-133
K-5.1 Cl-96 HCO3-29 AnGap-13
[**2191-11-22**] 06:45AM BLOOD Glucose-114* UreaN-34* Creat-1.4* Na-137
K-4.6 Cl-97 HCO3-29 AnGap-16
[**2191-11-22**] 06:45AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.4
[**2191-11-11**] 05:09PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 41483**] was transferred from OSH to
[**Hospital1 18**] for surgical care. Upon admission he underwent all
pre-operative work-up, including vein mapping and carotid
ultrasound. He remained medically managed, including Heparin
gtt, for several days awaiting Plavix load from cardiac cath to
washout. On [**11-16**] he was brought to the operating room where he
underwent a coronary artery bypass graft x 3. Please see
operative report for surgical details. He tolerated the
procedure well and was transferred to the CSRU for invasive
monitoring in stable condition. He remained intubated until
post-op day one, when he was weaned from sedation, awoke
neurologically intact and was extubated. On this day attempted
cardioversion was performed d/t atrial fibrillation and was then
paced at 90. But later he then converted back to AFIB. Of note,
he was in Afib prior to surgery d/t hyperthyroidism. On post-op
day two beta blockers and diuretics were started. He was gently
diuresed towards his pre-op weight. Chest tubes were removed and
he was transferred to the SDU on post-op day two. Although later
on this day he was transferred back to the CSRU d/t respiratory
distress for aggressive pulmonary toileting. On post-op day five
his epicardial pacing wires were removed and he was started on
Coumadin for AFib. On post-op day six he was transferred to the
SDU for continued post-op care. Physical therapy followed
patient during entire post-op course for strength and mobility.
He was discharged home on post-op day 9 with VNA and the
appropriate follow-up appointments. First blood draw tomorrow
[**11-26**] with results to be called to Dr. [**Last Name (STitle) **].
Medications on Admission:
Lisinopril, Plavix, Aspirin, Atenolol, Tapazole, Glucophage,
Lipitor, Humalog, Amitryptiline, Cymbalta
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*1*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*1*
5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*1*
6. Methimazole 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*1*
7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*1*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*1*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
10 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
12. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
13. Humalog 75/25
58 Units QAM
42 Units QPM
as prior to surgery
[**99**]. Coumadin 1 mg Tablet Sig: 0.5 Tablet PO once a day for 2
days: No coumadin tonight, [**11-24**], check INR [**11-26**].
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Cornary Artery Disease s/p Coronary Artery Bypass Graft x 3
PMH: s/p PTCA/stent [**82**], Atrial Fibrillation, Hyperthyroidism,
Diabetes Mellitus, Hyperchoelsterolemia, s/p hernia repair,
eczema, neuropathy, ?TIA
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] take shower. Wash incisions and pat dry. Do not take bath.
Do not apply lotions, creams or ointments to incisions
Do not drive for 1 month.
Do not lift more than 10 pounds for 2 months.
If you develop a fever, notice redness or drainage from
incision, please contact office immediately.
Call to schedule all follow-up appointments.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**3-11**] weeks
Dr. [**First Name (STitle) **] on Monday [**12-5**] at 10:15 AM
Completed by:[**2191-11-24**]
|
[
"V15.82",
"518.5",
"V45.82",
"272.0",
"414.01",
"357.2",
"600.00",
"242.90",
"250.60",
"427.31",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"99.61",
"99.04",
"36.15",
"89.60"
] |
icd9pcs
|
[
[
[]
]
] |
6789, 6844
|
3180, 4897
|
311, 400
|
7100, 7106
|
1264, 3157
|
7510, 7719
|
965, 983
|
5050, 6766
|
6865, 7079
|
4923, 5027
|
7130, 7487
|
998, 1245
|
252, 273
|
428, 683
|
705, 877
|
893, 949
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,900
| 154,879
|
7870+7871
|
Discharge summary
|
report+report
|
Admission Date: [**2199-3-10**] Discharge Date: [**2199-3-21**]
Date of Birth: [**2140-12-29**] Sex: M
Service: Vascular
CHIEF COMPLAINT: Gangrenous ulcers of the heels.
HISTORY OF PRESENT ILLNESS: This is a 58-year-old white male
with known coronary artery disease status post angioplasty
with stent placement of coronary artery in [**Month (only) 404**] of this
year for unstable angina. The patient has a history of
chronic atrial fibrillation/flutter. He is status post
ablation in [**Month (only) 404**] of this year secondary to bradycardia
with hypotension requiring an automatic implantable
cardioverter-defibrillator. Following ablation the hospital
course was complicated with congestive failure. The patient
also has a history of diabetes mellitus, pulmonary fibrosis,
gouty arthritis, sleep apnea, and depression. He was
hospitalized in our institution on Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
service for his cardiac problems from [**2199-1-20**] to
[**2199-2-13**]. During the admission Dr. [**Last Name (STitle) **] was
consulted regarding the patient's bilateral heel ulcerations.
An arteriogram was performed on [**2199-2-8**]. The patient
returns from rehabilitation now for elective
revascularization. The patient denies prior claudication or
rest pain.
ALLERGIES: CT intravenous contrast dye causes acute renal
failure. Verapamil causes hypersensitivity vasculitis.
PAST MEDICAL HISTORY: 1. Coronary artery disease status post
angioplasty with stent placement to left circumflex coronary
artery on [**2199-2-1**], placed on Plavix x 1 month. 2. Atrial
fibrillation/atrial flutter, ablation [**2199-2-4**]. He is on
Coumadin and amiodarone. 3. History of congestive heart
failure. 4. History of bradycardia and hypotension post
ablation on [**2199-2-4**]. 5. Implantable
cardioverter-defibrillator placed on [**2199-2-5**]. 6. History of
diabetes mellitus since age 30 with triopathy. 7. History of
gouty arthritis, recent treatment with colchicine. 8.
History of depression, stable. 9. Marked obesity. 10.
Recent weight loss of 50 pounds. 11. Obstructive sleep
apnea, some BiPAP at bedtime. 12. Pulmonary fibrosis by
biopsy in [**2198-1-23**]. 13. History of peripheral
vascular disease.
PAST SURGICAL HISTORY: 1. Bilateral cataract extractions
with lens implantation. 2. Bilateral laser therapy. 3. Lung
biopsy. 4. Mediastinoscopy for diagnosis of pulmonary
fibrosis.
MEDICATIONS ON TRANSFER: 1. Coumadin, which was discontinued
on [**2198-3-8**]. 2. Amiodarone 200 mg b.i.d. through [**2199-3-17**]
and then 200 mg q. day. 3. Carvedilol 12.5 mg b.i.d. 4.
Zestril 5 mg at h.s. 5. Zocor 20 mg q.d. 6. Celexa 10 mg
q.d. 7. Colace 100 mg b.i.d. 8. Motrin 400 mg q. 6 hours
p.r.n. for neck pain. 9. NPH Insulin 18 units q.a.m. with 5
units of R q.a.m. and q. supper.
SOCIAL HISTORY: The patient is a tile installer. He has a
history of asbestos exposure. He has had transfusions in the
past. He is a former smoker. He has not smoked for eight
years. He used to be a pack-per-day smoker x 20 years. He
denies alcohol use. He lives alone, is currently at [**Hospital3 7558**], ambulate with physical therapy.
REVIEW OF SYSTEMS: Positive for left knee swelling which was
tapped by the rheumatology service. Right hand second and
third metacarpal pain, erythema and redness treated with
colchicine with improvement.
PHYSICAL EXAMINATION: Vital signs showed a temperature of
97.6, pulse 80, respiratory rate 20, blood pressure 150/80.
General appearance was of an alert and cooperative white male
in no acute distress. HEENT: Tongue was midline, oropharynx
was clear. Carotids were palpable without bruits. Radial
pulses were palpable bilaterally, 2+. Femoral pulses were
nonpalpable secondary to body habitus. Popliteals were 1+
bilaterally. The dorsalis pedis and posterior tibial pulses
were Doppler signals bilaterally. Chest: Median sternotomy
incision was well healed. Right anterior thoracotomy
incision was well healed. Automatic implantable
cardioverter-defibrillator in the supraclavicular area.
Lungs: Clear to auscultation. Heart: Regular rate and
rhythm without murmurs. Abdomen: Obese and nontender with
bowel sounds present. Bone/joint examination: Feet equally
warm. There was no rubar of the forefoot. There was a large
black eschar of both heels, about 8 cm in diameter, positive
odor. There was a small opening on the posterior right heel
with purulent drainage. The left foot had a Charcot
deformity of the foot and ankle. The left heel was without
drainage or fluctuance. Satellite plantar ulcers were clean.
HOSPITAL COURSE: The patient was continued on preadmission
medications, intravenous antibiotics and Zosyn were begun.
Heparin at 900 units was begun for his history of atrial
fibrillation. Routine laboratory studies were obtained.
Complete blood count was white count 9.7, hematocrit 25.9,
INR 1.6, PTT 34.3, BUN 41, creatinine 2.0, K 4.4.
EKG showed a wide QRS rhythm with effusion complexes, left
atrial deviation, right bundle branch block, inferior infarct
age undetermined, possible anterolateral infarct age
undetermined.
Chest x-ray showed a chronic right lower lobe process.
Cardiology was requested to see the patient for perioperative
risk assessment. They felt the Plavix should be discontinued
since the patient is four weeks post stent placement; would
continue carvedilol and continue perioperative beta blockers.
Other recommendations were EPS should evaluate the appliance
to make sure it is sensing and functioning properly. The
patient did not require any further cardiac evaluation and
was cleared for any anticipated revascularization. He did
receive two units of packed red blood cells prior to surgery
for his hematocrit of 25.
On [**2199-3-12**] he underwent a right akinesis popliteal to DP
with nonreversed greater saphenous vein, angioscopy and valve
lysis. He required four units of packed red blood cells
intraoperatively. He was stable with a palpable graft pulse
at the end of the case with a biphasic dorsalis pedis pulse.
He was transferred to the recovery room for continued
monitoring and care. His postoperative hematocrit was 29.9.
Creatinine remained stable at 2.0. Blood gases were 7.34,
36, 222, 20 and -5. He was extubated in the postanesthesia
care unit. He continued monitoring and was transferred to
the vascular intensive care unit. He did require some
Neo-Synephrine for hypotension and maintained a systolic
pressure greater than 127.
Medicine was consulted to follow the patient during his
hospitalization. No new recommendations were made.
On postoperative day one the patient continued to require
Neo-Synephrine at 0.5 mcg per kg per minute. His hematocrit
was 28.2. CK was 21, troponin was less than 0.3, PB for
serial MBs of 1.6. Aggressive pulmonary toilet was
continued. His diet was advanced as tolerated. His fluids
were heparin locked. He remained in the vascular intensive
care unit for continued monitoring and care. He required an
additional two units of packed red blood cells for his drop
in his hematocrit on postoperative day one to 26.
Podiatry was consulted with recommendations to follow foot
wound. X-rays were obtained. There was evidence of
neuropathic changes involving the bilateral ankles, left
greater than right with no evidence of osteomyelitis.
The patient continued on his amiodarone. He was weaned off
his Neo-Synephrine on postoperative day two. Zosyn was
continued. There was no significant change in his physical
examination. He had a palpable graft pulse. He was
converted to oral beta blockers and continued his ACE
inhibitor. Monitoring was continued. He was tolerating his
diet. Cardiology recommended that the PA line be
discontinued as we no longer required it for hemodynamic
monitoring, so that the patient's EPS leads would not be
displaced.
After an additional two units of packed cells on
postoperative day number two, the patient's post-transfusion
hematocrit remained at 26.7. DIC parameters were obtained.
There was no evidence of DIC by examination. They felt there
was anemia of chronic origin. The patient was at baseline
but should maintain his hematocrit greater than 30 due to his
coronary artery disease.
On [**2199-3-16**] at bedside the patient had sharp excisional
debridement and rongeuring of the necrotic and fibrotic
tissue on the right foot. He tolerated the procedure well.
Santyl dressings were begun.
The patient showed slow clinical improvement. He was
transferred to the regular nursing floor on postoperative day
number five. His Lasix was decreased to 90 mg q. day.
Antibiotics were continued during hospitalization and then
discontinued. He is on Zosyn and vancomycin. He is on no
drops at the time of transfer. His hematocrit was stable at
27.4, BUN 34, creatinine 2.2, K 4.3 which is stable. INR was
1.2.
The patient was seen by physical therapy for inpatient
physical therapy that would be required prior to patient
being discharged to home.
A second excision and debridement was done at the bedside on
[**2199-3-17**] by the podiatry service of the right heel. Santyl
dressings were continued and Multi Podus splints were
recommended while the patient is in bed.
The patient underwent interrogation of his implantable
cardioverter-defibrillator the patient's AICD on the R wave
was [**3-27**], P wave was 1.5. AP threshold was 1.5 at 0.5. VP
threshold was 1.5 at 0.4. A plus B impedance was 4005.
Fluoroscopy of the leads revealed unchanged position. AICD
testing was performed. The pacer successfully detected
arrhythmias and treated. Recommendations were to continue
amiodarone and coumadinization should be continued. The
patient should follow up in the [**Hospital 3941**] clinic in two months.
Their number is [**Telephone/Fax (1) **].
The remainder of the hospital course was unremarkable. The
patient was discharged to rehabilitation in stable condition.
The wounds were clean, dry and intact with a functioning
graft pulse.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg q.d.
2. Carvedilol 12.5 mg b.i.d.
3. Simvastatin 20 mg q.d.
4. Citalopram hydrobromide 10 mg q.d.
5. Dulcolax psyllium 100 mg b.i.d.
6. Acetaminophen 500-1,000 mg q. 6 hours p.r.n.
7. Benadryl 25 mg q. 6 hours p.r.n. used as antihistamine.
8. Aspirin 325 mg q. day.
9. Lisinopril 5 mg at h.s.
10. Protonix 40 mg q.d.
11. Aluminum magnesium hydroxide 15-30 cc q.i.d. p.r.n.
12. Santyl dressings to heel ulcers bilaterally b.i.d. This
should be Santyl normal saline dressing and then dry
dressing.
13. Ambien 10 mg at h.s. p.r.n.
14. Percocet tablets [**1-24**] q. 4-6 hours p.r.n.
15. Insulin fixed dosing and sliding scale, please see flow
sheet.
16. Warfarin to maintain INR goal between 2.0 to 3.0.
17. NPH Insulin 18 units with 5 units of Regular at
breakfast, and 18 units with 5 units of Regular at dinner
time.
18. Insulin sliding scale was a.c. and at h.s. as follows:
Regular insulin, less than 200 no insulin; 201-250 two units;
251-300 four units; 301-350 six units; 351-400 eight units;
greater than 400 ten units.
DISCHARGE INSTRUCTIONS: Wound care includes a dry sterile
dressing to the left leg area q.d. Heel dressings are Santyl
b.i.d. with wet-to-dry gauze. The patient should be on a
BiPAP at h.s. for his obstructive sleep apnea. Ambulation:
The patient is to continue with Multi Podus splints
bilaterally while in bed and healing sandals when ambulating.
He should be nonweight bearing on the heels bilaterally.
FOLLOW UP: The patient should follow up with Dr. [**Last Name (STitle) **] in
two weeks from discharge; at the same time he should follow
up with the podiatry service. He should follow up with EPS
in two months, to call for an appointment at that time at
[**Telephone/Fax (1) **].
DISCHARGE DIAGNOSES:
1. Bilateral ischemic heel ulcerations status post right
above the knee popliteal to dorsalis pedis bypass with
nonreversed greater saphenous vein, angioscopy and valve
lysis on [**2199-3-12**].
2. Bilateral ischemic dry gangrene of heel ulcer status post
excisional debridement at the bedside.
3. Bilateral Charcot joint changes of the ankles and left
foot.
4. Coronary artery disease, stable.
5. Chronic atrial fibrillation anticoagulated.
6. History of ventricular tachycardia with implantable
cardioverter-defibrillator placed status post interrogation.
7. Blood loss anemia corrected.
8. Depression, stable.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. 2914
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2199-3-19**] 11:50
T: [**2199-3-19**] 12:00
JOB#: [**Job Number 28341**]
Admission Date: [**2199-3-10**] Discharge Date: [**2199-3-31**]
Date of Birth: [**2140-12-29**] Sex: M
Service: VASCULAR
ADDENDUM: The initial discharge summary was dictated on
[**2199-3-19**]. This is an addendum from [**2199-3-19**] to [**2199-4-1**].
HOSPITAL COURSE: The patient underwent a duplex of the graft
which showed no stenosis and the graft was patent. He
continued to be followed by the medical service for his
multiple medical problems which include gouty arthritis,
chronic congestive failure. We are also awaiting final
recommendations of Podiatry and Plastics regarding right
calcanectomy and flap procedure.
The patient's gout improved with low-dose colchicine instead
of using steroids which would interfere with any wound
healing.
Dr. [**Last Name (STitle) **] was requested to see the patient. The patient is
part of the program Advanced Cardiac Failure Program. Their
recommendations were to help diminish peripheral vascular
edema. He had severe dilated cardiomyopathy secondary to
coronary artery disease, hypertension, and diabetes with
systolic dysfunction and ejection fraction less than 20%. He
has no overt signs of fluid overload. His JVD is 8 cm at 30
degrees and he has 1+ pitting edema. Recommendations were
daily weights and restrict sodium in diet to 2 grams per 24
hours as well as a 2 liter fluid restriction over 24 hours.
Their recommendation was also to discontinue the
nonsteroidals secondary to renal function and cardiac
dysfunction.
It was noted while awaiting final decision on surgical date,
that the patient's hematocrit drifted to 22. He required 2
units of packed red cell transfusion with the onset of acute
right leg pain and swelling of his leg. The patient
continued to require multiple transfusions with serial
hematocrits.
On [**2199-3-25**], he went to the Vascular Lab. His right
[**Doctor Last Name **]-pedal graft was patent. There was no pseudoaneurysm
noted either in the proximal or distal anastomosis. The
patient received another 2 units of packed red blood cells
with Lasix between. Heparin was held. His hematocrit
finally stabilized at 26.8 on [**2199-3-27**]. A CT demonstrated no
retroperitoneal bleeding but a hematoma in the AK [**Doctor Last Name **] space.
Serial hematocrits were continued to be monitored and the
patient was prepared for surgery.
He underwent a right thigh hematoma evacuation on [**2199-3-28**].
He require 1 unit of packed red blood cells intraoperatively.
The findings showed a large deep space thrombus evacuated
oozing of the great saphenous vein tunnel. This was
cauterized. The bleeding was controlled. The wound was
closed.
The patient was transferred to the PACU in stable condition.
His hematocrit was 29.6. He continued to do well and was
transferred to the VICU for continued monitoring and care.
EPS was requested to see the patient and re-interrogate his
pacer after a Swan-Ganz had been placed. This was on
[**2199-3-28**]. This was interrogated.
On [**2199-3-29**], the patient's Swan-Ganz was removed under
fluoroscopy without incident. His hematocrit remained stable
at 27.5. Ambulation was begun on [**2199-3-30**]. The Foley was
discontinued. The second JP drain was removed. The patient
was transferred to the regular nursing floor for continued
care.
He was seen by Physical Therapy who felt that he would
require discharge to rehabilitation prior to returning home.
The patient remained strict nonweightbearing on the affected
right foot. Silvadene was applied to the skin areas b.i.d.
The patient will continue on his antibiotics two weeks
postdischarge and then be seen by Plastics, Dr. [**Last Name (STitle) **], and
Podiatry before planning Podiatry Plastic procedure.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg b.i.d.
2. Carvedilol 12.5 mg b.i.d.
3. Simvastatin 20 mg q.d.
4. .................... hydrobromide 10 mg q.d.
5. Colace 100 mg b.i.d.
6. Acetaminophen 500 mg one to two tablets q. six hours
p.r.n. pain.
7. Benadryl 25 mg q. six hours p.r.n.
8. Aspirin/calcium carbonate/magnesium hydroxide 325 mg
tablet one q.d.
9. Lisinopril 5 mg at h.s.
10. Protonix 40 mg q.d.
11. Magnesium hydroxide/aluminum hydroxide 200-225/5 cc oral
suspension 15-30 cc q.i.d. p.r.n.
12. Collagenase ointment to affected area b.i.d.
13. Zyloprim 5 mg one to two tablets h.s.
14. Percocet tablets 5/325 one to two q. 4-6 hours p.r.n.
pain.
15. Warfarin 5 mg at h.s., goal INR 2.0 to 3.0.
16. Lasix 40 mg q.d.
17. Ferrous sulfate 325 mg q.d.
18. Ascorbic acid 500 mg b.i.d.
19. Insulin fixed and sliding scales.
20. Lovenox 250 mg q. 24 hours.
21. Silvadene cream 1% b.i.d. to purple areas along the
middle of the thigh incision after saline rinse b.i.d.
22. Lasix dose changed to 20 mg q.d.
DISCHARGE DIAGNOSIS: Right thigh hematoma, status post
evacuation.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. 2914
Dictated By:[**Last Name (NamePattern1) 22071**]
MEDQUIST36
D: [**2199-3-31**] 06:44
T: [**2199-3-31**] 19:07
JOB#: [**Job Number 28342**]
|
[
"427.31",
"428.0",
"428.20",
"998.12",
"285.1",
"250.70",
"707.14",
"515",
"785.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.22",
"39.29",
"86.22",
"86.04",
"38.93",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
11884, 13032
|
16529, 17525
|
17547, 17849
|
13050, 16506
|
11193, 11579
|
2315, 2477
|
11591, 11863
|
3462, 4677
|
3251, 3439
|
160, 193
|
222, 1454
|
2503, 2882
|
1477, 2291
|
2899, 3231
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,041
| 183,336
|
10811
|
Discharge summary
|
report
|
Admission Date: [**2178-3-2**] Discharge Date: [**2178-3-10**]
Date of Birth: [**2135-5-5**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Ovarian Cancer
Major Surgical or Invasive Procedure:
[**2178-3-3**]: Exploratory laparotomy and biopsy of multiple
retroperitoneal nodules; takedown splenic flexure;
mobilization of both right and left lobes of the liver.
History of Present Illness:
42y.o. F with metastatic ovarian cancer (grade 3 papillary
serous carcinoma involving both ovaries). She underwent
laparotomy by Dr. [**First Name (STitle) 1022**] on [**2177-11-4**] for TAH/BSO, resection of a
pelvic mass, rectal resection with end sigmoid colostomy as well
as ileocecectomy. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was present during
this surgery noting involvement of metastases to the liver and
diaphragm. There was one large liver lesion in the segment
VII-VI
area and second one in the left lobe of the liver. There was
significant abdominal carcinomatosis and multiple nodules on
both
hemidiaphragms. Hemidiaphragms with bulky tumor measured up to
3-4 cm. The tumor along the right hemidiaphragmwas noted to be
densely adherent to the liver capsule. Dr. [**First Name (STitle) **] was consulted
and
the plan is for her to undergo a possible diaphragmatic
resection and reconstruction.
Past Medical History:
PMH: Brain aneurysm, nephrolithiasis
PSH: Coiling of brain aneurysm in [**2170**], lithotripsy [**2173**]
OB HISTORY: Vaginal delivery x1.
GYN HISTORY: Last Pap smear and mammogram were both recently
normal.
BRCA gene positive
Social History:
The patient does not smoke or drink. She is an accountant.
Family History:
Significant for mother with liver cancer (?Primary).
Physical Exam:
VS: 96.5 62 110/77 18 100% RA WT 77 Kg, Heigth: 5'5"
GENERAL: A&O, appears well. Pale, NAD. wearing scarf on head for
loss of hair from chemo
HEENT: per, mmm, pharynx wnl.
Neck: no lad, no TM, 2+ Carotids, no bruits
Lungs: clear, decreased RLL
COR: RRR, no murmurs.
ABD: soft, nontender, well-healed abdominal incisions with a
left
lower quadrant colostomy.
NEUROLOGIC: Grossly nl. A&O
SKIN: R inner calf with birth mark, no rashes
EXT: no CCE, 2+ DPs
Pertinent Results:
On Admission: [**2178-3-2**]
WBC-2.7*# RBC-3.78* Hgb-11.1* Hct-31.9* MCV-85 MCH-29.5#
MCHC-34.9# RDW-19.5* Plt Ct-173#
PT-12.8 PTT-25.9 INR(PT)-1.1
Glucose-108* UreaN-10 Creat-0.8 Na-144 K-3.4 Cl-104 HCO3-29
AnGap-14
ALT-46* AST-27 AlkPhos-51 TotBili-0.3
[**2178-3-10**] 05:35AM BLOOD WBC-7.1 RBC-3.28* Hgb-9.6* Hct-28.5*
MCV-87 MCH-29.3 MCHC-33.8 RDW-17.9* Plt Ct-229
[**2178-3-10**] 05:35AM BLOOD Glucose-102 UreaN-11 Creat-0.6 Na-137
K-3.6 Cl-98 HCO3-27 AnGap-16
[**2178-3-10**] 05:35AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.5*
Brief Hospital Course:
42 y/o female who is admitted a day prior to surgery for
conversion to heparin drip, is on lovenox at home.
She was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. PLease see the
operative note for full detail. In summary; There was no
evidence of a pelvic recurrence. The lesion in the
retroperitoneum seen on CT scan was sent for frozen section and
did not demonstrate evidence of malignancy. No lesions found
between the spleen and kidney. Multiple other nodules were found
throughout the abdomen, including 1 on the colon
which was taken down and completely excised. There was a small
serosal tear which was sutured. Colonic implants came back as
consistent with metastatic ovarian CA. There were no
diaphragmatic lesions and intra-op U/S did not show any evidence
of lesions within the liver. She was extubated and transferred
to the PACU in stable condition.
In the post op period she did have some pain issues. She was
using a dilaudid PCA which was uptitrated for better relief, she
also received a single Toradol dose.
On POD 4 she developed a fever to 101.4 (febrile neutropenia).
Vanco and Cefepime were started at this time and she received
one dose of Filgrastim. One blood culture came back as positive
for Staph Coag Negative. After 5 days of Vanco and 3 days of
Cefepime IV she was started on a 10 day course of Cefpodoxime
per ID recommendaions.
Blood cultures remain pending from the 13th and 14th. All other
blood cultures and the urine culture were negative.
She was restarted on Lovenox on POD 2, which will be continued
as an outpatient
She had no further issues with fever, however on POD7 she
complained of difficulty breathing and bilateral flank pain. The
chest xray indicated persistent atelectasis and elevated right
hemidiaphragm. No acute changes on EKG. The pain eventually
resolvedwithout further intervention.
JP drain removed on POD 2, ostomy started with output on POD 3.
She was tolerating diet and ambulating.
She will be following up with her oncologist later this week to
evaluate plan of care.
Medications on Admission:
Lovenox 100mg qd. Zofran prn (used during chemo). Decadron
(off now. was used during chemo)
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q 24H
(Every 24 Hours).
2. Cefpodoxime 100 mg Tablet Sig: Four (4) Tablet PO Q12H (every
12 hours) for 9 days.
Disp:*72 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Metastatic Ovarian CA
Discharge Condition:
Stable/good
Discharge Instructions:
Please call Dr [**First Name (STitle) **] for fever > 101, chills, nausea,
vomiting, profuse diarrhea, inability to take or keep down food,
fluids or medications.
Monitor the incision for redness, drainage or bleeding
You may shower, allow water to run over incision, pat dry and
leave incision open to the air. No tub baths
Staples will be removed at your next office visit with Dr
[**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] not drive or make important decisions while taking narcotic
pain medications
No heavy lifting (10 pound maximum)
Ostomy care per routine
Followup Instructions:
[**First Name5 (NamePattern1) 717**] [**Last Name (NamePattern1) 35281**] (Dr [**Last Name (STitle) 35282**] NP) [**2178-3-13**]: 11:00 AM [**Location (un) 24**] [**Hospital 10596**]: [**Telephone/Fax (1) 35283**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2178-3-19**] 1:40
Ostomy Care at home with [**Company 1519**]
Completed by:[**2178-3-11**]
|
[
"V12.51",
"197.6",
"198.89",
"V10.43",
"E878.8",
"780.60",
"998.59",
"997.4",
"V87.41",
"197.5",
"486",
"197.7",
"560.1",
"997.39",
"V44.3",
"V45.72",
"790.7",
"512.1",
"V88.01",
"288.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.41",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
5585, 5634
|
2913, 4991
|
326, 497
|
5700, 5714
|
2364, 2364
|
6348, 6779
|
1813, 1867
|
5134, 5562
|
5655, 5679
|
5017, 5111
|
5738, 6325
|
1882, 2345
|
272, 288
|
525, 1468
|
2378, 2890
|
1490, 1719
|
1735, 1797
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,790
| 138,635
|
12735
|
Discharge summary
|
report
|
Admission Date: [**2125-6-11**] Discharge Date: [**2125-6-22**]
Date of Birth: [**2057-7-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Cardiac Arrest
Major Surgical or Invasive Procedure:
Pulmonary Intubation
Placement of internal Cardiac Defibrillator
Ventricular Tachycardia Ablation
Cardiac catheterization
History of Present Illness:
Mr. [**Known lastname 39287**] is a 67 year old man with a history of CVA, CAD,
with known total LCx disease s/p cardiac catherization with
unsuccessful revascularization of the LCx in [**2123**], who
presetnted to [**Hospital3 4107**] after being found collapsed on the
ground near his lawn mower. CPR was started in the field by a
witness, and the patient was shocked once from an AED. When EMS
arrived, the patient was found to have a weak pulse. Shortly
after EMS arrival the patient went back into VFib, and again was
defibrillated. The patient was given 150mg of Amiodarone and
again went into VFib and recieved a 3rd shock. The patient then
regained a pulse and was noted to be in VTach, and eventually
recieved a total of 300mg Amiodarone. GCS during this time was
noted to be 3. The patient was brought to [**Hospital3 4107**] ED
and V/S at that time were: T-95.6, BP 92/66, R-26, P-72, O2 100%
on Mechanical Vent. Records from [**Hospital3 4107**] indicate the
patient continued to recieve CPR while in the ED, and a 12-lead
EKG showed ST elevation in leads III, aVF and ST depression in
leads II, V4-V6. Given these EKG changes and the possibility of
active ischemia, it was then arranged for the patient to be
transferred to [**Hospital1 18**] for elective cardiac catherization.
.
Notably, per wife and daughter patient has had reduced exercise
and exertional capacity since his MI in [**2123**]. Recently, he had
decreased exercise tolerance with DOE when ambulating short
distances, though orthopnea, PND or lower extremity edema.
.
On review of systems, wife denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Wife denies recent fevers, chills or
rigors. Wife denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: angioplasty [**2109**]
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- MI and vfib arrest, [**2123**], c. cath showed totally occluded L cx
that unable to intervene
- H/O TIA
Social History:
-Tobacco history:40 pack year hx, quit [**2108**]
-ETOH:none for 25 yrs
-Illicit drugs: none
Family History:
Mother: esophageal ca
Father: CAD
Physical Exam:
GENERAL: WDWN caucasian male in NAD
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva arepink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple, JVP flat
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: CTAB
ABDOMEN: + BS Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: 2+ carotid 2+ DP 2+ PT 2+
Left: 2+ carotid 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2125-6-18**] 07:05AM BLOOD WBC-6.6 RBC-4.02* Hgb-12.7* Hct-36.7*
MCV-91 MCH-31.6 MCHC-34.6 RDW-14.1 Plt Ct-262
[**2125-6-18**] 07:05AM BLOOD Plt Ct-262
[**2125-6-18**] 07:05AM BLOOD PT-14.0* PTT-95.8* INR(PT)-1.2*
[**2125-6-18**] 07:05AM BLOOD Glucose-151* UreaN-22* Creat-0.9 Na-138
K-3.9 Cl-99 HCO3-31 AnGap-12
[**2125-6-18**] 07:05AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.0
[**2125-6-22**] 07:00AM BLOOD WBC-9.3 RBC-3.47* Hgb-11.5* Hct-32.3*
MCV-93 MCH-33.1* MCHC-35.6* RDW-14.5 Plt Ct-253
[**2125-6-17**] 05:20AM BLOOD Neuts-60.1 Lymphs-27.8 Monos-7.4 Eos-4.4*
Baso-0.4
[**2125-6-22**] 07:00AM BLOOD PT-14.0* INR(PT)-1.2*
[**2125-6-22**] 07:00AM BLOOD Glucose-131* UreaN-23* Creat-0.8 Na-138
K-4.0 Cl-99 HCO3-27 AnGap-16
[**2125-6-21**] 03:50AM BLOOD Glucose-138* UreaN-28* Creat-0.9 Na-136
K-4.0 Cl-100 HCO3-27 AnGap-13
[**2125-6-14**] 02:59AM BLOOD LD(LDH)-296* CK(CPK)-298*
[**2125-6-13**] 04:31AM BLOOD CK(CPK)-144
[**2125-6-14**] 02:59AM BLOOD CK-MB-5 cTropnT-0.23*
[**2125-6-13**] 04:31AM BLOOD CK-MB-16* MB Indx-11.1* cTropnT-0.31*
[**2125-6-19**] 07:00AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.1
[**2125-6-14**] 02:59AM BLOOD Hapto-123
[**2125-6-12**] 04:01AM BLOOD %HbA1c-8.3*
[**2125-6-11**] 09:00PM BLOOD Glucose-211* Lactate-1.8 K-3.3*
[**6-11**] C.Cath:
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated two vessel coronary artery disease. The LMCA was
very short
and patent. The LAD had 100% occlusion of the distal LAD with
wrap
around vessel to the apex and inferior wall that recanalized via
left to
left collaterals. The diagonal branches were very small caliber
and had
60-70% stenoses in the proximal portion. The LCX was occluded
proximally. This was briefly probed with 3 wire while awaiting
further
outside hospital medical record which confirmed that the LCX
occlusion
to be chronic and underwent a failed attempt in [**2123**] at SEMC.
There were
faint collaterals from the RCA ot the OMB1 and OMB2. The RCA was
a very
tortuous vessel with hyperdominant sytsem. There was maximum 40%
stenosis and extreme tortuosity.
2. Limited resting hemodynamics were performed. The systemic
arterial
pressures were 103/68mmHg.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Normal systemic arterial pressures.
[**6-12**] Echo:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is moderate regional
left ventricular systolic dysfunction with severe focal
hypokinesis of the inferior, inferolateral, and inferoseptal
walls (EF 35%). 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 aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Concentric left
ventricular hypertrophy with moderate regional left ventricular
systolic dysfunction consistent with coronary artery disease.
Impaired left ventricular relaxation.
[**6-11**]: Femoral US
IMPRESSION:
Normal right groin ultrasound with no pseudoaneurysm, no AV
fistula, and no hematoma identified.
[**2125-6-14**]: Cardiac MR
1. Mild increase left ventricular cavity size with regional left
ventricular
systolic dysfunction. The LVEF was moderately decreased at 39%.
Late
gadolinium contrast-enhanced CMR images demonstrating areas of
hyperenhancement as described above. The findings are consistent
with
myocardial scar and low likelihood of functional recovery of the
basal-mid
inferolateral, and inferior walls.
2. Normal right ventricular cavity size and mild systolic
dysfunction. The
RVEF was mildly decreased at 40%.
3. The indexed diameters of the ascending and descending
thoracic aorta were
normal. The main pulmonary artery diameter index was normal.
4. A note is made of bibasal pulmonary atelectasis.
Brief Hospital Course:
ASSESSMENT AND PLAN
This is a 67 year old male with h/o CAD and s/p MI in [**2123**]
without successful intervention who was found down likely [**2-5**] VT
arrest, underwent c.cath without intervention and completed a
cooling protocol.
# CAD: On admission patient underwent cardiac catheterization
which demonstrated chronic LCX occlusion and LAD total occlusion
with collaterals done. ECHO with EF 35-40% and Inferolat/septal
HK. Patient has had some mild residual substernal chest pain
likely MSK [**2-5**] CPR and shocks, no new ECG changes to suggest
ischemia. Pt will continue medical management of his CAD with
high dose statin, ASA, and Metoprolol XR.
# Acute Systolic Dysfunction: EF 35% with hypokinesis as above
(ECHO [**6-12**]). No evidence of fluid overload. Has no O2 requirement
with activity, no rales on exam and no peripheral edema. He
should have a repeat transthoracic echocardiogram in [**4-9**] weeks
as outpatient. We have him on an ACE inhibitor and BB.
# S/P VT/VF arrest: On admission patient in sinus rhythm. An
amiodarone drip initiated given concern for recurrent VT which
was stopped after 24 hrs. Patient was followed by
electrophysiology during his course. He underwent cardiac MRI
that showed evidence of myocardial scar. VT ablation attempted
on [**6-19**] but was not successful due to inability to thread
necessary catheters. An ICD was placed on [**6-20**] . Patient will
follow up with device clinic and Dr. [**Last Name (STitle) **] as an outpatient.
Patient will continue taking metoprolol succinate 50mg daily.
# Atrial Fibrillation: Patient with new atrial fibrillation and
occasional episodes of rapid ventricular response that responded
to uptitration of metoprolol. Patient was initially on heparin
drip which was stopped prior to ICD placement. Warfarin was
started at 5mg daily. Patient will not be bridged with heparin
drip or lovenox given recent ICD placement and risk of bleeding.
# Altered Mental Status: Following cooling protocol patient was
immediately awake and alert. Patient followed by neurology who
feel he has some mild cognitive deficits and should follow up in
neurobehavioral clinic.
# Right femoral numbness and quadricep muscle weakness: New
onset after multiple procedures in right groin area. Pain has
resolved (possible muscle cramp) but numbness and weakness of
right quadricep area continues. neurology evaluated and thinks
likely local inflammation or nerve trauma, expects to improve
gradually. Weakness has improved in last 24 hours but still
unable to ambulate. Right groin looks benign with no evidence of
bleeding except for superficial ecchymosis. Two ultrasounds and
one abd CT scan has ruled out hematoma as etiology. Pt has EMG
ordered to be scheduled in 3 weeks and a f/u appt with Dr.
[**Last Name (STitle) 1274**] from neurology here.
# Hypertension: BP has remained well controlled. Patient remains
on ACE and BB.
# Hyperglycemia: Daughter reports pt had been on Metformin in
the past but had been d/c'ed. A1C of 8.3 here. Unclear workup of
high blood sugars in the past. Pt has required SC Lantus and
Humalog here with sliding scale. Would suggest stopping lantus
and humalog and starting/up-titrating metformin.
Medications on Admission:
Atorvastatin [Lipitor] 80 mg Tablet one Tablet(s) by mouth daily
Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
one Tablet(s) by mouth daily
Lisinopril 2.5 mg Tablet one Tablet(s) by mouth daily
Lorazepam 0.5 mg Tablet
one Tablet(s) by mouth every 6 hours as needed for anxiety takes
rarely per wife
Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
one Tablet(s) by mouth daily
Omeprazole 20 mg Capsule, Delayed Release(E.C.)
one Capsule(s) by mouth daily
Sertraline 50 mg Tablet one Tablet(s) by mouth daily
* OTCs *
Aspirin 325 mg Tablet one Tablet(s) by mouth daily
Discharge Medications:
1. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes for total 3 doses: if still have
chest pain after 3 doses, call 911.
Disp:*1 bottle* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO twice a
day as needed for constipation.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: check INR daily until at goal of [**2-6**], then titrate as
indicated.
11. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 4 doses.
12. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
13. Insulin Lispro 100 unit/mL Solution Sig: sliding scale units
Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Ventricular Tachycardia and Sudden Death
Coronary Artery Disease
Acute Systolic Dysfunction EF 35%
Femoral nerve
Discharge Condition:
stable
T: 98.4, HR 64-77 SR, BP: 107-136/78-91, O2 sat: 94% on RA
Discharge Instructions:
You had a cardiac arrest because of a dangerous heart rhythm.
You underwent a cooling protocol and had a cardiac
catheterization that showed old coronary heart disease. You had
a cardiac MRI which showed scar on the muscle of your heart that
is the likely cause of your abnormal rhythms. An ICD was placed
to deliver a shock if the dangerous heart rhytm returns. If the
ICD fires, please call Dr.[**Name (NI) 1565**] office right away. No
showers until after you are seen in the device clinic. You can
wash your hair and take a tub bath but don't get the ICD
dressing wet. Your blood sugars were high here and you were
started on insulin with fingersticks. Please talk to the doctors
at the rehab about starting oral medicines for your high blood
sugars. No lifting more than 5 pounds in 6 weeks. Your heart
function is weaker now, you will need an echocardiogram in [**1-5**]
months to evaluate. You may retain fluid in your lungs, legs and
stomach. Weigh yourself every morning berore breakfast, [**Name8 (MD) 138**] MD
if weight > 3 lbs in 1 day or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
Medication changes:
1. Stop taking your Imdur
2. Lisinopril was increased to 5 mg.
3. Warfarin (coumadin) was started, goal INR is 2.0-3.0.
4. Aspirin was decreased to 81mg.
6. Insulin Glargine and Humalog was started as your blood sugars
were very high.
.
Please call Dr. [**Last Name (STitle) **] if you have palpitations, the ICD
fires, if you have chest pain, trouble breathing, shortness of
breath with activity, fevers or if the ICD site looks infected.
Followup Instructions:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2125-6-27**] 2:00 [**Hospital Ward Name 23**]
Clinical Center, [**Location (un) 436**]
.
Electrophysiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/time: [**7-27**] at
1:20pm.
.
Cardiology and Primary Care: please make an appt to see Dr.
[**Last Name (STitle) 39288**] at [**Telephone/Fax (1) 4475**] in 1 week after you leave rehab.
.
Neurology:
EMG has been ordered in 3 weeks, please call the EMG department
at ([**Telephone/Fax (1) 3345**] to schedule
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1274**] Phone: ([**Telephone/Fax (1) 39289**] Date/time: Office
will call you with an appt in 4 weeks.
Completed by:[**2125-6-22**]
|
[
"428.0",
"414.01",
"427.1",
"355.79",
"584.9",
"V58.66",
"427.41",
"790.29",
"401.9",
"428.21",
"412",
"427.31",
"425.4",
"728.87"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"37.22",
"37.26",
"37.94",
"88.56",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12991, 13088
|
7826, 9774
|
287, 411
|
13245, 13313
|
3593, 3593
|
14920, 15705
|
3001, 3036
|
11678, 12968
|
13109, 13224
|
11062, 11655
|
5799, 7803
|
13337, 14436
|
3051, 3574
|
2646, 2737
|
14456, 14897
|
233, 249
|
439, 2530
|
3609, 5782
|
9789, 11036
|
2768, 2875
|
2574, 2626
|
2891, 2985
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,315
| 131,394
|
33251+57841
|
Discharge summary
|
report+addendum
|
Admission Date: [**2176-2-26**] Discharge Date: [**2176-3-3**]
Date of Birth: [**2117-3-30**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain and deformity
Major Surgical or Invasive Procedure:
Staged anterior and posterior spinal decompression and fusion
T4-L5
History of Present Illness:
Patinet has progressive thoracolumbar scoliosis
Past Medical History:
HTN, anxiety/panic d/o, etoh abuse
Social History:
+EtOH
Family History:
N/C
Physical Exam:
Patient is a thin white female with progressive thoracolumbar
scoliosis. She had good strength in both upper and lower
extremities. She was coronally imbalanced.
Pertinent Results:
[**2176-2-26**] 08:41AM TYPE-ART TIDAL VOL-450 O2-50 O2 FLOW-1
PO2-308* PCO2-40 PH-7.47* TOTAL CO2-30 BASE XS-5
INTUBATED-INTUBATED VENT-CONTROLLED
[**2176-2-26**] 08:41AM GLUCOSE-139* LACTATE-2.2* NA+-139 K+-2.8*
CL--99*
[**2176-2-26**] 08:41AM HGB-10.0* calcHCT-30
[**2176-2-26**] 08:41AM freeCa-1.14
[**2176-2-26**] 08:23AM TYPE-ART RATES-/8 TIDAL VOL-450 O2 FLOW-1
PO2-302* PCO2-43 PH-7.48* TOTAL CO2-33* BASE XS-8
INTUBATED-INTUBATED
[**2176-2-26**] 08:23AM GLUCOSE-153* LACTATE-2.1* NA+-140 K+-2.8*
CL--100
[**2176-2-26**] 08:23AM HGB-9.9* calcHCT-30 O2 SAT-99
[**2176-2-26**] 08:23AM freeCa-1.16
Brief Hospital Course:
Patient underwent a staged anterior and posterior spinal fusion.
She had achest tube placed at her initial surgery. This was
removed after her second posterior procedure. She had the
dressings changed which demonstrated no evidence of infection.
She had good strength in both upper and lower extremities. She
was able to ambulate independently before discharge.
Medications on Admission:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*100 Tablet(s)* Refills:*0*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
7. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours) as needed
for pain.
Disp:*100 Tablet Sustained Release 12 hr(s)* Refills:*0*
8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed for diarrhea.
Disp:*90 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All care vna
Discharge Diagnosis:
Scoliosis
Discharge Condition:
Stable-awake and alert- ambulating independently with TLSO
Discharge Instructions:
Ambulate with TLSO brace/ Keep dressings clean and dry
Physical Therapy:
Ambulate as tolerated in the TLSO brace
Treatments Frequency:
Keep incisions clean and dry
Followup Instructions:
10 days in office
Name: [**Known lastname 546**],[**Known firstname **] P. Unit No: [**Numeric Identifier 12530**]
Admission Date: [**2176-2-26**] Discharge Date: [**2176-3-3**]
Date of Birth: [**2117-3-30**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1740**]
Addendum:
Ms. [**Known lastname **] experienced acute post-op blood loss anemia and
required packed red cells with good effect.
Discharge Disposition:
Home With Service
Facility:
All care vna
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1743**] MD [**MD Number(1) 1744**]
Completed by:[**2176-3-12**]
|
[
"721.2",
"305.00",
"458.29",
"300.01",
"401.9",
"285.1",
"737.30",
"530.81",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.79",
"81.36",
"81.04",
"84.52",
"81.38",
"80.99",
"81.63",
"81.05",
"84.51",
"81.64"
] |
icd9pcs
|
[
[
[]
]
] |
4144, 4344
|
1390, 1753
|
299, 369
|
3361, 3422
|
746, 1367
|
3634, 4121
|
544, 549
|
2261, 3241
|
3328, 3340
|
1779, 2238
|
3446, 3501
|
564, 727
|
3519, 3559
|
3581, 3611
|
236, 261
|
397, 446
|
468, 504
|
520, 528
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,543
| 184,250
|
53847
|
Discharge summary
|
report
|
Admission Date: [**2153-6-23**] Discharge Date: [**2153-6-27**]
Date of Birth: [**2066-11-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 87293**]
Chief Complaint:
mechanical fall
Major Surgical or Invasive Procedure:
Right hip repair ORIF under general anesthesia
History of Present Illness:
Reason for MICU transfer: Unable to wean off the phenylephrine
s/p surgical repair of right hip fracture.
History of Present Illness: 86 yo male with mantle cell
lymphoma (last chemo tx [**6-4**]), malignant bilateral pleural
effusion with b/l indwelling pleurex catheters, afib and CAD who
presented to the ED after a mechanical fall on [**6-22**]. The
patient states he had gotten out of bed to grab a handkerchief
from a night stand when he lost his balance. His daughter heard
a crash from the next room and came in to find him laying on the
floor with right hip pain. The patient was able to recall the
events before and after the event and did not loose
consciousness or continance of bowel or bladder. The patient
suspects his fall was due to his weak right knee. He denies
loss of consciousness, CP or dizziness surrounding the event.
Pt did report chronic difficulty breathing and cough which are
attributed to his pleural effusions. These have not recently
worsened.
Of note, per OMR and his daughter, his baseline SBPs range from
90-110.
In the ED, initial VS were: HR: 80 BP: 123/69 Resp: 16 O(2)Sat:
99 on RA. He had a plain film of the hip which showed an
intertrochanteric femoral fracture. Orthopedics recommended
operative management and he was taken to the OR before transfer
to the medical floor. In the OR, patient was intubated and
underwent general anesthesia, he became hypotensive to the 90??????s
and was started on phenylepherine. Post operatively, anesthesia
was unable to wean the phenylephrine and he was admitted to the
MICU.
In the MICU, patient was weaned off pressors and stabilized on
room air. He was transferred to OMED for the rest of his stay.
Past Medical History:
afib
mantle cell lymphoma diagnosed in [**2148**], in remission until [**11-11**]
and recently restarted chemo
Recurrent pleural effusions
Right pneumothorax s/p pleurex cath placement [**5-12**]
CAD s/p stent in [**2147**]
CKD (baseline Cr 1.3)
hypothyroidism (possibly due to hx of amiodarone therapy)
s/p Left CEA [**2150**] (causing left facial droop)
osteoarthritis of the knees
s/p partial gastrectomy 50 years prior
Social History:
Pt recently moved from [**State 622**] to live with his daughter [**Name (NI) **] (a
nurse) in [**Name (NI) 86**]. He is a former smoker, quit 20 years ago. No
current alcohol use.
Family History:
Mother: dementia
Father: colon CA, stroke, MI
Son: esophageal cancer
Physical Exam:
Vitals: T: 97.6 HR: 99 BP 116/66 RR17 SaO2 99% on RA
General: Alert, oriented, no acute distress
[**Name (NI) 4459**]: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
CV: Borderline tachycardia, irregular rhythm, no murmurs, rubs,
gallops
Lungs: Coarse throughout. Pleurodex catheters in place
bilaterally
Abdomen: soft, non-tender, non-distended, ace bandage in place
over lower abd
GU: condom catheter present
Ext: R extremity bandaged, warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: grossly intact
Pertinent Results:
ADMISSION LABS
[**2153-6-23**] 11:50PM WBC-6.6 RBC-3.03* HGB-9.9* HCT-30.9* MCV-102*
MCH-32.5* MCHC-32.0 RDW-17.1*
[**2153-6-23**] 11:50PM PLT COUNT-65*
[**2153-6-23**] 09:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2153-6-23**] 10:30AM CK-MB-3 cTropnT-<0.01
DISCHARGE LABS
[**2153-6-27**] 06:00AM BLOOD WBC-5.1 RBC-2.97* Hgb-9.7* Hct-30.7*
MCV-103* MCH-32.6* MCHC-31.5 RDW-17.7* Plt Ct-49*
[**2153-6-25**] 06:01AM BLOOD Glucose-89 UreaN-34* Creat-1.5* Na-133
K-4.4 Cl-106 HCO3-20* AnGap-11
EKG: (18:30) Tachycardic, atrial fibrillation, no ST elevations,
q waves present in V3 and V4. (possibly due to poor lead
placement) Normal axis. Low voltage study.
MICRO/PATH
none
IMAGING
CXR ([**6-23**]): FINDINGS: There is mild cardiomegaly and mild
pulmonary vascular redistribution with small bilateral pleural
effusions. Drains are seen overlying bilateral hemidiaphragms.
IMPRESSION: Small bilateral pleural effusions, increased
compared to prior.
Brief Hospital Course:
86 yo male with mantle cell lymphoma, afib and CAD who presented
with a mechanical fall requiring surgical repair. He was
transferred to the MICU for post-op hypotension, stabilized, and
then came to OMED.
#Post-surgical hypotension: Pt had SBPs <90 in the post-op
period that required phenylephrine drip. He denied dizziness
etc at that time. Although he is known to have a SBP baseline
from 90-100, we ruled out cardiogenic causes (negative cardiac
enzymes and CXR), infectious etiologies (cultures negative,
clinical signs absent) and hypovolemia due to blood loss (Hct
stable). Pt weaned off phenylephrine [**6-23**] requiring gentle
hydration afterwards to maintain urine output. Patient had
episodes of hypotension at times triggered by draining his
bilateral pleurex catheters. This reponded well to fluid
boluses. At the time of discharge, patients pressures were
stable.
#Right femoral fracture: Patient is s/p an apparent mechanical
fall, s/p R intertroch fx and surgical repair (ORIF). Per
ortho,he has been anticoagulated on Lovenox 40mg SQ and is WBAT
on RLE. Tylelol and oxycodone was given prn for pain.
#Pleural effusions: Pt has recurrent pleural effusions, etiology
likely malignant vs effusion secondary to obstructive
lymphadenopathy. Pt has bl pleurex catheters which drained
>1.5L. We continued drainage daily for comfort and gave fluid
boluses PRN and montiored respiratory status.
#Thrombocytopenia: Pt noted to have low PLT since admission.
Per oncology, this is likely related to lymphoma. Less likely
due to result of chemotherapy (last tx [**6-4**]) or HIT. Aspirin was
held, no signs of overt bleeding developed.
#Anemia: Likely due to anemia of chronic disease with
dilutional component, Hct remained stable throughout admission.
# Mantle cell lymphoma: Dx in [**2148**], recurred in [**11-11**] after
years of remission. Last chemo (rituximab) was [**2153-6-4**]. In
MICU, he was seen by his primary oncologist who recommended
against further chemotherapy and suggested a transition to
comfort care. Patient remained DNR/okay to intubate. Patient's
daughter was at bedside toward the end of hospitalization and
supported transitioning to hospice. Hospice was consulted and
set up for home services were made.
# Afib: Pt with afib for a past few years. CHADS score is 1 for
age, he had previously been on coumadin however this was held
for pleurex catheter placement. Anticoagulation since admission
has been Lovenox only. Restarted Metoprolol 12.5mg po BID for
rate control [**6-24**], increased to TID dosing [**6-25**].
# CAD: Patient is s/p stent placement in [**2147**], low suspicion for
acute ischemia. Continued Metoprolol and Simvastatin. Held ASA
for thrombocytopenia
#Hypothyroidism: Patient remained clinically stable on
Levothyroxine 112mcg po daily
#Oropharyngeal candidiasis-resolved: Pt presented to oncologist
2 weeks ago with oral thrush, no longer showing showing clinical
signs at this time. Fluconazole was d/c'ed as it may have
contributed to thrombocytopenia.
#GERD: Pt remained stable on home regimen of omeprazole 20mg
[**Hospital1 **].
#Transitional Issues: Patient's condition was deteriorating at a
steady pace at the time of discharge. Hospice was consulted and
patient was transitioned in the hospital to hospice care with
daughter in agreement. Hospice made arrangements for home
visits and patient was discharged in stable condition with poor
prognosis.
-Daughter [**Name (NI) **] is a nurse and health care proxy.
-Code:DNR, ok to intubate in post-surgical period
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Mirtazapine 15 mg PO HS
2. Zolpidem Tartrate 5 mg PO HS
3. Metoprolol Tartrate 12.5 mg PO BID
4. Simvastatin 40 mg PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Fluconazole 50 mg PO Q24H
7. Omeprazole 20 mg PO BID
8. Levothyroxine Sodium 112 mcg PO DAILY
Discharge Medications:
1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
Five (5) mg PO every four (4) hours as needed for pain or
breathlessness: Give by mouth or under the toungue.
[**Name (NI) **]:*30 ml* Refills:*0*
3. Ativan 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours
as needed for anxiety.
[**Name (NI) **]:*16 Tablet(s)* Refills:*0*
4. atropine 1 % Drops Sig: Two (2) drops Ophthalmic every four
(4) hours as needed for secretions: Give under the tongue.
[**Name (NI) **]:*15 ml* Refills:*0*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO once a day: Please do not
take if your blood pressure is less than 80 mmHg, or at the
disgression of the hospice nurse.
[**Last Name (Titles) **]:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
7. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
10. Diflucan 50 mg Tablet Sig: One (1) Tablet PO once a day: For
oral candidiasis.
11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
[**Last Name (Titles) **]:*qs qs* Refills:*0*
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for shortness of breath or wheezing.
[**Last Name (Titles) **]:*qs qs* Refills:*0*
13. digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
14. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours).
[**Last Name (Titles) **]:*30 syringe* Refills:*2*
15. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
[**Last Name (Titles) **]:*600 ml* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis:
Hip fracture
Hypotension
Atrial fibrillation
Hypoxia secondary to pleural effusions
Secondary Diagnosis:
Mantel Cell Lymphoma
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted to the hospital for surgery after a fall.
Your blood pressure was low after surgery, and you were
transferred to the ICU for close monitoring. Your blood
pressures recovered after receiving intravenous fluids and you
were transferred to the oncology floor. Your oxygen saturations
intermittently became low, requiring drainage of your pleurex
catheters. Your heart rate was also high, requiring medications
to slow the heart down. It was decided between you and your
family that instead of pursuing aggressive medical care, we
would focus on making you comfortable. You will have hospice
services for supportive care on discharge.
The following changes were made to your home medications:
- Morphine was STARTED for comfort
- Lorazepam was STARTED for comfort
- Atropine drops were STARTED for comfort
- Albuterol and Ipratropium nebulizers were STARTED for
breathing comfort
- Digoxin was STARTED for heart rate control
- Metoprolol was INCREASED and SWITCHED to a once a day extended
release formulation
- Simvastatin was STOPPED
- Aspirin was STOPPED
- Levothyroxine was STOPPED
Followup Instructions:
Department: WEST PROCEDURAL CENTER
When: MONDAY [**2153-7-2**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 7769**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST PROCEDURAL CENTER
When: MONDAY [**2153-7-2**] at 2:00 PM [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2153-7-10**] at 12:00 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2153-7-3**]
|
[
"414.01",
"511.81",
"V45.82",
"V16.0",
"287.5",
"530.81",
"V87.41",
"820.21",
"799.02",
"V15.82",
"458.29",
"V58.61",
"V45.89",
"427.31",
"200.40",
"715.36",
"272.0",
"585.9",
"285.29",
"112.0",
"781.94",
"V49.86",
"244.9",
"E885.9",
"785.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.15"
] |
icd9pcs
|
[
[
[]
]
] |
10521, 10570
|
4469, 7595
|
321, 369
|
10760, 10850
|
3410, 4446
|
12041, 12989
|
2754, 2826
|
8456, 10498
|
10591, 10591
|
8061, 8433
|
10911, 11606
|
2841, 3391
|
11624, 12018
|
7616, 8035
|
266, 283
|
534, 2091
|
10716, 10739
|
10610, 10695
|
10865, 10887
|
2113, 2538
|
2554, 2738
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,880
| 120,155
|
1253
|
Discharge summary
|
report
|
Admission Date: [**2157-6-30**] Discharge Date: [**2157-7-11**]
Date of Birth: [**2097-4-4**] Sex: M
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
gallstone pancreatitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Pt is 60 y.o.M presented to [**Location (un) 7804**] hospital on [**6-29**] with
severe abdominal pain and nausea. He was found to have abdominal
tenderness, worse in the RUQ and epigastric area, elevated liver
and pancreatic enzymes and US findings consistant with GB
stones. He was also found to be hypotensive and tachycardic. He
was admitted to ICU started on IVF and Imipenem and next day
trasnferred to [**Hospital1 18**] for further mgt
Past Medical History:
NASH
GERD
gallstones
adrenal adenoma
kidney stones/left hydronephrosis
CRI (1.2)
cervical disk x3
s/p appy
s/p liver bx
s/p B ulnar nerve transposition
s/p cystoscopy
Social History:
married with 4 children a/w
td out of date
tob -
etoh wine daily
diet +exercise +
dental +
Family History:
mother died 72 breast ca
father died 69 MI
no sibs
Physical Exam:
[**Last Name (un) 664**] cooperative in mild distress
tachycardic, regular
CTAB
Abdomen: distended, tender to palpation, worse in the epigastirc
area
wwp, 1+ edema
Pertinent Results:
[**2157-6-30**] 03:28PM WBC-17.7*# RBC-4.86 HGB-14.2 HCT-42.2 MCV-87
MCH-29.1 MCHC-33.6 RDW-13.5
[**2157-6-30**] 03:28PM PLT COUNT-209
[**2157-6-30**] 03:28PM PT-12.7 PTT-41.3* INR(PT)-1.1
[**2157-6-30**] 01:25PM TYPE-ART PO2-205* PCO2-48* PH-7.28* TOTAL
CO2-24 BASE XS--4
[**2157-6-30**] 03:28PM ALBUMIN-3.1* CALCIUM-7.6* PHOSPHATE-2.1*
MAGNESIUM-1.5*
[**2157-6-30**] 03:28PM LIPASE-1301*
[**2157-6-30**] 03:28PM ALT(SGPT)-237* AST(SGOT)-69* ALK PHOS-144*
AMYLASE-902* TOT BILI-1.1
[**2157-6-30**] 03:28PM GLUCOSE-120* UREA N-27* CREAT-1.2 SODIUM-140
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14
[**2157-6-30**] 03:40PM freeCa-1.09*
[**2157-6-30**] 03:40PM LACTATE-1.9
[**2157-6-30**] 09:17PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
CT abdomen
1) Findings consistent with acute pancreatitis without evidence
of necrosis or peripancreatic abscess.
2) Mildly prominent common bile duct. No stones were identified.
MRCP would be more sensitive for detection of stones.
3) Small bilateral pleural effusions with associated
atelectasis.
4) Left adrenal adenoma unchanged when compared to the prior
study.
5) Heterogeneous enhancement of the left kidney parenchyma. It
could represent pylonephritis. Correlate with UA.
6) 3mm nonobstructive stone in the right kidney.
Brief Hospital Course:
Patient was admitted to the surgical service. in attempt to do
ERCP patient became apneic and unresponsive after administration
of fentanyl and versed. He never lost pulse and improved with
bag ventilation. Procedure was aborted, patient was transferred
to SICU. Over next few days he was treated with IVF/TPN/bowel
rest/Imipenem. Patient abdominal pain has improved and his liver
and pancreatic enzyme level has normalized. He was transferred
out of the ICU to the regular floor and started ambulating with
PT. At this point Hepatobilliary service and Dr. [**Last Name (STitle) **] was
consulted and patient was transferred to his service. Over next
few days patient was advanced to regular diet and oral meds
which he tolerated well. However, he then developed more
abdominal cramping, diarrhea and leukocytosis up to 27. At this
point imipenem was stopped and patient was started on Flagyl
(stool cx came back positive for C.Diff the next day). After 4
days of Flagyl treatment patient continued to have leukocytosis
and loose stools. His antibiotic coverage then was changed to PO
Vancomycin, at which point patient's WBC started to decrease and
stools normalized.
On hospital day 12, his diarrhea had stopped, he was tolerating
a regular diet, and his alkaline phosphatase and white blood
cell count were trending downward. The decision was made to
discharge him to home, with the plan for him to come back for a
cholecystectomy once his c difficile has been fully treated.
Medications on Admission:
Protonix
Mylanta
Zantac
Discharge Medications:
1. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
2. 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*
3. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every
4 hours) as needed for PAIN.
Disp:*40 Tablet(s)* Refills:*0*
4. Vancomycin HCl 125 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
gallstone pancreatitis
respiratory arrest associated with procedure (ERCP)
cholelithiasis
NASH
GERD
adrenal adenoma
kidney stones/left hydronephrosis
CRI (1.2)
hypokelimia
hypocalcemia
hypomagnesimia
failure to thrive
Discharge Condition:
good
Discharge Instructions:
ambulate as tolerated
Low fat diet
please come/call back if develop fever, chills, nausea,
vomiting, worsening diarrhea, worsening abdominal pain
Followup Instructions:
Please f/u with Dr. [**Last Name (STitle) **], please call office for appointment
upon discharge. ([**Telephone/Fax (1) 2363**] Your surgery has been scheduled
for Tuesday, [**7-19**].
|
[
"783.7",
"593.9",
"799.1",
"530.81",
"V64.1",
"724.2",
"041.83",
"571.8",
"577.0",
"574.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.71",
"96.04",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
4907, 4913
|
2719, 4200
|
288, 295
|
5175, 5181
|
1336, 2696
|
5375, 5563
|
1084, 1137
|
4274, 4884
|
4934, 5154
|
4226, 4251
|
5205, 5352
|
1152, 1317
|
226, 250
|
323, 768
|
790, 959
|
975, 1068
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,932
| 191,053
|
29177
|
Discharge summary
|
report
|
Admission Date: [**2114-2-13**] Discharge Date: [**2114-2-23**]
Date of Birth: [**2052-12-22**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Chronic mesenteric ischemia.
Major Surgical or Invasive Procedure:
Right common iliac to superior mesenteric artery bypass with
6-mm PTFE graft and reimplantation of inferior mesenteric artery
into infrarenal abdominal aorta.
History of Present Illness:
This 62-year-old lady has previously had a celiac angioplasty
and stent about 5 or 6 years ago for chronic mesenteric
ischemia. This has occluded. She recently
underwent an arteriogram. This showed her celiac artery to be
chronically occluded including the stent. Her proximal superior
mesenteric artery was totally occluded over a long segment. The
inferior mesenteric artery had a 90% stenosis at its origin and
there was a very large meandering mesenteric
artery reconstituting the superior mesenteric artery at the
takeoff of a replaced right hepatic artery.
Past Medical History:
PMH: gastric ulcer, smoker
PSH: celiac stent
Social History:
pos smoker
neg drinker
Family History:
n/c
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: 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:
[**2114-2-21**] 06:34AM BLOOD
WBC-9.5 RBC-3.43* Hgb-10.4* Hct-31.5* MCV-92 MCH-30.4 MCHC-33.1
RDW-14.2 Plt Ct-494*
[**2114-2-18**] 04:14PM
URINE Color-LtAmb Appear-SlHazy Sp [**Last Name (un) **]-1.010
URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1
[**2114-2-19**] 5:41 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final [**2114-2-20**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2114-2-19**] 4:06 AM
CHEST (PORTABLE AP)
Reason: pna?
Pulmonary edema has improved since [**2-17**], but there is still
a severe interstitial pulmonary abnormality that suggests a
combination of residual edema and a widespread infiltrative
process unrelated to cardiac decompensation. Interstitial
pneumonia, drug reaction, or chronic interstitial lung disease
are possibilities. The heart size is top normal. Pleural
effusion, if any, is small, on the right. Tip of the right
jugular line projects over the low SVC. Vascular stent and skin
staples noted in the upper abdomen.
Cardiology Report ECHO Study Date of [**2114-2-13**]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: 0.7 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.7 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.6 cm
Left Ventricle - Fractional Shortening: 0.37 (nl >= 0.29)
Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.7 cm (nl <= 3.4 cm)
Aorta - Arch: 2.5 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.3 cm (nl <= 2.5 cm)
Aortic Valve - LVOT Diam: 2.0 cm
INTERPRETATION:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function (LVEF>55%).
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal; mid inferoseptal - normal; basal inferior
- normal; mid inferior - normal; basal inferolateral - normal;
mid inferolateral - normal; basal anterolateral - normal; mid
anterolateral - normal; anterior apex - normal; septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Normal aortic arch diameter. Simple atheroma in aortic
arch. Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. No MS. Trivial MR.
TRICUSPID VALVE: No TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. There is no pericardial
effusion.
Brief Hospital Course:
Mrs. [**Known lastname 70202**] was admitted on [**2113-2-13**] for an elective Right
common iliac to superior mesenteric artery bypass with 6-mm PTFE
graft and reimplantation of inferior
mesenteric artery into infrarenal abdominal
aorta.Pre-operatively, she was consented, prepped, and brought
down to the operating room for surgery. Intra-operatively, she
was closely monitored and remained hemodynamically stable. She
tolerated the procedure well without any difficulty or
complication.
Post-operatively, she was extubated and transferred to the PACU
for further stabilization and monitoring. She was then
transferred to the floor for further recovery.
On the floor, she remained hemodynamically stable with her pain
controlled. She did develop an acute onset of SOB. Stat CXR
showed Pulmonary edema VS ARDS. She was transfered to the SICU.
While in the SICU she recieved aggressive pulmonary toilet.
After she was stabalized she was transfered back to the floor.
While on the floor she was gradually weaned from he O2.
She progressed with physical therapy to improve her strength and
mobility. She continues to make steady progress without any
incidents. She was discharged home with services.
Medications on Admission:
[**Last Name (un) 1724**]: protonix 40", sucralfate 1""
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. rolling walker
ROLLING WALKER
DISP # 1
FOR PHYSICAL THERAPY
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a
day.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Chronic mesenteric ischemia.
ARDS VS Flash pulm edema
Discharge Condition:
Stable
Discharge Instructions:
Introduction:
Like your other organs, the organs in your digestive system need
a constant supply of oxygen-[**Doctor First Name **] blood to function properly. A
diminished blood flow to your small intestine or colon is
referred to as intestinal ischemia (is-KE-me-uh).
Intestinal ischemia can cause pain and make it difficult for
your intestines to do their job. In severe cases, loss of blood
flow to the intestines can lead to damaged or dead intestinal
tissue, not unlike what happens to the heart during a heart
attack.
Intestinal ischemia may develop suddenly (acute intestinal
ischemia), often as a result of a blood clot blocking the flow
of blood to or from the intestines, or it may develop gradually
over time (chronic intestinal ischemia), due to a variety of
causes.
Undetected and untreated, intestinal ischemia may be fatal. This
condition, though uncommon, is serious and often requires
immediate medical care. Depending on the cause of your
intestinal ischemia, treatment options may include medications,
surgery or a procedure to open your arteries.
Signs and symptoms:
Although there are different types of intestinal ischemia, signs
and symptoms are most often perceived as having a sudden (acute)
or gradual (chronic) onset.
Signs and symptoms of acute intestinal ischemia typically
include:
Sudden abdominal pain that may range from mild to severe
An urgent need to move your bowels
Frequent, forceful bowel movements
Abdominal tenderness or distention
Blood in your stool
Nausea, vomiting
Fever
Chronic intestinal ischemia, in which blood flow to the
intestines is reduced over time, is characterized by:
Abdominal cramps or fullness, beginning within 30 minutes after
eating and lasting for one to three hours
Abdominal pain that gets progressively worse over weeks or
months
Fear of eating because of subsequent pain
Unintended weight loss
Diarrhea
Nausea, vomiting
Bloating
Chronic intestinal ischemia may progress to an acute episode. If
this happens, you might experience severe abdominal pain after
weeks or months of bouts of pain after eating.
Causes:
Mesenteric ischemia:
The aorta is the large artery that supplies your body's vessels
with oxygen-[**Doctor First Name **] blood pumped by your heart. The portion of the
aorta extending below your heart into your abdomen is the
abdominal aorta. Three arteries branching off the abdominal
aorta supply almost all of the blood to your digestive tract.
These arteries are the:
Celiac artery
Superior mesenteric artery
Inferior mesenteric artery
When the flow of blood through these arteries or their adjacent
draining veins is altered, whether the change is acute or
chronic, intestinal ischemia results.
Like other arteries in your body, any or all of the arteries
that serve your digestive tract may be affected by an
accumulation of cholesterol particles, scar tissue, calcium and
other cellular debris (atherosclerosis), which narrows those
arteries and restricts the amount of blood moving through them.
Atherosclerotic buildup can progressively reduce blood flow to
your small intestine, your large intestine or both. Chronic
intestinal ischemia is often the result of atherosclerotic
buildup.
Most of the time, acute intestinal ischemia is due to a blood
clot that forms in your heart and then travels to one of your
intestinal arteries. Other times a blood clot may develop in a
vein leading away from the intestines, diminishing the outflow
of deoxygenated blood. Sometimes intestinal ischemia occurs
because a portion of your intestine becomes trapped due to a
hernia (strangulated hernia) or due to adhesions from a previous
abdominal surgery. Other times it occurs because of heart
failure or low blood pressure.
Whatever the cause, diminished blood flow within your digestive
tract leaves cells with insufficient oxygen. Under these
conditions, cells become weak and die. As more and more cells
are damaged, inflammation and ulcers develop. This leads to an
inability to absorb food and nutrients, resulting in bloody
diarrhea. If damage is severe enough, infection and gangrene may
result. If untreated for long, intestinal ischemia can be fatal.
Intestinal ischemia is often divided into several categories:
Colon ischemia (ischemic colitis)
Disrupted blood flow to the colon is the most common type of
intestinal ischemia. It most often occurs in older adults,
although it may develop in younger people.
Signs and symptoms of colon ischemia are generally milder than
with other forms of intestinal ischemia, and severe
complications are uncommon. For most people, colon ischemia
appears as a sudden onset of mild, crampy pain on the left side
of the abdomen. What causes diminished blood flow to the colon
isn't always clear, but a number of conditions can make you more
vulnerable to colon ischemia:
Atherosclerosis:
Dangerously low blood pressure (hypotension) associated with
congestive heart failure, major surgery, trauma, shock or
life-threatening infection in your bloodstream (sepsis)
A blood clot in an artery supplying the colon
Bowel obstruction caused by a strangulated hernia, scar tissue
or a tumor
Heart, blood vessel, intestinal or gynecologic operations
Other medical disorders that affect your blood, such as
inflammation of your blood vessels (vasculitis), lupus or sickle
cell anemia
Some medications, especially those that constrict blood vessels,
such as some heart, migraine or hormone medications
Cocaine or methamphetamine use
Vigorous exercise such as long-distance running
Acute mesenteric ischemia:
This type of intestinal ischemia usually affects the small
intestine. It has an abrupt onset and may be due to:
A blood clot that dislodges from your heart and travels through
your bloodstream (emboli) to block an artery leading to your
intestines, usually the superior mesenteric artery. This is the
most common cause of acute mesenteric artery ischemia and can be
precipitated by congestive heart failure, an irregular heartbeat
(arrhythmia) or a heart attack.
A blood clot that develops within one of the main intestinal
arteries (thrombosis) and blocks blood flow, often as a result
of atherosclerosis. This type of acute ischemic episode tends to
occur in people with chronic intestinal ischemia.
Impaired blood flow resulting from low blood pressure due to
shock or heart failure. This is more common in people who are
critically ill and who have some degree of atherosclerosis. You
may hear this type of acute mesenteric ischemia referred to as
nonocclusive ischemia, which means that it's not due to a
vascular obstruction.
Aortic dissection , a partial tear in the main artery from the
heart (aorta), which causes a separation of the layers of the
aortic wall and bleeding into and along the wall of the aorta,
thus reducing blood flow to the intestines.
Chronic mesenteric ischemia:
Chronic mesenteric ischemia, also known as intestinal angina,
results from atherosclerosis. The disease process is generally
so gradual that at least two of the three major arteries
supplying your intestines become severely narrowed or completely
obstructed before you experience symptoms. A potentially
dangerous complication of chronic mesenteric ischemia is the
development of a blood clot within a diseased artery, causing
acute mesenteric ischemia.
Ischemia due to mesenteric venous thrombosis
Occasionally, a blood clot will develop in a vein draining
deoxygenated blood away from your intestines. Blockage of the
vein causes intestinal congestion, swelling and bleeding.
A blood clot in a mesenteric vein may result from:
Acute or chronic inflammation of the pancreas (pancreatitis)
Abdominal infection
Scarring of the liver (cirrhosis)
Cancers of the digestive system
Bowel diseases, such as ulcerative colitis, Crohn's disease or
diverticulitis
Disorders that make your blood more prone to clotting
(hypercoagulation disorders), such as an inherited protein
deficiency
Trauma to the abdomen
Hormone therapy, which can cause a blood clot
Risk factors:
Many of the risk factors for intestinal ischemia are those
associated with atherosclerosis and clogging of the mesenteric
arteries. These factors include:
Age (older than 50)
High blood pressure (hypertension)
Diabetes
Elevated levels of blood lipids or fats
Smoking
Your risk is also higher if you have a history of
atherosclerosis that affects blood flow in other areas of your
body, such as your heart (coronary artery disease), legs
(peripheral vascular disease) or the arteries serving your brain
(cerebrovascular disease).
Other factors that can increase your risk of intestinal ischemia
include low blood pressure, congestive heart failure, an
irregular heartbeat, a blood clotting disorder, a hernia and
previous abdominal surgery.
Risk factors for ischemia due to mesenteric venous thrombosis
include extended bed rest, obesity, certain types of cancer,
birth control pills, smoking, and a history of high blood
pressure or heart disease.
When to seek medical advice:
Seek immediate medical care anytime you have sudden, persistent
abdominal pain. A delay in treatment may make successful
treatment more difficult. Also, see your doctor promptly if you
have blood in your stool or if you have chronic abdominal pain
after eating, especially if you're also losing weight
unexpectedly.
Followup Instructions:
Call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 3121**]. Schedule an
appointment one month
Completed by:[**2114-2-23**]
|
[
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] |
icd9cm
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[
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icd9pcs
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344, 505
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7096, 7105
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6336, 6393
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7129, 16448
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1243, 1705
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276, 306
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533, 1098
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1120, 1167
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1183, 1207
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,895
| 186,724
|
32747
|
Discharge summary
|
report
|
Admission Date: [**2118-3-15**] Discharge Date: [**2118-3-18**]
Date of Birth: [**2048-8-25**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
syncope, adverse reaction to Taxotere
Major Surgical or Invasive Procedure:
Port-A-Cath placement
History of Present Illness:
Ms. [**Known lastname **] is a 69 y/o F with h/o Breast cancer s/p R partial
mastectomy, + nodal resection (only sentinel node positive)
currently on adjuvant therapy, who presented for scheduled
outpatient administration of taxotere cycle 2 yesterday and had
syncope and hypotension 40 minutes into infusion. She reports
that she was in her usual state of health, no recent fever or
other symptoms prior to starting treatment. Forty minutes into
infusion per report she became hypoxemic, bradycardic and then
decrease mental status. She only remebers feeling like she had
warmth in her mouth, taking a sip of water and then waking up
surrounded by people. BP recorded SBP 60's, transiently
bradycardic, then HR into the 160's. She received IV fluids and
benadryl 50 IV. She denies chest pain, palpitations, head aches,
dyspnea, wheezing, chest heaviness, abdominal pain or other
significant symptoms.
.
She was admitted to the MICU and monitored overnight. In ICU,
she was noted to be hypothermic, warmed, also received benadryl,
hydrocortisone. Weaned off non re-breather to room air within
30minutes. She ruled out for MI by cardiac enzymes.
.
Currently she reports a slight headache but otherwise denies any
complaints.
Past Medical History:
Hypertension
hypercholesterolemia
Lumbar disc
Spinal fusion
anxiety
Bilateral cataracts
s/p hemicolectomy post diverticulitis.
recent dx R breast cancer s/p surgery [**2118-1-25**] with positive lymph
nodes. Axilary disection and reexcision. Her-2 Neu negative ER
and PR +
Social History:
patient retired elementary school teacher. Widowed. 1 son
smoked +, quitted 30-35 years ago. Denied alcohol
Family History:
non contributory
Physical Exam:
Vitals: T:97.5 P:94 R:20 BP: 143/46 SaO2: 98%RA
General: Awake, alert, NAD
HEENT: moist oral mucose, no oral lesions
Pulmonary: CTAB, no wheezing/crackles
Cardiac: RRR, S1S2 no murmurs
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: no edema, no calf tenderness, warm DP's 2+B
Skin: no rashes or lesions noted.
Neurologic: alert, oriented x3
Pertinent Results:
[**2118-3-18**] Bone Scan:
1. No findings suspicious for metastatic disease.
2. Degenerative changes of the thoracic and lumbar spines, more
prominnent atL2-L3.
3. Atherosclerotic calcifications.
4. 5 mm left upper lobe nodule. Recommend follow up chest CT in
6 months.
.
[**2118-3-16**] ECHO: The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
a mild resting left ventricular outflow tract obstruction. The
gradient increased with the Valsalva manuever. 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 left ventricular
inflow pattern suggests impaired relaxation. The estimated
pulmonary artery systolic pressure is normal. There is a
minimally increased gradient consistent with trivial pulmonic
valve stenosis. There is a trivial/physiologic pericardial
effusion. There are no echocardiographic signs of tamponade.
.
[**2118-3-16**] MRI HEAD: 1. No intracranial metastasis.
2. Nine-mm enhancing extra-axial mass of the anterior falx
cerebri, which most likely represents a meningioma.
3. Signal abnormality of the C4 vertebral body which may
represent metastasis.
.
LABS ON DISCHARGE:
[**2118-3-15**] 12:00PM BLOOD WBC-11.0# RBC-3.69* Hgb-11.1* Hct-31.1*
MCV-84 MCH-30.0 MCHC-35.7* RDW-13.2 Plt Ct-394
[**2118-3-18**] 09:17AM BLOOD WBC-6.4# RBC-3.58* Hgb-11.0* Hct-30.7*
MCV-86 MCH-30.6 MCHC-35.7* RDW-13.8 Plt Ct-493*
[**2118-3-15**] 05:51PM BLOOD Glucose-121* UreaN-19 Creat-0.8 Na-134
K-3.6 Cl-97 HCO3-21* AnGap-20
[**2118-3-18**] 09:17AM BLOOD Glucose-106* UreaN-12 Creat-0.8 Na-135
K-4.1 Cl-100 HCO3-26 AnGap-13
[**2118-3-15**] 05:51PM BLOOD TSH-0.38
[**2118-3-17**] 07:10AM BLOOD Calcium-9.4 Phos-2.5* Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname **] is a 69 y/o female with h/o HTN, recently dx breast
cancer s/p R lumpectomy and nodal disection, + sentinal node now
on adjuvant chemotherapy who had syncopal episode while getting
infusion of Taxetere.
1) Syncope/hypotension: most likely adverse reaction to taxetere
which was infusing during the time that she had the event. Other
major cosideration would be cardiac dysrhythmia or MI, however
she ruled out for MI with no events on telemetry. She had an
echocardiogram showing mild diastolic dysfunction, EF >75%, no
cause for syncope. She also had an MRI of her head which did
not show any acute pathology. She had no further events during
her hospitalization.
2)Breast cancer: Given syncopal event treatment with taxetere
will be stopped and she will be switched to an alternative
chemotheraputic regimen to complete her adjuvant therapy. MRI of
head during admission showed signal abnormality of the C4
vertebral body which was concerning for possible metastasis.
She had a bone scan to follow up the MRI which did not show any
evidence of metastatic disease. She had port placed placed
during her admission for future access/chemo. She will follow
up with Dr. [**Last Name (STitle) **] in clinic.
3)Hypertension: normotensive, she was continued on enalapril.
4) Hypercholesterolemia: continue simvastatin
5)Anxiety -continue home dose alprazolam
6)pain - She was continued on home regimen of tylenol 1000mg
q6hr prn, home dose oxycontin 20mg qam (per pt only takes once
per day).
Medications on Admission:
Alprazolam 1-1.5mg four times daily
Dexamethasone 8mg [**Hospital1 **] on the day before, day of and day after
chemo
enlapril 20 mg qd
Fluticasone 50 2 sprays each nostril [**Hospital1 **]
Vicodin PRN for pain
lorazepam 0.5mg q8hours as needed for nausea
Boniva 2.5mg Tab qmonth
Naproxen 500mg [**Hospital1 **]
Ondansetron 8mg TID for 2 days after chemo
Oxycontin 20mg daily
Neulasta 1 SC 24 hours after chemo
Donnatal 16.2mg [**12-22**] by mouth daily
compazine 10mg q8 hours prn nausea
Ranitidine 150 daily
Simvastatin 10 mg tab qd
dyazide 37.5/25 one daily
Extra-strength tylenol 2 tabs q6h prn
colace 100mg [**1-24**] [**Hospital1 **] prn
Calcium carbonate vit d 1 tab day
Loratadine 10 mg Tab daily
Senna [**12-22**] tab [**Hospital1 **]
Discharge Medications:
1. Alprazolam 0.25 mg Tablet Sig: Six (6) Tablet PO QID (4 times
a day) as needed.
2. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
4. Boniva 2.5 mg Tablet Sig: One (1) Tablet PO once a month.
5. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO QAM (once a day (in the
morning)).
6. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed.
12. Naproxen 500 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for nausea.
14. Donnatal 16.2 mg Tablet Sig: 1-2 Tablets PO once a day.
15. Dyazide 37.5-25 mg Capsule Sig: One (1) Capsule PO once a
day.
16. Calcium 500 With D 500 (1,250)-400 mg-unit Tablet Sig: One
(1) Tablet PO once a day.
17. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
Taxotere adverse reaction
.
Breast cancer s/p Right partial mastectomy and lymph node
dissection
hypertension
hypercholesterolemia
s/p hemicolectomy for diverticulitis
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital after you lost consciousness
while getting your chemotherapy infusion. You were monitored in
the ICU and then on the oncology floor. You had blood tests
which did not show any evidece of a [**Last Name **] problem or infection
as a cause of her symptoms. You had a heart ultrasound which
did not show any significant abnormalities of your heart. You
also had bone scan as well which you can follow up with Dr.
[**Last Name (STitle) **] for the results.
A Port was placed during your admission for future access and
chemotherapy treatment.
None of your home medications were changed.
Please follow up as below.
Please call your doctor or return to the hospital if you
experience any concerning symptoms including fevers, chest pain,
difficulty breathing, light headedness, fainting or any other
concerning symptoms.
Followup Instructions:
You have follow up scheduled as below:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2118-4-5**] 12:00
Provider: [**First Name4 (NamePattern1) 4617**] [**Last Name (NamePattern1) 4618**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2118-4-5**] 1:00
.
Please call your primary care doctor, Dr. [**Last Name (STitle) 32496**] at
[**Telephone/Fax (1) 58523**] and schedule an appointment to be seen within one
to two weeks of discharge.
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
|
[
"401.9",
"E933.1",
"174.8",
"780.2",
"196.3",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.07"
] |
icd9pcs
|
[
[
[]
]
] |
8117, 8123
|
4400, 5926
|
342, 366
|
8343, 8350
|
2502, 3827
|
9255, 9903
|
2060, 2078
|
6720, 8094
|
8144, 8322
|
5952, 6697
|
8374, 9232
|
2093, 2483
|
265, 304
|
3846, 4377
|
394, 1620
|
1642, 1917
|
1934, 2044
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,796
| 125,121
|
53621
|
Discharge summary
|
report
|
Admission Date: [**2149-11-24**] Discharge Date: [**2149-12-1**]
Date of Birth: [**2098-4-25**] Sex: M
Service: MEDICINE
Allergies:
Ampicillin
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
worsening shortness of breath
Major Surgical or Invasive Procedure:
[**2149-11-25**]: TAVR with [**Doctor Last Name **] [**Last Name (un) 30978**] valve
History of Present Illness:
Patient is a 51yo caucasian male with severe aortic stenosis in
the setting of post mantle radiation for childhood lymphoma (age
4) resulting in chest cavity deformity, cervical kyphosis and
stiff fixed neck. History includes CAD with 80-90% proximal RCA
nondominant treated medically, multivalvular disease secondary
to radiation, complete heart block s/p PPM, PE s/p PPM, HTN, CKD
stage I. He was experiencing severe NHYA class III/IV symptoms
earlier this year, underwent BAV [**2149-10-14**] with short term
improvement. He now notes return of shortness of breath, able to
ambulated one block slowly before stopping due to SOB, able to
climb 2 stairs only, admits to dizziness when getting up quickly
or bending down. He was deemed not a surgical candidate for
surgical AVR at [**Hospital1 112**] in [**2147**]. He was also seen by cardiac surgery
at [**Hospital1 18**] and was again deemed not a surgical candidate for AVR
secondary to hostile mediastinum and anatomical deformities. He
was screened for TAVR and met criteria. He returns for elective
TAVR.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, bleeding at the time of surgery, myalgias, joint pains,
cough, hemoptysis, black stools or red stools. he denies recent
fevers, chills or rigors. he denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
palpitations. he admits to worsening shortness of breath.
Past Medical History:
1. Multivalvular disease secondary to mantle cell radiation as
a
child. Most prominent is his aortic stenosis with peak velocity
of 4.8 m/sec, peak gradient 91, mean 50, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 109**] is 0.9 cm2.
- s/p BAV [**2149-10-14**] (22mm)
2. Severe mitral annular calcification with mild functional MS
(mean gradient 3 mmHg).
3. Mild-to-moderate mitral regurgitation may be underestimated
due to his MAC.
4. At least moderate tricuspid regurgitation again potentially
underestimated due to shadowing.
5. Mild depression of LV function to 45-50%.
6. Complete heart block, status post [**Company 1543**] dual chamber
pacemaker (05/[**2149**]).
7. Pulmonary embolism - CTA done for CoreValve workup
identified
right acute right lower lobe PE with associated thrombosis of
right basilic and cephalic veins, presumed secondary to
pacemaker
implantation. Completed three months of Lovenox.
8. Hypertension.
9. CKD stage I.
10. Coronary artery disease with 70-80% stenosis of a
nondominant right coronary artery, otherwise, clean.
11. Hypothyroidism - s/p thyroidectomy
12. Hodgkin's lymphoma (at age 4) s/p Cobalt Radiation
Social History:
Lives with brother, 3 steps to enter home. All siblings
supportive, bring him meals.No services at present. Independent
ADL's. Uses motorized chair when out of the house due to
shortness of breath. 1ppd x 5yrs/quit 25yr ago
-ETOH: 3 24oz and 2 whiskey/week
-Illicit drugs: none
Family History:
Father deceased age 42, brain aneurysm. Mother deceased age 84,
glioblastoma. Five siblings.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Weight 70.4kg
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Face flushed, lips dusky. Oropharynx moist, upper partial.
NECK: Decreased ROM. Minimal extension.
CARDIAC: Murmer RSB. Left chest surgical incision well approx.
No thrills, lifts. No S3 or S4.
LUNGS: Cervical kyphosis, scoliosis (?). Resp were unlabored, no
accessory muscle use. No crackles, wheezes or rhonchi. Extreme
wasting neck upper torso area. Chest wall deformity.(+)clubbing.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. Abdomen rotund.
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+
DISCHARGE PHYSICAL EXAM:
Weight 74.1 kg
VS 98.3 HR 68-91 RR 16-18 BP 98-143/50-64 97%RA
Gen: awake, alert, pleasant, NAD
HEENT: anicteric, cervical kyphosis, OP moist, no JVD
CV: RRR, no murmurs
Lungs: CTAB
Abd: +BS, soft, NT/ND
Ext: L groin 2 cm site with serosanginous drainage, no erythema,
+ecchymosis, no edema, 2+ pulses
Pertinent Results:
Admission Labs:
[**2149-11-24**] 10:55AM GLUCOSE-157* UREA N-22* CREAT-1.1 SODIUM-141
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-24 ANION GAP-18
[**2149-11-24**] 10:55AM estGFR-Using this
[**2149-11-24**] 10:55AM ALT(SGPT)-32 AST(SGOT)-33 CK(CPK)-52 ALK
PHOS-116 TOT BILI-0.6
[**2149-11-24**] 10:55AM proBNP-2794*
[**2149-11-24**] 10:55AM ALBUMIN-4.4
[**2149-11-24**] 10:55AM WBC-6.6 RBC-4.00* HGB-12.1* HCT-36.4* MCV-91
MCH-30.2 MCHC-33.2 RDW-13.7
[**2149-11-24**] 10:55AM PLT COUNT-290
[**2149-11-24**] 10:55AM PT-12.4 PTT-31.9 INR(PT)-1.1
[**2149-11-24**] 10:38AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2149-11-24**] 10:38AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
Imaging:
[**2149-11-24**] CXR:
As compared to the previous radiograph, there is unchanged
position
of the right pectoral pacemaker and there is unchanged moderate
cardiomegaly with signs of mild-to-moderate pulmonary edema. No
pleural effusions. No other acute lung changes. No
pneumothorax. No pneumonia.
[**11-25**] CXR: Greater opacification in the right lower lung is
probably a combination of dependent edema and pleural effusion
layering posteriorly. In the interim, the patient has had an
aortic endoprosthesis placed. There is no pneumothorax.
Chronic moderate cardiomegaly is slightly larger today than on
[**11-24**], but it has been larger in the past. Pleural
effusions are presumed, but not appreciable. Transvenous right
atrial and right ventricular pacer leads are unchanged in their
respective positions.
[**2149-11-25**] ECHO:
Overall left ventricular systolic function is low normal (LVEF
50%). The right ventricular free wall is hypertrophied secondary
to marked ventricular interaction. The right ventricular cavity
is dilated with depressed free wall contractility. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. An aortic valve prosthesis
([**Last Name (un) 30978**]) is present. A mild paravalvular aortic valve leak is
probably present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
[**2149-11-26**] ECHO: Well seated [**Doctor Last Name **] [**Last Name (un) 30978**] AV bioprosthesis with
normal gradient and mild valvular and perivalvular AR. Symmetric
LVH with preserved global systolic function. Compared with the
prior study of [**2149-11-25**], mild perivalvular AR is now seen.
[**11-29**] CXR: IMPRESSION: AP and lateral chest compared to [**11-25**]:
Previous mild pulmonary edema has improved. There is sufficient
consolidation at the right lung base, which obscure that
hemidiaphragm on the lateral view and this could be pneumonia.
Small bilateral pleural effusions persist. Post-operative
enlargement of the cardiac silhouette is essentially stable.
Transvenous right atrial and right ventricular pacer leads are
unchanged in their respective positions and the CoreValve is
grossly unchanged. No pneumothorax.
[**11-29**] Groin U/S: IMPRESSION: Fluid tracking along the
subcutaneous tissues in the left thigh overlying the cath site
with no evidence of drainable collections. No evidence of
pseudoaneurysm.
Brief Hospital Course:
51yo male with severe symptomatic AS, multivalvular disease,CAD,
CHB s/p PPM, recent PE,chest wall deformity prohibitive for
surgical AVR, HTN, CKD stage 1.
ACTIVE ISSUES:
# Severe aortic stenosis: The patient was loaded with plavix and
given aspirin on the day prior to TAVR. He underwent TAVR with
an [**Doctor Last Name **] [**Last Name (un) 30978**] valve on [**2149-11-25**]. The procedure was without
complications and the post-procedure hematocrit was stable.
Blood pressures were maintained with phenylephrine which was
successfully weaned off on the day of the procedure. His mean
arterial pressures were maintained above 60. Blood pressures
continued to be labile after the procedure but did not require
restarting phenylephrine. Low dose beta blockers were restarted
on the day after the procedure and blood pressures tolerated
this well.
# Hospital-acquired pneumonia: Thought initially to be due to
pulmonary edema due to volume overload. Patient coughed up mucus
as improved significantly, consistent with mucus plugging.
Treated with guaifenesin and humidified oxygen with good effect.
Patient had low grade fever 100.2 on [**11-29**] and continued to
productive cough. Exam notable for dullness to percussion and
decreased breath sounds with egophany at R lung base and a
possible infiltrate on CXR. Started on levo/vanc for HAP.
INACTIVE ISSUES:
# CAD: RCA has 80-90% occlusion in nondominant system. He was
monitored for symptoms during hospitalization and remained
chest-pain free. He was continued on aspirin.
# Heart block: The patient has complete heart block s/p PPM,
last interrogation intrinsic CHB. The patient requesting
increase in set rate post procedure.
# Hypothyroidismn: The patient is s/p thyroidectomy and was
continued on levothyroxine.
# S/p Mantle radiation: Anesthesia was consulted for evaluation
for complicated intubation secondary to fixed neck. TEE was
deferred due to anatomy and TTE was utilized intraoperatively.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
hold on day of surgery
2. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K > 4.5, give with furosemide
3. Levothyroxine Sodium 150 mcg PO DAILY Start: In am
4. Metoprolol Succinate XL 100 mg PO DAILY
Hold on day of surgery
5. Aspirin 325 mg PO DAILY Start: In am
Discharge Medications:
1. Furosemide 40 mg PO DAILY
hold on day of surgery
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
Hold on day of surgery
RX *metoprolol succinate 100 mg 0.5 (One half) tablet(s) by
mouth daily Disp #*15 Tablet Refills:*3
4. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K > 4.5, give with furosemide
RX *potassium chloride [Klor-Con M20] 20 mEq 1 tab by mouth
daily Disp #*30 Tablet Refills:*3
5. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*5
6. Sulfameth/Trimethoprim DS 1 TAB PO DAILY Duration: 10 Days
continue if wound still drainig
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth daily Disp #*10 Tablet Refills:*1
7. Outpatient Lab Work
ICD-9: 424.1, 428
Labs: CBC, BUN, Creatnine
8. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*5
Discharge Disposition:
Home
Discharge Diagnosis:
Severe aortic stenosis s/p TAVR with [**Doctor Last Name **] [**Last Name (un) 30978**] valve.
Left groin wound dehiscence/hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 56272**],
It was a pleasure caring for you during your hospitalization at
[**Hospital1 18**]. You were admitted with increasing shortness of breath and
underwent an aortic valve replacement. The procedure went well
and you were discharged to follow up with your cardiologist.
Please take all medications as prescribed and attend all
follow-up appointments as indicated.
PLEASE REVIEW THE SEPARATE DISCHARGE INSTRUCTION SHEETS PROVIDED
TO YOU.
It is important to do the following:
1. take your temperature each evening (notify MD if >100.5)
2. change dry sterile dressing to left groin wound daily and as
needed.
3. Inspect groin wounds daily, notify MD if increase in redness
or drainage.
4. Shower daily with antibacterial soap.
5. No baths, swimming, jacuzzi - or anything that would submerse
you in potentially dirty water.
6. No lotions, ointments, creams to the groin sites.
7. You are being prescribed an antibiotic - Bactrim DS one tab
daily x 10days. If you still have drainage from the wound, we
will need to continue the antibiotic, please notify MD.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2150-4-6**] at 11:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"998.12",
"403.90",
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"998.30",
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"585.1",
"244.0",
"V10.72",
"414.01",
"V45.01",
"E879.8",
"738.3",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"35.05",
"37.78",
"37.22"
] |
icd9pcs
|
[
[
[]
]
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11711, 11717
|
8267, 8425
|
301, 387
|
11893, 11893
|
4828, 4828
|
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|
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3573, 4481
|
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|
8440, 9616
|
415, 1927
|
9633, 10235
|
4844, 8244
|
11908, 12020
|
1949, 3128
|
3144, 3423
|
4506, 4809
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,144
| 196,034
|
49699
|
Discharge summary
|
report
|
Admission Date: [**2203-6-7**] Discharge Date: [**2203-6-14**]
Date of Birth: [**2145-7-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Febrile seizure
Major Surgical or Invasive Procedure:
[**2203-6-7**] Intubation
[**2203-6-8**] RIJ line placement
[**2203-6-8**] IR-guided lumbar puncture
[**2203-6-9**] TEE
History of Present Illness:
57F presenting after witnessed seizure. She is intubated and
heavily sedated, so history is by report per discussion with ED
and with neurology resident, who interviewed pt's husband in [**Name (NI) **].
.
By report, pt awoke on the morning of admission feeling "unwell"
(tired), but went to work anyway. After returning from work, she
was watching television with her husband when ~7pm, she had a
witnessed tonic-clonic seizure lasting ~15 minutes. EMS was
activated, although the seizure had stopped by that time. She
received ativan 2mg IV x 2 by EMS for recurrence of seizure
activity, which then broke, and upon arrival to ED she was no
longer seizing.
.
She was found to be stuperous and intubated for airway
protection (etomidate, succs, dexamethasone 10mg ivx1). VS = 102
175/85 30 91% on unclear [**Name2 (NI) **] settings. ER notes indicated she
was "covered in stool." BP dropped to 92/50 after intubation for
which she received 4L IVF. Labs notable for leukocytosis 26 with
bandemia 14%, lactate 6.2, CRE 2.1 (bl ), NA 131, HCO3 16. CT
HEAD was unremarkable. She received CTX 2g, acyclovir, dilaintin
1g x1 @ 2250.
.
Neurology consult was obtained with exam limited by sedation.
.
Upon arrival to the MICU, pt is intubated and sedated, minimally
responsive to noxious stimuli (responds minimally to sternal
rub, withdraws to pain), with RR 20s (overbreathing [**Name2 (NI) **]).
Past Medical History:
- SLE c/b lupus nephritis
- Rheumatic heart disease, s/p bioprosthetic AVR [**9-9**], s/p
mechanical MVR with tricuspid valve annuloplasty [**10-13**]. Now with
moderate MS and MR, moderate AS and moderate to severe TR, mild
pHTN (42/16).
- HTN
- Raynaud??????s syndrome
- s/p cholecystectomy
- chronic anemia [**2-7**] recurrent GI bleeds, source unclear
(extensive GI workup including capsule endoscopy on [**11-26**] showed
no significant source for bleeding), on procrit [**2-7**] CRI, PPI for
GIB prophylaxis. Awaiting hematology consult (low hapto,
mechanical valves).
Social History:
The patient is married with one son lives with her husband.
[**Name (NI) 1403**] as an assistant to the CEO of [**Company 103926**]. Denies
tobacco, occasional alcohol use. Recently had just had a nice
vacation with her husband in [**Name (NI) 108**].
Family History:
Grandmother died from a CVA at age 50. Father died at age 70
from complications of diabetes.
Physical Exam:
On admission:
Vitals: T 103 HR 70 BP 104/76 RR 14 O2 100% on AC 500/40/14/5
General: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple-no meningismus, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
CV: Irregularly irregular, mechanical S1, and S2 with difficult
to hear heart sounds over ventilator
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash/petechiae
NEURO: pupils 3mm->2mm bilaterally, withdraws to pain minimally,
minimal arousal to sternal rub, dolls eyes intact. no gag.
Pertinent Results:
On admission:
[**2203-6-7**] 08:45PM BLOOD WBC-26.4* RBC-3.72* Hgb-11.3* Hct-34.2*
MCV-92 MCH-30.3 MCHC-33.0 RDW-15.7* Plt Ct-163
[**2203-6-7**] 08:45PM BLOOD Neuts-77* Bands-14* Lymphs-3* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1*
[**2203-6-6**] 09:05AM BLOOD PT-19.8* INR(PT)-1.8*
[**2203-6-7**] 08:45PM BLOOD Glucose-138* UreaN-35* Creat-2.1* Na-131*
K-5.1 Cl-101 HCO3-16* AnGap-19
[**2203-6-7**] 08:45PM BLOOD Calcium-8.7 Phos-3.6 Mg-1.3*
[**2203-6-8**] 02:45AM BLOOD ALT-28 AST-43* CK(CPK)-171* AlkPhos-111
TotBili-1.1
[**2203-6-7**] 09:03PM BLOOD Lactate-6.2*
.
[**2203-6-8**] 02:45AM TotBili-1.1
[**2203-6-8**] 02:35PM BLOOD LD(LDH)-423*
[**2203-6-8**] 02:35PM BLOOD Hapto-<20*
[**2203-6-9**] 01:39AM URINE Hemosid-NEGATIVE
.
[**2203-6-7**] ECG: Junctional rhythm with atrial premature complexes.
Possible left posterior fascicular block or inferior myocardial
infarction. Inferior/lateral ST-T changes may be due to
myocardial ischemia/myocardial
infarction Since previous tracing of [**2202-12-27**], rhythm new, axis
more right inferiorly, shorter Q-T interval and peaked T waves -
consider hyperkalemia - clinical correlation is suggested
.
[**2203-6-7**] CXR:
1. Satisfactory positioning of endotracheal and nasogastric
tubes.
2. Left lower lobe atelectasis.
.
[**2203-6-7**] CT head w/o contrast: No acute intracranial process.
Areas of encephalomalacia within the bilateral parietal and left
frontal regions likely attributed to prior ischemic insult.
.
[**2203-6-8**] CT head w/o contrast: No significant change since the
prior study dated [**2203-6-7**], unchanged areas of
encephalomalacia involving the bilateral temporoparietal lobes
and left frontal region, likely consistent with prior chronic
ischemic events. There is no evidence of acute intracranial
hemorrhage. If there is any clinical concern related with an
acute/subacute ischemic changes, correlation with MRI is
recommended if clinically warranted.
.
[**2203-6-8**] MRI/MRA brain:
1. Multiple areas in bilateral hemispheres, mostly frontal and
parietal
lobes, particularly in the left frontal lobe concerning for
subacute embolic infarcts.
2. No abnormalities seen within the circle of [**Location (un) 431**]
vasculature.
2. No evidence for hemorrhagic conversion.
3. Small vessel perivascular ischemic and age-related atrophy.
4. Prior left thalamic infarct.
.
[**2203-6-7**] TTE: The estimated right atrial pressure is 10-15mmHg.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. A bioprosthetic aortic
valve prosthesis is present. The transaortic gradient is higher
than expected for this type of prosthesis. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. Mild (1+) aortic
regurgitation is seen. A bileaflet mitral valve prosthesis is
present. The prosthetic mitral leaflets appear normal. No masses
or vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. Trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. A tricuspid
valve annuloplasty ring is present. No masses or vegetations are
seen on the tricuspid valve, but cannot be fully excluded due to
suboptimal image quality. Moderate [2+] tricuspid regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
The pulmonic valve leaflets are thickened. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2202-12-20**],
there is no significant change. No vegetations identified but a
TEE is required to assess prosthetic valves for endocarditis.
.
[**2203-6-9**] TEE:
1. Bileaflet mitral valve prosthesis with 2-cm long adjacent
vegetation. Mild paravalvular leak and 1+ mitral regurgitation.
2. Well-seated, normally functioning bioprosthetic aortic valve
replacement. No aortic vegetation.
3. Tricuspid annuloplasty ring is present. Mild tricuspid
regurgitation. No tricuspid or pulmonic valve vegetations.
.
Brief Hospital Course:
# Endocarditis: Patient had staph aureus in [**4-9**] BCx bottles from
admission and a history of mechanical valve as well as
bio-prostetic valve. She underwent TTE that was non-diagnostic
but a TEE showed vegetations on the mechanical MV. Id was
consulted and recommended she start on vanc and gentamicin while
awaiting sensitivities. She was also started on rifampin for
better penetration into the prosthesis. On [**2203-6-11**] it was noted
that she had PR prolongation of 250 msecs and on the am of
[**2203-6-12**] she had a 15 second pause. Family declined temporary
pacer wire placement. On further discussion, given that she was
failing medical therapy and was not a surgical candidate focus
was shifted towards comfort.
# seizure - Given fever, leukocytosis, bandemia, an infectious
etiology, particularly meningitis, seemed likely on
presentation. She was treated empirically with
vanc/ctx/acv/ampicillin. LP was performed in IR and revealed a
leukocytosis. MRI head showed multiple likely septic emboli.
She was continued on dilantin, dosed by level, and antibiotics
as above for endocarditis with presumed seeding of the CSF. She
was maintained on dilatin while she was comfort measures.
# hypotension - Patient had septic shock on presentation and
required levophed to maintain pressures after receiving 9L IVF.
After treatment with antibiotics for several days she was weaned
off levophed and maintained better BPs.
# metabolic acidosis - likely [**2-7**] lactate and infectious
etiology, lactate trended down with IVF and antibiotic
treatment.
# SLE c/b lupus nephritis: Dr. [**Last Name (STitle) 3057**] was contact[**Name (NI) **] and felt
her plaquenil should be held in the setting of her acute
illness.
# Rheumatic heart disease, s/p AVR, MVR: She was started on a
heparin gtt and coumadin was held given likelihood of procedures
during her hospitalization.
# HTN - Her home medications of coreg, valsartan and lisinopril
were held during this hospitalization.
# Code: DNR/DNI/CMO
# Communication: husband
# Patient passed away on [**2203-6-14**] at 3:32 am with her husband at
the bedside. The death was peaceful and the family was coping
appropriately. They respectfully declined an autopsy.
Medications on Admission:
- coreg 25mg po bid
- procrit 50mcg Q2WEEKS
- folic acid 2mg PO QDAILY
- plaquenil 200mg PO BID
- lisinopril 40mg PO QDAILY
- ativan 0.5-1.0 mg PO QDAILY PRN
- omeprazole 40 mg PO QDAILY
- oxycodone 5mg po q4-6hrs PRN
- kayexalate 15g PO QDAILY PRN K>5.7
- valsartan 80 mg PO QDAILY
- warfarin 3mg 6d per week, 2mg on TEUS
- ferrous gluconate 324mg PO QDAILY
- MVI
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
MRSA Endocarditis
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
None
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2203-6-14**]
|
[
"585.9",
"780.39",
"398.90",
"443.0",
"995.92",
"582.81",
"785.52",
"710.0",
"996.61",
"434.11",
"584.9",
"322.9",
"V42.2",
"421.0",
"403.90",
"276.1",
"518.81",
"276.2",
"038.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.04",
"88.72",
"38.93",
"88.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10451, 10460
|
7774, 10003
|
329, 450
|
10522, 10532
|
3588, 3588
|
10588, 10718
|
2755, 2849
|
10419, 10428
|
10481, 10501
|
10029, 10396
|
10556, 10565
|
2864, 2864
|
274, 291
|
478, 1870
|
3602, 7751
|
1892, 2468
|
2484, 2739
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,430
| 190,383
|
578
|
Discharge summary
|
report
|
Admission Date: [**2108-3-20**] Discharge Date: [**2108-3-23**]
Date of Birth: [**2043-7-15**] Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending:[**First Name3 (LF) 4358**]
Chief Complaint:
fever at dialysis
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
64M w/ h/o schizoaffective disorder & ESRD [**3-1**] lithium toxicity
admitted from [**Location (un) **] [**Location (un) **] for fever at HD, in ED febrile to
104F w/tachycardia to 130s (sinus), admitted to ICU for possible
septic shock, source still unclear. CXR clear. UA clean. No
line; LUE AVF w/normal ultrasound; no known graft material
therein per transplant surgery prior notes. Most of his care is
at [**Hospital1 112**] but he is transitioning to transplant nephrology at [**Hospital1 18**]
where he is being evaluated for transplant.
.
ROS negative for N/V, diarrhea, URI symptoms, no sick contacts.
On exam, only noted to have mild LLQ abdominal pain. Started on
vanc/zosyn in the ED after BCx and UCx sent; these were
continued in the ICU.. BPs have been stable 120s-130s since
admission, no pressor requirement; total 2L IVF received.
Afebrile since initial spike to 104 in the ED.
.
ICU labs notable for pancytopenia: WBC 2.4, Hct 27.6, Plt 98;
suspect medication effect. ICU staff called PCP's office to
inquire about temporality, prior workup; per report, pt has seen
Dr. [**First Name8 (NamePattern2) 2092**] [**Last Name (NamePattern1) 4594**] at [**Company 2860**] for pancytopenia. In [**2107-11-29**] he felt the
pt had appropriate retic index & felt thrombocytopenia was [**3-1**]
medication effect, no intervention required. PCP notes show
baseline plts 125-150; on last CBC in [**2107-11-29**], WBC 4.3,
11.3/32.9, Plts 107.
Past Medical History:
ESRD [**3-1**] lithium toxicity (started dialysis on [**9-8**] via LUE AVF)
Schizoaffective disorder
Bipolar disorder
Hypercholesterolemia
Hypertension
.
Past Surgical History:
s/p appendectomy
Social History:
Lives alone in [**Location (un) **], MA. Currently unemployed; studied
anthropology at the [**State 4595**].
- Tobacco: 2ppd x 30 years; quit at age 50
- Alcohol: Rare wine; last appx q4-5 months
- Illicits: None currently. H/o marijuana use in college
Family History:
Mother alive in [**State **], age [**Age over 90 **] w/Alzheimers disease. Father
deceased @age [**Age over 90 **]. Two brothers, both healthy, one in [**Name (NI) 4596**], MN
and one in [**Location (un) **].
Physical Exam:
ADMISSION
VS Tm 104.4 Tc 99.0 HR 105 BP 119/80 RR 19 O2 94%/RA
GEN Alert, oriented, no acute distress, pleasant
HEENT: NCAT, EOMI, PERRL, OP clear, sclera anicteric, dry
membranes w/ dried saliva around lips;
Neck: supple, JVP not elevated, no adenopathy palpated
CV: tachycardic RR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: soft NT ND + bulging flanks but no fluid wave,
hyperactive BS
Ext: LUE fistula w/palpable thrill throughout; no erythema,
induration, fluctuance, or TTP; fingers/toes all warm, well
perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact
Skin: no rashes or lesions except fine greasy scale across
erythematous nose & forehead
.
DISCHARGE
VS 98.5 98.0 95/68 (95/68-134/85) FS101
GEN Alert, oriented, sitting up in bed, no acute distress
HEENT: NCAT, EOMI, PERRL, OP clear, sclera anicteric MMM
Neck: supple, JVP not elevated, no adenopathy palpated
CV: tachycardic RR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: soft NT ND +lipodystrophy, no fluid wave, normoactiveBS
Ext: LUE fistula w/palpable thrill throughout; no erythema,
induration, fluctuance, or TTP; fingers/toes all warm, well
perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact
Skin: no rashes or lesions except fine greasy scale across
erythematous cheeks & forehead
Pertinent Results:
ADMISSION LABS
[**2108-3-20**] 08:50PM BLOOD WBC-3.7* RBC-3.45* Hgb-11.2* Hct-31.3*
MCV-91 MCH-32.4* MCHC-35.8* RDW-13.2 Plt Ct-103*
[**2108-3-20**] 08:50PM BLOOD Neuts-87.7* Lymphs-3.9* Monos-7.7 Eos-0.4
Baso-0.2
[**2108-3-20**] 08:50PM BLOOD PT-11.5 PTT-27.1 INR(PT)-1.1
[**2108-3-20**] 08:50PM BLOOD Glucose-105* UreaN-20 Creat-3.3*# Na-138
K-4.3 Cl-95* HCO3-29 AnGap-18
[**2108-3-20**] 08:50PM BLOOD ALT-18 AST-21 AlkPhos-203* Amylase-227*
TotBili-0.2
[**2108-3-20**] 08:50PM BLOOD Albumin-4.6
.
LACTATE TREND
[**2108-3-20**] 08:54PM BLOOD Lactate-2.3* K-4.3
[**2108-3-21**] 12:28AM BLOOD Lactate-1.1
.
URINALYSIS
[**2108-3-21**] 12:09AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2108-3-21**] 12:09AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2108-3-21**] 12:09AM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0.
.
DISCHARGE LABS
[**2108-3-23**] 07:27AM BLOOD WBC-3.1* RBC-3.46* Hgb-11.1* Hct-31.6*
MCV-91 MCH-32.0 MCHC-35.0 RDW-13.3 Plt Ct-88*
[**2108-3-23**] 07:27AM BLOOD Neuts-64.3 Lymphs-21.9 Monos-11.0 Eos-2.5
Baso-0.3
[**2108-3-23**] 07:27AM BLOOD Glucose-91 UreaN-30* Creat-4.4*# Na-141
K-4.4 Cl-100 HCO3-30 AnGap-15
[**2108-3-23**] 07:27AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0
.
MICRO
[**3-20**] Blood cultures x2 NGTD
[**3-20**] Urine culture - FINAL NEGATIVE
[**3-21**] Blood cultures x2 NGTD
[**3-22**] Blood cultures x2 NGTD
.
CXR: AP upright portable chest radiograph is obtained. Right CP
angle inferior most aspect is excluded. The imaged portions of
the lungs appear clear without focal consolidation, effusion, or
pneumothorax.
Cardiomediastinal silhouette is normal. Bony structures are
intact. No free air is seen below the right hemidiaphragm.
IMPRESSION: No acute findings in the chest.
.
[**3-21**] LUE NONVASCULAR ULTRASOUND
FINDINGS: Transverse and sagittal images were obtained of the
left upper arm at the area of interest indicated by the patient.
There is no fluid collection seen within the superficial
tissues. No suspicious soft tissue mass is identified. The
adjacent graft is noted to be patent but is not formally
evaluated.
IMPRESSION: No fluid collection or other signs of infection seen
in the left upper arm.
.
[**3-20**] EKG: Sinus tachycardia at 138 bpm. Normal axis and
intervals (QTc = 414); No ST-T wave changes.
Brief Hospital Course:
Assessment and Plan:
64 yo M w/ h/o ESRD [**3-1**] lithium toxicity being evaluated for
renal transplant admitted with fevers at dialysis, no source
identified by exam/imaging/labs, discharged home after he was
afebrile 24h off antibiotics.
# Fever/hypotension on admission:
Admitted to ICU with concern for SIRS, w/fever to 104, relative
hypotension (105->93 systolic evolved in the ED), elevated WBC
and tachycardia. Source unclear - studies were unrevealing (CXR
and UA wnl, UCx negative, BCx NGTD). Renal consult team
evaluated fistula and felt there was mild warmth but no
erythema; follow-up AVF ultrasound non-concerning for
inflammation. Patient reports he had been feeling malaised at
home yesterday even before going to HD, cancelled some social
appointments yesterday morning. ROS negative in full including
GI and GU. No evidence of thrombus on exam. Antibiotics were
stopped the morning of [**3-22**]; he remained afebrile for 24h
thereafter, so was discharged home with instructions to check
temperature [**Hospital1 **] and call PCP if [**Name Initial (PRE) **]>101, subjective fever or
malaise.
.
#Pancytopenia
All lines low on admission labs. ICU d/w PCP reveals this to be
a chronic issue, already evaluated by heme/onc at [**Company 2860**] a few
months ago and thought to be a med effect; no known med changes
since that time. Admission labs here were slightly worse than
prior, with Plts 98 from baseline 125-150. Peripheral smear was
evaluated by hematology fellow who saw microcytic hypochromic
RBCs and some atypical lymphocytes but no teardrop and no
dysplasia. Recommended he arrange f/u with heme-onc at [**Company 2860**],
will need bone marrow.
.
# ESRD on HD:
Pt has ESRD secondary to lithium toxicity, dialysis initiated in
[**8-/2107**] via LUE AVF without difficulty at [**Location (un) **] [**Location (un) **]. Being
evaluated by Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] for renal transplant.
Nephrology followed closely during this admission; transplant
surgery saw him in the ED. He was continued on HD qTuThSat, with
no difficulty accessing LUE AVF. Continued home sevelamer 800 mg
PO qAC, decreased iron 325 mg PO BID -> QD, continued epogen qHD
& started nephrocaps per renal recs.
.
# Schizoaffective/Bipolar disorder:
Well compensated on current regimen. Is followed by Dr. [**First Name4 (NamePattern1) 4597**]
[**Last Name (NamePattern1) **] who has followed him weekly for the past 15 years.
Continued home abilify, benztropine, clonipine, and haldol.
There was concern that his abilify may contribute to
pancytopenia, but defer any med changes to his outpatient
providers.
.
# Elevated Anion Gap on admission:
Anion gap of 14 on admission, likely secondary to lactate of 2.3
in setting of relative hypoperfusion, since resolved with PO
hydration.
.
TRANSITIONAL ISSUES
1. Follow-up pancytopenia, needs re-evaluation at [**Company 2860**], possible
med adjustment and bone marrow eval for MDS
2. Follow-up fever curve (patient will check temp [**Hospital1 **] for next
week)
Medications on Admission:
ARIPIPRAZOLE 30 mg PO once a day
BENZTROPINE 0.5 mg PO once a day
CLONAZEPAM 0.5 mg PO BID (1 mg qHS)
HALDOL 5mg PO breakfast, lunch; 10mg PO qHS
OMEPRAZOLE 20 mg PO daily
SEVELAMER HCL 800 mg Tablet qAC
SIMVASTATIN 10 mg PO daily
ASPIRIN 81 mg PO daily
DOCUSATE SODIUM 100 mg PO BID
FERROUS SULFATE 325 mg PO BID
SENNOSIDES 17.2 mg PO BID
Discharge Medications:
1. aripiprazole 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. benztropine 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): breakfast, lunch.
6. haloperidol 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. sennosides 17.2 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for constipation.
14. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 capsule* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with fever.
You went to the ICU first because we were concerned about
serious infection. You received broad-spectrum antibiotics
initially but stopped these after 2 days because your fever was
gone. You were feeling well and had no concerning results on
labs, x-rays or examination.
Please take your temperature twice daily (morning and night)
over the next week, and any time you feel feverish, sweaty, or
ill. If your temperature is 101 or greater, please call your
PCP's office.
We made the following changes to your medications:
DECREASED IRON TO ONCE-PER-DAY
STARTED NEPHROCAPS (RENAL VITAMIN SUPPLEMENT)
Please review your medication list with your doctor at your next
appointment.
Followup Instructions:
Name: [**Last Name (LF) 4598**],[**First Name3 (LF) 4599**] E.
Location: [**Hospital6 4600**] PRIMARY CARE
Address: [**Street Address(2) 2687**]., [**Apartment Address(1) **]-B, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 355**]
Appointment: Wednesday [**2108-3-28**] 11:50am
.
Your PCP may consider referring you back to see your
hematologist at [**Hospital1 4601**] for re-evaluation of your low blood
counts.
.
Department: TRANSPLANT
When: TUESDAY [**2108-4-17**] at 10:10 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"276.2",
"285.9",
"780.60",
"284.19",
"585.6",
"403.91",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11110, 11116
|
6501, 6763
|
289, 304
|
11166, 11166
|
4130, 6478
|
12067, 12817
|
2288, 2498
|
9930, 11087
|
11137, 11145
|
9565, 9907
|
11317, 11858
|
1984, 2002
|
2513, 4111
|
11887, 12044
|
232, 251
|
332, 1784
|
9174, 9539
|
11181, 11293
|
1806, 1961
|
2018, 2272
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,013
| 165,520
|
15547
|
Discharge summary
|
report
|
Admission Date: [**2125-10-4**] Discharge Date: [**2125-10-7**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is an 87 year old
female with a past medical history of hypertension, coronary
artery disease, hyperlipidemia, and non-Hodgkin's lymphoma,
who was transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]
from an outside hospital with pneumonia complicated by a
myocardial infarction and sepsis.
The patient was initially admitted to [**Hospital3 3834**]
[**Hospital3 **] on [**2125-10-3**] with shortness of breath, cough
and pneumonia. She then had an episode of hypotension in the
Emergency Room and was resuscitated with fluids. She was
transferred to the floor, where she began complaining about
chest pain. She had episodes of rapid atrial fibrillation.
She was then transferred to the Medical Intensive Care Unit
at [**Hospital3 3834**], where she received digoxin and
Lopressor. With that, she became hypotensive again with
systolic blood pressure in the low 70s.
The patient's electrocardiogram showed normal sinus rhythm
with nonspecific ST changes and a chest x-ray was significant
for a left lower lobe infiltrate. Her cardiac enzymes were
elevated, with a CPK of 163, MB 12.3, index 7.5 and troponin
4. An echocardiogram showed mitral regurgitation and left
ventricular ejection fraction of 70%. The patient was
treated in the Intensive Care Unit with heparin and a
nitroglycerin drip. She was given ceftriaxone but continued
to be hypotensive and was started on a Dopamine drip.
Swan catheterization was performed as well and showed a
cardiac output of 10 and systolic vascular resistance of 300.
The patient was then transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **]
[**First Name (Titles) **] [**Last Name (Titles) **] for further management.
HOSPITAL COURSE: On arrival here, the patient continued to
be hypotensive and required the use of multiple pressors,
including Dopamine, dobutamine and vasopressin. Cardiac
enzymes continued to rise. Her electrocardiogram was
significant for ST depressions in anterior and lateral leads.
The patient's respiratory status worsened as well. The
patient was consulted extensively by the Medical Intensive
Care Unit team and refused intubation. She also voiced her
desire to avoid resuscitation and intubation. The [**Hospital 228**]
health care proxy, her daughter [**Name (NI) 14880**], confirmed the
patient's will.
The patient remained unintubated, on pressors and
antibiotics. Over the course of the next 24 hours, she
continued to have chest pain and shortness of breath and was
made "Comfort Measures Only" per her and her family's
request. Since [**2125-10-6**], the patient remained on
antibiotics, off pressors and on a morphine sulfate drip for
comfort. She remained hypotensive over her course of stay in
the hospital.
DISPOSITION: On [**2125-10-7**] at 1:15 p.m., the patient
had a cardiac arrest and died. The chief cause of death was
a myocardial infarction and immediate cause was cardiac
arrest. Time of death was 1:20 p.m. on [**2125-10-7**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern4) 26613**]
MEDQUIST36
D: [**2125-10-7**] 14:43
T: [**2125-10-7**] 18:20
JOB#: [**Job Number 45003**]
|
[
"202.80",
"272.4",
"424.0",
"427.31",
"458.2",
"410.71",
"038.9",
"486",
"785.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
1939, 3437
|
123, 1921
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,795
| 197,067
|
16702
|
Discharge summary
|
report
|
Admission Date: [**2100-10-16**] Discharge Date: [**2100-10-19**]
Date of Birth: [**2058-4-2**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 42-year-old male
status post fall from a height of approximately 10 feet to
the pavement. The patient hit his head, landing on his left
side. There was no loss of consciousness.
He walked to the [**Hospital 26200**] Hospital for evaluation.
There, a right supraorbital laceration was irrigated and
closed. Later he developed left-sided pain and an episode of
hypotension with a systolic blood pressure of 90. He
responded to the crystalloid bolus. Found to have left upper
quadrant tenderness on examination. His initial hematocrit
was 41.2. A CAT scan was done which revealed a hematoma
involving the spleen and his left kidney. He was transferred
to the [**Hospital1 69**] for further
management. He was hemodynamically stable with a blood
pressure of 140/74 and a heart rate in the 80s.
Upon arrival here he complained of diffuse abdominal pain and
right foot pain.
PAST MEDICAL HISTORY:
1. Status post left knee surgery.
2. History of transverse myelitis.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco, or alcohol, or drugs.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 99.2, blood pressure was 130/palp,
heart rate was 88, respiratory rate was 20, oxygen saturation
was 95% on 2 liters nasal cannula. In general, [**Location (un) 2611**] Coma
Scale of 15. Head, eyes, ears, nose, and throat examination
revealed laceration already sutured over the left eye. Left
cheek abrasion. Pupils were equal and reactive. Extraocular
movements were intact. Stable tympanic membranes. Clear
cervical spine, nontender. Chest was clear to auscultation
bilaterally. Heart revealed a regular rate and rhythm. The
abdomen was diffusely tender with mild rigidity. Rectal
examination was guaiac-negative with a normal prostate. The
pelvis was stable and nontender. Back was nontender. No
stepoff. Extremities revealed ecchymosis over the right
great toe. Neurologically, the patient was intact.
PERTINENT LABORATORY DATA ON PRESENTATION: At the outside
hospital, hematocrit was 41.2. At [**Hospital1 190**], hematocrit was 34.2. INR was 1.1. A
toxicology screen revealed cocaine and opiates.
RADIOLOGY/IMAGING: A head computed tomography was negative.
A computed tomography of the abdomen revealed a grade 3
fracture of the upper pole of the spleen with a surrounding
hematoma. It also revealed a grade 4 fracture of the upper
pole of the left kidney with a surrounding hematoma. There
was blood seen along the liver and at the pelvis.
A chest x-ray was negative.
A pelvis x-ray was negative.
A head computed tomography was negative.
A cervical spine x-ray and thoracolumbosacral x-ray were
normal.
A right foot x-ray revealed first phalanx nondisplaced
fracture involving the joint.
HOSPITAL COURSE: The patient was admitted to the Trauma
Intensive Care Unit and q.4h. hematocrits were obtained. The
Orthopaedic Service was consulted for the toe fracture, and
they recommended a healing sandal, weightbearing as
tolerated. The patient's hematocrit remained stable in the
Intensive Care Unit. He had approximately 10 hematocrits
drawn, and they all ranged from 29 to 32.
The patient was transferred to the floor for surgical care on
hospital day one. On the floor, he had q.6h. hematocrit
check which were once again all stable. On hospital day
three, the patient was ambulating, making good urine, and
tolerating a regular diet. His pain was controlled with oral
medications.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE FOLLOWUP: The patient was to follow up with the
Trauma Clinic in one week.
MEDICATIONS ON DISCHARGE: Discharge medications included
Percocet one to two tablets p.o. q.4-6h. as needed (for
pain).
DISCHARGE INSTRUCTIONS: The patient was instructed very
clearly to not be involved with any type of contact activity
for six weeks.
DISCHARGE DIAGNOSES:
1. Grade 3 liver laceration.
2. Grade 4 left renal laceration.
3. Fracture of the right great toe.
[**Name6 (MD) 19851**] [**Name8 (MD) 19852**], M.D. [**MD Number(1) 19853**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2100-10-19**] 13:11
T: [**2100-10-23**] 04:48
JOB#: [**Job Number 38827**]
|
[
"E884.9",
"864.09",
"305.20",
"305.60",
"866.01",
"826.0",
"865.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4157, 4501
|
3907, 4002
|
1169, 1213
|
2998, 3692
|
4027, 4136
|
3707, 3793
|
3814, 3880
|
157, 1048
|
1070, 1142
|
1230, 2979
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,408
| 122,230
|
48139+59063+59064
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2135-6-19**] Discharge Date: [**2135-7-18**]
Date of Birth: [**2088-5-21**] Sex: F
Service: CSURG
Allergies:
Penicillins / Vancomycin And Derivatives / Percocet / Metformin
/ Rezulin / Metoclopramide / [**Doctor First Name **] / Sulfonamides / Zoloft /
Nsaids
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Increased DOE and generalized weakness.
Major Surgical or Invasive Procedure:
Re-do MVR, AVR (mechanical)
History of Present Illness:
This 47 year old African American female has a history of IDDM,
HTN, and is s/p MVR at age 16 for rheumatic heart disease. She
also has a history of depression and schizo-affective disorder.
She has had two years of worsening SOB, DOE, PND, orthopnea, and
generalized weakness. She had an ETT in [**3-13**] which revealed an
infero-lat. reversible defect and she underwent cardiac cath on
[**2135-4-28**] which showed clean coronaries and a poorly functioning
artificial mitral valve with severe mitral regurgitation, severe
tricuspid regurgitation, and 2+ aortic insufficiency. She had a
LVEF of 30%. She is now admitted for diuresis before redo
AVR/MVR.
Past Medical History:
Rheumatic heart disease
s/p MVR at age 16
HTN
IDDM
Depression
Schizo-affective disorder
Anxiety
GERD
SVT
Sickle cell trait
Social History:
Cigs: none
ETOH: none
Lives with husband.
Family History:
+ DM
Physical Exam:
Gen: WDWN BF in NAD
AVSS
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: Supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. w/ radiated murmur.
Lungs: Clear to A+P
CV: RRR w/out R/G, 3/6 SEM
Abd: Obese, + BS, soft, non-tender, w/out masses or
hepatosplenomegaly.
Ext: 2+ bil. LE edema, pulses DP trace bilat.
Neuro: Flat affect, non-focal.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2135-7-12**] 06:30AM 18.6* 3.38* 9.8* 28.8* 85 29.0 34.0 14.4
503*
BASIC COAGULATION (PT, PTT, PLT, INR) PT Plt Ct INR(PT)
[**2135-7-13**] 06:45AM 20.4* 2.8
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2135-7-12**] 06:30AM 193* 29* 1.4* 132* 4.9 96 25 16
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2135-7-12**] 06:30AM 2.0
Brief Hospital Course:
The patient was admitted on [**2135-6-19**] for medical evaluation and
aggressive diuresis prior to surgery. She was diuresed,
evaluated by [**Last Name (un) **] for her diabetes, and was taken to the CCU
on [**6-22**] for PA line placement for evaluation of PA pressures.
The swan showed good opening numbers,it was removed the
following day, and the patient was transferred back to the floor
prior to surgery.
On [**2135-6-27**] she underwent Redo MVR/AVR a [**Street Address(2) 17009**]. [**Male First Name (un) 923**] in the
mitral position and a 21mm St. [**Male First Name (un) 923**] in the aortic position.
Cross clamp time was 129 min. and total bypass time was 177 min.
She was transferred to the CSRU and profuse bleeding. She was
treated with multiple blood products and was taken back to the
OR for exploration. She then returned to the CSRU on Levophed,
Milrinone, Insulin, and Propofol. She had a stable post op
night and was extubated on POD#1. She was weaned off her drips
on POD#2 and was aggressively diuresed. Shr required aggressive
pulmonary therapy as well. She remained in the unit on
intermittent Neo and continued to progress. She went into
atrial fibrillation on POD#4 and had an increased Neo
requirement and was increasingly short of breath. She had an
echo which showed no tamponade and the valves were working well.
On [**7-1**] she was cardioverted into Sinus rhythm. She was
markedly improved and continued to improve.
She had a persistently elevated WBC ranging from 18,000 to
23,000 and she did not have a source. On POD#7 she was
transferred to the floor in stable condition. She continued to
be anticoagulated with coumadin, continued to be aggressively
diuresed, and continued to improve. She remained extremely
depressed and said that if she could, she would take all of her
pills and die. She was closely followed by psychiatry. They
increased her Paxil dose and she had a sitter. She eventually
improved and did not require a sitter, but she still says she
would like to take all of her pills, if she has access to them.
She had some vaginal discharge and was seen by GYN who examined
her and did a culture. She had normal vaginal flora and they
wanted her to follow up with her own gynecologist in [**1-11**] weeks.
She continued to improve with ambulation and on POD#16 she was
transferred to the inpatient psychiatry service. She did have a
sl. opening at the top of her sternal wound, with slight
drainage, and is being treated with softsorb TID.
Medications on Admission:
Paxil 60 mg. PO qd
Klonopin 1 mg. PO qd
Risperidal 3 mg. PO qd
Insulin 70/30 40 U qAM, 22 U qPM
Humalog SS
Coumadin 3 mg. PO qd
Zantac 150 mg. PO BID
Lopressor 50 mg. PO BID
Tolterodine 2 mg. PO qd
Edecrin 25 mg. PO qd
KCl 10 meq PO qd
Colace 100 mg. PO BID
Lisinopril 2.5 mg. PO qd
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Titrate for INR goal of [**2-9**].5.
4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
5. Risperidone 3 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
6. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO QD (once a day).
9. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
10. Paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO QAM (once
a day (in the morning)).
11. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H
(every 4 to 6 hours) as needed.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO QD (once
a day).
14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
15. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 1 doses.
16. Insulin 70/30 70-30 unit/mL Suspension Sig: One (1)
Subcutaneous twice a day: 42 units q breakfast and 22 units q
dinner.
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Titrate for INR goal of [**2-9**].5.
4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
5. Risperidone 3 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
6. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO QD (once a day).
9. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
10. Paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO QAM (once
a day (in the morning)).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO QD (once
a day).
13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
14. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 1 doses.
15. Insulin 70/30 70-30 unit/mL Suspension Sig: One (1)
Subcutaneous twice a day: 42 units q breakfast and 22 units q
dinner.
16. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours.
Discharge Disposition:
Extended Care
Facility:
Bostonian - [**Location (un) 86**]
Discharge Diagnosis:
Mitral regurgitation
Tricuspid regurgitation
Aortic insufficiency
Insulin dependent diabetes mellitis
Hypertension
Depression
Anxiety
Schizo-affective disorder
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium, diabetic diet
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] @ [**Last Name (un) **].
Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Make an appointment with Dr. [**Last Name (STitle) **]
Completed by:[**2135-7-13**] Name: [**Known lastname 3133**], [**Known firstname 16323**] M Unit No: [**Numeric Identifier 16324**]
Admission Date: [**2135-7-13**] Discharge Date: [**2135-7-13**]
Date of Birth: [**2088-5-21**] Sex: F
Service: PSY
ADDENDUM: The patient was transferred to the Inpatient
Psychiatric Floor on [**2135-7-13**]. Some of her medications
were changed, and they were the following, her insulin NPH
70/30 was changed to 48 units q. AM and 26 units q. PM, also
her Amiodarone was 400 mg p.o. q. day for one week and then
change to 200 mg p.o. q. day for three weeks. Her Coumadin
was 5 mg p.o. q. day, check coagulation screen q. day for an
INR goal of 3 to 3.5.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 3125**]
Dictated By:[**Last Name (NamePattern1) 16325**]
MEDQUIST36
D: [**2135-7-13**] 16:54:07
T: [**2135-7-13**] 18:55:44
Job#: [**Job Number 16326**]
Name: [**Known lastname 3133**],[**Known firstname 16323**] M Unit No: [**Numeric Identifier 16324**]
Admission Date: [**2135-6-19**] Discharge Date: [**2135-7-18**]
Date of Birth: [**2088-5-21**] Sex: F
Service: CSURG
Allergies:
Penicillins / Vancomycin And Derivatives / Percocet / Metformin
/ Rezulin / Metoclopramide / [**Doctor First Name **] / Sulfonamides / Zoloft /
Nsaids
Attending:[**First Name3 (LF) 674**]
Chief Complaint:
please see discharge summary
Major Surgical or Invasive Procedure:
please see discharge summary
Pertinent Results:
[**2135-7-18**] 10:25AM BLOOD WBC-12.7* RBC-3.30* Hgb-9.4* Hct-27.6*
MCV-84 MCH-28.5 MCHC-34.1 RDW-14.1 Plt Ct-433
[**2135-7-17**] 06:45AM BLOOD PT-21.5* INR(PT)-3.1
[**2135-7-16**] 06:30AM BLOOD PT-23.1* INR(PT)-3.5
[**2135-7-18**] 10:25AM BLOOD PT-21.0* PTT-37.3* INR(PT)-2.9
[**2135-7-18**] 10:25AM BLOOD Glucose-173* UreaN-22* Creat-1.2* Na-135
K-4.5 Cl-102 HCO3-24 AnGap-14
[**2135-7-17**] 06:20PM BLOOD Glucose-151* UreaN-26* Creat-1.3* Na-134
K-5.1 Cl-101 HCO3-18* AnGap-20
Brief Hospital Course:
Mrs. [**Known lastname **] was discharged to the inpatient psychiatric floor on
[**7-13**]. Shortly after arrival, she was found to be diaphoretic and
bradycardic, SBP in the 80s. Her EKG at the time showed
ventricular bigeminy at a rate of 80. She was readmitted to the
floor, and placed on telemetry. She did not have any documented
bradycardia, her amiodarone and lopressor were decreased. Her
creatinine was noted to be elevated to 1.9, thought to be due to
a combination of agressive diuresis and ACE inhibitor. Her
lasix was decreased and her ACE inhibitor was held as her SBP
was also low. She was also noted to have a larger separation of
the skin on the superior aspect of her sternal wound, which was
draining serous fluid.
Over the next several days, her creatinine decreased to 1.3, her
sternal wound was packed with normal saline wet to dry and began
to granulate in, and she had no documented bradycardia.
The psychiatry service evaluated Mrs. [**Last Name (STitle) **] on Friday [**7-15**] and
felt that she was no longer a threat to herself or others, and
did not need inpatient psychiatriac care. It was recomended
that patient be evaluated for short term rehab.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Warfarin Sodium 1 mg Tablet Sig: qd Tablet PO HS (at
bedtime): Titrate for INR goal of [**2-9**].5.
4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
5. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
7. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
8. Paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO QAM (once
a day (in the morning)).
9. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
11. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 1 doses.
12. Insulin 70/30 70-30 unit/mL Suspension Sig: One (1)
Subcutaneous twice a day: 48 units q breakfast and 24 units q
dinner.
13. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours.
14. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: One (1)
Subcutaneous four times a day: Humalog SSplease see attached
sliding scale.
15. Risperidone 2 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Multivitamin Capsule Sig: One (1) Cap PO QD (once a
day).
18. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO QD (once a day).
19. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO QD (once
a day).
20. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
Bostonian - [**Location (un) 42**]
Discharge Diagnosis:
status post mitral valve replacement
mitral regurgitation/tricuspid regurgitation/aortic
insufficiency
diabetes mellitus
status post redo sternotomy, mitral valve replacement/aortic
valve replacement
depression
pre-renal ATN
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 233**] MD if weight > 3 lbs.
Adhere to 2 gm sodium, diabetic diet
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] @ [**Last Name (un) 616**].
Make an appointment with Dr. [**Last Name (STitle) 1801**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 676**] for 4 weeks.
Make an appointment with Dr. [**Last Name (STitle) 16327**] for 3-4 weeks.
Provider: [**First Name8 (NamePattern2) 16328**] [**Last Name (NamePattern1) 16329**], [**Name12 (NameIs) 16330**] Where: [**Hospital6 189**]
[**Hospital3 762**] Phone:[**Telephone/Fax (1) 23**] Date/Time:[**2135-7-25**] 2:00
Provider: [**First Name8 (NamePattern2) 16328**] [**Last Name (NamePattern1) 16329**], [**Name12 (NameIs) 16330**] Where: [**Hospital6 189**]
[**Hospital3 762**] Phone:[**Telephone/Fax (1) 23**] Date/Time:[**2135-8-1**] 2:00
Provider: [**First Name8 (NamePattern2) 16328**] [**Last Name (NamePattern1) 16329**], [**Name12 (NameIs) 16330**] Where: [**Hospital6 189**]
[**Hospital3 762**] Phone:[**Telephone/Fax (1) 23**] Date/Time:[**2135-8-8**] 2:00
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2135-7-18**]
|
[
"250.00",
"428.0",
"E878.2",
"427.31",
"401.9",
"997.1",
"295.70",
"998.11",
"996.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.03",
"35.22",
"35.24",
"99.61",
"38.91",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
13809, 13870
|
10866, 12057
|
10312, 10342
|
14138, 14144
|
10361, 10843
|
14497, 15614
|
1388, 1394
|
12080, 13786
|
13891, 14117
|
4826, 5111
|
14168, 14474
|
1409, 1773
|
10244, 10274
|
506, 1167
|
1189, 1313
|
1329, 1372
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,150
| 136,908
|
49991
|
Discharge summary
|
report
|
Admission Date: [**2107-8-2**] Discharge Date: [**2107-8-2**]
Date of Birth: [**2030-1-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
chest pain radiating to back
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77yo man w/history of HTN that has had several episodes of chest
pain radiating to back and lasting several hours over past week.
Called PCP whom referred him to emergency department
Past Medical History:
HTN, Atrial tachyarrhythmias s/p ablation-PPM, CRI, GERD, BPH,
Depression, Hypothyroid, Gout, h/o PE, rt shoulder replacement
Social History:
Retired engineer,lives w/partner. Denies [**Name2 (NI) 11324**]. 1 drink
ETOH/day
Family History:
noncontributory
Physical Exam:
Gen: anxious
Neuro: A&O, nonfocal
Pulm: CTA bilat
CV: RRR no murmur
Abdm soft, NT/ND/+BS
Ext: warm, well perfused. palpable pulses
Pertinent Results:
[**2107-8-2**] 05:38AM GLUCOSE-108* UREA N-21* CREAT-1.2 SODIUM-142
POTASSIUM-2.9* CHLORIDE-104 TOTAL CO2-28 ANION GAP-13
[**2107-8-2**] 05:38AM ALT(SGPT)-26 AST(SGOT)-17 ALK PHOS-54
AMYLASE-71 TOT BILI-0.3
[**2107-8-2**] 05:38AM LIPASE-29
[**2107-8-2**] 05:38AM ALBUMIN-3.2* MAGNESIUM-2.0
[**2107-8-2**] 05:38AM WBC-9.6 RBC-3.57* HGB-12.3* HCT-34.3* MCV-96
MCH-34.4* MCHC-35.8* RDW-14.1
[**2107-8-2**] 05:38AM PLT COUNT-113*
[**2107-8-2**] 05:38AM PT-11.0 PTT-23.7 INR(PT)-0.9
[**2107-8-1**] 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
RADIOLOGY Preliminary Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2107-8-2**] 2:04 PM
CTA CHEST W&W/O C&RECONS, NON-; CT PELVIS W&W/O C
Reason: Evaluation of thoracic aorta. MMS ReconstructionATTN: Mr
[**Name13 (STitle) **]
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with chest pain radiating to back
REASON FOR THIS EXAMINATION:
Evaluation of thoracic aorta. MMS ReconstructionATTN: Mr [**First Name (Titles) 102180**] [**Last Name (Titles) 104390**]S for IV CONTRAST: None.
INDICATION: 77-year-old man with chest pain radiating to the
back.
COMPARISON: [**2107-8-1**].
TECHNIQUE: Continuous axial images of the chest were obtained
without IV contrast. Following the administration of IV Optiray
contrast images of the chest, abdomen and pelvis were obtained
with multiplanar images also reformatted.
CTA CHEST: Again seen is intramural hematoma involving the
descending aorta and focal penetrating ulcer not significantly
changed in appearance compared to the prior study. Mild
aneurysmal dilatation of the descending aorta is unchanged,
measuring 4.7 x 4.0 cm (series 3, image 20). There are small
bilateral pleural effusions. There are no enlarged pelvic or
inguinal lymph nodes. Calcifications are seen within the left
anterior descending coronary artery. Lung windows reveal no
pulmonary nodules or focal consolidations.
There is a filling defect in a subsegmental right lower lobe
pulmonary artery not confirmed on multiplanar reformatted images
possibly representing mixing artifact.
CT ABDOMEN WITH IV CONTRAST: The liver, gallbladder, spleen,
adrenal glands, pancreas are unremarkable. Kidneys are atrophic
with small hypodensities likely representing cysts but not fully
characterized. Scattered retroperitoneal nodes do not meet CT
criteria for enlargement. There is no free air or free fluid in
the abdomen.
CT PELVIS WITH IV CONTRAST: Rectum, sigmoid colon and bladder
are unremarkable. There is hypertrophy of the medial segment of
the prostate gland. No enlarged pelvic or inguinal lymph nodes.
There are degenerative changes of the shoulder joint and a right
humeral prosthesis. There are moderate degenerative changes of
the lower lumbar spine.
IMPRESSION:
1. Stable appearance of intramural hematoma and focal
penetrating ulcer involving the proximal descending thoracic
aorta with mild aneurysmal dilatation.
2. Small pleural effusions.
DR. [**First Name (STitle) **] [**Doctor Last Name **]
RADIOLOGY Final Report
CTU (ABD/PEL) W/CONTRAST [**2107-8-1**] 7:35 PM
CTA CHEST W&W/O C&RECONS, NON-; CTU (ABD/PEL) W/CONTRAST
Reason: eval dissection
Field of view: 40 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with chest pain radiating to back
REASON FOR THIS EXAMINATION:
eval dissection
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 73-year-old man with chest pain radiating to the back.
Evaluate for dissection.
Comparison is made to prior CT examination dated [**2106-11-26**].
CT OF THE CHEST/ABDOMEN/PELVIS
TECHNIQUE: MDCT acquired axial images were obtained through the
chest, abdomen, and pelvis with intravenous contrast only.
Coronal and sagittal reformations were evaluated.
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: There is no evidence
of acute aortic dissection. There has been interval progression
of ulcerating plaque within the descending aorta and amount of
mural thrombus. Additionally, there is mild aneurysmal
dilatation measuring approximately 4.1 x 4.5 cm (3:22). No
pathologically enlarged lymph nodes are identified. Artifact
from left-sided central venous catheter and pacemaker leads is
noted along with mild coronary artery calcification. The airways
are patent to the subsegmental level. There is bilateral
dependent atelectasis and a minimal left-sided pleural effusion,
new since prior examination. The lungs are otherwise clear.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver,
gallbladder, spleen, stomach, intra-abdominal bowel, pancreas,
and adrenal glands appear unremarkable. Both kidneys appear
slightly atrophic with bilateral hypoattenuating lesions, too
small to definitively characterize but likely representing
simple cyst. No free air or free fluid is noted within the
abdominal cavity. No pathologically enlarged lymph nodes are
present.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: There is hypertrophy
of the median lobe of the prostate with intrapelvic bowel and
urinary bladder appearing unremarkable. No free fluid is noted
within the pelvic cavity. No pathologically enlarged lymph nodes
are identified.
BONE WINDOWS: No malignant-appearing osseous lesions are
identified. There are severe multilevel degenerative changes
involving the thoracic and lumbar spine.
IMPRESSION:
1. Marked progression to mural thrombus and a focal aortic
ulceration involving the proximal descending thoracic aorta with
mild aneurysmal dilatation as noted above. No focal dissection
identified.
2. New minimal left-sided left pleural effusion.
3. Bilateral renal hypoattenuating lesions. Too small to
definitively characterize but likely representing simple cyst.
4. Enlarged prostate
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: TUE [**2107-8-2**] 4:55 PM
Brief Hospital Course:
Mr [**Known lastname 9904**] was admitted to the CSRU for blood pressure control
via the emergency room. He was initially controlled
w/Nicardipine infusion, this was transitioned to and increased
oral calcium channel blocker dose and the addition of an ACE
inhibitor to his existing oral regime. He was seen by CT surgery
as well as vascular surgery during this admission. He had CTA
torso w/reconstruction and it was decided he would benefit from
endovascular stenting.
The patient also had an echocardiogram and carotid ultrasound.
He was scheduled to return on Friday [**8-5**] for endovascular
stenting w/Dr [**Last Name (STitle) 914**]. He is also scheduled to return on [**8-4**] for
a neck CTA prior to surgery.
Medications on Admission:
Sotolol 120"
Synthroid 75'
Norvasc 5'
Buproprion 75'
Albuterol-prn
Nabumetone 750"
ASA 81'
Allopurinol 300'
Doxazosin 8'
Ultram 50-prn
Discharge Medications:
1. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*10 Tablet(s)* Refills:*0*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Ulcerated descending Aorta plaque w/aortic thrombus
PMH: HTN, CRI, BPH, Atrial tachyarrththymias s/p ablation/PPM,
GERD,
Depression, Hypothyroid, h/o PE '[**02**], gout, Rt shoulder
replacement
Discharge Condition:
good
Discharge Instructions:
Take all medications as prescribed.
Return to emergency department for any further symptoms of
chest/back pain.
Return to Radiology department([**Hospital Unit Name **]) on Thursday [**8-4**] @
3:30P for scheduled neck CTA.
Return to preop anesthesia area Friday [**8-5**] for endovascular
stenting
Followup Instructions:
neck CTA [**8-4**] 3:30P [**Hospital Unit Name **]
Preop holding area [**8-5**] 6A Clinical center
Completed by:[**2107-8-2**]
|
[
"441.03",
"V45.01",
"244.9",
"274.9",
"401.9",
"600.00",
"V12.72",
"593.9",
"444.1",
"786.59"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8728, 8734
|
7078, 7799
|
348, 355
|
8972, 8979
|
1014, 1892
|
9326, 9455
|
831, 848
|
7984, 8705
|
4331, 4381
|
8755, 8951
|
7825, 7961
|
9003, 9303
|
863, 995
|
280, 310
|
4410, 7055
|
383, 567
|
589, 716
|
732, 815
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,682
| 144,631
|
38659
|
Discharge summary
|
report
|
Admission Date: [**2127-2-18**] Discharge Date: [**2127-2-24**]
Date of Birth: [**2056-4-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Self inflicted stab wounds to abdomen
Major Surgical or Invasive Procedure:
[**2127-2-18**] Lysis of adhesions; oversewing of mesentery bleeding
sites
History of Present Illness:
70M w/ pancreatic cancer, s/p self-inflicted stab wounds to
subxiphoid and LUQ of abdomen; found by son in pool of blood;
knife in place upon presentation
Past Medical History:
PMH: DM, pancreatic non secreting islet cell cancer w. liver
mets, hepatic abscess
PSH:pancreatecomy; splenectomy; sleeve resection of the stomach;
radiofrequency ablation and hepatic embolization for liver mets,
which failed
Family History:
Noncontributory
Pertinent Results:
[**2127-2-19**] 12:00AM WBC-18.8* RBC-3.53* HGB-10.3* HCT-31.4*
MCV-89 MCH-29.3 MCHC-32.9 RDW-13.9
[**2127-2-19**] 12:00AM PLT COUNT-55*
[**2127-2-19**] 12:00AM PT-16.4* PTT-36.9* INR(PT)-1.5*
[**2127-2-18**] 11:35PM GLUCOSE-125* LACTATE-6.5* NA+-128* K+-4.3
CL--104
[**2127-2-18**] 10:43PM GLUCOSE-107* LACTATE-4.9* NA+-127* K+-4.7
CL--100
Chest xray [**2127-2-18**]
The patient was extubated in the meantime interval. The
cardiomediastinal
silhouette is stable. Bibasal opacities are developed in the
interim and most likely represent areas of atelectasis with most
likely present bilateral small amount of pleural effusion. There
is no evidence of pneumothorax. Mild increase in perihilar
vascular engorgement may be attributed to recent extubation and
increase in the venous return.
Brief Hospital Course:
He was admitted to the Trauma service and transferred to the
Trauma ICU for close monitoring and serial abdominal exams.
Hematocrits were followed closely and remained stable with most
recent value at time of this dictation of 33.
Psychiatry was consulted given the suicide attempt; he was
placed on sitters. Palliative Care/Ethics were also involved in
his care. After several family/team/consultant discussions the
decision was made to discharge patient to home with his family
who were agreeable to this plan.
Medications on Admission:
Unknown
Discharge Medications:
1. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
4. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for fever or pain.
5. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
6. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
8. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
9. Morphine 5 mg Suppository Sig: One (1) Supp Rectal every six
(6) hours as needed for pain.
Disp:*60 suppositories* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Self-inflicted stab wound to abdomen
Mesenteric injury
Pulmonary edema
Pneumonia
Discharge Condition:
Mental Status: Intermittently awake
Level of Consciousness: Lethargic
Discharge Instructions:
Your famiy has indicated that they would like to take you home
and provide 24 hour services for you.
You were admitted to the hospital after a self-inflicted
stabbing to your abdomen. An operation was performed to explore
your abdominal injuries and repair to one of the arteries in
your abdomen was done.
DO NOT lift objects greater than 10 lbs; avoid bending at your
waist.
Complete the antibitocs as directed for your pneumonia.
Take your medications as prescribed and if you are taking
narcotics take a stool softener and laxative to avoid
constipation.
You may sponge bathe or shower, no tub baths. Avoid letting
water saturate your wound.
Followup Instructions:
Follow up next week in clinic with Dr. [**Last Name (STitle) **] for evalaution
of your operative site and removal of staples. Call([**Telephone/Fax (1) 32046**] for an appointment.
Follow up with your primary providers at [**Hospital3 328**] Cancer
Institute as directed.
Completed by:[**2127-3-20**]
|
[
"868.14",
"486",
"276.2",
"863.99",
"V62.84",
"276.1",
"E849.0",
"157.9",
"276.6",
"293.0",
"568.0",
"458.9",
"309.0",
"197.7",
"E956"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"38.91",
"54.75",
"96.71",
"54.0",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3282, 3288
|
1741, 2256
|
355, 432
|
3416, 3416
|
918, 1718
|
4184, 4488
|
882, 899
|
2314, 3259
|
3309, 3395
|
2282, 2291
|
3511, 4161
|
274, 317
|
460, 616
|
3431, 3487
|
638, 866
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,999
| 194,748
|
49322
|
Discharge summary
|
report
|
Admission Date: [**2162-10-19**] Discharge Date: [**2162-10-24**]
Date of Birth: [**2085-12-8**] Sex: M
Service: UROLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old male
with a long history of benign prostatic hypertrophy and
urinary retention. The patient has previously undergone
several biopsies of the prostate which showed no evidence of
a malignancy. The most recent ultrasound of the prostate
done in [**2161-1-8**] showed an enlarged prostate
measuring 7.31 x 6.70 x 6.75 cm, for a calculated volume of
171 cc. No focal mass was identified. The patient's most
recent PSA (prostate specific antigen) value was 43.9, which
is an increase from low to mid 30s observed previously. The
patient was admitted for suprapubic prostatectomy.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft (LIMA to LAD, SVG to PCA, SVG to diagonal-1 to
ramus). Status post aortic valve replacement in [**2156**].
2. Mitral valve prolapse
3. Benign prostatic hypertrophy.
4. Atrial fibrillation.
5. Hypercholesterolemia.
PAST SURGICAL HISTORY:
1. Status post cholecystectomy.
2. Status post appendectomy.
3. Status post hernia repair.
4. Status post right femoral to popliteal bypass, [**2158**].
ALLERGIES: Sulfa causes rash.
MEDICATIONS ON ADMISSION:
1. Lescol.
2. Coumadin 1 mg twice a week and 0.5 mg five times a week.
3. Flomax 0.4 mg q.d.
4. Iron supplement.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives with wife and son at home.
No history of tobacco use. Rare history of alcohol use.
PHYSICAL EXAMINATION: Temperature 96.7??????, blood pressure
130/62, heart rate 80, respiratory rate 20, 99% on two
liters. GENERAL EXAM: Elderly male in no apparent distress.
HEENT: Within normal limits. CARDIAC: Systolic ejection
murmur at the upper sternal border to clavicle. Otherwise in
atrial fibrillation with frequent premature ventricular
contractions. LUNG: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: No
edema. Warm, well-perfused, old bypass scar noted.
LABORATORY STUDIES: White blood cell count 8.5, hematocrit
38.2, platelets 176, glucose 140, BUN 21, creatinine 1.1,
sodium 140, potassium 4.3, calcium 8.2, magnesium 1.6.
SUMMARY OF HOSPITAL COURSE: Given the rising PSA levels and
continued symptoms, the patient underwent open suprapubic
radical prostatectomy on [**2162-10-19**]. The patient tolerated
the procedure well. There were no complications. A
suprapubic tube was placed. A J-P drain was placed, as well
as a Foley catheter. Please see the full Operative Report
for details.
Postoperatively, the patient was noted to have ectopy and
atrial fibrillation. He was extubated without difficulty and
remained hemodynamically stable. The patient was treated
with intravenous potassium and magnesium and was transferred
to SICU for closer monitoring. Continuous bladder irrigation
was initiated. The patient was ruled out for a myocardial
infarction by enzymes. The patient's pain was controlled
with Toradol and morphine with good results. The patient was
placed on ampicillin and gentamicin. His hematocrit was
noted to be 28 and he was transfused with one unit of packed
red blood cells. He was originally made NPO and his diet was
advanced gradually after he was having flatus. The patient
was then transferred to the regular floor in stable
condition. The suprapubic tube remained in place. The urine
eventually cleared to light yellow. Continuous bladder
irrigation was decreased and eventually stopped after urine
remained to be clear.
The patient continued to have nonsustained ventricular
tachycardia. Cardiology was consulted. An echocardiogram
was obtained. The patient was also started on 12.5 mg of
p.o. Lopressor with good effect on heart rate. The patient
remained asymptomatic throughout his hospitalization without
any complaints of chest pain or shortness of breath. The
patient was transfused with an additional unit of packed red
blood cells on postoperative day #3 with a goal to maintain
his hematocrit above 30. The suprapubic tube was removed on
postoperative day #3 without any complications. The J-P
drain was removed on postoperative day #4. The patient
continued to make good urine. His incision remained clean,
dry and intact. He continued to tolerate a regular diet.
His intravenous fluids were discontinued.
The patient was discharged to home on [**2162-10-24**]. Condition
on discharge was good. Discharge destination is home.
DISCHARGE DIAGNOSES:
1. Benign prostatic hypertrophy, status post open radical
prostatectomy.
2. Chronic atrial fibrillation with supraventricular
tachycardia.
3. Hypercholesterolemia.
4. Hypertension.
DISCHARGE MEDICATIONS:
1. Ciprofloxacin 500 mg p.o. b.i.d., which the patient is to
start on [**2162-10-31**], the day before his Foley catheter is to
be removed.
2. Tylenol No. 3, 1 to 2 tabs p.o. q.4-6 hours p.r.n.
3. Lopressor 12.5 mg p.o. b.i.d.
4. Lescol, to continue his home dose.
5. Iron supplements.
6. Colace 100 mg p.o. b.i.d. p.r.n. constipation.
7. Tylenol 650 mg p.r.n. pain.
DISCHARGE INSTRUCTIONS:
1. The patient is to see Dr. [**Last Name (STitle) 986**] on [**2162-11-1**] for
Foley catheter removal.
2. The patient is to start taking ciprofloxacin on
[**2162-10-31**], the day before the Foley catheter is to be
removed.
3. The patient is to see his primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 172**], in approximately one week.
4. The patient is to see a cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**],
in approximately two weeks.
These instructions were explained to the patient.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 34-125
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2162-10-24**] 11:24
T: [**2162-10-24**] 11:15
JOB#: [**Job Number 14915**]
|
[
"414.01",
"600.0",
"V45.81",
"427.31",
"427.89",
"788.20",
"997.1",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"60.3"
] |
icd9pcs
|
[
[
[]
]
] |
1461, 1479
|
4593, 4779
|
4802, 5177
|
1327, 1445
|
5201, 6002
|
1111, 1301
|
2326, 4572
|
1621, 2297
|
166, 776
|
798, 1088
|
1495, 1598
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,813
| 183,214
|
30767
|
Discharge summary
|
report
|
Admission Date: [**2128-6-13**] Discharge Date: [**2128-6-19**]
Date of Birth: [**2049-11-6**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
transfer from OSH with basal ganglia bleed
Major Surgical or Invasive Procedure:
extraventricular drain placement
tracheal intubation with mechanical ventilation
History of Present Illness:
78yo woman with PMH significant for hypertension, DVT,
complained of headache and collapsed in front of her husband.
She was initially awake and response to voice but noted to have
a right hemiparesis. She was sent to an OSH ED, where BP was in
the 250s and she became unresponsive. She was intubated and
started on a nipride drip. Her OSH CT showed a right basal
ganglia hemorrhage (4x5x5cm), with blood tracked into all
ventricles with moderate hydrocephalus and 5mm midline shift.
She was transferred to [**Hospital1 18**] ED via [**Location (un) **] and received 200mg
fentanyl en route.
Past Medical History:
HTN, DVT, epistaxis
Social History:
lived with husband, very close family
Family History:
not elicited
Physical Exam:
PHYSICAL EXAM:
BP: 200/122 HR: 90 to 43 R 14 O2Sats 100% on vent
Gen: intubated and sedated
HEENT: Pupils: equall round at 2.5mm, trace reactive left, no
reaction to light of right pupil. + corneal bilat. No doll eyes.
Neck: intubated.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft
Extrem: extensor posturing of both lower extremities.
Neuro:
Mental status: intubated and sedated.
Cranial Nerves:
I: Not tested
II: Pupils: see above.
Unable to test the rest of CNs.
Motor: Extensor posturing of LE bilat. Normal bulk and
increasing tone of LE bilaterally. Occasional non-purposeful
movement of trunk. No withdrawal of upper extremities to noxious
stimuli; slight withdrawal vs triple flex of bilat lower
extremities to noxious stimuli.
Sensation: no facial grimace to stimuli.
Reflexes: minimal throughout.
Toes upgoing bilaterally
Pertinent Results:
On admission:
GLUCOSE-161* UREA N-9 CREAT-0.6 SODIUM-137 POTASSIUM-3.4
CHLORIDE-101 TOTAL CO2-23 ANION GAP-16
CALCIUM-8.8 PHOSPHATE-3.2 MAGNESIUM-2.0
WBC-11.4* RBC-3.82* HGB-12.4 HCT-36.7 MCV-96 RDW-15.8* PLT
COUNT-303
PT-12.5 PTT-24.3 INR(PT)-1.1
cardiac enzymes negative x 3
CT/MRI:
OSH CT: right basal ganglia hemorrhage 4x5x5cm, extending into
the
ventricles. Leftward MLS 5MM.
CXR: No evidence of pneumonia or CHF.
HCT: Large right thalamic bleed with intraventricular blood and
a small degree of subfalcine herniation. While the left
ventricular drain terminates within the left lateral ventricle,
the tip of the right ventricular drain is extra ventricular and
terminates near the lateral margin of the hematoma. There is no
prior study available to evaluate for progression or change in
ventricular size.
Repeat HCT: Stable appearance of the brain following removal of
right frontal drain.
Repeat HCT: 1)Unchanged appearance of right basal
ganglia/thalamic hemorrhage. 2) Question of rotatory fixation of
the upper cervical spine/occiput with potential lucency of
occipital condyles. This can be evaluated with dedicated skull
base CT or dedicated images and reformats can be performed if a
other Head CT is planned.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the neurology ICU for further
management. She had two extraventricular drains placed by the
neurosurgery team. The right drain was malpositioned, so it was
later removed. She was maintained on mechanical ventilation and
sedation was weaned off. Intraventricular tPA was infused
through the EVD with gradual clearing of the intraventricular
blood. However, she did not make any significant clinical
improvement. An extensive family discussion was conducted with
the medical staff, including social work, and the patient's
husband, daughter, and son. The family members stated that Mrs.
[**Known lastname **] had always expressed that she would not want to be "hooked
up" to any tubes or drains; they felt that she would have been
unhappy to even have had any surgical intervention and expressed
regret that they had decided to have the EVD and endotracheal
tube placed at all. In addition, they felt she would not want to
have to go to a nursing home for any length of time, nor would
she want a trach/PEG or any feeding tube even temporarily. They
were very confident that Mrs.[**Known lastname 72847**] wishes would be to be
extubated and have goals of care comfort only. As such, on [**6-19**],
when the entire family could be at the bedside, she was
extubated. She died shortly thereafter.
Medications on Admission:
lopressor, zoloft, lisinopril, crestor
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Right basal ganglion hemorrhage with intraventricular extension
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"996.2",
"V12.51",
"591",
"342.90",
"431",
"E878.1",
"401.0",
"E849.7",
"518.81",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"96.72",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
4784, 4793
|
3329, 4666
|
359, 441
|
4900, 4909
|
2077, 2077
|
4961, 4967
|
1177, 1191
|
4756, 4761
|
4814, 4879
|
4692, 4733
|
4933, 4938
|
1221, 1566
|
277, 321
|
469, 1062
|
1621, 2058
|
2091, 3306
|
1581, 1605
|
1084, 1105
|
1121, 1161
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,847
| 103,503
|
22678
|
Discharge summary
|
report
|
Admission Date: [**2105-11-22**] Discharge Date: [**2106-1-8**]
Date of Birth: [**2048-12-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
56 year old Portuguese male with 1 day history of chest pain and
dizziness.
Major Surgical or Invasive Procedure:
AVR(27mm valve) Homograft/Ascending aorta tube graft [**2105-12-8**]
Tracheostomy
Percutaneous feeding tube placement
History of Present Illness:
56 y.o. male, Portugese speaking, with history of AS/AI who
presented to an OSH with CP and dizziness after walking up a
[**Doctor Last Name **]. Pt reports that he had been experiencing chest pain with
heavy exertion for quite some time. Pt presented to [**Hospital 8**]
Hospital for evaluation. Per OSH records, the pt described the
pain as substernal in nature with radiation to the shoulders
R>L. Pt had subjective palpitations and dizziness with the pain
but no fevers, chills, diaphoresis, nausea, or vomiting. On
arrival to the OSH, the pt's pain was relieved with tylenol.
However, he was found to have a fever of 101 so was admitted to
the ICU for further evaluation. On workup, pt's CXR was
significant for a sidened mediastinum with a tortuous aortic
shadow. CT with contrast revealed a ascending aortic aneurysm of
6.5 cm with a normal descending aorta. Pt was ruled out for MI.
Five sets of blood cultures were drawn. There was a concern for
endocarditis so the pt was started emperically on rocephin,
gentamicin, and nafcillin. The pt was then transferred to [**Hospital1 18**]
for CT surgical evaluation for repair of his aneurysm.
Past Medical History:
1. HTN
2. AS and AI- Seen on echo at [**Hospital 8**] Hospital on 08/[**2104**]. AV
area of 0.7 cm2 and a gradient of 77 mmGg. Moderate AI. LVEF of
75%.
3. Right VP shunt s/p trauma approximately 30 years ago
Social History:
Pt is married and lives with his wife and children. He works as
a mechanic. He is Portugese speaking. No tobacco, ETOH, or
drugs.
Family History:
[**Name (NI) 1094**] father had DM. No history of CAD or hypercholesterolemia.
Physical Exam:
Gen- Alert and oriented. NAD. Resting comfortably in bed.
HEENT- NC AT. PERRL. MMM.
Cardiac- Irregularly irregular. IV/VI harsh holosystomic murmur
radiating throughout precordium and up to carotids. No JVD
appreciated.
Pulm- CTAB.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Skin- Multiple cherry hemangiomas on abdomen and chest; no
stigmata of endocarditis
Extremities- Trace LE edema. 2+ DP pulses.
Neuro: CN 2-12 intact, sensation intact throughout, strength 5/5
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2106-1-7**] 06:36AM 6.6 3.82* 11.7* 35.7* 94 30.6 32.8 17.0*
463*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2106-1-7**] 06:36AM 463*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2106-1-7**] 06:36AM 20 0.7 4.1
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2106-1-6**] 02:46AM 1.7
Source: Line-Picc; GREEN TOP
Cardiology Report ECHO Study Date of [**2105-12-28**]
PATIENT/TEST INFORMATION:
Indication: Endocarditis. Evaluation for abscess. Prosthetic
valve function.
BP (mm Hg): 105/85
HR (bpm): 85
Status: Inpatient
Date/Time: [**2105-12-28**] at 11:20
Test: Portable TEE (Complete)
Doppler: Full doppler and color doppler
Contrast: None
Tape Number: 2005W065-0:25
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 60% (nl >=55%)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2105-12-21**].
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the
body of the
LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous
echo contrast
in the body of the RA. No mass or thrombus in the RA or RAA. A
catheter or
pacing wire is seen in the RA and/or RV. No spontaneous echo
contrast in the
RAA. Normal interatrial septum.
LEFT VENTRICLE: Normal LV cavity size. Normal regional LV
systolic function.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Normal RV
systolic function.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no
atherosclerotic plaque.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Normal AVR
leaflets. No masses or vegetations on aortic valve. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or
vegetation on
mitral valve. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or
vegetation on tricuspid valve.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. 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). Local anesthesia was provided by benzocaine topical
spray. No TEE
related complications. The rhythm appears to be atrial
fibrillation. Compared
with the findings of the prior study, there has been no
significant change.
Echocardiographic results were reviewed by telephone with the
houseofficer
caring for the patient.
Conclusions:
1.The left atrium is normal in size. No spontaneous echo
contrast is seen in
the body of the left atrium or right atria.
2. A pacing wire is visualized in the right atrium and is free
of masses or
vegetations.
3. The left ventricular cavity size is normal. Regional left
ventricular wall
motion is normal. Overall left ventricular systolic function is
normal
(LVEF>55%).
4. Right ventricular chamber size and wall motion are normal.
5.The ascending, transverse and descending thoracic aorta are
normal in
diameter and free of atherosclerotic plaque.
6. A bioprosthetic aortic valve prosthesis is present. The
prosthetic aortic
leaflets appear normal. No masses or vegetations are seen on the
aortic valve.
No aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. No mass or
vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
The tricuspid
valve has no masses or vegetations.
8.There is a trivial/physiologic pericardial effusion.
Compared with the prior study (tape reviewed) of [**2105-12-21**] there
is no
diagnostic change.
RADIOLOGY Final Report
CT HEAD W/ CONTRAST [**2105-12-27**] 2:53 PM
CT HEAD W/ CONTRAST; CT 100CC NON IONIC CONTRAST
Reason: needs IV contrast to identify signs of infection w/in
fronta
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
57M s/p AVR, with persistent sepsis & CNS fluid collections
REASON FOR THIS EXAMINATION:
needs IV contrast to identify signs of infection w/in frontal
collections. last noncontrast study was inadequate
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Status-post aortic valve replacement with persistent
sepsis and CNS fluid collections.
COMPARISON: Same day approximately one (1) hour prior.
TECHNIQUE: Multiple axial images of the head were obtained
following the administration of 100 cc of Optiray.
CT HEAD W/IV CONTRAST: No enhancing intracranial collections
identified. Again seen, are bifrontal chronic subdural
collections, unchanged. There is a ventricular drainage catheter
via the right posterior approach, unchanged in position. There
is no shift of normally midline structures. No enhancing masses
are seen. There is no hydrocephalus.
IMPRESSION: Stable appearance of bifrontal chronic subdural
collections. No enhancing masses or enhancing collections
identified. Please note if meningeal infection is a concern, the
most sensitive test would be CSF analysis.
Brief Hospital Course:
The patient was admitted on [**2105-11-22**].On [**2105-11-23**], the pt was
also noted to be in new onset atrial fibrillation. He was loaded
with 200 mg of amiodarone and started on a heparin drip. On
arrival to [**Hospital1 18**], the pt was evaluated by CT [**Doctor First Name **] who delayed
valve repair until the patient was infection free. He was then
admitted to the CCU for further care. At that time, his
temperature was 102.9. Antibiotics were changed on admission to
gentamycin, vancomycin, and pen G. On the day following
admission ([**2105-11-23**]), it was found that all 10 bottles of
blood cultures from the OSH were growing gram positive cocci. ID
was consulted and the pt's antibiotics were changed to
vancomycin, gentamycin (until consistantly clean blood
cultures), and oxacillin. The pen G was discontinued. TTE was
significant for a LVEF of 30 to 35%; mild LA and RA enlargement;
severly dilated LV with diffuse hypokinesis; moderate dilation
of the aortic root; marked dilation fo the ascending aorta;
marked dilation of the aortic arch; severe AS; severe AR; mild
MR; mild TR; and mild PA systolic hypertension. TEE on
[**2105-11-24**] was negative for any vegitation or abcess suggestive
of endocarditis. At that time, ID felt that the infection was
most likely located [**Last Name (un) 7245**] in the aneurysm. By [**2105-11-25**], the
pt's fever curve was markedly decreased. He was transferred to
the [**Hospital Unit Name **] team for further care.
He grew out MSSA and the gentamycin was discontinued. He
developed fevers and an increased WBC again and was found to
have an abcess and vegitation on his aortic valve on TEE. He
blocked down and required temporary pacer placement. He was
restarted on Vanco and underwent cardiac cath prior to the OR.
On [**2105-12-8**] he underwent AVR homograft with a 27mm valve and
ascending aortic root replacement. He had purulent drainage
from his heart and aorta, and was transferred to the CSRU.
POD#1 he was on Epi and remained intubated. He was extremely
agitated and continued having high temps. He intermittently
required Neo and Vasopressin for profound hypotension. He was
closely followed by ID, Pulmonary, and EP. He was on Gent,
Vanco, Oxacillin, and Rifampin. He remained intubated and had
several TEEs which were all negative. Eventually his rhythm
recovered and the pacing wire was d/c'd. He had a negative LP
and head CT and was followed by neurology for agitation. All
cultures were negative. He was eventually started on
Casperfungin and POD #18 he defervesced and underwent a
tracheostomy on [**12-26**]. He continued to improve and the
Caspofungin was d/c'd. His antibiotics were eventually changed
to Rifampin and Oxacillin alone. He weaned quickly from the
vent., and failed a swallowing study, so he had a PEG placed on
[**1-5**]. On [**1-6**] he was transferred to the floor in stable
condition. He was discharged to acute rehab on POD#31 in stable
condition.
He needs to continue Oxacillin and Rifampin until [**1-22**]. He was
diagnosed with c. diff on [**1-3**] and should stay on Flagyl while
on abx.
Medications on Admission:
1. Amiodarone 200 mg QID
2. ASA 81 mg daily
3. Atorvastatin 20 mg daily
4. Docusate 100 mg [**Hospital1 **]
5. Gentamicin 100 mg IV Q8H
6. Weight based IV heparin
7. RISS
8. Oxacillin 2 gm IV Q4H
9. Pantoprazole 40 mg daily
10. Vancomycin 1000 mg IV Q12H
PRNs-
Tylenol
Bisacodyl
Ambien
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Acetaminophen 160 mg/5 mL Elixir Sig: Two (2) PO Q4-6H
(every 4 to 6 hours) as needed for temp>38.
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO PRN
(as needed) as needed for k < 4.4.
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): While on Oxacillin and Rifampin, pt. should stay
on Flagyl.
7. Rifampin 150 mg Capsule Sig: Three (3) Capsule PO Q12H (every
12 hours): D/C on [**2106-1-22**].
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
9. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. 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.
11. Oxacillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln
Injection Q4H (every 4 hours): D/C [**2106-1-22**].
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous twice a day.
13. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed
Subcutaneous four times a day: SS: BS 110-150 2U
151-200 4U
201-250 6U
251-300 8U
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
MSSA endocarditis
Prolonged intubation
Aortic stenosis
Atrial fibrillation
HTN
s/p VP shunt 30 yrs ago
C. diff
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**First Name (STitle) **] when discharged from rehab.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Completed by:[**2106-1-8**]
|
[
"441.2",
"787.2",
"V45.2",
"429.89",
"427.31",
"280.9",
"511.9",
"518.5",
"348.39",
"784.7",
"995.92",
"997.1",
"785.52",
"746.4",
"421.0",
"426.0",
"008.45",
"426.13",
"747.22",
"490",
"038.11",
"427.89",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"43.11",
"00.13",
"88.72",
"37.26",
"33.23",
"96.72",
"40.3",
"31.1",
"37.71",
"88.43",
"38.45",
"36.99",
"88.41",
"96.6",
"89.64",
"88.42",
"99.07",
"39.61",
"34.04",
"99.04",
"99.61",
"88.56",
"35.21",
"99.05",
"89.45",
"37.78",
"37.22",
"37.77"
] |
icd9pcs
|
[
[
[]
]
] |
12945, 13015
|
8009, 11127
|
397, 517
|
13170, 13177
|
2674, 3219
|
13389, 13575
|
2089, 2169
|
11463, 12922
|
6901, 6961
|
13036, 13149
|
11153, 11440
|
13201, 13366
|
3245, 6864
|
2184, 2655
|
282, 359
|
6990, 7986
|
545, 1694
|
1716, 1926
|
1942, 2073
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,833
| 120,000
|
15676
|
Discharge summary
|
report
|
Admission Date: [**2139-11-10**] Discharge Date: [**2139-11-14**]
Date of Birth: [**2056-6-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Adhesive Tape / Cortisone / Bee Sting Kit
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional fatigue, dyspnea, and chest discomfort
Major Surgical or Invasive Procedure:
[**2139-11-10**] - Coronary artery bypass grafting X 3 (LIMA to LAD , SVG
to OM, SVG to PDA)
History of Present Illness:
83 year old woman with exertional fatigue, dyspnea and
intermittent chest discomfort. Her recent EKG revealed new
anterior T-wave inversions and echo confirmed evidence of an
anteroapical nontransmural infarction. During a stress test she
developed dyspnea and inferolateral ST depressions. Then
underwent cardiac cath which revealed severe three vessel
coronary artery disease. She present today for surgical
evaluation.
Past Medical History:
Coronary Artery Disease s/p Myocardial Infarction
Dyslipidemia
Hiatal Hernia
Colon Polyps
Cataracts
obesity
Social History:
Pt lives alone. She is a former administrator. There
is no history of tobacco, alcohol, or illicit drug use.
Family History:
Notable for mother with migraine headaches, otherwise
no other neurologic disease.
Physical Exam:
Pulse: 74 Resp: 16 O2 sat: 98%
BP Right: 126/70 Left: 123/63
5'2" 160#
General: NAD
Skin: Warm[x] Dry [x] intact [x]
HEENT: NCAT[x] PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally []
Heart: RRR [x] Irregular [] Murmur - none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact, [**6-10**] strengths, no focal deficits
Pulses:
Femoral Right: 2 Left: 2
DP Right: NP Left: NP
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Pertinent Results:
[**2134-11-9**] CT Scan
No evidence of mediastinal or lung abnormalities that
corresponds to the opacity described in the prior chest x-ray
most likely superimposition of normal structures.
Calcified granulomas and 2-mm noncalcified lung nodules. If the
patient has no risk for lung malignancy, no followup is
recommended.
[**2139-11-10**] ECHO
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40 - 45 %). There is inferior HK and apical akinesis.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are moderately thickened. Mild (1- 2+ ) mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is AV-Paced, on IV NTG.
Good RV systolic fxn.
LV systolic fxn. Is mildly depressed. Apex remains akinetic,
while base and mid-papillary walls work well.
MR remains 1 - 2+.
No AI. Aorta intact.
[**2139-11-13**] 04:48AM BLOOD WBC-11.0 RBC-2.89* Hgb-9.5* Hct-27.0*
MCV-93 MCH-32.8* MCHC-35.1* RDW-12.6 Plt Ct-130*
[**2139-11-13**] 04:48AM BLOOD Plt Ct-130*
Brief Hospital Course:
Mrs. [**Known lastname 45222**] was admitted to the [**Hospital1 18**] on [**2139-11-10**] for surgical
management of her coronary artery disease. She was taken
directly to the operating room where she underwent coronary
artery bypass grafting. Please see operative note for details.
Postoperatively she was taken to the intensive care unit for
monitoring. Over the next 24 hours, she awoke neurologically
intact and was extubated. She transferred to the floor on POD #1
to begin increasing her activity level. Chest tubes were removed
on POD #2. Three of four pacing wires were removed on POD #3.
One of the RV leads has a 4-5 mm retained fragment of bare wire
under the skin in the subcutaneous fat despite cutdown. Mr.
[**Known lastname 45222**] was instructed to contact us if this extrudes through
skin. She continued to make good progress and was cleared for
discharge to the [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] in [**Location 1268**] on POD #4. All
follow-up appointments were advised.
Medications on Admission:
metoprolol ER 50 mg daily
lisinopril 10 mg daily
simvastatin 40 mg daily
ASA 81 mg daily
fish oil
MVI
Calcium
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
3. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. simvastatin 40 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) for 1 months.
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days. Tablet(s)
12. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Discharge Disposition:
Extended Care
Facility:
Saulding-[**Doctor First Name 533**] home
Discharge Diagnosis:
Coronary Artery Disease s/p Myocardial Infarction
Dyslipidemia
Hiatal Hernia
Colon Polyps
Cataracts
obesity
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema: 1+ lower extremities
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: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2139-12-3**] 1:30
Cardiologist Dr. [**Last Name (STitle) 14522**] [**12-14**] @ 11:15 AM
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 16258**] in [**5-11**] 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:[**2139-11-14**]
|
[
"E878.2",
"414.01",
"V14.0",
"553.3",
"410.12",
"996.01",
"V15.06",
"278.00",
"272.4",
"413.9",
"211.3",
"366.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5591, 5659
|
3284, 4312
|
374, 469
|
5811, 6044
|
1967, 3261
|
6968, 7533
|
1198, 1282
|
4472, 5568
|
5680, 5790
|
4338, 4449
|
6068, 6945
|
1297, 1948
|
284, 336
|
497, 921
|
943, 1053
|
1069, 1182
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,317
| 136,810
|
40924
|
Discharge summary
|
report
|
Admission Date: [**2124-8-7**] Discharge Date: [**2124-8-15**]
Date of Birth: [**2038-3-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Belladonna
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
unstable angina
Major Surgical or Invasive Procedure:
[**2124-8-9**] - CABG x3 (free LIMA to LAD, SVG to OM, SVG to PDA)
History of Present Illness:
This 86 year old man with known 3 vessel coronary artery disease
s/p cath [**2124-6-7**]. He has a history of hypertension, dyslipidemia
and non insulin dependent diabetes. He was diagnosed with a
right thalamic stroke in [**2124-2-1**] with a left carotid
stenosis. Echo at the time revealed an LVEF of 45% with mild
global hypokinesis. Subsequent ETT revealed evidence of an
inferior MI with mild ischemia, LVEF 30-35%. He was referred
previously to [**Hospital1 18**] for left heart catheterization which
revealed 3 vessel disease. It was decided at that time that he
would be treated with medical management. He reports that he
has had intermittent chest pain over the past three weeks. [**8-7**]
he was recathed at OSH and transferred to [**Hospital1 18**] for evaluation
of revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
Non insulin dependent diabetes
Prior silent MI by ETT
[**2124-2-27**]: right thalamic stroke with left hemiparesis, treated at
[**Hospital1 2025**]. Plavix initiated.
Frequency Ventricular ectopy
Hypothyroidism
[**2104**] skin cancer
Possible Sleep apnea
Chronic gout with admit to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with acute episode
involving right knee, s/p tap
Anemia
Glaucoma
Hard of hearing (has hearing aids but has not used since his
stroke)
Ocular migraines
Hx of frequent falls
Short term memory loss
Bilateral cataract surgery
Social History:
Patient is divorced and lives alone. He recently
moved into [**Location (un) 7661**] [**Hospital3 400**]. He has two
children. His daughter [**Name (NI) **] [**Name (NI) 56051**] is highly involved in
his
care, but she lives one hour away in NH. The other daughter
lives
in [**Name (NI) 12000**].
Smoked during world war II.
He does not drink
Family History:
non-contributory
Physical Exam:
Pulse: 86 Resp: 20- O2 sat: 95% RA
B/P 127/87
Height: [**5-6**]" Weight:140LB
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: Left:
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit none appreciated, pulses Right:2+ Left:2+
Pertinent Results:
[**2124-8-8**] Carotid Ultrasound
1. There is 40% stenosis in the right ICA and 40-59% stenosis in
the left
ICA.
2. Mild heterogeneous plaque in the left ICA and minimal amount
of plaque in the right carotid bulb.
[**2124-8-9**] ECHO
Conclusions
PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. The interatrial septum
is aneurysmal. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed (LVEF=35%). Doppler
parameters are most consistent with Grade I (mild) left
ventricular diastolic dysfunction. The right ventricular cavity
is dilated with normal free wall contractility. There are simple
atheroma in the ascending aorta. The aortic arch is mildly
dilated. There are complex (>4mm) atheroma in the aortic arch.
The descending thoracic aorta is mildly dilated. There are
simple 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. Trivial 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 receiving epinephrine by infusion.
The right ventricle displays normal systolic function. The left
ventricle displays some improvement in global systolic function
with an ejection fraction of about 45%. Valvular function is
unchanged. The thoracic aorta is inatct after decannulation.
[**2124-8-7**] CT scan
1. No appreciable supra-annular calcification in minimally
dilated, ascending thoracic aorta.
2. Severe coronary arterial calcifications.
3. 4mm pulmonary nodule in the right lower lobe warrants CT
reevaluation in 12 months, a reasonable adaption of the
[**Last Name (un) 8773**] guidelines
[**2124-8-14**] 12:25AM BLOOD WBC-7.4 RBC-3.50* Hgb-10.7* Hct-31.5*
MCV-90 MCH-30.6 MCHC-34.0 RDW-15.2 Plt Ct-227
[**2124-8-13**] 05:30AM BLOOD WBC-8.1 RBC-3.68* Hgb-11.1* Hct-32.2*
MCV-88 MCH-30.3 MCHC-34.5 RDW-15.2 Plt Ct-216#
[**2124-8-14**] 12:25AM BLOOD Glucose-243* UreaN-28* Creat-1.3* Na-141
K-4.7 Cl-107 HCO3-25 AnGap-14
[**2124-8-13**] 05:30AM BLOOD Glucose-94 UreaN-16 Creat-0.9 Na-142
K-3.6 Cl-105 HCO3-25 AnGap-16
[**2124-8-12**] 06:55AM BLOOD Glucose-183* UreaN-19 Creat-1.0 Na-140
K-3.7 Cl-103 HCO3-27 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname 89339**] was admitted to the [**Hospital1 18**] on [**2124-8-7**] via transfer
from an outside hospital for further management of his coronary
artery disease. He was worked up in the usual preoperative
manner. A carotid duplex ultrasound was obtained which revealed
a 40-59% stenosis in the left internal carotid artery and mild
disease in the right. A CT scan showed no significant
intracranial process, no appreciable supra-annular calcification
in minimally dilated, ascending thoracic aorta and 4mm pulmonary
nodule in the right lower lobe warrants CT reevaluation in 12
months. On [**2124-8-9**], Mr. [**Known lastname 89339**] was taken to the operating room
where he underwent coronary artery bypass grafting. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was hemodynamically stable,
weaned from inotropic and vasopressor support. He was confused
initially and treated with Haldol. Confusion cleared and he was
alert and oriented x 3 by POD 4. 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. Mr.
[**Known lastname 89339**] was not started on an ACE Inhibitor, as his blood
pressure would not tolerate it. This should be considered as an
outpatient. By the time of discharge on POD #6 the patient was
ambulating with assistance, the wound was healing and pain was
controlled with oral analgesics. The patient was discharged to
[**Location (un) 16493**]Rehab of [**Location 9583**] in good condition with
appropriate follow up instructions.
Medications on Admission:
ALLOPURINOL- 300 mg Tablet - 1
Tablet(s) by mouth daily
AMITRIPTYLINE - 25 mg Tablet - 1 Tablet(s) by mouth
daily,CLOPIDOGREL [PLAVIX]75 mg Tablet - 1 Tablet(s) by mouth
daily
GLIPIZIDE- 10 mg Tablet - 1 Tablet(s) by mouth twice a day
INDOMETHACIN 25 mg Capsule -1 Capsule(s) by mouth three times a
day
ISOSORBIDE MONONITRATE 30 mg Tablet Extended Release 24 hr -
1 Tablet(s) by mouth once a day
LEVOTHYROXINE 25 mcg Tablet -1 Tablet(s) by mouth daily
LOSARTAN - 25 mg Tablet - 1 Tablet(s) by mouth daily
METFORMIN 500 mg Tablet - 1 Tablet(s) by mouth twice a day
OMEPRAZOLE [PRILOSEC]- Dosage uncertain
SIMVASTATIN - 40 mg Tablet - 1Tablet(s) by mouth daily
Medications - OTC
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day
MULTIVITAMIN - (Prescribed by Other Provider
Discharge Medications:
1. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. pilocarpine HCl 4 % Drops Sig: One (1) Drop Ophthalmic Q6H
(every 6 hours).
4. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
10. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain, fever.
17. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
18. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): per attached sliding scale.
19. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a
day.
20. metoprolol tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day): Hold for HR<60,SBP<90.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 39857**] - [**Location 9583**]
Discharge Diagnosis:
Coronary artery disease s/p CABG x3
Hyperlipidemia
Non insulin dependent diabetes
Prior silent MI by ETT
[**2124-2-27**]: right thalamic stroke with left hemiparesis, treated at
[**Hospital1 2025**]. Plavix initiated.
Frequency Ventricular ectopy
Hypothyroidism
[**2104**] skin cancer
Possible Sleep apnea
Chronic gout with admit to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with acute episode
involving right knee, s/p tap
Anemia
Glaucoma
Hard of hearing (has hearing aids but has not used since his
stroke)
Ocular migraines
Hx of frequent falls
Short term memory loss
Bilateral cataract surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance, deconditioned
Incisional pain managed with Ultram, Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema - trace
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**], Thursday, [**2124-9-14**] 1:00
Cardiologist: [**Doctor Last Name **]-Te [**Doctor First Name **] [**Telephone/Fax (1) 65733**], [**9-5**] at 2:00pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 83352**] in [**4-4**] 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:[**2124-8-15**]
|
[
"V15.82",
"272.4",
"298.9",
"412",
"438.89",
"414.01",
"783.21",
"250.00",
"V10.83",
"411.1",
"V15.88",
"401.9",
"389.9",
"V58.63",
"244.9",
"285.9",
"274.9",
"438.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
10183, 10257
|
5593, 7521
|
307, 376
|
10922, 11165
|
2950, 5570
|
12054, 12693
|
2204, 2222
|
8399, 10160
|
10278, 10901
|
7547, 8376
|
11189, 12031
|
2237, 2931
|
251, 269
|
404, 1205
|
1227, 1827
|
1843, 2188
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,107
| 171,138
|
10347+56138
|
Discharge summary
|
report+addendum
|
Admission Date: [**2141-9-29**] Discharge Date: [**2141-10-6**]
Date of Birth: [**2066-12-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Change in Mental Status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 yo M w history of alzheimers dementia, CAD, noted to be
increasing restless and his usual daycare. Was also agitated and
combative. Upon nurses assesment, pupils noted to be rolled back
in his head, and patient noted to have shaking tremors of lower
extemities. All events witnessed by pt's wife and daughter who
were at Day Care withthe patient. Temp taken at Day care
registered at 103.1. BP 130/82. Family denied loss of
continence. No LOC, family states that they were able to
communicate with the patient during the shaking episode.
.
When EMS arrived to daycare, pt noted to be more restless, very
talkative, twitching leg movements, agitated, combative. EMS
arrived, found the patient FS noted to be 58, given [**1-17**] amp
D50, BS improved to 166. Taken to [**Hospital1 18**] ED.
.
Pt baseline is not oriented, doesn't recognize family due to his
dementia, but is able to take care of ADLs (shaving, toileting,
eating). Family reports patient entirely at baseline day prior
to admission, doing well, having gone to Temple during the
[**Hospital1 **] Holidays. The lethargy and increased agitation is new
for the patient and is especially concerning given the high
fevers.
.
Unable to obtain ROS from the patient. Per family, pt does not
have any CP, SOB, abd pain. They did mention that patient does
occasionally c/o pain in his legs. Denied cough, headaches,
dizziness, lightheadedness, nausea, vomiting, diarrhea.
.
In ED, T 103; HR 96; BP 130/70; RR 24; O2 sat 98% 2L NC. no
localizing symptoms, but difficult to assess given pt's
dementia. LP was peformed and was negative. BCx were taken. UA
negative. A dose of ceftaz and vanco were given empirically
given the pt's delta MS, fevers, bandemia. EKG significant for
sinus tach 102, LAD, no significant ST-T segment changes.
Past Medical History:
Dementia
CAD s/p CABG [**49**] yrs ago
Osteoarthritis
B 12 deficiency
H/O afib
h/o recent toe cellulits RLE tx'd with 14 days of PO Keflex.
Social History:
Pt lives at home with his wife and homemakers. Advance dementia,
but pt is able to dress and toilet himself (including shaving
his face and body). lifetime non-smoker and non-drinker.
Baseline ambulatory and able to participate in daycare
activities
Family History:
non-contributory
Physical Exam:
VS: T 102.4R, T99.5 axillary, BP 94/62; HR 88; 99%RA
Gen: lethargic male, diaphoretic in bed
HEENT: dry MM. Perrla, EOMI, but has trouble following commands
CV: tachy. reg s1 and s2. 2/6 systolic murmur best audible at
RUSB
CHEST: CTAB. No rales, rhonchi wheezes
ABD: + BS. Soft, NT, ND, no HSM.
EXT: bilat LE edema, but RLE > LLE signifcantly. warmth and
erythema from R dorsal surface all the up to the knee. no
palbable chords. No [**Last Name (un) 5813**] sign elicited.
LLE: [**Name (NI) **] PT and DP
RLE: [**Name (NI) **] PT and DP
NEURO: not able to cooperate with neuro exam. patient is
lethargic, but arousable, does not follow commands, but able to
respond to the family (this is off baseline, family states).
moves all 4 extremities (though not on command). no neck
stiffness
Pertinent Results:
<b>Admit Labs:</b>
[**2141-9-29**] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2141-9-29**] 03:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2141-9-29**] 03:30PM PLT COUNT-192
[**2141-9-29**] 03:30PM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2141-9-29**] 03:30PM NEUTS-90* BANDS-3 LYMPHS-4* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2141-9-29**] 03:30PM WBC-16.1* RBC-4.38* HGB-14.5 HCT-40.6 MCV-93
MCH-33.0* MCHC-35.6* RDW-14.3
[**2141-9-29**] 03:30PM CALCIUM-9.3 PHOSPHATE-2.2* MAGNESIUM-2.3
[**2141-9-29**] 03:30PM ALT(SGPT)-17 AST(SGOT)-30 ALK PHOS-95
AMYLASE-98 TOT BILI-1.0
[**2141-9-29**] 03:30PM estGFR-Using this
[**2141-9-29**] 03:30PM GLUCOSE-138* UREA N-14 CREAT-0.9 SODIUM-138
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-32 ANION GAP-14
[**2141-9-29**] 03:57PM GLUCOSE-136* LACTATE-1.3 K+-3.7
[**2141-9-29**] 03:57PM COMMENTS-GREEN TOP
[**2141-9-29**] 09:50PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-2* POLYS-1
LYMPHS-15 MONOS-81 MACROPHAG-3
[**2141-9-29**] 09:50PM CEREBROSPINAL FLUID (CSF) PROTEIN-186*
GLUCOSE-77
[**2141-9-29**] 10:33PM LACTATE-1.3
[**2141-9-29**] 10:33PM COMMENTS-GREEN TOP
<br>
<b>Other Labs:</b>
[**2141-10-1**] 05:40PM BLOOD CK(CPK)-649*
[**2141-10-2**] 06:00AM BLOOD CK(CPK)-497*
[**2141-10-3**] 10:00AM BLOOD ALT-17 AST-30 LD(LDH)-241 CK(CPK)-234*
AlkPhos-66 TotBili-0.6
[**2141-10-1**] 05:40PM BLOOD cTropnT-<0.01 proBNP-2987*
[**2141-10-2**] 06:00AM BLOOD cTropnT-0.01
[**2141-9-29**] 03:30PM BLOOD Cortsol-46.1*
[**2141-9-30**] 06:26AM BLOOD Cortsol-19.4
[**2141-9-29**] 03:30PM BLOOD TSH-0.65
[**2141-9-30**] 08:01PM BLOOD Type-ART Rates-/26 FiO2-92 O2 Flow-4
pO2-65* pCO2-36 pH-7.42 calTCO2-24 Base XS-0 AADO2-567 REQ O2-92
Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2141-9-30**] 08:01PM BLOOD Glucose-135* Lactate-0.9 Na-137 K-3.3*
Cl-108
[**2141-10-1**] 05:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2141-10-1**] 05:35PM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2141-10-1**] 05:35PM URINE RBC-74* WBC-0 Bacteri-MOD Yeast-FEW
Epi-<1
[**2141-10-1**] 05:35PM URINE Mucous-OCC
<br>
<b>Micro Data:</b>
Urine Cx ([**9-29**]) - Negative
Blood Cx ([**9-29**]) - Negative x 2
CSF Cx ([**9-29**]) - negative
RPR ([**9-30**]) - negative
Blood Cx ([**10-1**]) - no growth to date x 2 (final results pending)
Urine Cx ([**10-1**]) - negative
<br>
<b>Studies:</b>
CXR: [**9-29**]:
FINDINGS: Upright portable chest radiograph is obtained. Midline
sternotomy
wires and mediastinal clips are noted, likely related to prior
CABG. The
lungs are clear bilaterally, demonstrating no evidence of
airspace
consolidation, effusion, or CHF. There is minimal subsegmental
atelectasis at the left lung base, likely in the left lower
lobe. The cardiomediastinal silhouette is unremarkable. The
visualized osseous structures are intact. Bowel gas pattern in
the upper abdomen is unremarkable.
IMPRESSION:
No acute intrathoracic process
<br>
CHEST (PORTABLE AP) [**2141-9-30**] 8:12 PM
Single AP view of the chest is obtained supine on [**2141-9-30**] at
[**2053**] hours and is compared with the most recent study performed
the prior day. Again seen evidence of prior cardiac surgery.
There is mild pulmonary vascular congestion which may be in part
due to the supine position and underinflation of the lungs but
fluid overload or early failure would be a concern. The degree
of respiratory motion in the chest makes evaluation of the lower
lung fields suboptimal however there is a patchy increase in
lung markings at both bases.
IMPRESSION:
Findings are likely a combination of the underinflation, supine
position and some fluid overload. Recommend a repeat examination
when the patient condition permits to exclude developing
airspace disease at both bases.
<br>
UNILAT LOWER EXT VEINS RIGHT [**2141-9-30**] 3:44 AM
RIGHT LOWER EXTREMITY ULTRASOUND: Grayscale and color Doppler
son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and
popliteal veins was performed. There was normal flow,
augmentation, compressibility, and waveforms demonstrated. No
intraluminal thrombus was identified.
IMPRESSION: No evidence of right lower extremity deep vein
thrombosis.
<br>
CHEST (PORTABLE AP) [**2141-10-1**] 5:50 PM
IMPRESSION: AP chest compared to [**9-30**] and earlier on [**10-1**]
symmetrical opacification in the lower lungs has developed over
the past two days, due in part to small increasing bilateral
pleural effusion. This could be either dependent edema or
aspiration, more likely the former given some slight increase in
mild pulmonary vascular engorgement. No pneumothorax.
<br>
Head CT [**9-29**]: EAD CT WITHOUT CONTRAST: There is no comparison.
The study is somewhat degraded due to motion artifact. There is
no acute intracranial hemorrhage or mass effect. There is
generalized brain atrophy with slightly prominent ventricles,
with periventricular white matter hypodensity densities, likely
due to prior chronic small vessel ischemia. There is mild
mucosal thickening in the ethmoid sinus. Otherwise, the
surrounding osseous and soft tissue structures are unremarkable.
IMPRESSION: No acute intracranial hemorrhage. Chronic small
vessel ischemia.
<br>
TTE ([**10-2**]):
Conclusions:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 5-10 mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. There is mild pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a fat pad.
<br>
CHEST (PA & LAT) [**2141-10-4**] 9:28 AM
IMPRESSION: Resolution of pulmonary vascular congestion. Pleural
effusions and associated bibasilar atelectasis persist.
<br>
<b>Discharge Labs:</b>
WBC-7.7, Hct-38, Plt-277
Na-142, K-3.3, Cl-101, HCO3-34, BUN-20, Cr-1.3, Gluc-106,
Ca-9.1, Mg-2.7, Phos-2.8, Alb-3.3
Brief Hospital Course:
1) RLE Cellulitis
Initially treated with Vanc/Ceftaz for cellulitis. Later
changed to Vanc and Unasyn and subsequently Vanc and Zosyn.
Initially some concern for DVT. Pt placed on heparin drip.
Lower extremity dopplers negative as above and heparin stopped.
Over the course of hospitalization, cellulitis improved and on
discharge there was only minimal area of erythema.
<br>
2) Hypotension
On arrival to the floor, pt was hypotensive w/ SBPs in 80s. He
was given aggressive IV hydration and went to ICU. There,
patient received aggressive IV hydration and blood pressure
improved to 110s. He was subsequently transferred to the floor.
<br>
3) CHF, diastolic, acute on chronic/Acute Renal Failure
After patient was transferred to the floor, his O2 sat was
decreased (92% on RA) and he had significant secretions. Along
with this he was very lethargic. Clinical exam and CXR were
consistent with volume overload and pulmonary congestion. He
was diuresed with IV lasix over the next couple of days with
improvement in his overall respiratory status. His Cr went up
(from 0.8 to a peak of 1.5). Due to this, his Lasix was held on
the 2 days prior to discharge, however restarted on the day of
discharge when his Cr was back to 1.3. He had a repeat TTE with
the results as above (preserved systolic function with Grade I
diastolic dysfunction). Prior to discharge, his respiratory
status was stable and he was breathing comfortably on room air
with O2 sats in the mid to high 90s.
<br?
4) Pneumonia, question aspiration
After transfer to the floor on [**10-1**], patient had fever of 103,
thick secretions, and CXR that raised question of aspiration
pneumonia. Based on these findings, his antibiotics were
changed to Vancomycin and Zosyn. He was continued on these for
a few days until he remained afebrile with improved respiratory
status. He was subsequently changed to Levaquin and Flagyl to
complete a 10-day course. He was evaluted by speech and swallow
and was cleared for a regular diet due to no evidence of
aspiration on bedside evaluation. He still had significant
secretions so is being discharged with a home suction machine.
Consider Scopolamine patch if patient continues to have
significant secretions.
<br>
5) MS changes
Likely due to fever (source most likely RLE cellulitis). On
initial arrival on the floor, pt was febrile w/ hypotension.
Also had hypoglycemia (FS of 58). TSH, B12, Folate, RPR, head
CT all checked and unremarkable as above. He had an LP done in
ED w/ unremarkable results as above. During the initial part of
his hospitalization his mental status fluctuated from being
agitated (requiring restraints and sitter) to being lethargic
and minimally responsive. Family resisted haldol, so this was
not given. Once he was treated for infection, his mental status
improved and returned back to baseline.
<br>
6) Dementia, Alzheimer's type
Per family, pt is not oriented at baseline. As above mental
status varied, though back at baseline on discharge. He was
continued on Namenda and Aricept during hospitalization.
<br>
7) CAD
No active issues. Continued on asa 81mg and simvastatin.
<br>
Outstanding issues:
-f/u final blood culture results from [**10-1**]
-repeat CXR in [**4-21**] weeks
-monitor renal function with repeat chem-10 in 1 week
Medications on Admission:
Lasix 80mg qd
Simvastatin 40 mg qhs
KCl
MVI
Vit B12 SC q month
donepezil 5mg qhs
ASA 81mg qday
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
5. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
6. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
7. Vitamin B12-Vitamin B1 100-1 mg/mL Solution Sig: One (1)
Injection Intramuscular once a month.
8. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid ().
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
Congestive Heart Failure, Diastolic, Acute exacerbation
Likely Pneumonia (aspiration)
Cellulitis of Right lower extremity
Acute Renal Failure (in setting of diuresis)
Secondary:
Coronary Artery Disease
Dementia, Alzheimer's Type
Osteoarthritis
B12 Deficiency
Discharge Condition:
Afebrile, vital signs stable (O2 sats 95-96% on RA).
Pertinent discharge Labs:
BUN-20, Cr-1.3
WBC-7.7
Discharge Instructions:
Please complete the course of antibiotics as prescribed (last
dose on [**10-9**]). You should also take all your medications as
outlined in the provided medication list. Please arrange a
follow up appointment with your primary care doctor within 1
week. You will need to have your chemistry panel (including
tests for your kidney function) drawn at that time. You should
continue to take your lasix daily. Please weigh yourself daily.
If your weight increased by >3 lbs, please call your doctor.
You are being given a home suction machine which you can use for
your secretions.
.
Return to the emergency room or call your doctor if you have:
Fever
Shortness of Breath or Chest Pain
Followup Instructions:
Primary Care Doctor: Dr. [**Last Name (STitle) 34339**] (VA [**Hospital1 1474**]). [**Telephone/Fax (1) 34340**].
Please call for follow up within 1 week and to have labs drawn.
Cardiology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please call your doctor at the VA
[**Hospital1 1474**] to arrange a follow up appointment within 2 weeks.
Name: [**Known lastname 6054**],[**Known firstname **] N. Unit No: [**Numeric Identifier 6055**]
Admission Date: [**2141-9-29**] Discharge Date: [**2141-10-6**]
Date of Birth: [**2066-12-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2403**]
Addendum:
On arrival to medical floor, patient was hypotensive,
tachycardic, with elevated WBC in the setting of a known
infection (cellulitis). Thus, he met criteria for sepsis and
was transferred to the intensive care unit for further
management of his sepsis.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 197**] [**Name (NI) 198**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 2404**] MD [**MD Number(2) 2405**]
Completed by:[**2141-10-26**]
|
[
"428.33",
"427.31",
"682.6",
"995.92",
"428.0",
"038.9",
"V45.81",
"331.0",
"266.2",
"584.9",
"294.10",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16751, 16960
|
10178, 13478
|
339, 345
|
14877, 14940
|
3472, 4781
|
15715, 16728
|
2627, 2645
|
13624, 14472
|
14587, 14856
|
13504, 13601
|
15004, 15692
|
14956, 14980
|
2660, 3453
|
276, 301
|
373, 2181
|
2203, 2344
|
2360, 2611
|
4792, 10017
|
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