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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
6,574
| 172,379
|
1088
|
Discharge summary
|
report
|
Admission Date: [**2144-5-18**] Discharge Date: [**2144-5-23**]
Date of Birth: [**2105-10-3**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Cough and shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 38 yo AA woman with pmh significant for breast ca s/p
mastectomy in [**2135**], who has recently had mult. episodes of
recurrent pneumonia and was hospitalized from [**Date range (3) 7085**]
for VATS pleurodesis and biopsy of pleural lesion found by CT
scan as work up of recurrent pneumonia. She represented to the
ED on [**2144-5-18**] with "constant dry cough" and shortness of breath.
Pt states that she she has had sob and cough on and off for
many weeks but that since discharge the day before her sob has
worsened to the point of "practically being to out of breath to
speak." Pt denies recent fever, night sweats, chest pain,
rhinorrhea, audible wheezing, or exposure to allergens.
Past Medical History:
Breast cancer s/p right mastectomy in [**2135**]
Social History:
Lives in [**Location 86**], has support of sisters and close friends.
Denies alcohol, tobacco, or drug use.
Family History:
noncontributory
Physical Exam:
On discharge, vital signs are stable, pt is afebrile with good
oxygenation at rest and with exertion. Cardiac exam regular in
rate and rhythm without murmur, rub, or gallop. Lungs are clear
and surgery incision sites well healed. Abdomen is soft, nt,
nd, with normal bowel sounds and without hepatosplenomegaly.
Extremities are warm, with right arm mildly edematous but
without pain.
Pertinent Results:
CT of Chest [**2144-5-18**]:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Cardiomegaly with interstitial pulmonary edema and bilateral
pleural effusions.
3. Atelectasis of the entire left lower lobe.
4. Patchy opacities in the right upper lobe, consistent with
asymmetric pulmonary edema or aspiration.
5. Stable left pleural-based nodules, consistent with metastatic
disease.
6. Stable metastatic lesion in the sternum
CHEST (PA & LAT)[**2144-5-18**]:
IMPRESSION: Interval removal of chest tube without evidence of
pneumothorax. 2. Stable pleural based left apical opacity. 3.
Left lower lobe collapse/
consolidation. 3. Unchanged appearance of the prominent
interstitial markings. There is no overt CHF.
UNILAT UP EXT VEINS US [**2144-5-21**]
IMPRESSION: DVT within the right subclavian vein. This is
nonocclusive, and the age is indeterminate.
Brief Hospital Course:
Pt was admitted to MICU upon admission because of poor
oxygenation requiring non rebreather mask at 100% oxygen. On
hospital day two she had good oxygen saturation on room air and
was transferred to 11[**Hospital 1827**] medical floor. Pt was treated with
gentle diuresis and antibiotics for mild pulmonary edema, and
pneumonitis - nosocomial vs. aspiration s/p recent surgical
admission. During hospitalization, pt noted that her right arm
felt swollen and a RUE ultrasound confirmed a thrombus in th
right SCV. Pt was heparinized and subsequently started on
lovenox with eduation. During hospitalization pts VATS biopsy
results were completed by pathology and showed pleural biopsy to
be breast cancer. Pt was seen by oncology and hematology
regarding recurrence of breast cancer and thrombus.
Medications on Admission:
Percocet prn s/p recent surgery
Colace 100 mg po qd while taking percocet
MDI
Discharge Medications:
1. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Lovenox 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous
once a day for 10 days.
Disp:*10 syringes* Refills:*0*
3. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
4. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q4H (every 4 hours) as needed for 10 days.
Disp:*1 bottle* Refills:*0*
5. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 3 days.
Disp:*24 Capsule(s)* Refills:*0*
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-22**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Physician's Home care
Discharge Diagnosis:
Pneumonia
Deep Vein Thrombosis
Discharge Condition:
Pt is breathing without difficulty, good O2 saturation on room
air, vital signs are stable, pt is tolerating anti-coagulation
without incident.
Discharge Instructions:
Please return to the emergency room or call your primary care
doctor if you develop worsening shortness of breath.
Followup Instructions:
With Dr. [**Last Name (STitle) 19**] of oncology as arranged between pt and Dr. [**Last Name (STitle) 19**].
You will need to have your "INR" checked to manage your blood
thinners twice a week until it is stabilized. You should follow
this with Dr. [**Last Name (STitle) 5781**].
You should follow up with Dr. [**Last Name (STitle) 6160**] regarding the blood clot
in 3 months. Please call to make an appointment [**Telephone/Fax (1) 6161**]
Completed by:[**2144-6-7**]
|
[
"507.0",
"428.0",
"453.8",
"197.2",
"285.29",
"486",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4312, 4364
|
2613, 3415
|
340, 346
|
4439, 4584
|
1731, 2590
|
4747, 5220
|
1292, 1309
|
3543, 4289
|
4385, 4418
|
3441, 3520
|
4608, 4724
|
1324, 1712
|
271, 302
|
374, 1079
|
1101, 1151
|
1167, 1276
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,310
| 109,978
|
45184
|
Discharge summary
|
report
|
Admission Date: [**2165-6-25**] Discharge Date: [**2165-7-6**]
Date of Birth: [**2101-2-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Barrett's esophagus with high-grade dysplasia.
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy.
Transhiatal esophagectomy with left cervical
esophagogastrostomy.
Feeding jejunostomy.
Left sided chest ultrasound and diagnostic and therapeutic
paracentesis.
History of Present Illness:
Mrs. [**Known lastname 696**] is a 64 year-old female with known [**Doctor Last Name 15532**]
esophagus found to have high-grade dysphasia on screening EGD.
Past Medical History:
[**Doctor Last Name 15532**] Esophagus
Hiatal Hernia
Hypothyroidism
Social History:
Married with 4 healty children. Waitress
Tobacco: never. ETOH rare
Family History:
Mother died age [**Age over 90 **] s/p hip fracture
Father died age 84 of DMT2 complication
Siblings: 2 sisters, 3 brothers 1 died ag 50 of degenerative
neuro disease
Physical Exam:
Afebrile, AVSS
NAD
RRR
CTAB
SNTND BS+
Wound CDI
No c/c/e
Pertinent Results:
Tissue Pathology [**6-25**]
I. Esophagus and proximal stomach, esophagogastrectomy (A-Y):
1. Barrett's esophagus with small foci of intramucosal
carcinoma, arising in a background of extensive high grade
glandular dysplasia; see synoptic report.
2. No submucosal invasion is identified; examined esophageal
and gastric resection margins are free of malignancy and
dysplasia.
3. Squamous epithelium with mild active esophagitis.
4. Gastric segment with unremarkable fundic mucosa.
5. Eight (8) regional lymph nodes with no carcinoma identified
(0/8).
II. Left gastric lymph nodes, regional resection (Z-AC):
Six (6) lymph nodes with no carcinoma identified (0/6).
.
Pleural fluid [**7-1**] NEGATIVE FOR MALIGNANT CELLS. Reactive
mesothelial cells and histiocytes.
.
[**6-25**] CXR
IMPRESSION:
1. Endotracheal tube entering right mainstem bronchus and likely
associated left basal atelectasis/consolidation and probable
pleural effusion.
2. Nasogastric tube passes below the diaphragm with its sidewall
hole at the level of the diaphragm.
[**6-28**] CXR
NG tube tip is in unchanged position. Left lower lobe
retrocardiac opacity is persistent, corresponding to atelectasis
or pneumonic consolidation. Right lung remains clear. There is
no pneumothorax. Small left pleural effusion is unchanged as is
cardiomediastinal silhouette
[**7-1**] CXR
Decreased small left pleural effusion. Left lower lobe
atelectasis. Dilated neo esophagus with air-fluid level.
Brief Hospital Course:
Pt was admitted to Thoracic surgery s/p transhiatal
esophagectomy on [**2165-6-25**]. The patient tolerated the procedure
well without complications and with an EBL of 600. Post
operatively, the patient was transfered to the ICU per
esophagectomy protocol and was tranfused 1 u PRBC. The patient
was extubated on the night of POD#0. On POD#2, tolerated trophic
tube feeds at 30cc/hr. On POD#3, NGT was dc'd without issues.
On POD#6, epidural was d/c'd, tube feeds were held [**12-21**] nausea,
and pleural fluid was tapped by IP [**12-21**] increasing left sided
pleural effusion. On POD#9 pt passed the grape juice swallow
test and tolerated clears without nausea. On POD#10, JP was
dc'd and TF were advanced to goal, both without any
complications. On POD#11, staples were removed from her wound
and steristrips placed. Upon discharge, the patient was
afebrile with all vitals stable, tolerating full liquid diet,
ambulating well, and with pain controlled on po pain meds.
Medications on Admission:
Prilosec 40 mg once daily
Synthroid 75 mcg once daily
Discharge Medications:
1. Replete/Fiber Liquid Sig: 55 (fifty-five) cc PO every
hour: Please attach to pump so she gets a continuous flow of
tube feeds running at 55cc/hr. Thanks.
Disp:*60 bottles* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 5ml packs* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: please take while you are using pain meds.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Bayada Nurses Inc
Discharge Diagnosis:
Barrett's esophagus with high-grade dysplasia s/p
esophagogastroduodenscopy & feeding jejunostomy
Hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you experience chest
pain, shortness of breath, fever, chills, nausea, vomiting,
diarrhea, or abdominal pain.
If your feeding tube sutures become loose or break, please tape
the tube securely and call the office [**Telephone/Fax (1) 170**]. If your
feeding tube falls out, save the tube, call the office
immediately [**Telephone/Fax (1) 170**]. The tube needs to be replaced in a
timely manner because the tract will close within a few hours.
Do not put any medication down the tube unless they are in
liquid form.
Flush your feeding tube with 50cc of water every 8 hours if not
in use and before and after every feeding.
Followup Instructions:
Please call to schedule your follow-up appointment with Dr.
[**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] on the [**Hospital Ward Name 517**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) **].
Please report to the [**Location (un) **] radiology department a chest
x-ray 45 minutes before your schedule appointment.
Also, please call the office about your barium swallow study the
morning of your appointment.
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 250**]
|
[
"150.8",
"E878.8",
"518.0",
"530.85",
"553.3",
"458.29",
"998.11",
"244.9",
"511.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04",
"42.52",
"34.91",
"44.29",
"42.41",
"46.39",
"03.90",
"99.77",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
4281, 4329
|
2685, 3668
|
368, 558
|
4486, 4495
|
1196, 2662
|
5241, 5792
|
936, 1104
|
3772, 4258
|
4350, 4465
|
3694, 3749
|
4519, 5218
|
1119, 1177
|
281, 330
|
586, 744
|
766, 835
|
851, 920
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,349
| 145,545
|
29892+57669
|
Discharge summary
|
report+addendum
|
Admission Date: [**2153-2-7**] Discharge Date: [**2153-4-6**]
Date of Birth: [**2075-6-25**] Sex: M
Service: MEDICINE
Allergies:
Tramadol
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
colonoscopy
EGD
capsule endoscopy
History of Present Illness:
Patient is 77 male with h/o HTN who p/w BRBPR yesterday morning,
multiple episodes. Had black stool for 3D prior to presenting
with emesis on day of admission per ED, but denied this upon
admission to CCU. Pt denied abd pain, nor recent abdominal pain
after eating. Was lightheaded with multiple episodes of BRBPR,
no chest pressure or SOB. Never had bleeding prior. Had a
colonoscopy about 4 months ago at [**Hospital1 336**] and remembers that this
was negative. It was reported that EMS felt the patient was
suicidal, but pt denied this on admission.
.
In the [**Name (NI) **], pt was noted to be tachycardic, with HR in 100s,
which decreased to 90s with 500cc IVF. Hct was 19. Pt underwent
NG lavage, which was negative. Transferred to MICU for further
management.
.
Past Medical History:
HTN
anxiety
Social History:
Wife just died last week, has not had chance to bury her yet.
Concerned about cat in appartment. Unable to read or write -
wife took care of all finances, etc. Pt denies tobacco, h/o EtOH
but quit.
Family History:
noncontributory
Physical Exam:
VS: 97.9, 134/66, 74, 20, 96% RA, LOS 5L positive
Gen: well appearing, NAD
HEENT: PERRL, EOMI, MMM, OP clear
CV: RRR, nl S1/S2, no m/r/g
Pulm: CTAB
Abd: soft, NT/ND, +BS, no masses
Ext: 2+ LE edema to knees
Neuro: A&O x 3, MAE
Pertinent Results:
[**2153-2-7**] 09:30AM PT-12.5 PTT-25.4 INR(PT)-1.1
[**2153-2-7**] 09:30AM PLT COUNT-275
[**2153-2-7**] 09:30AM HYPOCHROM-2+
[**2153-2-7**] 09:30AM NEUTS-81.9* LYMPHS-13.6* MONOS-3.4 EOS-0.4
BASOS-0.5
[**2153-2-7**] 09:30AM WBC-9.3 RBC-2.10* HGB-6.3* HCT-19.1* MCV-91
MCH-30.0 MCHC-32.9 RDW-14.3
[**2153-2-7**] 09:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2153-2-7**] 09:30AM estGFR-Using this
[**2153-2-7**] 09:30AM GLUCOSE-146* UREA N-23* CREAT-1.0 SODIUM-140
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-27 ANION GAP-10
[**2153-2-7**] 02:09PM HCT-21.2*
[**2153-2-7**] 10:09PM HCT-25.0*
.
head CT:
1. No evidence of hemorrhage.
2. Hypodensity of the cerebral periventricular white matter,
particularly adjacent to the occipital [**Doctor Last Name 534**] of the right lateral
ventricle. This could represent chronic microvascular ischemia.
.
head MRI: Focal area of T2 hyperintense signal involving the
right posterior periventricular white matter suggestive of
chronic microvascular ischemic or gliotic changes. Correlation
with gadolinium-enhanced images would be recommended for further
evaluation. It should be noted that the patient refused the
administration of gadolinium near the termination of the exam
and requested to leave the radiology department. There are no
acute territorial infarcts seen on diffusion images. Followup is
suggested.
.
colonoscopy: Polyps in the ascending colon (polypectomy)
Diverticulosis of the ascending colon, transverse colon and
descending colon
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum.
Should have routine capsule study & repeat colonoscopy in 3
years pending histology. Bright blood probably diverticular
bleed.
.
EGD:
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
.
Echo: EF>55%. Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Borderline pulmonary artery systolic hypertension. Mildly
dilated aortic arch.
.
RLE USN: Nonocclusive, probably subacute right popliteal DVT.
Brief Hospital Course:
A/P: 77M with h/o HTN who p/w GI bleed found to be unsafe to d/c
home so awaiting guardianship.
.
# Cognitive status- The patient presented with poor baseline
cognitive ability. His wife had been the primary caretaker. As
she had recently passed away, there was concern that the patient
would not be able to successfully manage independant living. A
psych consult was requested for evaluation of the patient's
ability to take care of himself. Neuropsych testing documented
cognitive impairment NOS. The examiner was concerned that Mr.
[**Known lastname 9733**] cognitive limitations would limit his ability to
live independantly. He was seen again on [**3-23**] by psychiatry who
felt the patient had significant problems with learning and
shifting cognitive sets, and based on this since his wife was
the primary caretaker, it was felt Mr. [**Known lastname **] would not be
able to safely function independently on his own. The primary
doctor for the patient was also contact[**Name (NI) **] and felt the patient
would have trouble caring for himself. Both social work and
legal services were involved in obtaining guardianship for this
patient and placement for this patient.
.
# GI bleed - The patient was admitted to the MICU with a HCT 19
where he was transfused a total of 6 units. His hct was stable
at 31. The patient underwent EGD and colonoscopy by GI. The EGD
ruled out an upper GI bleed, while the colonoscopy demonstrated
3 polyps (nonbleeding) which were removed, diverticulosis, and
grade I internal hemorrhoids. Therefore, the BRBPR was
attributed to diverticulosis. The pathology on the excised
polyps came back as adenoma. A repeat colonoscopy was
recommended in three years. A capsule study was also recommended
and was done as an inpatient. The patient was transferred to the
floor and his Hct remained stable. His capsule study is still
pending and should be followed as an outpatient.
.
# Lower extremity edema: The patient has a history of lower
extremity edema. He had no history of gout and no evidence of
changes. This was followed and remained fairly stable with
lasix, TEDS, low salt diet and leg elevation.
.
# Hypertension - The patient's BP was controlled with Lisinopril
and metoprolol.
.
# Right popliteal DVT- On [**3-7**] the patient chronically
edemetous LEs appeared asymetric. A LE USN of the RLE showed a
subacute DVT, partially re-canalized. He was started on coumadin
and bridged with heparin until therapuetic. The patient will
need to remain on coumadin for 6 months with weekly INR checks.
His last INR was 2.6 on [**4-2**] and at that time he was on coumadin
5mg Qhs alternating with 2.5 mg (on mon/weds/fri). He had
previously been on 5 mg qhs, but was slightly supratherapeutic
and has been stable on the 5 mg and 2.5 mg regimen. His next
Inr should be checked on [**4-9**] and needs to be checked weekly.
The patient may need a full hypercoagulable work-up in the
future by his primary doctor.
.
# SVT: The patient had one episode of symptomatic SVT with a P
160, likely AVNRT. He complained of "heartburn and mild
dyspnea". The SVT broke immediately with carotid massage and the
patient's symptoms resolved. He was started on metoprolol and
this was titrated up to 25mg [**Hospital1 **]. He had no recurrent episodes.
.
# GERD: The patient was started on protonix per his request for
heartburn with good symptom control.
.
# Right medial buttock furuncle- The patient was noted to have a
right buttock furuncle, and should continue warm compresses, and
neosporin with daily dry dressing changes, until his lesion is
fully healed.
.
# Weight loss - The patient had mentioned a > 60 lbs weight loss
over past year, but no further information was able to be
obtained. A full outpatient work-up should be considered, and a
cancer screen may be necessary.
Medications on Admission:
(pt could not list meds, does not know doses):
lisinopril
clonidine
Ultram
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
2. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn.
3. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO QPM (once a day
(in the evening)).
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
15. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
16. Trazodone 100 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
17. Outpatient Lab Work
Have PT, PTT, INR checked on [**4-9**] and every week. Call Dr.
[**Last Name (STitle) 67760**] for problems at ([**Telephone/Fax (1) 71454**]
18. Neomycin-BacitracnZn-Polymyxin 3.5-400-5,000 mg-unit-unit/g
Ointment Sig: One (1) Appl Topical QID (4 times a day): apply
over right medial buttock furuncle with guaze dressing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care
Discharge Diagnosis:
Primary:
1) GI bleed with acute blood loss anemia
2) Cognitive impairment NOS
3) DVT
Secondary:
1) HTN
2) Glaucoma
3) Weight Loss - 60 lbs
4) AVNRT
5) Chronic lower extremity edema, NOS
Discharge Condition:
stable, tolerating medications
Discharge Instructions:
You presented with a GI bleed and later developed a dvt. You
will continue coumadin and will need close monitoring of your
INR.
.
Please present to the hospital or call your primary care
provider if you have chest pain or shortness of breath, headache
or dizziness, fever or chills.
.
Please take all of your medications as directed
Followup Instructions:
***GIVEN history of > 60 lbs weight loss over past year, please
consider full cancer screening/evaluation*****
.
Follow-up with Dr. [**Last Name (STitle) 67760**]. Call ([**Telephone/Fax (1) 71454**] for more
information.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Name: [**Known lastname 1632**],[**Known firstname **] Unit No: [**Numeric Identifier 12007**]
Admission Date: [**2153-2-7**] Discharge Date: [**2153-4-6**]
Date of Birth: [**2075-6-25**] Sex: M
Service: MEDICINE
Allergies:
Tramadol
Attending:[**First Name3 (LF) 1305**]
Addendum:
# Capsule endoscopy results: As the patient was leaving, an
email was obtained with the preliminary results of his capsule
study. His preliminary read revealed active ulcerations and some
stricturing, there are also pseudopolyps. An attempt was made to
call Dr. [**Last Name (STitle) **] for an appointment, but the office was closed.
The patient needs follow-up and this can be arranged by calling
Dr. [**Last Name (STitle) 12008**] ([**Telephone/Fax (1) 12009**] or Dr. [**Last Name (STitle) **]([**Telephone/Fax (1) 4813**]. The
final results should also be obtained as an outpatient.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1307**]
Completed by:[**2153-4-6**]
|
[
"459.81",
"680.5",
"780.52",
"285.1",
"530.81",
"294.8",
"428.0",
"783.21",
"455.0",
"309.89",
"401.9",
"453.41",
"300.00",
"787.1",
"427.89",
"211.3",
"782.3",
"365.9",
"562.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"45.42",
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11438, 11642
|
3775, 7587
|
272, 307
|
9729, 9762
|
1655, 2298
|
10144, 11415
|
1375, 1392
|
7713, 9421
|
9519, 9708
|
7613, 7690
|
9786, 10121
|
1407, 1636
|
227, 234
|
335, 1108
|
2307, 3752
|
1130, 1143
|
1159, 1359
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,238
| 164,153
|
54207
|
Discharge summary
|
report
|
Admission Date: [**2201-5-28**] Discharge Date: [**2201-7-16**]
Date of Birth: [**2157-7-16**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Percocet
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
small bowel obstruction
Major Surgical or Invasive Procedure:
right colectomy
lysis of adhesions
History of Present Illness:
The patient is a 43-year-old
male, status post cadaveric renal transplant in [**2187**]. This
has been complicated by chronic allograft nephropathy.
However, the patient was admitted to the hospital on
[**2201-5-28**] with nausea, vomiting and diarrhea. The patient
progressed to have a partial bowel obstruction with KUB and
CAT scan showing partial small bowel obstruction. However,
CAT scan was also read as having a mass in the right lower
quadrant. The patient was managed conservatively with IV
hydration, antibiotics, as well as NG tube decompression.
However, the patient still was tender with low-grade fevers.
Therefore, the patient was screened for the operating room and
recieved right colectomy on [**2201-6-9**].
The patient is now nine days status post
exploratory laparotomy and right colectomy for an appendiceal
phlegmon involving the cecum. The patient admits he did well
postoperatively but he had a prolonged ileus, however, the
caliber of the patient's ileus/partial small bowel
obstruction has increased over the past 48 hours. The
patient has had serial worsening of KUBs but considerable
distinction of his small bowel. The patient has become more
toxic with low-grade tachycardia and tachypnea and increasing
abdominal distention with worsening of physical and x-ray
examinations as well as the general deterioration in his
clinical status. The patient was taken to the Operating Room
for exploratory laparotomy.
Past Medical History:
right colectomy
lysis of adhesions
end stage renal disease
graft failure
clostridium dificil
zoster
Physical Exam:
Gen: A&O
CV: RRR
lungs: clear to auscultation
abd: soft, nontender, distended, erythema along dermatomal lines
on Right flank
colostomy: pink intact
Pertinent Results:
[**2201-5-28**] 05:37PM GLUCOSE-72 UREA N-56* CREAT-2.9* SODIUM-129*
POTASSIUM-3.2* CHLORIDE-96 TOTAL CO2-15* ANION GAP-21*
[**2201-5-28**] 05:37PM WBC-8.7 RBC-3.35* HGB-7.0* HCT-21.8* MCV-65*
MCH-20.9* MCHC-32.0 RDW-17.7*
[**2201-5-28**] 05:37PM NEUTS-74.8* BANDS-0 LYMPHS-20.3 MONOS-4.0
EOS-0.8 BASOS-0.1
[**2201-5-28**] 05:37PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-3+ POLYCHROM-NORMAL
[**2201-5-28**] 05:37PM PLT SMR-NORMAL PLT COUNT-176
[**2201-5-28**] 12:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2201-5-28**] 12:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2201-5-28**] 12:30PM URINE RBC-[**2-13**]* WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2201-5-28**] 10:45AM GLUCOSE-80 UREA N-63* CREAT-3.0* SODIUM-129*
POTASSIUM-3.6 CHLORIDE-93* TOTAL CO2-18* ANION GAP-22*
[**2201-5-28**] 10:45AM TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF
[**2201-5-28**] 10:45AM LACTATE-1.1
[**2201-5-28**] 10:45AM WBC-7.6 RBC-3.51* HGB-7.0* HCT-23.3* MCV-67*
MCH-20.1*# MCHC-30.2* RDW-17.5*
[**2201-5-28**] 10:45AM NEUTS-68.2 BANDS-0 LYMPHS-26.4 MONOS-4.2
EOS-1.0 BASOS-0.2
[**2201-5-28**] 10:45AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-3+ POLYCHROM-NORMAL SPHEROCYT-1+
SCHISTOCY-1+ TEARDROP-1+ ELLIPTOCY-1+
[**2201-5-28**] 10:45AM PLT COUNT-208
[**2201-5-28**] 10:45AM PT-14.3* PTT-39.1* INR(PT)-1.4
Brief Hospital Course:
[**6-6**] CT:1. Increase in size of bilateral pleural effusions with
consolidation at both lung bases. In addition there is
opacification in the lingular region. This is consistent with
worsening multifocal pneumonia.
2. Soft tissue like mass as described above. This may be
inflammatory or represent a lymphomatous type mass. This mass
also appears to be causing a partial small bowel obstruction as
there are loops of non-dilated bowel adjacent to it as well as
other more dilated loops. This appearance of dilated bowel has
progressed compared with the prior study.
3. Increased ascites.
4. Diverticulosis without diverticulitis.
[**6-9**]: Right colectomy
[**7-3**] CXR large right pleural effusion
[**7-7**] tx thoracent: 500cc
[**7-9**] LUE AV fistula patent
[**7-12**] Cdiff + and zoster
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Acyclovir 200 mg/5 mL Suspension Sig: 1.5 PO Q12H (every 12
hours): Pt should get 300mg [**Hospital1 **].
Disp:*30 * Refills:*2*
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QD (once
a day).
Disp:*30 Capsule(s)* Refills:*2*
5. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Diphenhydramine HCl 25 mg Capsule Sig: [**12-12**] Capsules PO HS (at
bedtime) as needed for sleep.
Disp:*40 Capsule(s)* Refills:*0*
7. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
2X/WEEK (MO,TH).
Disp:*30 * Refills:*2*
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
Disp:*30 * Refills:*2*
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*30 * Refills:*2*
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO QD PRN ().
Disp:*30 Tablet(s)* Refills:*2*
11. Metoclopramide HCl 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
12. Minoxidil 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
13. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed for anal rash.
Disp:*30 * Refills:*0*
14. 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*
15. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: Two (2)
Tablet PO Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
16. Terazosin HCl 5 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
17. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
18. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
19. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days: Take for ten more days.
Disp:*30 Tablet(s)* Refills:*0*
21. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO once a day:
steroid taper: start at 4mg for one week, then decrease by one
mg each week.
Disp:*120 Tablet(s)* Refills:*2*
22. Iron Sucrose 100 mg/5 mL Solution Sig: 1.5 Intravenous
every other day for 3 doses: please give during dialysis.
Disp:*3 * Refills:*0*
23. Papain 2.5 % Solution 10-20 cc NGT PRN clogged NGT
10-20cc flush for feeding tube PRN clogged NGT
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
right colectomy
lysis of adhesions
end stage renal disease
graft failure
clostridium dificil
zoster
Discharge Condition:
stable
Discharge Instructions:
1. Please monitor for the following: fever, chills, nausea,
vomiting, inability to tolerate food/drink. If any of these
occur, please contact your physician [**Name Initial (PRE) 2227**].
2. Follow schedule for labs every Monday and thursday: chem7,
cbc, Ca, PO4, AST, T.bili, U/A, and immunosuppresent levels
Followup Instructions:
Please follow up with Dr.[**Name (NI) 670**] for an appointment next
week.
Completed by:[**2201-7-16**]
|
[
"486",
"789.5",
"560.1",
"996.81",
"560.81",
"584.5",
"540.1",
"997.4",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"45.42",
"39.95",
"96.04",
"96.07",
"99.15",
"45.73",
"54.59",
"88.35",
"99.04",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7327, 7397
|
3637, 4441
|
311, 348
|
7541, 7549
|
2146, 3614
|
7909, 8015
|
4464, 7304
|
7418, 7520
|
7573, 7886
|
1977, 2127
|
248, 273
|
381, 1838
|
1860, 1962
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,020
| 131,230
|
26560+57505
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-2-8**] Discharge Date: [**2107-2-21**]
Date of Birth: [**2041-5-18**] Sex: M
Service: VSU
CHIEF COMPLAINT: Ischemic right foot.
HISTORY OF PRESENT ILLNESS: The patient is a hospital
transfer from [**Hospital3 26615**]. He was initially evaluated at [**Hospital3 26616**] on [**2107-2-28**]. He was brought into the emergency
room by the EMS with complaints of right foot pain over the
last several weeks. Denies any injury to the area. He also
denies any systemic infections, illnesses with fever, chest
pain, abdominal pain, productive coughing or genitourinary
symptoms. He had a recent outpatient vascular exam on the
right lower extremity which revealed multiple narrowings and
no significant blood flow distant to the popliteal artery,
but he was uncertain what plans were made to deal with the
problem.
Patient was initially evaluated in the emergency room there.
Patient was transferred to our hospital for further
evaluation and care under the care of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**].
PAST MEDICAL HISTORY: Allergies: BuSpar and Percodan.
Manifestations unknown.
MEDICATIONS ON ADMISSION: Trazodone 65 mg at bedtime,
Protonix 40 mg once daily, Risperdal 0.25 mg at bedtime,
Toprol XL 100 mg once daily and hydrochlorothiazide.
SOCIAL HISTORY: Patient lives alone. Habits: Patient is a
current smoker. Has a history of alcohol abuse. Has a history
of marijuana use.
ILLNESSES: Right foot ischemia, history of hypertension,
history of alcohol abuse, history of bipolar disorder,
history of paranoia, history of GERD, postoperative blood-
loss anemia, transfused.
PHYSICAL EXAMINATION: Patient is alert and oriented x3 in no
acute distress. Cachectic looking. Lungs are clear to
auscultation. Heart is a regular rate and rhythm. Abdominal
exam is unremarkable. Pulses are palpable femorals and
popliteals bilaterally. The pedal pulses are monophasic
Dopplerable signals bilaterally.
HOSPITAL COURSE: Patient was initially evaluated in the
emergency room and then transferred to the in-house vascular
service for continued care. Patient had pulse volume
recordings done on [**2107-2-9**], which demonstrated severe
aortoiliac disease on the right with probable occlusion and
significant aortoiliac disease on the left with additional
bilateral SFA and tibial disease. The Dopplers on the right
were monophasic. Femoral and popliteal absent pedal pulses.
On the left he had monophasic femoral, popliteal with absent
posterior tibial and monophasic DP. The metatarsal pressure
on the right was 6 mm, on the left was 9. The ABI on the left
was 0.50; on the right it could not be calculated.
Patient was placed on a CIWA scale and thiamin and folate on
admission prophylactically. The patient underwent a
diagnostic arteriogram on [**2107-2-11**], which demonstrated
a left external ileac was occluded, the left common iliac was
occluded, the profunda femoralis was occluded. There was a
patent SFA with 3-vessel runoff.
Nutritional services followed the patient secondary to
question of malnutrition. Recommendations were to continue
calorie count and Boost with meals.
Cardiology was consulted in preparation for preoperative risk
assessment. They recommended a Persantine MIBI given that the
procedure scheduled (aorto bilateral femoral) is a high risk.
Patient's exercise capacity is unknown. A maximized blood
pressure control with beta blockade. Consider adding an ACE
inhibitor for added blood pressure control and would add a
statin to the [**Hospital 228**] medical regimen. Also recommended to
continue the Toprol, to continue his current
hydrochlorothiazide.
Patient underwent a Persantine MIBI on [**2107-2-15**]. The
stress portion was without symptoms or EKG changes. The
nuclear study showed a normal left ventricular function and
wall motion without perfusion defects. Echocardiogram was
obtained which showed an ejection fraction greater than 55%.
The left ventricle showed moderate symmetric left ventricular
hypertrophy with a normal LV cavity size and normal regional
wall motion. Studies with no resting LVOT. There was mild
aortic valve leaflet thickening without aortic stenosis or
aortic regurgitation. The mitral valve leaflets showed no
prolapse with 1% MR. [**First Name (Titles) **] [**Last Name (Titles) **] valves were normal with
trivial TR. PA systolic pressures could not be determined.
There is a normal pulmonic valve leaflet with physiologic PR.
CT of the abdomen and pelvis was obtained which demonstrated
aorta as a normal in caliber with scattered calcification and
plaque. There was calcification at the celiac origin
resulting in a high-grade stenosis and a poststenotic
dilatation. A regular artery stenotic is stenotic at the
origin was partially calcified. There was moderate stenosis
of the SMA. The right common iliac, the right internal and
external iliac arteries are occluded with severe segmental
calcification. There is a tiny collateral supplying the right
common femoral artery. The left common iliac and internal
iliac are heavily calcified but patent. The left external
iliac was occluded. The left common femoral artery was patent
with collaterals slow.
A CT of the abdomen showed the liver, gallbladder, pancreas
and large small bowel loops appeared unremarkable. Spleen is
15.5 cm. There were several hypodense lesions in the kidney
which most likely represents cyst. The left adrenal gland
demonstrates a 9 mm nodule.
The CT of the abdomen with contrast: The bladder is
unremarkable. Sigmoid colon contains multiple diverticula
without evidence of diverticulitis. The bone windows showed a
laminectomy of L5 and S1 with fixation wires between the os
sacrum and the lower spine. There is a [**12-6**] grade
anterolisthesis of L5 and L6.
On [**2-17**] patient proceeded to undergo aortobifemoral
bypass with a 6mm x 18 mm Dacron graft. Patient tolerated the
procedure well and was transferred to the PACU in stable
condition postoperatively. He remained in the PACU intubated,
sedated. His pulse showed warm feet bilaterally with stable
bilateral gangrenous toes, but the PT and DP on the right
were biphasic Dopplerable signal. The PT and DP on the left
were triphasic signal. Nitroglycerin was ________ for
systolic hypertension. This was weaned off, and the blood
pressure was under control. Patient was continued on
perioperative cephazolin and Flagyl. Patient was extubated
and transferred to the VICU for continued monitoring and
care.
On postoperative day 1 there were no overnight events. He was
afebrile. Dressings were clean, dry, intact. The groins were
clean. The pulse exam remained unchanged. Blood pressure was
well controlled, and his pain was well controlled.
On postoperative day 2 patient's overnight temperature was
101.3 to 101. Aggressive pulmonary toiletry was instituted.
Patient's chest x-ray showed a basilar atelectasis, left
being greater than the right with small right pleural
effusion and somewhat perihilar haziness suggesting
asymmetric pulmonary edema versus aspiration.
The chest x-ray on [**2-20**] showed the interstitial pulmonary
edema was slightly improved. The right basilar atelectasis
had resolved. There was a dense consolidation in the left
lung base associated with the pleural effusion indicating
pneumonia.
Blood and urine cultures were negative. Patient was continued
on aggressive pulmonary toiletry. Vancomycin and levofloxacin
were started empirically for patient's aspiration pneumonia.
Patient continued to be diuresed.
On postoperative day 3 patient required an increase in his
Ativan dosing, continued aggressive diuresis. His diet was
advanced as tolerated. His Lopressor was increased for rate
control. Patient was evaluated by physical therapy, who felt
that the patient may require long-term care if his mental
status and functional capacity do not improve. Social service
followed the patient and discussed with his sister the
medical condition and problems of the patient. Sister is very
much supportive and would like to be involved in the care.
Social service will discuss this with the patient. Patient
will be discharged to rehab when medically stable.
DISCHARGE MEDICATIONS:
1. Risperidone 0.26 mg once daily.
2. Ipratropium bromide 0.02 % solution, inhalations q.6h.
3. Acetaminophen 325 mg tablets [**12-6**] q.4-6h. p.r.n.
4. Trazodone 50 mg at bedtime.
5. Albuterol sulfate 0.083% solution, inhalations q.6h.
6. Protonix 40 mg once daily.
7. Levofloxacin 250 mg q.24h.
8. Lopressor 50 mg b.i.d.
9. Calcium carbonate 500 mg t.i.d.
10. Lorazepam 2 mg q.4h. around the clock. Hold for sedation.
DISCHARGE DIAGNOSES:
1. Right foot ischemia status post diagnostic arteriogram on
[**2-11**] status post aortobifemoral bypass with Dacron
graft [**2107-2-17**].
2. History of hypertension, controlled.
3. History of alcohol abuse.
4. History of bipolar disorder.
5. History of paranoia.
6. Postoperative blood-loss anemia, transfused.
7. Postoperative aspiration pneumonia left lower lobe,
treated.
8. History of gastroesophageal reflux disease.
9. History of SMA celiac and right middle artery stenosis by
CT scan.
10. History of chronic obstructive pulmonary disease by CT
scan.
11. History of diverticulosis of the sigmoid colon without
diverticulitis by CT scan.
FOLLOWUP: Patient should follow up with Dr. [**Last Name (STitle) 1391**] in 2
weeks time. Should call for an appointment at [**Telephone/Fax (1) 1393**].
DISCHARGE INSTRUCTIONS: Patient may shower. No tub baths.
Ambulate essential distances. No driving until seen in
followup. Patient should be continued on a stool softener as
long as he is on analgesics. Call Dr.[**Name (NI) 1392**] office if he
develops temperature greater than 101.5 or the wounds become
erythematous or drain purulent material.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2107-2-21**] 11:20:36
T: [**2107-2-21**] 12:52:28
Job#: [**Job Number 65568**]
Name: [**Known lastname **],[**Known firstname 63**] Unit No: [**Numeric Identifier 11523**]
Admission Date: [**2107-2-8**] Discharge Date: [**2107-3-2**]
Date of Birth: [**2041-5-18**] Sex: M
Service: SURGERY
Allergies:
Buspar / Percodan
Attending:[**First Name3 (LF) 231**]
Addendum:
[**Date range (1) 11524**] awaiting rehab screening.
[**3-2**] lorazepam taper completed. stool for c.diff x3 negative.
Patient discharand off antibiotics.ged to rehab. stable.
[**Hospital **] rehab stay not to extend after thirty days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7340**] - Maplewood - [**Location (un) 7190**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2107-3-2**]
|
[
"440.24",
"496",
"997.3",
"707.15",
"305.00",
"401.9",
"507.0",
"530.81",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"99.04",
"39.25"
] |
icd9pcs
|
[
[
[]
]
] |
10730, 10972
|
8669, 9506
|
8217, 8648
|
1192, 1331
|
2008, 8194
|
9531, 10707
|
1692, 1990
|
153, 175
|
204, 1085
|
1108, 1165
|
1348, 1669
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,150
| 113,950
|
12167
|
Discharge summary
|
report
|
Admission Date: [**2105-8-24**] Discharge Date: [**2105-9-2**]
Date of Birth: [**2031-5-28**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
ICU callout, orginally admitted with fevers, chills, neutropenia
s/p chemo in afib with RVR.
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
Mr. [**Known lastname 4401**] is a 74 year-old male with PAF off anticoagulation,
and recently diagnosed extensive stage small cell lung cancer
status post Y stent tracheal placement for obstruction, status
post Carboplatin/Etoposide chemotherapy on [**2105-8-11**], who
presented from the ED with febrile neutropenia and AF with RVR.
He was recently admitted to [**Hospital1 18**] [**2105-8-6**] -> [**2105-8-14**] to
expedite work-up of his newly diagnosed lung mass, as above
confirmed as extensive stage SCLC. During this admission, he
underwent placement of a Y tracheal stent, and received
chemotherapy. He was also treated with Unasyn for presumed
post-obstructive pneumonia. His Coumadin was discontinued after
finding encroachment of his mass on his pulmonary artery. He was
in NSR at the time of discharge.
*
He now presented with a 1-week history of progressive cough, and
increased sputum production, which he describes as whitish. In
the ICU, the patient also complained of moderately severe
"throat pain", which he has had for about a month, worsening,
with associated hoarseness as well as odynophagia with both
solids and liquids. No clear dysphagia. No hemoptysis. He
reports some RS pain with coughing, no other chest pain. No
increase in SOB. No lower extremity swelling. He denies
abdominal pain, no rectal pain, no GU complaints. + Chills at
home. Tmax at home 100.5, which prompted his daughter to bring
him to the [**Name (NI) **].
*
In the ICU, antibiotics were continued (vanc, cefepime), and ENT
evaluation was requested for hoarseness, odynophagia. The
patient's afib was controlled with IV diltiazem pushes and
metoprolol PO. The patient remained hemodynamically stable.
Past Medical History:
PAF
HTN
Hyperlipidemia
CRI
PVD
AAA S/P repair 4 mon ago
? Etoh abuse
Social History:
Lives alone. Family lives in [**State 38104**]. Has five kids and many
grandchildren. Divorced. Quit smoking 4 mon ago. Smoked 1 pack
per week for 50 years. Denies history of ETOH abuse, however,
OMR notes report this. Has 1-2 drinks per month. No drug use.
Family History:
Son died of brain tumor at age 16. Did not know parents, was
raised by step parents.
Physical Exam:
VS: 97.1, HR 83-120 (afib); BP 116/82, 99%2L
GEN: WDWN male in NAD sitting on the side of the bed.
HEENT: PERRL. EOMI. OP clear. MMM.
NECK: supple, no LAD.
LUNGS: Decreased BS on R over mid-lung field, also dull to
percussion. Mild wheezes, no rhales or rhonchi heard.
CV: RRR. Normal S1S2 NO M/R/G
ABD: soft, NT/ND, no HSM.
EXT: No C/C/E.
BACK: No spinal tenderness, no CVAT.
NEURO: Strength 5/5 b/l. Sensation grossly intact b/l UE and LE.
Pertinent Results:
[**2105-8-24**] 07:40AM PT-13.3* PTT-29.1 INR(PT)-1.2*
[**2105-8-24**] 07:40AM PLT SMR-LOW PLT COUNT-92*#
[**2105-8-24**] 07:40AM WBC-0.7*# RBC-4.24* HGB-11.7* HCT-33.8*
MCV-80* MCH-27.6 MCHC-34.6 RDW-16.9*
[**2105-8-24**] 07:40AM NEUTS-5* BANDS-0 LYMPHS-60* MONOS-35* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-0
[**2105-8-24**] 07:40AM cTropnT-<0.01
[**2105-8-24**] 07:40AM GLUCOSE-127* UREA N-28* CREAT-1.7* SODIUM-135
POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14
[**2105-8-24**] 08:02AM LACTATE-1.7
..................
[**2105-9-2**] 12:00AM BLOOD WBC-8.4 RBC-3.62* Hgb-10.0* Hct-29.4*
MCV-81* MCH-27.7 MCHC-34.1 RDW-18.8* Plt Ct-284
[**2105-9-2**] 12:00AM BLOOD Glucose-108* UreaN-12 Creat-1.2 Na-138
K-4.0 Cl-104 HCO3-26 AnGap-12
[**2105-9-2**] 12:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
[**2105-8-28**] 12:12AM BLOOD calTIBC-179* Hapto-315* Ferritn-479*
TRF-138*
[**2105-8-27**] 07:45AM BLOOD CRP-135.5*
....................
Cultures:
Sputum: 9/12,13,14,16,17- all neg for AFB, 16,17 with <10
epithelial cells.
.
Blood cultures:
[**8-24**]: 1/4 bottles Strep bovis pan sensitive, [**8-25**] and [**8-27**]
negative to date
.
Imaging:
Swallowing study: IMPRESSION: 1) No penetration or aspiration.
CXR: IMPRESSION: Decreased size of the right hilar mass since
the prior study. Improved aeration of the right lung. No
infiltrate.
.
CT Chest: IMPRESSION:
1. No pulmonary embolism.
2. Decrease in size of large dominant right hilar mass.
3. Tracheobronchial stent in unchanged position. Although the
right hilar mass narrows the right upper and middle lobe bronchi
they remain patent.
4. New tree-in-[**Male First Name (un) 239**] opacity of the peripheral right upper and
middle lobes is nonspecific but may be infectious, inflammatory,
or possibly represent lymphangitic spread of tumor.
5. New small areas of posterobasilar consolidation at both lung
bases may be due to atelectasis but could represent infection.
.
ECHO [**2105-8-26**]: The left atrium is moderately dilated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. Tissue velocity imaging demonstrates an E/e' <8
suggesting a normal left ventricular filling pressure (<12mmHg).
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 no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2105-4-17**], the
focal thickening of the aortic leaflets is slightly more
pronounced, but no aortic regurgitation is identified.
If the clinical suspicion for endocarditis is moderate or high,
a TEE may be better able to define the aortic valve morphology
and to evaluate for possible vegetations.
.
Colonoscopy [**2105-9-1**]:Pt with multiple polyps that were removed
and sent for pathology.
Brief Hospital Course:
ASSESSMENT AND PLAN: 74 year-old male with extensive stage SCLC
with tracheal obstruction status post tracheal stent, status
post first cycle of chemotherapy [**2105-8-11**], with febrile
neutropenia, AF with RVR now improved.
*
1. Strep bovis baceremia with Hx of Febrile neutropenia: On
admission patient was found to have febrile neutropenia. As
such, the patient was pancultured and found to have 1/4 bottles
positive for Strep bovis. Given previous history thickened
aortic valve and aortic valve vegetation, the patient was
diagnosed with presumed bacterial endocarditis. As recommended
by infectious disease, he will be treated with IV penicillin for
4 weeks. Additionally, patient received colonoscopy given
suspicious nature of strep bovis bacteremia for colonic lesions.
Pathology is pending. PICC was placed for long term Abx. The
patient will likely need lifelong S Bovis suppression per ID (as
pt has aortic graft). Therefore, the patient will follow up with
ID ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**]) after discharge. Neutropenia did resolve as
patient had gotten neulasta.
- Penicillin 3 mill U IV Q4 x 4 weeks (Finishes [**9-23**])
- VNA for IV Abx
- F/U per ID
*
2. Tree-in-[**Male First Name (un) 239**] opacity CT findings: CT chest showed findings
that could represent fungal or mycobacterial. However, patient
had multiple induced sputum samples as well as fungal blood
tests that were all negative. Therefore, the patient was take
off respiratory precautions. Therefore, the abnormal findings
likely represent progression of lung cancer.
.
3. Odynophagia/cough: Concomitant hoarseness could be secondary
to recurrent laryngeal nerve involvement of neoplasm versus
related to odynophagia. Improved with symptomatic treatment and
decreased coughing as odynophagia is likely due to persistent
coughing that is secondary to lung cancer. Pt was given
symptomatic control with viscous lidocaine and narcotics with
nebs as needed for comfort
*
4. Paroxysmal Atrial Fibrillation: Initially patient had
elevated heart rate and was evaluated in ICU. However, pt
converted to sinus rhythm spontaneously after metoprolol
administration. He was kept on telemetry for duration of
hospitalization but did not have elevated heart rate in days
prior to discharge. Pt was discharged with home medications
amniodarone and [**Last Name (LF) **], [**First Name3 (LF) **] titrate as needed. Not on
anticoagulation at present given mass encroachment on pulmonary
vessels.
*
5. Oral Herpes: pt with small lesion on left lip. This is new
and pt has a history of previous lip sores.
- Acyclovir 400 mg PO Five times daily x 14 days
.
6. Extensive stage SCLC: Some radiographic response status post
1 cycle of chemotherapy. Pt received 1st day of second course of
chemotherapy while inpatient to be followed up for second and
third days as outpatient. (Carboplatin day 1, Etoposide day [**12-16**]
q 21 d Cycle 1 and cycle 2 day 1 given in hospital
Carboplatin AUC 5 465 mg, Etoposide 80 mg/m2 = 160 mg.)
Additionally pt was to return for neulasta on Saturday.
*
7. Anemia : Anemic (although hematocrit low at baseline),
Suspect secondary to recent chemotherapy.
- Colonoscopy shows multiple polypoid lesions, likely cause of
bleeding. Await path report. Pt received multiple transfusions
with goal hct of 30 while in pre-chemotherapy status.
*
8. FEN: Pt refused low Na diet. Electrolytes WNL.
.
9. Prophylaxis: Heparin SC BID. No need for protonix. Bowel
regimen prn.
Medications on Admission:
amidodarone 200 mg QD
ASA 81 mg QD
coumadin 5 mg QD
lisinopril 20 mg QD
Metoprolol 50 mg [**Hospital1 **]
Discharge Medications:
1. Penicillin G Pot in Dextrose 3,000,000 unit/50 mL Piggyback
Sig: Fifty (50) mL Intravenous Q4H (every 4 hours) for 21 days:
Finishes course on [**9-23**].
Disp:*6300 mL* Refills:*0*
2. PICC
PICC line care per protocol
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*1*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Insomnia.
Disp:*30 Tablet(s)* Refills:*1*
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for Constipation.
Disp:*60 Capsule(s)* Refills:*0*
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for coughing.
Disp:*1 1* Refills:*0*
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for Pain.
Disp:*180 Tablet(s)* Refills:*0*
17. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO 5X/D (5
times a day) for 14 days.
Disp:*70 Capsule(s)* Refills:*0*
18. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*2*
19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed for nausea, anxiety.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]
Discharge Diagnosis:
Small cell lung cancer
Streptococcus bovis Endocarditis
Discharge Condition:
stable
Discharge Instructions:
You will need an outpatient colonoscopy. Please call your PCP
to arrange.
-please see page 1 for specific line care instructions
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 3274**].([**Telephone/Fax (1) 3280**] and [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3280**], to arrange plans for further
chemotherapy
.
please return to clinic (7F outpatient clinic) for neulasta
injection on [**2105-9-5**] (saturday).
Please attend the following appointments:
Provider: [**Name10 (NameIs) 8111**] [**Name11 (NameIs) 8112**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2105-9-3**] 11:30
.
Provider: [**Name Initial (NameIs) 4426**] 19 Date/Time:[**2105-9-3**] 11:30
.
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Date/Time:[**2105-9-3**] 11:30
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Date/Time:[**2105-9-3**] 11:30
Provider: [**Name Initial (NameIs) 4426**] 19 Date/Time:[**2105-9-3**] 11:30
Provider: [**Name10 (NameIs) 8111**] [**Name11 (NameIs) 8112**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2105-9-3**] 11:30
.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**], infections disease clinic, [**Hospital Ward Name 23**] Building;
[**2105-9-22**], 11am.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
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icd9cm
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[
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2128, 2198
|
2214, 2475
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,170
| 105,807
|
46245
|
Discharge summary
|
report
|
Admission Date: [**2167-11-18**] Discharge Date: [**2167-11-23**]
Date of Birth: [**2094-9-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Erythromycin
Base
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Palpitations/dizziness/Dyspnea on exertion
Major Surgical or Invasive Procedure:
Replacement of ascending aorta with a Vascutek Dacron 28
mm tube graft using deep hypothermic circulatory arrest.
History of Present Illness:
73 year old female with occassional dizziness and palpitations
which began about 6 weeks ago. She underwent an echocardiogram
which revealed an ascending aortic aneurysm measuring 4.9cm. A
CT
scan was obtained which showed the ascending aorta to measure
5.7cm. Given the above findings, she has been referred for
surgical evalutation.
Past Medical History:
Bilateral renal calculi
Urinary frequency with urge incontinence
Breast cancer x2
Hypertension
Glaucoma
Depression
Subdural bleed bilaterally from trauma. Closed head injury.
Social History:
Lives with: Son in [**Name2 (NI) 87591**]
Occupation: Retired
Tobacco: Denies
ETOH: Rare use
Family History:
Non contributory
Physical Exam:
Pulse: 85 Resp: 18 O2 sat: 98%
B/P Right: 130/82 Left: 114/83
Height: 60" Weight: 144lb
General: WDWN in NAD
Skin: Warm[X] Dry [X] intact [X] No C/C/E
HEENT: NCAT[X] PERRLA [X] EOMI [X] Anicteric sclera, OP benign.
Teeth appear in good repair
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]Bilateral mastectomy scars.
Prominent right clavicle.
Heart: RRR, NlS1-S2, No M/R/G appreciated
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X]
Neuro: Grossly intact. Mild facial asymmetry
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit None
Pertinent Results:
Admission Labs:
[**2167-11-18**] 09:37AM GLUCOSE-114* LACTATE-2.3* NA+-138 K+-3.5
CL--96*
[**2167-11-18**] 01:11PM GLUCOSE-154* LACTATE-4.1* NA+-133* K+-3.1*
CL--105
[**2167-11-18**] 01:13PM PT-14.5* PTT-28.7 INR(PT)-1.3*
[**2167-11-18**] 01:13PM PLT COUNT-213
[**2167-11-18**] 01:13PM WBC-16.3*# RBC-2.67*# HGB-8.0*# HCT-23.0*#
MCV-86 MCH-29.9 MCHC-34.6 RDW-14.1
[**2167-11-18**] 03:06PM UREA N-14 CREAT-0.7 SODIUM-140 POTASSIUM-3.1*
CHLORIDE-111* TOTAL CO2-22 ANION GAP-10
Discharge Labs:
[**2167-11-23**] 06:00AM BLOOD WBC-7.8 RBC-2.76* Hgb-8.5* Hct-24.2*
MCV-88 MCH-30.7 MCHC-35.0 RDW-14.5 Plt Ct-322
[**2167-11-23**] 06:00AM BLOOD Plt Ct-322
[**2167-11-20**] 01:34AM BLOOD PT-15.3* PTT-27.0 INR(PT)-1.3*
[**2167-11-23**] 06:00AM BLOOD Glucose-94 UreaN-19 Creat-1.0 Na-142
K-3.7 Cl-107 HCO3-26 AnGap-13
Radiology Report CHEST (PA & LAT) Study Date of [**2167-11-21**] 1:30 PM
[**Hospital 93**] MEDICAL CONDITION: 73 year old woman with POD #3 s/p
hemiarch with increased SOB, please evaluate for incresed
pleural effusions.
Final Report: In comparison with study of [**11-20**], the patient has
taken a better inspiration. However, there is increased
opacification at the right base with an oblique configuration,
consistent with volume loss in the right lower lung.
Retrocardiac opacification persists, consistent with pleural
fluid and volume loss in the left lower lobe.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.7 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Left Ventricle - Stroke Volume: 6 ml/beat
Aorta - Annulus: 1.9 cm <= 3.0 cm
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.1 cm <= 3.0 cm
Aorta - Ascending: *5.2 cm <= 3.4 cm
Aorta - Arch: *3.9 cm <= 3.0 cm
Aorta - Descending Thoracic: *3.7 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 2
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Valve Area: *1.9 cm2 >= 3.0 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size. Normal LV cavity size. Normal regional LV systolic
function. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque. Normal aortic diameter at
the sinus level. Moderately dilated ascending aorta
AORTIC VALVE: Normal aortic valve leaflets (3). Mild to moderate
([**12-20**]+) AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. 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.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Left ventricular wall thicknesses and cavity size are normal.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 45%). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 45 cm from the
incisors. The ascending aorta is moderately dilated,with
preserved aortic root diameters.The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. Mild to
moderate ([**12-20**]+) aortic regurgitation is seen.The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.There is a PFO Visualized by 2D
and CFD.
Post Bypass
Patient is now s/p Ascending aortic replacement with a Dacron
Graft
The proximal end of the Dacron graft is visualized just distal
to the Sinotubular junction with the distal end proximal to the
innominate
Currently on a Neosynephrine drip at 1.6 mcg/kg/min
The LV function is preserved with an EF of >55%
There is persistent [**12-20**]+ Central Aortic regurgitation.
There are no dissection flaps visualized in the ascending aorta
.
All finding Pre and Post Bypass communicated to Dr [**Last Name (STitle) 914**]
Electronically signed by [**Name6 (MD) 15425**] [**Name8 (MD) 15426**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2167-11-19**] 11:18
Brief Hospital Course:
The patient was brought to the operating room on [**2167-11-18**] where
the patient underwent replacement of the ascending aorta with a
Vascutek Dacron 28mm tube graft using deep hypothermic
circulatory arrest. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes were discontinued on post-operative day number one
without complication and the epicardial pacing wires were
discontinued on post-operative day number 3 without
complications. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD five the patient was ambulating with [**Year (4 digits) **],
the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to home with visiting
nursed in good condition with appropriate follow up
instructions.
Medications on Admission:
ANASTROZOLE [ARIMIDEX] - (Prescribed by Other Provider) - 1 mg
Tablet - 1 Tablet(s) by mouth once a day
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth once a day
POTASSIUM CITRATE - (Prescribed by Other Provider) - 10 mEq
(1,080 mg) Tablet Sustained Release - 1 Tablet(s) by mouth four
times a day
SERTRALINE [ZOLOFT] - (Prescribed by Other Provider) - 100 mg
Tablet - 1 Tablet(s) by mouth once a day
TIMOLOL - (Prescribed by Other Provider) - Dosage uncertain
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - (Prescribed by
Other Provider) - 400 unit Capsule - 1 Capsule(s) by mouth once
a
day
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. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
5. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
8. anastrozole 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Ascending aortic aneurysm extending into the aortic arch s/p
replacement
Bilateral renal calculi
Urinary frequency with urge incontinence
Breast cancer
Hypertension
Glaucoma
Depression
Subdural bleed bilaterally from trauma. Closed head injury.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 83786**] pain managed with tylenol
[**Last Name (NamePattern1) 83786**] Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] :[**2167-12-8**] @
1:30
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 10381**] in [**3-23**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] in 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:[**2167-11-23**]
|
[
"V15.52",
"401.9",
"518.5",
"V45.71",
"788.30",
"424.1",
"311",
"V45.79",
"V10.3",
"285.1",
"365.9",
"V13.01",
"441.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
9807, 9862
|
6868, 8170
|
377, 497
|
10151, 10396
|
2016, 2016
|
11269, 11887
|
1188, 1207
|
8862, 9784
|
2947, 5230
|
9883, 10130
|
8196, 8839
|
10420, 11246
|
2519, 2910
|
5273, 6845
|
1222, 1997
|
294, 339
|
525, 862
|
2032, 2503
|
884, 1061
|
1077, 1172
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,669
| 179,084
|
30898
|
Discharge summary
|
report
|
Admission Date: [**2101-9-5**] Discharge Date: [**2101-9-13**]
Date of Birth: [**2019-12-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dypsnea on exertion
Major Surgical or Invasive Procedure:
[**2101-9-5**] Aortic Valve Replacement([**Street Address(2) 17167**]. [**Male First Name (un) 923**] Regent
mechanical valve)
History of Present Illness:
This is a 81 yo female with severe aortic stenosis followed by
serial echos. She complains of dyspnea on exertion and displays
Class III heart failure. Most recent echo showed [**Location (un) 109**] 0.5 cm2.
Cardiac cath showed 70% diagonal lesion. Based upon the above,
she was referred to Dr. [**Last Name (STitle) 1290**] for cardiac surgical
intervention.
Past Medical History:
Aortic Stenosis
Hypercholesterolemia
Type II Diabetes Mellitus
Hypertension
Obesity
Osteoarthritis
Pulmonary Nodules
Social History:
Quit tobacco 25 years ago. Occasional ETOH. Lives with husband.
Family History:
Non-contributory
Physical Exam:
62" 240#
obese, NAD
scattered spider veins throughout
PERRLA,EOMI,anicteric,left tear duct abnormal
neck supple, no JVD, murmur radiates to bil. carotids
CTAB
RRR with 4/6 SEM throughout precordium to carotids
soft, NT, ND, no HSM
warm, well-perfused, no peripheral edema
no obvious varicosities
neuro grossly nonfocal exam; MAE [**4-14**] strengths
2+ bil. radials
1+ bil. DPs
1+ right fem/2+ left fem
NP PTs
Pertinent Results:
[**2101-9-13**] 06:00AM BLOOD WBC-8.8 RBC-3.18* Hgb-9.3* Hct-28.4*
MCV-89 MCH-29.2 MCHC-32.7 RDW-14.6 Plt Ct-283
[**2101-9-13**] 06:00AM BLOOD PT-21.5* PTT-28.3 INR(PT)-2.1*
[**2101-9-12**] 10:51AM BLOOD PT-19.4* PTT-26.1 INR(PT)-1.9*
[**2101-9-11**] 06:14AM BLOOD PT-19.7* PTT-31.8 INR(PT)-1.9*
[**2101-9-10**] 05:27AM BLOOD PT-21.2* PTT-36.6* INR(PT)-2.1*
[**2101-9-9**] 08:00AM BLOOD PT-24.3* PTT-33.3 INR(PT)-2.4*
[**2101-9-8**] 12:06PM BLOOD PT-18.8* INR(PT)-1.8*
[**2101-9-13**] 06:00AM BLOOD UreaN-33* Creat-1.3* K-4.3
[**2101-9-12**] 10:51AM BLOOD UreaN-35* Creat-1.3* K-4.3
[**2101-9-11**] 06:14AM BLOOD UreaN-36* Creat-1.4* K-3.9
[**2101-9-10**] 05:27AM BLOOD UreaN-40* Creat-1.4* K-3.9
[**2101-9-12**] 10:51AM BLOOD Mg-2.5
[**2101-9-13**] Chest x-ray: When compared to prior studies dated
[**2101-9-7**] and [**9-6**], bilateral small pleural effusions,
greater on the left side, have slightly increased in amount.
Left perihilar and left lower lobe retrocardiac atelectases are
unchanged. Left cardiac border is obscured by the pleural and
parenchymal abnormalities. Right internal jugular vein catheter
tip is in unchanged position in the SVC. There is no
pneumothorax.
[**2101-9-5**] Intraop TEE:
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 40 %).
3. Right ventricular chamber size is normal.
4. There are complex (>4mm) atheroma in the ascending aorta. The
descending thoracic aorta is mildly dilated. There are complex
(>4mm) atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <0.8cm2). Moderate (2+) aortic
regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. There is
severe mitral annular calcification. Mild to moderate ([**1-11**]+)
mitral regurgitation is seen.
7. The tricuspid valve leaflets are mildly thickened.
8. The pulmonic valve leaflets are thickened.
9. There is a small pericardial effusion.
POST-BYPASS:
1. Biventricular systolic function is unchanged.
2. Mechanical valve seen in the aortic postion. Leaflets move
well and the valve appears well seated. Washing jets seen.
3. Mild mitral regurgitation present.
4. Aorta intact post decannulation.
Brief Hospital Course:
Admitted [**9-5**] and underwent AVR with Dr. [**Last Name (STitle) 1290**]. Transferred
to the CSRU in stable condition on phenylephrine and propofol
drips. Extubated the next day and transferred to the floor on
POD #2 to begin increasing her activity level. Went into A fib
on POD #2 and treated with Amiodarone. Coumadin also started for
her mechanical valve and dosed for a goal around 2.5 to 3.0.
Chest tubes and pacing wires were eventually removed without
complication. By POD#3, she converted back to a normal sinus
rhythm. She maintained a normal sinus rhythm for the remainder
of her hospital stay. No further episodes of atrial fibrillation
were noted. Over several days, she continued to make clinical
improvements with diuresis and was medically cleared for
discharge to home on [**9-13**]. Following discharge, she is
to get a follow-up CT scan of the chest in 6 months for
bilateral pulmonary nodules. Dr. [**Last Name (STitle) **] office has been
notified of this finding. Dr. [**Last Name (STitle) 17887**] will also monitor
Coumadin as an outpatient.
Medications on Admission:
lisinopril 20 mg/HCTZ 12.5 mg daily
ecotrin 325 mg daily
glipizide 2.5 mg daily
zocor 20 mg daily
amoxicillin prn dental
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2
weeks.
Disp:*42 Capsule, Sustained Release(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*20 Tablet(s)* Refills:*0*
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 7 days: then decrease to 200 mg daily until
discontinued by cardiologist.
Disp:*45 Tablet(s)* Refills:*0*
13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day for
1 days: then INR check to be calld to Dr. [**Last Name (STitle) **] office for
continued dosing.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
s/p Aortic Valve Replacement(mechanical)
Postop Pleural Effusions
Postop Atrial Fibrillation
AS
NIDDM
HTN
obesity
osteoarthritis
elev. chol.
Discharge Condition:
good
Discharge Instructions:
shower daily, pat incisions dry, no baths
no lotions, creams or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call surgeon for fever greater than 100.5, redness or drainage
CHEST CT scan IN 6 MONTHS for bilateral lung nodules
Followup Instructions:
see Dr. [**Last Name (STitle) 17887**] in [**1-11**] weeks
see Dr. [**Last Name (STitle) 7047**] in [**2-12**] weeks
see Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
CHEST CT SCAN IN 6 months
Completed by:[**2101-10-25**]
|
[
"518.89",
"V43.65",
"278.00",
"401.9",
"250.00",
"424.1",
"593.9",
"427.31",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.93",
"33.22",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
7023, 7078
|
4040, 5110
|
341, 470
|
7262, 7269
|
1567, 4017
|
7594, 7848
|
1099, 1117
|
5281, 7000
|
7099, 7241
|
5136, 5258
|
7293, 7571
|
1132, 1548
|
282, 303
|
498, 860
|
882, 1001
|
1017, 1083
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,447
| 169,244
|
51887
|
Discharge summary
|
report
|
Admission Date: [**2114-6-15**] Discharge Date: [**2114-6-18**]
Date of Birth: [**2048-10-17**] Sex: F
Service: MEDICINE
Allergies:
Wellbutrin / Metoprolol / Prunes / Pravastatin / cilostazol
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Post intervention complications
Major Surgical or Invasive Procedure:
1. [**2114-6-15**] PTA of left [**Month/Day/Year 1793**]
2. [**2114-6-15**] Urgent repeat PTA of left [**Month/Day/Year 1793**]
History of Present Illness:
65 yo F with an elaborate past history including DM, HLD, HTN,
tobacco abuse, with known history of bilateral lower extremity
peripheral vascular disease. She presented in [**5-/2114**] for lower
extremity stenting in the setting of claudication symptoms as
she had ABIs of 0.63 on her right lower extremity and 0.68 on
the left lower extremity. Diffuse disease was seen in both
lower extremities. Given R>L claudication symptoms, the
proximal RSFA was stented, with scheduel follow up in 4 weeks
for left sided intervention. In the interim the patient was
evaluated for a drug rash while on cilostazol, clopidogrel, and
pravastatin, leading to discontinuation of all three
medications. She was switched to Prasugrel and continued off
cilostazol and pravastation with resolution of her rash. The
patient returned today for intervention of her left [**Year (4 digits) 1793**] tandem
90% lesions with L [**Name (NI) 1793**] PTA stenting In the cath lab, the
patient initiall had a R CFA access performed which revealed
critical mid-distal L [**Name (NI) 1793**] calcific lesions (95%) with slow flow
beyond the lesion as well as SSFA and popliteal diffuse disease
with absence of flow below the knees. The L [**Name (NI) 1793**] was PTA'd with
a 4.0 balloon, and the R CAF was closed with an Exoseal with
adequate hemostasis. Per report three hours post procedure the
patient complained of severe left upper thigh pain with a noted
groin hematoma. Urgently brought back to the cath lab with L
brachial aa access. At 1540 hrs the patient was noted to be
hypotensive after administartion of IA NTG (200mcg) to 84 mmHg
systolic and was bolused with NS. SBP low at 1700hrs at 68 mm
Hg with noted HCT drop from 42.9 to 29.1. Stat 2 U PRBC
transfusion initatied, as BPs hovered from 50-80 mmHg systolic,
with intiation of dopamine and levophed gtt. BIlateral
hematomas noted, with expansion of R groin hematoma documated
around 1800 hrs. Fem stop application at that time. During
[**Last Name (LF) 107429**], [**First Name3 (LF) **] extensive spiral [**First Name3 (LF) 1793**] dissection on the left
was noted, and repeat PTA of the L [**First Name3 (LF) 1793**] was performed to treat
presumed perforation and proven dissection. A total contrast
load of approximately 500 cc's documented at time of completed
second [**First Name3 (LF) 107429**]. Transferred to CCU for observation.
In the CCU patient is in NAD without pain symptoms.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, new myalgias, joint pains, cough, hemoptysis,
black stools or red stools. She denies recent fevers, chills or
rigors. 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:
DM type II with peripheral neuropathy
Lumbar radiculopathy
Regional sympathetic dystrophy with narcotic's agreement
Hypertension
Hyperlipidemia
Depression
Leukocytosis chronically-etiology unclear
Degenerative disc disease with disc herniations
Eye surgery- cataract/lens
Hiatal hernia
Chronic diarrhea with questionable Crohn's disease
Barrett's esophagus
Osteoarthritis
Diverticulosis
Adrenal adenoma [**12/2101**] with negative functional
workup, adrenals normal on CT scan 08/[**2104**].
Recurrent UTIs
Nephrolithiasis
Obesity
SURGICAL HX
-s/p sigmoid colectomy for diverticular abscess in [**9-7**]
-s/p cystoscopy & ureteroscopy with laser lithotripsy
on left by Dr. [**Last Name (STitle) 770**] in [**2108-7-10**].
- Status post left ESWL, [**3-/2108**]
- Status post left knee surgery by Dr. [**Last Name (STitle) **], [**5-/2107**], removal
of deep orthopedic hardware and diagnostic arthroscopy with
medial meniscectomy, lateral meniscectomy, medial tibial plateau
chondroplasty.
-Status post CMG cystoscopy, VCUG [**4-/2105**] by Dr. [**Last Name (STitle) 8872**].
-Status post TAHBSO for her ovarian cyst in [**2079**].
-Status post left knee fracture repair at [**Hospital1 756**] '[**91**].
-Status post right mastoidectomy at age 10.
-h/o 3rd degree burn, age 5 with skin graft to back.
Social History:
- Tobacco history: Quit tobacco 6 weeks ago. Smoked at least 1
ppd for 40 years. Prior drinker, although denies current
alcohol use. Prior history of intranasal cocaine use during her
youth. No history of IVDA, no current drug use. Lives alone.
Has 2 sons who are local. Disabled.
Family History:
Father died at age 61, diabetes mellitus, status post leg
amputation, hypertension, history of MI. Mother died at age 72,
history of breast cancer, emphysema, exsmoker. Brother living,
age 55, healthy. One brother died at age 57 in [**2104**] after having
back surgery, question cause. He had a history of chronic renal
failure and was about to be started on dialysis. Two sons, 39
and 40, one with a bad stomach. Two grandchildren alive and
well.
Physical Exam:
On Admission
VS: T=Afebrile BP= 121/70 HR=94 RR=16 O2 sat= 98%
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with difficult to appreciate JVP given body habitus
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2/6 systolic murmur loudest near apex.
No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits but residual murmur
can be auscultated in abdomen. Central abdominal scar c/w prior
TAHBSO
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Lower
extremities appear very mottled consistent with prior physical
exam findings.
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
On Discharge
afebrile, BP 124/75, HR 80s, RR 10, saturation > 95% RA
exam unchanged except:
lower extremity mottling is resolved, extremities are still cool
to the touch but with good color and dopplerable DP pulses
Groin is extensively bruised bilaterally but without palpable
masses or bruits
Pertinent Results:
ADMISSION LABS
[**2114-6-15**] 10:24AM BLOOD WBC-16.1* RBC-4.56 Hgb-12.9 Hct-40.3
MCV-88 MCH-28.3 MCHC-32.1 RDW-14.0 Plt Ct-302
[**2114-6-16**] 04:33AM BLOOD PT-10.4 PTT-23.3* INR(PT)-1.0
[**2114-6-16**] 04:33AM BLOOD Glucose-100 UreaN-15 Creat-0.6 Na-136
K-3.5 Cl-101 HCO3-26 AnGap-13
[**2114-6-16**] 04:33AM BLOOD Calcium-7.7* Phos-3.5 Mg-1.4*
[**2114-6-15**] 05:29PM BLOOD Type-ART pO2-67* pCO2-44 pH-7.30*
calTCO2-23 Base XS--4 Intubat-NOT INTUBA
HCT TREND
[**2114-6-15**] 10:24AM BLOOD WBC-16.1* RBC-4.56 Hgb-12.9 Hct-40.3
MCV-88 MCH-28.3 MCHC-32.1 RDW-14.0 Plt Ct-302
[**2114-6-15**] 03:50PM BLOOD WBC-13.1* RBC-3.38*# Hgb-9.6*# Hct-29.4*#
MCV-87 MCH-28.3 MCHC-32.5 RDW-14.2 Plt Ct-279
[**2114-6-16**] 04:33AM BLOOD WBC-15.5* RBC-4.94# Hgb-14.2# Hct-43.1#
MCV-87 MCH-28.7 MCHC-32.9 RDW-14.3 Plt Ct-258
[**2114-6-17**] 12:14PM BLOOD WBC-8.9 RBC-4.52 Hgb-13.3 Hct-40.0 MCV-88
MCH-29.4 MCHC-33.2 RDW-14.3 Plt Ct-198
PERIPHERAL CATH: [**2114-6-15**] #1
-Severe L [**Year (4 digits) 1793**] stenosis successfully treated with PTA using a 4.0
balloon
- Successful closure of the R CAF with an Exoseal with adequate
hemostasis
PERIPHERAL CATH: [**2114-6-15**] #2
-Successful repeat PTA of the L [**Year (4 digits) 1793**] performed to treat presumed
perforation and proven dissection
-Hypovolemic shock likely secondary to bleeding treated with
maximal support
-FemStop applied to R CFA
-Successful removal of L brachial artery sheath with adequate
hemostasis
DISCHARGE LABS:
[**2114-6-18**] 05:23AM BLOOD WBC-8.2 RBC-4.30 Hgb-12.6 Hct-38.0 MCV-88
MCH-29.3 MCHC-33.1 RDW-14.3 Plt Ct-182
[**2114-6-18**] 05:23AM BLOOD Glucose-121* UreaN-14 Creat-0.5 Na-140
K-4.1 Cl-106 HCO3-28 AnGap-10
[**2114-6-18**] 05:23AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.6
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
Ms. [**Known lastname 107430**] is a 65 year old female with severe peripheral
vascular disease presenting from [**Known lastname 107429**] lab after
iatrogenic dissection of left superficial femoral artery (L [**Known lastname 1793**])
leading to hemorrhage and hypotension. She recieved blood
transfusions and her bleeding stopped, she remained stable and
was able to be discharged to home with physical therapy.
ACTIVE PROBLEMS:
# [**Name2 (NI) 1793**] Dissection and Incidental Hematomas: Patient brought to
cath lab on [**6-15**] for elective PTA to left [**Month/Year (2) 1793**] for peripheral
vascular disease. Initially tolerated procedure well, but
developed left thigh pain prior to transfer from suite and left
thigh hematoma was noted. Repeat urgent angiography was obtained
via left brachial artery. Dissection of left [**Month/Year (2) 1793**] was noted and
corrected with repeat PTA. Patient then became hypotensive and
was noted to have evolving hematoma from prior access site in
RFA. Femstop was applied and patient received 4 units pRBC for
dropping HCT with appropriate bump. She briefly required
dopamine for hypotension. She was transferred to the CCU for
further monitoring where she was quickly weaned from dopamine
and FemStop was removed without incident. She remained
hemodynamically stable.
CHRONIC PROBLEMS
# Peripheral vascular disease (PVD): Severe PVD as noted in HPI.
Is s/p stenting to RFA and PTA to LFA. Prasurgrel was initially
held in setting of acute infection with continuation of ASA 325.
Prasugrel was restarted prior to discharge after hemostasis and
resuscitation was ensured. She was noted to have dopplerable
distal pulses bilaterally.
# Hypertension (HTN): Home regimen includes lisinopril 20 [**Hospital1 **]
and HCTZ 25 daily. These were initially held on admission due to
acute hemorrhage and hypovolemic shock. Lisinopril was then
restarted without incident. HCTZ was restarted prior to
discharge.
# Diabetes mellitus (DM): Continued sliding scale insulin with
34 units lantus while in house.
# Insomnia: Continued clonazepam QHS prn insomnia. Also received
trazodone on request.
#Tobacco Abuse: On Chantix at home. Used nicotine patch while in
house. Notably, Chantix is discouraged in CAD/PVD, but after
further discussion, it was continued on discharge.
#Neuropathy: Stable. Continued nortryptyline. Also takes Detrol
at home for incontinence, which was held during hospitalization.
TRANSITIONAL ISSUES:
- restart Chantix on discharge for smoking sessation
- Should be scheduled for outpatient ABI to assess
revascularization
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientPharmacy.
1. Lisinopril 20 mg PO BID
2. Nortriptyline 50 mg PO HS
3. Glargine 34 Units Breakfast
4. Chantix *NF* (varenicline) 1 mg Oral [**Hospital1 **]
5. Prasugrel 10 mg PO DAILY
6. Ranitidine 300 mg PO DAILY
7. Clonazepam 1 mg PO QHS
8. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]:PRN congestion
9. Hydrochlorothiazide 25 mg PO DAILY
10. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO BID:PRN pain
11. Naproxen 250 mg PO Q12H
12. Detrol LA *NF* (tolterodine) 4 mg Oral Q24HRS
13. Aspirin 325 mg PO DAILY
14. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral [**Hospital1 **]
15. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg Oral Daily
Discharge Medications:
1. Glargine 34 Units Breakfast
2. Lisinopril 20 mg PO BID
3. Nortriptyline 50 mg PO HS
4. Chantix *NF* (varenicline) 1 mg Oral [**Hospital1 **]
5. Prasugrel 10 mg PO DAILY
6. Ranitidine 300 mg PO DAILY
7. Clonazepam 1 mg PO QHS
8. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]:PRN congestion
9. Hydrochlorothiazide 25 mg PO DAILY
10. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO BID:PRN pain
11. Naproxen 250 mg PO Q12H
12. Detrol LA *NF* (tolterodine) 4 mg Oral Q24HRS
13. Aspirin 325 mg PO DAILY
14. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral [**Hospital1 **]
15. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg Oral Daily
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Peripheral artery disease
2. Dissection of left [**Location (un) 1793**]
3. Right groin hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 107430**],
You were admitted to the hospital for a procedure to open
clogged arteries in your left leg. After the procedure, you
developed some serious bleeding from these arteries requiring
you to go back to the catheterization lab and receive several
blood transfusions. After successfully stopping the bleeding, we
watched you very closely and you had no more signs of bleeding.
We made no changes to your medications. Please note the
following appointments which have already been scheduled. It has
been a pleasure taking care of you!
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2114-6-19**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3031**], M.D. [**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: HMFP
When: MONDAY [**2114-7-2**] at 2:40 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 15631**], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2114-7-12**] at 1:40 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
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22,941
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Discharge summary
|
report
|
Admission Date: [**2119-9-25**] [**Month/Day/Year **] Date: [**2119-10-3**]
Service: MEDICINE
Allergies:
Lisinopril / Macrodantin / Ampicillin / Clindamycin / Neosporin
/ Trazodone / Vancomycin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Bright Red Blood Per Rectum
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
86 yo F with brittle diabetes mellitus, porcine AVR, CAD, CHF
(EF 30-35%), Afib (off coumadin for 8wks) presents with low Hct
and guaiac positive stools. Per pt and family, pt had routine
blood work last week and was noted to have low Hct. Hct noted to
be 22 one day prior to admission. Per family, pt has been
admitted twice at OSH for the past [**5-15**] wks for low Hct. Pt had 2
transfusions at OSH with the most recent one 2 wks ago. Pt had
EGD [**5-15**] wks ago at OSH and revealed watermelon stomach. She is
transferred here for possible argon therapy for watermelon
stomach as well as inpatient colonoscopy. Pt denies nausea,
vomiting, hematemesis. Pt mentions RUQ pain, which comes and
goes, assoicated with movement, not associated with eating. Pt
claims poor apetitte and decreased po intake. Pt mentions ~7lbs
loss in the past 4 wks. PT denies using NSAIDS. Of note, she has
never underwent colonoscopy.
Past Medical History:
- HTN
- DM1 dx at 39y/o (45yrs) with neuroapthy, gastroparesis; denies
retinopathy
- CAD s/p CABG [**2095**], PCI
- AVR (porcine) [**2110**]
- CHF: EF 30-35% [**3-/2116**]
- Afib
- Right pleural effusion of unclear [**Name2 (NI) **]
- Hypothyroidism
- hyponatremia
Social History:
Widowed. Is a non-smoker and lives with her daughter. Was
independent in ADL's, no tobacco or etoh
Family History:
Mother died of MI at 66, father died of esophageal collapse,
rupture. Brother with MI in 70's.
Physical Exam:
On admission
Vitals: afebrile, 169/51, 66, 18, 100 RA
General: Alert, oriented female, appears stated age, no acute
distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregular rhythm, normal S1, prominent S2, grade II-III
holosystolic murmur heard best at LLSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On [**Name2 (NI) **]:
vitals 95 160/D 56 24 97RA
General: alert and oriented female, appears stated age, NAD
Neck: supple, no JVD, no LAD
Lungs: clear bilaterally
CV: irregular rhythm. [**1-13**] holosystolic murmur at LLSB
Abd: soft, ND, NT +ABS, no organomegally
GU: foley in place
Ext: warm and well perfused 2+ DP pulses.
Pertinent Results:
[**2119-9-25**] WBC-5.9 RBC-2.38* Hgb-8.1* Hct-25.0* Plt Ct-322
[**2119-9-27**] Hct-28.4*
[**2119-9-28**] WBC-12.8* RBC-2.79* Hgb-9.0* Hct-29.5* Plt Ct-188
[**2119-9-29**] WBC-9.0 RBC-2.19* Hgb-7.3* Hct-23.1* Plt Ct-227
[**2119-10-1**] WBC-7.6 RBC-3.40* Hgb-11.0* Hct-34.1* Plt Ct-170
[**2119-10-2**] WBC-6.2 RBC-3.56* Hgb-11.5* Hct-35.8* Plt Ct-178
[**2119-10-3**] WBC-7.8 RBC-3.15* Hgb-10.4* Hct-31.5* Plt Ct-183
[**2119-9-25**]
Glucose-132* UreaN-25* Creat-0.8 Na-134 K-4.8 Cl-96 HCO3-29
AnGap-14
[**2119-10-3**]
Glucose-209* UreaN-23* Creat-0.8 Na-141 K-3.7 Cl-105 HCO3-31
AnGap-9
[**2119-9-29**] 04:09AM BLOOD CK(CPK)-36
[**2119-9-29**] 09:35AM BLOOD CK(CPK)-37
[**2119-9-29**] 04:09AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2119-9-29**] 09:35AM BLOOD CK-MB-NotDone cTropnT-0.07*
RENAL ULTRASOUND WITH DOPPLER [**2119-9-28**]: Normal grayscale
appearance of the kidneys with no evidence of hydronephrosis.
Limited Doppler evaluation, but slightly elevated resistive
indices and slight dampening of the systolic upstroke
bilaterally. These findings are nonspecific and may be related
to underlying chronic renal parenchymal disease.
Brief Hospital Course:
86 yo F with DM, porcine AVR, CAD, CHF (EF 30-35%), Afib (off
coumadin for 8wks), and watermelon stomach and melena.
# GI bleed/Gastric Antral Vascular Ectasia: Patient was admitted
for EGD and colonoscopy for evaluation of BRBPR and possible
treatment for watermelon stomach with possible argon therapy.
On admission, patient was type and screened and followed with
serial hematocrits. During bowel prep, patient was noted to
have 3 melanotic stools. She was hemodynamically stable, but
transferred to the MICU for evaluation, Hcts were stable, and
she returned to the floor on [**9-27**] with a midline for access
with plan for EGD/colonoscopy the following morning. Magnesium
citrate bowel prep was incomplete and EGD/colonoscopy was
postponed for another day. For the third bowel preparation,
go-lytly was used due to concern for use of Magnesium Citrate in
setting of acute renal failure (see below). After finishing
preparation with no noted melena or bleeding, patient
experienced substurnal tightness with possible elevation in
troponin and likely demand ischemia (see below). Due to this,
GI postponed the procedure until [**10-2**]. Following another
go-lytely prep, EGD showed gastric anteral variceal ectasia
which was treated with argon laser therapy. Again bowel prep
was incomplete. Pt refused another attempt at colonoscopy,
understanding the risks of a colonic source of bleeding or
possible malignancy. Her son was present during her refusal,
and agreed with her decision.
# NSTEMI - On the night of [**2119-9-28**], Mrs. [**Known lastname 28694**]
experienced substernal tightness. EKG showed possible new ST
depression in precordial leads with possible deepening of ST
depression in V6. Pain responded to nitroglycerin. Troponin
was 0.07, however patient had been in acute renal failure.
Statin and beta-blocker were started and patient was transfused
2 units PRBCs to Hct>30. In setting of known GI bleeding,
aspirin was not given. Beta-blocker was titrated as tolerated.
Telemetry continued with no events.
.
# Acute renal failure - On hospital day 3, creatinine increased.
Labs also indicated a metabolic alkalosis. Urine electrolytes
indicated FENA 0.39%. Renal function improved with IV fluids.
Alkalosis most likely secondary to volume contraction and also
improved with fluids. Renal function was monitored closely
during rest of admission and creatinine returned to baseline of
0.8.
.
# Diabetes mellitus, type I: Complicated by peripheral
neuropathy and gastroparesis. Patient takes 16U NPH and 4U
Humalin at breakfast with gentle sliding scale when BG > 250.
2Units of NPH were added as a nighttime dose. Glucose monitored
daily and sliding scale altered accordingly. She had no
hypoglycemic episodes. Blood sugars tended to run high. She
requires further management of her diabetes which is a chronic
issue. Defer to outpt setting or to rehab as it is not an acute
issue. Pt and family are concerned about possibility of
hypoglyemcemia given h/o brittle diabetes.
.
# Systolic CHF: Per most recent Echo in [**Last Name (LF) **], [**First Name3 (LF) **] 30-35%. Patient
was euvolemic on admission. In setting of GI bleed, lasix was
held. After transfusion of 2 units PRBCs, patient experienced
shortness of breath consistent with pulmonary edema. Patient
recieved 2 administrations of Lasix IV with appropriate diuresis
and resolution of dyspnea. Her symptoms resolved, upon
stabilization of GI bleed, lasix was restarted.
.
# Afib: Currently rate controlled on metoprolol. Currently off
anticoaguation during past 8 weeks for GIB. Patient was
monitored on telemetry during admission and rate controlled with
a beta blocker.
.
# HTN: Cozaar, metoprolol, Imdur and lasix held on admission in
setting of GI bleed. Patient became hypertensive after
transfusion with 2 units packed red blood cells. Mrs.
[**Known lastname 28694**] was given metoprolol then lasix overnight with
improvement in blood pressure. When hematocrit had stabilized,
losartan and lasix were restarted. Imdur and amlodipine were
held given transient episodes of bradycardia increased dose of
metropolol.
.
# Porcine AVR: stable; does not require anticoagulation for this
indication.
.
# CAD: s/p CABG [**2095**], PCI. Continued statin and cozaar. She
was restarted on ASA 81 mg daily after Hct was noted to be
stable.
.
# UTIs - Patient with evidence of UTI on UA after leukocytosis
noted on routine labs. Patient was started on Cipro for
possible UTI pending culture results. Inital culture was
consistent with contamination. Foley was changed, white count
improved. Urine culture was positive for Cipro resistant Ecoli.
Treatment was held given improvement in leukocytosis. It was
believed that Ecoli represented colonization.
Medications on Admission:
B12 1000mcg qd
Amlodipine 5mg qd
Calcitriol 0.25mcg qd
Calcium+d 500mg [**Hospital1 **]
cozaar 100mg qd
Evista 60mg qd
Ferrous sulfate 65mg tid
Vit C 250 mg tid
Folic acid 400mcg qd
Docusate 100mg [**Hospital1 **]
Isosorbide mononitrate 60mg qd
lasix 20mg qd
levothroxine 50mcg qd
metoprolol 12.5mg [**Hospital1 **]
MV qd
Nitroglycerin 0.3mg as needed
Omeprazole 20mg [**Hospital1 **]
zinc sulfate 220mg qd
Enteric ASA 81mg qd
Zocor 10mg qd
[**Hospital1 **] Medications:
1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day. Capsule(s)
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily ().
5. Ascorbic Acid 500 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO
MON,TUES,WED,[**Last Name (un) **],FRI,SAT ().
11. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO SUNDAY
().
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED) as needed for chest
pain, pressure.
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed for
indigestion.
16. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
19. Insulin - NPH
Please administer NPH - 14 units in AM and 2 units QHS.
20. Insulin - Humalog
Please administer 4 units in AM.
21. Humalog, Insulin Sliding Scale
Please administer per attached sliding scale
22. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
[**Last Name (un) **] Disposition:
Extended Care
Facility:
Lifecare Center of [**Location 15289**]
[**Location **] Diagnosis:
primary: gastric antral variceal ectasia, GI bleed
secondary: acute renal failure, hypertension, diabetes mellitus
type I,
[**Location **] Condition:
Hematocrit stable
[**Location **] Instructions:
You were admitted for evaluation of a bleed in your
gastrointestinal system. You were noted to have a condition
called gastric antral variceal ectasia which may have been the
source of the bleed. A camera was used to look into your
stomach and these ulcerations caused by the gastric antral
variceal ectasia were treated with laser therapy. It is unclear
if this is the only source of your bleed. We did not look into
your colon with the camera because after several unsuccessful
attempts to clean your bowel successfully, you refused further
attempts understanding that we may have incompletely treated
your bleeding site or not discovered a possible cancer.
Your sugars were also noted to be high. Due to your concern of
hypoglycemia, an evening dose of NPH 2 units was added to your
current regimen. A conservative sliding scale is being provided
which you should continue as outpt. Blood sugars up to 450 are
being tolerated.
During your hospitalization several of your medications were
changed or discontinued as noted:
- amlodipine discontinued
- isosorbide mononitrate discontinued
- insulin adjusted - please take 16units NPH and 4 units Humalog
in the morning. Please take 2 units NPH at bedtime. You may
require additional insulin titration at your rehab center.
.
Please call your primary care doctor or return to the emergency
department if you develop chest pain, shortness of breath,
dizziness, fall, blood in stool, black stool or any other
concerning symptom.
Followup Instructions:
Please make an appointment to follow up with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab for check of your blood count
and follow up your blood sugars.
Please follow up Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**]
Specialty: Cardiology
Date and time: Monday, [**10-16**] at 8:40am
Location: [**Location (un) **], [**Location (un) 86**], MA, [**Hospital Ward Name 23**] Bldg, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 62**]
Completed by:[**2119-10-3**]
|
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"357.2",
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
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"38.93"
] |
icd9pcs
|
[
[
[]
]
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3927, 8699
|
335, 346
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2762, 3904
|
12811, 13353
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1712, 1808
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8725, 9168
|
1823, 2743
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268, 297
|
9198, 12788
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374, 1292
|
1314, 1580
|
1596, 1696
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,049
| 188,129
|
7421
|
Discharge summary
|
report
|
Admission Date: [**2162-1-17**] Discharge Date: [**2162-1-23**]
Date of Birth: [**2090-12-3**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 4975**]
Chief Complaint:
Fatigue and lightheadedness.
Major Surgical or Invasive Procedure:
Cardiac cath with...
History of Present Illness:
Mr. [**Known firstname **] [**Initial (NamePattern1) **] [**Known lastname 27235**] is a very nice 71 YO gentleman with history
of MI s/p 4V CABG complicated by stroke who comes with weakness
and lightheadedness. Three days ago he was brooming the snow and
after 10-15 minutes of activity he noted to be very weak,
fatigued and lightheaded. He stopped and sat down and after [**6-6**]
minutes symptoms resolved. Patient denies any chest pain, chest
dyscomfort, pressure, diaphoresis. However, there was mild
shortness of breath associated and mild blury vission.
Yesterday, patient was brushing the snow of the car and he noted
the same exact symptoms. This time he went down to his knees due
to weakness without hitting himself. It took him close to 5
minutes to be able to sit down. Symptoms resolved after [**11-11**]
minutes. He denies any leg swelling, PND, orthopnea,
palpitations, syncope. His wife got concern and brought him to
the ER today. Upon arrival he had Temp 96.1 F, BP 119/57 mmHg,
HR 78 bpm, RR 16 X', SpO2 100%. Patient had EKG changes
including ST depression in V4-V6 (poor quality) with borderline
Troponin I of 0.08. He was given ASA and put on heparin gtt. He
got ASA at home. He was guaiac negative. Of note, patient
presented with shortness of breath without chest pain (per
patient) when he had his MI earlier this year.
Past Medical History:
* CAD s/p MI CABGx4 on IABP (LIMA-->LAD; SVG-->D1; SVG-->OM;
SVG-->Postero-lateral branch).
* Postoperative embolic stroke in distal M1 of left MCA
* Ischemic cardiomyopathy with systolic heart failure, EF 50%
* Diabetes Mellitus Type 2: Diagnosed 15 years ago and
originally controlled with oral hypoglycemics. Now only with
diet. Last Hgb A1C 6.5%
* Hypertension: Diagnosed 25 years ago
* Prostate cancer s/p XRT (recently completed) and currently on
adjuvant Lupron
* Facial basal cell carcinoma
* s/p Tonsillectomy
Social History:
Social history is significant for the absence of current tobacco
use. Pt quit smoking in [**2131**] and has history of 20 pack-year.
There is history of alcohol abuse. He drinks 3 beers on daily
basis, but has CAGE of 1 (C). His last drink was today. Married
with 4 children and 7 grandchildren. He is currently retired and
worked as equipement designer for radiation oncology units at
[**Hospital1 18**], [**Hospital1 112**] and [**Company 2860**].
Family History:
There is no family history of premature coronary artery disease
or sudden death. His mother died of Alzheimer complications age
84, his father died of stroke in his 60s. He has 1 brother that
died 65 of lung cancer and 2 other healthy brothers and 2
daughters. [**Name (NI) **] has 4 healthy kids and 7 grandchildren.
Physical Exam:
VITAL SIGNS - Temp 97.8 F, HR 65 X', BP 103/60 mmHg, RR 14 X',
SpO2 99% on RA, weight 168 pounds.
<br>
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No r/g. No thrills, lifts. No S3 or S4. SEM
[**3-4**] in RUSB in early systole. No clicks.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Neurologic: Minimental 25, A&Ox3, Strenght [**6-1**] in upper and
lower extremities including biceps, triceps, deltoids, anterior
and posterior compartments of forearm, psoas, ant and post
compartment of thigh and leg muscles. Hyper-reflexia in lower
extremities and normal DTRs in upper extremities. Good anal
sphyncter tone. Patient was not walked. Craneal nerves [**3-10**]
normal. Good finger-nose. Mildly slurred speech. NEgative
babinsky bilateraly. Good propiosception and sensation to touch
bilateraly.
Anal: empty vault, GUAIAC NEGATIVE.
<b>
<i>Pulses:</i>
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
On Admission:
[**2162-1-17**] 05:05PM WBC-8.6 RBC-3.23* HGB-10.6* HCT-30.0* MCV-93
MCH-32.9* MCHC-35.5* RDW-13.3
[**2162-1-17**] 05:05PM NEUTS-73.3* LYMPHS-17.2* MONOS-8.3 EOS-1.0
BASOS-0.3
[**2162-1-17**] 05:05PM PLT COUNT-184
[**2162-1-17**] 05:05PM PT-12.9 PTT-24.3 INR(PT)-1.1
[**2162-1-17**] 05:05PM GLUCOSE-134* UREA N-19 CREAT-1.0 SODIUM-137
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
[**2162-1-17**] 05:05PM CK(CPK)-159
[**2162-1-17**] 05:05PM cTropnT-0.08*
[**2162-1-17**] 05:05PM CK-MB-8
[**2162-1-17**] 11:00PM MAGNESIUM-1.7
[**2162-1-17**] 11:00PM CK-MB-6 cTropnT-0.09*
[**2162-1-17**] 11:00PM CK(CPK)-125
CXR: There is stable moderate cardiomegaly. The mediastinal
contours are unchanged. The patient is status post sternotomy.
The lungs are over-inflated, likely representing COAD. There is
no pleural effusion or
pneumothorax.
.
Cardiac Catheterization [**1-18**]:
1. Selective coronary angiography of this left dominant system
revealed
severe native three vessel disease. The LMCA was heavily
calcified with
a distal 80% lesion. The LAD was heavily calcified with an
ostial 90%
lesion. There was proximal diffuse disease up to 50% lesion. The
vessel
was occluded mid-vessel after S1 and at D2. The grafted stump of
D2 was
occluded with faint filling of the distal vessel via left to
left
collaterals. The Lcx was heavily calcified. There was was a high
early
take-off atrial branch. The major grafted OM2 stump was
occluded. The
mid AV groove Lcx had a 60% lesion after OM2. The LPL 1 origin
had a 70%
stenosis. The distal AV groove Cx had a 40% lesion after LPL 2.
There
was competative flow in the LPDA. There was TIMI 1 flow into
distal Lcx.
The RCA was non-dominant. The mid vessel had a total occlusion
with
reconstitution via vasa collaterals.
2. Resting limited hemodynamics revealed moderately left sided
filling
pressures with an LVEDP of 23 mmHg. There was normal systemic
arterial
pressure with central aortic pressure of 119/57 mmHg. On careful
pullback from left ventricle to aorta there was no transaortic
gradient.
3. Selective vein graft angiography revealed an ostial 50% and
proximal
95% lesion in the SVG-OM2 with TIMI 2 flow. The SVG-diagonal and
SVG-LPL
were occluded.
4. Aortography revealed no aortic regurgitation and no
additional grafts
were seen.
5. Left ventriculography was deferred.
6. Successful PTCA and placement of a 2.25x16mm Taxus Atom
drug-eluting
stent in the origin/proximal SVG-OM were performed. Final
angiography
showed normal flow, no apparent dissection, and no residual
stenosis.
(See PTCA comments.)
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate diastolic dysfunction
3. Stenosed SVG-OM2
4. Placement of a drug-eluting stent in the origin/proximal
SVG-OM.
.
Cardiac catheterization [**1-20**]:
1. Coronary angiography of this left dominant system
demonstrated heavy
calcification of the LMCA and LCx with a subtotal occlusion of
the
distal LMCA.
2. Graft angiography of the SVG-OM showed a patent stent and
normal
flow.
3. Limited resting hemodynamics revealed a central aortic
pressure of
100/49 mmHg.
4. Unsuccessful attempt at PCI of the LMCA-LCX was performed.
(See PTCA
comments.)
FINAL DIAGNOSIS:
1. Unsuccessful attempt at PCI of the LMCA was performed.
.
ECHO [**1-19**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal inferior hypokinesis and possible
inferolateral hypokinesis (views suboptimal). There is no left
ventricular outflow obstruction at rest or with Valsalva. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion.
Compared with the prior study (images reviewed) of [**2161-3-11**],
left ventricular systolic function appears similar and is much
improved compared to pre-CABG study of [**2161-1-29**].
.
ECHO [**1-22**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with inferior,
basal inferoseptal and basal inferolateral hypokinesis (most
severe in the basal inferior segment). The remaining segments
contract normally (LVEF = 45%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. IMPRESSION: Mild
regional left ventricular systolic dysfunction, c/w CAD.
Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2162-1-19**],
the findings are similar.
.
CT Abd/Pelvis [**1-21**]:
IMPRESSION:
1. No definite retroperitoneal hemorrhage.
2. Chronically present soft tissue density at the left pelvic
side wall is
most likely lymph node conglomerate.
3. Osseous metastasis to the left ischium/inferior pubic ramus
and T10
vertebral body, which maintains its height.
4. Bilateral small pleural effusions and probable interstitial
edema.
Brief Hospital Course:
71 yo M with hx 4V CABG [**2-3**] complicated by embolic stroke, HTN
and DM who presented on [**1-17**] with lightheadedness, SOB and near
syncope after shoveling snow. Atr the time he had no chest pain,
palpitations or diaphoresis. On arrival to ED, VSS and EKG
showed STD in V4-V6 and troponin 0.08. It felt was felt that
these sx were likely angina and thus pt was taken to the cath
lab [**1-18**]. Initial cath showed LMCA heavily calcified (distal
80%), LAD with ostial 90%, prox dz 50%, occluded after S1 and
D2, LIMA-LAD patent, LCX heavily calcified, OM2 stump occluded,
SVG-OM2 ostial 50% with proximal 95%- pt had DES placed to
SVG-OM. Pt subsequently underwent a repeat cath [**1-20**] with
planned atherectomy to LMCA/LCX but attempt was unsuccessful.
The procedure was complicated by hypotension and ? bradycardia
as pt was placed on dopamine briefly and also had temporary
pacing wire initially. This was removed shortly thereafter.
However given his initial sx it is not clear that this was truly
a coronary event but rather his sx may have been heart block as
discussed below. His subsequent EKG had new STD laterally and
STE AVR/V1 and trop 0.28 but this is likely peri-procedure
emboli. He was continued on statin, aspirin, plavix, beta
blocker.
On [**1-21**], pt was planning on going home but had an episode of
feeling lightheaded, similar to his symptoms that brought him in
initially. Telemetry at the time notable for bradycardia and pt
was hypotensive to the 60s. EKG showed AV dissociation. A
temporary pacing wire was placed and pt was transferred to the
CCU for further monitoring. He did well on a low dose of
beta-blocker and temporary pacer was set at rate of 45, though
he maintained a rate in the 50-70s. A pacemaker was placed on
[**1-22**].
Also of note, pt had 8 Point Hct drop post procedure and had a
new right femoral bruit on exam. A STAT CT scan of the
abdomen/pelvis showed no evidence of RP bleed. His hematocrit
was 22 at the lowest, and he received a total of 3 units of
pRBCs with bump in his CRIT to 28. Hemolysis labs were also sent
and showed no evidence of significant hemolysis. Serial
hematocrits were stable.
.
#. Pump: Last ECHO [**3-6**] with EF 50% and repeat ECHO [**1-19**] showed
EF of 50%; mild regional left ventricular systolic dysfunction
with basal inferior hypokinesis and possible inferolateral
hypokinesis. Pt appears euvolemic on exam.
-Pt not on ACE [**2-28**] hypokalemia (per outpatient records). Given
concern for a new murmur on exam, a repeat ECHO was ordered on
[**1-22**] and showed mild MR but was not felt to be significantly
differenct from prior.
.
# h/o CVA: Patient with normal neurologic exam at this point,
except for midly slurred speech at baseline.
.
#. Diabetes Mellitus: Diet controlled at home, continue sliding
scale
Medications on Admission:
Lipitor 80 mg PO Daily
Plavix 75 mg PO Daily
Deram-Smoothe/FS Scalp [**Doctor First Name **] 0.01% app in psoraiasi rash for 1 wk
Vitamin B12 250 mcg PO Daily
Metoprolol 25 mg PO BID (Twice a day)
Lupron Depot (4 Mo) 30 mg IM Q4 Months
Aspirin 81 mg PO Daily
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Non-ST elevation myocardial infarction
Complete heart block
.
Secondary Diagnosis:
Coronary artery disease s/p CABG
Ischemic cardiomyopathy with systolic heart failure, EF 50%
Diabetes Mellitus Type 2
Hypertension
Discharge Condition:
Stable, breathing comfortably on room air.
Discharge Instructions:
You were seen at [**Hospital1 18**] for fatigue. Upon arrival your EKG showed
some changes concerning for heart attack and your cardiac blood
markers were elevated. You were started on medications to stop
clotting in your heart arteries and were taken to the cath lab,
where they found 2 blocked vessels. A stent was placed in one of
them, the other one was attempted, but unable to be stented.
The morning after your second cardiac catherization you felt
lightheaded and were found to be an abnormal heart rhythm called
complete heart block. You were transferred to the CCU and had a
pacemaker placed.
Please take all medications as prescribed. The following changes
were made to your medication regimen:
1. You should take Plavix 75mg everday. It is very important
that you take this medication everyday, as it prevents
thrombosis in the stent.
2. You should take Keflex for 3 days. 500mg every 6 hours. This
is to prevent infection at the pacer site.
Please slowly resume your activities. If you have any chest
pain, palpitations, lighheadedness/weakness again or anything
else that concerns you please come back to the ER.
.
We strongly recommend that you cut down your alcohol intake
since it can damage your liver and increase the likelihood of
heart disease. Please ask your PCP on more [**Name9 (PRE) 27236**] about
this.
Please call your doctor or return to the hospital if you have
chest pain, shortness of breath, lightheadedness, ir any other
concerning symtoms.
Followup Instructions:
You have a follow-up appointment with [**First Name8 (NamePattern2) 27237**] [**Last Name (NamePattern1) 3100**], NP in
cardiology clinic on [**2-1**] at 8:30.
.
Device clinic, appt to check the pacemaker: Provider: [**Name10 (NameIs) 676**]
CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2162-1-29**] 11:00
.
You have a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] on [**2-21**] at 3pm
.
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2162-2-2**]
8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2162-2-22**] 3:00
Completed by:[**2162-1-25**]
|
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"414.01",
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icd9cm
|
[
[
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[
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icd9pcs
|
[
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13247, 13305
|
10127, 12938
|
300, 322
|
13582, 13627
|
4592, 4592
|
15154, 15919
|
2725, 3044
|
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|
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|
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|
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|
13428, 13561
|
13345, 13407
|
4606, 7192
|
1721, 2242
|
2258, 2709
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,124
| 172,650
|
47007
|
Discharge summary
|
report
|
Admission Date: [**2137-5-12**] Discharge Date: [**2137-5-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Reason for MICU admission: respiratory distress s/p intubation
in ED
Major Surgical or Invasive Procedure:
Endotracheal intubation
RIJ central line placement
History of Present Illness:
This is an 85 year old man with PMH significant for HTN, CHF,
chronic kidney disease who presents with repiratory distress. He
had been hospitalized multiple times recently at [**Hospital1 18**],
beginning in [**11-24**] with a mechanical fall then re-presented that
month with pneumonia. In [**2-25**] he returned with a DVT in the
right common and deep common femoral veins and CHF exacerbation,
as well as troponin elevations and a bibasilar pneumonia.
.
He now presents following a fall at home. Per his wife and
notes, he was at home for the last three days following
discharge from rehab. He was reportedly sitting in a chair at
home, then fell off the chair. His wife found him on the ground,
awake and talking, and called EMS to get him to [**Hospital1 18**] for
evaluation. He did not have any obvioud trauma. His wife says he
noted chest heaviness and heart racing earlier in the day, and
had seemed short of breath since discharge from rehab.
.
In the ED, he was noted to be in respiratory distress, tachypnic
to 35, and O2 sat was 80%. His extremities were cool. He denied
chest pain, nausea, vomiting, incontinence, fevers, chills,
palpitations. Due to his respiratory distress, code status was
confirmed and the patient was intubated. Antibiotics were
started with vancomycin, levofloxacin, and flagyl, then blood
cultures were sent. CXR was felt to not have a striking
pneumonia. CT angiogram was considered but not done due to
elevated creatinine, and VQ scan was also considered. He got 1.8
liters of fluid and was empirically started on heparin because
his INR was 1.8, then transferred to the MICU.
Past Medical History:
1. HTN
2. CKD: baseline around 2.3
3. bipolar disorder - on lithium previously
4. hyperlipidemia
5. prostate surgery many years ago - indication not specified
6. Patient reports hospitalization in [**2111**]'s for MI but does not
know details.
7. Urinary incontinence
8. MI ([**2111**]) and a recent NSTEMI in [**Month (only) **]/06
9. DVT
10. CHF with EF [**2-25**] 30-40% with multiple hypokinetic walls
11. UTI's
12. Anemia
13. Possible reactive airway disease with response to prednisone
[**2-25**]
14. Hematuria
15. Pneumonia [**2-25**]
Social History:
Patient lives with his wife of > 60 years in an [**Hospital3 **]
senior facility in [**Location (un) **]. Has 2 grown children, one is
[**State **] and one in [**State 760**]. Remote history of tobacco. No
alcohol.
Family History:
Non-contributory
Physical Exam:
V: T101.2 100/50 P85 98% AC 500x18 100%
Gen: intubated, sedated, in no distress
HEENT: pupils small, reactive
Neck: JVP elevated at 30 degrees
Resp: lungs with crackles diffusely bilaterally
CV: irreg irreg, normal S1s2 no murmurs
Abd: soft NTND +BS
Ext: cool extremities, 2+ pitting edema bilaterally
Neuro: sedated.
Pertinent Results:
EKG: atrial fibrillation at rate of 98, ST depressions in V5 and
V6, likely J point elevation in V2/V3. LVH. Wide QRS -
interventricular conduction abnormality.
.
RADIOLOGY Final Report
BILAT LOWER EXT VEINS PORT [**2137-5-13**] 9:13 AM
BILAT LOWER EXT VEINS PORT
Reason: SWOLLEN LEGS AND HYPOXIA
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with swollen LEs and hypoxia.
REASON FOR THIS EXAMINATION:
?DVT
DOPPLER ULTRASOUND STUDY OF BOTH LOWER LIMB VEINS
CLINICAL DETAILS: Evaluate for deep venous thrombosis.
FINDINGS:
Right and left lower limb veins are patent and compressible with
phasic venous flow and increased venous return with augmentation
demonstrated on Doppler.
CONCLUSION:
1. No right or left lower limb deep venous thrombosis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42121**]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: MON [**2137-5-13**] 1:34 PM
.
Cardiology Report ECHO Study Date of [**2137-5-13**]
PATIENT/TEST INFORMATION:
Indication: Congestive heart failure.
Weight (lb): 182
BP (mm Hg): 103/58
HR (bpm): 103
Status: Inpatient
Date/Time: [**2137-5-13**] at 13:11
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: Definity
Tape Number: 2006W000-0:00
Test Location: West MICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.9 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.3 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.3 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.4 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.5 cm
Left Ventricle - Fractional Shortening: *0.17 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 15% to 20% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.9 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - E Wave Deceleration Time: 142 msec
TR Gradient (+ RA = PASP): *30 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement. Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Severe global LV
[**Name (STitle) 39407**]. Severely depressed LVEF. [Intrinsic LV systolic
function likely
depressed given the severity of valvular regurgitation.] No LV
mass/thrombus.
RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. Normal RV
systolic function. [Intrinsic RV systolic function likely more
depressed given
the severity of TR].
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Mild to moderate ([**1-21**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Moderate (2+) MR.
TRICUSPID VALVE: Moderate [2+] TR. Borderline PA systolic
hypertension.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is mildly dilated. The left atrium is
elongated. The right
atrium is moderately dilated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. There is severe global left ventricular
[**Month/Day (2) 39407**].
Overall left ventricular systolic function is severely
depressed. No masses or
thrombi are seen in the left ventricle. Intrinsic LV function
likely more
depressed given the mitral and aortic regurgitation.
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal. [Intrinsic right ventricular systolic
function is likely
more depressed given the severity of tricuspid regurgitation.]
4. Mild to moderate ([**1-21**]+) aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen.
6.Moderate [2+] tricuspid regurgitation is seen.
7.There is borderline pulmonary artery systolic hypertension.
8.There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2137-3-7**],
the MR is now worse and the anterior, inferior and inferolateral
walls are
more hypokinetic with a marked decrease in overall LV function.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2137-5-13**]
16:28.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
([**Numeric Identifier 99680**])
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2137-5-12**] 7:50 PM
CHEST (PORTABLE AP)
Reason: r/o chf
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with
REASON FOR THIS EXAMINATION:
r/o chf
INDICATION: Evaluate for CHF.
COMPARISON: [**2137-3-5**].
AP CHEST RADIOGRAPH
Study is limited by patient breathing. Cardiomegaly appears
unchanged. Mediastinal and hilar contours appear unchanged.
Increased opacities at the lower lobes bilaterally are seen.
There is slight increase in the pulmonary vascularity suggesting
mild CHF.
IMPRESSION: Increased lower lobe opacity bilaterally consistent
with aspiration or pneumonia. Mild CHF.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 7204**] [**Name (STitle) 7205**]
Approved: MON [**2137-5-13**] 10:35 AM
.
[**2137-5-14**] 10:27 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2137-5-14**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
? OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. HEAVY GROWTH.
GRAM NEGATIVE ROD(S). RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
.
BCX NGTD
Brief Hospital Course:
A/P: 85 year old man with recent history of CHF, pneumonia, DVT
in [**1-25**], admitted with acute shortness of breath requring
intubation in ED.
.
1. respiratory failure - DDx includes CHF, PE, pneumonia.
Initially with cool extremities suggestive of cardiogenic shock
but was found to be guaiac positive with falling Hct. Was on
anticoagulation for LE DVT; suspect he was anemic, developed AF,
then went into heart failure/pulm edema and resp failure and
then had an NSTEMI. Electively intubated in ED for hypoxia and
tachypnea. Bilateral pleural effusions on CXR, not tappable via
US [**5-13**]. Patient was extubated [**5-14**] without complication. PE not
excluded but patient will need long-term anticoagulation anyway
for his past DVT and AF. TTE [**5-13**] showed depressed EF 15-20%,
[**1-21**]+ AR, 2+MR/TR worsened MR [**First Name (Titles) **] [**Last Name (Titles) 39407**] of ant/inf/inflt
walls (Prior EF 30-40%). Amiodarone and digoxin were started;
amiodarone dosing should be changed to 400mg QD on [**5-21**]. Levo,
flagyl and vanco were initially started, then levo/flagyl d/c'd.
Vancomycin continued for coag-positive Staph aureus in sputum
(sensitivities still pending at time of discharge); he should
complete a full week (through [**2137-5-18**]) of vancomycin (1g Q48
hrs, hold for trough>15). His central line should be removed
after the last dose of vancomycin.
.
2. GIB - guaiac positive with melena [**5-12**]. No clear h/o GIBs but
has been on anticoagulation as an outpt for recent deep vein
thrombosis involving the right common femoral and deep femoral
veins [**2137-2-19**]. No NG lavage performed since Hct stable on [**5-14**]
and pt was just extubated. Patient received 2 units PRBC for
chronic anemia and drifting hct and was maintained on protonix
Q12 with slow advancement of diet to clears once hct stable. Pt
seen by GI; bleeding thought to be from ulcer/gastritis in
setting of anticoagulation, and EGD/colonoscopy deferred until
pt's respiratory status stabilizes and risk/benefit ratio is
more favorable. he should stay on [**Hospital1 **] protonix and can restart
his coumadin, and he only needs to follow-up with GI if he
develops more bleeding.
.
3. A fib - Pt had A fib on last EKG [**3-4**] but otherwise no
evidence of previous A fib by reports. Could be contributing to
CHF picture by reducing the atrial kick. TEE negative for
thrombus/effusion and EF 15-20% [**1-21**]+ AR, 2+ MR/TR and worsened
MR, inf/ant/infolateral [**Month/Day (2) 39407**]. Loaded w/IV amiodarone on
PO maintenance; dose should switch to 400mg PO QD on [**2137-5-21**]. A
digoxin level should be checked within a few days with
adjustment of dosage as necessary. Coumadin should be restarted
[**2137-5-16**] and INRs checked, with goal [**2-22**].
.
4. Elevated troponins with likely NSTEMI. Last NSTEMI [**2137-2-19**]
was started on ASA/plavix no stent/intervention. No h/o
stents/intervention. Has cardiac disease and was on medical
management. CK peaked at 193 on admission and have been
downtrending. TropT peaked at 0.82 [**5-13**]. Continue ASA, statin,
cont ACEi and titrate up as tolerated. Loaded with digoxin
(renally dosed for CrCl 31). He does not need to be on plavix as
he has no stents.
.
5. h/o HTN - hold hydralazine, isordil for now and titrate up
ACEi
.
6. chronic kidney disease at recent baseline of 2.6-3.0. Likely
has reduced forward flow in the setting of severe CHF. Weaned O2
keeping sat>93%. Diuresed with IV lasix based on clinical status
by day, with close monitoring of CVP and UOP.
.
7. h/o R LE DVT in [**1-25**] - Anticoagulation held in setting of
given guaiac positive stools. bilateral LENIs this admission neg
for DVT
.
8. anemia - MCV 97. send iron studies consistent with ACD likely
also component of iron deficiency. Threshold Hct<28 to
transfuse.
.
9. h/o bipolar disorder - continue valproate.
.
10. proph - Held anticoagulation until Hct stable, will restart
coumadin [**5-16**]. Pneumoboots, PPI [**Hospital1 **], bowel regimen, HOB>30
degrees, OOB to chair/PT consult
.
11. FEN - start clears and advance as tolerated
.
12. access - RIJ [**5-12**]; unable to get PIV on [**5-16**] so IJ left in
place; line should be pulled as soon as vancomycin is done with
placement of PICC or PIV as necessary
.
13. code status - Full
.
14. communication - with wife [**Telephone/Fax (1) 99681**] and son [**Telephone/Fax (1) 99682**]
.
15. dispo - transferred to [**Hospital3 105**] per family wishes
Medications on Admission:
Acetaminophen 325 mg Tablet PO Q4-6H
Aspirin 325 mg PO DAILY
Divalproex 125 mg PO QAM, 250 mg PO HS
Furosemide 40 mg PO DAILY
Clopidogrel 75 mg PO DAILY
Atorvastatin 80 mg PO DAILY
Metoprolol Tartrate 75 mg PO TID
Hydralazine 50 mg PO Q6H
Isosorbide Dinitrate 10 mg PO TID
Ipratropium Inhalation Q6H (every 6 hours) as needed.
Senna 8.6 mg PO BID
Docusate Sodium 100 mg PO BID
Pantoprazole 40 mg PO Q24H
Calcium Acetate 1334 mg PO three times a day: with meals.
Coumadin 4 mg PO QD
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: Five (5) mL PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*100 mL* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID
(2 times a day).
Disp:*600 mL* Refills:*2*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
7. Depakote 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QAM.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Depakote 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QPM.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day): hold for SBP<100.
Disp:*45 Tablet(s)* Refills:*2*
11. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q48H (every 48 hours): 7 days total (through
[**2137-5-18**]); last dose given [**2137-5-15**] at 6am; hold if trough > 15.
Disp:*15 gram* Refills:*2*
12. Amiodarone 200 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): for 1 week (last dose [**5-20**]), then decrease dose to
400mg PO QD.
Disp:*60 Tablet(s)* Refills:*2*
13. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day:
first dose [**2137-5-21**].
Disp:*30 Tablet(s)* Refills:*2*
14. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal [**2-22**].
Disp:*30 Tablet(s)* Refills:*2*
15. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Acute respiratory failure
GI bleed / Blood loss anemia
CHF
CRI (baseline 2.6-3.1)
Atrial fibrillation
Guiac-positive stool
NSTEMI
Anemia of chronic disease
Bipolar disorder
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500ml
Take all medications as directed.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2137-7-30**] 10:30
Call Dr. [**Last Name (STitle) 1266**] at [**Telephone/Fax (1) 608**] for an appointment 2 weeks
after you leave the hospital
|
[
"280.0",
"412",
"296.7",
"401.9",
"427.31",
"493.90",
"535.51",
"518.81",
"396.3",
"398.91",
"585.9",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
16713, 16784
|
9715, 14177
|
330, 382
|
17001, 17008
|
3216, 3522
|
17216, 17520
|
2844, 2862
|
14709, 16690
|
8187, 8208
|
16805, 16980
|
14203, 14686
|
17032, 17193
|
4356, 7889
|
2877, 3197
|
9355, 9692
|
222, 292
|
8237, 9314
|
410, 2030
|
7921, 8150
|
2052, 2596
|
2612, 2828
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,030
| 131,906
|
3726+55498
|
Discharge summary
|
report+addendum
|
Admission Date: [**2128-10-14**] Discharge Date: [**2128-10-20**]
Date of Birth: [**2068-7-14**] Sex: M
Service: MEDICINE
Allergies:
Oxycodone / Zanaflex
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Fever, hypoxia, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 16807**] is a 60 yo M, recently discharged from [**Hospital1 18**] on
[**2128-10-11**] after a VATS w/LLL Wedge resection for lung CA on
[**10-6**]. His recent admission was complicated by hypoxia, a
pneumothorax s/p chest tube placement and removal and then
urinary retention which ultimately resolved. He was discharged
home with VNA services to follow-up with Dr. [**Last Name (STitle) **] and
Oncology as an outpatient.
.
On the day of admission, a VNA came to change his dressings. She
found that the patient was slightly hypotensive with SBP 80's
and hypoxic and called an ambulance. The patient himself states
that has been feeling a little anxious and shaky but feels
normal. He states that the nurse over-reacted as his SBP
typically runs 90's and that he requires oxygen at baseline. He
denies any changes in his health in the past few days, denies
taking additional dilauded, no fevers, no chills, no coughing, +
vomiting on the day after discharge, but no subsequent vomiting,
nausea or diarrhea. He endorses left lateral/flank chest pain
[**1-17**] recent incisions but denies substernal or "heart" pain. No
dyspnea. He denies any sensation of lightheadedness or syncope.
.
In the ED: The patient had no complaints. Thoracic surgery saw
the patient and remarked that he was more hypoxic than baseline.
Per thoracic's his baseline is O2 88-91% 4-5L NC, BP 90's, nl
PCo2 50's. Vitals signs in the ED were SBP 80's->90's
spontaneously, O2 saturation 92% on NRB,low 80's on 6L NC, temp
101.0. CXR clear. Started on Vanc and Zosyn. He was given
fluids. EKG showed deeper ST depressions and T wave inversion,
trop 0.6 - > started on heparin for ACS vs PE. A non-contrast CT
showed no fluid collection, no hematoma, some bibasilar
atelectasis. The patient was also found to have renal failure
and transaminitis.
Past Medical History:
Coronary Artery Disease s/p 1v CABG in [**2111**] (SVG -> RCA),
occluded RCA and SVG->RCA graft on Cath in [**1-20**] and RCA fills w/
collaterals; PCI to LAD(3.0x23 Cypher) in [**8-20**] and OM1(2.5x15
Vision-BMS) in [**5-/2127**]
Supraventricular tachycardia s/p ablation
Peripheral [**Year (4 digits) 1106**] disease s/p Right femoral to dorsalis pedis
vein graft, L. femoral-peroneal bypass, right femoral-DP vein
graft bypass, and left BKA, Excision of vein graft and aneurysm
of the right common femoral artery with proximal vein bypass
with interposition segment of nonreversed right basilic vein.
Cath [**8-20**] showed LSFA stents were totally occluded with
collaterals
Emphysema: Home Oxygen 2-4 Liters
Pulmonary Embolism: on coumadin [**11-20**]
Hypercholesterolemia
Total thyroidectomy for thyroid CA->Hypothyroidism
Bilateral inguinal hernia repair
CVA [**2116**] with left-sided weakness
Carotid Stenosis: Right Total occulsion
Seizure disorder
Ischemic neuropathy
Social History:
He denies alcohol use. He smoked 1 ppd for 20 years but quit in
[**2126**]. Lives alone with multiple family members living nearby.
Formerly worked as a computer systems engineer but had to retire
in [**2109**] due to multiple surgeries and medical problems.
Currently on disability. Reports asbestos exposure for 7 years
at a building he worked at.
Family History:
Noncontributory, sister with history of ruptured cerebral
aneurysm at age 48.
Physical Exam:
VS: Temp 98.7 HR 74 BP 124/75 RR 11 SAO2 90-96% 4L NC
Gen: NAD
HEENT: OP clear, EOMI, no scleral icterus
Neck: No JVD, no LAD
Cor: RRR no m/r/g
Pulm: CTAB
Chest: well healing wound on left posterior w/ TTP no swelling
or erythema, no pus; healing wound on left chst/flank with
bruising and TTP but no pus or erythema
Abd: hypoactive bowel sounds, lower abd hematoma, abd diffusely
tender to moderate palpation on left side and RLQ but not RQU,
no rebound, no guarding; distended but not tense, no tympanic
Extrem: no c/c/e
Skin: no rashes
Neuro: non-focal, AOx3, attentive
Pertinent Results:
[**2128-10-14**] 12:00PM BLOOD Neuts-83.4* Lymphs-10.6* Monos-5.1
Eos-0.6 Baso-0.4
[**2128-10-14**] 12:00PM BLOOD PT-19.4* PTT-29.6 INR(PT)-1.8*
[**2128-10-14**] 12:00PM BLOOD Glucose-119* UreaN-51* Creat-2.3*# Na-135
K-5.5* Cl-92* HCO3-31 AnGap-18
[**2128-10-14**] 12:00PM BLOOD ALT-2358* AST-2079* CK(CPK)-258*
AlkPhos-86 TotBili-1.2
[**2128-10-15**] 05:07AM BLOOD ALT-1530* AST-788* CK(CPK)-290*
AlkPhos-72 TotBili-1.1
[**2128-10-14**] 12:00PM BLOOD CK-MB-6 proBNP-[**Numeric Identifier 16808**]*
[**2128-10-14**] 12:00PM BLOOD cTropnT-0.64*
[**2128-10-14**] 07:53PM BLOOD CK-MB-9 cTropnT-0.61*
[**2128-10-15**] 05:07AM BLOOD CK-MB-8 cTropnT-0.61*
[**2128-10-15**] 05:07AM BLOOD Calcium-7.6* Phos-2.5* Mg-2.2
[**2128-10-14**] 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2128-10-14**] 12:06PM BLOOD Lactate-2.5*
[**2128-10-14**] 01:50PM BLOOD Lactate-1.4
.
Cardiac Cath ([**4-/2128**]):
1. Coronary angiography of this right dominant system revealed
minimal disease of the LMCA, widely patent prior LAD stents,
mild restenosis of OM1, and 100% occluded RCA that fills via LCx
collaterals.
2. Arterial bypass angiography revealed 100% occluded
SVG->R-PDA.
3. Resting hemodynamics revealed elevated and equalized right
and left sided filling pressures with RVEDP, mean PCWP, and
LVEDP of 20 mm Hg. PASP was severely elevated at 71 mm Hg.
Systemic arterial pressure was moderately elevated. Cardiac
index was preserved at 2.7 l/min/m2.
4. Left ventriculography revealed 1+ mitral regurgitation and
LVEF of
50% with inferior hypokinesis.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent prior LAD stent, mild restenosis of OM1 stent.
3. Occluded SVG-->R-PDA.
4. Severely elevated right heart pressures and pulmonary
hypertension.
5. Equalization of left and right sided filling pressures with
possible
restrictive vs. constrictive physiology.
.
EKG ([**2128-10-14**]): Sinus rhythm. Prolonged P-R interval. Right
ventricular hypertrophy with secondary repolarization
abnormalities. Compared to the previous tracing of [**2128-10-7**] the
inferior ST-T wave changes are not as apparent. The other
findings are siimlar. Clinical correlation is suggested.
.
CT chest/abd ([**2128-10-14**]): No evidence of focal fluid collection
in the abdomen or pelvis to suggest an abscess. No evidence of
hematoma in the chest, abdomen or pelvis. Mild compressive
atelectasis is seen in the left lower lobe subjacent to a trace
left pleural effusion. The patient is status post left VATS
wedge resection of a spiculated left lower lobe pulmonary
nodule. Note is made of subcutaneous air along the anterolateral
left chest wall.
.
RUQ U/S ([**2128-10-14**]):
FINDINGS: There are no focal liver lesions. There is normal
hepatopetal flow within the main portal vein. The gallbladder
has a 6 x 6 x 6 mm nonobstructive shadowing gallstone. The
gallbladder is not distended, and no gallbladder wall thickening
or pericholecystic fluid is present. The common bile duct is
normal measuring 5 mm. There is no free abdominal fluid. There
is no intra- or extra- hepatic biliary dilatation. The spleen is
enlarged but stable measuring 17 cm.
IMPRESSION:
1. Cholelithiasis without cholecystitis.
2. Stable splenomegaly.
.
Bilateral LENIs ([**2128-10-15**]): No evidence of deep vein thrombosis
in either leg.
.
Echo ([**2128-10-15**]): The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. There is mild global
left ventricular hypokinesis (LVEF = 40-45 %). The right
ventricular cavity is markedly dilated with moderate global free
wall hypokinesis with apical sparing. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad. Compared with the prior study (images
reviewed) of [**2128-4-16**], left ventricular systolic function is
now depressed.
.
CT/CTA Chest, Abdomen, Pelvis ([**2128-10-15**]):
1. No evidence of pulmonary embolism.
2. Moderate-sized left pleural effusion, with associated
atelectasis of the
adjacent lung.
3. Bilateral renal hypodensities, too small to characterize.
4. Extensive atheromatous disease of the abdominal aorta.
.
CXR [**2128-10-18**]: Moderate left pleural effusion with subpulmonic
component slightly increased from previous imaging on [**2128-10-15**].
Small right pleural effusion.
Brief Hospital Course:
Mr. [**Known lastname 16807**] is a 60 year old male with a history of CAD, PVD,
and NSCLC recently s/p VATS and LUL resection who presented with
hypotension and hypoxia.
1. Hypotension: The patient's initial presentation with
hypotension resolved after receiving IVF boluses. The etiology
is unclear, but likely a mix of poor PO intake, resuming normal
home anti-hypertensive regimen, and taking dilaudid for pain
control post-operatively at home. He also had NSTEMI (see
below) - unclear whether this was the primary event or a result
of hypotension. The patient also had a CTA to rule out PE. Low
dose metoprolol was restarted as patient's blood pressure
stabilized at baseline systolic values of 90s-100s.
2. Hypoxia: The patient's hypoxia resolved shortly after
presentation. Chest CT revealed a left-sided pleural effusion.
There was no evidence of pneumonia. CXR on [**10-18**] showed moderate
left lower and middle lobe effusion, slightly increased from
previous imaging on [**10-15**]. This was thought consistent with
recent h/o thoracic surgery, and given patient's low blood
pressures, diuresis was considered but held. Patient will follow
up with cardiothoracic surgery in the week following discharge.
Saturations remained in low 90s on 4L NC, which is his home O2
regimen.
3. Fever: Patient presented with fever, but given negative blood
and urine cultures, and no consolidation on CXR, infectious
etiology was not thought to be the precipitant. Fevers
resolved. He did have a positive monospot test, though his
symptoms are inconsistent with active infectious mononucleosis.
CMV Ag negative.
4. Transaminitis: On admission the patient was found to have a
transaminitis. He had a very similar episode of hypotension,
renal failure, and transaminitis in [**2128-3-16**] in which he was
diagnosed with shock liver. His transaminitis is likely due to
hypotension in the setting of extensive [**Year (4 digits) 1106**] disease. His
statin was held, to be restarted as an outpatient. Transaminitis
downtrended throughout his admission.
5. Acute renal failure: The patient presented with acute renal
failure and a creatinine elevated to 2.3 on presentation. ARF
likely due to hypotension and [**Year (4 digits) 1106**] disease. Over time, the
patient's creatinine gradually trended back down to normal.
6. NSTEMI: The patient presented with a troponin of 0.60, CKD
258 and EKG with worsening TWI and ST depressions suggesting ACS
although MB fraction was low. It is also possible that troponin
was elevated in the setting of renal failure. Enzymes were
cycled and CK peaked at 477. Enzyme leak likely related to
transient hypotension and not to unstable clot formation,
therefore his heparin drip was discontinued. Aspirin and plavix
were continued. Statin was held for transaminitis. Metoprolol
was restarted at low dose as the hypotension resolved. The above
was discussed with his primary cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
who also followed him in-house.
7. Recent VATS: The patient was continued on tramadol and
dilauded PO. The patient was followed by thoracic surgery.
8. History of COPD: nebs and Advair were continued. Will be
discharged back on home O2 at 3-4L nasal canula at all times.
9. Hx Seizure: cont Keppra.
10. Hx PE/DVT: off coumadin but INR 1.8 on admission. LENIs
were negative for DVT. Not on coumadin due to past bleed while
on anticoagulation in [**2125**].
Medications on Admission:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID
3. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H PRN
4. Levetiracetam 750 mg Tablet Sig: Two (2) Tablet PO q12
hours.
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
7. Nitroglycerin 0.3 mg Tablet, Sublingual PRN
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device DAILY
9. Aspirin 325 mg Tablet PO DAILY (Daily).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H
15. Gabapentin 800 mg Tablet TID
16. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed. [**Hospital1 **]:*60 Tablet(s)* Refills:*0*
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. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain.
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily): w/inhalation device daily.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times
a day.
14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
15. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
16. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
19. Metoprolol Tartrate 25 mg Tablet Sig: [**12-17**] tablet Tablet PO
twice a day.
20. oxygen
Home O2 by nasal canula at 3-4L/min at all times.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: hypotension, with associated NSTEMI, acute renal
failure, and transaminitis
Seconary: s/p recent left lower lobe wedge resection
Discharge Condition:
Stable, improved. Kidney function back to baseline, saturating
at baseline on home O2 requirement, and blood pressure to
baseline 90s systolic.
Discharge Instructions:
You were admitted for low blood pressure, low oxygen saturation,
and fevers. Your visiting nurse found you with low blood
pressures at home shortly following discharge from your recent
admission for wedge resection of a right lung nodule. Due to
hypotension, your cardiac enzymes, liver function, and renal
function all showed evidence of temporary hypotension, which
resolved with IV fluids and holding your blood pressure
medications.
Please continue to take all your medications. You are being
dischared on a lower dose of your blood pressure medication:
please take metoprolol 12.5mg PO BID. Your cholesterol
medication (atorvastatin) has been stopped temporarily, and your
cardiologist will discuss restarting this at your follow up
appointment.
Return to the hospital if you have low blood pressure, fevers,
shortness of breath or low oxygen saturation, syncope,
lightheadedness, or chest pain.
Follow up with your thoracic surgeon, cardiology, primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) 5564**] as described below.
Followup Instructions:
Provider (CT surgeon): [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD
Phone:[**2127**] Date/Time:[**2128-10-26**] 3:30
Provider (Cardiology): Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD Phone: [**Telephone/Fax (1) **].
Date/Time:[**2128-10-27**] 2:30
Provider (PCP): [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16800**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2128-10-29**] Time to be determined. Please phone
[**Telephone/Fax (1) **]
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2128-11-29**]
3:15
Provider (Thoracic Oncology): Thoracic Oncology will contact you
to set up an appointment. If you do not hear from them within
10 days, please phone [**2128**] to set up an appointment.
Please schedule follow up with your pulmonologst, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 16809**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Name: [**Known lastname 2631**],[**Known firstname 422**] Unit No: [**Numeric Identifier 2632**]
Admission Date: [**2128-10-14**] Discharge Date: [**2128-10-20**]
Date of Birth: [**2068-7-14**] Sex: M
Service: MEDICINE
Allergies:
Oxycodone / Zanaflex
Attending:[**First Name3 (LF) 839**]
Addendum:
The patient was discharged on Gabapentin 600 mg [**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. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain.
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily): w/inhalation device daily.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
14. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
15. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
18. Metoprolol Tartrate 25 mg Tablet Sig: [**12-17**] tablet Tablet PO
twice a day.
19. oxygen
Home O2 by nasal canula at 3-4L/min at all times.
20. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 841**]
Completed by:[**2128-10-20**]
|
[
"V45.82",
"574.20",
"V58.61",
"790.4",
"276.51",
"997.1",
"433.10",
"V12.51",
"345.90",
"458.9",
"349.9",
"V45.89",
"272.0",
"410.71",
"162.5",
"584.9",
"E878.8",
"511.9",
"V49.75",
"443.9",
"492.8",
"V15.84",
"414.01",
"V10.87",
"244.8",
"414.02"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
19950, 20128
|
8969, 12446
|
311, 317
|
15487, 15633
|
4261, 5843
|
16735, 18194
|
3574, 3653
|
18217, 19927
|
15325, 15466
|
12472, 13517
|
5860, 8946
|
15657, 16712
|
3668, 4242
|
244, 273
|
345, 2189
|
2211, 3191
|
3207, 3558
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,602
| 196,111
|
16160
|
Discharge summary
|
report
|
Admission Date: [**2141-1-24**] Discharge Date: [**2141-2-2**]
Date of Birth: [**2087-5-11**] Sex: F
Service:
ADMISSION DIAGNOSIS: Constrictive pericarditis.
DISCHARGE DIAGNOSES:
1. Constrictive pericardial thickening.
2. Pulmonary embolus.
3. Status post pericardectomy.
HISTORY OF PRESENT ILLNESS: The patient is a 53 year old
woman with a history of Hodgkin's lymphoma diagnosed
approximately twenty-five years ago and treated with
chemotherapy/radiation. The patient has also had a pulmonary
embolism approximately fifteen years ago. She was admitted
to [**Hospital3 35813**] Center on [**2141-1-18**], for increased
shortness of breath, chest tightness, nonproductive cough
associated with tachycardia. Deep vein thrombosis and
pulmonary embolus workup was negative. Spiral chest CT did,
however, reveal a thickened pericardium with pericardial
effusion. Follow-up echocardiogram confirmed a markedly
thickened pericardium, moderate effusion with right atrial
collapse, septal dyskinesis. There were marked respiratory
variations of mitral valve flow. The patient further
underwent cardiac catheterization demonstrating an ejection
fraction of greater than 65% and no evidence of any coronary
artery disease. The patient was then transferred to [**Hospital1 1444**] for pericardectomy.
PAST MEDICAL HISTORY:
1. Hodgkin's lymphoma.
2. Status post chemotherapy/radiation.
3. History of pulmonary embolus.
4. Hypothyroidism.
PAST SURGICAL HISTORY:
1. Cholecystectomy, [**2111**].
2. Splenectomy, [**2107**].
3. Broken leg, [**2130**].
MEDICATIONS ON ADMISSION:
1. Synthroid 75 mcg once daily.
2. Solu-Cortef 100 mg q6hours.
3. Indomethacin 25 mg p.o. three times a day.
4. Lorazepam 0.5 mg three times a day.
5. Lasix 20 mg p.o. once daily.
6. Zosyn.
7. Zithromax.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient is a middle age woman in
no acute distress. Vital signs reveal a temperature 97.1
degrees Fahrenheit, heart rate 107, blood pressure 151/64,
oxygen saturation 99% on four liters of oxygen, 107.2
kilograms. Head, eyes, ears, nose and throat is atraumatic,
normocephalic. Extraocular movements are intact. The pupils
are equal, round, and reactive to light and accommodation.
Anicteric. The throat is clear. The neck is supple without
masses or lymphadenopathy. No bruit or jugular venous
distention. Chest is clear to auscultation bilaterally.
Cardiovascular examination is regular rate and rhythm, no
murmurs, rubs or gallops. The abdomen is soft, nontender,
nondistended without masses or organomegaly. Extremities are
warm, noncyanotic, nonedematous times four. Neurologic
examination is grossly intact.
HOSPITAL COURSE: The patient was transferred on [**2141-1-24**], to
[**Hospital1 69**] for pericardectomy. The
patient was taken to the operating room on [**2141-1-25**], and had
pericardectomy. It was noted by anesthesia on intraoperative
transesophageal echocardiogram that there was a fresh
clot/thrombus seen in the left main pulmonary artery. The
patient otherwise tolerated the procedure well and was
transferred to the CSRU for closer monitoring. On the
evening of postoperative day number zero, the patient was put
on a Heparin drip for anticoagulation of her pulmonary
embolus. The patient otherwise did well and was extubated on
postoperative day number zero.
On postoperative day number one, the patient was transferred
to the SICU due to the need for bed availability. The
patient was stable overnight and oxygen was weaned as
tolerated. The patient continued to do well though she was
in sinus tachycardia and was transferred to the floor later
on postoperative day number two. Her anticoagulation was
continued and the patient was begun on oral Coumadin therapy.
Diuresis was also pushed with oral Lasix. The rest of the
[**Hospital 228**] hospital course was unremarkable and the patient
remained in persistent sinus tachycardia, likely thought due
to the existing pulmonary embolus.
Ultimately, the patient was discharged on postoperative day
number eight tolerating regular diet and adequate pain
control with p.o. pain medications. At the time, she was
cleared by physical therapy. The patient's INR at discharge
was 1.9.
CONDITION ON DISCHARGE: Good.
DISPOSITION: To home.
DIET: Ad lib.
MEDICATIONS ON DISCHARGE:
1. Levothyroxine 75 mcg once daily.
2. Lasix 40 mg p.o. twice a day times seven days.
3. Potassium Chloride 20 meq twice a day times seven days.
4. Percocet 5/325 one to two tablets q4hours p.r.n.
5. Colace 100 mg twice a day.
6. Coumadin 5 mg once daily.
7. Lopressor 12.5 mg p.o. twice a day.
8. Ativan 0.5 to 1.0 mg q6hours p.r.n.
INSTRUCTIONS: The patient is to have close follow-up with
her primary care physician for INR checks. Goal INR should
be between 2.0 and 3.0. The patient should follow-up with
Cardiology within one to two weeks time and address the need
for diuresis as well as adjustment of cardiac medications at
that time. The patient should follow-up with Dr. [**Last Name (STitle) **] in
four weeks time.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2141-2-2**] 17:47
T: [**2141-2-2**] 18:19
JOB#: [**Job Number 46157**]
|
[
"997.1",
"V10.72",
"V12.51",
"E879.2",
"427.89",
"415.19",
"990",
"423.1",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.31",
"39.32",
"34.99",
"37.24",
"34.24",
"89.68"
] |
icd9pcs
|
[
[
[]
]
] |
201, 298
|
4362, 5379
|
1608, 1858
|
2727, 4264
|
1491, 1582
|
1881, 2710
|
152, 180
|
327, 1327
|
1349, 1468
|
4289, 4336
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,234
| 144,747
|
39119
|
Discharge summary
|
report
|
Admission Date: [**2144-5-6**] Discharge Date: [**2144-5-18**]
Date of Birth: [**2075-6-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x 4 (LIMA to LAD, SVG to OM1, SVG
to OM2, SVG to PDA) [**5-6**]
History of Present Illness:
This 68 year old male reports left shoulder pain with moderate
exertion and occasionally with rest. He had 2 episodes of
dizziness with exertion which was relieved with rest. He denies
chest pain, shortness of breath, or syncope. He underwent an
outpatient stress test on [**2144-3-12**] which had to be
stopped due to severe claudication. Results are listed below.
He presented at a previous admission for elective cardiac
catherization which revealed triple vessel disease and he was
referred for evaluation for surgical revascularization. He was
admitted now for elective operation.
Past Medical History:
hypertension
hyperlipidemia
preipheral vascular disease
noninsulin dependent diabetes mellitus
s/p tonsillectomy
s/p transurethral prostate resection
Social History:
Race:Caucasian
Last Dental Exam:edentulous
Lives with:wife, [**Name (NI) **] (lives in one story house, 2 steps to
get in)
Occupation:part time employee at [**Company **] (stock room)
Tobacco:Current/ 1ppd x55 yrs, now [**1-26**] cigs/day. Has not smoked
in 2 days
ETOH:none
Family History:
Father suffered an MI in his 50s
Physical Exam:
Admission:
Pulse: 46 Resp: 14 O2 sat: 97%RA
B/P Right:166/72 Left: 176/68
Height: 5'5" Weight:131lbs
General: NAD, cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] No Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [] Edema Varicosities:
None
[]
Neuro: Grossly intact
Pulses:
Femoral Right: not palpable Left: not palpable
DP Right: not palpable Left: not palpable
PT [**Name (NI) 167**]: not palpable Left: not palpable
Radial Right: +3 Left: +3
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2144-5-6**] Echo: Pre Bypass: The left atrium is mildly dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with inferior basal
hypokinesis. Overall left ventricular systolic function is
mildly depressed (LVEF= 50%). Right ventricular chamber size and
free wall motion are normal. There are complex (>4mm) atheroma
in the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. Post Bypass: Preserved Biventricular
function. LVEF 50-55%. MR remains Mild. Aortic contours intact.
Remaining exam is unchanged. All findings discussed with
surgeons at the time of the exam.
[**2144-5-18**] 05:20AM BLOOD Hct-34.8*
[**2144-5-14**] 05:40AM BLOOD Plt Ct-362
[**2144-5-18**] 05:20AM BLOOD UreaN-14 Creat-0.7 K-4.6
Brief Hospital Course:
Mr. [**Known lastname 64461**] was a same day admit after undergoing pre-operative
work-up prior to admission. On [**5-6**] he was brought to the
Operating Room where he underwent coronary artery bypass graft x
4. Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours he was weaned from
sedation, awoke confused and agitated but non-focal.
Narcotics and benzodiazepines were held. His agitation improved
with Haldol but he had an extended stay in the intensive care
unit for close supervision to avoid a fall. His chest tubes,
wires, and Foley were removed. His beta-blockade was titrated as
indicated. Oral hyperglycemic agents were resumed as well as
his ACE. His mental status improved and he was able to transfer
to the floor on POD 6.
Physical Therapy worked with him for strength and
mobility.Arrangments were made for follow up after discharge.
Post-operative delirium continued on the floor and geriatrics
consult was obtained. Medication recommendations were made and
carried through. Cleared for discharge to home on POD #12. Pt is
to make all follow-up appts. as per discharge instructions. Pt
is to make appt to see PCP next week and check BS regularly to
help determine further mgmt. of DM meds.
Medications on Admission:
GLIMEPIRIDE - (Prescribed by Other Provider) - 4 mg Tablet -
one
Tablet(s) by mouth twice a day
LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet -
one
Tablet(s) by mouth daily
METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet -
one Tablet(s) by mouth twice a day
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Sustained Release 24 hr - one Tablet(s) by mouth daily
SIMVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet -
one Tablet(s) by mouth daily
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - one
Tablet(s) by mouth daily
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- 1,000 mg Capsule - one Capsule(s) by mouth three times a day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every 4
hours as needed as needed for pain.
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 2 weeks: as needed for constipation.
Disp:*30 Capsule(s)* Refills:*1*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
5. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Glimepiride 4 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY @1400
().
Disp:*30 Tablet(s)* Refills:*1*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Coronary artery disease
s/p coronary artery bypss graft x 4
Hypertension
Hyperlipidemia
Peripheral Vascular Disease
Noninsulin dependent Diabetes Mellitus
s/p Tonsillectomy
s/p transurethral resection of prostate
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with Tylenol and Ultram prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month until follow up with surgeon and off
all narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2144-6-11**] at 1:15PM ([**Telephone/Fax (1) 170**])
Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 61740**] in [**1-25**] weeks ([**Telephone/Fax (1) 62076**])
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8098**] in [**1-25**] weeks ([**Telephone/Fax (1) **])
Completed by:[**2144-5-18**]
|
[
"272.4",
"250.00",
"411.1",
"414.01",
"305.1",
"443.9",
"293.0",
"427.89",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
6902, 6958
|
3418, 4741
|
321, 416
|
7215, 7323
|
2304, 3395
|
7872, 8313
|
1520, 1554
|
5512, 6879
|
6979, 7194
|
4767, 5489
|
7347, 7849
|
1569, 2285
|
258, 283
|
444, 1036
|
1058, 1211
|
1227, 1504
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,583
| 198,100
|
2882
|
Discharge summary
|
report
|
Admission Date: [**2125-1-15**] Discharge Date: [**2125-1-22**]
Service: MEDICINE
Allergies:
Amoxicillin / Cephalosporins / Penicillins / Carbapenem
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy
Cauterization of bleeding sigmoid blood vessel
Placement of post-pyloric feeding tube
History of Present Illness:
An [**Age over 90 **] year old woman with a past medical history of severe
mitral regurgitation, congestive heart failure, coronary artery
disease, diabetes mellitus,peripheral vascular disease, chronic
renal insufficiency, history of LGIB who presents to the ED from
[**Hospital 100**] Rehab with BRBPR. Pt was noted to have large amount of
blood noted in the bed at [**Hospital 100**] Rehab.
.
She had had an episode in [**2-17**] of a LGIB as well. Then, it was
recommended that she have a flexible sigmoidoscopy, which showed
an ulcer in the transverse colon and rectum thought to be due to
infection, ischemia, or rectal prolapse.
REVIEW OF SYSTEMS: Negative for fevers, chills, nausea,
vomiting, shortness of breath, chest pain, lightheadedness and
abdominal pain. The patient reports decreased appetite and
decreased weight loss.
Past Medical History:
1. Coronary artery disease, status post coronary artery
bypass graft at [**Hospital1 112**] in [**2115**] - LIMA -> LAD; NSTEMI in [**2118**] with
cath at that time showing 4+ MR, moderate three vessel native
disease in
with a patent LIMA to the LAD. LAD occluded in the mid portion.
D1 had an 80% stenosis. The LCx had a 30% proximal and 50% mid
stenosis. The OM1 had an aneurysmal 40-50% stenosis. The RCA
had a 70% mid stenosis. The LIMA to the LAD was patent.
2. Aortic valve replacement with a porcine valve in [**2115**].
3. Congestive heart failure with severe left ventricular
hypertrophy and diastolic dysfunction. EF 75%, RV wall
hypokinesis,
4. Insulin dependent diabetes mellitus (adult onset)
5. Severe mitral regurgitation - 4+ MR. [**First Name (Titles) **] [**Last Name (Titles) **] surgery
6. Chronic renal insufficiency.
7. Peripheral vascular disease, status post left lower extremity
bypass.
8. History of deep vein thrombosis.
9. Rheumatoid arthritis.
10. Gout.
11. History of atrial fibrillation - on coumadin
12. Hypothyroidism.
13. Gastroesophageal reflux disease.
14. Total abdominal hysterectomy/bilateral
salpingo-oophorectomy.
15. Depression.
16. Osteoporosis.
17. Hematochezia ([**2122-2-14**]).
18. Dementia
19. Pulmonary hypertension
Social History:
The patient lives in the [**Hospital3 **] Facility and her
daughter is present health care proxy. [**Name (NI) **] [**Name2 (NI) **]/EtOH/IVDU
Family History:
noncontributory
Physical Exam:
95.9, 136/83, 108, 95% RA.
gen-well appearing in NAD
heent-NC/AT, PERRL, EOMI, anicteric, MM dry
neck-supple, no JVD, no LAD, no CB, 2+ carotids with nl upstroke
cvs-RRR, nl S1/S2 without extra heart sounds, no M/R/G
appreciated, pulm-CTAB
back-symmetric, no vetebral tenderness, no CVA tenderness
abd-soft, mild tenderness, ND, NABS without HSM
ext-no c/c/e, 2+ DPs b/l
skin-WWP, large L iliac crest decub, R heel ulcer and
excoriations on L shin.
neuro-A&O times to self only. moves all 4's
Pertinent Results:
admission labs:
CBC:
WBC-9.4 RBC-4.83 HGB-12.9 HCT-38.0 MCV-79*# MCH-26.8* MCHC-34.0
RDW-17.4*
NEUTS-81.2* LYMPHS-10.1* MONOS-5.0 EOS-2.6 BASOS-1.0
PLT COUNT-297
coags:
PT-16.0* PTT-29.6 INR(PT)-1.5*
electrolytes: GLUCOSE-120* UREA N-33* CREAT-1.3* SODIUM-143
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15
ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-4.2
cardiac enzymes:
[**2125-1-15**] 11:26AM CK(CPK)-20*
[**2125-1-15**] 11:26AM cTropnT-<0.01
[**2125-1-15**] 11:53PM CK(CPK)-48
[**2125-1-15**] 11:53PM CK-MB-3 cTropnT-<0.01
serial Hct:
[**2125-1-15**] 05:39PM HCT-35.3*
[**2125-1-16**] 12:19PM BLOOD Hct-27.7*
[**2125-1-16**] 08:08PM BLOOD Hct-37.0
[**2125-1-17**] 02:07PM BLOOD Hct-36.6
[**2125-1-21**] 04:30AM BLOOD WBC-9.3 RBC-3.95* Hgb-11.3* Hct-34.5*
MCV-87 MCH-28.7 MCHC-32.9 RDW-18.7* Plt Ct-209
Imaging:
[**2125-1-15**] tagged RBC scan: Abnormal increased tracer activity at
approximately 25 minutes consistent with bleeding in the region
of the sigmoid colon.
[**2125-1-16**] CXR: 1. Slight cardiomegaly and mild CHF/fluid overload.
2. Left retrocardiac opacity represents atelectasis or
consolidation.
Brief Hospital Course:
1. lower GI bleed - Tagged scan positive for bleed in the
[**Last Name (un) 13962**] colon, and a mesenteric angiogram showed active
extravasation from a small branch of the superior hemorrhoidal
artery in the low rectum; no embolization performed. She had an
episode of hypotension into SBP 40s after passing a large clot.
General surgery was consulted, but considered pt too high for
surgery. GI was eventually able to perform colonoscopy and
cauterize a visible vessel within an ulcer in the rectum that
had stigmata of bleeding. Pt was given FFP and vitamin K to try
to correct her coagulopathy as well, and was transfused with
PRBCs. Her Hct remained fairly stable during the remainder of
her hospitalization. She was kept NPO, and given IV bid PPI.
Pt developed another GI bleed a few days later, but no
transfusions were required.
2. acute renal failure - likely was [**1-18**] prerenal azotemia in
the setting of GI bleed. With fluid resuscitation, however,
pt's Cr remained 1.3-1.6.
3. heart failure - pt needed diuresis for fluid overload. Pt's
po meds were held initially in the setting of mental status
change and inability to swallow pills. She was treated with
hydralazine for afterload reduction. A Dobhoff was eventually
placed, and pt was able to get her po meds; her cardiac regimen
was restarted.
4. atrial fibrillation - pt developed RVR into the 180s, and
was started on an amiodarone gtt. These medications were
stopped when pt was made CMO.
5. heel ulcers - podiatry was consulted, and pt was given
multipodus boots, and wet to dry dressings. She was kept on
levofloxacin and flagyl for empiric antibiotic coverage of the
wound.
6. FEN/GI - pt had Dobhoff placed eventually and tube feeds
were started. These were eventually stopped when pt was made
CMO. Pt was hypernatremic during her hospital stay, as well,
and was given D5W to correct this. Her fluid status was an
ongoing issue, and she required both IVF and lasix during the
course of her stay.
7. Access - Pt had EJ and peripheral IVs in place, no central
line.
8. Code - pt was initially DNR/DNI. Multiple discussions were
had with the family, and it was eventually agreed that she
should be made comfort measures only, given her overall poor
prognosis and risk of rebleed. Palliative care consult was
called for extra family support and to facilitate transition to
hospice care. Pt was placed on a morphine drip, requiring
1.5mg/hour to be clearly comfortable. All medications except
for comfort-oriented medications were discontinued. Her tube
feeds were stopped, and the Dobhoff was removed. Pt passed away
soon after comfort measures initiated, family deferred autopsy.
Dao [**Doctor Last Name **], MS4
Supervised by [**Doctor Last Name **] [**Numeric Identifier 13963**]
Medications on Admission:
1. Tylenol 975 mg b.i.d.
2. Amiodarone 200 mg p.o. q.d.
3. Calcium carbonate 650 mg p.o. b.i.d.
4. Iron sulfate 325 mg p.o. q.d.
5. Carvedilol 3.125 mg p.o. b.i.d.
6. Colace 200 mg p.o. b.i.d.
7. Hydralazine 25 mg p.o. t.i.d.
8. Levothyroxine 125 mcg p.o. q.d.
9. Simvastatin 20 mg p.o. q.d.
10. Sorbitol 50 mg p.o. b.i.d.
11. Albuterol and Ipratropium nebulizers
12. Robitussin 5 to 10 ml p.o. q. 6 hours prn.
13. Anusol suppository prn.
14. Humulin 70/30 20 units q. AM, 14 units q. PM
15. Isosorbide 5 t.i.d.
16. Senna one tablet p.o. b.i.d.
17. Protonix 40 mg p.o. q. 24 hours.
18. Lasix 60 mg p.o. q.d.
19. Levofloxacin 250 mg p.o. q.d. for 14 days, for right
lower extremity ulcer.
20. Metronidazole 500 mg p.o. t.i.d. for 14 days for right
lower extremity ulcer.
Discharge Medications:
N/A
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Gastrointestinal bleed
Acute renal failure
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
None
|
[
"276.0",
"733.00",
"294.8",
"428.0",
"V42.2",
"427.31",
"276.50",
"250.00",
"530.81",
"714.0",
"578.9",
"707.04",
"569.41",
"584.9",
"244.9",
"443.9",
"707.07",
"585.9",
"285.1",
"424.0",
"V45.81",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"45.24",
"96.6",
"99.07",
"99.04",
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
8084, 8149
|
4442, 7236
|
291, 402
|
8236, 8246
|
3289, 3289
|
8298, 8306
|
2742, 2759
|
8056, 8061
|
8170, 8215
|
7262, 8033
|
8270, 8275
|
2774, 3270
|
1087, 1270
|
3661, 4419
|
224, 253
|
430, 1068
|
3306, 3644
|
1292, 2565
|
2581, 2726
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,042
| 116,445
|
31080
|
Discharge summary
|
report
|
Admission Date: [**2107-8-10**] Discharge Date: [**2107-8-18**]
Date of Birth: [**2056-7-31**] Sex: M
Service: SURGERY
Allergies:
Erythromycin Base / adhesive tape / Tegaderm
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Abdominal pain, persistent portal vein thrombosis.
Major Surgical or Invasive Procedure:
[**2107-8-10**]: Portal venography and thrombolysis.
[**2107-8-11**]: Portal venography, mechanical portal vein thrombolysis.
[**2107-8-12**]: Gelfoam embolization of right hepatic artery branch.
[**2107-8-12**]: Cholecystectomy and attempted portal vein thrombectomy.
History of Present Illness:
Mr. [**Known lastname 73394**] is a 51 year-old male with a history of Crohn's
disease who was seen in the emergency room at [**Hospital1 18**] on [**2107-7-31**] with right upper quadrant abdominal pain. A CT of the
abdomen and pelvis was performed, which demonstrated moderate
colonic fecal load as well as a partially obstructing thrombus
in the right posterior portal vein, main portal vein, and SMV
before the portal vein confluence. He was discharged home by
the ED and returned again to the ED on [**2107-8-10**]. He once
again was complaining of right upper quadrant abdominal pain and
an ultrasound demonstrated complete portal vein thrombosis.
Past Medical History:
-Crohn's disease
-Non-alcoholic steatohepatitis with transaminemia
-Glucocorticoid associated osteopenia
-Peri-anal fistula
-Nephrolithiasis requiring lithotripsy
-Osteoporosis (spine T-score -3.0)
-Hypogonadotrophic hypogonadism: treated with clomiphene since
[**1-/2105**] and had been taking testosterone supplementation prior
-Toe fracture and spinal compression fracture
-Ileocolectomy (at least 20cm of small bowel and possibly equal
length of colon) [**2103**] after presenting with an obstruction two
years after stopping 6-MP in effort to conceive
Social History:
No EtOH, tobacco, or other drug use.
Family History:
No clotting/bleeding disorders. No DVT or PE.
Physical Exam:
Physical Exam on Admission:
Vitals: T 98, HR 105, BP 123/64, RR 16, O2 100RA
Gen: alert and oriented x3, NAD, lying comfortably on gurney;
skin and sclerae anicteric
CV: RRR, no murmur, neck veins flat
Resp: cta bilaterally, no respiratory distress
Abd: well-healed incision c/w previous surgery; soft, ND, +BS;
mildly TTP in RUQ; negative [**Doctor Last Name **] sign; no fluid wave; liver
and spleen not palpable
Extr: warm, 2+ peripheral pulses bilaterally; calves soft,
[**Last Name (un) 5813**] sign negative
Physical Exam on Discharge:
Vitals: T 97.8, HR 90, BP 134/76, RR 18, 99% O2 on RA.
Gen: Alert, oriented, in NAD.
CV: RRR, no m/r/g.
Resp: CTA bilaterally.
Abd: Soft, non tender, mildly distended throughout. Abdominal
incision clean/dry/intact with steri-strips in place. Resolving
right flank ecchymosis.
Ext: 1+ peripheral edema bilateral lower extremities, TEDs in
place. 2+ peripheral pulses throughout.
Pertinent Results:
[**2107-8-9**] 08:30PM BLOOD WBC-11.6* RBC-4.82 Hgb-14.5 Hct-42.5
MCV-88 MCH-30.1 MCHC-34.1 RDW-13.3 Plt Ct-235
[**2107-8-11**] 05:15PM BLOOD Hct-31.6*
[**2107-8-11**] 07:59PM BLOOD Hct-29.4*
[**2107-8-12**] 02:07AM BLOOD WBC-18.1*# RBC-3.85* Hgb-11.3* Hct-32.3*
MCV-84 MCH-29.5 MCHC-35.1* RDW-13.6 Plt Ct-163
[**2107-8-12**] 02:00PM BLOOD WBC-13.9* RBC-3.08* Hgb-9.3* Hct-25.7*
MCV-84 MCH-30.3 MCHC-36.3* RDW-14.1 Plt Ct-194
[**2107-8-12**] 07:18PM BLOOD Hct-29.2*
[**2107-8-13**] 11:59PM BLOOD Hct-29.0* Plt Ct-112*
[**2107-8-14**] 11:37AM BLOOD Hct-31.0*
[**2107-8-16**] 05:54AM BLOOD WBC-10.0 RBC-3.84* Hgb-11.5* Hct-31.9*
MCV-83 MCH-29.9 MCHC-35.9* RDW-15.2 Plt Ct-154
[**2107-8-17**] 05:03AM BLOOD WBC-9.5 RBC-3.89* Hgb-11.4* Hct-32.7*
MCV-84 MCH-29.3 MCHC-34.9 RDW-15.4 Plt Ct-197
[**2107-8-10**] 03:00AM BLOOD PT-13.5* PTT-22.0 INR(PT)-1.2*
[**2107-8-12**] 02:07AM BLOOD PT-15.7* PTT-21.6* INR(PT)-1.4*
[**2107-8-11**] 02:16PM BLOOD PTT-47.9*
[**2107-8-11**] 07:59PM BLOOD PTT-79.3*
[**2107-8-12**] 02:07AM BLOOD PT-15.7* PTT-21.6* INR(PT)-1.4*
[**2107-8-12**] 11:25AM BLOOD PT-14.3* PTT-22.0 INR(PT)-1.2*
[**2107-8-13**] 07:36PM BLOOD PT-13.6* PTT-25.1 INR(PT)-1.2*
[**2107-8-16**] 05:54AM BLOOD PT-12.6 PTT-26.9 INR(PT)-1.1
[**2107-8-17**] 05:03AM BLOOD PT-15.2* PTT-31.7 INR(PT)-1.3*
.
[**2107-8-18**] 05:30AM BLOOD PT-28.2* INR(PT)-2.7* = ***INR ON
DISCHARGE***
.
[**2107-8-10**] 03:00AM BLOOD Fibrino-533*
[**2107-8-11**] 02:11AM BLOOD Fibrino-559*
[**2107-8-13**] 11:59PM BLOOD Fibrino-556*#
.
Hematologic clotting workup laboratory values:
[**2107-8-10**] 03:00AM BLOOD Fact V-100
[**2107-8-10**] 03:00AM BLOOD ProtCFn-85 ProtSAg-92
[**2107-8-10**] 03:00AM BLOOD ACA IgG-3.9 ACA IgM-2.8
[**2107-8-10**] 03:00AM BLOOD PROTHROMBIN MUTATION ANALYSIS-Test:
Negative
.
[**2107-8-9**] 08:30PM BLOOD Glucose-186* UreaN-15 Creat-1.0 Na-135
K-4.4 Cl-99 HCO3-27 AnGap-13
[**2107-8-12**] 03:12PM BLOOD Glucose-133* UreaN-20 Creat-1.3* Na-141
K-5.3* Cl-110* HCO3-25 AnGap-11
[**2107-8-17**] 05:03AM BLOOD Glucose-107* UreaN-12 Creat-0.7 Na-139
K-3.7 Cl-106 HCO3-25 AnGap-12
[**2107-8-9**] 08:30PM BLOOD ALT-25 AST-19 LD(LDH)-167 AlkPhos-85
TotBili-0.3
[**2107-8-12**] 03:12PM BLOOD ALT-145* AST-120* CK(CPK)-194 AlkPhos-41
TotBili-1.8*
[**2107-8-13**] 02:20AM BLOOD ALT-283* AST-225* AlkPhos-60 TotBili-0.9
[**2107-8-14**] 03:20AM BLOOD ALT-209* AST-125* LD(LDH)-281* AlkPhos-68
TotBili-1.3
[**2107-8-17**] 05:03AM BLOOD ALT-97* AST-44* AlkPhos-81 TotBili-0.6
[**2107-8-12**] 03:12PM BLOOD CK-MB-3 cTropnT-<0.01
[**2107-8-12**] 11:10PM BLOOD CK-MB-6 cTropnT-<0.01
[**2107-8-13**] 06:14AM BLOOD CK-MB-5 cTropnT-<0.01
[**2107-8-10**] 07:35AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.0
[**2107-8-12**] 03:12PM BLOOD Albumin-2.3* Calcium-7.9* Phos-4.8*#
Mg-1.8
[**2107-8-17**] 05:03AM BLOOD Albumin-2.5* Calcium-7.7* Phos-2.6*
Mg-2.0
[**2107-8-13**] 11:59PM BLOOD Hapto-97
[**2107-8-13**] 11:59PM BLOOD D-Dimer-6140*
.
Imaging and Interventional Radiology:
.
[**2107-8-9**] Abdominal US:
IMPRESSION:
1. No flow demonstrated in the main or left portal veins,
compatible with
thrombosis. Right portal vein not visualized and is also likely
occluded.
2. Echogenic liver, compatible with fatty infiltration; other
forms of
hepatic cirrhosis/fibrosis cannot be excluded.
3. Focal area of fatty sparing adjacent to the gallbladder in
the right lobe.
3. No gallstones or evidence of acute cholecystitis.
.
[**2107-8-10**] CTA abdomen/pelvis:
IMPRESSION:
1. Thrombosis within the splanchnic venous circulation is more
extensive with
thrombus now seen within the main portal vein, left main portal
vein,
anterior/posterior branches of the right main portal vein, and
throughout much
of the SMV. The splenic vein, IVC, and hepatic veins remain
patent.
2. Enhancing soft tissue lesion within the gallbladder fundus
could be a
polyp or adenomyomatosis.
3. Bilateral small renal hypodensities are too small to
characterize but
statistically are simple cysts.
.
[**2107-8-10**] Portal venography:
FINDINGS:
1. Extensive thrombotic occlusion involving the upper SMV, main
portal vein
and right portal vein.
2. Partial cavernous transformation of the portal vein.
3. Patent splenic vein and inferior mesenteric vein.
4. Prominent coronary vein.
IMPRESSION:
Successful percutaneous transhepatic portal venography and
placement of [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 73395**]-[**Doctor Last Name 6632**] 5 French infusion catheter for TPA infusion.
PLAN:
The patient will return to interventional radiology for repeat
venogram and
potential mechanical thrombectomy/thrombolysis on the following
day.
.
[**2107-8-11**] Portal venography:
1. Initial portal venography demonstrated substantial lysis of
thrombus
burden in the main portal vein and in the distal superior
mesenteric vein
relative to the initial procedure performed on [**2107-8-10**].
2. Mechanical thrombectomy and pulse-spray tPA infusion was
performed in the
main portal vein and distal superior mesenteric vein followed by
mechanical
thrombectomy in the left portal vein.
3. Successful recanalization of the left portal vein by
mechanical
thrombectomy alone.
4. Persistent occlusion of the right portal vein at the
conclusion of the
procedure.
.
[**2107-8-12**] CTA abdomen/pelvis:
IMPRESSION:
1. New large volume of complex fluid within the abdomen is
highly concerning for hemoperitoneum given the patient's history
of recent mechanical portal venous/SMV thrombolysis. There is
evidence of several sites of active extravasation involving
hepatic segment V. Small regions of hyperdense fluid and an
associated locule of air within hepatic segment V also reflect
hepatic injury.
2. Persistent thrombosis of the main portal vein, left main
portal vein, and anterior/posterior branches of the right main
portal vein. Partial occlusion of the SMV is also again noted.
The splenic vein remains patent.
3. New bilateral pleural effusions with associated compressive
atelectasis,
right greater than left.
4. Unchanged enhancing lesion in the gallbladder fundus
measuring 9 x 5 mm
could be a polyp or adenomyomatosis, as previously described on
recent CT.
5. Non-obstructive right renal calculi.
.
[**2107-8-12**] Transcatheter embolization:
IMPRESSION: Identification of a region of active extravasation
at the lateral periphery of segment VI of a branch of the right
hepatic artery. Successful embolization with Gelfoam.
.
[**2107-8-13**] CTA abdomen/pelvis:
IMPRESSION:
1. Interval extension of a portal venous clot now extending
three-fourths of the way to the splenic hilum within the splenic
vein. Interval re
canalization of a small branch of the left portal vein.
2. New areas of heterogeneous enhancement in the segment VI and
inferior
portion of segment VII concerning for early infarction.
3. Moderately high-density fluid around the liver could be
postoperative. No areas of active extravasation noted.
Brief Hospital Course:
On presentation to [**Hospital1 18**] on [**2107-8-10**], the patient was once again
complaining of right upper quadrant abdominal pain, and an
ultrasound demonstrated complete portal vein thrombosis (a
progression from the thrombosis of the right posterior portal
vein and a short segment of the SMV seen on his [**2107-8-1**] CT
abdomen during his recent presentation to the ED for abdominal
pain). On [**2107-8-10**] CT scan demonstrated a thrombosed portal vein
including the main, right and left portal veins and extension of
the clot into the superior mesenteric vein. He was
anticoagulated and underwent placement of a transhepatic
catheter in the portal vein by interventional radiology on
[**2107-8-10**] with infusion of TPA. On [**2107-8-11**] he underwent successful
transhepatic percutaneous thrombectomy by interventional
radiology with the AngioJet and additional TPA. Flow was able
to be reestablished in the main portal vein, superior mesenteric
vein and left portal vein. The right portal vein could not be
thrombectomized. Postoperatively, he developed hypotension and
was found on CT scan to be bleeding from a branch of the right
hepatic artery that had been injured at the time of the
percutaneous procedure. He was taken again to interventional
radiology the morning of [**2107-8-12**], where he underwent embolization
of a branch of the right hepatic artery. A CT scan showed a
large amount of blood and clot in the abdomen. The CT further
demonstrated that the right, left and main portal veins were
once again thrombosed with thrombosis of the superior mesenteric
vein as well. Therefore the patient was brought to the
operating room for evacuation of the intra-abdominal blood and
hematoma with attempt at open portal vein thrombectomy on
[**2107-8-12**]. A large amount of old blood and clots were then removed.
Since the porta was quite deep and foreshortened, the
gallbladder was removed for better exposure. A dissection to
identify the portal vein was attempted, however due to extensive
collaterals and few viable planes, the attempt at portal vein
thrombectomy was abandoned due to the risk of proceeding.
Hemostasis was obtained, and Surgicel was used superiorly and
inferiorly. The patient returned to the ICU postoperatively, off
his heparin drip and intubated. While in the ICU his hematocrit
was stabilized with multiple units of blood products. A
postoperative CTA abdomen showed no areas of active
extravasation. His heparin drip was restarted on [**2107-8-15**], he was
successfully extubated, and transferred to the floor. Warfarin
was begun on [**2107-8-16**], for a goal INR of [**3-10**]. His heparin drip
was discontinued [**2107-8-17**], and he was begun on enoxaparin 80 mg
twice a day. Enoxaparin teaching was provided, which the patient
received well. On discharge his INR was therapeutic at 2.7. He
was discharged home on warfarin and enoxaparin. His enoxaparin
and warfarin dosages on discharge were appropriately titrated,
and follow up labs were arranged, which the patient will fax to
Dr.[**Name (NI) 1369**] office for further titration and management of his
anticoagulation regimen going forward. His pain medications were
transitioned from IV to oral when the patient was tolerating a
regular diet. On discharge he was in minimal pain, and was
ambulating independently, tolerating a regular diet.
.
While inpatient, the patient was followed by the
gastroenterology service given his history of Crohn's disease,
and also was seen by the hematology service to asses the cause
of his portal vein thrombosis. His home clomiphene and forteo
were held given their association with clotting, and a
hypercoagulability workup was sent, which was entirely negative
at the time of discharge (see labs above). He will follow up
with hematology as an outpatient for potential further
hematologic testing to determine the underlying cause of his
clotting.
Medications on Admission:
Humira 40mg every other week, clomiphene citrate 50mg qd,
vitamin D2 50,000 U tablet once a week, Lunesta 3mg qhs, Viagra
100mg prn, teriparatide 20mcg sq qhs, tumeric, ursodiol 1500mg
once a day, Align, MVI, omega-3 fatty acids
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
2. Humira 40 mg/0.8 mL Kit Sig: One (1) dose Subcutaneous every
2 weeks: Resume on Sunday [**8-21**].
3. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
4. ursodiol 500 mg Tablet Sig: Three (3) Tablet PO at bedtime.
5. Lunesta 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for insomnia.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
8. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day): Use evening of [**8-18**] only.
Disp:*10 syringes* Refills:*0*
9. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: Take
at same time in early evening.
Disp:*150 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Portal Vein Thrombus with extension to the SMV.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills,
increased abdominal pain. Monitor for signs of elevated INR from
coumadin to include nosebleed, rectal bleeding, dark/tarry
stool, easy bruising, bleeding that won't stop.
.
Have labs drawn on Monday [**8-22**]. Have results faxed to Dr
[**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 22248**]. Dr [**Last Name (STitle) 4727**] office will follow up
with you regarding any dosage changes and time for next blood
draw.
.
No heavy lifting greater than 10 pounds until notified you may
do so. For now, walking is your best exercise. Timeline for
increasing intensity of exercise is dependent on your progress.
Walking is an excellent exercise for now and is highly
encouraged.
.
No driving if taking narcotic pain medication
You may shower, allow water to run over incision and pat area
dry. No lotions or creams to incision area.
Avoid green/leafy [**Last Name (LF) 73396**], [**First Name3 (LF) 691**] multi-vitamin with Vitamin K
in it. These foods and Vitamin K can alter and bind your
coumadin leaving you with a lower INR and increased risk of clot
extension.
Followup Instructions:
Labs at [**Hospital Ward Name 23**] Building Outpatient Lab Friday [**8-19**]
Labs at [**Hospital Ward Name 1826**] Building [**Location (un) 436**] Saturday [**8-20**] at 8 AM
....
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Last Name (Titles) 23**], [**Location (un) **];
Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2107-8-23**] 10:20
...
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PhD [**Hospital Unit Name **], [**Last Name (NamePattern1) **], [**Location (un) 86**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2107-8-24**] 2:00
...
[**2107-10-5**] 11:00a [**Last Name (LF) **],[**First Name3 (LF) **] I.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
...
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2107-9-27**]
1:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2107-8-18**]
|
[
"458.29",
"998.2",
"565.1",
"555.2",
"V13.51",
"571.8",
"790.01",
"253.4",
"V58.65",
"789.01",
"733.90",
"564.00",
"557.0",
"452",
"E870.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.11",
"99.10",
"39.31",
"51.22",
"39.79",
"88.47",
"88.64",
"96.57",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
14964, 14970
|
9860, 13769
|
354, 625
|
15062, 15062
|
2966, 9837
|
16415, 17548
|
1961, 2009
|
14048, 14941
|
14991, 15041
|
13795, 14025
|
15213, 16392
|
2024, 2038
|
2567, 2947
|
264, 316
|
653, 1311
|
2052, 2539
|
15077, 15189
|
1333, 1891
|
1907, 1945
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,916
| 170,444
|
25586
|
Discharge summary
|
report
|
Admission Date: [**2176-7-9**] Discharge Date: [**2176-7-16**]
Date of Birth: [**2093-3-27**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
found unresponsive at home
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is an 83 year-old woman of unknown handedness with
a past medical history including hypertension, DM, and stroke
who was initially evaluated at [**Hospital6 2561**] after she
was found to be unresponsive and was transferred to the [**Hospital1 18**]
after she was found to have a large left intraparenchymal
hemorrhage.
According to the patient's live-in male fried, she was last
known well at about 2:30 am, at which time she was watching
television.He went into the kitchen for a short while and
returned to find her "unresponsive." He tried calling her name
and moving her around without appreciable effect.
Accordingly,he pressed lifeline. She was reportedly intubated
in the field in the absence of sedation.
She was initially transported to [**Hospital6 2561**] for
evaluation. Initial vital signs were recorded as T96.5, p86, bp
156/95, O2 sat 100% on CMV 500/12/5/50%. An initial exam
described pupils of fixed at 3mm, roving eye movements,
decerebrate posturing, and downgoing toes bilaterally. A
non-contrast CT of the head demonstrate a large left
intraparenchymal hemorrhage. She was given mannitol 100 mg/
3minutes and keppra 500 mg IV x 1 prior to transfer to the
[**Hospital1 18**].
Past Medical History:
Review of systems is negative for preceding headache, fevers,
and
illness per the patient's significant other.
.
PMHx (per notes and significant other):
- CAD, s/p CABG
- HTN
- DM
- bilateral CEAs
- Stroke (left occipital per imaging)
- right knee surgery
Social History:
- lives [**Last Name (un) 5767**] significant other
- does not work
- has one son to whom she is reportedly not close/in contact
- Tobacco: sig other denies
- EtOH: sig other denies
- Recreational Drug Use: sig other denies
Family History:
- negative for stroke
Physical Exam:
Vitals: T: 36.5 P: 102 R: 20 BP: 205/59 SaO2: 100%
CMV: FiO2 100 TV 500 PEEP 5
General: Does not arouse to voice or noxious stimulation
HEENT: intubated
Cardiac: Distant. Regular rate, normal S1 and S2.
Pulmonary: slightly coarse breath sounds bilaterally anteriorly.
Abdomen: Obese. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: cool.
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: Does not arouse to loud voice, noxious
stimulation.
Cranial Nerves:
* I: Olfaction not evaluated.
* II: PERRL 3 mm and unreactive to light.
* III, IV, VI: roving eye movements.
* V, VII: corneal intact on left, possible subtle response on
right (but minimal)--> absent upon re-evaluation
* IX, X: gag intact
* Doll's Eyes Maneuver: eyes roving
Motor:
* Bulk: No evidence of atrophy.
* Tone: slight rigidity in upper extremities bilaterally.
Strength:
* Left Upper Extremity: no spontaneous movement
* Right Upper Extremity: no spontaneous movement
* Left Lower Extremity: no spontaneous movement
* Right Lower Extremity: no spontaneous movement
Reflexes:
* Babinski: extensor bilaterally
Sensation:
* Noxious: decerebrate posturing to stimulation on right,
performs what looks like decorticate posturing to stimulation on
left but does appear to withdraw from source of stimulation when
performed with UE in decorticate position. Triple flexion in
lower extremities bilaterally.
Pertinent Results:
na 133, k 5.5, cl 94, bicarb 26, glu 190
wbc 19.1, hct 29.2 (mcv 87), plt 365
coags nl
lactate 3.9
.
IMAGING
Non-contrast CT of the Head: reviewed with radiology
- evidence of large intraparenchymal hemorrhage in the left
frontal, temporal, parietal lobes with intraventricular
extension
- subfalcine herniation
- temporal horns prominent suggestive of early uncal herniation
- 6 mm midline shift
- possible former left occipital stroke
Brief Hospital Course:
On [**2176-7-9**] the pt was admitted to the neurosurgery service after
rpesenting to the ER from an OSH. She was found unresponsive
initially in bed and found to have a large L basal ganglia bleed
with intraventricular extension. The grave prognosis was
discussed with family who made patient DNR/DNI but will remain
intubated. She remained intubated without any issues. With
ongoing discussions/updates with the family. It was ultimately
decided to make her comfortable and she expired at 0105 on
[**2176-7-16**]
Medications on Admission:
- mvi po daily
- triam/hctz 37.5/25 mg po daily
- metoprolol 100 mg po qam, 50 mg po qhs
- gabapentin 100 mg po QID
- tylenol prn pain
- caltrate 600 mg po daily
- tramadol 50 mg po bid
- glyburide 2.5 mg po daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal hemmorrhage with intraventricular extension
Discharge Condition:
Expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2176-7-16**]
|
[
"250.00",
"438.89",
"780.39",
"414.00",
"348.4",
"585.9",
"584.9",
"431",
"403.90",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
4900, 4909
|
4087, 4607
|
345, 352
|
5013, 5022
|
3626, 4064
|
5075, 5110
|
2148, 2171
|
4871, 4877
|
4930, 4992
|
4633, 4848
|
5046, 5052
|
2186, 2557
|
279, 307
|
380, 1611
|
2688, 3607
|
2596, 2672
|
2581, 2581
|
1633, 1890
|
1906, 2132
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,617
| 128,104
|
55063
|
Discharge summary
|
report
|
Admission Date: [**2154-9-17**] Discharge Date: [**2154-9-27**]
Date of Birth: [**2073-10-26**] Sex: F
Service: SURGERY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 32912**]
Chief Complaint:
Pancreatic mass
Major Surgical or Invasive Procedure:
[**2154-9-17**]:
PROCEDURES:
1. Exploratory laparoscopy.
2. Laparoscopic liver biopsy x2.
3. Exploratory laparotomy.
4. Pylorus-sparing radical pancreatoduodenectomy requiring
7 hours - 22 modifier.
5. Cholecystectomy.
6. End-to-side ductal mucosa pancreaticojejunostomy, no
stent.
7. Hepaticojejunostomy.
8. Antecolic duodenojejunostomy.
9. Placement of gold fiducials.
10.Transgastric feeding jejunostomy.
History of Present Illness:
Mrs. [**Known lastname **] is an 80-year-old woman who first developed
obstructive jaundice in late [**Month (only) 205**]. At that time, a plastic
stent was inserted. Recently, Mrs.[**Doctor Last Name 112378**] quality of life
has been excellent. Her weight is stable. Her energy level has
improved after the placement of her stent, and her functional
status has returned to [**Location 213**].
Mrs. [**Known lastname **] completed her preoperative cardiology evaluation
with Dr. [**Last Name (STitle) **]. She has not had any symptoms of ischemic
heart disease, and has stable left ventricular function with an
ejection fraction in the mid 40s. Dr. [**Last Name (STitle) **] is holding her
Lipitor and the enalapril at the current time and cleared her
for surgery.
Past Medical History:
Persistent proteinuria associated with type 2 diabetes mellitus
HTN
CORONARY ARTERY DISEASE - NATIVE CORONARY ARTERY(aka CAD)
PRE-DIABETES, diet controlled
DIASTOLIC DYSFUNCTION, LEFT VENTRICLE
HYPERCHOLESTEROLEMIA
OSTEOPENIA
Chronic constipation
ANEMIA - IRON DEFIC, UNSPEC
ESOPHAGEAL REFLUX
DEPRESSIVE DISORDER
Kidney stone
CKD (chronic kidney disease) stage 2, GFR 60-89 ml/min
DM W NEUROLOGIC COMPLIC
Myocardial infarct, old, "silent"
Proteinuria
RECTAL PROLAPSE
ATROPHIC VAGINITIS
*note atrius records list gallstone but pt denies
Social History:
quit [**2127**] 2PPD for 25yrs. Single no children lives alone. Denies
other drug use.
Family History:
Father with leukemia and type 2 diabetes, mother with CHF.
Brother with COPD.
Physical Exam:
Prior Discharge:
VS: 98.5, 88, 117/63, 12, 97% RA
GEN: NAD, Very pleasant
CV: RRR, no m/r/g
PULM: Diminished bilateraly on bases
ABD: Bilateral subcostal incision with staples, left site packed
with moist-to-dry dressing. GJ-tube currently capped and site
c/d/i with dressing. Old RLQ JP site x 2 with DSD and c/d/i.
EXTR: Warm, + PP, no c/c/e
Pertinent Results:
[**2154-9-23**] 10:35AM BLOOD WBC-9.1 RBC-3.69* Hgb-11.9* Hct-37.3
MCV-101* MCH-32.3* MCHC-31.9 RDW-14.2 Plt Ct-218
[**2154-9-25**] 12:50PM BLOOD Glucose-141* UreaN-13 Creat-0.7 Na-136
K-3.6 Cl-96 HCO3-31 AnGap-13
[**2154-9-17**] 11:08PM BLOOD ALT-64* AST-145* CK(CPK)-301* Amylase-35
TotBili-1.1
[**2154-9-25**] 12:50PM BLOOD Albumin-3.1* Calcium-8.5 Phos-2.6* Mg-1.9
[**2154-9-27**] 09:19AM ASCITES Amylase-7
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 112379**],[**Known firstname **] [**2073-10-26**] 80 Female [**-1/4105**]
[**Numeric Identifier 112380**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. [**Hospital1 **]/rate
SPECIMEN SUBMITTED: segment 3 liver biopsy, common hepatic duct,
pancreatic neck body junction, gallbladder, common hepatic
artery lymph node, whipple specimen.
Procedure date Tissue received Report Date Diagnosed
by
[**2154-9-17**] [**2154-9-17**] [**2154-9-20**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl
DIAGNOSIS:
I. Pancreas, duodenum, and bile duct segment, Whipple procedure
(A-AB):
A. Pancreatic adenocarcinoma with invasion of the duodenal wall
(pT3); see synoptic report.
B. Twenty lymph nodes with no carcinoma seen (0/20-pN0).
C. Chronic pancreatitis.
D. Duodenum with focus of heterotopic pancreas within the wall.
II. Liver, "segment 3", biopsies (AC-AD):
A. Biopsy designated as right shows focal bile ductular
proliferation, cholestasis, and associated mixed inflammation;
no carcinoma seen.
B. Biopsy designated as left shows more pronounced neutrophilic
aggregation among multiple foci of bile ductular proliferation
consistent with bile duct hamartoma; no carcinoma seen.
III. Common hepatic duct (AE-AG):
Bile duct segment with marked edema and surface erosion and
ulceration; no carcinoma seen.
IV. Pancreatic neck/body junction, Whipple procedure (AH-AI):
Changes of chronic pancreatitis; no carcinoma seen.
V. Lymph node, common hepatic artery (AJ-AK): One lymph node
with no carcinoma seen (0/1).
VI. Gallbladder ([**Doctor Last Name **]):
A. Cholelithiasis, mixed type.
B. Chronic cholecystitis with autolysis of the epithelium.
Pancreas (Exocrine): Resection Synopsis
Staging according to American Joint Committee on Cancer Staging
Manual -- 7th Edition, [**2150**]
MACROSCOPIC
Specimen Type: Pylorus sparing pancreaticoduodenectomy, partial
pancreatectomy.
Tumor Site: Pancreatic head.
Tumor Size Greatest dimension: 1.8 cm.
Other organs/Tissues Received: Gallbladder.
MICROSCOPIC
Histologic Type: Ductal adenocarcinoma.
Histologic Grade: G2: Moderately differentiated.
EXTENT OF INVASION
Primary Tumor: pT3: Tumor extends beyond the pancreas but
without involvement of the celiac axis or the superior
mesenteric artery.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 21 (includes separately submitted lymph
node).
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins:
Margins uninvolved by invasive carcinoma:
Distance from closest margin: 5 mm. Specified margin:
Uncinate process.
Venous/Lymphatic vessel invasion: Present.
Perineural invasion: Present.
Additional Pathologic Findings: Pancreatic intraepithelial
neoplasia, low grade, chronic pancreatitis.
Clinical: Pancreatic duct cancer.
Brief Hospital Course:
The patient with newly diagnosed with pancreatic mass was
admitted to the Surgical Oncology Service for evaluation and
treatment. On [**2154-9-17**], the patient underwent pylorus-sparing
radical pancreatoduodenectomy, cholecystectomy, placement of
gold fiducials and transgastric feeding jejunostomy, which went
well without complication (reader referred to the Operative Note
for details). Post operatively, patient was extubated and
transferred in ICU for hypotension. In ICU she required short
period of pressors support, was transfused with 1 unit of pRBC,
received IV Albumin and crystalloids. The patient's blood
pressure improved and she was transferred to the floor on POD #
2. The patient was hemodynamically stable.
Neuro: The patient received Bupivacaine/Dilaudid via epidural
catheter, with good effect and adequate pain control. When
tolerating oral intake, the patient was transitioned to oral
pain medications.
CV: Brief episode of hypotension immediately post op, which
required placement in ICU for pressors support. Pressors were
weaned off on POD # 1, blood pressure improved. On the floor,
patient had intermittent episodes of orthostatic hypotension,
which also improved prior discharge.
Pulmonary: Post op, patient received 1 units of pRBC, 4 vials of
Albumin and 3600 cc of crystalloids for hypotension. She
developed bilateral pulmonary effusions secondary to fluid
overload and was required supplemental O2. Patient's fluids were
discontinued and she received Lasix x 2. Patient's O2 was weaned
off, early ambulation and incentive spirrometry were encouraged
throughout hospitalization. Prior discharge patient's
respiratory status improved, she is no longer require
supplemental O2.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced to clears on POD # 4 and to fulls on
POD # 5. The patient developed post op ileus and was started on
aggressive bowel regiment and she was made NPO. Tubefeed was
started on POD # 6 and was advanced to goal on POD # 8. The
patient was able to move her bowels on POD # 8, her diet was
advanced to full and was well tolerated. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Wound was evaluated
daily and small amount of purulent drainage was noticed on POD #
6. Several staples were removed and patient's wound was packed
with moist-to-dry dressing. The patient remained afebrile with
WBC within normal limits. She will continue to change her
dressing [**Hospital1 **] while in Rehab.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: As above. Prior discharge HCT was stable.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a full
liquids diet, ambulating with assist, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
Atenolol 12.5 mg PO QD, Aspirin 81 mg PO QD, NTG 0.4mg PRN (not
requiring), Escitalopram 10mg PO QHS, Multivitamin
Discharge Medications:
1. Acetaminophen 650 mg PO QID
2. Docusate Sodium 100 mg PO BID
3. Escitalopram Oxalate 10 mg PO QHS
4. Insulin SC
Sliding Scale
Fingerstick QID
Insulin SC Sliding Scale using REG Insulin
5. Metoclopramide 10 mg PO QIDACHS
6. Multivitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-31**] tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
8. Pantoprazole 40 mg PO Q24H
9. Psyllium 1 PKT PO TID
10. Senna 1 TAB PO BID
11. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 2199**]
Discharge Diagnosis:
1. Ductal adenocarcinoma
2. Post op hypotension
3. Bilateral pleural effusions
4. Cholelithiasis, mixed type.
5. Chronic cholecystitis
6. Post op ileus
7. Wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] for surgical
resection of your pancreatic mass. You have done well in the
post operative period and are now safe to go in Rehab to
complete your recovery with the following instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-9**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*The VNA nurse will change you dressing twice a day
.
G-tube: Keep capped.
.
J-tube: Flush with 30 cc of tap water Q6H. Please monitor for
signs and symptoms of infection, dislocation.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2154-10-3**] at 1:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 104214**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2154-9-27**]
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109
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15328
|
Discharge summary
|
report
|
Admission Date: [**2141-5-24**] Discharge Date: [**2141-6-6**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Face, Left arm and breast swelling
Major Surgical or Invasive Procedure:
Intravenous Catheterization of SVC/IVC.
History of Present Illness:
23 year old woman with ESRD, SLE, recently placed PD catheter
who presents with periorbital swelling and Hypertensive urgency.
Of note she was recently admitted for tongue swelling on
[**4-7**]. At that time she was treated with Solu-Medrol,
famotidine and Benadryl in the emergency room, which was
continued for a total of three doses on the floor. The swelling
improved throughout her stay. She had been on both an ACE, [**Last Name (un) **]
and DRI at home, which she has been taking for many years.
Patient states that the tongue swelling is most likely due to a
sardine allergy. However, she had recently added Dilaudid to her
medications following PD catheter placement, so allergy to
Dilaudid was also considered. The ACE, [**Last Name (un) **] and DRI were held on
the day of admission for ?angioedema but restarted on day of
discharge without incident so she was discharged on them.
She returned to the ED [**5-24**] with acute onset bilateral eye
swelling since night of [**5-23**]. VS T 97.9 HR 78 BP 231/120 RR 20
Sat 100% RA. She was given IV solumedrol 125iv, benadryl IV, and
pepcid. Her BP was noted to be 240's despite labetolol 900mg po,
then labetolol 20mg iv x2 so was started on labetolol gtt:
highest dose 2mg/min. This was stopped after 35 minutes, in
favor of nitro gtt. States compliant with meds at home.
Patient was comfortable on admission to the MICU. Notes pain in
abdomen 7.5/10 related to PD catheter placement (has had since
then), improves with morphine. Also notes swelling in eyes/face
since last night (has had in the past but never this severe,
always goes away on its own). She feels whole body is swollen
slightly but no more upper extremities than lower. She denies
visual changes, HA, change in hearing/tinitus, congestion, sore
throat, cough, SOB, chest pain, palpitations, nausea, vomitting,
diarrhea. Has baseline constipation (takes stool softener), last
BM 2 days ago (normal), no melena, brbpr, diarrhea. No dysuria,
hematuria, change in uop, increase weight or size (clothes fit
the same), tingling, numbness, weakness, discoordination, rash,
joint pain, recent travel, ill contacts, exotic foods. She notes
episode of throat swelling over weekend resolved, seemed to be
related to sardine eating (not new for her).
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**]
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
to be due to the posterior reversible leukoencephalopathy
syndrome
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
PAST SURGICAL HISTORY:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient
denies past or current alcohol, tobacco, or illicit drug use.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
ON ADMISSION:
VS: T 98.0 BP 187/120 HR 77 RR 17 Sat 100% on RA
GEN: NAD
HEENT: + periorbital edema, AT, NC, PERRLA, EOMI, no conjuctival
injection, anicteric, OP clear, MMM
Neck: supple, no LAD, no carotid bruits
CV: RRR, nl s1, s2, II/VI HSM at R/L USB, S4, no rub
PULM: CTAB, no w/r/r with good air movement throughout
ABD: soft, mildly tender at PD catheter, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL, no femoral bruits, trace
non-pitting edema
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated. No
asterixis
PSYCH: appropriate affect
ON [**6-6**]:
-General: AAOx3, in NAD.
-VS: Tc: 95.2, Tmax (24hrs): 97.8 BP: 172/98 (80/43, 240/110 on
[**5-30**]; 120/70, 218/120 over last 24 hrs), P: 80 (80, 98), RR: 16,
O2: 98% RA.
-HEENT: Head NC, AT. MMM. Face, Neck swollen: equal bilaterally.
-Neck: Supple, No JVD, No tracheal deviation.
-CV: RRR, S1,S2. Grade II/XII holosystolic murmur radiating to R
carotid. JVP not elevated. No S4.
-Lungs: CTAB, no w/r.
-Abdomen: +BS, soft, nontender.
-Extremities: Warm, no lower extremity edema. L arm appears
slightly less swollen than yesterday. Dorsalis pedis and radial
pulses strong bilaterally. No evidence of rashes, ulcers or
varicose veins.
-Breast: L breast still swollen relative to R, but diminished
from initial presentation of swelling. Skin no longer tense.
Pertinent Results:
WBC-3.9* RBC-2.19* Hgb-6.6* Hct-20.4* MCV-93 MCH-30.3 MCHC-32.4
RDW-19.7* Plt Ct-114*
- Neuts-52.8 Lymphs-39.9 Monos-5.0 Eos-2.0 Baso-0.2
PT-20.5* PTT-89.9* INR(PT)-1.9*
Fibrino-268
Thrombn-37.4*#
AT III-92 ProtCFn-65* ProtCAg-PND ProtSFn-68
Glucose-105 UreaN-62* Creat-8.1* Na-139 K-4.5 Cl-109* HCO3-17*
ALT-14 AST-35 LD(LDH)-254* CK(CPK)-176* AlkPhos-137*
Amylase-277* TotBili-0.4
Calcium-6.8* Phos-5.9* Mg-1.5*
Hapto-90
Homocys-37.8*
PTH-1603*
UA: Color Straw Appear Clear SpecGr 1.009 pH 6.0 Urobil Neg Bili
Neg Leuk Sm Bld Neg Nitr Neg Prot 30 Glu Neg Ket Neg RBC 0-2 WBC
[**11-30**] Bact Few Yeast None Epi 0-2
U Tox: Urine Opiates Pos;Urine Benzos, Barbs, Cocaine, Amphet,
Mthdne Negative; UCG: Negative
STUDIES:
Portable CXR [**5-24**]: Small left pleural effusion with associated
atelectasis, although early pneumonia cannot be excluded. No
CHF.
ECG [**5-24**]: NSR (87), nl axis and intervals, TWI V5-V6, no change
from [**5-20**].
MRA [**5-24**]:
1. Occlusion of the right internal jugular vein below the
mandible which communicates with external jugular and subclavian
vein. Appearance suggest chronic disease.
2. Patent SVC.
3. Patent but narrowed left internal jugular vein but left
brachiocephalic
vein not visualized (possibly from technique).
4. Bibasilar atelectasis
US upper extremity [**5-26**]:
[**Doctor Last Name **]-scale, color and Doppler son[**Name (NI) 1417**] of the left IJ,
subclavian,
axillary, brachial, basilic, and cephalic veins were performed.
There is
normal flow, compression, and augmentation seen in all of the
vessels.
IMPRESSION: No evidence of deep vein thrombosis in the left arm.
MRV Chest [**5-30**]:
1. Limited study which demonstrates a chronically occluded and
completely
atrophic left brachiocephalic vein.
2. Right internal jugular vein not identified, likely
chronically occluded. Left internal jugular vein is very
diminuitive as before.
3. Large right external jugular vein emptying into the
subclavian vein.
Venogram [**5-31**]:
1. Occlusion of the left brachiocephalic vein at the junction of
the subclavian and internal jugular with extensive collateral
formation consistent with chronic obstruction.
2. Patent left brachial, axillary, subclavian, and distal
internal jugular
vein.
3. Unsuccessful attempt to recanalize the left brachiocephalic
vein using a catheter and guidewire technique.
Brief Hospital Course:
Ms. [**Known lastname **] is a 23yo woman with a history of SLE, ESRD and HTN
who presented with acute onset bilateral facial swelling and
hypertensive urgency, which developed into L sided facial, L arm
and L breast swelling throughout her stay.
# L facial/arm and breast swelling: Initially this presented
only as facial swellingand ACE and [**Last Name (un) **] were held for possible
angioedema, however holding medications nad giving benadryl
failed to relieve symptoms. We then suspected possible venous
thrombus with occlusion leading to edema. US of upper left
extremity failed to show evidence of acute occlusion, but showed
R IJ occlusion consistent with prior studies. MRA could not
visualize the L brachiocephalic vein. Repeat MRV suggested
chronic occlusion of the L brachiocephalic vein. Venogram
performed on [**5-31**] showed extensive collateralization of the L
brachiocephalic vein with patent flow through these collaterals.
Intervention on the L brachiocephalic vein was attempted by IR,
but was unsuccessful. The primary team, renal team, [**Month/Year (2) **]
team and hematology team suspect that the most likely etiology
of her swelling is an acute-on-chronic (now occlusive) thrombus
of the L brachiocephalic vein. For this reason, the patient was
placed on Heparin IV as a bridge to coumadin anticoagulation
with goal INR [**2-12**]. Per consult with hematology the patient is to
remain on this regimen for at least 6 months, and will then
revisit as an outpatient the question of possible lifelong
anticoagulation. The patient has had extensive negative testing
for hypercoagulable states, including during this work-up with
negative anticardiolipin, antiphospholipid, Beta-2 glycoprotein
and AT3 antibodies. Protein C and S levels were unremarkable.
Although her clots seem to have all occured in the setting of
lines, her continued thrombosis is likey due to
hypercoagulability from her lupus (in absence of lupus
anticoagulant). Her INR will be followed first by Dr. [**Last Name (STitle) 4883**],
her nephrologist, and then by the coumadin clinic of [**Company 191**]. It
will be especially important that her coumadin be well titrated
given her risk of intracranial bleed with hypertension. This was
communicated tothe patient and she understands and plans to be
compliant with frequent blood draws for INR testing and varying
her coumadin dose as directed.
.
# Hypertension: The patient has chronically labile hypertension,
with frequent episodes of hypertensive urgency over systolic
200, as well as lows as far as the 80s during this admission. It
remains unclear why her blood pressure is so chronically labile.
The hope is that once she starts dialysis this will help to
stabilize her blood pressure, however in the interim various
adjustments were made to her regimen. The patient received
frequent extra doses during her stay (especially of
hydralazine), however, this occasionally causes her blood
pressure to swing too low to tolerate her subsequent standing
dose of medication. We stopped her Ace and [**Last Name (un) **] as above. We
discharged her to home on a regimen that was reviewed with her
nephrologist, Dr. [**Last Name (STitle) 4883**]. She is discharged on clonidine
patch 0.3mg qweek, labetalol 900mg po tid, nifedipine CR 90mg po
bid, hydralazine 35mg po tid. These medications were reviewed
extensively with the patient and she was given prescriptions for
all meds. She is discharged with home VNA for blood pressure
checks and assistance with meds. She has purchased a portable BP
cuff and will keep a BP diary to bring to subsequent
appointments as well. The importance of BP control, especially
in the setting of new anticoagulation, was discussed extensively
with the patient. Her goal SBP is 140-160 at this time.
.
# ESRD: The patient has ESRD due to lupus nephritis. PD catheter
was placed before admission and the patient received morphine
prn pain at her catheter site. The renal team followed her
closely throughout her stay. She was treated for hypocalcemia as
well as hyperkalemia. Her regimen was changed to calcitriol
0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol
400units po qday, ergocalciferol 50,000 units po qweek for ten
weeks. She plans to start HD within 1-2 weeks of discharge. She
will call [**Doctor First Name 3040**] the PD nurse tomorrow to set up an appointment
to have her catheter flushed and to start PD. She will be
closely followed by Dr. [**Last Name (STitle) 4883**] at PD.
# SLE: The patient was maintained on her home dose of prednisone
15mg po qday throughout her stay. She has no symptoms of acute
SLE flare, so her nephrologist and outpatient physicians may
attempt to wean this down as an outpatient.
.
# abnormal pap smear: The pt is noted to have an abnormal pap
and colpo two years ago with CIN 2 and high risk HPV. This has
never been repeated, as the patient failed to schedule
appointments and DNK others. We discussed the importance of
following this up with the patient, and at her request scheduled
her for an ob/gyn appointment as an outpatient shortly after
discharge.
The patient was discharged to home with a clear plan to call
[**Doctor First Name 3040**], the PD nurse on the day after discharge to set up an
appointment to have her PD catheter flushed later this week, as
well as to set a date to start her PD. She will see Dr. [**Last Name (STitle) 44539**]
in [**Hospital **] clinic within the next 1-2 weeks. She will have her blood
drawn for INR in two days and faxed to Dr. [**Last Name (STitle) 4883**],
subsequently this will be faxed to the [**Company 191**] coumadin clinic and
her dose will be adjusted for INR [**2-12**]. We have also given her
the phone number to call [**Company 191**] and establish care with a new PCP,
[**Name10 (NameIs) 3**] her old PCP has now graduated and her complex management
makes a PCP [**Name Initial (PRE) 44540**]. (Her PCP must be at [**Company 191**] for the [**Company 191**]
coumadin clinic to follow her as well.) Finally, the patient was
given an appointment with ob/gyn to have a follow up pap smear,
as her last pap and colpo two years ago showed CIN 2 with high
risk HPV and this has not been followed.
The above plan and appoitnments were reviewed with the pt and
her mother extensively. [**Name2 (NI) **] medication hcanges were also
extensively reviewed.
Medications on Admission:
Hydralazine 50 mg PO TID
Labetalol 900 mg PO TID
Nicardipine 60 mg Sustained Release PO once a day
Cinacalcet 30 mg PO DAILY: she is not sure if taking
Calcium Acetate 667 mg PO TID W/MEALS
Sodium Bicarbonate 1300 mg PO TID
Aliskiren 150 mg PO once a day (was never taking)
Pantoprazole 40 mg PO once a day
Valsartan 320mg PO DAILY
Lisinopril 40 mg PO bid
Clonidine 0.3 mg/24 hr Patch Weekly QSUN: not sure when last
placed
Prednisone 15 mg PO DAILY
Morphine 15 mg Tablet PO Q6H as needed
Ergocalciferol (Vitamin D2) 50,000 unit Capsule daily: states
not taking
Epo 4,000 units M/W/F: states not taking
colace
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
Disp:*4 Patch Weekly(s)* Refills:*2*
3. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
5. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO once
a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO qwednesday (): for 10 weeks.
Disp:*10 Capsule(s)* Refills:*0*
8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times
a day.
Disp:*270 Tablet(s)* Refills:*2*
9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
10. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: dose
to be adjusted by coumadin clinic.
Disp:*120 Tablet(s)* Refills:*2*
11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
12. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for itching.
Disp:*50 Capsule(s)* Refills:*0*
13. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
15. Morphine 15 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
16. Outpatient Lab Work
Please have blood drawn on Friday, [**6-9**] for PT/INR. Please have
result faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you
to adjust your coumadin (also called warfarin) dose as needed.
17. Outpatient Lab Work
Please have blood drawn on Monday [**2141-6-12**] for PT/INR and twice
per week thereafter until told by coumadin clinic that you can
decrease lab draws. Please have result faxed to the [**Hospital1 18**]
coumadin clinic at [**Telephone/Fax (1) 3534**]. They will call you to adjust
your coumadin (also called warfarin) dose as needed.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnoses:
Malignant Hypertension (Hypertensive Urgency)
Acute Exacerbation of Chronic Left Brachiocephalic vein
occlusion
Anemia
Secondary Diagnoses:
SLE
ESRD
Hypertrophic Cardiomyopathy
Thrombocytopenia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted and treated for an acute exacerbation of a
chronic left brachiocephalic vein occlusion (a chronically
obstructed large vein closed off entirely) and hypertensive
urgency (very high blood pressure). We attempted to remove the
clot in your left brachiocephalic vein, but were unable to do
so. You have been started on long-term Coumadin (also called
warfarin) therapy to prevent future blood clots and to allow
natural dissolution of your current blood clot.
Please change your medicines to only those you are given here!
There were many changes and it is very important that you stick
to the medication list as you have large, life-threatening
swings in the blood pressure when not taking consistently.
We also treated you for high potassium levels and anemia, and
low vitamin D and calcium levels, which are related to your
kidney failure. Please follow up with Dr. [**Last Name (STitle) 4883**] for long term
treatment.
Please check your blood pressure three times per day and keep a
blood pressure diary to bring with you to all medical
appointments.
Please have your blood drawn on Friday [**6-9**] for PT/INR and faxed
to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you if needed to
adjust your coumadin (warfarin) dose. After that, please have
your blood drawn on Monday [**6-12**] for PT/INR and faxed to the [**Hospital1 18**]
coumadin clinic at [**Telephone/Fax (1) 434**]. They will follow you in a
regular way to adjust your coumadin dose as needed.
MEDICINES FOR BLOOD PRESSURE:
LABETALOL 900mg three times per day (same as before)
HYDRALAZINE 25mg three times per day (lower dose than before)
CLONIDINE PATCH 0.3mg qWednesday (same as before)
NIFEDIPINE SR 90mg twice per day (new medicine!)
**stop taking your lisinopril, nicardipine, Diovan and
Aliskerin!**
MEDICINES FOR RENAL FAILURE:
ERGOCALCIFEROL [**Numeric Identifier 1871**] units pill every Wednesday (same as before)
CHOLECALCIFEROL 400 units every day (new)
CALCITRIOL 0.25 mg every day (new)
SODIUM BICARBONATE 1300mg once per day (less often then before)
** stop taking your calcium acetate (phoslo), cinecalcet, and
epo injection (you'll get it at peritoneal dialysis only)**
OTHER MEDICINES:
PANTOPRAZOLE 40mg every day (same as before)
PREDNISONE 15mg every day (same as before)
MORPHINE 15mg every 6 hrs if needed for pain (same as before)
ATIVAN 1mg as needed for anxiety (same as before)
BENADRYL 25mg every 6 hrs if needed for itch (new)
COLACE 100mg twice per day if needed for constipation(same as
before)
APPOINTMENTS:
**1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on
Friday to flush your dialysis catheter and start dialysis next
week!
2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2141-6-30**] 10:00AM
3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**]
Date/Time: [**2141-6-13**] 9:30AM
**4. Please call [**Hospital3 **] next week to make an
appointment with a new primary doctor. I recommend Dr.
[**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT
IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE
FOLLOWED IN [**Hospital **] CLINIC.
**5. Please have your blood drawn as above. Your coumadin level
will be followed by the [**Hospital 197**] clinic. Their phone # is
[**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**].
If you have increased swelling, fever greater than 101,
shortness of breath, chest pain, or if you at any time become
concerned about your health please contact Dr. [**Last Name (STitle) 4883**] or go to
the nearest ER.
Followup Instructions:
APPOINTMENTS:
**1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on
Friday to flush your dialysis catheter and start dialysis next
week!
2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2141-6-30**] 10:00AM
3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**]
Date/Time: [**2141-6-13**] 9:30AM
**4. Please call [**Hospital3 **] next week to make an
appointment with a new primary doctor. I recommend Dr.
[**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT
IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE
FOLLOWED IN [**Hospital **] CLINIC.
**5. Please have your blood drawn as above. Your coumadin level
will be followed by the [**Hospital 197**] clinic. Their phone # is
[**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**].
Completed by:[**2141-6-17**]
|
[
"284.1",
"789.09",
"251.8",
"276.7",
"403.01",
"459.2",
"287.4",
"453.8",
"458.29",
"252.00",
"585.6",
"285.21",
"787.01",
"425.4",
"795.00",
"582.81",
"710.0",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17824, 17881
|
8308, 14665
|
315, 356
|
18139, 18148
|
5923, 8285
|
22049, 23158
|
4367, 4491
|
15326, 17801
|
17902, 18041
|
14691, 15303
|
18172, 22026
|
3985, 4149
|
4506, 4506
|
18062, 18118
|
241, 277
|
384, 2652
|
4520, 5903
|
2674, 3962
|
4165, 4351
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,191
| 175,029
|
51369
|
Discharge summary
|
report
|
Admission Date: [**2161-4-10**] Discharge Date: [**2161-4-17**]
Date of Birth: [**2098-9-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**2161-4-10**] Aortic Valve Replacement utilizing a [**Street Address(2) 66683**].
[**Male First Name (un) **] mechanical valve
History of Present Illness:
This is a pleasant 62 year old female who was recently diagnosed
with critical aortic stenosis back in [**2161-1-15**] after being
hospitalized initially for shortness of breath and cough.
Cardiac catheterization at that time confirmed aortic stenosis
with a valve area of 0.6cm2 with a peak gradient of 73 mmHg.
Coronary angiography showed a right dominant system and clean
coronary arteries. Since that time, she has experienced multiple
syncopal episodes. She also has required hospitalization earlier
this month for congestive heart failure. Her most recent echo is
from [**2161-3-23**] which revealed severe aortic stenosis with peak and
mean gradients of 113 and 78 mmHg respectively. There was no
aortic insufficiency and only 1+ mitral regurgitation. Her LVEF
was normal, greater than 55%. She now presents for cardiac
surgical intervention.
Past Medical History:
Aortic Stenosis, Congestive Heart Failure, Hypercholesterolemia,
Hypertension, Diabetes mellitus with neuropathy, SLE, Rheumatoid
arthritis, Pseudogout, Asthma, Anxiety, Depression, s/p
Hysterectomy, s/p Right Breast Lumpectomy, s/p Knee Surgery
Social History:
Smoked ~3 cigs/day X 15 years, quit 30 years ago. Admits to only
rare ETOH. Denies recreational drugs. She is married with
children.
Family History:
No premature coronary artery disease
Physical Exam:
Vitals: BP 126/79, HR 98, RR 18
General: obese female in no acute distress
HEENT: oropharynx benign, EOMI, PERRL
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, 3/6 systolic murmur
Lungs: clear bilaterally, slightly decreased at bases
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities, dark lesions left lower
extremity
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2161-3-23**] Carotid Ultrasound - minimal disease of both internal
carotid arteries
[**Last Name (NamePattern4) 4125**]ospital Course:
On the day of admission, Mrs. [**Known lastname 106519**] underwent an aortic valve
replacement with a [**Street Address(2) 66683**]. [**Male First Name (un) 923**] mechanical prosthesis.
The operation was uneventful and she transferred to the CSRU in
stable condition. For further operative details, please see
seperate dictated operative note. Within 24 hours, she awoke
neurologically intact and was extubated. She maintained stable
hemodynamics but was noted to have decreased urine output in the
setting of a rising creatinine. Natrecor was initiated with a
good response. Her creatinine peaked to 2.0. As her renal
function, Natrecor was discontinued and she was transitioned to
intravenous Lasix. Her CSRU course was otherwise uneventful and
she transferred to the SDU on postoperative day three. She
tolerated beta blockade and remained in a normal sinus rhythm.
Her INR was monitored daily and Warfarin was dosed for a goal
INR between 2.0 - 3.0. She temporarily required Heparin for a
subtherapeutic prothrombin time. Over several days, she
continued to make clinical improvements and her renal function
returned to baseline. She was cleared for discharge on
postoperative day seven. At time of discharge, her BP was 113/57
with a HR of 82. Her chest x-ray showed small bilateral pleural
effusions and her oxygen saturations were 97% on room air. All
surgical wounds were clean, dry and intact. She will follow-up
with Dr. [**Last Name (Prefixes) **], her cardiologist and her primary care
physician as an outpatient.
Medications on Admission:
Allopurinol 300 qd, Aspirin 81 qd, Atrovent MDI, Benicar, Prozac
20 qd, Lasix, Glyburide, Humalog and Lantus Insulin, Lipitor 10
qd, Neurontin 400 qd, Plaquenil 200 qd, Albuterol MDI
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
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. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily). Capsule(s)
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
10. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Glyburide-Metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily):
3mg [**4-17**], check INR [**4-18**] with results called to Dr. [**Last Name (STitle) 3314**].
Disp:*90 Tablet(s)* Refills:*2*
13. Insulin Glargine 100 unit/mL Cartridge Subcutaneous
14. Insulin Lispro (Human) Subcutaneous
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 1
weeks: 40mg [**Hospital1 **] x 1 week then resume preop dose of 20mg daily.
Disp:*30 Tablet(s)* Refills:*0*
16. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 1 weeks.
Disp:*14 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Aortic Stenosis - s/p mechanical AVR, Postoperative Acute Renal
Insufficiency, Postop Anemia, Congestive Heart Failure,
Hypercholesterolemia, Hypertension, Diabetes mellitus with
neuropathy, SLE, Rheumatoid arthritis, Pseudogout, Asthma,
Anxiety, Depression,
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**5-20**] weeks - call for appt.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**] in [**3-20**] weeks - call for appt.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**3-20**] weeks - call for appt.
Coumadin to be followed by Dr. [**Last Name (STitle) 3314**]
Completed by:[**2161-5-15**]
|
[
"428.0",
"710.0",
"493.90",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13",
"35.22",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5838, 5889
|
314, 445
|
6192, 6199
|
2237, 2325
|
6518, 6896
|
1761, 1799
|
4138, 5815
|
5910, 6171
|
3931, 4115
|
6223, 6495
|
1814, 2218
|
2376, 3905
|
267, 276
|
473, 1324
|
1346, 1594
|
1610, 1745
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,364
| 169,795
|
37894
|
Discharge summary
|
report
|
Admission Date: [**2153-10-9**] Discharge Date: [**2153-10-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Subdural hematoma after mechanical fall.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
84-year old man with a history of atrial fibrillation on
Coumadin, CAD, decreased EF, PVD, CKD, and anemia, presented to
[**Hospital3 17921**] Center after mechanical fall. Around 4 AM on
[**2153-10-9**] while at home in [**Hospital3 **], he walked with his
walker into the bathroom. He states walker got caught on a rug
and he fell down, hitting the front of his head on the floor,
denies loss of consciousness. The pt called EMS himself and
taken to an outside hospital. His GCS was 15. His initial head
CT showed bilateral mixed density subdural hemorrhage 12 mm on R
and 11 mm on L with no evidence of midline shift and mild
bilateral uncal herniation with partial effacement of
supracellar cistern. Initial INR was > 7 and he was subsequently
transferred to the [**Hospital1 18**] for further care. In ED he was given
profilnine 2700 units, 2 units FFP and vitamin K 10 mg IV. No
h/o prior falls.
Past Medical History:
PMH:
Atrial fibrillation
CAD
Decreased EF
PVD
CKD
Anemia
Ostemoyelitis
PSH:
CABG [**58**] years prior
TURP
Bilateral CEA
Bilateral total hip replacements
Bilateral cataracts
L foot 2nd digit amputation [**8-29**]
Social History:
Lives in [**Hospital3 **]. Uses walker and fell the day before
admission. Denies current or past tobacco use. Rare alcohol use.
No history of illegal substance use. No recent travel. Lives in
[**Location 5450**] NH.
Family History:
No family history of early MI, arrhythmia, cardiomyopathy, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS; 97.8 147/84 90 16 93% RA
Gen: NAD
Skin: superficial abrasion on forehead, bridge of nose with
ecchymoses as well as above upper lip. Scant perioral dry
blood.
Superficial abrasion on bilateral knees.
CV: irregularly irregular, no murmurs
Pulm: CTA anteriorly
Abd: soft, NT, ND
Ext: no edema. Lower left 2nd digit amputated.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact.
No L/R confusion or neglect.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light 2.5mm-->2mm
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**]: Unable to assess [**1-22**] C-collar in place.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. No pronator drift. Strength full power [**4-24**] in R and L
delt, bicep, tricep, WrE, FE, FF, IP, quad, ham, DF, PF.
Sensation: Intact to light touch throughout.
Reflexes: trace and symmetric throughout. Downgoing toes.
Coordination: normal on finger-nose-finger bilaterally
Pertinent Results:
Blood:
[**2153-10-9**] 07:15AM BLOOD WBC-11.0 RBC-3.66* Hgb-11.8* Hct-35.1*
MCV-96 MCH-32.3* MCHC-33.6 RDW-13.8 Plt Ct-272
[**2153-10-9**] Neuts-68.0 Lymphs-24.3 Monos-3.4 Eos-3.9 Baso-0.3
[**2153-10-13**] PT-13.3 PTT-25.7 INR(PT)-1.1
[**2153-10-9**] PT-15.2* PTT-27.9 INR(PT)-1.3*
[**2153-10-9**] PT-58.8* PTT-38.0* INR(PT)-6.6*
[**2153-10-9**] Glucose-150* UreaN-28* Creat-1.5* Na-140 K-4.9 Cl-102
HCO3-29 AnGap-14
[**2153-10-12**] ALT-12 AST-22 LD(LDH)-242 AlkPhos-62 TotBili-0.6
[**2153-10-10**] Calcium-8.4 Phos-2.7 Mg-2.2
Urine:
[**2153-10-12**] URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2153-10-12**] URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-SM
[**2153-10-12**] URINE RBC-261* WBC-15* Bacteri-FEW Yeast-FEW Epi-0
[**2153-10-12**] URINE Hours-RANDOM UreaN-1033 Creat-170 Na-57
[**2153-10-12**] URINE Osmolal-648
Microbiology:
MRSA screen [**2153-10-9**]: negative
Urine culture [**2153-10-14**]: Enterococcus (resistant to
Tetracyclines)
Reports:
Echocardiogram, transthoracic [**2153-10-11**]:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
severe systolic and diastolic dysfunction. Moderate aortic
stenosis. Moderate pulmonary artery hypertension.
CT head w/o contrast [**2153-10-9**] 7:38 a.m.: 1. Extensive
bihemispheric subdural hematoma with hypodense and hyperdense
components, the duration/chronicity of the hematoma cannot be
accurately assessed on the CT study. An MRI, if clinically
indicated, can be done to appropirately date the collections.
Findings are stable since the prior study at OSH.
2. A left frontal lenticular shaped hemorrhage with a
fluid-fluid level, could represent an epidural hematoma, albeit
atypical given location, and lack of fracture.
3. No evidence of intraparenchymal/intraventricular hemorrhage.
CT head w/o contrast [**2153-10-12**]: Overall, minimal change with
redemonstration of extensive bilateral subdural blood.
Brief Hospital Course:
1. Subdural hematoma: The patient initially presented to
[**Hospital3 17921**] Center, where he was found to have bilateral
subdural hematoma with no midline shift but with mild uncal
herniation and partial effacement of supracellar cistern. His
INR was >7 at the time. The patient was transferred to [**Hospital1 18**] for
further management. In the emergency department, his
anticoagulation was reversed with profilnine 2700 units, 2 units
FFP and 10 mg IV Vitamin K. Hydralazine was used to maintain
SBP<140, along with the patient's home carvedilol, terazosin,
and lisinopril. Carvedilol was later discontinued and metoprolol
initiated in the setting of bradycardia (see below). The patient
was monitored by serial neurologic examination and repeat head
CTs. The patient should remain off of Coumadin for at least 4
weeks, and may NOT restart Coumadin until he has been
reevaluated by neurosurgery. The patient will be reevaluated by
neurosurgery in 4 weeks, at which time he will have repeat head
CT. Per neurosurgery, he could start aspirin or subcutaneous
heparin in 1 week, but only if absolutely required.
2. Sinus bradycardia: In the intensive care unit, the patient
had an episode of bradycardia to 20 while sleeping. Blood
pressure and other VS remained stable. The patient's bradycardia
could be related to carvedilol (which he was taking at his home
dose), to his known subdural hematoma, or possible to sleep
apnea and urinary retention. The cardiology service was
consulted and recommended changing carvedilol to metoprolol. He
was seen by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] who did not recommend pacemaker.
3. Non-sustained ventricular tachycardia: After discontinuing
carvedilol, the patient had a 20-beat run of NSVT during which
he was asymptomatic. He was evaluated by cardiology, who
recommended metoprolol and repeat echocardiogram. The
echocardiogram showed systolic and diastolic dysfunction, with
LV EF 30%.
4. Paroxysmal atrial fibrillation: The patient was on warfarin
for PAF. His warfarin was held and his anticoagulation reversed
for subdural hematoma, as above. Per neurosurgery, he needs to
remains off of Coumadin for at least 4 weeks and until
reevaluated by neurosurgery (see above).
5. Chronic systolic and diastolic heart failure: The patient's
cardiac function was evaluated by echocardiogram, which showed
systolic and diastolic dysfunction, with LV EF 30%. Initially,
he was treated with his home regimen of Coreg and lisinopril,
with furosemide held. On [**2153-10-10**], carvedilol was discontinued
in the setting of sinus bradycardia and metoprolol was
initiated. On [**2153-10-10**], furosemide was resumed at the patient's
home dose of 20 mg PO daily, and lisinopril was uptitrated to 20
mg daily.
6. Foley catheter trauma: Patient had a Foley placed in the
Neuro-ICU. Then he pulled out his Foley catheter on [**2153-10-12**],
resulting in frank macroscopic hematuria without clots and
urinary retention with bladder scan >500 cc. We placed Foley
catheter and had urology evaluate him. He pulled catheter
multiple times and required restraints (Pt was delirius at the
time just after ICU). Urine is now clear. We started Flomax and
the plan is voiding trial in a week and replace Foley with
urology follow up if still unable to void. To get an appointment
can call: ([**Telephone/Fax (1) 772**].
7. Delirum: Patient had delirium after ICU stay. It was thought
to be secondarely to subdural hematomas, urinary retention and
ICU. Infectious work up showed very tiny pneumonia and
indeterminate UA, but urine culture grew enterococcus ampicillin
sensitive. Therefore, we started a 7-day course of ampicillin.
Remaining infetious work up was unclear. Currently he waxes and
wanes and is slowly improving. We will continue antibiotics and
re-orienting him. Avoiding narcotics and benzodiacepines.
Medications on Admission:
Carvedilol 3.125 mg [**Hospital1 **]
Niacin 500 mg
Coumadin 5 mg daily
Terazosin 1 mg qhs
Lasix 20 mg daily
Lisinopril 15 mg daily
Alendronate 70 mg q thurs
Discharge Medications:
1. Appointment
[**11-22**] at 1:30 for the CT and 2pm for the office
appointment. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2153-11-22**] 2:00 Please call [**Telephone/Fax (1) 3231**] for any
concerns.
2. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
3. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain or T>100.4.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Five (5)
Tablet PO DAILY (Daily).
10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Ampicillin 500 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 5 days.
14. Urine
Voiding trial 1 week from now and re-place Foley if fails.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Care
Discharge Diagnosis:
Primary:
1. Subdural hematoma
2. Coagulopathy secondary to warfarin therapy
3. Chronic systolic and diastolic congestive heart failure
4. Sinus bradycardia
5. Non-sustained ventricular tachycardia
6. Paroxysmal atrial fibrillation
7. Genitourinary trauma from Foley catheter
Secondary:
1. Chronic anemia
2. Chronic kidney disease
Discharge Condition:
Stable, unsteady in feet, on atrial fibrillation rate
controlled. Tolerating diet with assistance and eating at 90
degrees.
Discharge Instructions:
You came to the hospital after falling at home and were found to
have a subdural hematoma and a very high level of
anticoagulation. You warfarin was held and your anticoagulation
was reversed. You may NOT resume warfarin for at least 4 weeks,
and you may NOT resume warfarin until told to do so by your
neurosurgeons. You will follow up with Dr. [**First Name (STitle) **] (neurosurgery)
in 4 weeks. At that time, you will need to have another head CT
(see below).
In the intensive care unit, you were observed to have a very low
heart rate. For this reason, your Coreg was discontinued, and
you were started on a new medicine called metoprolol. It was
thought that it was secondary to the bleeding in your head,
urinary retention, sleep and possibly sleep apnea. You will need
outpatient follow up with sleep study.
Return to the hospital for changes in mental status, visual
changes, weakness, tingling, numbness, chest pain, difficulty
breathing, or any other symptom that is concerning to you.
Followup Instructions:
You will need to see Dr. [**First Name (STitle) **] for the diagnosis of subdural
hematoma. You will need a CT of the head without contrast before
this appointment. We have made an appointment for you on
[**11-22**] at 1:30 for the CT and 2pm for the office
appointment. Please call [**Telephone/Fax (1) 3231**] for any concerns. Then you
will see Dr. [**First Name (STitle) **] at 2:00. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD
Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2153-11-22**] 2:00
You should stay off anticoagulation fo at least 4 weeks. In 1
week you could potentially start aspirin or subcutaneous heparin
only if extremely needed and directed to do so by your doctors.
Completed by:[**2153-10-18**]
|
[
"443.9",
"599.0",
"852.21",
"E885.9",
"293.0",
"788.29",
"599.72",
"486",
"V58.61",
"867.0",
"V43.64",
"428.42",
"414.00",
"285.21",
"V45.81",
"585.9",
"E941.3",
"E928.9",
"286.9",
"427.31",
"041.04",
"428.0",
"403.90",
"427.89",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10733, 10780
|
5249, 9119
|
304, 311
|
11154, 11279
|
3260, 5226
|
12327, 13091
|
1728, 1841
|
9326, 10710
|
10801, 11133
|
9145, 9303
|
11303, 12304
|
1856, 2197
|
224, 266
|
339, 1242
|
2441, 3241
|
2212, 2425
|
1264, 1479
|
1495, 1712
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,908
| 131,093
|
7689+7690
|
Discharge summary
|
report+report
|
Admission Date: [**2126-3-9**] Discharge Date: [**2126-3-11**]
Date of Birth: [**2075-1-26**] Sex: F
Service:
HISTORY: This is a 51-year-old white female admitted for
syncope.
HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known lastname 27953**] is a 51-year-old
lady who has a two day history of fever, sore throat and
myalgia culminating in her having a syncopal episode after
taking a warm shower with no head injury. She subsequently
spoke with her doctor who recommended she come to the
Emergency Room. In the Emergency Room she had a normal head
CT, EKG and laboratory values but was admitted for
observation on telemetry and during her physical examination
she had a witnessed episode of syncope with hypotension to
the 80's as well as sinus bradycardia with a junctional
escape rhythm. This happened again and she was transferred
to the ICU for further observation. According to the
patient, she had been doing well until the upper respiratory
tract infection the last three days which had been also in
her family. After she woke up she had no post ictal
confusion. She had no chest pain, no palpitations, no
shortness of breath, no diarrhea, no nausea, no vomiting, no
abdominal pain, no abdominal cramping. She did notice sore
throat, nasal congestion and yellow sputum and the fact that
she had been perhaps not taking good po for the past week or
so. She recalled on previous episode of syncope about 6
months prior at an N*Sync concert where she was overwhelmed
by the masses of people and had an episode of syncope during
which her blood glucose was 47 and she was told this was
likely related to that. During this episode her blood
glucose was 102. There was no family history of sudden
cardiac death, no personal history of previous cardiac
problems.
PAST MEDICAL HISTORY: Notable for benign thyroid mass, a
stage III bronchoalveolar carcinoma which was incidentally
discovered during the work-up of the mass, status post right
upper lobe resection as well as chemo radiation ending
approximately 6 months ago, history of gastric bypass. She
has a past surgical history as above.
MEDICATIONS: Temafinen which is an herbal remedy to help
with cold and hot flashes. She also took some calcium
supplements and nothing else.
REVIEW OF SYSTEMS: No dysuria, no hematemesis, no seizures,
no headaches, no rashes, no arthralgias. Other systems
negative or as in HPI.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Notable for no history of sudden cardiac
death.
SOCIAL HISTORY: She worked previously in a bank, currently
working in a Day Care. Has two kids, no drugs, no tobacco,
no alcohol, married.
PHYSICAL EXAMINATION: She was a pleasant woman in no acute
distress. Neck was supple. Blood pressure was 115/60, pulse
95, respiratory rate 18, saturation 97% on room air,
temperature 97. Oropharynx was clear. Neck was supple, no
lymphadenopathy. JVP was less than 10. Lungs were clear
bilaterally. Carotids had no bruits. Heart was regular rate
and rhythm with no murmurs, rubs or gallops. Extremities had
no edema. Neurologically she has a horizontal nystagmus but
no other focal findings. Her CBC was notable for white count
of 3 with a normal differential, hematocrit 41, platelet
count 163,000, normal electrolyte panel. Chest x-ray showed
an elevated right hemidiaphragm but no acute infiltrate.
Head CT was negative.
HOSPITAL COURSE:
1. Syncope: She had no further episodes of bradycardia or
syncope. She was seen by electrophysiology service who felt
this was consistent with a vasovagal episode that she has had
several times now and other than aggressive hydration,
suggested no further intervention. They did recommend an
outpatient echocardiogram given that she had a resting
tachycardia throughout her stay. Again, she had no
recurrences of her bradycardia or syncope.
2. URI/UTI: She had an abnormal urinalysis as well as URI
symptoms and was treated with a five day course of Levaquin.
DISCHARGE DIAGNOSIS:
1. Syncope.
2. Urinary tract infection.
3. Upper respiratory tract infection.
DISCHARGE CONDITION: Excellent.
DISCHARGE PLAN: She is to follow-up with her PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 15505**] and have a follow-up echocardiogram. She has also
been advised to aggressively hydrate herself. If her syncope
should recur, she may benefit from a beta blocker in the
future.
DISCHARGE MEDICATIONS: Levaquin, calcium supplements,
Tylenol and Temafinen.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1569**] 12-684
Dictated By:[**Last Name (STitle) 27954**]
MEDQUIST36
D: [**2126-3-10**] 20:41
T: [**2126-3-13**] 13:44
JOB#: [**Job Number **]
cc:[**Last Name (NamePattern4) 27955**] Admission Date: [**2126-3-9**] Discharge Date: [**2126-3-11**]
Date of Birth: [**2075-1-26**] Sex: F
Service: ICU
HISTORY OF PRESENT ILLNESS: This is a 51-year-old white
woman with a history of lung cancer status post
chemoradiation and surgery who presented with an episode of
syncope. Mrs. [**Known lastname 27953**] had a three day history of fevers
and shortness of breath and a sore throat and myalgias. She
had been fairly well rested at home but had not had good po
intake. She was feeling better on Saturday morning when she
went to take a warm shower and had an episode of syncope and
found herself in the fetal position in the bathtub. No
apparent head injury. She tried to stay at home but was
convinced by her husband to call her doctor who told her to
come to the Emergency Department. In the Emergency
Department she was fine. She had a work-up which included a
negative head CT and a normal electrocardiogram and
electrolytes.
She was admitted for observation on the floor. There, during
a physical examination by the medical students, in which she
was standing up after she had done head to toe walking, she
had an episode of syncope and on her rhythm strips she had
sinus bradycardia to the 40s with a junctional escape rhythm.
This syncopal episode was associated with loss of bowel and
bladder function. She subsequently had a repeat episode in
the ensuing minutes, again, with sinus bradycardia and
junctional escape and was transferred to the Intensive Care
Unit for further observation.
PAST MEDICAL HISTORY: Notable for incidental finding of
bronchial alveolar carcinoma, Stage 3A, status post right
upper lobe resection in [**2125-3-8**]. Also chemotherapy
and radiation finishing about six months ago. History of a
benign thyroid mass. History of morbid obesity, status post
gastric bypass in [**2123**].
ALLERGIES: She has no known drug allergies.
MEDICATIONS: She was on [**Last Name (LF) 27956**], [**First Name3 (LF) **] herbal remedy for hot
flashes, as well as calcium supplementation.
SOCIAL HISTORY: She worked in a bank. Currently works in
DayCare and has two kids. Does not drink, smoke or use
drugs. Is married.
REVIEW OF SYSTEMS: Notable for the lack of dysuria,
hematemesis, seizures, headaches, rashes or arthralgia, chest
pain, shortness of breath and palpitations all lacking. She
did note a runny nose and nasal congestion.
FAMILY HISTORY: Family history of no sudden cardiac death.
PHYSICAL EXAMINATION: She was a pleasant woman in no acute
distress. Blood pressure 115/60. Pulse of 95. Respiratory
rate of 18, saturating 97% on room air. Temperature of 97.
Oropharynx was clear. There was no neck lymphadenopathy. No
conjunctival injection. Carotids were clear of bruits.
Cardiac exam revealed a normal S1, S2 with mild tachycardia.
There was no murmurs, rubs or gallops. No abdominal heart
sounds. Lungs were clear throughout. Abdomen was soft,
nontender with no hepatosplenomegaly. Extremities had no
edema. Her neurological exam was notable for horizontal
nystagmus. She was otherwise nonfocal.
LABORATORY EXAM: White blood cell count of 3,000 with a
normal differential, hematocrit of 41, platelets of 163,000.
Electrolyte panel: Sodium 139, potassium 3.8, chloride 99,
bicarbonate 25, BUN of 15, creatinine 0.8, glucose of 92.
Her blood glucose during her syncopal episode was 102. Chest
x-ray was clear of any new infiltrates. Head CT was
negative. Electrocardiogram was sinus with normal axis,
normal intervals and no acute ischemic changes.
HOSPITAL COURSE: Mrs. [**Known lastname 27953**] was hydrated and observed.
She had no further episodes of bradycardia or syncope. She
did have a urinalysis which had white cells on it. She was
seen by the Electrophysiology Service who concluded that this
was a classic vasovagal episode in the setting of dehydration
and recommended a vigorous hydration as well as treatment of
her urinary tract infection. If she has further episodes
like this in the future, she may benefit from beta-blocker to
prevent her vasovagal induced vasodepressor syncope.
DISCHARGE DIAGNOSES:
1. Syncope.
2. Urinary tract infection.
3. History of lung cancer.
DISCHARGE MEDICATIONS: She will be discharged on a five day
course of Levaquin.
FOLLOW-UP PLAN: As per recommendations of the
Electrophysiology Service, she should have an echocardiogram
in the ensuing week or two to assess her structural cardiac
function. She will also see her primary care physician and
has been instructed to rehydrate herself vigorously in the
ensuing days.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1569**] 12-684
Dictated By:[**First Name3 (LF) 27957**]
MEDQUIST36
D: [**2126-3-13**] 13:38
T: [**2126-3-13**] 13:38
JOB#: [**Job Number 27958**]
cc:[**Last Name (NamePattern1) 27959**]
|
[
"780.2",
"041.4",
"785.0",
"458.0",
"599.0",
"788.30",
"V10.11",
"465.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4128, 4140
|
7212, 7256
|
8922, 8993
|
9017, 9648
|
4024, 4106
|
8363, 8901
|
7279, 8345
|
6994, 7195
|
4943, 6321
|
4157, 4434
|
6344, 6838
|
6855, 6974
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,754
| 190,609
|
50390+59251
|
Discharge summary
|
report+addendum
|
Admission Date: [**2144-10-13**] Discharge Date: [**2144-10-16**]
Date of Birth: [**2073-6-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
melana
Major Surgical or Invasive Procedure:
EGD [**2144-10-15**]
History of Present Illness:
71M Russian speaking man with hyperlipidemia, hypertension, CHF,
CAD, s/p stent to LAD in [**2142**], complete heart block, s/p
pacemaker implantation ESRD on HD, diverticulosos on coumadin
who presented to PCPs office with fatigue, DOE and intermittent
nonexertional [**4-30**] nonradiating squeezing CP that resolved with
SLNG and was typical of past angina. Patient also reports that
he's has ~5 days of black stools, approximately once per day for
the past 5 days. He was guaiac positive in the ED and found to
have a Hct of 17, down from his baseline of 26-30. Patient is on
ASA, PLavix, and Coumadin. He denies any dysphagia, odynophagia,
wretching, etoh intake, NSAID intake, gerd symptoms, excessive
warfarin
.
He is a dialysis patient and had his last dialysis on saturday
in [**Country **], from where he returned 2 days ago.
Past Medical History:
CAD, s/p stent to the LAD on [**2142**] then overlapping DES to the
LAD
on [**2144-8-26**]
Hypertension
CHF- EF 55%, 1+ MR, mild LVH by echo [**6-/2141**] (EF 49% by stress
MIBI [**2144-8-21**])
Diabetes
Hyperlipidemia
Heart block s/p pacemaker [**2-/2142**]
Chronic renal failure on HD q MON, and Friday (plan for a
transplant in the future)
S/P right arm AV fistula [**3-/2143**]
Cellulitis [**6-/2141**]
Bilateral adrenal adenomas
Diverticulosis
Antral polyps
Cholelithiasis by CT on [**2143-7-16**]
S/P right CFA pseudoaneurysm repair [**2143-7-16**] for wound cellulitis
post catheterization
Social History:
Restauranteur
Denies etoh intake, tobacco use or illicit drug use
40 pk-yr history, quit 24 yr ago.
Family History:
Negative for coronary artery disease. Mother: died of multiple
myeloma at age 84. Father: Died at age 30 as a casualty of war
Physical Exam:
Vitals - T:97.4 BP:154/58 HR:77 RR:20 02 sat:100RA
GENERAL: laying in bed, NAD
SKIN: warm and well perfused, bilateral LE venous stasis changed
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pale conjunctiva,
patent nares, MMM, good dentition, supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, diastolic murmur at base
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
[**2144-10-13**] CXR line placement: IMPRESSION: Stable cardiac
silhouette. Satisfactory position of right IJ line with no
pneumothorax.
Labs:
[**2144-10-13**] 02:45PM BLOOD WBC-7.1 RBC-1.82*# Hgb-5.8*# Hct-17.0*#
MCV-93 MCH-31.6 MCHC-33.9 RDW-15.6* Plt Ct-240
[**2144-10-15**] 03:40AM BLOOD WBC-9.5 RBC-3.16*# Hgb-9.5*# Hct-28.0*
MCV-89 MCH-30.0 MCHC-33.9 RDW-16.8* Plt Ct-208
[**2144-10-16**] 02:25AM BLOOD WBC-9.3 RBC-3.05* Hgb-9.3* Hct-27.0*
MCV-89 MCH-30.6 MCHC-34.6 RDW-16.7* Plt Ct-224
[**2144-10-16**] 08:15AM BLOOD Hct-27.4*
[**2144-10-13**] 02:45PM BLOOD PT-28.3* PTT-60.5* INR(PT)-2.9*
[**2144-10-16**] 02:25AM BLOOD PT-16.3* PTT-28.9 INR(PT)-1.5*
[**2144-10-13**] 02:45PM BLOOD Glucose-168* UreaN-100* Creat-6.8* Na-136
K-5.0 Cl-105 HCO3-19* AnGap-17
[**2144-10-16**] 02:25AM BLOOD Glucose-100 UreaN-59* Creat-4.8* Na-139
K-4.4 Cl-105 HCO3-26 AnGap-12
[**2144-10-13**] 02:45PM BLOOD CK(CPK)-215*
[**2144-10-13**] 05:50PM BLOOD CK(CPK)-206*
[**2144-10-14**] 02:59AM BLOOD CK(CPK)-157
[**2144-10-13**] 02:45PM BLOOD CK-MB-9 cTropnT-0.10*
[**2144-10-13**] 05:50PM BLOOD CK-MB-9 cTropnT-0.10*
[**2144-10-14**] 02:59AM BLOOD CK-MB-8 cTropnT-0.11*
[**2144-10-13**] 05:50PM BLOOD Calcium-8.8 Phos-4.6* Mg-3.0*
Brief Hospital Course:
71M with CAD s/p PCI, ESRD on HD, CHB s/p PPM, with GI Bleed,
s/p HD and 4U pRBCs on [**10-15**].
.
.
GI Bleed: He received a total of 9 units of PRBCs. His HCT
remained stable at 27. An EGD showed bleeding in the 2nd and 3rd
portion of the duodenum. He also had coffee ground emesis in the
stomach and a thickened area in the antrum. This was not
biopsied because his INR was too elevated. He remained stable
with HCT of 27. He was continued on his aspirin and plavix given
his cardiac stent placed a month ago. However, after discussion
with his cardiologist, Dr. [**Last Name (STitle) **], it was decided that his
coumadin could be discontinued (was on it for aflutter s/p
ablation). He was reversed with FFP and vitamin K to bring his
INR down to help stop the bleeding. He is scheduled to have
another EGD on Monday [**2144-10-19**] to bx the thickened
antrum and look for any residual bleeding.
.
ESRD on HD: Nephrology was aware and he received dialysis while
in house.
.
CAD: No evidence of NSTEMI with unchanged EKG and negative
cardiac enzymes. He was continued on his statin. Continued
aspirin and plavix as described above.
HCT goal was 30 given CAD.
PUMP: EF55%, held his BB initially given GI bleed and then
restarted once stable. Diovan restarted. Furosemide restarted on
discharge.
RHYTHM: complete heart block s/p PPM.
.
DM2: gave insulin per sliding scale
.
.
After discussion with the patient, the patient's PCP and the
MICU team, it was decided that he was safe for discharge with
close follow up.
Medications on Admission:
ASA 325 mg 1 tab daily
Toprol XL 100 daily
Glyburide 1.25 mg 2 tabs for increased BS (usually 1 time
weekly)
Calcium Acetate 667 mg 1 tab in am and 2 tabs in the pm
Lasix 40 mg 2 tabs [**Hospital1 **]
Lipitor 20 mg 1 tab daily
Nifedipine 30 mg 1 tab in am and 2 tabs in the pm
Plavix 75 mg 1 tab daily
Diovan 80 mg daily
Lorox 0.77% to the bottom of the feet
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: GI bleed, acute blood loss anemia
.
Secondary diagnosis:
CAD s/p stent
HTN
DM2
ESRD on HD
Discharge Condition:
Afebrile, stable vital signs, tolerating POs, ambulating without
difficulty.
Discharge Instructions:
You came in with a GI bleed and were found to have a HCT of 17
which is very low. You were given a total of 7 units of PRBC.
You had a GI procedure, EGD, which showed bleeding in the small
bowel. You will require a follow-up EGD on Monday with Dr.
[**Last Name (STitle) **]. Please avoid taking your ASA until after the
procedure. Please return to your regularly scheduled
hemodialysis on Mondays and Fridays.
.
1. Please take all medication as prescribed.
2. Please attempt to make all medical appointments.
3. Please return to the Emergency Room if you have any
concerning symptoms.
.
Please follow up with Dr. [**Last Name (STitle) 3357**] in the next week.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 3357**], your PCP, [**Name10 (NameIs) **] the next week
[**Telephone/Fax (1) 4606**]. His office said to call the schedule the
appointment.
.
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2144-10-19**] 8:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2799**] Date/Time:[**2144-10-19**]
8:00
Completed by:[**2144-10-21**] Name: [**Known lastname 17075**],[**Known firstname 17076**] Unit No: [**Numeric Identifier 17077**]
Admission Date: [**2144-10-13**] Discharge Date: [**2144-10-16**]
Date of Birth: [**2073-6-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10790**]
Addendum:
CAD: No evidence of NSTEMI with unchanged EKG and negative
cardiac enzymes. He was continued on his statin. Continued
aspirin and plavix as described above.
HCT goal was 30 given CAD.
PUMP: Patient with diastolic heart failure with an estimated
EF55%. His BB initially given GI bleed and then
restarted once stable. Diovan restarted. Furosemide restarted on
discharge.
RHYTHM: complete heart block s/p PPM.
Brief Hospital Course:
CAD: No evidence of NSTEMI with unchanged EKG and negative
cardiac enzymes. He was continued on his statin. Continued
aspirin and plavix as described above.
HCT goal was 30 given CAD.
PUMP: Patient with diastolic heart failure with an estimated
EF55%. His BB initially given GI bleed and then
restarted once stable. Diovan restarted. Furosemide restarted on
discharge.
RHYTHM: complete heart block s/p PPM.
Discharge Disposition:
Home
[**Doctor First Name 3354**] [**First Name8 (NamePattern2) **] [**Name8 (MD) 3353**] MD [**MD Number(2) 10791**]
Completed by:[**2144-11-19**]
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2,040
| 115,117
|
10204
|
Discharge summary
|
report
|
Admission Date: [**2145-10-27**] Discharge Date: [**2145-11-13**]
Date of Birth: [**2082-10-25**] Sex: M
Service: MEDICINE
CHIEF COMPLAINT: Fever.
HISTORY OF PRESENT ILLNESS: This is a 63 year old primarily
Spanish speaking male with a history of end-stage renal
disease secondary to diabetes mellitus on dialysis. The
patient also has a history of coronary artery disease,
chronic obstructive pulmonary disease, recurrent Methicillin
resistant Staphylococcus aureus/VRE dialysis catheter
infection and status post Methicillin resistant
Staphylococcus aureus epidural abscess of L2 to 3, status
post incision and drainage in [**2144-7-15**]. The patient is
now here from his outpatient hemodialysis center with a fever
up to 103.3 F., lethargy and back pain. Per the hemodialysis
center notes the patient had a temperature the previous night
at home, however, he was afebrile at the beginning of his
hemodialysis session. The patient was given Tylenol for his
back pain which did not help. The patient also complained of
increased back pain. His pain was mostly between the
shoulders. Temperature came down to 101.8 F. Blood cultures
were drawn times two. The patient was given one gram of
Kefzol and 80 mg of intravenous Gentamicin and sent to the
[**Hospital1 69**] Emergency Department.
At [**Hospital1 69**], the patient was
given 1 gram of Vancomycin and 2 grams of ceftriaxone. A
lumbar puncture was performed. A head CT scan was performed
and was negative. The patient received about a liter of
intravenous fluids. Initially, the patient was only
minimally responsive and could only open his eyes, however,
he quickly perked up and after the antibiotics, he was alert
and oriented times three. He complained of mild headache,
mostly bifrontal and mild neck pain as well as the thoracic
back pain. The patient denied any chest pain or shortness of
breath.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis.
2. Diabetes mellitus, non-insulin dependent.
3. Chronic obstructive pulmonary disease.
4. One vessel coronary artery disease, status post
catheterization in [**8-/2145**]; status post left circumflex
percutaneous transluminal coronary angioplasty and stent.
5. Congestive heart failure.
6. History of Methicillin resistant Staphylococcus aureus L2
to 3 epidural abscess with incision and drainage in [**2144-7-15**].
7. Recurrent line infections with Methicillin resistant
Staphylococcus aureus, VRE and Klebsiella.
8. Thrombosis in right internal jugular, right subclavian
and right brachiocephalic veins in 10/[**2144**].
9. Peptic ulcer disease.
10. Hypertension.
11. History of medication noncompliance.
MEDICATIONS ON ADMISSION:
1. Epogen.
2. Coumadin 4 mg p.o. q. day.
3. Ambien 5 mg q. h.s.
4. Amitriptyline 25 mg p.o. q. day.
5. Protonix 40 mg p.o. q. day.
6. Aspirin 325 mg p.o. q. day.
7. Plavix 75 mg p.o. q. day.
8. Norvasc 10 mg p.o. q. day.
9. Enalapril 20 mg p.o. q. day.
10. Metoprolol 25 mg p.o. three times a day.
11. Tylenol p.r.n.
12. Senna p.r.n.
13. Colace p.r.n.
14. Tums with meals.
15. Regular insulin sliding scale.
SOCIAL HISTORY: The patient is married and is a nonsmoker
and nondrinker.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 103.2 F.; blood pressure
128/44; pulse 88; respiratory rate 14; O2 saturation 100% on
two liters. In general, the patient is alert and oriented
times three in no apparent distress. HEENT: Oropharynx
clear; anicteric. Pupils equally round and reactive to light
and accommodation. Extraocular movements are intact. Neck
supple; no lymphadenopathy. Generalized plethora and edema
of neck. Cardiovascular: Regular rate and rhythm, no
murmurs, gallops or rubs. Lungs are clear to auscultation
bilaterally. Chest: Left sided Quinton dialysis catheter
without any surrounding erythema or exudate, nontender. Back
with no costovertebral angle tenderness. Minimal paraspinal
thoracic tenderness to palpation. Extremities: Cachectic;
no cyanosis, clubbing or edema. Left sided AV fistula with
positive thrill. Abdomen soft, nontender, nondistended.
Normoactive bowel sounds. No hepatosplenomegaly, masses or
bruits. Neurologic: Alert and oriented times three. No
focal signs.
LABORATORY: White blood cell count 14.7 with a differential
of 92% neutrophils, 11% lymphocytes, hematocrit 34.3,
platelets 127, sodium 141, potassium 3.5, chloride 99,
bicarbonate 27, BUN 25, creatinine 3.5, glucose 224. CK 22,
PT 16.4, PTT 42.7, INR 1.8.
Lumbar puncture tube #1, 9 white blood cells with 6% polys,
48% lymphocytes, 46% monocytes, 18 red blood cells. Glucose
173. Tube #2, white blood cells 9 with a differential of 2%
polys, 51% lymphocytes, 47% monocytes, 3 red blood cells and
a protein of 37.
Chest x-ray with poor inspiration, diffuse haziness but no
focal infiltrates. Head CT scan with no evidence of bleeding
or masses.
EKG with normal sinus rhythm at 99 beats per minute. T wave
inversions in I and AVL, [**Street Address(2) 4793**] depressions with T wave
inversions in V4 through V6. Biphasic T waves in V2 to V3.
No old electrocardiograms accessible for comparison.
HOSPITAL COURSE: In short, this is a 63 year old Spanish
speaking male with a history of end-stage renal disease on
hemodialysis, diabetes mellitus, coronary artery disease
status post left circumflex stent, chronic obstructive
pulmonary disease, history of recurrent dialysis catheter
infections with Methicillin resistant Staphylococcus aureus
and VRE, and history of Methicillin resistant Staphylococcus
aureus epidural abscess, who now presents with fever,
lethargy, back pain and headache.
1. INFECTIOUS DISEASE: The patient did not have any further
high spikes after being admitted. He had only low spikes for
a couple of days and then was afebrile afterwards. The
patient had blood cultures drawn in the Emergency Department.
These were negative without any growth. The patient's fever
was presumed to be secondary to his left sided Quinton
catheter, even though it did not show any obvious signs of
infection. The patient was kept on a regimen of Vancomycin
and Gentamicin for broad coverage.
Of note, the patient's blood cultures from his dialysis
center were found to be positive, growing four out of four
tubes of Methicillin sensitive Staphylococcus aureus. This
was found to be overall pan sensitive, only resistant to
penicillin, Ampicillin and tetracycline. However, the MIC
was only low for oxacillin at a level of 0.25. For this
reason, the patient was switched from Vancomycin and
Gentamicin to intravenous Oxacillin at a dose of 1 gram q.
four hours. His Quinton dialysis line was pulled after
dialysis was started with his left AV fistula. The Quinton
tip also grew Methicillin sensitive Staphylococcus aureus.
The patient was unable to have a right sided PICC line placed
because of the extensive network of clots in his right
internal jugular, subclavian and brachiocephalic veins.
However, a midline catheter was successfully placed on [**11-4**].
The patient was continued on intravenous Oxacillin.
Because the patient was also having back pain, and given his
history of an epidural abscess, there was a concern that he
might have seeded his vertebrae, thus causing osteomyelitis.
The patient received an MRI of the spine. This was negative
for an epidural abscess, but did show increased signal and
paravertebral swelling anterior to C3 through 5, suspicious
for osteomyelitis. Even though this is not the area where
the patient was having pain, it was decided that the patient
should be treated for presumed osteomyelitis for a total of
six weeks on antibiotics.
Given that the patient was bacteremic with Methicillin
sensitive Staphylococcus aureus, there was also concern that
he may have seeded his heart valves. The patient had a
transthoracic echocardiogram a couple of days after
admission. This showed low normal left ventricular ejection
fraction, small ASD, but only mild mitral regurgitation and
no change in his valves. A transesophageal echocardiogram
was planned for [**11-4**], but during the procedure, the patient
was unable to tolerate the tube and therefore it was aborted.
2. ACCESS: As already noted, the patient came in with a
left sided Quinton catheter. He also had an AV fistula with
a positive thrill that had been placed in [**2145-7-15**], but
had not been used yet. The Quinton catheter was taken out
after the AV fistula was tested and found to be usable. A
midline catheter was placed in the right side for intravenous
antibiotics. Unfortunately, after a couple of sessions of
dialysis, it was realized that there was not good blood flow
going through the left sided AV fistula.
The patient initially had an AV fistula ultrasound and then
an AV fistulogram. This revealed the stenosis between the
arterial and venous components. The patient had an
angioplasty to open up the AV fistula. This was performed by
Transplant Surgery. As a temporary measure, the patient
received a central line for dialysis through his left sided
EJ. Transplant Surgery's recommendation was to leave the AV
fistula alone for one to two weeks following the angioplasty
and then to retest it.
3. CARDIOVASCULAR: The patient's initial presentation had
some concerning T wave and ST changes on his EKG even though
an old EKG was not accessible. The patient was ruled out by
serial cardiac enzymes. He had no episodes of chest pain or
shortness of breath. The patient was kept on his regimen of
aspirin, Plavix, Lopressor, and Enalapril for cardiac health.
The patient also received a Nitroglycerin patch.
4. HEMATOLOGIC: The patient has a history of right sided
clots in his internal jugular, subclavian, brachiocephalic
veins; for this reason, he is on anticoagulation. Because of
all the interventional procedures performed, the patient was
mostly off of Coumadin, but was kept on a heparin drip
towards the end of his stay. We were just waiting for his
Coumadin to become therapeutic. He was placed on 7.5 mg of
Coumadin. His INR on [**2145-11-12**], was 1.6. It was expected
to become therapeutic by [**2145-11-13**], with a goal range of
probably between 2.0 to 3.0.
5. RENAL: The patient is followed closely by the Renal
Team. He received hemodialysis every Monday, Wednesday and
Friday. There were no further complications during
hemodialysis including fever, hypotension, or volume
overload.
CONDITION AT DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Coumadin 7.5 mg p.o. q. day.
2. Calcium carbonate 1000 mg p.o. three times a day, taken
with meals.
3. Oxacillin 1 gram intravenous q. four hours, to be taken
until [**2145-12-13**].
4. Sarna lotion, one application topically twice a day
p.r.n.
5. Nitroglycerin Ointment 2%, 0.5 inches topically q. six
hours.
6. Ambien 5 mg p.o. q. h.s. p.r.n.
7. Percocet one tablet p.o. q. four to six hours p.r.n. back
pain.
8. Nitroglycerin 0.3 mg sublingually p.r.n. chest pain.
9. Milk of Magnesia 15 to 30 ml p.o. four times a day p.r.n.
10. Bisacodyl 10 mg p.o./p.r. q. day p.r.n.
11. Lopressor 100 mg p.o. three times a day; hold for
systolic blood pressure less than 100, pulse less than 60.
12. Norvasc 10 mg p.o. q. day.
13. Enalapril 20 mg p.o. q. day.
14. Plavix 75 mg p.o. q. day.
15. Enteric coated aspirin 325 mg p.o. q. day.
16. Protonix 40 mg p.o. q. 24 hours.
17. Amitriptyline 25 mg p.o. q. h.s.
18. Colace 100 mg p.o. twice a day.
19. Senna two tablets p.o. q. day.
20. Tylenol 325 to 650 mg p.o. q. four to six hours p.r.n.
21. Lantus 15 units subcutaneously q. a.m.
22. Regular insulin sliding scale.
DISCHARGE INSTRUCTIONS:
1. The patient is to be discharged to East Point
Rehabilitation once his INR is within therapeutic range.
2. The patient will follow-up with his renal doctors.
3. The patient will continue to receive hemodialysis every
Monday, Wednesday and Friday.
4. The patient will also need to be seen for removal of his
temporary external jugular dialysis catheter once his AV
fistula is retested and working again.
DISCHARGE DIAGNOSES:
1. Methicillin sensitive Staphylococcus aureus bacteremia,
now resolved.
2. Osteomyelitis.
3. End-stage renal disease on hemodialysis.
4. Diabetes mellitus.
5. Coronary artery disease, status post left circumflex
stent.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Name8 (MD) 3839**]
MEDQUIST36
D: [**2145-11-12**] 13:40
T: [**2145-11-12**] 13:49
JOB#: [**Job Number 34027**]
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45,604
| 111,038
|
44746
|
Discharge summary
|
report
|
Admission Date: [**2101-6-1**] Discharge Date: [**2101-6-10**]
Date of Birth: [**2048-5-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Diarrhea, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly, this is a 53yoM with h/o EtOH abuse, depression w/ SI
who was admitted to the MICU on [**2101-6-1**] for guiaic + stool,
diarrhea, fevers, and hypotension. In the ED, he was
aggressively fluid resuscitated, NG lavage returned coffee
grounds. GI was [**Date Range 4221**] and decided no emergent scope was
indicated; started octreotide and pantoprazole. For fever,
elevated WBC, and hypotension, he was treated empirically with
Vanc/Zosyn.
.
In the ICU, the patient's BP improved after fluid resuscitation.
For profuse diarrhea, stool studies returned C.diff +. CT Abd
showed severe pancolitis. Hct fell to 23.9 on [**6-2**], and he was
transfused 2U PRBC. Since yesterday, Hct has stabilized ~ 30.
Stool has turned from black to brown, no longer guiaic +. He
remains on [**Hospital1 **] pantoprazole. Last fever was yesterday. GI has
plans for inpatient EGD on Monday and outpatient colonoscopy.
Last EGD at [**Hospital1 2177**] in [**4-15**] showed gastritis and esophagitis in the
lower 1/3 esophagus, no varices. Patient's antibiotics have been
tapered to IV flagyl and PO vancomycin. He is currently
tolerating clears. SW has been following the case and has
arranged for his house to be cleaned on Tuesday (apparently,
large amts of C.diff + stool in home) and patient has expressed
intermittent interest in substance abuse program. Per MICU
resident, patient last scored on CIWA yesterday.
.
Currently, VS 99.2 103 117/75 96% on RA. The patient is A&Ox3.
He has extensive cuts and brusing on body. Abdomen is soft,
nontender. Flexiseal in place with liquid brown stool. He denies
abdominal pain. He denies SI.
.
ROS: Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
nausea, vomiting, constipation, dysuria, hematuria.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
Depression w/ SI (recent admit to psych from [**4-26**] to [**4-29**])
Anemia/leukopenia
EtOH abuse
Social History:
Admits to drinking heavily (~[**2-6**] pint vodka/day); last drink 3
days PTA. No tobacco or illicits. Lives by himself.
Family History:
Father committed suicide.
Physical Exam:
On transfer to floor:
GENERAL - disshevled appearing, sutured L eyebrow lac, R
forehead bruise
HEENT - NC/AT, anisocoria - longstanding, EOMI, sclerae
anicteric, dry MM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - pneumoboots in place, WWP, extensive bruising on
legs, no c/c/e, 2+ peripheral pulses (radials, DPs)
GU/GI: foley and flexiseal in place
NEURO - awake, A&Ox3, CN II-XII intact, muscle strength 4/5
throughout (RN reports wobbly getting into chair), normal
cerebellar exam
Access: 4 PIVs
.
ON discharge:
Pertinent Results:
[**2101-6-1**] 06:40PM BLOOD WBC-23.3*# RBC-3.92* Hgb-11.1* Hct-33.6*
MCV-86 MCH-28.4 MCHC-33.0 RDW-17.6* Plt Ct-348#
[**2101-6-1**] 06:40PM BLOOD Neuts-92.6* Lymphs-5.0* Monos-1.9*
Eos-0.1 Baso-0.4
[**2101-6-1**] 06:40PM BLOOD PT-16.8* PTT-30.4 INR(PT)-1.5*
[**2101-6-3**] 03:18PM BLOOD Ret Aut-0.3*
[**2101-6-1**] 06:40PM BLOOD Glucose-132* UreaN-13 Creat-1.1 Na-135
K-3.3 Cl-97 HCO3-21* AnGap-20
[**2101-6-1**] 06:40PM BLOOD ALT-8 AST-13 CK(CPK)-65 AlkPhos-72
TotBili-0.9
[**2101-6-1**] 06:40PM BLOOD Lipase-12
[**2101-6-1**] 06:40PM BLOOD cTropnT-<0.01
[**2101-6-1**] 06:40PM BLOOD Albumin-3.4* Calcium-9.9 Phos-0.6*#
Mg-1.8
[**2101-6-2**] 06:25AM BLOOD VitB12-1244* Folate-7.5
[**2101-6-1**] 06:40PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2101-6-1**] 06:54PM BLOOD Glucose-131* Lactate-1.5 Na-134* K-3.4*
Cl-97* calHCO3-21
[**2101-6-1**] 06:54PM BLOOD freeCa-1.26
CT HEAD [**2101-6-1**]
1. No acute intracranial hemorrhage or fractures.
2. Mild bifrontal soft tissue swelling.
CXR [**2101-6-1**]
Normal chest.
CT ABD/PELVIS [**2101-6-2**]
1. Severe pancolitis with imaging features consistent with the
provided
history of Clostridium difficile. No radiographic findings of
obstruction,
perforation, or other complication noted.
2. Cholelithiasis.
3. Trace right pleural effusion and mild-to-moderate amount of
intra-
abdominal/pelvic ascites. Mild soft tissue anasarca.
Brief Hospital Course:
53yoM with h/o EtOH abuse, depression w/ SI who was admitted to
the MICU on [**2101-6-1**] with hypotension, C.diff colitis and an
upper GI bleed.
.
Severe C.difficile: Treated initially with oral vancomycin 500mg
q6H and flagyl, then narrowed to oral vancomycin 125mg which
will be continued for a total of 3 weeks. He initially required
a flexiseal due to copious stool output, but this was
discontinued on [**2101-6-8**] and he remained continent of stool. He
tolerated a regular diet. His house was found to have residual
stool and was cleaned by his case manager prior to discharge.
.
UGIB/Esophagitis: EGD was completed which showed esophagitis
attributable to his chronic alcohol abuse. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 95728**]
revealed active esophagitis without evidence of Barrett's
esophagus. He was treated with pantoprazole [**Hospital1 **] and will
continue this upon discharge. Once the esophagitis heals and he
remains abstinent from alcohol, the PPI can be weaned by his
primary care doctor.
.
Alcohol Abuse: He was initially placed on a CIWA with IV valium
as needed, he required valium on [**6-1**], but no longer after [**6-2**].
Given thiamine, folate and multivitamin. Social work was
closely involved with the patient and offered ETOH abstinence
counseling and close outpatient follow up has been arranged.
.
Recurrent Falls: Believed to be secondary to ETOH abuse. Recent
head CT's were negative. B12 and folate were normal. 2 month
old sutures were removed from a left eyelid laceration without
complication.
.
The patient was FULL CODE for this admission.
Medications on Admission:
Home: (reports he was only taking seroquel)
thimaine 100 mg qday
folic acid 1 mg qday
MVI qday
ferrous sulfate 325 mg qday
omeprazole 20 mg qday
quetiapine 25 mg qday
Discharge Medications:
1. 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*
2. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. vancomycin 125 mg Capsule Sig: One (1) Capsule PO once a day
for 14 days.
Disp:*14 Capsule(s)* Refills:*0*
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Severe C.difficile colitis
Esophagitis causing Upper Gastrointestinal Bleeding
ETOH abuse
.
Secondary:
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for GI bleeding and diarrhea.
Stool studies showed that you had an infection called
clostridium difficile. We treated you with antibiotics and you
improved - you will need to complete a continue with antibiotics
for the diarrhea. The gastroenterology doctors [**First Name (Titles) **] [**Last Name (Titles) 4221**]
and performed an endoscopy, which showed that you have
esophagitis (inflammation of the esophagus, likely due to acid
reflux). This should heal with continuing acid-reflux
medications. The most important intervention for your health is
to stop drinking alcohol entirely.
.
We made the following changes to your medications:
- INCREASE pantoprazole to 40mg twice daily
- START multivitamin 1 tab daily
- START vancomycin 125mg every 6 hours for 14 days
- START tramadol 50mg PO q6H as needed for pain
.
Your follow-up information is listed below.
Followup Instructions:
[**Hospital 12091**] Community Health Center
Structured outpatient Substance Abuse Program
Monday [**2100-6-13**] at 9:00AM
[**Location (un) 95729**]Basement
[**Location (un) 669**], MA
Phone: [**Telephone/Fax (1) 95730**]
*They can arrange (also with Dr.[**Name (NI) 95731**] help) for you to see a
psychiatrist and therapist.
Department: Internal Medicine
Physician: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Time: [**2101-6-23**] 11:00AM
Location: [**Last Name (un) 95732**], [**Location (un) 86**], [**Numeric Identifier 4809**]
Phone:([**Telephone/Fax (1) 95733**]
Completed by:[**2101-6-10**]
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2189, 2319
|
2335, 2457
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,067
| 192,309
|
50764
|
Discharge summary
|
report
|
Admission Date: [**2168-8-12**] Discharge Date: [**2168-8-19**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
L tongue and facial swelling
Major Surgical or Invasive Procedure:
Elective intubation for airway protection
History of Present Illness:
88F with a history of CAD, tachyarrhythmia with a pacemaker in
place, HTN, and s/p CVA with residual L side deficits who lives
at [**Hospital 100**] Rehab who presents with painful L tongue and facial
swelling for the past 12 hours. By report, the patient began to
have pain under the left side of her tongue last night. This AM
her tongue was swollen and painful, and the swelling had spread
to her face. By report she had odynophagia, dysphagia, and
dysphonia this AM. She was brought to the ED for evaluation.
.
In the ED initial vital signs were 98.1 72 104/61 18 96% on RA.
Initial exam and history was concerning for Ludwig's angina, and
ENT was consulted. Her initial labs were notable for a WBC of
11.4 with 82% PMNs and no bands. Based on her significant tongue
edema, ENT was concerned about airway compromised. The patient
is DNR DNI, but agreed to elective intubation for reversible
causes. She was intubated for airway protection and underwent a
neck CT which did not show Ludwig's angina, but did show
significant sialadenitis. On exam, pus was expressed from her L
submandibular gland and sent for culture. She received
vancomycin 1000mg IV x1, levofloxacin 750mg IV x1, and
metronidazole 500mg IV x1 and admitted to the [**Hospital Unit Name 153**] for further
management.
.
In the [**Hospital Unit Name 153**] she is intubated and sedated.
.
Review of Systems:
- Deferred, as intubated and sedated
Past Medical History:
- SAH/Stroke ([**2156**]: Stable Left Hemiplegia)
- Breast cancer S/P L Mastectomy ([**2138**])
- COPD
- S/P L Hip Fx ([**2146**])
- S/P L Femur Fx ([**2152**])
- S/P R Tibial Fx ([**2157**])
- Idiopathic colitis ([**2160**])
- HTN
- Pacemaker placement ([**2165**]) Enpulse E2DR01 for recurrent
syncope due to NSVT and hypotension
- UGI bleed [**2163**]
- CAD
Social History:
Social History:
- Tobacco: 40+ pack years, quit several years ago
- etOH: Denied in the past
- Illicits: Denied in the past
Family History:
Family History:
- Mother: Died of leukemia age 74
- Father: Died fo CHF age 75
Physical Exam:
GEN: Intubated and sedated
VS: 94.5 71 188/99 17 100% on CMV Vt 480 R 16 FiO2 0.60
PEEP 5 pressure support 8
HEENT: Dry tongue, outside of mouth, palpable fullness under the
L mandible, no adenopathy, thyroid is difficult to assess due to
habitus, JVP at 8cm
CV: RR, loud S1, NL S2 no S3S4 MRG
PULM: Bronchial BS at the R apex, otherwise CTA
ABD: BS+, soft, NTND, no masses or HSM
LIMBS: No LE edema, no tremors or asterixis, no clubbing,
+contracture of the L arm
SKIN: No rashes or skin breakdown
NEURO: Deferred while sedated.
Pertinent Results:
[**2168-8-12**] 11:43PM LACTATE-1.6
[**2168-8-12**] 11:33PM GLUCOSE-114* UREA N-25* CREAT-1.0 SODIUM-143
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-22 ANION GAP-16
[**2168-8-12**] 11:33PM CALCIUM-8.1* PHOSPHATE-3.8 MAGNESIUM-1.7
[**2168-8-12**] 11:33PM WBC-9.3 RBC-4.06* HGB-12.4 HCT-36.1 MCV-89
MCH-30.4 MCHC-34.2 RDW-13.8
[**2168-8-12**] 11:33PM PLT COUNT-242
[**2168-8-12**] 11:33PM PT-13.3 PTT-28.3 INR(PT)-1.1
[**2168-8-12**] 03:04PM TYPE-ART RATES-/16 TIDAL VOL-480 O2-60 PO2-87
PCO2-38 PH-7.37 TOTAL CO2-23 BASE XS--2 -ASSIST/CON
INTUBATED-INTUBATED
[**2168-8-12**] 11:41AM LACTATE-1.0
[**2168-8-12**] 11:00AM GLUCOSE-92 UREA N-29* CREAT-0.9 SODIUM-142
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-26 ANION GAP-14
[**2168-8-12**] 11:00AM estGFR-Using this
[**2168-8-12**] 11:00AM ALT(SGPT)-6 AST(SGOT)-13 LD(LDH)-191 ALK
PHOS-104 TOT BILI-0.5
[**2168-8-12**] 11:00AM ALBUMIN-3.8
[**2168-8-12**] 11:00AM WBC-11.4* RBC-4.35 HGB-13.4 HCT-38.4 MCV-88
MCH-30.8 MCHC-34.8 RDW-13.8
[**2168-8-12**] 11:00AM NEUTS-82.0* LYMPHS-11.1* MONOS-4.8 EOS-1.8
BASOS-0.3
[**2168-8-12**] 11:00AM PLT COUNT-257
[**2168-8-12**] 11:00AM PT-12.8 PTT-28.2 INR(PT)-1.1
.
- CT NECK W/CONTRAST (EG:PAROTIDS) Study Date of [**2168-8-12**] 12:14
PM Within the left Warthin's duct draining the left
submandibular gland are multiple calcified stones measuring up
to 5 mm. The duct itself is enlarged, with a hyperemic wall. The
left submandibular gland is also hyperemic, and enlarged, and
contains multiple sialoliths. No focal fluid collection is
identified. The submandibular space appears uninvolved. There is
inflammatory stranding in the subcutaneous tissues of the neck
from the thyroid cartilage up to the angle of the mandible. No
significant lymphadenopathy is seen. Visualized intracranial
contents appear normal. The carotid arteries and vertebrobasilar
system demonstrate normal contrast enhancement, without focal
filling defects, aneurysm, occlusion, or significant
atherosclerotic change. An aneurysm clip is seen in the right
middle cranial fossa. The mastoid air cells are clear, there is
minimal mucosal thickening of the left maxillary and ethmoid
sinuses. There is opacification of the sphenoid sinus which is
likely related to recent intubation. Within the neck, there is a
1.3 x 1.8 cm round mass possibly arising from the isthmus with
enhancing and hypodense components, which has increased in size
compared with prior. The lung apices demonstrate marked
emphysematous change, as seen on prior. There is multilevel
degenerative change of the cervical and visualized thoracic
spine. The patient is intubated, with the tip of the ET tube
approximately 3 cm from the carina. The balloon appears somewhat
hyperinflated. IMPRESSION: 1. Sialadenitis of the left
submandibular gland with multiple stones in the left Warthin's
duct which is dilated and hyperemic. No focal fluid collection.
2. Midline neck mass possibly arising from inferior aspect of
the isthmus gland of the thyroid, increased in size compared
with prior.Recommend evaluation with thyroid ultrasound. 3.
Intubated state, with a prominent appearing endotracheal tube
balloon. 4. Emphysema.
Time Taken Not Noted Log-In Date/Time: [**2168-8-12**] 11:42 am
SWAB ABSCESS.
**FINAL REPORT [**2168-8-16**]**
GRAM STAIN (Final [**2168-8-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2168-8-16**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
BETA STREPTOCOCCUS GROUP B. RARE GROWTH.
ANAEROBIC CULTURE (Final [**2168-8-16**]): NO ANAEROBES ISOLATED.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2168-8-18**] 05:41 971 30* 0.9 138 3.6 101 26 15
Brief Hospital Course:
# Sialadenitis: Found to have multiple sialoliths on CT thought
to be causing stasis and infection. The patient was covered
broadly per ENT recommendations for gram positives and
oropharyngeal flora with vancomycin 1000mg IV Q24H ,
levofloxacin 500mg IV Q24H , and metronidazole 500mg IV Q8H .
Blood cultures were sent and were negative upon discharge. Wound
cultures were sent and grew out rare group B Beta Strep. She was
found to be MRSA negative. Antibiotics moved to Levoflox and
Clindamycin, to be continued x 2 week course through [**2168-8-26**].
.
# Airway protection: Electively intubated due to significant
edema on exam with threatened compromise of the upper airway.
She was sedated with propofol and fentanyl. Started on
dexamethasone 10mg IV Q8H per ENT to decrease airway edema in
preparation for extubation. This was discontinued after the
patientw as successfully extubated.
.
#Aspiration: Had witnessed aspiration with meds on [**2168-8-18**], with
hypoxia. Resolved with suctioning of pills. S&S consult done
with recs to ground thin diet and precautions as listed in
treatments section.
.
# Hypothermia: T94.5 on admission. Unclear if related to sepsis,
hypothyroidism, or techinical difficulties with measuring
temperature due to mouth swelling. TSH was normal.
.
# HTN: Significantly hypertensive on admission, but improved
with bolus pain control with fentanyl. Outpatient metoprolol,
HCTZ, and lisinopril were held in the periseptic period and then
restarted. She continued to have hypertensive spikes with SBP
into the 180s and was started on Hydralazine 10mg IV q6h to keep
her SBP <150.
.
# dCHF: Diuresed with 20IV Lasix after episode of desaturation
[**2168-8-16**]; hypoxia resolved.
.
# aFib: By chart review, not new. Chads-2 score 4 in the setting
of h/o hemorrhagic CVA with high fall and bleeding risk. Holding
coumadin anticoagulation for now; can further assess with PCP
after acute hospitalization.
.
# History of GIB: Switched her home omeprazole to pantoprazole
40mg IV daily.
.
# History of CVA with contractures: Outpatient tizanidine was
held while NPO and restarted once able to tolerate PO.
.
# Incidental Neck mass: found on CT (see results). Needs
outpatient thyroid ultrasound followup
.
# CODE: DNR/DNI
Medications on Admission:
- Acetaminophen PRN pain
- Tizanidine 4 mg PO BID and 6 mg PO HS
- Metoprolol succinate 50 mg PO HS
- Omeprazole 20 mg PO daily
- Vitamin D2 [**Numeric Identifier 1871**] units PO daily
- HCTZ 12.5 mg PO daily
- Lisinopril 20 mg PO HS
- Calcium carbonate 1300 mg PO daily
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Tizanidine 2 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for dyspnea.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
11. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours).
12. Clindamycin Phosphate 150 mg/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
13. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Sialoadenitis w/ sespsis
Aspiration causing hypoxia
Incidental neck mass which needs outpatient follow up
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted with infection of the salivary gland with
sepsis. You were treated with antibiotics which will continue.
You had an incident of aspirating causing trouble breathing and
your diet order was changed. You are being discharged back to
acute rehab facility
Followup Instructions:
to acute rehab
will need f/u thyroid ultrasound
|
[
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"428.0",
"438.20",
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"263.0",
"403.10",
"427.31",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10768, 10834
|
6926, 9184
|
248, 291
|
10984, 10984
|
2931, 6903
|
11456, 11507
|
2296, 2360
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9506, 10745
|
10855, 10963
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9210, 9483
|
11160, 11433
|
2375, 2912
|
1697, 1735
|
180, 210
|
319, 1678
|
10999, 11136
|
1757, 2120
|
2152, 2264
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,872
| 192,458
|
2518
|
Discharge summary
|
report
|
Admission Date: [**2185-3-15**] Discharge Date: [**2185-3-17**]
Date of Birth: [**2131-11-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Lipitor / Glucophage
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53yoF with hx of DM, asthma, DVTs s/p IVC filter on plavix and
coumadin,who presents from home with acute onset shortness of
breath and pleuritic chest pain. Mrs. [**Known lastname 11468**] was at home
babys[**Name (NI) 12854**] for her grandaughter, sitting on the sofa, when she
became acutely short of breath. She had pain with inspiration,
but no other chest pain or chest pressure, no n/v, no
diaphoresis. At home she has stable [**2-22**] pillow orthopnea,
becomes short of breath with mild exertion although she does not
report any history of chest pain with exertion. Of note, she
reports she has never experienced acute shortness of breath like
this before. EMS was called, found pt to have systolic blood
pressure of 200, she was given nitro and lasix for presumed
heart failure (although she has no documented history of CHF).
She reports some mild URI symptoms 2 weeks ago which are now
resolved, as well as increased bilateral leg edema at that time,
but no current fevers, chills, or cough. She also reports that
she has been compliant with all of her medications.
In the [**Hospital1 18**] ED, her vitals were temp of 100.5, HR 81, BP
153/87, RR 22, 100% on nonrebreather, with desatting to the 70s
on room air. Labs were significant for normal chem 7, WBC 6,
BNP of 1168 and negative Troponins. EKG was unchanged from
previous. CXR showed cardiomegaly, and a density in the right
lower lobe which was read as possible early infection vs.
atelectasis. She was given a dose of levofloxacin for community
aquired pna and trasnfered to the [**Hospital Unit Name 153**] for further management.
She reports dark stools, but these are unchanged (she is on PO
iron), ROS was otherwise negative.
Past Medical History:
-Poorly controlled DMII
-hypertension
-asthma
-anemia - profound iron deficiency [**2-21**] gastric and duodenal AV
malformations, transfusion dependent, Hct baseline around 22-29
-depression
-migraines
-obesity
-chronic abdominal pain
-delayed gastric emptying
-diverticulosis
-extensive DVT [**2-27**] s/p thrombectomy, IVC filter placement,
common and external iliac vein stenting
on coumadin/plavix
-OSA, on BiPAP 20/16
-? Meningioma (lesion identified by CT on [**6-27**] in left
perimesencephalic region, being followed)
-S/p appendectomy
-S/p bilateral oophorectomy and hysterectomy
-gout
Social History:
Mrs. [**Known lastname 11468**] reports living by herself in [**Location (un) 686**], although
her daughter lives nearby and she babysits for her grandaughter
[**Name (NI) 12855**]. She is currently out of work, but formerly
worked as a special needs counsellor. She does not drink
alcohol. She quit smoking one year ago, but had a history of 1
pack per week for 40 years. She has no history of any drug use.
Family History:
Mother and father both died of [**Name (NI) 499**] CA, and she also has a
grandmother and uncle with [**Name2 (NI) 499**] CA. No hx of hypercoagulability
or AVMS.
Physical Exam:
VITAL SIGNS:
T= 96.2 BP= 157/77 HR=82 RR=22 O2=100% on NRB (15L)
.
.
PHYSICAL EXAM
GENERAL: Very pleasant, increased work of breathing
HEENT: Normocephalic, atraumatic. Conjunctival pallor. No
scleral icterus. PERRL/EOMI. OP clear. Neck Supple
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVD to the earlobe
LUNGS: Dimished breath sounds, crackles in the bases
bilaterally, R>L
ABDOMEN: Obese, soft, diffusely tender to palpation, no guarding
EXTREMITIES: Cool, 1+ edema, 1+ dorsalis pedis/ posterior tibial
pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact
BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
CBC: 6.9 > 27.3 (baseline 21-30) < 503 Diff: N 83.1, L 10.7
.
Na 139
K 4.0
Cl 103
HCO3 27
BUN 8
Cre 0.9
.
U/A: negative
.
Trop-T: <0.01
CK: 158 MB: 6
.
PT: 23.4 PTT: 25.5 INR: 2.3
.
proBNP: 1168
.
STUDIES:
.
CXR:
SINGLE AP VIEW OF THE CHEST: Examination is limited by
breathing. Within
this limitation, there is density and atelectasis in the right
lower lobe.
Underlying or early infection cannot be excluded in this region.
The
remainder of the lungs are clear without pneumothorax, pleural
effusion. The
heart size is enlarged. The mediastinal and hilar contours are
normal. No
soft tissue or osseous abnormality is detected.
IMPRESSION:
1. Limited study, however, interval development of a density and
atelectasis
in the right lower lobe. Early infection cannot be excluded.
2. Cardiac enlargement.
.
Echocardiogram:
The left atrium is moderately dilated. The estimated right
atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation. Diastolic dysfunction with increased
PCWP. Mild pulmonary artery systolic hypertension.
<br>
[**2185-3-15**] 2:50 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2185-3-16**]**
URINE CULTURE (Final [**2185-3-16**]): <10,000 organisms/ml.
<br>
[**3-16**] Pelvis and L-spine film to r/o fx [**2-21**] to fall:
HISTORY: Morbid obesity with diabetes with back pain after fall.
FINDINGS: The prior study is not available on the PACS at this
time. The
vertebra and intervertebral disc spaces are quite well
maintained without
evidence of compression fracture. Of incidental note is evidence
of previous [**Month/Day (2) 1106**] surgery on the left and an IVC filter.
Brief Hospital Course:
53 yo F with hx of DM, asthma, DVTs s/p IVC filter on plavix and
coumadin now, who presents from home with acute onset shortness
of breath and evidence of heart failure on arrival to the ICU
and PNA with initial hypoxia to the 70s - and placed on a NRB.
Ms. [**Known lastname 11468**] was quickly weaned off of the non-rebreather that
was started in the ED to 4L NC. She was stable on her
night-time CPAP overnight in the ICU (admitted to ICU [**2-21**] to sig
hypoxia, noted recieved IVF prior in ED with PNA as admitted
dx). Antibiotics were continued for community-acquired PNA.
Given her presentation in the setting of elevated systolic blood
pressure, she was diuresed with 20mg IV furosemide for concern
of flash pulmonary edema contributing to her hypoxia. On am of
[**3-16**] - pt more stable from resp standpoint with 97% on RA, pt
was transferred to floor, give 1 more dose of po lasix 20mg -
feeling well am of [**3-17**] - ambulating without DOE, 92% on RA o2
sat, Echo showing evid of mild pulm HTN and dCHF without evid of
sCHF. Pt will be given CHF instruction, given a Rx for 20mg po
lasix but to be taking only PRN - not on a scheduled dose for
now - ***will need close f/u with her PCP in regards to this
with focus now to keep BP controlled.
<br>
1. Dyspnea - more likely due to mild secondary pulmonary HTN
with low thresholds for decompensation - here with mild PNA,
bacterial (Community acquired) and CHF exacerbation - diastolic
confirmed more by echo this stay -Failure supported by clincial
history of worsening orthopnea and dyspnea with exertion as well
as elevated BNP on admission, and elevated JVD and crackles on
exam. No previous diagnosis of heart failure but risk factors
for CAD and stress in [**4-27**] showing mild inferior wall reversible
perfusion abnormality and LVEF of 49%, as well as evidence of
diastolic dysfunction on [**2182**] ECHO. CXR with increased hilar
fullness, as well as focal RLL opacity. Low grade temp in ED
with normal WBC and no symptoms of pneumonia are less suggestive
of infection although crackles in R>L consistent with focal
opacity of RLL on CXR. No evidence of ACS with no EKG changes,
one negative set of cardiac biomarkers. Given that patient is
therapeutic on coumadin with IVC filter, PE is less likely.
-as above d/c with PRN lasix 20mg as needed based on daily wts
(see d/c instructions)
-ECHO noted
-serial cardiac biomarkers x3 were negative to note.
-Continue Levofloxacin for 5 day course to cover for community
aquired pna (given 2 more days at d/c)
-CPAP on home settings
-cont toprol at current dose
<br>
2. DMII, controlled, without complications:
-*****Home regimen of lantus and sliding scale, though noted pt
recieving 72u qhs, not with noon and qhs regime as recorded on
admission - pt to cont JUST qhs and bring BS log to PCP for [**Name Initial (PRE) **]/u
as BS controlled in 100s on regime in-patient and [**Doctor First Name **] diet
-calorie restricted [**Doctor First Name **] diet (1800)
<br>
3. Anemia, chronic blood loss - Patient w/ chronic anemia due to
multiple oozing AVM's and chronically guaiac +. Hct is near
baseline range and low suspicion that cause of acute
presentation - though my have small degree of contribution - as
d/w in [**Hospital Unit Name 153**] - plan will be to tranfuse for Hct<25.
-Hct at 26.0 at time of d/c
-Continue PPI
-Continue iron
<br>
4. DVT/Anticoagulation
-Continue home plavix and coumadin
-Low threshold for CTA given history
-Daily INR
-noted on plavix - ****question for PCP whether to continue this
for long-term to be f/u as outpt - noted per pt/family "history
of head clot in [**2-27**] - reason for plavix" - records reviewed -
particularly neuro note in [**6-27**] - per re-review of imaging in
[**2-27**] - felt lesion more - meningioma in the left prepontine
cistern. Will defer to PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] evidence of acute worsening of
chronic GI bleed will d/c but stable at time of d/c and will
defer to PCP for longterm.
<br>
5. HTN - better controlled in hospital, occas elevated but when
pain increased. Pt with oxycontin at home with prn percocet.
-Continue home regimen of antihypertensives with imdur,
lisinopril, toprol
-pt to resume home pain regime
<br>
6. Asthma - no evidence of exacerbation at this time
-continue home regimen
<br>
7. OSA/OHA (apnea)
-cont cpap at home setting as above
<br>
8. Neuropathy/Chronic Pain: though noted recent fall with
worsened lower back pain with mild ttp on coccux.
-Continue Gabapentin at decreased dose while in respiratory
distress
-coot home dose oxycontin
-L-S spine films done - NO FX
-PT evaluation - pt ambulated well - no further services needed
per assessment
<br>
CODE STATUS: Full code
EMERGENCY CONTACT: Daughter
Dispo - d/c to home with close PCP f/u in [**1-21**] wks
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs q4
BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - 50 mg-325 mg-40 q6
CLOPIDOGREL - 75 mg qd
CPAP 16 WITH 2 LITERS OXYGEN
FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 2 sprays [**Hospital1 **]
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
[**Hospital1 **]
GABAPENTIN - 800 mg tid
HYDROCORTISONE ACETATE [ANUSOL-HC] - 25 mg Suppository prn
INSULIN GLARGINE [LANTUS] - 100 unit/mL Cartridge - 72 units at
noon and at bedtime sq daily
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - according to
sliding scale administer twice a day - No Substitution
ISOSORBIDE MONONITRATE - 30 qd
LISINOPRIL - 40 mg Tablet - qd
METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth four times
a
day before meals and at bedtime
METOPROLOL SUCCINATE - 200 mg qd
OXYCODONE [OXYCONTIN] - 15 mg Tablet SR [**Hospital1 **]
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet q6prn
PANTOPRAZOLE - 40 mg qd
PROMETHAZINE-CODEINE [PHENERGAN-CODEINE] - 10 prn
SIMVASTATIN - 40 mg qd
TRAZODONE - 50 mg Tablet - qhs
UREA [CARMOL 40] - 40 % Cream - apply to both feet [**Hospital1 **]
WARFARIN [COUMADIN] - 5 mg Tablet - 1 [**1-21**] Tablet(s) by mouth on
Mon, Wed, [**Last Name (LF) **], [**First Name3 (LF) **]. 1 tablet on Tues, Thurs and Sat.
DOCUSATE SODIUM - 100mg [**Hospital1 **]
FERROUS SULFATE - 325 mg [**Hospital1 **]
LORATADINE - 10mg qd
SENNA - 8.6 mg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO AS DIRECTED:
please take only days you gain more than 2 pounds as listed in
your instructions.
Disp:*20 Tablet(s)* Refills:*0*
16. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
19. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO 4X/WEEK
([**Doctor First Name **],MO,WE,FR).
20. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK
(TU,TH,SA).
21. Insulin Glargine 100 unit/mL Solution Sig: One (1) 72 units
Subcutaneous at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
# Mild Pulmonary HTN
# Apnea
# Pneumonia
# mild Diastolic CHF
# Diabetes
# Anemia, from chronic GI blood losses - your blood counts were
stable and did not require more blood here
# history of DVT
# HTN
# Neuropathy
# Chronic Back Pain - note - x-rays did NOT show any evidence
you had a fracture
Discharge Condition:
stable, ambulating well, o2 sat of 93% RA
Discharge Instructions:
Your diagnoses are as below, note your x-ray films did not show
any evidence of any fracture. Your [**Last Name **] problem for admission
was your breathing which was found to be multifactorial as
listed below - with the 2 main news problems being a pneumonia
and mild CHF. Given your heart failure is mild (from
long-standing HTN) you will need to focus most on having your
blood controlled for now and will be prescribed lasix (water
pill) only for an as needed bases as the following:
<br>
Check your weight every morning following going to the bathroom,
if you gain more than 2 pounds from day prior - take 1 lasix
tablet (20mg), if you gain more than 4 pounds call your provider
and likely take 2 tablets (40mg).
<br>
If your symptoms worsen with breathing, develop new chest pain,
new blood in your stools, and any other concerning symptom
please call your provider or return to the emergency room.
<br>
You have your PCP f/u appointment as below next week. Make sure
you make this appointment. Note cont your lantus at 72unit qhs -
record your blood sugars and bring to PCP [**Name Initial (PRE) 648**].
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11980**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2185-3-22**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8718**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2185-4-5**]
1:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7975**] [**Name12 (NameIs) 7975**] INTERNAL MEDICINE
Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2185-4-8**] 10:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2185-3-17**]
|
[
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"346.90",
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"486",
"311",
"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
15104, 15161
|
6661, 11486
|
309, 316
|
15502, 15546
|
4105, 6638
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16711, 17327
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3131, 3295
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12970, 15081
|
15182, 15481
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11512, 12947
|
15570, 16688
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3310, 4086
|
266, 271
|
344, 2063
|
2085, 2683
|
2699, 3115
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,580
| 174,871
|
26341
|
Discharge summary
|
report
|
Admission Date: [**2130-10-23**] Discharge Date: [**2130-10-27**]
Date of Birth: [**2083-8-25**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 3012**] is a 47 year old homeless male with alcohol abuse,
history of complicated withdrawl, seziures, PFO s/p CVAs with
most recent left middle frontal stroke in [**8-17**] as well as
pyomyositis/clavicular osteo treated with 6 weeks of vanco
completed in [**10-6**] who is transferred from [**Hospital1 882**] with altered
mental status. The patient left [**Hospital1 18**] AMA late last night
during treatment for ETOH intoxication/seizures, transaminitis.
He was reportedly found this morning in a train station and
brought to [**Hospital 882**] hospital. At [**Hospital1 882**] he was noted to be
delerious, his BAL was ???, he was treated with ativan for
presumed ETOH withdrawl. Their ICU was full so he was
transferred to [**Hospital1 18**]. CT head was first reported as normal, but
[**Hospital1 882**] called the [**Hospital1 18**] ED to say that there was ? hypodense
lesion in the right frontal lobe. Of note, during his previous
admission, he patient was seen by neuro for seizures and started
on Keppra with a plan to taper lamictal, there was some concern
that his seizures were related to a new CVA rather than ETOH.
He also had a resolving transaminitis of unclear etiology, [**Name (NI) 5283**]
U/S showed fatty infiltrate and no sign of cholelithiasis. His
lipase was elevated at 70, but patient refused to be NPO. He
also complained of right arm pain, Xrays revealed a
non-displaced fracture, [**Name (NI) **] saw him and did a nerve block. He
has known residual left arm weakness from prior osteo.
.
In the [**Hospital1 **] ED, V/S were HR: 103, BP: 126/85, RR:15 02 sa98% on
RA. He was agitated and required 4 point restraints. He was
treated for presumed ETOH withdrawl with Diazepam and Ativan x
???. His BAL was 79 and he was NOT noted to have seizure. He
had a FAST scan due to abraison on his abdomen which did not
show free fluid. OSH Head CT was reviewed by radiology and
preliminarily negative, repeat head CT w/o contrast was also
done and this showed no acute intracranial process.
.
On the floor, the patient was calm, alert and oriented x2, and
with prompting x3. He intermittently fell asleep during the
interview and his speech was somewhat garbled but he was easily
rousable and could relate details of the previous day. He is
unsure what happened after he left the hospital last night.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, headache, rhinorrhea, cough, shortness
of breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
dysuria. Denied arthralgias or myalgias except in the left upper
extremity, unchanged from prior.
.
Past Medical History:
Past Medical History:
- Hepatitis C - untreated
- Alcohol Abuse with previous withdrawal seizures and DT's
- Depression
- C6-C7 disk degeneration spondylosis s/p C6-C7 anterior
diskectomy [**7-18**], fusion C6-7, anterior instrumentation C6-C7
with Dr. [**Last Name (STitle) 65184**].
- recent left frontal CVA as above with aphasia
- C6/7 spinal cord contusion [**4-17**] admission
- Thrombocytopenia, since [**4-17**]
- Anemia
- Leukopenia
- Medial orbital wall fracture [**3-19**]
- Panic attack [**6-17**]
Social History:
Social History: (per OMR notes)
He is homeless and lives in shelters or at his sister's home in
[**Location (un) **], NH. He smokes half a pack of cigarettes per day and
denies any drug use. Drinks alcohol daily, varies from 1 pint
to [**2-10**] gallon of vodka.
Family History:
Family History: (per OMR notes)
mother and father with stroke and hypertension.
.
Physical Exam:
Admission
Vitals: T: BP: P:114 R: 18 O2: 98% on RA
General: Alert, NAD
HEENT: Several small abraisons on face, no scalp tenderness,
sclera anicteric, MM dry, oropharynx clear.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, no murmurs, rubs.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
[**2130-10-27**] 0755:
At time pt left AMA, pt was AAOx3, was able to clearly state the
risks of leaving AMA even prior to being told the risks,
including possible death. Pt ackowleded these risks and chose
to sign AMA paperwork and leave AMA.
Pertinent Results:
WBC: 6.1
N:62.3 L:30.8 M:5.8 E:0.8 Bas:0.4
HCT: 36.5
PLT: 74
U/A with mod bact, [**4-13**] WBC.
Urine cx neg
Serum ETOH: 79
Serum Tox, Urine Tox: negative
ALT 345 AST 345 LDH 384
CK 3468 -> 1163
.
Images:
CT head w/o contrast (here [**10-23**]) and CT head [**Hospital1 882**]: prelim:no
acute intracranial process.
CT c-cpine: no acute fracture
[**2130-10-26**] 04:17AM BLOOD WBC-5.0 RBC-3.84* Hgb-11.3* Hct-33.7*
MCV-88 MCH-29.5 MCHC-33.7 RDW-16.0* Plt Ct-129*
[**2130-10-27**] 07:40AM BLOOD WBC-PND RBC-PND Hgb-PND Hct-PND MCV-PND
MCH-PND MCHC-PND Plt Ct-PND
[**2130-10-26**] 04:17AM BLOOD Glucose-101 UreaN-8 Creat-0.9 Na-139
K-3.7 Cl-106 HCO3-18* AnGap-19
[**2130-10-27**] 07:40AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
[**2130-10-22**] 05:20AM BLOOD ALT-345* AST-345* LD(LDH)-384*
CK(CPK)-175* AlkPhos-62 TotBili-0.5
[**2130-10-23**] 06:27PM BLOOD ALT-387* AST-401* CK(CPK)-3042*
AlkPhos-62 TotBili-0.8
[**2130-10-25**] 03:57AM BLOOD ALT-289* AST-281* LD(LDH)-454*
CK(CPK)-3468* AlkPhos-55 TotBili-0.8
[**2130-10-26**] 04:17AM BLOOD ALT-273* AST-223* LD(LDH)-358*
CK(CPK)-1163* AlkPhos-58 TotBili-0.7
[**2130-10-26**] 04:17AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.9
[**2130-10-27**] 07:40AM BLOOD Calcium-PND Phos-PND Mg-PND
[**2130-10-23**] 08:30AM BLOOD ASA-NEG Ethanol-79* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2130-10-26**] 05:27AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.021
[**2130-10-26**] 05:27AM URINE Blood-LG Nitrite-POS Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG
[**2130-10-26**] 05:27AM URINE RBC-379* WBC-214* Bacteri-NONE Yeast-NONE
Epi-0
[**2130-10-24**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2130-10-23**] URINE URINE CULTURE- NO GROWTH. FINAL.
[**2130-10-23**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
Brief Hospital Course:
[**Hospital Unit Name 153**] course:
# Altered mental status: most likely due to ETOH withdrawl that
he didn??????t finish during last admission when he left AMA. Also,
with pt??????s h/o seizure and stroke, both could also cause AMS.
Stroke is unlikely bc neuro exam was intact except for chronic
weakness in left arm s/p infection there. Seizure also less
likely bc pt??????s AMS persisted too long. Pt was maintained on CIWA
protocol. Initially, the scores were >20, requiring heavy doses
of IV Ativan and Valium. Code Purple was called during the
night of admission and pt was put in 4 pt restraints. Since
then, pt has imrpoved clinically over time, requiring less and
less of the benzos. Pt is currenlty on PO Valium PRN. Also,
Neuro was following, as per their recs, Keppra dose was inc to
1000mg [**Hospital1 **] and Lamictal was continued. A Lamictal level from
[**10-20**] is still pending. Medications that may reduce his seizure
threshold (i.e., fluoroquinolones, flagyl, antipsychotics) need
to be avoided. Also, they recommended to use zyprexa or
seroquel over halodol if needed for agitation. Also, pt has an
outpatient f/u appt with Neuro.
.
# Thrombocytopenia: Patient intermittently thrombocytopenic over
the last year. Most likely related to ETOH. His plts were
monitored daily. HIT seemed unlikely so SC Heparin was used for
ppx. Pt showed no acute signs of bleeding.
.
# Elev CK: Likely [**3-13**] to injury/ETOH. Hypothyroidism is a
possible cause as well, however TSH wnl recently. CK trending
down since admissionwith IVF hydration.
.
# Transaminitis: During Likely [**3-13**] ETOH abuse. Also, recent Hep
serologies indicate pt is HCV positive. Pt is HIV negative.
Recent [**Month/Day (2) 5283**] U/S with fatty infiltrate but no other abnormality.
Home meds Remeron and Simvastatin were held. Pt could benefit
from an outpatient f/u with liver service.
.
# History of PFO: Pt was continued full dose aspirin.
.
Pt was initially NPO when agitated/disoriented. Once more
stable, was advanced to clears, and ultimately a regular diet.
Pt was maintained on SC Heparin for DVT ppx.
.
On morning following MICU call out, pt signed out against
medical advice. Pt was able to clearly state the risks of
leaving the hospital, including possible death. Patient signed
the AMA form and left the hospital.
Medications on Admission:
Medications: (per D/C summary dated [**10-22**])
Keppra 750mg [**Hospital1 **], then increase to 1000mg [**Hospital1 **] on [**2130-10-25**]
Ativan 1mg [**Hospital1 **], then decrease to 1mg daily on [**2130-10-26**] for 3 days
then stop
Multivitamin Daily
Protonix 40mg Daily
Folate 1mg Daily
Thiamine 100mg Daily
Remeron 30mg QHS
Aspirin 325mg Daily
Fluoxetine 40mg Daily
Lamictal 200mg Daily
Chantix--unsure of dose, patient has been on for 4-6 weeks and
is still smoking
Discharge Medications:
1. Patient left AMA; instructed to resume previous medications,
as would not wait for medication update.
Discharge Disposition:
Home
Discharge Diagnosis:
# Seizures
# Epilepsy
# Alcohol withdrawl
# Left hospital AMA
Discharge Condition:
Against medical advice.
Discharge Instructions:
You were admitted with seizures which may be related to alcohol
withdrawl, and required an admission to the ICU. You have
chosen to leave the hospital against medical advice, which is
extremely dangerous, and you have been warned that you may die.
You acknowledged this risk, and exhibited understanding of this
risk, and signed the Against Medical Advice form.
Please seek medical attention if you develop more seizures or
alcohol withdrawl symptoms.
.
Please resume your medications as per prior to this
hospitalization. Your medications were not able to be updated,
as you refused to complete this hospitalization, and would not
stay for updating.
Followup Instructions:
outpatient epilepsy appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 877**] on [**11-24**].
We have made an appointment for you to see a neurologist on
[**2130-11-24**] at 1:30pm.
|
[
"682.6",
"V60.0",
"291.81",
"728.88",
"300.4",
"438.11",
"571.1",
"070.54",
"287.5",
"276.50",
"345.90",
"745.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9560, 9566
|
6569, 6616
|
296, 302
|
9672, 9698
|
4727, 6546
|
10400, 10617
|
3864, 3932
|
9430, 9537
|
9587, 9651
|
8930, 9407
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9722, 10376
|
3947, 4708
|
235, 258
|
2710, 3016
|
330, 2692
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6631, 8904
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3060, 3550
|
3582, 3832
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,461
| 110,002
|
37337
|
Discharge summary
|
report
|
Admission Date: [**2117-10-27**] Discharge Date: [**2117-11-30**]
Date of Birth: [**2080-10-11**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Sepsis, respiratory failure, pneumonia
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
electrical and chemical cardioversion
placement of left subclavian central venous HD catheter
placement of right IJ venous catheter
placement of right radial arterial line
hemodialysis
History of Present Illness:
Mr. [**Known lastname 83984**] is 37 year old man, with a history of DM, who
presented to [**Hospital6 **] on [**2117-10-21**] after a
syncopal episode. There was a question of a seizure in the field
prior to arrival. Per his family he had a upper respiratory
illness (starting [**10-12**]) with sneezing, cough for 7-10 days
with decreased PO intake and general malasie prior to
presentation. He was in shock on admission, was intubated and
started on levophed and Tamiflu, Levaquin, and Vancomycin. H1N1
was originally suspected, however Flu swab has remained
negative. He developed MSSA in the blood cultures and his
antibiotics were narrowed to naficillin. He remained on
vasopressors until [**10-24**].
His course was complicated by ARF with Cr of 1.9 worsening to
7.2 thought to be [**1-4**] ATN and requiring HD for hyperkalemia to
6. He had a HD line placed on [**10-24**]. He also had intermittant
A. fib treated with Cardizem as well as a wide complex
tachycardia. Echo showed a preserved EF without evidence of
vegitation.
On transport on [**2117-10-27**] he was paralysized and given boluses of
versed and fentanyl. HR remained tachycardic in the 140s.
Past Medical History:
DM - diet controlled
HTN
Social History:
Works as a chef. Lives in [**Location 9583**] with parents. No tobacco
or illicts. Heavy drinker.
Family History:
DMII. Father CAD. Mom RA, CVA, DM. Two brothers with CAD.
Physical Exam:
On Admission:
Vitals T 100.6 P 147 BP152/90 O2 sat. 92% on CMV
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:
[**2117-10-27**] 11:09PM WBC-12.5* RBC-4.12* HGB-12.8* HCT-37.9*
MCV-92 MCH-31.1 MCHC-33.8 RDW-14.8
[**2117-10-27**] 11:09PM NEUTS-82* BANDS-1 LYMPHS-10* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2117-10-27**] 11:09PM PLT COUNT-214
[**2117-10-27**] 11:09PM GLUCOSE-147* UREA N-39* CREAT-5.4* SODIUM-144
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-25 ANION GAP-20
[**2117-10-27**] 11:09PM ALBUMIN-2.2* CALCIUM-7.5* PHOSPHATE-6.0*
MAGNESIUM-2.2
[**2117-10-27**] 11:09PM ALT(SGPT)-52* AST(SGOT)-104* LD(LDH)-437*
CK(CPK)-238* ALK PHOS-260* TOT BILI-5.2*
[**2117-10-27**] 11:09PM PT-14.4* PTT-42.1* INR(PT)-1.2*
.
Discharge labs:
[**2117-11-25**]
Glucose UreaN Creat Na K Cl HCO3 AnGap
84 13 0.8 140 3.9 104 24 16
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
5.9 3.58* 10.8* 33.1* 92 30.0 32.5 15.3 236
.
Imaging:
ECG Study Date of [**2117-10-27**] 10:53:18 PM
Sinus tachycardia. Incomplete right bundle-branch block.
Non-specific
ST-T wave changes. The P-R interval is 160 milliseconds.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
147 160 106 296/448 0 101 -60
.
ECG Study Date of [**2117-11-4**] 3:16:42 AM
Supraventricular tachycardia most likely representing
atrio-ventricular nodal reentrant tachycardia but cannot exclude
orthodromic atrio-ventricular reciprocating tachycardia.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
170 0 84 298/490 0 82 -95
.
CT HEAD W/O CONTRAST Study Date of [**2117-10-28**]
IMPRESSION: No acute intracranial process. Evaluation for
infection is
limited on CT. Sinus disease. Fluid within the mastoid air cells
bilaterally.
.
CT TORSO W/O CONTRAST Study Date of [**2117-10-28**]
IMPRESSION:
1. Evaluation limited due to lack of IV contrast and streak
artifact from
overlying arms. Multifocal pneumonia as seen on recent chest
x-ray.
2. Fatty liver. Otherwise, non-contrast appearance of the
abdomen and pelvis is unremarkable except for small amount of
free fluid.
.
ECHOCARDIOGRAPHY [**2117-11-1**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with borderline normal free
wall function. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. The pulmonary artery
systolic pressure could not be determined. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
.
CHEST (PORTABLE AP) Study Date of [**2117-11-16**]
FINDINGS: In comparison with study of [**11-15**], there is little
overall change in the appearance of the cardiomediastinal
silhouette with extensive right paratracheal thickening.
Extensive left lung consolidation has somewhat decreased since
the previous study. Also, the area of opacification in the right
lung has improved.
.
MR HEAD W/O CONTRAST Study Date of [**2117-11-22**]
IMPRESSION:
1. Extensive confluent T2 and FLAIR hyperintensities throughout
the centrum semiovale and peritrigonal regions without
restricted diffusion. The findings most likely represent
sequelae of a systemic metabolic/hypoxic insult with additional
considerations to include infectious or HIV-related processes
such as PML or viral encephalopathy. Given the marked
hypotension 3 weeks prior, the findings could represent evolving
watershed infarcts with pseudonormalization of the ADC map or
even osmotic demyelination in the appropriate context.
Correlation with the patient's history and followup examination
with gadolinium administration is recommended in further
evaluation.
2. Bilateral mastoid air cell effusions as well as maxillary and
sphenoid
sinus disease, which may in part be related to recent
intubation.
.
MR HEAD W/ CONTRAST Study Date of [**2117-11-22**]
IMPRESSION: Patchy foci of enhancement throughout the signal
abnormality
within the centrum semiovale with primary differential
considerations again including metabolic/hypoxic processes. The
findings could relate to subacute infarcts relating to prior
watershed event or osmotic demyelination. Correlation with CSF
sampling is recommended.
.
EMG Study Date of [**2117-11-24**]
Clinical Interpretation: Complex abnormal study. There is
electrophysiologic evidence for a mild sensorimotor neuropathy
with demyelinating and axonal features. Although this can be
seen in diabetes, the EMG reveals ongoing denervation and
chronic reinnervation in the upper and lower extremities,
suggesting a subacute process. The differential diagnosis
includes critical illness polyneuropathy and axonal variant of
[**First Name9 (NamePattern2) 7816**] [**Location (un) **] syndrome. An incidental moderate median
neuropathy at the left wrist is noted (as in carpal tunnel
syndrome).
.
MICROBIOLOGY:
[**2117-10-31**] 2:19 pm BLOOD CULTURE Source: Line-cvl.
**FINAL REPORT [**2117-11-4**]**
Blood Culture, Routine (Final [**2117-11-3**]):
KLEBSIELLA PNEUMONIAE.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species. FINAL SENSITIVITIES.
sensitivity testing performed by Microscan.
MEROPENEM = SENSITIVE ( <=1 MCG/ML ).
CEFEPIME = RESISTANT ( >=16 MCG/ML ).
UNASYN (AMPICILLIN/SULBACTAM) = RESISTANT ( >=16 MCG/ML
).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN------------ =>16 R
AMPICILLIN/SULBACTAM-- R
CEFAZOLIN------------- =>16 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>16 R
CEFTRIAXONE----------- =>32 R
CIPROFLOXACIN--------- =>2 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- S
PIPERACILLIN/TAZO----- 32 I
TOBRAMYCIN------------ =>64 R
TRIMETHOPRIM/SULFA---- <=2 S
Anaerobic Bottle Gram Stain (Final [**2117-11-1**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 83985**] [**Doctor Last Name 83986**] @ 0340 ON [**11-1**] - CC6D.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2117-11-1**]): GRAM NEGATIVE
ROD(S).
====
[**2117-10-31**] 2:30 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2117-11-3**]**
GRAM STAIN (Final [**2117-10-31**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2117-11-3**]):
Commensal Respiratory Flora Absent.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
286-2926K
[**2117-10-28**].
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 8 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
Brief Hospital Course:
This is a 37 y/o male with [**Hospital **] transfered from an OSH after
presenting in septic shock with Staph pneumonia / bacteremia
with a course complicated by ARF and tachycardia. He grew MSSA
in blood/sputum (at the OSH), Klebsiella in his blood and
klebsiella and pseudomonas in sputum at [**Hospital1 18**].
.
# Severe septic shock: The patient had known bacteremia,
pneumonia and sinus disease by CT scan at admission to OSH.
These findings, in addition to elevated mixed venous O2Sat of
84% and his mottled appearance suggested a septic etiology.
Cardiogenic shock was deemed unlikely, given the pt's robust BP
despite tachycardia to the 170s, high mixed venous O2sat, and
preserved LVEF on ECHO.
.
# Community Acquired Pneumonia: At presentation, the patient's
blood pressure was stable, off pressors. Culture data was
positive for MSSA in the sputum and blood early in OSH course.
CT scan showed a multi-focal pneumonia, with L > R infiltrates,
but no sign of empyema. TTE showed no vegetations. H1N1 was a
consideration, and the pt was initially treated for flu with
Tamiflu; however, after negative influenza DFA x 2 at the OSH
and another negative DFA at [**Hospital1 18**], Tamiflu was stopped. Patient
completed a 14 day course of Meropenem (inititially
nafcillin/meropenem/gentamicin narrowed to Meropenem).
.
# Ventilator-Associated Pneumonia: After intubation at the OSH,
his sputum cultures at BIDCMC grew Klebsiella pneumoniae and
pseudomonas in the sputum, and Klebsiella in the blood. Per ID
consult, patient's antiobitic regimen was changed from
nafcillin/meropenem/gent to: solely Meropenem--with a course
from [**11-5**] (the last negative blood culture) to [**11-19**], for a
total of 14 days.
.
# Klebsiella Bacteremia: Patient was treated with a 14 day
course of meropenam.
.
# Coagulase-negative Staphylococcus Bacteremia: This was felt
to be line-related. Pt was treated with 7 day course of
Vancomycin.
.
# Acute Respiratory Distress: The patient had bilateral
infiltrates on CXR and CT chest and high oxygen requirement. He
had a long course of intubation (18 days), extubated on [**11-10**]
following precedex treatment. At discharge, the patient was
satting well on room air.
.
# Acute renal failure from Acute Tubular Necrosis: Due to
hyperkalemia in the setting of ARF, the pt required HD, and
renal consult service followed him closely. Patient was
oliguric, then had post-ATN diuresis, and renal function
improved considerably, at discharge his Cr was back to baseline.
However, the patient had persistent hypomagnesemia on discharge
requiring daily supplementation, likely [**1-4**] magnesium wasting
from recovering ARF/ATN. He was discharged on magnesium po
supplementation with instructions to f/u labs in rehab.
.
# Mental depression: After extubation, pt was found to have
mental slowing with word-finding difficulties and inattention.
Both improved steadily during the hospitalization. This is most
likely a hypoxic process given the extent of ventilatory support
needed. MRI with and without contrast showed patchy foci of
enhancement throughout the signal abnormality within the centrum
semiovale with primary differential including metabolic/hypoxic
processes, subacute infarcts relating to prior watershed event,
or osmotic demyelination. Neurology suggested that this may be
a congenital defect given the symmetry on MRI; he has no prior
MRIs. LP showed no evidence of bacterial infection but was
notable for elevated protein, mildly low glucose, and only 4
WBCs. This can be c/w but less likely aseptic meningitis, CSF
cultures pending at time of discharge. Patient is scheduled for
neurology f/u as outpt with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**].
.
# Critical illness myopathy: Patient developed myopathy during
his ICU stay. This is most likely critical illness myopathy
given greater proximal than distal muscle weakness, prolonged
failure to wean from mechanical ventilation, and initially
elevated CK. Given elevated protein in CSF and viral prodrome,
GBS is a consideration but less likely. EMG showed mild
sensorimotor neuropathy with demyelinating and axonal features
with differential diagnosis including critical
illness polyneuropathy and axonal variant of [**First Name9 (NamePattern2) 7816**] [**Location (un) **]
syndrome. Neurology felt his history was more consistent with
ICU myopathy. He was followed by physical therapy and by
discharge, his proximal muscles were 4+/5 in strength.
.
# Magnesium deficiency: Pt was noted to be persistently
hypomagnesiemia despite aggressive repletion. He had no other
electrolyte abnormalities, inc. K, Ca. Urinary Mg excretion was
extremely high at 355 mg/24 hr, likely due to postATN tubular
dysfunction. He was started on po repletion and his Mg will
needed to be followed at rehab.
.
# Tachycardia/ AFib: Although the patient's tachycardia appeared
sinus on arrival, during his course he had couple runs of
tachycardia that appeared to be regular SVT with aberrancy that
were self-limited and well-tolerated. His OSH EKG showed RBBB as
recently as [**10-26**], and there were reports of atrial fibrillation
requiring treatment with diltiazem. At one point, the patient
went into regular SVT with aberrancy during dialysis, which was
treated w/ lopressor 10, dilt 20 IV and dilt PO60 with
conversion back to sinus after 1-2 hours. Atrial irritation was
believed due to an IJ that was too deep, and was subsequently
pulled back. During another HD session, he again had aberrant
SVT, thought to be due to intracellular shifts. Finally, the
patient had another episode, during which he underwent
synchronized cardioversion and was chemically cardioverted with
amiodarone and adenosine--after this episode, adenosine was kept
at the bedside. EP was consulted, and 24 hour amiodarone was
completed. The patient had persistent tachycardia and
hypertension during his hospitalization, treated with diltiazem,
metoprolol, amlodipine, and hydralazine. Diltiazem and the
Clonidine patch were discontinued in the MICU. Lisinopril was
initiated. When he was transferred to the medical floor, he was
in NSR. The patient was eventually discharged on lisinopril,
metoprolol and amlodipine (all new medications for him).
.
# Hypertension: The patient was frequently hypertensive to the
170s and 200s SBP. This was treated with a clonidine patch due
to concern of agitation/anxiety as trigger in addition to
diltiazem, metoprolol, amlodipine, hydralazine. Diltiazem and
the Clonidine patch were discontinued in the MICU, and
Lisinopril was initiated. The patient was eventually discharged
on lisinopril, metoprolol and amlodipine.
.
# Rash on back, abdomen, thighs: Appeared to be consistent with
a drug rash, which could have been triggerred by Vanc or
Cefepime, although statistically Cefepime would be more likely.
Both drugs were discontinued on [**10-31**]; and the patient changed
to Meropenem. The rash improved clinically, became less
erythematous, and was treated with clobetasol [**Hospital1 **] 0.05% for
abdomen, and clotrimazole/hydro groin cream for rash. Vancomycin
was later added back on, without worsening of the patient's
rash--further increasing our suspicion that Cefepime was the
culprit. This rash had resolved by discharge and the
clotrimazole and hydrocortisone cream were not continued.
.
# Sacral decubitus ulcer, stage 2: This was cared for by
nursning.
.
# DM2: Patient was diet controlled prior to admission. He was
treated with glargine 50 units qHS and ISS. His insulin
requirements improved as he clinically improved. Would suggest
discharging patient on glargine and insulin sliding scale. He
will need teaching related to using insulin and using a sliding
scale. Please make sure he has close follow up with his PCP.
# Demand ischemia: During this hospitalization the patient
presented with elevated troponin and CK, but CKMB was normal
(2). This elevation was thought to be due to demand ischemia in
the setting of shock and persistent tachycardia, as well as
renal insufficiency. Cardiac enzymes were trended, and his
Troponin did not continue to rise.
.
# Mild LFT elevation: This was thought to be [**1-4**] prolonged
hypotension. His LFTs normalized over the course of his
hospitalization.
.
# Code: Full code confirmed
Medications on Admission:
Home: None
.
Medications on Transfer:
Novolog SS
Multivit
nafcilliln 2g q4h start [**10-24**]
Oseltamivir 90 mg [**Hospital1 **] started [**10-22**]
Pantoprazole 40mg IV daily
propofol gtt
acematinophen 1000mg q6h prn
ibuprofen 600mg q8h prn
morphine 2mg IV prn
NTG SL prn
Levalbuterol HFA 4 puffs q6hs
artifical tears oint q4hs
ASA 325mg Daily
Chlorhexidien 15ml q12h
plavix 75mg daily
Heparin gtt started [**10-24**]
.
previous meds in OSH:
enoxaparin 40mg daily start [**10-22**], d/c [**10-25**]
diltiazem gtt started [**10-23**], d/c [**10-25**]
levofloxacin 750mg q48h start [**10-24**], d/c [**10-25**]
digoxin 0.125 x 2 on [**10-23**]
Vancomcyin 1g IV start [**10-22**]
Discharge Medications:
1. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
3. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
4. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) unit
Subcutaneous at bedtime.
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal TID PRN () as needed for hemorrhoid.
7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Magnesium Oxide 400 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
11. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four
times a day: dose based on sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] State Hospital
Discharge Diagnosis:
Primary Diagnoses:
- Community Acquired Pneumonia: Methicillin Sensitive Staph
Aureus pneumonia.
- Ventilator Associated Pneumonia: Multi-Drug-Resistant
Klebsiella and Pseudomonas.
- Bacteremia
- Septic shock
- Supra-Ventricular Tachycardia with aberrancy
- Intensive Care Unit myopathy.
- Acute Renal Failure
- Magnesium wasting
- Encephalopathy
- Extensive T2/FLAIR hyperintensities deep white matter not
otherwise specified
- Stage II sacral decubitus ulcer
Secondary:
- Diabetes mellitus type II
- Hypertension
Discharge Condition:
Afebrile, satting well on room air. Patient is alert, speaking
in short sentences and following commands/answering questions.
.
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
It was a pleasure to be involved in your care, Mr. [**Known lastname 83984**].
You were hospitalized at [**Hospital1 18**] for septic shock--low blood
pressure due to an infection. You had a severe pneumonia (a lung
infection) and blood infection, which required placement of a
breathing tube, intra-venous antibiotics and a prolonged stay in
the Medical ICU. As a result of your infection, your kidneys
gave out, and you required hemodialysis--however, with
improvement of your infection, your kidneys function improved
and returned to [**Location 213**]. At times during your hospitalization,
your heart rate became very fast and your blood pressure was
very elevated--this was treated with medications, and has since
resolved. Because of prolonged ICU stay, your muscle has become
very weak, and you need aggressive physical therapy to regain
your strength.
You also underwent brain MRI because you had some confusion
after you were extubated. The MRI had some abnormalities,
likely due to how sick you were. You then underwent a procedure
called lumbar puncture to further evaluate these changes noted
in MRIs; no active infection was found. You were also seen by
Neurology specialists.
NEW MEDICATIONS:
--Magnesium oxide
--Colace
--Multivitamin
--Linsinopril
--Pramoxine-Minreral Oil Rectal Ointment
--Clotrimazole
--Insulin Glargine
--Insulin
Followup Instructions:
You have an appointment to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
(Neurology).
Date: [**2116-12-30**]
Time: 11:00am
Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg. Floor 8
Please make sure you call patient registration before coming to
the appointment([**Telephone/Fax (1) 22161**]
Please make an appointment to see your Primary Care Physician
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42394**] [**Telephone/Fax (1) 83987**] within 1 week of discharge from
rehab. Make sure you have your blood sugar checked at this visit
as you were started on an insulin regimen for diabetes while you
were an inpatient.
|
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icd9cm
|
[
[
[]
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] |
[
"96.04",
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[
[
[]
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20364, 20422
|
10374, 18699
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309, 535
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20982, 21111
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2537, 2537
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22662, 23400
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1913, 1972
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19428, 20341
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3194, 10351
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1987, 1987
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231, 271
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563, 1733
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2553, 3178
|
2001, 2518
|
21125, 21257
|
18764, 19405
|
1755, 1782
|
1798, 1897
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,264
| 135,431
|
41840
|
Discharge summary
|
report
|
Admission Date: [**2188-10-16**] Discharge Date: [**2188-11-7**]
Date of Birth: [**2107-9-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2188-10-16**] Coronary artery bypass grafting (Left interior mammary
artery to left anterior descending, saphenous vein graft to
diagonal, saphenous vein graft to obtuse marginal, saphenous
vein to right coronary artery)
[**2188-10-20**] emergency L femoral Thrombectomy /angioplasty
History of Present Illness:
Ms. [**Known lastname 90871**] is an 81 year old female who was admitted to vascular
surgery with severe bilateral lower extremity claudication. She
has been followed for aortic stenosis with serial echos, but
recently had an abnormal stress test. A cardiac catheterization
revealed severe three vessel coronary artery disease. She was
referred for cardiac surgery prior to any peripheral
revascularization.
Past Medical History:
severe peripheral vascular disease (R>L claudication)
non insulin dependent diabetes mellitus
atrial fibrillation
aortic stenosis
Bilateral foot neuropathy
chronic obstructive pulmonary disease
CVA [**2170**] (no residual deficit)
paroxysmal atrial fibrillation
hypertension
depression
osteoarthritis
hypothyroidism
hypercholesterolemia
peptic ulcer disease
ventral hernia
eczema
gastric ulcer repair [**2174**]
incisional herniorrhaphy
Bilateral cataract extractions
Social History:
Ms. [**Known lastname 90871**] lives alone and has family in [**State 1727**]. She is retired.
She quit smoking 18 years ago and has a 50-100 pack year
history. She reports drinking less than one alcoholic beverage
per week.
Family History:
Ms. [**Known lastname 90872**] sister died of a myocardial infarction at age 54.
Her son [**Known lastname 1834**] a coronary artery bypass grafting and aortic
valve replacement in his 50s.
Physical Exam:
Pulse:64 Resp: 16 O2 sat: 99%
B/P Right: 163/70 Left: 161/62
Height: 63" Weight: 155
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD appreciated
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade _3/6 SEm radiates
throughout precordium and carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x];no HSM; well-healed abd scars
Extremities: Warm [x], well-perfused [x] Edema []none _____
Varicosities: Bilateral R > L
Neuro: Grossly intact [x]; MAE [**5-15**] strengths; nonfocal exam
Pulses:
Femoral Right: NP Left:1+
DP Right: NP Left:NP
PT [**Name (NI) 167**]: NP Left:NP
Radial Right: trace Left:1+
Carotid Bruit : murmur radiates to B carotids
Pertinent Results:
Admission Labs;
[**2188-10-15**] 04:00PM URINE RBC-0 WBC-10* BACTERIA-NONE YEAST-NONE
EPI-1 RENAL EPI-<1
[**2188-10-15**] 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
[**2188-10-15**] 04:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2188-10-15**] 04:00PM PT-12.1 PTT-22.4 INR(PT)-1.0
[**2188-10-15**] 04:00PM PLT COUNT-306
[**2188-10-15**] 04:00PM NEUTS-64.7 LYMPHS-28.4 MONOS-3.6 EOS-2.6
BASOS-0.7
[**2188-10-15**] 04:00PM WBC-11.8* RBC-3.63* HGB-11.3* HCT-33.0*
MCV-91 MCH-31.0 MCHC-34.1 RDW-12.5
[**2188-10-15**] 04:00PM %HbA1c-7.0* eAG-154*
[**2188-10-15**] 04:00PM TOT PROT-7.3 ALBUMIN-4.7 GLOBULIN-2.6
[**2188-10-15**] 04:00PM ALT(SGPT)-20 AST(SGOT)-22 LD(LDH)-208 ALK
PHOS-51 TOT BILI-0.2
[**2188-10-15**] 04:00PM UREA N-35* CREAT-1.6*
SODIUM-142 POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-24 ANION
GAP-22*
TEE [**2188-10-16**]:Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Doppler parameters are most consistent with normal left
ventricular diastolic function. Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the ascending aorta. There are complex (>4mm) atheroma in the
aortic arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
Trivial mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at
time of surgery.
POST-BYPASS: The patient is AV paced. The patient is on no
inotropes. Biventricular function is unchanged. Mitral
regurgitation is unchanged. Aortic stenosis is unchanged. The
aorta is intact post-decannulation.
Discharge labs:
[**2188-11-7**] 03:03AM BLOOD WBC-28.2*# RBC-3.01* Hgb-9.2* Hct-29.1*
MCV-97 MCH-30.7 MCHC-31.8 RDW-15.7* Plt Ct-194
[**2188-11-7**] 03:03AM BLOOD Plt Ct-194
[**2188-11-7**] 03:03AM BLOOD PT-22.9* PTT-50.4* INR(PT)-2.1*
[**2188-11-7**] 03:03AM BLOOD Glucose-74 UreaN-61* Creat-4.1*# Na-141
K-4.7 Cl-100 HCO3-21* AnGap-25*
[**2188-11-5**] 06:44PM BLOOD ALT-59* AST-91* LD(LDH)-316* AlkPhos-165*
Amylase-362* TotBili-2.3*
[**2188-11-7**] 08:24AM BLOOD Type-CENTRAL VE pH-7.21* calTCO2-14*
[**2188-11-7**] 08:24AM BLOOD Glucose-13* Lactate-14.3* Na-138 K-5.4*
Cl-103 calHCO3-14*
Brief Hospital Course:
On [**2188-10-16**] Ms. [**Known lastname 90871**] [**Last Name (Titles) 1834**] coronary artery bypass grafting
times four performed by Dr. [**First Name (STitle) **] [**Name (STitle) **]. Please see the
operative note for details. She tolerated the procedure well
and was transferred in critical but stable condition to the
surgical intensive care unit. She was extubated and did well
initially. Beta blockade was resumed and she was diuresed
towards her preoperative weight.
Her atrial fibrillation was somewhat difficult to control from a
rate standpoint.
Coumadin was given for the fibrillation. On [**10-19**] she acutely
became cyanotic, hypotensive and lethargic. She was brought
emergently to the ICU, intubated, a Swan Ganz catheter placed,
arterial monitoring begun as well. her initial BP was in the
60's with a cardiac index of 0.6. Epinephrine, Milrinone and
Neo Synephrine were begun with improvement of all parameters
over an hour or so. The index rose to >2 and pressors were
weaned. She became anuric despite adequate BP,CI and correction
of her acidosis. Her legs were severely mottled, but the left
failed to resolve and was pulseless.
She was taken to the Operating Room by Dr. [**Last Name (STitle) **] for
thrombectomy and angioplasty of the left common femoral artery.
She remained anuric and CVVH was begun. HD was susequently
tolerated and she was transitioned to this. She awoke,
seemingly intact after the initial insult. She also had a
significant rise in her liver enzymes. She developed
thrombocytopenia and ultimately was HIT assay
negative.Argatroban was changed back to heparin. The platelet
count continued to improve slowly. She had some rectal bleeding
which resolved. Tube feeds were started. GNR bacteremia was
treated with meropenem.
The patient was extubated and seemed to be progressing toward
discharge to rehabilitation. On POD22 the patient became
increasingly lethargic, see lost the pulse in her right leg and
was becoming increasingly acidotic. After a discussion with both
sons it was decided not to pursue any further agressive therapy,
she was made comfort measures only and passed away a short time
later.
Medications on Admission:
ALPRAZOLAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1
Tablet(s) by mouth twice a day
CLONIDINE - (Prescribed by Other Provider) - 0.2 mg Tablet - 1
Tablet(s) by mouth twice a day
DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1
Tablet(s) by mouth once a day
FLUOXETINE - (Prescribed by Other Provider) - 20 mg Capsule - 1
Capsule(s) by mouth once a day
GLYBURIDE - (Prescribed by Other Provider) - 5 mg Tablet - 2
Tablet(s) by mouth twice a day
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 60 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day
LANSOPRAZOLE [PREVACID SOLUTAB] - (Prescribed by Other
Provider)
- 30 mg Tablet,Rapid Dissolve, DR - 1 Tablet(s) by mouth once a
day
LEVOTHYROXINE - (Prescribed by Other Provider) - 25 mcg Tablet
-
1 Tablet(s) by mouth once a day
LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth twice a day
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 2
Tablet(s) by mouth twice a day
ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth once a day
TRIAMTERENE-HYDROCHLOROTHIAZID - (Prescribed by Other Provider)
- 37.5 mg-25 mg Capsule - 1 Capsule(s) by mouth once a day
VERAPAMIL - (Prescribed by Other Provider) - 240 mg Cap,Ext
Release Pellets 24 hr - 1 Cap(s) by mouth once a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth once a
day
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2188-11-13**]
|
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272, 293
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76,327
| 142,755
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33347
|
Discharge summary
|
report
|
Admission Date: [**2147-10-25**] Discharge Date: [**2147-11-22**]
Date of Birth: [**2106-1-28**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Adhesive Bandage
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
intubation x 4 [**10-25**], [**10-27**], [**11-4**], [**11-8**]
History of Present Illness:
HPI: 41 yo M with PMH of pulmonary hypertension, ESLD from
alcohol and hepatitis C on [**Month/Year (2) **] list, hypothyroidism who
presents with altered mental status. He is currently intubated
so history taken from his mother over the phone and from [**Name (NI) **] and
chart. The day prior to presentation, the patient was
complaining of feeling sick and nauseated. He vomited several
times but did take all of his medications per his mother as she
gives them to him. She went to check on him the morning of
presentation and he was unresponsive and gagging on emesis. She
called EMS. She reports that the patient has been having 2 bowel
movements per day over the last two days. Denies known fevers,
chills, diarrhea, abdominal pain. Of note, he has gained
significant weight and his spironolactone was increased from 100
to 200mg daily and then up to 300mg on [**2147-10-24**].
.
At the OSH, he was intubated for airway protection. CXR was
negative for infiltrate, u/a was clean and CT of the head was
negative for an acute process. He was given lasix 100mg x1 and
transferred to [**Hospital1 18**] ED.
.
In our ED, his initial vitals were T 96.4, HR 104, BP 132/87,
100% o2sat on vent. He had a repeat CXR to confirm his ETT
placement. A RUQ u/s showed small stones and marked ascites, and
he had a diagnostic paracentesis. He was given levo/flagyl
empirically and was given lactulose.
.
Currently, he is on the vent, but following some commands and
denies pain.
Past Medical History:
-ESLD secondary to alcohol and hepatitis C on [**Hospital1 **] list
-grade 1 esophageal varices
-pulmonary hypertension
-hypothyroidism
-anxiety disorder
-h/o ETOH and IVDU
-osteoporosis
Social History:
Pt lives with his Mother. Pt quit smoking [**5-29**], was smoking
1/3ppd. Quit drinking etoh 11 years ago. Prior remote hx of IVD
as teen. No current drug use.
Family History:
Mother with DM and HTN. Father with rheumatic heart disease.
Physical Exam:
General Appearance: Anxious, jaundice
Eyes/Conjunctiva: PERRL, scleral icterus
Head, Ears, Nose, Throat: MMM, no LAD
Cardiovascular: normal s1/s2, tachycardic with systolic murmur
difficult to characterize given tachycardia
Pulm: CTA b/l
Abdominal: Non-tender, Bowel sounds present, Distended with
clinical ascites, no tenderness
Extremities: Right: 2+, Left: 2+, No Cyanosis, + Clubbing
Neurologic: Follows commands, no clonus, no asterixis noted
Pertinent Results:
Labs on Admission:
[**2147-10-25**] 07:51PM BLOOD WBC-11.7* RBC-2.77* Hgb-9.5* Hct-27.9*
MCV-101* MCH-34.4* MCHC-34.1 RDW-18.8* Plt Ct-94*
[**2147-10-25**] 07:51PM BLOOD PT-19.9* PTT-41.2* INR(PT)-1.9*
[**2147-10-25**] 07:51PM BLOOD Glucose-100 UreaN-22* Creat-0.8 Na-135
K-3.8 Cl-103 HCO3-25 AnGap-11
[**2147-10-25**] 07:51PM BLOOD ALT-69* AST-125* LD(LDH)-371*
AlkPhos-146* TotBili-7.7*
[**2147-10-25**] 07:51PM BLOOD Albumin-2.6* Calcium-8.6 Phos-3.7 Mg-2.1
[**2147-10-25**] 07:57PM BLOOD Type-ART pO2-205* pCO2-29* pH-7.54*
calTCO2-26 Base XS-3
[**2147-10-25**] 07:57PM BLOOD Lactate-2.2*
[**2147-10-25**] 03:44PM ASCITES WBC-90* RBC-315* Polys-7* Lymphs-13*
Monos-0 Plasma-1* Mesothe-7* Macroph-72*
[**2147-10-25**] 03:44PM ASCITES TotPro-573 Glucose-133 Albumin-PND
.
Labs on Discharge:
[**2147-11-22**] 06:15AM BLOOD WBC-7.1 RBC-2.72* Hgb-9.2* Hct-26.2*
MCV-97 MCH-34.0* MCHC-35.2* RDW-18.5* Plt Ct-84*
[**2147-11-15**] 12:06AM BLOOD Neuts-79.9* Lymphs-13.0* Monos-6.5
Eos-0.4 Baso-0.1
[**2147-11-22**] 06:15AM BLOOD PT-25.1* PTT-53.8* INR(PT)-2.5*
[**2147-11-22**] 06:15AM BLOOD Plt Ct-84*
[**2147-11-22**] 06:15AM BLOOD Glucose-98 UreaN-10 Creat-0.9 Na-134
K-3.4 Cl-108 HCO3-17* AnGap-12
[**2147-11-22**] 06:15AM BLOOD ALT-65* AST-153* AlkPhos-221*
TotBili-6.5*
.
Imaging:
[**2147-10-25**] RUQ U/S: Limited study due to marked ascites.
1. Cirrhotic, shrunken liver. 2. Thickened, collapsed
gallbladder with multiple shadowing echogenic foci consistent
with calcified gallstones. Possible stone within the neck.
.
[**2147-10-25**] CXR: The lungs are of low volume, most likely due to
poor inspiratory effort. The cardiomediastinal silhouette is
stable. There are no focal pulmonary consolidations.
.
[**2147-11-15**] Abd US:
1. Findings consistent with liver cirrhosis, no focal lesion.
2. Patent hepatic vasculature.
3. Cholelithiasis.
4. Splenomegaly.
5. Large abdominal ascites.
.
[**2147-11-15**] CXR: The heart is not enlarged. There is no CHF, focal
infiltrate, or effusion. Compared with [**2147-11-10**], the ET tube and
NG tube have been removed. Note is made of a subtle narrowing of
the upper trachea, at a level approximately 6.1 cm above the
carina -- ? subtle tracheomalacia.
.
ECHO [**2147-11-21**]: The left atrium is normal in size. A secundum
type atrial septal defect is probably present. The estimated
right atrial pressure is 10-20mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**12-21**]+) mitral regurgitation is seen.
There is mild to moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION: Mild
to moderate pulmonary hypertension (estimated PASP 42-52 mm Hg).
Preserved regional and global biventricular systolic function.
Mild to moderate mitral regurgitation. Probable secundum type
atrial septal defect (known positive bubble study on [**2147-8-15**]).
Compared with the prior study (images reviewed) of [**2147-10-20**],
estimated pulmonary artery systolic pressure is slightly higher
(IVC not well visualized on prior study).
Brief Hospital Course:
Brief Hospital Course:
OSH course [**10-25**]
41 yo male with pmh of pulmonary htn, ESLD from etoh/hepC on the
[**Month/Day (1) **] list, admitted on [**10-25**] after being found down with
altered mental status and vomitting by his mother on [**10-24**].
[**Name2 (NI) 3003**] to admission he had nonbloody n/v x 2 days and it was
thought that he may have not taken his lactulose. When his
mother found him down, EMS took him to an OSH where he was
intubated for airway protection. Imaging including CXR and CT
head were unremarkable. He was given 100 mg IV lasix x1 and
tansferred to [**Hospital1 18**].
.
ED and Initial MICU course [**Date range (1) 77407**]
In our ED he was given levo/flagyl and a diagnostic para was
done which didn't showed evidence of SBP. He was given
lactulose in the MICU and was extubated on [**10-25**] as his mental
status cleared. Levo/flagyl was stopped and he was continued on
his prophylactic cipro. His Tbili began to increase to 8.5 (was
baseline [**3-25**]) and an abd US showed stones with a posssible stone
at the neck of the gallbladder.
.
[**Doctor Last Name 3271**]-[**Doctor Last Name 679**] course [**Date range (1) 77408**]
He was called out to the floor on [**10-26**] and had a therapeutic
para which removed 4 L of fluid and showed no evidence of SBP.
The morning after transfer on [**10-27**] he was found unresponsive and
hypoxic to the 80's. A code was called and he was intubated for
airway protection and transfered to the MICU.
.
MICU course [**Date range (1) 45409**]
While in the ICU the patient was given lactulose. A CT of his
chest showed no evidence of pneumonia or aspiration. There was
initally concern for decreased withdrawal in his lower
extremities and neuro was consulted for concern for possible
seizure activity or other neurologic involvement. He had a head
CT on [**10-27**] which showed no acute change, but did identify
possible partial collapse of the superior endplate of the C5
vertebral body. He had a normal MRA of the neck and an MRI of
his head showed no acute infarct and some increased signal in
the basal ganglia which is consistent with hepatic
encephalopathy.
.
He was extubated on the morning of [**10-28**] after his mental status
improved with lactulose. He was fed through a NGT during his
stay due to concern for aspiration, however this was removed
prior to his transfer to the floor.
.
[**Doctor Last Name 3271**]-[**Doctor Last Name 679**] course [**Date range (1) 77409**]
He was on the floor from [**10-28**] to [**11-4**] with clearing of his
mental status on lactulose.
.
MICU course [**Date range (1) 40579**]
On the morning of [**11-4**] he was found to have an acute change in
mental status, was not following commands, and was without a gag
reflex, so a respiratory code was called and he was intubated
for airway protection. He was transferred to the ICU where he
was given lactulose with clearing of his mental status. He was
extubated on [**11-5**]. During his stay in the ICU he experience
some abdominal pain and constipation and underwent a CT of his
abd/pelvis which showed no bowel obstruction. He then had a
bowel movement with relief of his pain.
.
[**Doctor Last Name 3271**]-[**Doctor Last Name 679**] course [**Date range (1) 63832**]
He was then on the floor from [**11-6**] to [**11-8**]. He was
hyponatremic so his diuretics were held and he was on fluid
restriction. On the morning of [**11-9**] he was found unresponsive
and was not prtoecting his airway. He had a small amount of
blood running from his nose. A NGT was placed, but no blood
returned. A code was called for respiratory depression and he
was intubated (for the fourth time this hospitalization).
.
MICU course [**Date range (1) 76199**]
In the ICU he was given lactulose and quickly responded and was
extubated. There was discussion about possibly placing a trach,
but as the ultimate cause of his respiratory depression is
[**Last Name (un) 5487**] it was decided to hold off on this.
.
He was continued on CPAP at night with a scheduled overnight
lactulose dose. He had underwent a therapeutic para on [**11-6**] on
the floor which showed 70 WBCs with 7% polys. On [**11-10**] the
ascitic fluid grew out coag neg staph. As he hasn't been
febrile, had abdominal pain, or a leukocytosis, this was not
treated as it was likely a contaminant. Sildenafil was
restarted for his pulmonary hypertension.
.
[**Doctor Last Name 3271**]-Try course [**Date range (1) 77410**]
He was transferred back to the floor on [**11-13**] and only remained
there for one day during which he had ARF with a Cr of 1.6. His
diuretics were stopped. The early morning of [**11-15**] he had an
acute change of mental status (had decreased recent bowel
movements in response to lactulose in the setting of nausea and
vomiting some of the lactulose). He attributed his nausea to
flagyl which had been started to decrease the risk of
encephalopathy. Flagyl was stopped. He was transferred to the
MICU where he received increased amounts of lactulose.
.
MICU course [**11-15**] - [**11-16**]
On the evening of transfer he triggered on the floor for altered
mental status and lack of bowel movement despite multiple doses
of lactulose. On review of records, he did have 6 bowel
movements earlier in the day, however he seemed to have stopped
responding to lactulose during the evening. Of note, his
creatinine was elevated to 1.6 above his baseline of 1 which was
new for him. On arrival to the ICU he was delerious and
combative, requiring 4-point restraints for staff safety as well
as to keep him from putting tubes and lines. He was given
haldol 2.5 mg IV x 2 and a lactulose enema. His encephalopathy
cleared by morning. He had a RUQ ultrasound that showed normal
hepatic blood flow and a large amount of abdominal ascities.
.
On his morning labs his hematocrit had dropped from 24 to 21 and
he had an INR of 2.5. His stools were guiaic positive but brown
in color. Additionally he spiked a fever of 100.7. He was
transfused with 1 unit of pack RBCs and 2 units of FFP and then
underwent a diagnositic paracentesis that showed no evidence of
SBP. He was also pan-cultured. His fever defervesed. His
hematocrit was initially stable at 24 post-transfusion but
dropped to 22.2 by the following morning. He continued to have
brown stools and no other obvious source of bleeding. He
remained alert and oriented without further encephalopathy.
Pantoprazole was increased to Q12H given his likely slow GI
ooze. Per hepatology recs his sildenafil was stopped as it was
thought that this medication might be contributing to agitation.
.
[**Doctor Last Name 3271**]-[**Doctor Last Name 679**] course 11/27-11/
The patient has been alert and oriented x3 on the floor and
wears his CPAP at night. Plan is for EGD on Monday to evaluate
for varices given guiaic positive stools and anemia.
.
Patient's main medical issues during this hospitalization:
.
# Change in mental status/Respiratory status: His frequent
episodes of hepatic encephalopathy have an unknown precipitant.
He has had four episodes of change in mental status with
decreased airway protection which required intubation. There
was concern that other processes such as OSA or central sleep
apnea could be contributing. He underwent a sleep study here
which showed mild OSA. He was started on CPAP at night (prior
to his 4th intubation). He was also started on a scheduled
overnight lactulose dose at 2am to decrease the risk of him
having too little lacutlose overnight (as all of his episodes
have occured in the early morning. His sildenafil (for
pulmonary hypertension) was stopped as below.
.
# ESLD: The patient has hepatic cirrhosis secondary to alcohol
and hepatitis C. He is followed by Dr. [**Last Name (STitle) 497**] and on the
[**Last Name (STitle) **] list. On admission his Tbili was more elevated than
his baseline of [**3-25**], however this trended down to his baseline
during the hospitalization. He was continued on rifaximin and
lactulose as above. His diuretics were initally continued,
however they were stopped and restarted multiple times due to
hyponatremia and acute renal failure. Eventually it was decided
to indefinately hold his diuretics as he seemed to decompensate
in some fashion every time they were restarted.
.
The patient's underwent a paracentesis on [**10-26**] during which 4 L
were removed, however the para site continued to spontaneously
drain multiple liters of fluid per day for a few days after the
procedure. He had additional therapeutic paracentesis on [**11-6**]
6 L and [**2147-11-22**] 7 L removed. He was continued on ciprofloxacin
for SBP ppx.
.
# Anemia/Thrombocytopenia: The patient is chronically anemia
and thrombocytopenic. He is Hct and Plts remained within their
baseline range during this hospitalization initally. During his
4th MICU course his Hct dropped to 21 and he had guiaic positive
stool. He was transfused 1 unit of PRBC and 2 units of FFP and
his Hct increased appropriately and remained stable. He
underwent an EGD Monday, [**2147-11-20**] which demonstrated 4
cords of grade II varices were seen in the middle third of the
esophagus and lower third of the esophagus. The varices were not
bleeding. He was started on Nadolol 20 mg qd.
.
# Hypothyroidism: The patient's TSH was found to be elevated at
4.9 His dose of levothyroxine was increased to 88mcg per day.
He will need to have his TSH checked in 4 weeks as an
outpatient.
.
# Pulmonary hypertension: He was continued on Sildenafil for
pulmonary hypertension initally. He was not able to receive
Iloprost initially while inpatient because it was not on
formulary and his mother was going to bring it in. He was
restarted on it in the middle of his hospitalization. His
sildenafil was stopped after he had multiple episodes of acute
respiratory decline as it can theoretically cause an increase in
vasodilation of the upperairways and worsen OSA. His outpatient
pulmonalogist was made aware. Patient had an ECHO which
demonstrated Mild to moderate pulmonary hypertension (estimated
PASP 42-52 mm Hg). The estimated pulmonary artery systolic
pressure is slightly higher, however IVC not visualized on prior
study therefore artery pressure artificially lower.
- Patient was not discharged on Sildenafil and will require f/u
ECHO to assess for worsening pulmonary hypertension. Worsening
pulmonary HTN will prevent him from being a [**Year (4 digits) **]
candidate.
Medications on Admission:
1. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
2. Lactulose 10 gram/15 mL Solution Sig: One (1) PO four times
a day: Take up to 4 times per day as needed to have [**2-21**] bowel
movements per day.
3. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID
4. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO three times a
day: also known as Revatio.
5. Iloprost Inhalation
6. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID as needed
for cramps.
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID
9. CALCIUM 500+D 500 (1,250)-400 mg-unit Tablet, Chewable Sig:
One (1) Tablet, Chewable PO twice a day.
10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day: Do not take at same time as Ciprofloxacin.
11. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia.
12. Spironolactone 300 mg Tablet PO DAILY
13. Hyoscyamine Sulfate 0.15 mg Tablet Sig: One (1) Tablet PO
three times a day as needed for cramps.
14. Furosemide 40mg [**Hospital1 **]
Discharge Medications:
1. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
2. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q2H
(every 2 hours) as needed for confusion.
3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. CALCIUM 500+D 500 (1,250)-400 mg-unit Tablet, Chewable Sig:
One (1) Tablet, Chewable PO once a day.
7. Magnesium 200 mg Tablet Sig: Two (2) Tablet PO once a day: Do
not take at same time as Ciprofloxacin. .
Disp:*60 Tablet(s)* Refills:*2*
8. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO QID
(4 times a day).
Disp:*qs qs* Refills:*2*
9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Home oxygen
2L continuous pulse dose for portability. Patient: [**Known lastname **],[**Known firstname **]
[**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Number: [**Medical Record Number 77411**] [**2106-1-28**] Address: [**Street Address(2) 77412**]
[**Location (un) **],[**Numeric Identifier 77413**] Diagnosis: Obstructive sleep apnea, COPD
11. CPAP
5 - 15 CM H2O Patient: [**Known lastname **],[**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Number: [**Medical Record Number 77411**] [**1-28**],[**2105**] Address: [**Street Address(2) 77412**] [**Location (un) **],[**Numeric Identifier 77413**] Diagnosis:
Obstructive sleep apnea, COPD Without CPAP: [**2147-11-8**] sat 57%.
12. Iloprost 10 mcg/mL Solution for Nebulization Sig: One (1)
nebulizer treatment Inhalation 6x daily.
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA SE MASS
Discharge Diagnosis:
Primary -
End-stage liver disease
Obstructive sleep apnea
Recurrent ascites
Pulmonary hypertension
Discharge Condition:
Good, ambulating, stable vitals.
Discharge Instructions:
You were admitted to the hospital due to decreased mental status
and decreased airway protection which required intubation
(breathing tube). You had three further episodes of decreased
mental status and decreased airway protection caused by
obstructive sleep apnea.
Because of this, you were started on CPAP (breathing machine) at
night. It is very important to wear your CPAP every night.
We have stopped your Sildenafil (Revatio) as this may worsen
your sleep apnea. You should no longer take this medication at
home.
You will need an ECHO in 1 month (due [**2146-12-22**]) to assess your
heart/pulmonary hypertension.
Please review your medication list closely. We have made the
following changes:
1) Stopped Sildenafil due to increased risk of sleep apnea
2) Stopped Lasix and Spironolactone due to low sodium. Do not
re-start until told by your Liver doctor.
3) DO NOT TAKE ANY SEDATING MEDS OR OPIODS (this includes your
prior scripts of trazadone, cyclobenzaprine).
4) We have increased your doses of Lactulose and Rifaximin
5) We have increased your dose of Levothyroxine
It is very important to take your Iloprost as prescribed.
Otherwise, take all your medication as prescribed by your
doctor.
Attend all your follow up appointments. You will need an ECHO in
1 month (due [**2146-12-22**]) to assess pulmonary hypertension.
Return to the ER or call your doctor if you experience fever,
chills, nausea, vomiting, abdominal pain, bleeding or other
concerning symptoms.
Followup Instructions:
Please keep your previously scheduled appointments:
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2147-11-29**] 1:40. Please tell them you will need an ECHO
in 1 month (due [**2146-12-22**]) to assess pulmonary hypertension.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2148-1-15**] 8:55
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2148-1-15**] 9:15
Completed by:[**2147-11-28**]
|
[
"327.23",
"287.5",
"571.5",
"070.44",
"416.8",
"276.3",
"571.2",
"789.59",
"244.9",
"285.9",
"518.81",
"787.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"54.91",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
19834, 19876
|
6320, 16772
|
316, 382
|
20019, 20054
|
2831, 2836
|
21586, 22166
|
2285, 2347
|
17921, 19811
|
19897, 19998
|
16798, 17898
|
20078, 21563
|
2362, 2812
|
255, 278
|
3624, 6274
|
410, 1881
|
2850, 3605
|
1903, 2091
|
2107, 2269
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,518
| 171,197
|
39053
|
Discharge summary
|
report
|
Admission Date: [**2159-4-4**] Discharge Date: [**2159-4-10**]
Date of Birth: [**2140-10-6**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Fall from height ~50ft
Major Surgical or Invasive Procedure:
[**2159-4-5**]
1. Irrigation and debridement open pelvic fracture down to
and inclusive of bone.
2. Open reduction internal fixation right acetabular
fracture with retrograde anterior column screw.
3. Examination under anesthesia with stress on fluoroscopy
for stability for assessment of pelvic stability.
[**2159-4-6**]
1. Application of halo vest.
2. Closed reduction under fluoroscopic guidance of odontoid
fracture.
History of Present Illness:
18 y/o M s/p fall from 50 feet; +EtOH. ? LOC. Presents to [**Hospital1 18**]
ED with bilateral pulmonary contusions, small left apical
pneumothorax and orthopaedic injuries including open right
acetabular fracture and Type II dens fracture.
Past Medical History:
Denies
Family History:
Noncontributory
Physical Exam:
Constitutional: Anxious
HEENT: 2 cm left forehead wound, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Tachycardic, regular
Abdominal: Nondistended, Nontender, Soft
GU/Flank: No costovertebral angle tenderness
Extr/Back: Wounds over right superior iliac crest and
femoral triangle, wound over left lower leg
Skin: Abrasions over left chest and left thigh
Neuro: Speech fluent
Psych: Intoxicated
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2159-4-4**] 11:48PM GLUCOSE-99 UREA N-11 CREAT-1.0 SODIUM-143
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-23 ANION GAP-15
[**2159-4-4**] 11:48PM CALCIUM-8.3* PHOSPHATE-2.6* MAGNESIUM-1.7
[**2159-4-4**] 11:48PM HCT-39.3*
[**2159-4-4**] 11:48PM PT-13.5* PTT-25.8 INR(PT)-1.2*
[**2159-4-4**] 08:30PM ASA-NEG ETHANOL-187* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2159-4-4**] 08:30PM WBC-10.2 RBC-4.66 HGB-13.8* HCT-40.0 MCV-86
MCH-29.6 MCHC-34.4 RDW-12.6
IMAGING ON ADMISSION:
Ct head: NO acute intracranial process or fractures.
CT C-Spine: Non-displaced type II dens fracture with
non-displaced fracture of the right arch of C2.
CT Chest/Abd/Pelvis: Right ischial non displaced fracture
extending up to posterior acetabular wall and ilium. Small left
pneumothorax with small left paravertebral pneumatocele.
Bilateral pulmonary contusions. Displaced left scapular
fracture. Laceration
to anterior abdominal wall in right lower quadrant with air
extending into the retroperitoneum posterior to the right psoas.
CTA head/neck: No evidence of dissection, stenosis or
extravasation. 3x3 mm basilar artery aneurysm.
.
Brief Hospital Course:
He was admitted to the Trauma Service. Orthopedic Spine and
Orthopedics were consulted given his injuries. He was taken to
the operating room on [**4-5**] for repair of his acetabular fracture
without any complications. On [**4-6**] he was taken back to the
operating room by Spine surgery for application of Halo for his
spine fractures.
Neurologically he is intact, awake, alert and oriented and moves
all extremities.
Postoperatively he has done well; his pain is being controlled
with oral narcotics, he is on a bowel regimen and on Heparin
subcutaneously for DVT prophylaxis. He is tolerating a regular
diet. He was evaluated by Physical therapy and is being
recommended for rehab after his acute hospital stay.
Social work was consulted for coping, emotional support and
counseling surrounding his + blood alcohol level.
Medications on Admission:
Denies
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
5. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
7. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) patch
Transdermal Q Weekly (Sat): weaning dose, previously on 0.2 mg
weekly. [**Month (only) 116**] d/c in 1 week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Fall from height ~50ft
Bilat pulmonary contusions L>R
Small left apical pneumothorax
Type II dens fracture
C2 transverse process fracture
Right acetabular fracture
Left displaced scapular body fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were hospitalized following a fall from a height of ~50 ft;
as a result you sustained fractures of your cervical spine,
scapula and right leg. Your injuries required surgical repair.
You are being recommended for rehab after your acute hospital
stay.
Followup Instructions:
Follow up in 2 weeks with Dr. [**Last Name (STitle) 1352**], Ortho Spine, call
[**Telephone/Fax (1) 3736**] for an appointment.
Follow up in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 85162**] Trauma for
your sacpula and acetabular fractures, call [**Telephone/Fax (1) 1228**] for an
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2159-4-25**]
|
[
"808.1",
"314.01",
"805.02",
"811.09",
"E884.9",
"861.21",
"305.00",
"860.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.53",
"79.39",
"79.69",
"02.94"
] |
icd9pcs
|
[
[
[]
]
] |
4493, 4563
|
2875, 3705
|
341, 781
|
4813, 4813
|
1710, 2195
|
5274, 5783
|
1097, 1114
|
3762, 4470
|
4584, 4792
|
3731, 3739
|
4995, 5251
|
1129, 1691
|
274, 303
|
809, 1051
|
2219, 2852
|
2209, 2209
|
4828, 4971
|
1073, 1081
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,679
| 172,004
|
36774+36775
|
Discharge summary
|
report+report
|
Admission Date: [**2137-8-14**] Discharge Date: [**2137-8-24**]
Date of Birth: [**2070-9-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Newly identified duodenal mass.
Major Surgical or Invasive Procedure:
[**2137-8-14**] - Pylorus-preserving Whipple's resection and open
cholecystectomy
History of Present Illness:
The patient is a 66 year old male with a newly identified
duodenal mass, originally diagnosed at [**Hospital3 10310**] Hospital
as part of a work-up for blood loss and cholangitis. The patient
was originally admitted to AGH with complaint of nausea and
epigastric discomfort. He was found be febrile and have elevated
LFTs/pancreatic enzymes and was treated initially for
cholangitis with levaquin and flagyl (started [**2137-8-4**]). Abdominal
ultrasound was unremarkable. HIDA scan was consistent with signs
of acute cholecytitis. The patient underwent an EGD, which
showed a large exophytic mass involving 70% of the duodenum. He
was transferred to [**Hospital1 18**] for management of the cholangitis and
evaluation for possible surgical intervention. The patient
returns to [**Hospital1 18**] for planned Whipple surgery.
Past Medical History:
PMHx: Newly discovered duodenal mass, HTN, GERD, single episode
paroxysmal atrial fibrillation.
.
PSHx: (R) sided hernia repair.
Social History:
Married and lives with wife. Retired [**Name2 (NI) **]. Sedentary. Does
not smoke. No alcohol.
Family History:
Non-contributory.
Physical Exam:
On Admission:
AVSS/afebrile
GEN: Obese male in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. No [**Doctor First Name **].
LUNGS: CTA(B)
COR: RRR; nl S1/S2 w/o m/c/r.
ABD: Protuberant. Soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal/grossly intact.
SKIN: Intact w/o lesion or rash.
Pertinent Results:
[**2137-8-14**] 06:30PM GLUCOSE-137* UREA N-15 CREAT-1.5* SODIUM-141
POTASSIUM-5.3* CHLORIDE-111* TOTAL CO2-23 ANION GAP-12
[**2137-8-14**] 06:30PM CALCIUM-8.6 PHOSPHATE-5.1*# MAGNESIUM-1.9
[**2137-8-14**] 06:30PM WBC-24.4*# RBC-3.58* HGB-9.4* HCT-30.6*
MCV-85 MCH-26.1* MCHC-30.6* RDW-13.9
[**2137-8-14**] 06:30PM PLT COUNT-502*
[**2137-8-14**] 06:30PM PT-13.4 INR(PT)-1.1
[**2137-8-14**] 04:36PM TYPE-ART O2-43 PO2-174* PCO2-42 PH-7.33*
TOTAL CO2-23 BASE XS--3 INTUBATED-INTUBATED
[**2137-8-14**] 04:36PM freeCa-1.04*
.
[**2137-8-14**] Pathology Report Tissue: gallbladder, proximal: PENDING.
.
[**2137-8-16**] Portable AP CXR:
In comparison with the study of [**8-14**], there is increasing
basilar
opacification on the right with a somewhat less opacification on
the left. Findings are consistent with atelectasis and probable
fusion. Upper lungs are clear. Monitoring and support devices
remain in place.
.
[**2137-8-23**] 06:40AM BLOOD WBC-17.0* RBC-3.31* Hgb-8.8* Hct-27.4*
MCV-83 MCH-26.7* MCHC-32.3 RDW-15.4 Plt Ct-627*
[**2137-8-23**] 06:40AM BLOOD Plt Ct-627*
[**2137-8-23**] 06:40AM BLOOD Glucose-128* UreaN-11 Creat-1.0 Na-141
K-3.9 Cl-103 HCO3-29 AnGap-13
[**2137-8-23**] 06:40AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.0
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
[**2137-8-14**] for treatment of a duodenal mass. On [**2137-8-14**], the
patient underwent pylorus-preserving pancreaticoduodenectomy
(Whipple) and open cholecystectomy, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO with an NG tube, on IV fluids,
with a foley catheter and a JP drain in place, and a
Bupivacaine/Dilaudid epidural for pain control. The patient was
hemodynamically stable.
Post-operative pain was initially well controlled with the
Bupivacaine/Dilaudid epidural. The NG tube was accidentally
self-discontinued by the patient on POD#2 instead of removal on
POD#3; the NGT was not re-inserted as the patient exhibited
bowel sounds and the NGT put out only 150mL overnight. The
patient did not experience any subsequent abdominal pain,
nausea, vomiting. On the morning of POD#3 ([**2137-8-17**]), the patient
was noted to have incisional dehiscence, which, over the course
of [**12-28**] hours, became overt evisceration with omentum showing in
the field. Dr. [**Last Name (STitle) **] was on hand to evaluate the finding
immediately, and followed the patient closely until he was able
to bring the patient to the Operating Room early that afternoon
for emergent exploratory laparotomy and repair of the abdominal
incision dehiscence, which went well without complication (see
Operative Note for further details).
Upon return to the floor post-operatively, the patient was NPO
on IV fluids, with a foley catheter, and continued
Bupivacaine/Dilaudid epidural for pain control with ongoing good
effect. He was started on sips of clears on [**2137-8-18**], and on
[**2137-8-19**] the epidural was discontinued and changed to Dialudid PO
PRN for pain control with good effect. His diet was further
advanced to clear liquids with good tolerability, and the foley
was discontinued six hours after the epidural was removed. He
was able to void without problem.
By POD#6 s/p Whipple, the patient was back on track on the
Whipple Clinical Pathway. His diet was adavnced to fulls, and
later that evening a JP amylase was sent. On [**8-21**], the JP was
discontinued, and his diet advanced to regular with continued
good tolerability.
Mr. [**Known lastname 2470**] received 2 units of blood intraop on [**2137-8-14**] and a 3rd
unit in [**2137-8-22**] when his hematocrit drifted to 25. At the time
of discharge it was 27.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care.
Physical Therapy was consulted. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. The patient's blood sugar was monitored regularly
throughout the stay; sliding scale insulin was administered when
indicated.
At the time of discharge on [**2137-8-24**], the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. Staples were removed, and steri-strips
placed. He was discharged home without services. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
1. Atenolol 25mg PO qday
2. Diltiazem 60mg PO qid
3. Omeprazole 20mg PO qday
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation: Over-the-counter.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-1**]
hours as needed for fever or pain.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Duodenal cancer.
Discharge Condition:
Good.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-5**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please call ([**Telephone/Fax (1) 471**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) 468**] (Surgery) in 2 weeks.
Please call ([**Telephone/Fax (1) 83130**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 38828**] (PCP) in 2 weeks.
Completed by:[**2137-8-24**] Admission Date: [**2137-8-25**] Discharge Date: [**2137-8-25**]
Date of Birth: [**2070-9-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Hypotension, shock
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66 year-old gentleman presents 14 hours after he was discharged
from the hospital following a 11[**Hospital 15386**] hospital stay for a Whipple
procedure as a transfer from OSH in shock. Upon discharge this
AM, patient was doing very well. T 98.9, HR 76, BP 148/78,
100%RA. He was tolerating po intake, having BMs, and passing
flatus without complaints of abdominal pain. Family reports
that
when patient arrived home after discharge, he was doing quite
well. He had lunch and dinner with his family and was laughing
and enjoying his time with his family throughout the day. He
fell asleep at around 10:30 last night and woke up 15 minutes
later in severe abdominal pain. The family reports he has never
had pain like this throughout his hospitalization or
postoperative course. The patient was taken to an OSH close to
home. At the OSH, he quickly became tachypneic and needed to be
intubated. Upon intubation, the ED physician at the OSH saw the
patient's oropharynx filled with red blood. The patient then
became hypotensive and required dopamine to support his BP.
Efforts were made at the OSH to stabilize the patient to the
best
of their ability. Once this was accomplished, they transferred
the patient to [**Hospital1 18**] intubated and on pressors.
Past Medical History:
PMHx: Newly discovered duodenal mass, HTN, GERD, single episode
paroxysmal atrial fibrillation.
PSHx: (R) sided hernia repair, pylorus-preserving Whipple
procedure [**2137-8-14**], abdominal closure for dehiscence [**2137-8-17**]
Social History:
Married and lives with wife. Retired [**Name2 (NI) **]. Sedentary. Does
not smoke. No alcohol.
Family History:
Non-contributory.
Physical Exam:
VS: T 95, HR 82, BP 76/42, O2 sat 92%
GEN: Intubated, sedated, not following commands, NGT has some
dark bloody contents
HEENT: Pupils fixed and dilated at 4mm B/L, no scleral icterus
CV: RRR, nl S1 and S2
LUNGS: decreased breath sounds at bases B/L, clear at apices
ABD: Soft, distended, tympanitic, no obvious hernias, incision
healing well except for tiny area of fat necrosis at apex of
wound, no cellulitis or discoloration
EXT: slightly mottled legs B/L, faintly palpable femoral pulses
B/L
RECTAL: guaiac negative
Pertinent Results:
Labs on arrival:
WBC 52.3, HCT 40.6, PLT 312
Na 142, K 4.6, Cl 108, HCO3 10, BUN 14, Cr 0.7, Gluc 161
INR 1.8, PTT 19.9
ABG: 7.0/59/142/16 Lactate 9
Brief Hospital Course:
Patient was first stabilized in the ED with aggressive fluid
resuscitation. In the ED, patient received a right femoral
arterial and was placed on maximum ventilatory support. FAST
exam performed by ED attending was negative. Patient received a
total of 6 units of pRBCs between the OSH and the [**Hospital1 18**] ED. He
also received 5 L of crystalloid, but had minimal urinary
output. Patient's blood pressure was as low as SBP of 60s upon
arrival to ED but improved to SBP 90s when levophed was added.
Patient was admitted to the SICU from the ED. Aggressive
resuscitation resumed with crystalloid, and colloid was
administered to correct the patient's coagulopathy. Patient
only maintained O2 saturation levels to the high 80s over a few
hours. Patient's abdomen also became extremely distended.
Bladder pressures rose to 25mm Hg, and patient had minimal urine
output. Patient was started on broad spectrum antibiotics.
Serial ABGs were obtained. pH was never higher than 7.06. The
ABG obtained prior to making the patient CMO was 7.02/70/55/19.
This patient's stay in the SICU was very brief, as his clinical
condition rapidly deteriorated. The patient's family was spoken
to on several occasions during the patient's brief hospital stay
by Dr. [**Last Name (STitle) 468**]. Dr. [**Last Name (STitle) 468**] kept the family well-informed as to
how critical the patient's condition was. Once the patient
required maximum support, the patient's family came to a
concensus that they wanted the patient to be CMO - they stated
the patient would not want to be on such heavy support. The
patient was made CMO in the AM of [**2137-8-25**]. He expired within 8
minutes of being taken off the vent.
Disposition upon Discharge: Death
Medications on Admission:
Reglan 10 mg po qid, Colace 100 mg [**Hospital1 **], Senna 8.6mg po bid,
Tylenol prn, Omeprazole 20 mg po qday, Atenolol 25 mg po qday,
Hydromorphone 2 to 4 mg q4hrs prn pain Capsule, Diltiazem 60 mg
po qid
Discharge Medications:
NONE
Discharge Disposition:
Expired
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
Hypotension, shock, cardiopulmonary arrest
Discharge Condition:
Death
Discharge Instructions:
None
Followup Instructions:
None
|
[
"427.31",
"998.0",
"401.9",
"286.9",
"V45.3",
"998.11",
"518.81",
"E878.2",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
14750, 14789
|
12713, 14439
|
10274, 10280
|
14875, 14882
|
12538, 12690
|
14935, 14942
|
11962, 11981
|
14721, 14727
|
14810, 14854
|
14489, 14698
|
14906, 14912
|
9124, 9613
|
11996, 12519
|
10216, 10236
|
14455, 14463
|
10308, 11578
|
1615, 1900
|
11600, 11833
|
11849, 11946
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,131
| 160,199
|
23164+23165
|
Discharge summary
|
report+report
|
Admission Date: [**2129-4-14**] Discharge Date: [**2129-4-18**]
Date of Birth: [**2095-12-17**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 6716**]
Chief Complaint:
Fibroids/infertility
Major Surgical or Invasive Procedure:
Abdominal mulitiple myomectomy
Transfusion of 3 units of packed red blood cells
History of Present Illness:
The patient is a 33 y.o. G4P1031 with recurrent miscarriages and
a known fibroid uterus who presented for surgical management.
An ultrasound on [**2129-3-2**] revealed multiple fibroids, the largest
of which was 8.2 x 6.2 x 6.2 cm in right upper uterus.
Past Medical History:
PMH: None
PSH: Cesarean x 1
POBHx: Cesarean x 1; SAB x 3
PGYNHx: Recurrent miscarriages
Social History:
Denies tobacco, alcohol, IVDA. Lives with husband.
Family History:
Non-contributory
Physical Exam:
(In office)
BP: 130/86
Chest: Lungs clear bilaterally
CV: RRR
Abd: +Palpable masses in pelvis, consistent with fibroids
Pelvic: No cervical lesions. Approx 20 cm sized uterus. Not
possible to evaluate adnexae.
Pertinent Results:
[**2129-4-14**] 08:09PM HGB-7.9* calcHCT-24
[**2129-4-15**] 01:43AM BLOOD Hct-34.2*
Brief Hospital Course:
On [**2129-4-14**], the patient underwent an exam under anesthesia,
exploratory laparotomy, and multiple myomectomy.
Intraoperatively, she lost approximately [**2123**] cc of blood, and a
hematocrit was 24. She was transfused 3 units of PRBC with a
subsequent rise in her hematocrit to 34. Over her 4 day
in-hospital course, the patient's post-op hct slowly trended
down to a stable value at 24.2.
The patient's course was complicated by post-operative
tachycardia. The patient's vital signs otherwise remained
stable throughout her course and her tachycardia was attributed
to a combination of pain as well as anemia. However, given that
the patient was able to ambulate without difficulty or
lightheadedness and she was othterwise asymptomatic, further
blood transfusions were held. Additionally, on POD#2, the
patient spiked a temperature of 101.3. Blood and urine cultures
were obtained, which, to date, have no growth. Given an
elevated WBC of 29.3, the patient was started empirically on
broad spectrum antibiotic coverage with gentamycin and
clindamycin. She subsequently defervesced and her WBC trended
down.
Otherwise, she did well postoperatively. By the time of
discharge, she was ambulating and voiding without difficulty,
tolerating a regular diet, her pain was well-controlled with
oral pain medication, and her incision remained clean/dry/intact
with staples. Her tachycardia was improved with a heartrate
around 100 upon discharge.
The patient will follow-up with Dr. [**Name (NI) **] in 2 weeks in
clinic.
Medications on Admission:
None
Discharge Medications:
1. 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*
2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Fibroid uterus
Post-operative blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor if you experience fevers/chills,
nausea/vomiting, chest pains or shortness of breath, redness
around or drainage from your incision, increasing abdominal
pain, or any other symptoms that concern you.
No heavy lifting (>15 lbs) for 6 weeks.
No driving while taking narcotics.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] OB/GYN PPS CC8 (SB) Where: OB/GYN
PPS CC8 (SB) Date/Time:[**2129-5-4**] 4:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] OB/GYN PPS CC8 (SB) Where: OB/GYN
PPS CC8 (SB) Date/Time:[**2129-5-24**] 1:30
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 6721**]
Admission Date: [**2129-4-14**] Discharge Date: [**2129-4-18**]
Date of Birth: [**2095-12-17**] Sex: F
Service: GYN
HISTORY OF PRESENT ILLNESS: The patient presented for
multiple myomectomy for symptomatic fibroid uterus. This is a
33-year-old gravida 4, para 1, 0, 3, 1, who preoperatively
voiced understanding of her gyn pathology and agreed to the
risks of the surgical procedure which included transfusions.
Because of her desire to preserve her future childbearing,
the patient accepted the risk of transfusion certainly above
that of having a hysterectomy. She must rather receive blood
products than to lose her uterus if possible. The patient
understood because of the size of her uterus which on 23/05
ultrasound was noted to be 15.0 x 9.5 x 18.0 cm, she knew
this would be a challenging multiple myomectomy involving a
possible significant blood loss. So she underwent multiple
myomectomy with the removal of 19 fibroids on [**2129-4-14**].
Estimated blood loss was [**2123**] cc and she received 3 units of
packed red blood cells in total and her hematocrit at the
postoperative check was at 34. That was prior to the
calibration. After calibration her blood count was noted to
be ranging from 24 to 26 percent.
On postoperative No. 2 the patient spiked to 101.3 and then
had a decrease in her temperature curve. She was now status
post 3 units of packed red blood cells and status post
multiple myomectomy. There was no clear source of her
temperature. Her urinalysis was negative. Her incision was
healing well and her white count was at 29,000. She was
started on gentamycin and clindamycin with a temperature
spike, however since that spike, the temperature curve was
decreasing and on postoperative day No. 3, she was noted to
be afebrile and the thought was to continue the antibiotics
until she was afebrile for at least 24 hours.
On postoperative day No. 4, she had a normal temperature
curve. She was tolerating PO's. Her hematocrit was stable and
she was sent home on pain medication with instructions and to
follow up with Dr. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 59587**]
Dictated By:[**Last Name (NamePattern1) 59588**]
MEDQUIST36
D: [**2129-5-30**] 17:47:16
T: [**2129-5-31**] 08:33:08
Job#: [**Job Number 59589**]
|
[
"218.9",
"997.1",
"276.5",
"285.1",
"998.89",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"68.29"
] |
icd9pcs
|
[
[
[]
]
] |
3148, 3154
|
1285, 2822
|
351, 433
|
3246, 3252
|
1175, 1262
|
3599, 4129
|
911, 929
|
2877, 3125
|
3175, 3225
|
2848, 2854
|
3276, 3576
|
944, 1156
|
291, 313
|
4158, 6412
|
738, 827
|
843, 895
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,882
| 161,655
|
51643
|
Discharge summary
|
report
|
Admission Date: [**2122-4-23**] Discharge Date: [**2122-4-26**]
Service: PCU
HISTORY OF PRESENT ILLNESS: This is a 78 -year-old gentleman
with a history of coronary artery disease, status post
coronary artery bypass graft times two, a porcine mitral
valve replacement, and class III congestive heart failure.
The patient was recently admitted from [**2122-4-1**] to [**2122-4-7**]
to the Coronary Care Unit East where he received inotropic
support with milrinone for increased creatinine of 2.8. His
creatinine improved on the milrinone, it was 2.2 on the day
of discharge. He was asymptomatic during his
hospitalization. He did not have any shortness of breath,
dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea,
or lower extremity swelling.
During that admission, his Lasix had been decreased from 40
mg [**Hospital1 **], to q day, his carvedilol dose was increased from
3.125 mg [**Hospital1 **] to 6.25 mg [**Hospital1 **]. On [**4-16**], the patient's
Lasix dose had been increased back to 40 mg [**Hospital1 **] times three
days for dyspnea on exertion and a weight gain of three to
four pounds. The patient reports that concurrent with the
weight gain, he has noticed a decrease in urine output over
the past few days prior to admission. However, he has not
noted any difference in his breathing.
The patient states that he can walk half a mile before he
develops shortness of breath. He denies any orthopnea,
paroxysmal nocturnal dyspnea, leg swelling, increase in
abdominal girth. No dietary indiscretions or medical
noncompliance. However, his creatinine had been monitored
since his discharge and was found to be 5.2 on [**2122-4-23**]. The
patient was then encouraged to enter the hospital for a
direct admission to the Coronary Care Unit for possible IV
milrinone and Swan Ganz catheterization to assist filling
pressures.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post a coronary artery
bypass graft in [**2102**]. A re-do coronary artery bypass graft
was performed in [**2121-3-26**]. The patient had a
catheterization in [**2122-1-26**] in which he received a stent
to his vein graft to the left anterior descending.
2. Severe class III congestive heart failure. On [**12/2121**],
ejection fraction was found to be less than 20%. He is
status post a porcine mitral valve replacement from [**2121-3-26**]. He is status post a DDD pacemaker which he received in
[**2121-3-26**] for complete heart block after his coronary artery
bypass graft. He had a revision of his pacer in [**2121-12-26**] performed by Dr. [**Last Name (STitle) **].
3. Hypercholesterolemia.
4. A history of atrial fibrillation which occurred post
coronary artery bypass graft in [**2121-3-26**]. The patient was
initially started on Coumadin, but was stopped secondary to
hemoptysis in [**2121-7-26**].
5. Chronic renal insufficiency with a baseline creatinine of
2.0.
ADMITTING MEDICATIONS: Lasix 40 mg po q day, Zestril 5.0 mg
po q day, carvedilol 6.25 mg po bid, Lipitor 10 mg q Monday,
Wednesday, Friday, Digoxin 0.125 mg q Monday, Wednesday,
Friday, aspirin 325 mg po q day, amiodarone 100 mg po q day,
Prilosec 20 mg po q day, Flonase prn.
ALLERGIES: Include penicillin and doxycycline which gives
the patient a rash.
SOCIAL HISTORY: The patient is a retired architect. He
denies smoking or alcohol.
PHYSICAL EXAMINATION: In general, the patient was a
pleasant, elderly gentleman, lying in bed, flat, in no
apparent distress. Vital signs: temperature 96.3 F, his
heart rate was 70, his respirations were 14, blood pressure
of 78/39. His baseline systolic blood pressures run in the
70's to 80's. His oxygen saturation was 99% on room air.
Head, eyes, ears, nose, and throat: dry mucous membranes,
oropharynx is clear, anicteric. Neck: his jugular venous
pulse was about 8.0 cm. His heart was regular rate and
rhythm, there was a left sided heave, a positive S3, and a
III/VI holosystolic murmur heard at the right and left upper
sternal borders. Lung examination clear to auscultation
bilaterally, some mild left base wheezing. Abdomen: soft,
nontender, nondistended, bowel sounds were heard, no
hepatosplenomegaly, no ascites. Extremities: no edema.
LABORATORY DATA: Sodium 135, potassium of 5.3, chloride 99,
bicarbonate 21, BUN of 129, creatinine of 5.8 with a baseline
of 2.0, glucose 154. White blood cells 4.7, hematocrit 32.9,
platelets of 131,000. PT 13.7, PTT 28, INR 1.2. ALT 21, AST
20, alkaline phosphatase 78, amylase 122, total bilirubin
0.3. Digoxin 1.2, phosphate 6.6.
An echocardiogram in [**2121-12-26**] showed an ejection
fraction of less than 20%, globally depressed left ventricle,
except for the posterior basal region, moderate tricuspid
regurgitation, mild pulmonary hypertension. A
catheterization on [**2122-2-14**] showed a wedge pressure of 20, a
pulmonary arterial pressure of 50/16, right ventricular
pressure 44/8, and a right atrial pressure of 10.
Electrocardiogram showed a paced rhythm, no changes noted
from [**2122-1-26**] electrocardiogram. Chest x-ray showed
blunting of the left costophrenic angle, otherwise no changes
from a chest x-ray on [**2122-2-11**].
HOSPITAL COURSE: The patient was a 78 -year-old gentleman
with severe congestive heart failure and an increase in
creatinine. There was little clinical evidence for
decompensation of his heart failure. The patient was denying
orthopnea, paroxysmal nocturnal dyspnea. He had no rales on
lung examination. He had no increase in O2 requirements.
His physical examination suggested that he was more likely
"dry."
Given his acute renal failure and a creatinine of 5.8, his
Lasix, Zestril, and Digoxin were all held. A Swan Ganz
catheter was placed to assess his pressures. His pulmonary
capillary wedge pressure was found to be 14, supporting a
diagnosis of prerenal dehydration, not congestion. He
received supplemental fluid boluses, which reduced his
creatinine slowly. He had a mild increase in his central
venous pressure with fluid, but no appreciable difference in
his pulmonary wedge pressure.
By 10:00 PM on [**4-25**], his creatinine was 4.5. He was then
placed on continuous maintenance fluids which brought his
creatinine down to 4.2 at 07:00 AM on [**2122-4-26**]. There were
no signs of heart failure. Dr. [**First Name (STitle) 2031**] agreed with the
Cardiology team that the patient could be discharged on
[**2122-4-26**], as his creatinine continued to decrease.
DISCHARGE MEDICATIONS: There were some changes to the
patient's medications while he was in house. The patient was
started on Cozaar 25 mg po q day instead of his Zestril
admission drug. The patient was instructed to decrease his
Lasix dose to 20 mg per day from 40 mg at his admission,
starting on [**2122-4-27**] (Monday). His potassium supplements
were decreased to 20 mEq per day from 60 mEq at admission.
He was instructed to continue his Digoxin dose as well as his
carvedilol at 6.25 mg [**Hospital1 **], amiodarone 100 mg q day, Prilosec
20 mg q day, and his Flonase and aspirin. He was encouraged
to drink six cups of fluid per day.
FOLLOW UP: The patient will see Dr. [**First Name (STitle) 2031**] in the clinic on
Thursday, [**4-30**]. He will have his electrolytes, Digoxin
level, and phosphate level checked on Wednesday, [**4-29**].
DISCHARGE DIAGNOSIS:
Prerenal acute renal failure secondary to dehydration.
[**Last Name (LF) **],[**Name8 (MD) **] M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2122-4-26**] 22:55
T: [**2122-4-27**] 10:32
JOB#: [**Job Number **]
|
[
"428.0",
"584.9",
"V42.2",
"414.01",
"V45.81",
"276.5",
"593.9",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6498, 7122
|
7352, 7636
|
5201, 6474
|
7134, 7331
|
3385, 5183
|
116, 1871
|
1893, 3277
|
3294, 3362
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,886
| 139,093
|
35924
|
Discharge summary
|
report
|
Admission Date: [**2104-12-4**] Discharge Date: [**2104-12-8**]
Date of Birth: [**2030-3-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Transferred for Cardiac Cath
Major Surgical or Invasive Procedure:
Pulmonary artery catheter
Cardiac Catheterization with 5 stents to RCA and 2 stents to LCx
complicated by LCx disection
History of Present Illness:
Pt is a 74yo F with a PMH significant for basal cell carcinoma
4yrs prior s/p resection and XRT, left breast lumpectomy 20yrs
prior and no other documented medical history presented to
[**Hospital **] Hospital with SOB. The patient reports that she has had
progressive chronic cough, SOB, mucus over the last 6 months.
She states that she has been getting SOB walking up her driveway
and going up 10 stairs. The patient reports that on [**12-2**] she was
driving back from work and developed worsening cough and acutely
short of breath. She called 911 and taken to the hospital. The
patient did not have any chest pain. Of note she frequently has
high salt meals and the day of the episode of dyspnea, the
patient had a sauerkraut/hot dog meal.
.
At [**Location (un) **] she was found to have pulomary edema and diuresed 1L.
She was ruled out for MI with CE. She did however have elevated
BNP. She also underwent a CTA chest to r/o PE and revealed a
bilateral pulmonary masses and lymphadenopathy as well as a
spiculated soft tissue mass in the right subpectoral fat. She
reportly had an ECHO at OSH with EF 35-40% and
inferoposterolateral hypokinesis. The patient also had new
inverted T-waves on ECG. Given her multiple risk factors for CAD
and ischemic ekg changes, she was transferred to [**Hospital1 18**] for
cardiac catheterization.
.
Upon transfer to [**Hospital1 18**] the patient stated that her breathing had
improved since admission, but was not back to her baseline. She
is not on O2 at home. She denied any chest pain, leg swelling or
edema. She also denied weight loss or weight gain.
.
Once admitted to the Cardiology service, she was continued on
metoprolol, aspirin, plavix, and atorvastatin. She underwent
cardiac catheterization [**2104-12-5**] during which anatomy showed LCX
70-80% mid circ, OM2, and RCA 70% proximal, TO distal, 70% PL.
She received 5 bare metal stents to her RCA and 2 bare metal
stents to her LCx. During deployment of the stent her LCx was
dissected with myocardial stain. This was treated with an
overlapping stent with restoration of flow. She experienced [**6-29**]
chest pain/tightness during the perforation with associated
diaphoresis. She did not experience nausea or left arm, left jaw
radiation. She underwent a stat echo which did not reveal
echocardiographic evidence of perforation or tamponade.
.
Her primary oncologist was contact[**Name (NI) **] and will follow-up the lung
masses as an outpatient.
Past Medical History:
Basal Cell Carcinoma dx 4yrs prior s/p resection and XRT
SLE Dx in [**2080**] (treated w/ prednisone 3yrs)
Left Breast Lumpectomy 20-25yrs ago
Cholecystectomy [**47**] yrs prior
hypercholesterolemia (though this was diagnosed at [**Location (un) **] per
pt)
Social History:
Social history is significant for current tobacco use
3-5cigs/day currently x60yrs (1ppd at max). There is no history
of alcohol abuse. She lives with her daughter and is divorced
with 3 children. She works as a bank clerk at Fidelity.
Family History:
Father MI/stomach cancer 67/ Brother MI @ 61, Sister Cardiac
Cath @ 64/
Physical Exam:
VS - 98.4 134/64 72 18 97%RA
Gen: female in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 6 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. +S3, No m/r/g. No thrills, lifts. No S4.
Chest: No chest wall deformities, Resp were unlabored, no
accessory muscle use. + mild crackles in the lower lung fields,
no wheezes or rhonchi.
Abd: vertical midline scar, soft, NTND.
Ext: No c/c/ trace edema
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission labs/ OSH labs:
LABS on [**12-5**]:
137 97 17 147 AGap=12
-------------
3.4 31 0.7
CK: 40 MB: Notdone Trop-T: <0.01
Ca: 9.1 Mg: 1.9 P: 2.8
proBNP: 1303
11.6>----<222
36.5
PT: 14.4 PTT: 26.2 INR: 1.3
OSH LABS:
WBC:10.5 Hct:38.4 Plt: 238
PT:14.1 INR:1.1
137 101 13
-------------- 117
3.5 30 0.53
LDL:114 HDL:32 TG:230
[**2104-12-8**] 05:50AM BLOOD WBC-10.6 RBC-4.14* Hgb-11.6* Hct-34.6*
MCV-84 MCH-28.1 MCHC-33.6 RDW-14.6 Plt Ct-230
[**2104-12-7**] 05:52AM BLOOD PT-14.0* PTT-26.9 INR(PT)-1.2*
[**2104-12-8**] 05:50AM BLOOD Glucose-107* UreaN-22* Creat-0.7 Na-140
K-4.3 Cl-100 HCO3-31 AnGap-13
[**2104-12-4**] 09:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-1303*
[**2104-12-5**] 08:53PM BLOOD CK-MB-NotDone
[**2104-12-6**] 05:05AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2104-12-4**] 09:30PM BLOOD CK(CPK)-40
[**2104-12-5**] 08:53PM BLOOD CK(CPK)-48
[**2104-12-6**] 05:05AM BLOOD CK(CPK)-42
[**2104-12-8**] 05:50AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.3
[**2104-12-5**] 08:53AM BLOOD Type-ART O2 Flow-2 pO2-121* pCO2-52*
pH-7.40 calTCO2-33* Base XS-6 Intubat-NOT INTUBA
[**2104-12-5**] 08:53AM BLOOD Glucose-130* K-4.5
[**2104-12-5**] 08:53AM BLOOD O2 Sat-98
Cardiology Report ECG Study Date of [**2104-12-4**] 9:06:44 PM
Sinus rhythm with baseline artifact. Inferior myocardial
infarction. No
previous tracing available for comparison.
Cath [**12-5**]
1. Selective coronary angiography of this right domiant system
demonstrated two (2) vessel coronary artery disease. The right
coronary
artery was diffusely diseased including a total occlusion in the
distal
portion of the vessel along with a 70% lesion in the proximal
portion of
the vessel. The left main demonstrated no angiographically
apparent
disease. The left anterior descending artery demonstrated a 70%
lesion
in the proximal portion of the first diagonal. The left
circumflex
demonstrated an 80% lesion in the mid portion of the vessel
extending
into the second obtuse marginal.
2. LV ventriculography was deferred.
3. Resting hemodynamics demonstrated elevated right (RVEDP =
19mm Hg)
and left (mean PCWP = 26 mm Hg) filling pressures. The cardiac
index
was preserved.
4. Successful PTCA and stenting of the distal right coronary
artery
with three bare metal stents (See PTCA comments).
5. Successful PTCA and stenting of the proximal right coronary
artery
with two overlapping bare metal stents (See PTCA comments).
6. Successful stenting of the mid LCX extending into the second
obtuse
marginal with two overlapping bare metal stents. Procedure
complicated
by an edge dissection with myocardial blushing. Echocardiogram
demonstrated no angiographically apparent effusion. Pt
transferred to
the unit for observation hemodynamically stable.
7. Successful closure of the right femoral arteriotomy site
with an 8F
Angioseal closure device.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Preserved cardiac index via Fick
3. Moderate pulmonary hypertension
4. Successful stenting of the distal RCA with three bare metal
stents
5. Successful stenting of the proximal RCA with two overlapping
bare
metal stents
6. Successful stenting of the mid LCX/OM2 with two overlapping
bare
metal stents complicated by an edge dissection with myocardial
staining.
Echocardiogram demonstrated no evidence of tamponade or
effusion.
7. Successful closure of the right femoral arteriotomy site
with an 8F
angioseal closure device.
TTE [**12-5**]
The left ventricular cavity size is normal. LV systolic function
appears depressed. Right ventricular chamber size and free wall
motion are normal. There is no pericardial effusion.
TTE [**12-5**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears moderately-to-severely
depressed (ejection fraction 30 percent) secondary to akinesis
of the inferior septum and inferior free wall and hypokinesis of
the posterior wall. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2104-12-5**], no major change is evident.
TTE [**12-6**]
LV systolic function appears depressed. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no pericardial effusion. There is an anterior
space which most likely represents a fat pad.
Compared with the findings of the prior study (images reviewed)
of [**2104-12-5**], no major change is evident.
[**12-5**] CXR
Cardiomegaly is moderate. The aorta is tortuous. Increase in
interstitial
markings is consistent with volume overload. 2.2 left
retrocardiac nodule and
1.3 right apical nodule are the only nodules clearly depicted on
this chest x-
ray. Other nodules could be present and should be correlated
with prior
imaging from another hospital.
A catheter installed via a femoral vein is ending in the right
atrium. There
is no pleural effusion.
Brief Hospital Course:
Patient is a 74yo F with a PMH significant for basal cell
carcinoma 4yrs prior s/p resection and XRT, left breast
lumpectomy presented to OSH with SOB and transferred here for
cardiac cath.
.
#. Left Circumflex Dissection: occurred during deployment of
second stent to LCX, prompting transfer to the ccu. Patient
experienced chest pain during the dissection but was chest pain
free susequently. Echo in cath lab without evidence of
tamponade. Repeat echos were unchanged. The patient remained
asymptomatic without clinical signs of tamponade.
.
#. CAD: Patient with three vessel disease, received 5 BMS to RCA
and 2 BMS to LCX. ASA, plavix, BB, statin were continued. Pt
was counseled on smoking cessation.
.
#. Pump: EF 35-40% at OSH. Pt with pulmonary edema on CXR and
small right effusion on CT. Pt also with trace lower ext edema.
Pt respirtory status improved with IV lasix. In the ccu she was
diuresed 1.2 L with improvement in respiratory status. She was
discharged on lasix 20mg daily.
.
#. Rhythm: She remained in NSR.
.
#. Dyspnea: Pt with SOB. CTA was negative for PE. Pt found to
have pulmonary edema on CXR likely element of CHF given EF
35-40%. Additionally, pt found to have masses concerning for
malignancy on CT. Only small R effusion seen. Pt with extensive
smoking history as well has h/o basal cell carcinoma. The
patient will follow-up with her oncologist as an outpatient for
follow-up. Dr. [**Last Name (STitle) 33667**] saw her at the OSH.
.
#. HTN: Pt was hypertensive at the OSH. She was started on
metoprolol. Will cont metoprolol 12.5 mg TID for now and titrate
as needed. She was sent home on Toprol XL 75mg daily.
.
#. Lung Mass: Seen on CT. Primary oncologist Dr. [**Last Name (STitle) 33667**] aware
and will follow-up as outpatient after hospitalization.
.
#. Tobacco Abuse: Counseled patient on smoking cessation.
Nicotine gum prn.
.
#. FEN: Cardiac diet/ replete lytes prn
.
#. Access: PIV
.
#. PPx: Heparin Sq/ bowel regimen prn
.
#. Code: FULL CODE- confirmed with patient. She does not wanted
to be intubated long-term, but does want intervention acutely.
.
#. Contact: [**Name (NI) 5321**] (Daughter) HCP [**Telephone/Fax (1) 81612**]
Medications on Admission:
none at home
Discharge Medications:
Transfer Meds:
Metoprolol 12.5 q6
Plavix 75mg daily
ASA 325mg daily
Lasix 40mg IV daily
nitro paste prn hypertension
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease s/p 5 stents to RCA and 2 stents to LCx
complicated by LCx disection
Acute Systolic Heart Failure
Hypertension
Lung mass
Discharge Condition:
Stable. Ambulating without assistance. Breathing comfortably on
room air.
Discharge Instructions:
You were seen and evaluated for your shortness of breath. You
underwent cardiac catheterization and had 7 stents placed. The
procedure was complicated by disection of one of the arteries of
your heart. You were also found to have new nodules in your
lungs on CT scan. It is important to followup with your
oncologist regarding further workup of these findings.
Please take all your medications as presribed. The following
changes were made to your medication regimen.
1. Please take lasix 20 mg daily
2. Please take Toprol XL 75 mg daily
3. Please take aspirin 325 mg daily
4. Please take plavix 75 mg daily. It is important that you
take this medication every day. Do not stop this medication
unless told to do so by a cardiologist.
5. Please take lisinopril 5 mg daily
6. Please take atorvastatin 80 mg daily
Please keep all your follow up appointments as scheduled.
Please stop smoking. Information was given to you on admission
regarding smoking cessation.
Please weigh yourself every day. Please call your primary care
physician or your cardiologist if you gain more than 2 lbs in 24
hours or 3 lbs in 72 hours. Please limit your salt intake to
less than 2 grams per day.
Please seek immediate medical attention if you experience any
chest pain, difficulty breathing, unexplained weight gain,
swelling in your legs or any other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**]
[**Last Name (NamePattern1) 33667**]. We have scheduled you an appointment for this Thursday,
[**2104-12-11**] at 9:30 AM. The office phone number is [**Telephone/Fax (1) 81613**].
Dr. [**Last Name (STitle) 33667**] can refer you to a cardiologist near your home. You
should be seen by a cardiologist in [**12-24**] week of this
hospitalization.
Completed by:[**2104-12-9**]
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,262
| 100,570
|
44669
|
Discharge summary
|
report
|
Admission Date: [**2149-10-3**] Discharge Date: [**2149-10-9**]
Date of Birth: [**2116-3-25**] Sex: F
Service: GYNECOLOGY
ADMISSION DIAGNOSES:
1. Unwanted pregnancy.
2. Desires permanent sterilization.
DISCHARGE DIAGNOSES:
1. Status post dilatation and evacuation.
2. Status post uterine perforation.
3. Status post uterine repair.
4. Status post sigmoid resection.
5. Status post end-to-end reanastomosis.
6. Status post tubal ligation.
HISTORY OF PRESENT ILLNESS: This 33-year-old G6, P5 with
last menstrual period of [**2149-7-17**] presented for a
termination and permanent sterilization.
PAST OBSTETRICAL HISTORY: G6, P5, status post five
spontaneous vaginal deliveries, no complications.
PAST GYNECOLOGY HISTORY: Normal menses, last menstrual
period [**2149-7-17**]. Last pap within normal limits.
PAST MEDICAL HISTORY: Mitral valve prolapse confirmed on an
echocardiogram.
PAST SURGICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco, ethanol or drugs.
PHYSICAL EXAM ON ADMISSION: Blood pressure 100/60. Weight
of 130. In general, no acute distress. Pulmonary: Clear to
auscultation bilaterally. Cor: 1-2/6 systolic ejection
murmur. Breasts: No masses. Abdomen: Soft, nontender,
nondistended. Pelvic exam: Normal external genitalia. Good
vaginal support. No cervical lesions. Uterus consistent
with 12 weeks size. Adnexa: No masses or tenderness.
Rectal exam: Within normal limits. Negative guaiac.
HOSPITAL COURSE: On [**2149-10-3**], this 33-year-old G6,
P5 underwent a dilatation and evacuation which was
complicated by a uterine perforation and injury to the
sigmoid mesentery. An intraoperative Surgery consult was
obtained. The Surgery Team recommended a partial resection
of the denuded bowel. The patient underwent a
resection and an end-to-end reanastomosis. The patient also
underwent a repair of the uterine perforation as well as a
tubal ligation. Intraoperatively, the patient received a
total of four units of packed red blood cells, two units of
FFP and 1500 cc of hetastarch. Please see the full operative
note for details.
1. Hematology: Intraoperatively, the patient's hematocrit
nadired at 14. As previously stated, the patient received a
total of four units of packed red blood cells and two units
of FFP intraoperatively. After surgery the patient was
transferred to the Surgical Intensive Care Unit where serial
hematocrits were followed. The patient's laboratories were
notable for a likely dilutional as well as consumptive
coagulopathy. On the first night after surgery, the
patient's hematocrit fell to 19.5. Her platelets were 84,000
and her INR was elevated at 1.5. On the first postoperative
day, the patient received an additional two units of packed
red blood cells, two units of FFP and four units of
cryoprecipitate. On postoperative day number two, the
patient received an additional two units of packed red blood
cells so the total products she received were eight units of
packed red blood cells, six units of FFP and four units of
cryoprecipitate. Her hematocrit stabilized at 29 and her INR
stabilized at 1.1. The patient's platelets slowly increased
to 128,000 on discharge. The patient had no further problems
with bleeding during the hospitalization.
2. Neurology: The patient was originally intubated and
sedated and was given a morphine drip for pain. This was
continued through postoperative day number one and the
propofol was weaned on postoperative day number one and she
was extubated later that day. The patient was started on a
Dilaudid PCA for pain which she used until postoperative day
number five. The patient was then changed to Percocet and
Motrin which she tolerated well. The patient was discharged
on Percocet and Motrin.
3. Pulmonary: As previously stated, the patient was
intubated until postoperative day number one. During the
first postoperative day, the patient had wheezing consistent
with an underlying asthma. The patient was given albuterol
with good response. The patient was extubated on
postoperative day number one at which time incentive
spirometry was encouraged. The patient had no further
problems from a pulmonary prospective during the
hospitalization.
4. Coronary: The patient was stable from a coronary
prospective throughout the hospitalization.
5. Gastrointestinal: The patient initially was NPO with
intravenous fluids and had an nasogastric tube placed. The
nasogastric tube was removed on postoperative day number one.
The patient was NPO until postoperative day number four. The
patient began passing flatus at this time and began to take
sips. The patient tolerated sips without a problem, was
advanced to clears, and by postoperative day number six was
tolerating solids. The patient was initially on intravenous
Protonix for gastrointestinal prophylaxis which was stopped
on postoperative day number four. On the evening of
postoperative day number four, the patient complained of
midsternal/epigastric pain. The patient was restarted on
intravenous Protonix with good relief. An electrocardiogram
was done at the time which was within normal limits.
6. Genitourinary: After the surgery, the patient received
two doses of 1000 mcg of Cytotec per rectum for uterine
atony. The patient was also started on Methergine .2 mg q. 6
hours times 48 hours. The patient's bleeding was appropriate
and she did not require any further uterotonics. The patient
had a Foley catheter until postoperative day number three.
After the catheter was removed she had no difficulties
voiding.
7. Infectious Disease: The patient was originally started
on ampicillin, gentamicin and clindamycin. She received a
total of 36 hours of these antibiotics. The patient was
afebrile during the entire hospitalization. The patient was
started on no further antibiotics.
8. Prophylaxis: The patient was on Pneumoboots beginning on
postoperative day number zero. On postoperative day number
two, the patient complained of some left thigh pain and
swelling. Although the clinical suspicion was low, the
patient underwent a bilateral lower extremity Dopplers to
rule out deep vein thrombosis and the ultrasound was
negative. The patient was also on intravenous Protonix for
gastrointestinal prophylaxis.
9. Support: The patient was seen by Social Work during her
admission and was encouraged to contact Dr. [**Name (NI) **] if
she needs any additional support after discharge.
The patient was discharged to home on postoperative day
number six. The patient was instructed to follow-up with Dr.
[**Name (NI) **] in one week and with Dr. [**Last Name (STitle) 1305**] from General
Surgery in two weeks. The patient was discharged to home on
Percocet 5/325, Motrin and Colace.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6721**]
Dictated By:[**Doctor Last Name 95593**]
MEDQUIST36
D: [**2149-10-15**] 18:19
T: [**2149-10-15**] 18:19
JOB#: [**Job Number 95594**]
|
[
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"493.90",
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] |
icd9cm
|
[
[
[]
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] |
[
"99.07",
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"99.04",
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icd9pcs
|
[
[
[]
]
] |
243, 465
|
1539, 7091
|
940, 1006
|
160, 222
|
494, 838
|
1083, 1521
|
861, 916
|
1023, 1068
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,288
| 140,013
|
25466
|
Discharge summary
|
report
|
Admission Date: [**2180-2-17**] Discharge Date: [**2180-2-22**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Fall - found to have ICH at outside hospital hence transferred
here for further evaluation and care.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a [**Age over 90 **] year-old right-handed woman with a PMH of DM and
HTN who was transferred from [**Location (un) 620**] with an ICH.
Ms. [**Known lastname **] states that she was in her USOH this morning but she
felt "weak" after breakfast but denied focal weakness. She got
and slipped back, falling without LOC. She thinks she may have
struck her head. She was unable to get up because her L arm was
weak. She also noticed that her speech was slurred.
EMS was called and she was noted to have L sided weakness and a
BS of 215. She was taken to the OSH where she was bradycardic
(40's) and HTN (SBP 220). Her exam was reportedly notable for L
sided weakness, L facial droop and dysarthria. A head CT was
done which was reported as a pontine bleed but on review of the
images, she has a R BG bleed. Screening labs showed an INR of
1.1, platelets of 243 and a troponin of >0.01. Her K was
elevated but hemolyzed. She was started on a nitro drip and
transferred here for further care.
ROS:
The pt denied headache, loss of vision, blurred vision,
diplopia, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denied difficulties producing or
comprehending speech. Denied focal numbness, paraesthesia. No
bowel or bladder incontinence or retention. Denied difficulty
with gait. The pt
denied recent fever or chills. No night sweats or recent weight
loss or gain. Denied cough, shortness of breath. Denied chest
pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias. Denied rash.
Past Medical History:
- Iron deficiency anemia
- DM
- GIB (pt denies)
- Squamous cell of leg (pt states she had a second opinion and
was told it was not CA)
- afib
- HTN
- glaucoma
- cataracts
Social History:
-lives at [**Location 1036**] with husband
-EtOh: denies
-tobacco: denies
-drugs: denies
Family History:
-mother: unknown
-father: stroke, DM
Physical Exam:
Vitals: T: P: 44 R: 16 BP: 179/74-220/96 SaO2: 99% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx; significant opacification of both corneas
Neck: Supple, no carotid bruits appreciated.
Pulmonary: decreased breath sounds at bases
Cardiac: nl. S1S2, no murmur
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: no edema.
Skin: multiple pigmented lesions (one on her R leg which is
slightly ulcerated)
Neurologic:
-Mental Status: Alert, oriented x 3 ([**Hospital 86**] hospital rather than
[**Hospital1 **]). Able to relate history without difficulty. Attentive, but
has difficulty with [**Doctor Last Name 1841**] backwards, continues to do them forwards
without difficulty and does not change task despite cues;
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt. was able to
name both high and low frequency objects but has difficulty
seeing objects on the card (calls the feather a leaf, calls the
cactus a plant and thinks the key looks like a hatchet). Unable
to read, says the letters are too small and needs a large
magnifying glass to read at baseline. Speech was mildly
dysarthric. Able to follow both midline and appendicular
commands
on the R but with repeated cues. There was no evidence of
apraxia
or neglect.
CN
I: not tested
II,III: VFF to confrontation, pupils 4mm->2mm bilaterally,
unable
to visualize fundi through the lense opacification
III,IV,V: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: L facial droop
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**5-23**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: + R resting and postural tremor. Slightly decreased bulk
throughout. No asterixis. Motor impersistence, requires repeated
cues to follow strength testing. No pronator drift on the R.
The
R arm, R leg and L leg are all briskly antigravity and she is at
least a 4 in all groups but has motor impersistence so it is
difficult to access if there is subtle weakness. The L arm does
not move to voluntarily or to nox stim but raising the hand in
front of her she is able to move her fingers slightly. She knows
it is her hand.
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 0 mute
R 1 1 1 0 0 mute
-Sensory: No deficits to light touch. No extinction to DSS.
Unreliable vibratory & proprioception response throughout.
-Coordination: No dysmetria on FNF on the R. Unable on the L.
-Gait: deferred given HTN
Pertinent Results:
[**2180-2-17**] 05:32PM BLOOD WBC-7.9 RBC-3.04* Hgb-9.7* Hct-27.4*
MCV-90 MCH-31.9 MCHC-35.3* RDW-13.5 Plt Ct-232
[**2180-2-22**] 05:30AM BLOOD Glucose-122* UreaN-29* Creat-0.7 Na-137
K-4.1 Cl-101 HCO3-29 AnGap-11
[**2180-2-17**] 05:32PM BLOOD ALT-15 AST-21 LD(LDH)-169 CK(CPK)-97
AlkPhos-72 TotBili-0.6
[**2180-2-17**] 05:32PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2180-2-18**] 03:10AM BLOOD CK-MB-3 cTropnT-<0.01
[**2180-2-22**] 05:30AM BLOOD Calcium-9.7 Phos-3.0 Mg-1.8
[**2180-2-18**] 03:10AM BLOOD %HbA1c-6.1*
[**2180-2-18**] 03:10AM BLOOD Triglyc-48 HDL-50 CHOL/HD-2.6 LDLcalc-70
CT HEAD: Acute right basal ganglia hemorrhage with small amount
of
surrounding edema. Unchanged in size and configuration since
prior study done earlier in the morning. No midline shift. No
new hemorrhage identified.
MRI HEAD:
1. Signal abnormality in the right basal ganglia consistent with
recent
hemorrhage and findings on prior CT.
2. No evidence of new hemorrhage or other acute intracranial
abnormality.
3. Narrowing of distal M2 segment of the right MCA; however,
this may be at
the limit of resolution of MRA.
4. Stable remote left MCA infarct.
5. Probable small remote hemorrhage in the pons.
Echocardiogram:
The left atrium is markedly dilated. The right atrium is
markedly dilated. No atrial septal defect is seen by 2D or color
Doppler. The estimated right atrial pressure is 10-20mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 70%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade III/IV
(severe) LV diastolic dysfunction. There is no ventricular
septal defect. The right ventricular free wall is hypertrophied.
The right ventricular cavity is dilated with depressed free wall
contractility. There are focal calcifications in the aortic
arch. 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. There
is no mitral valve prolapse. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
The main pulmonary artery is dilated. The branch pulmonary
arteries are dilated. There is no pericardial effusion.
L shoulder x-ray: There is a comminuted fracture of the left
humeral head and neck with lateral displacement of the proximal
fracture
fragment. Mild osteoarthrosis of the acromioclavicular joint is
noted. The
visualized portion of the left lung is clear.
Brief Hospital Course:
Patient is a [**Age over 90 **] year old woman hx of atrial fibrillation, not on
coumadin, who had a fall on the morning of admission and found
that she was dysarthric with left arm and
leg weakness. She was initially taken to [**Hospital3 628**] where
CT brain showed a
right basal ganglia hemorrhage. There is also an old left
frontal infarct.
On exam, patient is alert and oriented x3 with intact fluency,
comprehension, naming,
repetition. Mild dysarthria. Left lower facial droop. Left arm
is 1-2/5 Strength with 2/5 strength in fingers. Left leg is [**4-23**]
IP, 4-/5 hamstrings, 4+/5 knees, [**4-23**] foot dorsiflexion and
plantarflexion. Right arm is [**5-23**]. right leg is 5-/5 IP, [**5-23**]
hamstrings and knees, [**5-23**] foot dorsiflexion and plantarflexion.
Intact sensation.
Given the site of bleed and hx of HTN, most likely due to
hypertension but also signs of amyloid angiopathy found on MRI.
Given significant left arm pain and hx of fall, she also had a
shoulder x-ray showing L humeral fracture and orthopedics was
consulted who recommended soft sling for comfort but no other
intervention for now. She is recommended for light pendulum
exercises and will be seeing Dr. [**Last Name (STitle) **] (orthopedics) as
outpatient.
She was also found to have significant bradycardia and pauses
for which cardiology was consulted but since she denies any
symptoms inclduing lightheadedness, dizziness or syncope and
since the fall at home was thought to be mechanical, plus
patient's refusal for pacemaker placement, no further
intervention was undertaken during this admission. She does not
have cardiology follow-up scheduled but if she does become
symptomatic or if she wishes to reconsider pacemaker placement,
she is encouraged to get referral through her PCP.
Patient was evaluated per PT/OT during this admission who
recommends acute rehab for intense, inpatient physical therapy.
She will be following up with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (neurology)
as outpatient and she is also encouraged to follow-up with PCP
[**Name Initial (PRE) 176**] 2 weeks of discharge. Although she has atrial
fibrillation, given that she presented with ICH, she was started
on aspirin 81mg only.
Medications on Admission:
- Cozaar 100 mg daily
- nifedipine 30mg PO QD
- glipizide XL 2.5 mg b.i.d.
- tylenol PM 500mg QHS PRN
- neo/polymixin dexamethasone eye ointment to eyelashes QHS
- Alphagan [**Hospital1 **] to both eyes
- travatan drops QD to both eyes
- supplemental Fe
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed: Pain or T>100.4.
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Hold for SBP < 100.
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily): Hold if SBP < 100.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Discontinue if ambulatory and no
concern for DVT.
9. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO BID (2 times a day): Hold if
not taking food.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Right basal ganglia hemorrhage likely due to hypertension and
amyloid angiopathy
Left humeral fracture
Bradycardia
Discharge Condition:
Stable - left sided weakness plus immobile left arm due to
humeral fracture.
Discharge Instructions:
You were admitted after a fall at home and found to have left
sided weakness. Upon further evaluation, you were found to have
right basal ganglia hemorrhage most likely from hypertension and
amyloid angiopathy.
You were also found to have L humeral fracture for which you
were seen by orthopedics placed a soft sling for comfort and you
are allowed to do pendulum movements. No surgical intervention
was warranted and you will be following up with Dr. [**Last Name (STitle) **]
(orthoperdics) as outpatient.
Also, during this admission, you have been noted to have
bradycardia and significant pausese during this appt for which
you were seen by cardiologist but given that you do not have
clinical symptoms and since you refuse pacemaker placement,
there will be no scheduled follow-up with cardiologist at this
point. If you do experience dizziness, lightheadedness or
fainting spells, please call your PCP who will refer you to a
cardiologist for further evaluation and re-visiting of pacemaker
placement.
Please take your medications as scheduled. Also, please follow
up with your medical care providers as listed below.
Please call your doctor or go to the nearest ED if you have new
weakness, numbness, speech problems including slurring of
speech, and/or other concerns.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2180-3-22**] 2:00 - [**Hospital Ward Name 23**] Clinical Center [**Location (un) 858**];
please call [**Telephone/Fax (1) **] to update your insurance/demographic
information prior to your appointment.
Please follow-up with your PCP (Dr. [**Last Name (STitle) **] within 2~3 weeks of
discharge - please report any lightheadedness, dizziness or
syncopal episodes to your PCP or if you wish to reconsider about
pacemaker placement for which he can refer you to a
cardiologist.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2180-3-9**] 10:50
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2180-3-9**] 10:30 - please arrive at 10:30 for the x-ray
prior to seeing Dr. [**Last Name (STitle) **].
Completed by:[**2180-2-22**]
|
[
"E888.9",
"784.5",
"427.31",
"518.0",
"812.20",
"250.00",
"280.9",
"427.89",
"351.8",
"401.0",
"342.00",
"336.9",
"564.00",
"277.30",
"431",
"365.9",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11462, 11539
|
7863, 10149
|
372, 379
|
11697, 11775
|
5145, 5731
|
13108, 14131
|
2370, 2411
|
10453, 11439
|
11560, 11676
|
10175, 10430
|
11799, 13085
|
2426, 2952
|
232, 334
|
407, 2050
|
5740, 7840
|
2967, 5126
|
2072, 2245
|
2261, 2354
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,381
| 198,341
|
8304
|
Discharge summary
|
report
|
Admission Date: [**2133-9-6**] Discharge Date: [**2133-9-12**]
Date of Birth: [**2069-2-2**] Sex: F
Service: SURGERY
Allergies:
Latex
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Head injury s/p fall
Major Surgical or Invasive Procedure:
Closed reduction (R side open bite) madibular repair [**9-9**]
History of Present Illness:
Patient is a 64F who reportedly fell, striking the left side of
her face on the pavement at approximately 1:20 pm this afternoon
while ambulating on uneven pavement. She denies any dizziness
preceding the fall. States she simply tripped. Denies chest
pain, shortness of breath, palpitations, visual change, nausea,
vomiting or any other preceding symptoms.
Past Medical History:
1) Paroxysmal atrial fibrillation (starting [**4-/2133**])
2) Mitral valve prolapse
3) Hypothyroidism
4) Polymyalgia Rheumatica, treated with steroid taper
5) Osteoporosis
Social History:
The patient denies current tobacco use and drinks alcohol
socially. She denies any difficulty doing her activities of
daily living. She is a retired clerical worker from the
pathology department of the NEDH. She smoked [**3-17**] cigarettes
daily for several years but quite 30 years ago.
Family History:
Father died at 74 from a CVA. Mother died at 84 from cardiac
issues. No children or siblings. No history of other familial
disease.
Physical Exam:
Vitals T: 99.0 BP: 140/74 HR:68 RR:14 O2Sats:96%RA
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, left buccal abrasion, laceration to left
chin(sutured).
Pupils: PERRL EOMs: Intact
NECK: Supple, no LAD, no appreciable JVD
CV: RRR, normal S1S2, no murmurs, rubs or gallops
PULM: CTAB
ABD: Soft, NTND, normoactive bowel sounds, no organomegaly, no
abdominal bruit appreciated
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-16**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Pertinent Results:
[**2133-9-6**] 05:50PM GLUCOSE-161* UREA N-17 CREAT-0.9 SODIUM-139
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
[**2133-9-6**] 05:50PM estGFR-Using this
[**2133-9-6**] 05:50PM PHENYTOIN-23.7*
[**2133-9-6**] 05:50PM WBC-13.5*# RBC-3.99* HGB-12.5 HCT-36.8 MCV-92
MCH-31.3 MCHC-34.0 RDW-12.8
[**2133-9-6**] 05:50PM NEUTS-90.6* LYMPHS-7.3* MONOS-1.3* EOS-0.5
BASOS-0.3
[**2133-9-6**] 05:50PM PLT COUNT-269#
[**2133-9-6**] 05:50PM PT-13.8* PTT-27.9 INR(PT)-1.2*
[**9-6**] CT head: Extensive right SDH slightly larger than OSH.
Scattered SAH involving the right cerebral hemisphere. 4.4 mm
leftward subfalcine herniation without uncal or downward
transtentorial herniation. no acute fx
[**9-6**] CT face: non-displaced L mandibular fx, R coronoid fx, tmj
intact b/l
[**9-7**]: Compared to prior exam from [**2133-9-6**] the right
cerebral
convexity subdural hematoma and right sylvian fissure
subarachnoid hemorrhage is unchanged. No new hemorrhage is
identified.
[**9-11**] CHEST (PORTABLE AP)
Focal linear right basilar atelectasis with otherwise clear
lungs.
Brief Hospital Course:
Pt was admitted on [**9-6**] for a right subdural hemmorhage, right
subrachnoid hemmorhage with subfalcine herniation, left
mandibular fracture and right coronoid fracture. Pt's ASA was
held and she was loaded with Dilantin. Pt was followed with Q1
hour neuro checks and a repeat NCHCT which showed a stable
subdural hematoma and a stable subarachnoid hemorrhage. The
pt's mental status remained stable throughout the admission.
OMFS was consulted and performed closed reduction of the
bilateral fractures of the mandible. A nutrition consult was
obtained and the pt was able to supplement her liquid diet
adequately with liquid shakes. Pt with questionable syncopal
episode on [**9-11**] while sitting in bed. Witness claimed that pt
was unresponsive in bed. When assessed the pt was awake and
alert, denying chest pain, shortness of breath, lightheadedness,
headache, visual change or any other symptoms other than jaw
pain. CXR, EKG, FSBS and labs were all normal. This episode
likely represented dehydration in the setting of a
post-operative period in which her PO intake was very poor,
coupled with administration of her normal blood pressure
medications and additional narcotics for pain control. Pt had
no further syncopal episodes. The plan was discussed with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] and the decision was made to titrate down the
blood pressure medications with close follow-up as an
outpatient.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right Subdural Hemmorhage
Right Sub Arachnoid Hemmorhage w/ subfalcine herniation
Left mandibular fracture
Right Coronoid fracture
Discharge Condition:
VSS, Tolerating a liquid diet, Pain well controlled with Po
(liquid) pain medications
Discharge Instructions:
You have been given wire cutters in the event of an Emergency.
If you develop any shortness of breath, nausea, vomiting you
will need to cut the wires on both sides and return to the
Emergency room.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your 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.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] at ([**Telephone/Fax (1) 21461**] to schedule a
follow-up appointment for next week (starting [**9-14**]). He will
need to adjust your blood pressure medications.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with Oral Surgery Trauma
Clinic next Friday ([**2133-9-18**]) Call [**Telephone/Fax (1) 274**] for an
appointment.
Please follow up with Dr. [**Last Name (STitle) 548**] of Neurosurgery; Please call
([**Telephone/Fax (1) 88**] to schedule a follow-up appointment in [**3-17**] weeks.
You will need to tell them when you schedule an appointment
that you will need to have a repeat Head CT scan before your
appoinment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2133-9-28**]
|
[
"518.0",
"733.00",
"852.21",
"852.01",
"276.52",
"244.9",
"348.4",
"458.29",
"780.2",
"E885.9",
"873.44",
"802.29",
"427.31",
"401.9",
"725"
] |
icd9cm
|
[
[
[]
]
] |
[
"76.75",
"86.59",
"93.55"
] |
icd9pcs
|
[
[
[]
]
] |
4729, 4787
|
3236, 4706
|
284, 349
|
4963, 5051
|
2132, 2622
|
6362, 7283
|
1257, 1390
|
4808, 4942
|
5075, 6339
|
1405, 1835
|
224, 246
|
377, 737
|
2631, 3213
|
1850, 2113
|
759, 933
|
949, 1241
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,052
| 185,131
|
46432
|
Discharge summary
|
report
|
Admission Date: [**2154-2-11**] Discharge Date: [**2154-2-22**]
Date of Birth: [**2086-6-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Intubation with successful extubation
History of Present Illness:
67 yo F w/ recent CABG c/b ARF req. HD (3 wks prior), DMII, CVA,
HTN, PVD, ESRD presents from NH w/ resp. distress, tachypnea.
She was given 40 IV lasix enroute to the ED. Per her daughters,
she had been conversant and feeling relatively well up until
yesterday but then began to act confused over the course of the
day and eventually became incoherent.
In the ED the pt. was noted to be tachypneic with diffuse
crackles on exam. Initial vitals notable for a fever of 102.8. A
CXR showed finding c/w pulm edema (although consolidation could
not be r/o). She was started on a nitro GTT and BIPAP was
initiated as daughters would not allow intubation. Per report,
tachypnea improved with BIPAP. Additionally, pt. was given a
dose of levoflox/vanco in the ED for empiric pna coverage. Also,
on presentation pt had a BG of 500 and was given 10u of insulin.
Her K was 6.4 for which she was given. Also, there was a
question of inferior ischemic changes on ECG (?mild STE in the
inferior leads). CE were sent, blood cx, urine cx sent and pt.
was transported to the MICU.
On arrival to the MICU, confused, aggitated, tachypneic, not
tolerating BIPAP. Pt intubated for airway protection and art
line placed. While in the MICU, she was treated for pneumonia
with Vanc/Cefepime for 9 days and antibiotics were discontinued
the day of transfer to the floor. Since then intermittently
looked better, but then intermittently aspirates with acute
respiratory decompensation. Had NSTEMI upon arrival to ICU and
was treated appropriately with heparin gtt for 48hrs. Renal
was also consulted and had been following for acute on chronic
renal insufficiency. She hasn't needed HD in awhile. She
additionally has a history of old stroke, not new here. Also
has a hx of arterial clot after Ao-Fem bypass, but does not to
need to be on coumadin anymore as per her vascular doctor. Last
respiratory decompensation was [**2154-2-18**] at 1am, that resolved with
agressive suctioning, lasix IV and brief treatment with nitro
gtt. She has recalcitrant BP's and the ICU team has been
titrating BP meds. Upon transfer she is on Labetalol 600 TID,
Imdur TID, Captopril TID, but still intermittently 170's. Major
issue now is aspiration and swallowing: repeat swallow study
today with appropriate diet modifications. PEG in place and
getting TFs.
Upon transfer to the floor, she is pleasant, denies any
difficulty breathing or pain. She is oriented to person and
place. Denies any recent fever, chills or other complaints.
Past Medical History:
- Type II diabetes since [**2131**]
- Cerebrovascular accident in [**2142**] with left-sided weakness
- Hypertension
- DVT on coumadin
- Peripheral vascular disease s/p ABF bypass graft [**2136**]; graft
thrombectomy in [**2147**].
- Neuropathy
- History of hyperkalemia
Social History:
Former smoker (quit [**2140**]). Lives alone in an elder building.
Attends adult day care every day. Has 4 children. Denies EtOH
use.
Family History:
Mother with HTN; Father with stroke. No known early coronary
disease or sudden death.
Physical Exam:
VS: Tc: 97.1 BP: 155/55 HR: 80 RR: 18 O2sat 99% RA
GEN: Pleasant, speaking in full sentences
HEENT: PERRL, MMM, poor dentition
RESP: CTAB anteriorly with end-expiratory wheeze posteriorly
(right greater than left), occassional rales in bases
bilaterally, no rhonchi
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly, PEG in
place without any surrounding erythema
EXT: no L radial pulse palpable, 1+ R radial pulse
SKIN: no rashes/no jaundice, lower extremity wounds dressing
C/D/I, no evidence of infection
Pertinent Results:
[**2154-2-11**] 10:00AM WBC-16.0* RBC-4.59 HGB-13.5 HCT-41.4 MCV-90
MCH-29.4 MCHC-32.6 RDW-15.3 NEUTS-81.8* LYMPHS-16.5* MONOS-1.3*
EOS-0.1 BASOS-0.3 PLT COUNT-368
[**2154-2-11**] 10:00AM GLUCOSE-638* UREA N-45* CREAT-2.8* SODIUM-134
POTASSIUM-6.4* CHLORIDE-93* TOTAL CO2-30 ANION GAP-17
CALCIUM-8.6 PHOSPHATE-3.1 MAGNESIUM-2.4
[**2154-2-11**] 10:25AM LACTATE-2.5*
[**2154-2-11**] 10:00AM CK-MB-17* MB INDX-9.1* cTropnT-0.9*
CK(CPK)-187*
[**2154-2-11**] 11:45AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-1000 KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-[**2-20**]* WBC-[**2-20**]
BACTERIA-FEW YEAST-MOD EPI-0-2
[**2154-2-11**] 01:08PM TYPE-ART TEMP-38.8 PO2-447* PCO2-41 PH-7.42
TOTAL CO2-28 BASE XS-2 INTUBATED-NOT INTUBA VENT-SPONTANEOU
[**2154-2-21**] 05:45AM BLOOD WBC-9.3 RBC-2.97* Hgb-8.8* Hct-26.8*
MCV-90 MCH-29.7 MCHC-33.0 RDW-16.1* Plt Ct-318
[**2154-2-21**] 05:45AM BLOOD Glucose-86 UreaN-53* Creat-2.5* Na-139
K-3.8 Cl-106 HCO3-24 AnGap-13
[**2154-2-16**] 03:23AM BLOOD calTIBC-181* Ferritn-919* TRF-139*
[**2154-2-18**] 05:38AM BLOOD Type-ART Temp-36.6 PEEP-5 O2 Flow-40
pO2-142* pCO2-38 pH-7.41 calTCO2-25 Base XS-0 Intubat-NOT INTUBA
Vent-CONTROLLED
[**2154-2-18**] 05:38AM BLOOD Lactate-0.8
CXR, SINGLE VIEW CHEST, PORTABLE UPRIGHT [**2154-2-11**]: There has been
interval development of increased interstitial and alveolar
opacities within the lungs. The patient is status post median
sternotomy and CABG. Percutaneous gastric tube and surgical
clips seen within the abdomen. IMPRESSION: Interval development
of diffuse interstitial and alveolar opacities most consistent
with pulmonary edema. However, multifocal pnemonia should also
be considered and follow-up films after treatment will be of
benefit.
CT HEAD W/O CONTRAST Study Date of [**2154-2-11**] 11:48 PM
No significant change from [**2154-1-5**]. Chronic ischemic changes
with no evidence of hemorrhage or recent infarction.
CT HEAD W/O CONTRAST Study Date of [**2154-2-13**] 5:01 AM
No significant interval change without evidence for acute
intracranial hemorrhage.
RENAL U.S. Study Date of [**2154-2-18**] 2:02 PM
1. Due to the patient's inability to hold breath, the Doppler
study could not be performed, and therefore, renal artery
stenosis could not be assessed.
2. 7-mm nonobstructing stone in the right kidney. 5-mm stone
versus vascular calcifications in the left kidney.
3. 1.9-cm cyst in the left kidney.
VIDEO OROPHARYNGEAL SWA Study Date of [**2154-2-19**] 1:09 PM
1. Aspiration of thin & nectar thick liquids during swallows
with straws.
2. Suggestion of impaired or increased vocal fold abduction or
closure.
Brief Hospital Course:
67 yo F with recent STEMI status post 3 vessel CABG complicated
by ARF/HD, DM II, HTN, history of CVA, admitted from
rehabilitation facility with respiratory distress and mental
status changes.
# Respiratory failure: This was her admitting diagnosis. She
was intubated for airway protection given altered mental status
on CPAP. CXR consistent with pulmonary edema but given fever
could also have PNA vs flu. Hypertensive prior to intubation
which could have exacerbated pulmonary edema but post-intubation
she became normotensive. While in the ICU was treated
presumptively for hospital acquired pneumonia with vanc/cefepime
for a 9 day course. Successfully extubated without need for
reintubation. Continued to have intermittent respiratory
distress that was attributed to aspiration events. Not clearly
assessed for PE, given that she was receiving heparin at her
rehab. Lower extremity Dopplers were also obtained given concern
for PE, though this was low on differential. Doppler exam was
negative for thrombus. Upon transfer to the floor is doing well
on RA with intermittent nebs for increased SOB. Continued to
monitor for evidence of infection, and she had no further
evidence of this. Continued with Nebulizers PRN and aspiration
precautions. Lastly, she was started on steroids [**2-18**] AM for
acute respiratory distress, despite lack of evidence for asthma
vs COPD flair. Respiratory status seemingly improved mildly.
Upon discharge was on rapid taper of steroids, which will be
continued at her outpatient facility. Home dose Lasix of 20mg
daily was not restarted prior to discharge but this should be
considered if her volume status becomes an issue.
# Altered Mental Status: Per family, patient is oriented x 3 at
baseline. During initial assessment she was very confused and
combative, prompting intubation for airway protection. A CT
head was obtained and revealed no significant interval change
without evidence for acute intracranial hemorrhage. After
extubation, her mental status improved greatly but she did not
return to baseline. Likely her initial presentation was due to
pneumonia and urinary tract infection. She continues to improve
daily and is oriented to self and location, but not date upon
discharge.
# UTI: Grew Enterobacter. Completed course for UTI with
cefepime.
# Hypertension: SBPs 160-180s since admission. Per ICU notes,
it was unclear why patient was acutely hypertensive during this
hospitalization. Evaluation for renal artery stenosis was
ineffective given inability of patient to comply with the U/s
exam. Lower extremity Dopplers were also obtained given concern
for PE, though this was low on differential. Doppler exam was
negative for thrombus. Upon discharged was being fairly well
controlled with Hydralazine 40 mg q6 hours, isosorbide dinitrate
40mg TID, Labetalol 800mg po TID and Lisinopril 40mg daily.
Rehab facility may up titrate as needed for improved control.
Home dose Lasix of 20mg daily was not restarted prior to
discharge but this should be considered if her volume status
becomes an issue.
# CAD: s/p CABG in [**12-25**]. Patient did rule in for NSTEMI. Was
treated with heparin gtt for 48 hours, which was completed prior
to transfer to the floor. Denied any chest pain or other
symptoms during rest of hospital course. Continued aspirin
325mg, as well as Atorvastatin 80mg and beta blocker.
# Chronic Kidney Disease: post-op CABG course complicated by
renal failure requiring dialysis but current Cr similar to that
prior to discharge. Upon transfer to the floor, ICU nursing
reports decreased urine output during last ICU day, but still
maintaining 20-30 cc/hr. Continued to renally dose medications
and Renal Service followed her throughout her inpatient stay.
Discharged with outpatient follow-up for this issue. Also
discharged on Epoetin three times weekly for associated anemia.
Hematocrit stable during inpatient stay.
# DM: Hyperglycemia. [**Last Name (un) **] was consulted and provided
inpatient recommendations for improved glycemic control.
Discharged on Humalog insulin sliding scale. Can up titrate at
facility as needed for improved control.
# Surgical wounds: Obtained wound consult for bilateral lower
extremity surgical wounds while inpatient. Continued wound care
per wound consult.
# Post-foley void: At the time of writing this summary, patient
is awaiting post-foley void. If she fails to do so prior to
transfer, the foley will be replaced and she can proceed with
voiding trials at her facility.
FULL CODE
Communication w/ [**First Name9 (NamePattern2) 2759**] [**Name (NI) 7346**] ([**Telephone/Fax (1) 98636**]; ([**Telephone/Fax (1) 98637**] and
[**Last Name (un) 50269**] ([**Telephone/Fax (1) 98638**]; ([**Telephone/Fax (1) 98639**]
Medications on Admission:
Simvastatin 80 PO DAILY
Albuterol nebs
Atrovent nebs
Aspirin 81 mg qdaily
Lansoprazole 30 mg qdaily
Tramadol 50 mg prn
Colace
Hydralazine 20mg q6hrs
Calcitriol 0.25 mcg qod
Furosemide 20 mg qdaily
Metoprolol Tartrate 150mg tid
Isosorbide Dinitrate PO TID
Insulin sliding and fixed
Discharge Medications:
1. Famotidine 20 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q24H (every 24
hours).
2. Citalopram 20 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
3. Calcitriol 0.25 mcg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
5. Atorvastatin 80 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 325 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: Ten (10) mL PO BID (2
times a day): hold for loose stools .
8. Olanzapine 2.5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia or agitation.
9. Epoetin Alfa 10,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1) mL
Injection QMOWEFR (Monday -Wednesday-Friday).
10. Hydralazine 10 mg Tablet [**Telephone/Fax (1) **]: Four (4) Tablet PO Q6H (every
6 hours): Hold for sbp < 100 .
11. Ipratropium Bromide 0.02 % Solution [**Telephone/Fax (1) **]: One (1) Inhalation
Q6H (every 6 hours).
12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Telephone/Fax (1) **]:
One (1) Neb Inhalation Q2H (every 2 hours) as needed for
wheezing.
13. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1) mL
Injection TID (3 times a day): [**Month (only) 116**] discontinue if patient
becomes increasingly ambulatory.
14. Lisinopril 20 mg Tablet [**Month (only) **]: Two (2) Tablet PO DAILY
(Daily): SBP < 100 .
15. Labetalol 200 mg Tablet [**Month (only) **]: Four (4) Tablet PO TID (3 times
a day): Hold if SBP<95 or HR<60 .
16. Isosorbide Dinitrate 20 mg Tablet [**Month (only) **]: Two (2) Tablet PO TID
(3 times a day): Hold for SBP < 100 .
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month (only) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
18. Senna 8.6 mg Tablet [**Month (only) **]: One (1) Tablet PO Q 8H (Every 8
Hours): Hold for loose stools.
19. Prednisone 10 mg Tablet [**Month (only) **]: 1-2 Tablets PO once a day for 3
days: Patient is on a prednisone taper. She started [**2154-2-18**] with
40mg; upon discharge she is at 20mg daily. Plan for 20mg
[**2154-2-23**], then 10mg [**Date range (1) 98640**]. With stop [**2-25**].
20. Outpatient Physical Therapy
To evaluate and treat as needed.
21. Outpatient Occupational Therapy
To evaluate and treat as needed.
22. Outpatient Speech/Swallowing Therapy
To evaluate and treat as needed. Plan to modify diet as patient
improves from acute illness. Unclear at discharge if may take
all nutrition po, but this is the goal of the family.
23. Insulin Sliding Scale
Please see attached insulin sliding scale with fingerstick
checks QID
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary: Pneumonia, respiratory distress
Secondary: Type 2 Diabetes, history of stroke, hypertension,
chronic kidney disease
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted from your rehab about having difficulty
breathing. You were treated for pneumonia with 9 days of
antibiotics and your breathing improved. Upon discharge, you
were continuing to have occasional wheezing, which improved with
nebulizers. Thus, you are being discharged to a nursing
facility for further care and recoverly.
Please take all medications as prescribed. Your facility has
been provided with a list of all the medications you should be
taking.
Keep all outpatient appointments. The facility physician will
monitor you during your stay there.
Consult the facility physician if you notice shortness of
breath, fever, chills, difficulty breathing, chest pain, painful
urination or for any other symptom which is concerning to you.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2154-3-18**] 1:00
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,729
| 153,652
|
13256+13257
|
Discharge summary
|
report+report
|
Admission Date: [**2154-8-16**] Discharge Date: [**2154-8-25**]
Service: Acove Service
HISTORY OF PRESENT ILLNESS: The patient is an 86 year old
male with a history of recurrent pancreatitis secondary to
gallstone, coronary artery disease, status post coronary
artery bypass graft five years ago transferred from [**Hospital3 40375**] for further evaluation and treatment of his
pancreatitis. Of note, the patient presented this past [**Month (only) **]
with an episode of pancreatitis. During this episode he
presented with worsening epigastric pain. A computerized
tomography scan in [**Month (only) **] revealed that there was evidence of
stranding around the pancreas consistent with pancreatitis
without any large abscesses. The gallbladder contained
stone. There was some calcification at the head of the
pancreas. Magnetic resonance in [**Month (only) **] revealed acute
pancreatitis, multiple liver cysts, gallstones, bilateral
pleural effusions as well as a 4 cm infrarenal abdominal
aortic aneurysm. During that admission in [**Month (only) **], the
patient's amylase and lipase had returned to [**Location 213**] values.
The amylase had peaked to approximately 7800 at an outside
hospital. More recently the patient presented to [**Hospital3 40375**] with a five day history of abdominal pain. On
[**8-13**], he had a computerized tomography scan which showed
progression of a sequela from the pancreatitis with a new
inflammatory mass as well as thick parapancreatic collection.
The gallbladder revealed one radiopaque stone with probable
intrahepatic bile duct dilatation, ascites, as well as
bilateral pleural effusion. KUB suggested some dilated bowel
loops which suggested a dynamic ileus as opposed to
obstruction. During that admission he did not have any
amylase or lipase elevations and he required one unit of
packed red blood cells. He was transferred to [**Hospital6 1760**] on [**2154-8-16**] where he
presented with right upper quadrant and right lower quadrant
abdominal tenderness. He has had a bowel movement on the
morning of admission but denied any nausea, vomiting or
bloody stools. The patient complained of a 30 lb weight loss
over the past several months. He had had decrease in intake
p.o. since he had been NPO during his hospitalization course
for pancreatitis.
PAST MEDICAL HISTORY: Coronary artery disease status post
coronary artery bypass graft five years ago; history of
hyperlipidemia; history of atrial fibrillation; history of
pancreatitis; history of 4 cm abdominal aortic aneurysm.
HOME MEDICATIONS: Aspirin 325 mg p.o. q. day; Lipitor 10 mg
p.o. q. day; Digoxin 0.125 mg p.o. q. day; Atenolol 25 mg
p.o. q. day; Iron 325 mg p.o. q. day; Protonix 40 mg p.o. q.
day; Senokot.
ALLERGIES: Iodine and contrast dye which make him have a
rash on his body, however, it does not cause any throat
swelling nor known difficulty breathing. He is also allergic
to Morphine which causes him to become goofy.
FAMILY HISTORY: Non-contributory
SOCIAL HISTORY: The patient lives in [**Hospital1 6687**] and denies
any alcohol or tobacco use.
REVIEW OF SYSTEMS: Notable for right upper quadrant and
right lower quadrant abdominal pain over the last day and he
denies any blood stools. There is chest pain, shortness of
breath and cough.
PHYSICAL EXAMINATION: Temperature on is 98.6, blood pressure
140/80, pulse is 62 with respirations of 16. He is
comfortable in no acute distress. His head, eyes, ears, nose
and throat examination was normocephalic, atraumatic.
Extraocular muscles were intact with sclera anicteric. Heart
was regular with ectopic beats but no appreciable murmurs,
rubs or gallops. Lungs were clear to auscultation
bilaterally except for some decreased breathsounds in the
left base. Abdomen, he had some tenderness in the right
abdomen, fairly diffuse tenderness, however, the abdomen was
felt not distended. He had hypoactive bowel sounds. He had
no cyanosis, clubbing or edema. His rectal examination was
heme negative, nonfocal neurological examination.
LABORATORY DATA: Laboratory data on admission were notable
for a white count 14.7, neutrophil count of 86%, hematocrit
27.8, platelets 347. Chem-7 had BUN 25, creatinine 1.2 and
amylase was 52, total bilirubin 0.6, lipase 64, ALT 21, AST
28, LD 215, alkaline phosphatase slightly elevated at 156.
Albumin was low at a value of 1.9.
HOSPITAL COURSE: The patient was admitted from the outside
hospital and at that time he was transferred to [**Hospital6 1760**] for further treatment and
evaluation of his pancreatitis. On admission he had a fairly
benign abdominal examination and a trial of clear diet was
tolerated, however, he did not tolerate the diet very well as
he became nauseous with that. Therefore bowel rest and NPO
was continued. He was initially treated with Ampicillin and
Flagyl beginning on [**8-18**] for coverage of possible
gastrointestinal infection. He had an magnetic resonance
imaging scan of the abdomen with and without contrast.
Magnetic resonance imaging scan was performed given his
history of contrast allergy. Magnetic resonance imaging scan
showed focal pancreatitis with marked inflammation involving
the pancreatic head and neck which had been increased in size
from the previous magnetic resonance cholangiopancreatography
from [**2154-6-28**]. The inflammatory mass is likely
developing fluid collection, however, there are no
appreciable fluid collections that could be drained at the
time. Magnetic resonance imaging scan also showed
cholelithiasis and no choledocholithiasis, multiple liver
cysts, bilateral pleural effusion and ascites, however, did
not show any pancreatic or biliary ductal dilatation. Also
during this hospital course the patient had a chest x-ray
which showed that there was a possible left lower lobe
pneumonia. The chest x-ray was consistent with either
pneumonia versus atelectasis. He was started on Levaquin for
this on approximately [**8-23**]. Of note, the patient
received a small dose of Ativan prior to the magnetic
resonance imaging scan and the patient had had episodes of
confusion after this for approximately 24 to 48 hours
afterward. His episodes of confusion and mental status
changes have resolved. The patient had a PICC placed and was
receiving total parenteral nutrition through this PICC for
his nutrition. The patient developed worsening abdominal
pain on [**8-23**]. Between admission and [**8-23**] the
patient's abdominal pain actually had improved and he had no
episodes of abdominal pain. His worsening abdominal pain
prompted a noncontrast computerized tomography scan to be
done. This showed that there was interval enlargement of the
bilateral pleural effusions with associated atelectasis. It
also showed that there was interval enlargement in the amount
of ascites present. There were unchanged low attenuation
areas in the liver which were previously described on
magnetic resonance imaging. There were evidence of
gallstones in the bladder. There was also evidence of
colonic diverticulosis and evidence of diverticulitis. There
was worsening stranding around the pancreas which was
consistent with pancreatitis. The fluid collection drawn of
the pancreas suggested developing new pseudocysts. Of note,
this abdominal tenderness was deferred. The abdominal
tenderness at this time was on his left side where as on
admission his abdominal tenderness was on his right side.
His abdominal tenderness improved over the next couple of
days. However, it was felt that the patient's ascites could
be tapped and sent for analysis. Also of note during this
admission, the patient was noted to have an elevated INR of
approximately 1.8 to 2 and this was treated with supplemental
Vitamin K in his total parenteral nutrition.
This is a preliminary dictation and will be continued and
finished upon the patient's discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], M.D. [**MD Number(1) 6243**]
Dictated By:[**Last Name (NamePattern1) 7602**]
MEDQUIST36
D: [**2154-8-25**] 14:00
T: [**2154-8-25**] 14:11
JOB#: [**Job Number 40376**]
Admission Date: [**2154-8-16**] Discharge Date: [**2154-10-2**]
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is an
86-year-old gentlemen with a history of recurrent
pancreatitis secondary to gallstones, who transferred from
[**Hospital3 22439**] for further evaluation and treatment of a
new episode of pancreatitis. The last episode was in [**Month (only) **] of
this year. During this episode, he presented with worsening
epigastric pain. During the previous episode in [**Month (only) **], MRI
was performed, which revealed acute pancreatitis, multiple
liver cysts, gallstones, bilateral pleural effusions, and a
4-cm infrarenal abdominal aortic aneurysm. The patient did
have a peak amylase of 7800 during this time, but the amylase
and lipase did return to normal values prior to discharge.
During this more recent episode, a CT scan was performed on
[**2154-8-13**], which revealed progression of the previous
pancreatitis with a new inflammatory mass, as well as a thick
area of pancreatic collection.
One radiopaque stone was seen in the gallbladder with
probable intrahepatic bile duct dilatation. KUB: Dilated
bowel loops suggestive of ileus. The patient did not have
any elevations in amylase or lipase at [**Hospital3 **].
He was subsequently transferred to [**Hospital1 190**] on [**2154-8-16**], where he presented with right
upper quadrant and right lower quadrant abdominal tenderness.
He did have a bowel movement on the morning of admission. He
denied any nausea, vomiting, or blood stools. Mr. [**Known lastname 40377**] has
noted a 30 pound weight over the past several months, as well
as decreased PO intake.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG five years ago.
2. History of hyperlipidemia.
3. History of atrial fibrillation.
4. History of pancreatitis.
5. 4-cm abdominal aortic aneurysm.
HOME MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Lipitor 10 mg q.d.
3. Digoxin 0.125 mg PO q.d.
4. Atenolol 25 mg q.d.
5. Iron 325 mg q.d.
6. Protonix 40 mg q.d.
7. Senokot p.r.n.
ALLERGIES: The patient is allergic to IODINE AND CONTRAST
DYE, WHICH CAUSE A RASH, although it does not cause any
throat swelling or difficulty breathing. THE PATIENT NOTES
MENTAL STATUS CHANGES WITH MORPHINE.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Mr. [**Known lastname 40377**] lives in [**Hospital1 6687**]. He denies
alcohol or tobacco use.
REVIEW OF SYSTEMS: Review of systems is notable for right
upper quadrant and right lower quadrant abdominal pain. The
patient denies bloody stools. There was no chest pain,
shortness of breath, or cough. He has also noted a 30-pound
weight loss.
PHYSICAL EXAMINATION: Examination revealed the following:
Temperature 98.6, blood pressure 148/80, pulse 62,
respirations 16. He is in no acute distress. HEENT::
Normocephalic, atraumatic. Extraocular muscles are intact.
Sclerae were anicteric. HEART: Heart was regular with no
appreciable murmurs, rubs, or gallops. LUNGS: Lungs were
clear to auscultation except for decreased breath sounds at
the left base. ABDOMEN: Soft, nondistended with mild
diffuse tenderness on the right. He had hypoactive bowel
sounds. RECTAL: Examination was guaiac negative.
EXTREMITIES: Extremities were without clubbing, cyanosis or
edema.
LABORATORY DATA: Laboratory data revealed the following:
WBC 14.7, with 86% neutrophils, hematocrit 27.8, platelet
count 247,000, BUN 25, creatinine 1.2, amylase 52, total
bilirubin 0.6, lipase 64, ALT 21, AST 28, LDH 215, alkaline
phosphatase 156, albumin 1.9.
HOSPITAL COURSE: Mr. [**Known lastname 40377**] was admitted for further
treatment and evaluation of the pancreatitis. On admission,
he was give a trial of clear liquids, which he did not
tolerate. He was subsequently placed on bowel rest and NPO.
Ampicillin and Flagyl were begun for coverage of possible GI
infection. MRI revealed focal pancreatitis with marked
inflammation involving the pancreatic head and neck. There
were no appreciable fluid collections that could be drained
at that time. The MRI also revealed cholelithiasis without
choledocholithiasis, multiple liver cysts, bilateral pleural
effusions and ascites and no evidence of pancreatic or ductal
dilatation.
Chest x-ray was suggestive of possible left lower lobe
pneumonia and Mr. [**Known lastname 40377**] was subsequently started on Levaquin.
PIC line was placed so that Mr. [**Known lastname 40377**] could receive total
parenteral nutrition.
On [**2154-8-23**], Mr. [**Known lastname 40377**] complained of worsening abdominal
pain. Noncontrast CT was performed at this time, which
revealed interval enlargement of bilateral pleural effusions
with associated atelectasis. It also showed increase of
ascites. There were unchanged low attenuation areas of the
liver. There was worsening stranding around the pancreas,
which was consistent with pancreatitis. Abdominal tenderness
did improve over the next several days. Mr. [**Known lastname 40377**] was kept
NPO with TPN supplementation. Vitamin K was also added to
the TPN to increase INR of 1.8 to 2. Ascitic fluid was
tapped, which revealed white blood cells of [**Pager number **], RBC 899 with
56% neutrophils, 30% lymphocytes, total protein 3.5, amylase
15, albumin 1.3, triglycerides 18. Cultures of the fluid
revealed no growth.
Surgery consultation was obtained on [**2154-8-26**] due to
increased size of fluid collections/phlegmon/question of
pseudocyst, for further evaluation and management.
Triglycerides levels were checked in case TPN with fat was
causing elevation. The value was found to be 69.
Echocardiogram was performed on [**2154-8-28**], which revealed
mildly dilated left atrium and severe left ventricular
hypokinesis, mild AR, and mild-to-moderate MR with an EF of
less than 20%. Mr. [**Known lastname 40377**] was tried on small amounts of oral
intake, not noted increasing abdominal pain immediately
afterwards. He was then placed back NPO except for oral
medications. Rectal tube was placed on [**2154-8-30**] to assist
in decompression of the abdomen. On [**2154-9-2**], Mr. [**Known lastname 40377**] was
transfused one unit of packed red blood cells for hematocrit
of 26.5. The abdominal distention was felt to be improving
and Mr. [**Known lastname 40377**] was again slowly advanced in diet.
On [**2154-9-4**], Mr. [**Known lastname 40377**] was noted to have some increasing
confusion. Head CT was performed to rule out a stroke. This
examination was negative. On [**2154-9-4**], Mr. [**Known lastname 40377**] was
transferred to the Blue Surgery Service. Mr. [**Known lastname 40377**] was again
transfused for decreased hematocrit. The mental status
progressively improved over the next several days.
On [**2154-9-7**], Mr. [**Known lastname 40377**] was noted to have tachypnea and
shortness of breath. Chest x-ray revealed increased pleural
effusion. This effusion responded to Lasix therapy and the
pulmonary status improved. PO intake was encouraged.
Mr. [**Known lastname 40378**] abdominal status improved. TPN was cycled.
On [**2154-9-11**], Mr. [**Known lastname 40377**] was noted to have a temperature of
101.3 with respiratory rate in the 40s. Blood cultures were
sent and chest x-ray revealed left pleural effusion versus
left lower lobe pneumonia. Due to the poor pulmonary status,
Mr. [**Known lastname 40377**] was transferred to the Surgical Intensive Care
Unit. In the ICU, the atrial fibrillation was controlled
with Digoxin and Tylenol. He was diuresed with Lasix and
Diamox and he received aggressive pulmonary toilet.
Thoracentesis on the left was performed and 1200 cc fluid
were removed. At this time, the bursa was also aspirated
with 5 cc fluid. Mr. [**Known lastname 40377**] was started on Ciprofloxacin and
elbow bursa and sputum cultures were followed. Vancomycin
was added on [**2154-9-13**]. Mr. [**Known lastname 40378**] pulmonary status
improved with diuresis and he was unstable for transfer back
to the floor on [**2154-9-14**]. Mr. [**Known lastname 40377**] was continued on TPN
for the next several days and encouraged to increase the oral
intake. However, he was unable to take adequate POs and
subsequently feeding J tube was placed on [**2154-9-24**]. The
procedure was performed without complication. Mr. [**Known lastname 40377**] was
subsequently transferred to the floor after recovery in the
PACU. He was started on 20 cc per hour of ?????? strength tube
feeds and slowly increased. The TPN was weaned as the tube
feeds were increased towards goal.
By [**2154-10-10**] Mr. [**Known lastname 40377**] was at goal tube feeds at 70 cc per
hour of Impact with fiber. He continued to work with the
Department of Physical Therapy. The TPN was discontinued.
Mr. [**Known lastname 40377**] was felt stable at this time for transfer to a
rehabilitation facility.
PHYSICAL EXAMINATION: Physical examination on discharge
revealed the following: Vital signs: Temperature 97.7,
pulse 100, blood pressure 132/84, respirations 30, oxygen
saturation 92% on two liters. He was comfortable and in no
apparent distress, mildly tachycardiac. LUNGS: Lungs were
clear bilaterally. The patient had slightly decreased breath
sounds at the left lung base. ABDOMEN: Abdomen was soft,
nontender, and nondistended without bowel sounds. J tube was
in place. EXTREMITIES: Extremities were without clubbing,
cyanosis or edema.
DISCHARGE MEDICATIONS:
1. Tube feeds, Impact with fiber at 70 cc per hour.
2. Glycerine suppository one suppository pr, p.r.n.
3. Heparin 5000 units subcutaneously, q.12h.
4. Digoxin 0.125 mg PO q.d.
5. Atenolol 25 mg q.d.
6. Lisinopril 25 mg PO q.d.
7. Iron sulfate 325 mg t.i.d.
8. Zinc sulfate 220 mg q.d.
9. Ipratropium bromide one nebulized inhaler q.6h.
10. Albuterol one nebulizer inhaler, q.6h, p.r.n.
11. Clotrimazole cream one application to buttocks p.r.n..
12. Nystatin oral suspension 5 ml PO q.i.d.p.r.n.
13. Tylenol 325 mg to 650 mg q.4h. to 6h.p.r.n.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Mr. [**Known lastname 40377**] is to be transferred to the
[**Hospital3 7**] Rehabilitation Facility.
DISCHARGE DIAGNOSES:
1. Gallstones pancreatitis.
2. Ascites.
3. Status post feeding jejunostomy tube.
4. Poor oral intake.
5. Pleural effusions.
6. Left lower lobe pneumonia.
7. Low hematocrit requiring multiple transfusions.
8. Atrial fibrillation.
9. 4-cm abdominal aortic aneurysm.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Name8 (MD) 11235**]
MEDQUIST36
D: [**2154-10-1**] 10:46
T: [**2154-10-1**] 10:55
JOB#: [**Job Number 40379**]
|
[
"574.20",
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icd9cm
|
[
[
[]
]
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[
"83.94",
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icd9pcs
|
[
[
[]
]
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18225, 18356
|
10468, 10486
|
18377, 18881
|
17649, 18203
|
11770, 17071
|
10073, 10451
|
17094, 17626
|
10621, 10852
|
127, 2328
|
9861, 10055
|
10503, 10601
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,282
| 121,149
|
35976
|
Discharge summary
|
report
|
Admission Date: [**2134-1-23**] Discharge Date: [**2134-1-26**]
Date of Birth: [**2088-4-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
severe epigastric abd pain
Major Surgical or Invasive Procedure:
ERCP with stent placement
History of Present Illness:
This is a 45M with hx HTN, PTSD, lipids, presenting with severe
epigastric abd pain since [**1-22**] 11 PM, found to have gallstone
pancreatitis and dehydration. At OSH: Tbili 2.0, LFTs:
[**Telephone/Fax (3) 81674**], Tbili 2.0, Lipase [**2027**], WBC 15, Hct 53.8.
He reported +N/V, very minimal urine output, severe dry mouth.
He denies drinking. Denies F/C/dysuria/hematachezia.
Past Medical History:
PTSD, HTN, R TKR
Social History:
Gulf war veteran.
No EtOH
Physical Exam:
98.9, 62, 163/50, 20, 96% RA
Gen: A+O x 3, in severe, doubled over pain
CV: RRR
Chest: CTAb bilat
Abd: mild distended, very tender in epigastrium, with guarding
and rebound. No hernias, guaiac negative
Pertinent Results:
[**2134-1-25**] 01:30AM BLOOD WBC-15.3* RBC-4.96 Hgb-15.7 Hct-43.2
MCV-87 MCH-31.7 MCHC-36.4* RDW-14.6 Plt Ct-158
[**2134-1-23**] 01:00PM BLOOD WBC-14.0* RBC-5.74 Hgb-18.2* Hct-49.8
MCV-87 MCH-31.6 MCHC-36.5* RDW-14.5 Plt Ct-253
[**2134-1-25**] 01:30AM BLOOD Glucose-133* UreaN-15 Creat-0.8 Na-142
K-3.2* Cl-106 HCO3-26 AnGap-13
[**2134-1-23**] 01:00PM BLOOD Glucose-237* UreaN-15 Creat-0.9 Na-138
K-3.8 Cl-101 HCO3-25 AnGap-16
[**2134-1-25**] 01:30AM BLOOD ALT-329* AST-172* LD(LDH)-540* AlkPhos-76
Amylase-356* TotBili-5.3*
[**2134-1-24**] 12:30AM BLOOD ALT-460* AST-348* LD(LDH)-522* AlkPhos-87
Amylase-420* TotBili-5.9*
[**2134-1-25**] 01:30AM BLOOD Lipase-620*
[**2134-1-23**] 01:00PM BLOOD Lipase-1409*
[**2134-1-25**] 01:30AM BLOOD Calcium-7.3* Phos-1.4* Mg-2.2
.
Date: Sunday, [**2134-1-24**] Endoscopist(s): [**Name6 (MD) **] [**Name8 (MD) **],
MD
[**First Name (Titles) **] [**Last Name (Titles) 81600**], MD (fellow)
Impression: Severe peri-mapullary edema
Cholangiogram was normal without presence of stones or
strictures.
A small sphincteromy was perfomred.
A biliary stent was placed.
Recommendations: Follow for response/complications
Follow LFTs.
Continue broad spectrum antibiotics
Consider cholecystectomy - timing to be determined by surgical
staff.
Repeat ERCP in 10 weeks for stent removal
.
Brief Hospital Course:
This is a 45 yo male with severe epigastric abd pain since and
found to have gallstone pancreatitis and dehydration for
aggressive IV hydration.
He was admitted to the ICU
Neuro: dilaudid PCA for pain
CV: lopressor, prn hydralazine for BP control
Resp: BiPAP at night for OSA (pt will have his own brought in
today)
GI: He went for ERCP with stent placement/sphincterotomy and
sludge removal. He had peri-ampullary edema. He was kept NPO,
IVF, follow UOP, trend LFTs/[**Doctor First Name **]/lipase. His
tbili/amylase/lipase were all trending down. We recommend a
cholecystectomy by the end of the week.
Nutrition: NPO/IVF
Renal: dehydration, f/u UOP, aggressive IVF resuscitation
Heme: Hct hemoconcentrated, continue to follow
Endo: tight blood sugar control. He was on an insulin gtt while
in the ICU and was then switched to a sliding scale when
transferred to the floor.
ID: on Unasyn for 24 hrs; follow WBC
Medications on Admission:
Lithium 300', HCTZ 25', Prilosec 20', Motrin, Lisinopril 40',
Ritalin 20''', Simvastatin 20'
Discharge Medications:
1. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Dilaudid 1 mg/mL Solution Sig: 0.25-1 mg Injection every four
(4) hours as needed for pain.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever,pain.
8. Insulin Regular Human 100 unit/mL Solution Sig: Sliding scale
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Acute Abdominal Pain
Dehydration
Hyperglycemia
Gallstone Pancreatitis
Discharge Condition:
Good
Discharge Instructions:
You were admitted for Gallstone Pancreatitis and had an ERCP and
stent placement. You are being transferred to the VA for
continued care. You need to have your gallbladder out in the
near future.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued fluid losses from
the PTC catheter, vomiting, diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**11-25**] lbs) for 6 weeks.
Followup Instructions:
Please follow-up with your PCP and [**Name9 (PRE) 1268**] VA surgeon.
Completed by:[**2134-1-26**]
|
[
"574.51",
"577.0",
"276.51",
"309.81",
"789.09",
"338.29",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
4244, 4259
|
2439, 3355
|
340, 368
|
4373, 4380
|
1101, 2416
|
6070, 6171
|
3498, 4221
|
4280, 4352
|
3381, 3475
|
4404, 6047
|
878, 1082
|
274, 302
|
396, 779
|
801, 820
|
836, 863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,611
| 184,345
|
7826
|
Discharge summary
|
report
|
Admission Date: [**2196-6-30**] Discharge Date: [**2196-7-9**]
Date of Birth: [**2128-5-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Fever and Weight loss
Major Surgical or Invasive Procedure:
[**2196-7-2**] - 1. Aortic valve replacement with a size 21-mm
[**Last Name (un) 3843**]-[**Doctor Last Name **] Magna tissue valve.2. Pericardial patch
repair of left ventricular outflow tract.
History of Present Illness:
Mr. [**Known lastname 1968**] is a 68 yo male with RCA stenting in [**2190**], aortic
stenosis sp Mosaic aortic valve in [**2-/2192**], right hip
replacement in [**6-/2194**], BPH, and ED who presents with FUO since
[**3-19**].
Of note, he had a dental bridge done in [**Month (only) 404**], for which he
was appropriately treated with Amoxicillin peri-operatively. On
[**3-19**] while snow shoeing in at Sunapee in [**Location (un) 3844**] he
developed a rigors, fever, cough and myalgias of his left thigh.
He remembers the date distinctly because of the intense rigors
and muscle pain in his left thigh. He was in all of his ski wear
with the heat on and could not shake the chills. The chills and
fevers have continued intermittently approx 2-3x weekly since
that time. His fever had peaked at 101.9-102, and last night had
fever to 103.
Since [**Month (only) 547**] he has noted a decline in appeptite (everything
smells horrible), 20 pound weight loss, fatigue, dizziness with
blood pressure that runs lower than normal for him.
He initially saw a pulmonologist for the cough. He was treated
with a Z-Pack for URI without improvement. He was given a
prednisone taper and his cough improved. He does not note any
changes in his fever pattern while on prednisone (no
improvement, or worsening). He also notes severe night sweats
soaking through 3 t-shirts per night. As an aside he notes the
red cross will not accept his blood because of positive
hepatitis antibodies (unknown what type) and says that occurred
after having a "booster" from his PCP.
He has travelled multiple places for skiing trips over the past
few months. He travelled to [**Country 6962**] in [**Month (only) 404**], [**State 8449**] in
[**Month (only) 958**], and [**Location (un) 3844**]. He took Amoxicillin 500mg daily for 4
weeks, to make himself feel better for skiing.
He has reportedly had negative radiographs and a negative CT for
his cough. He works on the Appalachian Trail, and reports that
he gets about [**11-16**] tic bites per year. Lyme titer was
reportedly negative. He has a new anemia with an HCT in the low
30s. A PPD was not placed due to the negative nature of his CT
and X-Rays.
He was evaluated by a hematologist/oncologist and after one
interview, he questioned endocarditis as a source. He discussed
this with Dr. [**Last Name (STitle) 1911**] and had a planned TEE for this
morning. However he developed a fever to 103 and went to [**Hospital3 25354**]. Two sets of blood cultures were drawn and one
gram vancomycin was given. He was then transported to our ED.
He endorses injecting Tremix into his penis for erectile
dysfunction 12-18 times since sometime mid last year. He says
that he never noticed an abnormal or cloudy vial. Patient
endorses a rash on his back and chest in [**Month (only) 958**] that resolved
without intervention and was papular in nature. Denies any chest
discomfort, palpitations, shortness of breath, lower extremity
swelling, orthopnea.
He has had mild headache, one episode of abdominal pain, no
changes in bowel habits, BRBPR, change in vision, weakness,
numbness, new lumps or bumps. He denies sexual activity with
anyone other than his wife, and denies knowing of his wife
having other sexual partners. [**Name (NI) **] denies drug use.
Overnight, blood cultures were sent. Gentimicin 210mg IV was
given in addition to the vanco he received. EKG was performed
with increase in ST depression/scooping laterally. CXR performed
and was unremarkable. Troponin flat at 0.11, 0.10 (MBs negative
x2).
This morning he is resting in bed, tired, with cough, but very
pleasant and otherwise feeling ok.
Past Medical History:
Stent to RCA [**2190**]
Mosaic Aortic Valve [**2-/2192**]
Right Hip Replacement [**6-/2194**]
BPH
ED
Prostatitis
Social History:
Retired. Lives in [**Location **],Ma. Married with two children. No
tobacco. Etoh 10 drinks weekly. No drugs.
Family History:
Grandmother, Grandfather with heart failure. Brother with MI at
age 70.
Physical Exam:
VS: 97.7, 99/67, 68, 18, 99%RA
GENERAL: Patient appear ill, NAD, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, no mucosal
lesions in the mouth.
NECK: Supple, no JVD.
HEART: RRR, III/VI SEM heard across the precordium and radiating
to the carotids which has been noted previously, no heave.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: No lower extremity edema. 2+ peripheral pulses.
Mild tenderness on palpation of the right hand, without
erythema, swelling.
SKIN: No obvious [**Last Name (un) **] lesions or splinter hemorrhages. No
rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII intact, strength 5/5 in
upper/lower extremity. Normal sensation.
Pertinent Results:
Admission Labs:
[**2196-7-1**] 04:18AM BLOOD WBC-14.5*# RBC-3.75* Hgb-10.6* Hct-32.3*
MCV-86 MCH-28.2 MCHC-32.7 RDW-16.1* Plt Ct-232
[**2196-7-1**] 04:18AM BLOOD PT-13.8* PTT-26.9 INR(PT)-1.2*
[**2196-7-1**] 04:18AM BLOOD Glucose-125* UreaN-14 Creat-0.8 Na-140
K-4.0 Cl-105 HCO3-26 AnGap-13
[**2196-7-1**] 04:18AM BLOOD ALT-17 AST-27 LD(LDH)-292* CK(CPK)-31*
AlkPhos-177* TotBili-0.6
[**2196-7-1**] 04:18AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.5 Mg-2.0
Iron-10*
STUDIES:
TEE (Complete) Done [**2196-7-1**]
Conclusions
No spontaneous echo contrast is seen in the body of the left
atrium. No atrial septal defect is seen by 2D or color Doppler.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch and descending
thoracic aorta to 45 cm. A bioprosthetic aortic valve prosthesis
is present with abnormal rocking motion of the aortic annulus,
suggestive of partial dehiscence. The prosthetic aortic valve
leaflets are thickened with a moderate sized vegetation (0.4x0.8
cm) on the non-coronary cusp (clips 56, 61). No aortic valve
abscess is seen. Trace central aortic regurgitation is seen
(clips 14, 23). The mitral valve leaflets are mildly thickened
with trivial mitral regurgitation. No mass or vegetation is seen
on the mitral valve. The tricuspid valve leaflets are mildly
thickened. No vegetation/mass is seen on the pulmonic valve.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Moderate sized vegetation on the bioprothestic
aortic valve with partial dehiscence. Trace aortic
regurgitation. Normal biventricular systolic function.
Compared with the prior study (images reviewed) of [**2192-3-3**],
the vegetation and partial dehiscence of the bioprosthetic
aortic valve is new.
Brief Hospital Course:
Mr. [**Known lastname 1968**] presented with fevers, weightloss, malaise and cough
that began in [**Month (only) 956**]. He was admitted for a TEE to rule out
endocarditis given his prosthetic valve. He was initially
started on antibiotics at the OSH and in the Emergency
Department (Gentamicin, Vancomycin, Cefepime). ID was consulted
for medical management as well as Cardiac Surgery for surgical
management. Antibiotics were stopped in efforts to obtain
positive cultures. He had blood cultures drawn in the ED as well
as in the morning after admission. TEE showed a moderate sized
vegetation and partial valve dehiscence. He was taken to cardiac
surgery the following morning where he underwent a redo
sternotomy with an aortic valve replacement and a patch repair
of the left ventricular outflow tract. Please see operative note
for details. Postoperatively he was taken to the intensive care
unit for monitoring. Over the next 24 hours, he awoke
neurologically intact and was extubated. 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. ID continued to follow and direct the
antibiotic course. OR tissue culture would grow
ABIOTROPHIA/GRANULICATELLA SPECIES. Antibiotics were changed to
Penicillin G and Gentamicin to continue through 6 weeks from
[**2196-7-2**]. He did develop a scant amount of serous drainage on
POD 5. Diuresis was increased and this did improve. By the
time of discharge on POD 6 the patient was ambulating, yet
deconditioned, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to [**Hospital 1514**]
Health Care in good condition with appropriate follow up
instructions.
Medications on Admission:
Fish oil 1000-mg/day
Aspirin 325-mg/day
Gemfibrozil 300-mg [**Hospital1 **]
Terazosin 10-mg/day
Singulair 10-mg/day
Advil 3x/day
Tylenol 3x/day
Tremix Injections (ED)
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: then decrease to 200mg by mouth [**Hospital1 **] x 1week,
then decrease to 200mg by mouth daily.
Disp:*28 Tablet(s)* Refills:*1*
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. potassium chloride 20 mEq Packet Sig: One (1) PO once a day
for 7 days.
Disp:*7 tablets* Refills:*0*
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
5. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO four times
a day as needed for fevber/pain.
Disp:*30 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
7. 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*
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. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*QS ML(s)* Refills:*0*
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*14 Suppository(s)* Refills:*0*
11. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. gemfibrozil 600 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
13. terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
14. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. Penicillin G Potassium 4 Million Units IV Q4H
17. Gentamicin 100 mg IV Q8H Start: In am
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1514**] Health Care Center - [**Location (un) 1514**]
Discharge Diagnosis:
Primary:
Endocarditis with valve dehiscence
Past Medical History:
CAD s/p RCA stent [**2190**]
Mosaic aortic valve replacement [**2-12**]
Right hip replacement [**6-13**]
Htn
Prostatitis
BPH
ED
Past Surgical History:
s/p AVR [**2-12**]
s/p R THR [**6-13**]
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+
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**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2196-8-1**] 1:30
Cardiologist: Dr. [**Last Name (STitle) 1911**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 28261**] [**Telephone/Fax (1) 28262**] in [**5-10**] 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 Q week: CBC with diff, Chem 7, Gent trough, ESR, CRP -
first draw 1 hr before 4th dose of Gent - Fax results to Dr
[**Last Name (STitle) 9461**] fax [**Telephone/Fax (1) 1419**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2196-7-9**]
|
[
"996.71",
"414.01",
"V45.82",
"996.61",
"V43.64",
"041.89",
"607.84",
"401.9",
"E878.4",
"421.0",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"88.72",
"35.39",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
11427, 11519
|
7193, 9137
|
295, 492
|
11820, 12034
|
5341, 5341
|
13008, 13848
|
4444, 4518
|
9354, 11404
|
11540, 11585
|
9163, 9331
|
12058, 12985
|
11758, 11799
|
4533, 5322
|
234, 257
|
520, 4163
|
5357, 7170
|
11607, 11735
|
4316, 4428
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,576
| 175,678
|
43058
|
Discharge summary
|
report
|
Admission Date: [**2145-4-28**] Discharge Date: [**2145-5-4**]
Date of Birth: [**2082-10-3**] Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Amoxicillin
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
SOB, chest pain
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
62 yo F with metastatic breast cancer, on Xeloda and Herceptin
since [**2138**] (herceptin alone since [**2135**]), presents with 1 week of
CP and SOB. She describes a nonpleuritic chest tightness only
with exertion and also LE edema. She returned recently from a
trip to [**Male First Name (un) 1056**], and went to see her PCP. [**Name10 (NameIs) **] ordered by
her PCP showed bilateral pleural effusions for which she was
sent to the ED. CTA showed bilateral pleural effusions,
moderate pericardial effusion worse than before, but no PE or
aortic dissection. She had a viral cold recently.
.
In [**2132**], around the same time that she was diagnosed with breast
cancer, she was also found to have pleural and pericardial
effusions, preceded by a viral prodrome. She had a thoracentesis
that did not reveal malignant cells. She had several follow up
echos showing resolving pericardial effusion. It was concluded
that this was a viral related serositis and not due to
metastatic breast cancer. Her last echo was in 3/98.
.
On this admission, another TTE was obtained which showed
echocardiographic evidence for cardiac tamponade. She had a CT
chest 2 weeks ago for cancer staging purposes which showed a
small pericardial effusion. She underwent pericardiocentesis
and was then transferred to the CCU for further management
.
Currently, patient feels some soreness in her chest where the
pericardiocentesis was performed. Otherwise, she feels her
breathing is improved, but not yet back to her baseline. No
chest pain, abdominal pain, palpitation, lightheadedness.
.
On review of systems, she 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 exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of
palpitations, syncope or presyncope.
Past Medical History:
Breast cancer - diagnosed [**2132**], s/p R mastectomy, on herceptin
since [**2135**] and xeloda since [**2138**]
Hypothyroidism
h/o one past episode of pericardial effusion in [**2132**]
Social History:
She is divorced and is a ticketing officer with american
airlines. No kids. She smokes approximately half a pack a day
and has for ten years. She drinks alcohol socially.
Family History:
Two maternal aunts who developed breast cancer, one in her 50's
and one in her late 60's. There is no other breast or ovarian
cancer in her family. Her father died of lymphoma
Physical Exam:
On trasnfer to CCU
VS: 145/70, 98, 26, 93% 2L
Pulsus: 18 mmHg
GEN: Pleasant, well appearing woman in NAD, mildly dyspneic
HEENT: PERRLA, EOMI, MMM, OP clear, no LAD, JVP low
LUNGS: bibasilar crackles with pleural effusion R>L
CVS: S1S2, RRR, no m/r/g
ABD: soft, ND, NT, +BS, no ascites
EXT: 1+ bilateral pedal edema to ankles, 2+ peripheral pulses
NEURO: CN II-XII grossly intact, no focal deficits
Pertinent Results:
Cardiac Cath Study Date of [**2145-4-29**]
COMMENTS:
1- Emergent pericardiocentesis was performed via subxyphoid
access in
the usual fashion.
2- Pericardial space easily accessed and more than 600 cc of
bloody
fluid
3- Pericardial drain left in place
4- No complications
FINAL DIAGNOSIS:
1. Pericardial tamponade
2. Successful emergent pericardiocentesis and removal of >600 cc
of
bloody fluid
3. Pericardial drain left in place
4. Postprocedure bedside echocardiography showed resolution of
pericardial effusion and well expanded RA and RV without
tamponade
physiology
5. Patient was transferred to the CCU for observation
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2145-4-28**]
7:35 PM
IMPRESSION:
1. No pulmonary embolus or acute aortic syndrome.
2. Large (new) pericardial effusion, raising concern for
tamponade.
Correlation with echocardiography is recommended.
3. Enlargement of bilateral pleural effusions, moderate on the
right and
small on the left, with associated compressive atelectasis.
4. Stable adenopathy compared to [**2145-4-7**].
.
TTE (Complete) Done [**2145-4-29**] at 8:59:16 AM
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 10-20mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic arch is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) 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 a large pericardial
effusion. The effusion appears circumferential. There is brief
right atrial diastolic collapse. There is right ventricular
diastolic collapse, consistent with impaired fillling/tamponade
physiology. There is significant, accentuated respiratory
variation in mitral/tricuspid valve inflows, consistent with
impaired ventricular filling.
IMPRESSION: Normal biventricular systolic function. There is
echocardiographic evidence for cardiac tamponade.
.
Portable TTE (Focused views) Done [**2145-4-29**] at 4:44:04 PM
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
is no pericardial effusion. A catheter is seen in the
pericardial space.
Compared with the prior study (images reviewed) of [**2145-4-29**],
the pericardial fluid has been removed. The right ventricle is
larger without evidence of tamponade physiology.
.
Portable TTE (Focused views) Done [**2145-4-30**] at 12:00:00 PM
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
Trivial mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling. The echo findings
are suggestive but not diagnostic of pericardial constriction.
IMPRESSION: No significant residual pericardial effusion. Study
consistent with effusive-constrictive physiology following
drainage of pericardial effusion.
.
CBC
[**2145-5-2**] 05:47AM BLOOD WBC-4.9 RBC-3.95* Hgb-12.4 Hct-38.5
MCV-97 MCH-31.5 MCHC-32.3 RDW-16.9* Plt Ct-274
[**2145-5-1**] 04:29AM BLOOD WBC-5.2 RBC-3.97* Hgb-12.6 Hct-38.1
MCV-96 MCH-31.8 MCHC-33.1 RDW-16.4* Plt Ct-275
[**2145-4-30**] 03:02AM BLOOD WBC-5.0 RBC-3.76* Hgb-12.1 Hct-37.0
MCV-98 MCH-32.1* MCHC-32.6 RDW-17.3* Plt Ct-249
[**2145-4-29**] 08:05AM BLOOD WBC-3.5* RBC-3.28* Hgb-10.4* Hct-32.3*
MCV-99* MCH-31.9 MCHC-32.3 RDW-16.3* Plt Ct-207
[**2145-4-28**] 05:30PM BLOOD WBC-4.2 RBC-3.39* Hgb-11.0* Hct-33.8*
MCV-100* MCH-32.5* MCHC-32.6 RDW-17.8* Plt Ct-229
.
Chemistry
[**2145-5-2**] 05:47AM BLOOD Glucose-124* UreaN-11 Creat-0.7 Na-142
K-3.9 Cl-106 HCO3-26 AnGap-14
[**2145-5-1**] 04:29AM BLOOD Glucose-115* UreaN-13 Creat-0.7 Na-141
K-3.6 Cl-104 HCO3-29 AnGap-12
[**2145-4-30**] 03:02AM BLOOD Glucose-112* UreaN-10 Creat-0.6 Na-142
K-3.9 Cl-106 HCO3-26 AnGap-14
[**2145-4-29**] 08:05AM BLOOD Glucose-125* UreaN-12 Creat-0.7 Na-142
K-4.3 Cl-109* HCO3-27 AnGap-10
[**2145-4-28**] 05:30PM BLOOD Glucose-107* UreaN-14 Creat-0.7 Na-142
K-4.3 Cl-107 HCO3-24 AnGap-15
[**2145-5-2**] 05:47AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
[**2145-5-1**] 04:29AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.1
[**2145-4-30**] 03:02AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
[**2145-4-29**] 08:05AM BLOOD Albumin-3.9 Calcium-8.6 Phos-3.7 Mg-2.1
.
LFT
[**2145-5-1**] 04:29AM BLOOD ALT-29 AST-35 LD(LDH)-197 AlkPhos-133*
TotBili-1.8*
[**2145-4-30**] 03:02AM BLOOD ALT-44* AST-53* AlkPhos-140* TotBili-1.8*
DirBili-0.4* IndBili-1.4
[**2145-4-29**] 08:05AM BLOOD ALT-43* AST-49* LD(LDH)-224 AlkPhos-119*
TotBili-1.6*
.
Pericardial fluid
- Cytology - pending
- WBC 1150, Hct 17, Polys 3%, Lymphs 3%, Monos 0%, Mesothe 1%,
Macro 53%, Other 40%
- TotProt 5.2, Glucose 93, LD(LDH) 274, Amylase 36, Albumin 3.3
.
[**2145-4-29**] 4:25 pm FLUID,OTHER PERICARDIAL.
GRAM STAIN (Final [**2145-4-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2145-5-2**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2145-4-30**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
62 F with metastatic breast cancer with acute onset bilateral
pleural effusion and worsening pericardial effusion found to
have tamponade physiology.
.
#. PUMP/Tamponade - patient has a history of one other episode
of pericardial effusion in [**2132**], likely of viral etiology, which
resolved on its own. Two weeks ago on CT chest for staging
purposes, she was found to have a small pericardial effusion and
no pleural effusion. On admission, she had no clinical evidence
of tamponade, however TTE showed significant pericardial
effusion with tamponade physiology. She had a viral cold
recently, and the rapid onset symptoms could again suggest a
viral serositis, however would not explain the presence of blood
in pericardial fluid. She has no signs of infection: no white
count or fever. Malignant effusion remains high on the
differential; her breast cancer has been stable for years,
however the presence of blood and 40% other cells in pericardial
fluid raises this suspicion. Herceptin has a <1% occurrence of
pericardial effusion, unlikely to be the culprit as she has been
on it stabily since [**2135**]. Patient does not appear uremic on
labs nor does she have a history of collagen vascular disease.
Has not had radiation to her chest. Unlikely due to MI, as
symptoms were gradual in onset, and she is CE negative x1.
.
Patient is now s/p pericardiocentesis and hemodynamically
stable. The drain was removed after several days after it
stopped draining. Pulsus was checked 3-4 times a day with
improvement following pericardiocentesis and is currently [**3-9**]. A
repeat echo done on [**2145-5-4**] showed no recurrent fluid. She was
set up with repeat echo in about 4 weeks with follow up with Dr [**Doctor Last Name 11723**] scheduled. Cytology was pending at the time of
discharge.
.
Currently while patient is stable, there are no plans for
pericardial window, however if effusion reaccumulates, a
pericardial window would be indicated.
.
Pleural effusions: Pt with bilateral pleural effusions that
appear new since early [**Month (only) 116**]. High suspicion for malignancy. As
the pt was satting well on room air and asymptomatic, there was
no plan for thoracocentesis at the time of discharge.
#. BREAST CANCER - chemotherapy was held during this admission
per oncology recommendations. Patient will continue to follow
up with her primary oncologist. Cytology from effusions was
pending at time of discharge.
Medications on Admission:
Herceptin 6mg/kg - IV infusion, every 3 weeks
Capecitabine [Xeloda] 500 mg - 2 tabs in the AM, 3 tabs in the
PM - 2 weeks on, 1 week off.
Fluticasone 50 mcg 2 sprays each nostril daily
Ibuprofen 600 mg TID prn pain
Levothyroxine 75 mcg daily
Lorazepam 1 mg qhs
Zolpidem 10 mg qhs prn insomnia
Discharge Medications:
1. Herceptin 440 mg Recon Soln Sig: One (1) Intravenous q3
weeks: 6 mg/kg .
2. Xeloda 500 mg Tablet Sig: ASDIR Tablet PO ASDIR: 2 tabs in
the AM, 3 tabs in the PM - 2 weeks on, 1 week off.
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] PRN () as needed for nasal congestion.
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
7. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Home
Discharge Diagnosis:
(1) Pericardial Effusion
(2) Pleural effusions
(3) Breast cancer history
Discharge Condition:
Stable for home; ambulating on room air, mild shortness of
breath on activity.
Discharge Instructions:
Dear Ms [**Last Name (Titles) 5025**],
You were admitted because you had worsening shortness of breath.
This occurred because we found you had accumulated fluid around
your heart and lungs. Fluid around the heart is a serious
condition and can cause your blood pressure to fall, so to treat
this, we drained this fluid to relieve the pressure on your
heart. We don't know for sure yet why you have fluid in these
areas, but it can happen because of your breast cancer history.
We are waiting on results from the fluid we removed to determine
whether cancer is the cause. You will need close follow up with
cardiology and they will follow up on this result.
.
We did not make any changes in your medications during this
hospitalization.
.
Please call your doctor immediately or return to the emergency
department if you start to feel increasingly short of breath,
dizzy or lightheaded, or have any other concerning symptoms.
.
You have follow up appointments scheduled with cardiology as
below. The echocardiogram will be done on the same day; you
should receive a call about this. Please call [**Telephone/Fax (1) 62**] if
you have not heard from them over the next week to confirm these
appointments.
Followup Instructions:
Your cardiology appointment with Dr[**Doctor Last Name 3733**] is on [**6-18**]
at 320 PM. Please call [**Telephone/Fax (1) 62**] if you have not heard from
them over the next week to confirm these appointments.
.
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2145-5-5**]
12:15
Provider: [**First Name8 (NamePattern2) 2191**] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2145-5-5**]
2:00
Provider: [**Name10 (NameIs) 17246**] [**Name11 (NameIs) **], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2145-5-25**] 12:00
|
[
"V45.71",
"174.9",
"305.1",
"244.9",
"423.3",
"420.90",
"511.9",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
12610, 12616
|
9154, 11598
|
296, 316
|
12733, 12814
|
3352, 3623
|
14070, 14670
|
2740, 2917
|
11941, 12587
|
12637, 12712
|
11624, 11918
|
3640, 8898
|
12838, 14047
|
2932, 3333
|
9077, 9077
|
9110, 9131
|
241, 258
|
344, 2323
|
8934, 9041
|
2345, 2535
|
2551, 2724
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,129
| 136,619
|
16586
|
Discharge summary
|
report
|
Admission Date: [**2200-12-10**] Discharge Date: [**2200-12-20**]
Date of Birth: [**2144-10-6**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: Patient is an unfortunate
56-year-old male smoker with no significant past medical
history who presented to a hospital in [**State **] in [**Month (only) **] of
this year for complaint of abdominal distention and weight
loss. Patient was found to be jaundiced and underwent an
abdominal CT scan which showed multiple abdominal masses from
the posterior aspect to the stomach to the spleen and also
tail of the pancreas, plus lymphadenopathy and likely liver
metastases.
The patient was briefly hospitalized in [**State **] for mental
status changes, but after hydration, returned to baseline
mentation and left against medical advice to travel to [**Location (un) 86**]
to seek appropriate medical care. The patient traveled on a
bus with his sister, who is very involved in his care for 23
hours, and when arriving in [**Location (un) 86**], was weak and unable to
ambulate. Patient was brought to the [**Hospital1 **]
Emergency Department.
In the Emergency Department, the patient was minimally
responsive. Temperature of 95.7, blood pressure of 100/65,
pulse of 105, sating of 95% on 3 liters and 89% on room air.
He had a chest x-ray showing a right lower lobe infiltrate.
Was started on levo and Flagyl, and he had a VQ scan that was
intermediate probability for pulmonary embolus. He had a
head MRI which was negative for lesions, and he was started
on Heparin for question of pulmonary embolus given the high
clinical suspicion. He was also given Narcan as there had
been some question of narcotics given at the outside hospital
and had minimal improvement in mental status.
The morning of transfer to the MICU, the patient was found by
his floor team with a blood pressure of 80/45, 93% on 2
liters nasal cannula. Was given 2 liters of normal saline
bolus with improvement of blood pressure to the 90s with
saturations which dropped to the low 90s on 7 liters face
mask. The patient again became minimally responsive and had
no change in mental status with Narcan administration.
PAST MEDICAL HISTORY: Unremarkable.
MEDICATIONS: The patient's only medication on admission was
Vicodin.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is divorced with two young
children. He has a 65 pack year tobacco history. No history
of alcohol or IV drug use. The patient has large extended
and very involved family.
On transfer to the MICU, the patient's temperature is 95.0,
blood pressure of 93/60, pulse of 105, and sating of 93% on 7
liters face mask. In general, he is uncomfortable with
orientation only to self. HEENT revealed anicteric sclerae.
Neck: Jugular venous distention at about 7 cm. Chest: The
patient was using accessory muscles to breathe, had
diminished breath sounds at the right base, and bronchial
breath sounds throughout. Cardiovascular examination was
notable for being tachycardic. Abdomen: It was soft and
distended. He did have hepatomegaly and normoactive bowel
sounds. Extremities: The patient had 2+ edema bilateral
lower extremities that was taught with weeping skin, however,
his extremities were warm with adequate capillary refill.
Neurologically, the patient was moving all four extremities
spontaneously and could follow simple commands.
Patient's white count on admission was 12.0, hematocrit 42.9,
platelets 168. The patient had an INR of 2.9, PTT of greater
than 150. Patient's electrolytes were notable for a BUN of
105 and a creatinine of 2.3. Patient's LFTs were grossly
elevated as well. He had an ALT of 154 and AST of 427, and
LD of 993, and alkaline phosphatase of 735, and a T bilirubin
of 3.1.
Given the concern for pulmonary embolus, the patient had an
echocardiogram which showed no evidence of right ventricular
dysfunction. Patient's urinalysis was unremarkable.
In short, this is a 56-year-old man with reported abdominal
mass diagnosed on CT scan at outside hospital presenting here
with change in mental status, hypoxic, acute renal failure,
infiltrate on chest x-ray, and hypotension.
HOSPITAL COURSE: Patient was aggressively fluid resuscitated
as needed, and started on dopamine. The patient required
intubation to support his ventilation during this time.
Patient was also started on stress dosed steroids and
broad-spectrum antibiotics given concern for sepsis or
possible adrenal insufficiency. Despite aggressive
intervention, the patient's clinical status continued to
deteriorate. The patient's acute renal failure worsened, and
he continued to space fluids.
Patient developed marked ascites, which was thought to be
likely to metastatic disease in his belly. He had a
diagnostic tap done which was consistent with spontaneous
bacterial peritonitis, however, no cultures ever grew from
this. Patient's cytology from this tap was negative as well.
Patient's family understood his poor prognosis, however,
patient had stated a clear wish to continue being intubated
until passing away, and not to be disconnected from any
life-support measures, plus patient was made CPR not
indicated by Dr. [**First Name (STitle) **]. Patient was supported with fluids
and pressors. Unfortunately, his coagulopathy and renal
failure continued to worsen and despite fluid, pressors, and
ventilatory support, the patient because bradycardic, and
finally arrested on the morning of [**2200-12-20**].
Patient was pronounced at 9:40 am on [**2200-12-20**]. Family was
notified and postmortem examination was arranged for.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **], M.D.
Dictated By:[**Name8 (MD) 8330**]
MEDQUIST36
D: [**2201-1-31**] 12:36
T: [**2201-2-3**] 05:22
JOB#: [**Job Number **]
|
[
"789.5",
"038.9",
"486",
"518.81",
"197.7",
"199.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.91",
"96.04",
"38.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
4195, 5854
|
164, 2164
|
2187, 2327
|
2344, 4177
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,260
| 117,755
|
5178
|
Discharge summary
|
report
|
Admission Date: [**2117-1-16**] Discharge Date: [**2117-1-20**]
Date of Birth: [**2072-7-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Patient admitted with bright red blood from rectum and
dizziness.
Major Surgical or Invasive Procedure:
Status Post EGD
History of Present Illness:
44 M s/p open gastric bypass in [**9-20**] c/b stenosis and dilation
post-op now p/w with maroon stools x 3 days. he states that he
recently started taking aspirin the past month. Had syncopal
episode at home. HCT at OSH was 25, got 1 unit PRBC and now
here
his HCT was 23.8. NGT placed by ED resident [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3827**]
as
instructed by his attending revealed a mildly positive lavage,
not gross blood though. He was diaphoretic and very pale. He
got 2 units of PRBC through a level one with good improvement in
symptoms. SBP also increased from 80s to 100s, color and
diaphoresis improved.
Past Medical History:
PMH: hypertension, dyslipidemia, OSA on CPAP
PSH: ankle fx, wisdom teeth
Social History:
He denies tobacco or recreational drug usage, has 12-14 beers a
week and drinks can of caffeine-free diet soda 6 days a week. He
is employed as a sales manager traveling 1000 miles per week. He
is married living with his wife age 41 and their 2 children ages
10 and 8.
Family History:
Family history is noted for both parents living father age 65
with heart disease, hyperlipidemia, arthritis and obesity;
mother age 67 with hyperlipidemia and arthritis. There is strong
family h/o asthma.
Physical Exam:
PE: 97.8 94 80s->110 systolic after 2 units 16 94
AAOx3, diaphoretic and pale
RRR
CTAB
soft NT/ND, well healed scar
Grossly positive blood on rectal, no masses or hemorrhoids felt,
no BRB but more red than melena
no edema, extrem warm
Pertinent Results:
[**2117-1-15**] 11:35PM BLOOD WBC-5.6 RBC-2.58*# Hgb-8.7*# Hct-23.8*#
MCV-92 MCH-33.6* MCHC-36.4* RDW-13.6 Plt Ct-183
[**2117-1-16**] 03:31AM BLOOD WBC-7.2 RBC-3.22* Hgb-10.2* Hct-28.5*
MCV-89 MCH-31.7 MCHC-35.8* RDW-14.0 Plt Ct-149*
[**2117-1-16**] 11:26AM BLOOD Hct-21.6*
[**2117-1-17**] 02:07AM BLOOD WBC-3.0*# RBC-2.24*# Hgb-7.1*# Hct-20.3*
MCV-91 MCH-31.4 MCHC-34.7 RDW-14.8 Plt Ct-105*
[**2117-1-18**] 06:50AM BLOOD Hct-26.5*
Brief Hospital Course:
Patient admitted with bright red blood per rectum with
dizziness. Patient was given 2 units of packed cells in the
emergency room with improved symptoms. A nasogastric tube was
placed and lavaged. He was transferred to the intensive care
unit where he was closely monitored. He had an EGD on [**2117-1-16**]
which revealed an ulcer at the GJ anastomosis that was injected.
His current hematocrit level is 26.5. He was advanced to a
Bariatric stage 3 with tolerance.
On discharge he is tolerating bariatric stage 5 and hct is
stable at 27.3. He will follow up with Dr. [**Last Name (STitle) **] in 2 weeks
and then have a follow up EGD on [**2-25**].
Medications on Admission:
VALSARTAN [DIOVAN] - (Prescribed by Other Provider) - 160 mg
Tablet - one Tablet(s) by mouth per day
Medications - OTC
CALCIUM - (Prescribed by Other Provider) - 500 mg Tablet - one
Tablet(s) by mouth daily
CYANOCOBALAMIN [VITAMIN B-12] - (Prescribed by Other Provider) -
Dosage uncertain
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet -
Tablet(s) by mouth twice a day
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal Bleed
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Followup Instructions:
Dr. [**Last Name (STitle) **] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building [**Location (un) **] -
[**Telephone/Fax (1) 3201**] - Appointment at [**2-4**] at 9:45 and then
again on [**3-11**] at 9:15.
You will be having your endoscopy on [**2-25**] at 12:30, all
information regarding this procedure will be mailed to you.
Completed by:[**2117-1-20**]
|
[
"780.2",
"327.23",
"534.40",
"458.9",
"V45.86",
"280.0",
"272.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
3927, 3933
|
2408, 3063
|
379, 397
|
4000, 4000
|
1952, 2385
|
4955, 5330
|
1475, 1681
|
3493, 3904
|
3954, 3979
|
3089, 3470
|
4145, 4932
|
1696, 1933
|
274, 341
|
425, 1076
|
4014, 4121
|
1098, 1172
|
1188, 1459
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,690
| 153,640
|
22536
|
Discharge summary
|
report
|
Admission Date: [**2150-8-16**] Discharge Date: [**2150-8-20**]
Date of Birth: [**2076-9-12**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Motrin / Niacin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
1. Endotracheal intubation
History of Present Illness:
Respiratory failure ans shortness of breath
Past Medical History:
No HTN, DM
MI ([**2146**])
tongue CA s/p resection
L lung CA s/p lobectomy
prostate CA s/p prostatectomy
gastric CA s/p partial gastrectomy
skin CA s/p multiple excisions
R lung mass (BX shows non-malignant process.)
Social History:
Lives with his wife in senior housing; smoked 150 pack-years
until [**2146**]; drinks 5-6 beers/day on most days.
Family History:
Brother died of MI at 39 yo.
Mother died of CA.
Physical Exam:
See ICU history and physical
Pertinent Results:
[**2150-8-19**] 03:46AM BLOOD WBC-18.7* RBC-4.69# Hgb-11.9*# Hct-39.0*#
MCV-83 MCH-25.4* MCHC-30.5* RDW-16.5* Plt Ct-736*
[**2150-8-16**] 12:40AM BLOOD WBC-13.8*# RBC-3.53* Hgb-8.2* Hct-27.3*
MCV-77*# MCH-23.3*# MCHC-30.1* RDW-16.3* Plt Ct-793*#
[**2150-8-17**] 05:13AM BLOOD Neuts-94.3* Bands-0 Lymphs-3.4* Monos-2.1
Eos-0 Baso-0
[**2150-8-16**] 05:30AM BLOOD Neuts-95.6* Bands-0 Lymphs-2.6*
Monos-1.6* Eos-0.1 Baso-0.1
[**2150-8-19**] 03:46AM BLOOD Plt Ct-736*
[**2150-8-18**] 08:00AM BLOOD PTT-51.5*
[**2150-8-18**] 04:49AM BLOOD Plt Ct-515*
[**2150-8-18**] 01:32AM BLOOD PT-13.8* PTT-44.0* INR(PT)-1.3
[**2150-8-16**] 12:40AM BLOOD Plt Smr-VERY HIGH Plt Ct-793*#
[**2150-8-19**] 03:46AM BLOOD Glucose-146* UreaN-44* Creat-1.2 Na-145
K-5.4* Cl-108 HCO3-25 AnGap-17
[**2150-8-18**] 04:49AM BLOOD Glucose-174* UreaN-33* Creat-1.0 Na-143
K-4.1 Cl-108 HCO3-25 AnGap-14
[**2150-8-17**] 05:13AM BLOOD Glucose-195* UreaN-23* Creat-0.9 Na-140
K-5.0 Cl-110* HCO3-23 AnGap-12
[**2150-8-16**] 08:05PM BLOOD K-5.5*
[**2150-8-16**] 04:44PM BLOOD K-5.2*
[**2150-8-16**] 01:25PM BLOOD UreaN-21* Creat-0.9 K-5.5* Cl-108 HCO3-22
[**2150-8-16**] 12:40AM BLOOD Glucose-145* UreaN-19 Creat-1.0 Na-139
K-4.6 Cl-103 HCO3-24 AnGap-17
[**2150-8-19**] 03:46AM BLOOD ALT-32 AST-40 AlkPhos-166* TotBili-0.3
[**2150-8-17**] 05:13AM BLOOD ALT-27 AST-69* CK(CPK)-315* AlkPhos-158*
TotBili-0.8
[**2150-8-16**] 08:05PM BLOOD CK(CPK)-523*
[**2150-8-16**] 12:40AM BLOOD CK(CPK)-233*
[**2150-8-18**] 04:49AM BLOOD CK-MB-7 cTropnT-0.90*
[**2150-8-17**] 05:13AM BLOOD CK-MB-27* MB Indx-8.6* cTropnT-1.35*
[**2150-8-16**] 08:05PM BLOOD CK-MB-46* MB Indx-8.8* cTropnT-1.43*
[**2150-8-16**] 05:30AM BLOOD CK-MB-16* MB Indx-7.3* cTropnT-0.39*
[**2150-8-16**] 12:40AM BLOOD CK-MB-21* MB Indx-9.0* cTropnT-0.45*
[**2150-8-18**] 04:49AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.3
[**2150-8-16**] 05:30AM BLOOD Albumin-2.8* Calcium-7.9* Phos-4.2 Mg-2.4
Iron-23* Cholest-104
[**2150-8-16**] 12:40AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.5
[**2150-8-16**] 05:30AM BLOOD calTIBC-200* Ferritn-250 TRF-154*
[**2150-8-16**] 05:30AM BLOOD Triglyc-82 HDL-44 CHOL/HD-2.4 LDLcalc-44
[**2150-8-19**] 03:59AM BLOOD Type-ART FiO2-100 pO2-93 pCO2-58*
pH-7.27* calHCO3-28 Base XS--1 AADO2-566 REQ O2-93 Intubat-NOT
INTUBA
[**2150-8-18**] 05:01AM BLOOD Type-ART Temp-36.4 pO2-77* pCO2-39
pH-7.42 calHCO3-26 Base XS-0
[**2150-8-17**] 01:01PM BLOOD Type-ART pO2-109* pCO2-39 pH-7.39
calHCO3-24 Base XS-0
[**2150-8-17**] 07:05AM BLOOD Type-ART Temp-36.4 pO2-112* pCO2-38
pH-7.39 calHCO3-24 Base XS--1 Intubat-INTUBATED
[**2150-8-17**] 12:40AM BLOOD Type-ART Temp-36.9 pO2-154* pCO2-36
pH-7.40 calHCO3-23 Base XS--1 Intubat-INTUBATED
[**2150-8-16**] 08:14AM BLOOD Type-ART pO2-277* pCO2-39 pH-7.35
calHCO3-22 Base XS--3
[**2150-8-16**] 05:47AM BLOOD Type-ART Rates-/36 Tidal V-500 FiO2-100
pO2-94 pCO2-40 pH-7.32* calHCO3-22 Base XS--5 AADO2-599 REQ
O2-95 -ASSIST/CON Intubat-INTUBATED
[**2150-8-17**] 07:05AM BLOOD Lactate-1.4
[**2150-8-16**] 08:14AM BLOOD Hgb-11.0* calcHCT-33
IMPRESSION:
1) No evidence of pulmonary embolism.
2) Bilateral consolidation with moderately sized right-sided
pleural effusion, likely postobstructive. Soft tissue density
obstructing the RLL bronchus and right bronchus intermedius.
3) Focal cystic lesion in the right lower lobe, displacing the
vessels around it, concerning for a malignant lesion.
4) Mixed attenuation soft tissue mass in the right chest wall,
concerning for metastatic lesion.
5) Mediastinal lymphadenopathy.
6) Status post partial lobectomy with apparent radiation change
in the anterior lungs.
Brief Hospital Course:
73 yr old male with metastatic lung cancer, CAD s/p NSTEMI in
[**2149**] admitted with post-obstructive PNA and NSTEMI. Presented to
[**Hospital1 46**] with right chest pain, dyspnea and hemoptysis; ST dep
V3-V6; received 1u PRBC, Unasyn, and 1u PRBCs (hct 26).
Transferred to [**Hospital1 18**] [**8-16**] for further management. Started on
heparin gtt. CTA negative for PE, but bilateral LL PNA w/ lg RLL
mass and mod RLL effusion. Thoracentesis attempt unsuccessful.
Due to respiratory distress and hypotension, he was intubated,
after which he had hemoptysis (heparin gtt stopped). After
intubation, pt had episodes of hemoptysis so the heparin drip
was stopped.
.
Past Medical History:
1. CAD: MI in [**2146**] and [**2149**] s/p stent to mid-RCA; nl EF in [**2149**]
- cath in [**2149**] showing 3-vessel disease (LAD, LCx, RCA)
2. Squamous cell lung cancer in RLL and 2 nodules in upper lobe
with possible mets to the liver (recent CT in [**7-19**] showed
increase in size of RLL mass, now 8 x 7 cm) s/p radiation in
[**2149**]
3. L lung CA s/p lobectomy in [**2149**]
4. prostate CA s/p prostatectomy in [**2141**]
5. gastric ulcer s/p partial gastrectomy with Billroth II in
[**2143**]
6. Mouth and tongue cancer s/p resection in [**2145**]?
7. Right-sided blindness due to emboli from right ICA
8. skin CA s/p multiple excisions
9. atrial fibrillation
10. COPD
11. Anemia
.
A/P: 73 yoM w/ CAD s/p MI in [**2149**] and hx of multiple cancers
including metastatic right lung squamous cell carcinoma presents
from [**Hospital3 **] with NSTEMI, post-obstructive PNA, and
hemoptysis leading to respiratory failure.
1. Respiratory failure: possibilities include pneumonia,
pleural effusion (either from PE, pneumonia, malignancy), CHF
and COPD exacerbation. Pt with low grade fever in ED and with
hx of large mass, post-obstructive pneumonia possible but not
likely primary cause of dyspnea. Steroids and nebs could not
improve pt's dyspnea in ED so not likely to be COPD flare. CTA
negative for PE, bilateral LL PNA R>L (RLL necrotizing
component), 6.8 cm RLL mass, mod RLL effusion.
Levaquin/clindamycin started to cover post-obstructive
pneumonia, solumedrol/atrovent/albuterol for COPD. Mechanical
ventilation weaned, extubated [**2150-8-18**], to face tent then nasal
canula on [**2150-8-19**] after discussion with family.
2. Hemoptysis: Differential includes PE, bronchiectasis, CHF,
lung cancer eroding into vessel, pneumonia, all of which are
likely in this patient. Heparin gtt initially held, restarted
[**8-16**] p.m. without recurrence. Bronchoscopy discussed amd deferred
given family goals. COntinued hemoptysis throughout admission.
Scopolomine patch started [**2150-8-19**] to assist in control of
secretions.
3. Demand Ischemia/NSTEMI: Pt likely with bump in troponin and
EKG changes [**3-18**] acute resp distress and demand ischemia.
Heparin drip initially discontinued due to bloody secretions,
restarted [**8-16**] p.m. Heparin discontinued [**2150-8-19**]. Peak TnT 1.43
[**8-16**]. ASA, plavix, statin (check lipids and increase statin if
needed) continued. Started on small dose metoprolol 12.5 po TID
on [**8-17**] to maintain low BP adn rate given ischemia. Transfusion
threshold HCT >30 resulted in transfusion of PRBC x 4 units.
4. Hypotension: Likely [**3-18**] sedation but also concern for
cardiogenic shock given EKG changes and troponin increase. No
evidence of sepsis. Pt has not been on long term steroids and
no reason for adrenal insufficiency. [**Last Name (un) **] stim would not be
helpful given that pt received steroids in ED. Wean off
propofol and use versed/fentanyl for sedation. All
anti-hypertensives initially held.
5. Anemia: Pt with B12 deficiency and anemia of chronic disease.
Baseline Hct of 30 and transfused at outside hospital for hct
of 26. Given pt's CAD, ideal hct of 30. Hct dropping since
admission, guaic neg but copius bloody secretions from ET tube,
concern for hemoptysis.
Received 3u PRBCs (last [**8-17**] a.m.), given active myocardial
ischemia, hemoptysis.
6. Leukocytosis: Likely [**3-18**] pneumonia but may also be due to a
possible PE. UA negative. Covered for post-obstructive
pneumonia with levo/clinda.
7. Access: triple lumen femoral line ([**8-15**]), left a-line ([**8-16**])
8. Code: DNR/DNI on admission; continue mechanical ventilation
for now, but would not want long-term cath. Family meetings
throughout stay.
9. Comm: wife and 2 daughters (one is ER nurse). PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 18323**] Home [**Telephone/Fax (1) 58490**]. Office [**Telephone/Fax (1) 18325**]
MICU Addend: MICU course documented above. Patient's condition
notable for hemoptysis, respiratory failure, demand ischemia,
hyperkalemia, and respiratory acidosis while weaning from care.
[**2150-8-19**] Family meeting to discuss goals of care. Discussed at
great length with wife, daughter, and sons. Goals of care
modified to comfort care with discontinuation of routine lab
testing, antibiotics, and routine medications. Morphine and
lorazepam continued for sedation and pain control. Scopolomine
patch continued to assist in secretion control. Patient
prepared for transfer to medicine [**Hospital1 **] and palliative care.
Social work provided excellent coverage and answered all patient
questions.
Discharge Medications:
see palliative care notes
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute respiratory failure
Discharge Condition:
Critical
Discharge Instructions:
transferred to palliative care
|
[
"266.2",
"162.9",
"197.7",
"V45.82",
"197.2",
"518.81",
"491.21",
"285.9",
"486",
"276.7",
"410.71",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9951, 9960
|
4507, 5176
|
307, 337
|
10029, 10039
|
912, 4484
|
798, 848
|
9901, 9928
|
9981, 10008
|
10063, 10096
|
863, 893
|
248, 269
|
365, 410
|
5198, 9878
|
666, 782
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,274
| 125,603
|
51424
|
Discharge summary
|
report
|
Admission Date: [**2168-1-22**] Discharge Date: [**2168-1-28**]
Date of Birth: [**2089-3-25**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Demerol
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
transfer from OSH for submassive PE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 F with htn, HL, [**Hospital 106626**] transferred from OSH for new
cardiomyopathy and question for AICD placement. She had been
doing well until [**Month (only) **] when she got ill with pneumonia. Since
then, she has not gone home and has been boucing between rehab
and hospitalization. In early [**Month (only) 404**], she has severe pnuemonia
requiring ICU stay but did not get intubated. She improved and
went to rehab. Then on [**1-13**], she developed SOB and was
admitted to [**Hospital3 7571**]again. She ruled out for acute MI.
She was diagnosed with bilateral lower lobe PNA and was given a
course of Vanc/Zosyn (transitioned to Vanc/Augmentin), and a
steroid course for COPD flare. She also had CHF and was diuresed
until her creatinine bumped. Per report from OSH, she had a
normal echo about 6 months ago, and repeat echo in early
Janurary showed new depressed EF of 30-50% with WMA. Repeat echo
on [**2168-1-14**] showed further depressed EF of 20-30%. She also had a
Dobumatine/persantine stressed test that was abnormal. She is
then sent to [**Hospital1 18**] for management of new cardiomyopathy and
abnormal stress test.
.
At [**Hospital3 **], she also had diarrhea and Cdiff cultures were
negative. Nonetheless, she was started on Flagyl emperically.
Her stools were occult blood negative. Her hct dropped to 27 and
because of her CHF, she was given two units of blood and her hct
bumped to 31-35.
Past Medical History:
PAST MEDICAL HISTORY:
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
.
Cardiac History: CABG: none
.
Percutaneous coronary intervention, in [**2164**] anatomy as follows:
Clean coronaries
.
Pacemaker/ICD: none
.
Other Past History:
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Cards: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**], Rheum: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8467**]
pAtrial fibrillation
Aortic slerosis
CHF
NIDDM
HTN
Obesity
Hyperlipidemia
DVT/PE- [**2150**]/93
R carotid artery 60% stenosis
RA - took embrel and methotrexate in the past
ASA allergy--> anaphylaxis in [**2128**]
Social History:
50 pk-yr tob history, quit [**2138**]. 1 EtOH daily. Lives with her
husband in [**Name (NI) **], MA.
Family History:
Mother and father with CAD in their 50s, one sister with CHF and
another sister died with AS, sister with DM.
Physical Exam:
VS - 97.0 117/56 72 16 93% 2.5L
Gen: female in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. II/ VI SEM, No r/g. No thrills, lifts. No S3
or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. + crackles in the lower
lung fields, no wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/ +1 pititng edema b/l. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
LABS ON ADMISSION:
.
[**2168-1-22**] 09:25PM GLUCOSE-102 UREA N-31* CREAT-1.3* SODIUM-139
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-29 ANION GAP-9
[**2168-1-22**] 09:25PM estGFR-Using this
[**2168-1-22**] 09:25PM ALBUMIN-2.7* CALCIUM-8.3* PHOSPHATE-3.2
MAGNESIUM-2.3
[**2168-1-22**] 09:25PM WBC-9.5 RBC-3.75* HGB-11.7* HCT-34.8* MCV-93
MCH-31.2 MCHC-33.6 RDW-17.2*
[**2168-1-22**] 09:25PM NEUTS-75.0* LYMPHS-12.5* MONOS-4.9 EOS-6.5*
BASOS-1.2
[**2168-1-22**] 09:25PM PLT COUNT-124*
[**2168-1-22**] 09:25PM PT-20.4* PTT-31.3 INR(PT)-1.9*
.
LABS ON DISCHARGE
[**2168-1-27**] 06:45AM BLOOD WBC-9.4 RBC-3.22* Hgb-10.1* Hct-29.8*
MCV-92 MCH-31.2 MCHC-33.8 RDW-17.5* Plt Ct-162
[**2168-1-27**] 06:45AM BLOOD PT-20.9* PTT-70.8* INR(PT)-2.0*
[**2168-1-27**] 06:45AM BLOOD Glucose-74 UreaN-20 Creat-1.2* Na-136
K-3.9 Cl-107 HCO3-24 AnGap-9
[**2168-1-26**] 03:09AM BLOOD ALT-10 AST-12 LD(LDH)-231 AlkPhos-50
TotBili-0.5
[**2168-1-23**] 05:45AM BLOOD cTropnT-0.01 proBNP-5564*
[**2168-1-24**] 03:41AM BLOOD cTropnT-0.02* proBNP-6310*
[**2168-1-27**] 06:45AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9
[**2168-1-23**] 05:45AM BLOOD calTIBC-176* Ferritn-595* TRF-135*
[**2168-1-25**] 05:45AM BLOOD TSH-6.3*
[**2168-1-25**] 05:45AM BLOOD Free T4-1.2
[**2168-1-23**] 05:45AM BLOOD PEP-NO SPECIFI
[**2168-1-23**] 09:07AM URINE Hours-RANDOM Creat-176 TotProt-91
Prot/Cr-0.5*
[**2168-1-23**] 09:07AM URINE U-PEP-NON-SELECT IFE-NO MONOCLO
.
MICRO:
C.diff ([**1-22**], [**1-23**]) - negative
Fecal cultures ([**1-22**], [**1-24**])- negative for shigella/salmonella,
negative for campylobacter. +Fecal leukocytes on [**1-24**]
O&P ([**1-25**])- negative x 2
MRSA screen- pending
.
.
RADIOLOGY:
CXR [**1-22**]
IMPRESSION:
Abnormal opacities involving both lungs. The reticular and
nodular pattern
involving both lungs, relatively sparing the left upper lung, is
nonspecific.
Diagnostic considerations include pulmonary edema superimposed
on chronic
interstitial disease. Pneumonia is not excluded. These findings
would be
better characterized with CT examination of the chest.
.
ECHO [**1-22**]
The left atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis, with septal near-akinesis (LVEF =
25%). The left ventricle appears visually dyssnchronous. Right
ventricular chamber size is normal. with borderline normal free
wall function. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are moderately thickened. Mild to moderate ([**12-25**]+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The main pulmonary artery is dilated. A 12 x
9-mm mobile echodensity is seen just proximal to the pumonary
artery bifurcation, most consistent with thrombus. The pulmonary
artery systolic pressure could not be determined.
IMPRESSION: Probable main pulmonary artery thrombus. Severe
global left ventricular dysfunction, with mild regional
variation, suggesting multivessel CAD. Mild to moderate mitral
regurgitation.
.
EKG [**1-23**]
Sinus rhythm. Occasional premature atrial contractions. Diffuse
ST-T wave
abnormalities. Cannot rule out myocardial ischemia. Compared to
tracing #1
left bundle-branch block has resolved. However, diffuse ST-T
wave
abnormalities are now present. Clinical correlation is
suggested.
Rate PR QRS QT/QTc P QRS T
85 144 94 374/417 47 21 172
.
CTA CHEST [**1-23**]
IMPRESSION:
1. Large pulmonary embolus extending from main pulmonary artery
into the
right main pulmonary artery and into branches of the right
pulmonary artery in
the upper, middle and lower lobes.
2. Bilateral pleural effusions.
3. Background pulmonary interstitial fibrosis in a subpleural
and
predominantly basal distribution, with involvement also of the
lingular
segment of the left upper lobe.
.
Bilateral LENIs [**1-23**]
IMPRESSION: No bilateral lower extremity DVT.
.
EKG [**1-24**]
Sinus tachycardia. Left bundle-branch block. Compared to the
previous tracing
of [**2165-4-4**] left bundle-branch block is new.
Rate PR QRS QT/QTc P QRS T
104 146 146 380/457 91 -21 132
.
EKG [**1-24**]
Atrial fibrillation with rapid ventricular response. Left
bundle-branch block
which is likely rate-related. Compared to the previous tracing
of [**2168-1-24**]
atrial fibrillation with rapid ventricular response has
appeared.
Rate PR QRS QT/QTc P QRS T
107 0 92 364/446 0 21 -142
.
CXR [**1-24**]
A single portable radiograph of the chest again demonstrates an
abnormal
interstitial pattern involving both lungs with relative sparing
of the left
upper lung, similar to [**2168-1-22**]. Bilateral breast implants are
again noted.
The trachea is midline. No pneumothorax is evident. The
cardiomediastinal
contours are unchanged. Lung volumes are low normal. Overall,
there is
little interval change.
.
CXR [**1-25**]
IMPRESSION: No significant change in findings suspicious for
pulmonary
fibrosis.
.
RENAL U/S [**1-25**]
RENAL ULTRASOUND: The right kidney measures 12.4 cm. The left
kidney
measures 11.7 cm. There is no hydronephrosis, stone or solid
renal mass
demonstrated. The patient was not able to hold her breath for
Doppler
assessment, though venous flow is seen in the renal parenchyma
bilaterally.
The main renal veins could not be assessed.
IMPRESSION: No son[**Name (NI) 493**] evidence of renal mass.
.
REPEAT TEE [**1-27**]: The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is mildly dilated with severe global hypokinesis and
inferior akinesis (LVEF = 25-30 %). No masses or thrombi are
seen in the left ventricle. The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets are mildly
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. Compared with
the prior study (images reviewed) of [**2168-1-23**], the severity of
mitral regurgitation is slightly worse and mild pulmonary artery
systolic hypertension is now identified. Mild aortic valve
stenosis is now suggested.
Brief Hospital Course:
Ms [**Known lastname 106627**] is a 78 year-old female with hypertension,
hyperlipidemia, paroxysmal atrial fibrillation who was
transferred from an outside hospital for workup for new
cardiomyopathy (LVEF 20%), and was found to have a submassive
pulmonary embolism, transferred to the CCU for haemodynamic
monitoring.
.
Patient is a 78 F with htn, HL, pafib admitted from OSH for new
cardiomyopathy (likely ICH), question of PNA, and diarrhea, now
with submassive pulmonary embolism.
.
# Pulmonary embolism - Unclear etiology, no LE DVT on Doppler.
Hx of prior PE. Pt was at least temporarily subtheraputic on
coumadin at OSH and per family likely missed some coumadin
doses. Discharged on heparin gtt sliding scale as a bridge to
warfarin treatment with higher INR goal, 2.5-3. Will need
lifelong coumadin. SPEP, UPEP pending for hypercoag w/u, per
report pt [**Name (NI) **] on age appropriate cancer screening. No evidence
LE clot, no IVC filter for now. Renal u/s negative for renal
mass, thrombus.
.
#. Pump. New cardiomypathy. Pt with EF of 30-50% in [**2167-12-26**], but
repeat ECHO in [**1-14**] showed EF 20-30%. Patient diuresed from 204
to 193.6lbs at [**Location (un) **] with improvement in her dyspnea. Fixed
defects on echocardiogram suggest ischemic cardiomyopathy. Other
possibilities include: infectious state given patient's recent
pneumonia and chronic illness. Less likely non-ischemic
etilogies include rheumatologic, myeloma, Hepatitis, HIV and as
a consequence of RV failure . Normal iron, only slightly
increased TSH. Need 9 months optimal medical therapy before
possible consideration of ICD placement. Unlikely ischemic due
to clean coronaries on cath here in [**2164**]. SPEP, UPEP pending as
above.
.
#. Lung Infiltrates: Patient's infiltrates may suggest chronic
interstitial lung disease (related to methotrexate or rheumatoid
arthritis) rather than pneumonia. D/c??????d abx [**1-24**], given no
evidence for acute infection, augmentin may have caused
worsening diarrhea. Pulmonary status was unchanged on and off
Abx.
.
#. Rhythm: Pt currently with NSR, has PAF. Discontinued digoxin.
Added back on low dose BB with good response. Continue heparin
for AC as bridge to Coumadin resumed, goal INR 2.5-3.0 as above.
.
# Diarrhea: Pt reports diarrhea x ~ 2 weeks. Continues to have
diarrhea here 4-5 episodes a day. Pt has had negative C.
difficile x 3 , but was still started on flagyl for a total of a
10 day course. Flagyl stopped. Given concern for large PE and
low preload, potentially low CO, low threshold to consider bowel
ischemia should she decompensate or develop bloody diarrhea. Per
pt and RN this am, diarrhea is better but persists. Received
Immodium with good effect. Stool studies, including bacterial
cultures, O&P all negative. D/c abx as above. Prelim stool
studies have fecal leukocytes. All other stool tudies negative.
.
#. CAD: CE neg at OSH r/o for MI. Focal wall-motion
abnormalities suggest ischemic etiology. Reportedly clean cath
[**2164**], no plans to cath at present. Cont ASA, Simvastatin 10mg PO
daily. Resumed Metoprolol, Lisinopril, Lasix on hold.
.
# HTN: Holding amlodipine, Imdur, lisinopril, given concern for
hypotension.
Resumed BB for PAF.
.
# Anemia: Pt with chronic anemia. Hct 29.8. Pt was given 2U at
OSH. No evidence of active bleed. This is near her baseline.
Medications on Admission:
Xopenex PRN
Nitroglycerin SL PRN
Prilosec 20
Mucinex 600 [**Hospital1 **]
Celexa 20
Lasix 40 (on hold since [**1-21**])
Augmentin [**Hospital1 **] x 4 more days
Lisinopril 7.5
Cholestyramine 1 pack before meals
Mag oxide 400 [**Hospital1 **] x 3 more days
Humalog sliding scale
Calcium 600 [**Hospital1 **]
Vitamin B 400 [**Hospital1 **]
Glyburide 1.25 daily
Toprol XL 50 [**Hospital1 **]
Citirizine 10
zocro 10
folic acid 1
coumadin 1
fosamax 70 q week
asa 325
allopurinol 150
kcl 20 daily (hold since [**1-21**])
vitamin c 1000
imdur 5 [**Hospital1 **]
flagyl 500 tid x 7 more days
Discharge Medications:
1. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation q6 () as needed.
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
17. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED).
18. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Heparin IV continous as per sliding scale until [**2168-1-30**] goal
PTT 60-80
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **], [**Hospital1 189**] MA
Discharge Diagnosis:
PRIMARY:
Pulmonary embolism
Paroxysmal atrial fibrillation
Systolic congestive heart failure (EF 25%)
Pneumonia
.
Discharge Condition:
Good, hemodynamically stable, afebrile, satting in mid-90s on 4L
Discharge Instructions:
You were admitted for management after you were found to have a
large pulmonary embolism in your heart. You have had low blood
pressures likely secondary to this blood clot. Your blood
pressure stabilized, and you were started on heparin then
Coumadin to prevent further clots. You will be going home on
Coumadin. You have highy impaired heart function, and should
continue to follow-up with your cardiologist after discharge.
.
Because of your decreased heart function it is importnat that
you weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. In
addition you should adhere to 2 gm sodium diet and limit your
fluid intake to 1500ml.
.
On exam, we noted some assymetric swelling in your left breast,
which you PCP should follow up with a routine mammogram.
.
Please take your medications as prescribed.
.
If you experience any chest pain, SOB, nausea, lightheadedness,
return to the ED.
Followup Instructions:
Heme-Onc: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2805**] [**2168-2-19**] 9:00am ([**Telephone/Fax (1) 14703**]
Pulmonary: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2168**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital Ward Name 23**] building
[**Location (un) 436**]. Please arrive at 2:30pm to check in and have
spirometry. [**2168-2-17**] 3:00pm ([**Telephone/Fax (1) 513**]
.
Cardiology Dr. [**Last Name (STitle) 11493**]: Wed [**2168-2-17**] 1:20pm
[**Telephone/Fax (1) 11767**]
.
Please followup with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 6955**] [**Telephone/Fax (1) 22629**]
1-2 weeks after discharge from rehab.
Completed by:[**2168-1-28**]
|
[
"433.10",
"425.4",
"414.01",
"415.19",
"427.31",
"787.91",
"428.20",
"403.90",
"V12.51",
"278.00",
"440.0",
"250.00",
"486",
"714.0",
"585.9",
"285.29",
"272.4",
"428.0",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15629, 15696
|
10030, 13372
|
315, 322
|
15854, 15921
|
3634, 3639
|
16879, 17689
|
2616, 2728
|
14007, 15606
|
15717, 15833
|
13398, 13984
|
15945, 16856
|
2743, 3615
|
240, 277
|
350, 1772
|
3653, 10007
|
1816, 2482
|
2498, 2600
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,820
| 144,881
|
28973
|
Discharge summary
|
report
|
Admission Date: [**2168-12-3**] Discharge Date: [**2168-12-5**]
Date of Birth: [**2119-1-15**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: A 49 year old gentleman with alcohol
cirrhosis and grade II esophageal varices, rectal varices who
returns to the hospital with BRBPR after leaving AMA today just
prior to EGD and colonoscopy to evaluate for the source of
bleed. He had one additional episode of BRBPR while out of the
hospital.
.
On prior admisson, he reported he had melena 5 days ago. He was
recently admitted from [**Date range (1) 58975**] for BRBPR. Sigmoidoscopy showed
internal and external hemorrhoids with oozing but no significant
bleeding. His HCT was stable without transfusions and he was
discharged. Starting at 11PM, he began having BRBPR, 4 episodes
100cc each time. He denied any lightheadedness, SOB, CP.
In the ED, VS: 98.2, 116, 165/95, 16, 100%RA. While in the ED,
he had 2 more episdoes of 250 cc each, bright red blood mixed
with clot. Exam was sig. for no TTP on abdominal exam. He has 2
PIVs placed. Patient received 2 units pRBCs. PPI 40mg IV
restarted.
Past Medical History:
1)Diabetes mellitus
2)EtOH Cirrhosis c/b esophageal and rectal variceal bleed, now
s/p TIPSS in [**1-1**].
3)Esophageal varices banding [**8-30**] and [**1-1**]
4)portal hypertensive gastropathy.
5)Diverticulosis
6)h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear ([**11-30**])
7)Hypertension
8)Anemia- baseline Hct = 34
9)Tobacco use
10)Depression
Social History:
Drinks daily since he was 21, drinks 2 beers a day. Smokes 1ppd,
35 pack year hx. Lives with wife and 2 children. He works at
night as a BU custodian. Remote history of cocaine use 15 years
prior, but has not used since then and has never used IV drugs.
Currently drinking ~ 2 beers/day by report
Family History:
Mother died at age 59 from end-stage renal disease. She also had
a history of diabetes. Father alive at age 64. The patient
states he has some issue with his prostate, but is unclear what
this is. The patient's son died of end-stage renal disease at
the age of 23. The son also had a history of juvenile diabetes.
The patient has two other children, a son aged 22 and daughter
aged 16, both of whom are healthy and a brother with diabetes
mellitus.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur at LUSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Discharge Labs:
[**2168-12-5**] 04:01AM BLOOD WBC-7.6 RBC-2.77* Hgb-8.9* Hct-23.8*
MCV-86 MCH-32.3* MCHC-37.5* RDW-17.3* Plt Ct-69*
[**2168-12-5**] 04:01AM BLOOD PT-17.0* PTT-30.2 INR(PT)-1.5*
[**2168-12-5**] 04:01AM BLOOD Glucose-125* UreaN-9 Creat-0.8 Na-136
K-4.0 Cl-105 HCO3-25 AnGap-10
Abdominal U/S [**12-3**]:
IMPRESSION:
1. Patent TIPS; mid-TIPS velocity unchanged; difference in
proximal and
distal TIPS recorded velocities from previous examinations could
be
technical and could be reevaluated with short interval follow up
ultrasound
if indicated.
2. Hepatopetal main portal venous flow and appropriate reversal
of flow in
left portal vein, unchanged from prior.
Brief Hospital Course:
49-year-old male with Etoh cirrhosis complicated by esophageal
and rectal variceal hemorrhages, status post TIPS, presented
with continued BRBPR.
# BRBPR/Anemia: The patient remained hemodynamically stable but
with falling hematocrit on serial checks. He was tranfused to
maintain a hematocrit greater than 25. He was started on
octreotide and PPI IV with ceftriaxone for SBp prophylaxis. The
patient was scheduled for EGD/Colonoscopy however left against
medical advice before these tests could be performed.
# EtOH Cirrhosis: The patient reported drinking as recent as the
night of admission, but did not appear intoxicated. He was
maintained on a CIWA scale for withdrawal prophylaxis and had
vitamin repletion therapy. Social work was consulted. The
patient left against medical advice.
# Diabetes Mellitus: The patient was maintained on an insulin
sliding scale while admitted.
Medications on Admission:
1. Folic Acid 1 mg PO DAILY
2. Glipizide 5 mg PO once a day.
3. Omeprazole 40 mg PO once a day.
4. Sucralfate 1 gram PO QID
5. Thiamine HCl 100 mg PO DAILY
6. Multivitamin
7. Iron 325 mg PO once a day
Discharge Medications:
Left AMA
1. Folic Acid 1 mg PO DAILY
2. Glipizide 5 mg PO once a day.
3. Omeprazole 40 mg PO once a day.
4. Sucralfate 1 gram PO QID
5. Thiamine HCl 100 mg PO DAILY
6. Multivitamin
7. Iron 325 mg PO once a day
Discharge Disposition:
Home
Facility:
Against medical advice
Discharge Diagnosis:
Lower gastrointestinal Bleed, source unconfirmed as patient left
against medical advice.
Discharge Condition:
Vital signs stable, still actively bleeding per rectum
Discharge Instructions:
Patient left against medical advice, advised to return
immediately.
Followup Instructions:
Patient left against medical advice, advised to return
immediately.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"401.9",
"250.00",
"455.3",
"562.10",
"572.3",
"537.89",
"455.0",
"571.2",
"305.00",
"569.3",
"280.0",
"311",
"272.0",
"456.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"48.23"
] |
icd9pcs
|
[
[
[]
]
] |
5078, 5118
|
3698, 4592
|
284, 290
|
5250, 5306
|
2997, 2997
|
5422, 5628
|
2051, 2504
|
4843, 5055
|
5139, 5229
|
4618, 4820
|
5330, 5399
|
3014, 3675
|
2519, 2978
|
239, 246
|
346, 1295
|
1317, 1720
|
1736, 2035
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,275
| 154,450
|
28059
|
Discharge summary
|
report
|
Admission Date: [**2106-7-18**] Discharge Date: [**2106-8-5**]
Date of Birth: [**2073-9-15**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
urinary tract infection, possible hypoxic episode
Major Surgical or Invasive Procedure:
left femoral line placement
left PICC placement
History of Present Illness:
HPI: 32 yo M with TBI [**1-18**] to motorcycle accident in [**2091**],
seizure d/o, non-responsive at baseline was brought to ED today
by his mother for shortness of breath and turning blue. Per mom,
patient has been coughing for a few days which signficantly
worsened on Friday (2 days ago). Patient was noted to have
episodes of difficulty with breathing, and today patient was
noted to turn blue when he was coughing. Mom got worried, so
brought him to the ED. Per mom, patient has been having fevers
during the past 3 days, the highest axillary temperature was
101F. In addition, patient's urine has been darker than usual.
Patient had a large BM yesterday, but mom thinks he [**Year (4 digits) 15598**]'t have
diarrhea. Mom [**Name (NI) 15598**]'t think patient was in any pain.
.
In the ED, initial VS: 115/79, 145, 24, 95% RA initially. Except
for tachycardia and tachypnea, exam unremarkable per ED. No
indwelling foley. CXR was unremarkable. UA had evidence of UTI.
He was also found to have elevated lactate. HR got better with
IVF (2L IVF), down to 100s. Patient received IV CTX for UTI. No
documented hypoxia in the ED, although there is a questionable
90% at triage. ED Techs thought he looked "blue" at one point.
On transfer, VS: 98.4, 96/70 (relatively stable), 102, 18, 100%
3L.
Past Medical History:
-Traumatic head and neck injury s/p MVC in [**2091**] in Bolivia with
brain and spinal cord damage, s/p shunt and shunt revision.
Baseline non-verbal, spastic quadriparesis. Bites his hands and
has caused scarring from past bites.
-Recurrent complex partial seizures with secondary
generalization
s/p MVC, described in prior notes as a "shaking of his
extremities, facial twitching and/or mouth movements/lip
smacking", usually occur in clusters and are prolonged. Last
seizure 4 years ago. Previously on Dilantin, transitioned to
Depakote which became ineffective, Keppra added when he had
recurrence of his events approximately 4 years ago. Dr. [**Last Name (STitle) **]
titrated him off Depakote [**4-22**]. Patient was instructed to take
Keppra 1500 mg [**Hospital1 **], but was only taking 750 mg [**Hospital1 **] "because his
mother did not make the dose increase as recommended because he
has not had any seizures and becuase she is trying to make
Keppra
last longer."
-History of pansensitive Proteus UTI with urinary retention
[**2104-3-18**]
Social History:
He lives with mother and is minimally functional since the
accident per his mother "like a one month old baby". He requires
maximal assist to move and is wheeled around in a chair.
Family History:
Noncontributory
Physical Exam:
On Admission
Vitals - T:97.4 BP:110/80 HR:109 RR:24 02 sat:97% on 2L
GENERAL: unresponsive, eyes wide open, well appearing, in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRL. MMM. OP clear. Neck Supple, No LAD, No
thyromegaly.
CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No
murmurs, rubs or [**Last Name (un) 549**].
LUNGS: tachypneic, CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. Lower extremities inverted.
SKIN: No rashes or ecchymoses. Left hand has scar from bites.
NEURO: Unresponsive, eyes wide open. CNII-XII grossly intact.
quadriplegic, lower extremities inverted.
.
Exam on discharge:
vitals: T 98.8 HR 95 BP 108/72 RR 16 99% RA
GENERAL: sleeping, well appearing, in NAD, turns head/opens eyes
to name
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. palpable shunt in left IJ. PERRL. MMM. OP
clear. Neck Supple, No LAD, No thyromegaly.
CARDIAC: RRR. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. Lower extremities inverted, plegic. UEs with
limited flex/ext
SKIN: No rashes or ecchymoses. Left hand has scar from bites.
well healed sacral ulcer
NEURO: CNII-XII grossly intact. quadriplegic, lower extremities
inverted.
Pertinent Results:
[**2106-7-18**]
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
URINE [**Last Name (un) 3143**]-MOD NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-NEG
BILIRUBIN-SM UROBILNGN-4* PH-7.0 LEUK-MOD
URINE RBC-[**2-18**]* WBC->50 BACTERIA-MOD YEAST-NONE EPI-0-2
LACTATE-2.9*
GLUCOSE-172* UREA N-9 CREAT-0.7 SODIUM-138 POTASSIUM-5.1
CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
estGFR-Using this
WBC-13.6* RBC-4.29* HGB-12.0*# HCT-36.5* MCV-85 MCH-28.0
MCHC-32.9 RDW-14.4
NEUTS-80.8* LYMPHS-14.1* MONOS-2.9 EOS-1.8 BASOS-0.4
PLT COUNT-386#
Labs on discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
9.5 3.71* 10.0* 31.1* 84 26.9* 32.1 16.2* 448*
Glucose UreaN Creat Na K Cl HCO3 AnGap
103 6 1.0 141 4 108 25 10
ALT AST alk phse tbil
17 19 106 0.3
Calcium Phos Mg
8.3* 3.5 2.0
[**2106-8-3**] 5:39 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2106-8-4**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2106-8-4**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2106-8-1**] 6:37 pm URINE Source: Catheter.
**FINAL REPORT [**2106-8-2**]**
URINE CULTURE (Final [**2106-8-2**]): NO GROWTH
[**2106-8-1**] 8:00 pm [**Month/Day/Year 3143**] CULTURE
[**Month/Day/Year **] Culture, Routine (Pending):
all [**Month/Day/Year **] cultures with no growth since [**2106-7-21**]
CXR portable [**8-2**]
Right hemidiaphragm is chronically elevated, possibly related to
thoracolumbar scoliosis. Mild left lower lobe atelectasis
improved. Upper lungs clear. No pleural effusion or evidence of
central adenopathy. Right-sided shunt catheter is intact and
unchanged. Tip of the new left PIC line projects over the mid
SVC. No pleural effusion or pneumothorax
TTE
An echodensity consistent with a catheter or shunt is seen
within the right atrium (this could be better characterized by
TEE or CT). The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. The estimated pulmonary artery systolic pressure is
normal. There is a very small pericardial effusion. There are no
echocardiographic signs of tamponade
CT head/neck
IMPRESSION:
1. Right internal jugular vein thrombus with marked perivenous
inflammatory
stranding and inflammatory changes tracking through the right
neck. These
findings are most compatible with thrombophlebitis as seen with
Lemierre's
syndrome. No drainable fluid collection identified.
2. Edema within the oropharyngeal mucosa and uvula without
evidence of
abscess.
3. Periapical lucencies surrounding molars in the left mandible,
likely
represents odontogenic disease or infection.
4. Minimal stranding in the anterior mediastinum, better
evaluated on
dedicated chest CT.
Brief Hospital Course:
Patient is a 32 year old male with a history of a traumatic
brain injury about 10 years ago, who is unresponsive at
baseline, with a history of seizure disorder (last seizure about
one year ago) who presented with a urinary tract infection and
questionable hypoxic episode.
# Staph aureus, coag (-) and (+) bacteremia - Following
admission to the floor, the patient was treated for an
uncomplicated UTI with ceftriaxone. The patient developed
intermittent episodes of hypotension and low grade fever, which
required IV fluid boluses and additional antibiotic coverage
with zosyn and vancomycin. Patient then became acutely
hypotensive and febrile, [**Month/Year (2) **] pressure did not respond to IV
fluids, and the patient was transferred to the ICU for further
management. A brief course of levophed was required to maintain
[**Month/Year (2) **] pressure. In the ICU, the patient was noted to have
developed a right-sided neck swelling. Ultrasound confirmed a
right internal jugular thrombus, and CT head/neck was consistent
with a thrombophlebitis. At this time, [**Month/Year (2) **] cultures grew out
both coag (-) and (+) S. aureus, and antibiotic coverage with
vancomycin was continued. There was a concern for Lemierre's
syndrome, thus zosyn was continued. Neurosurgery was consulted,
as the patient had a known non-functioning right
ventricular-atrial shunt running through the right internal
jugular vein. The decision was made to not remove the hardware,
as the patient was clinically improving at this point, and the
procedure would have been difficult with high risk.
Sensitivities from the [**Month/Year (2) **] cultures showed pan-sensitive S.
aureus, and antibiotic coverage was narrowed to nafcillin per
the infectious disease consult team. [**Month/Year (2) **] cultures since
[**2106-7-21**] have showed no growth. The patient was continued on
nafcillin. The nafcillin will be continued for six weeks, and
will end on [**2106-9-7**].
# Right internal jugular thrombophlebitis - Therapeutic lovenox
was initiated in the ICU. The Hematology service was consulted
for length of treatment and they felt that anticoagulation
should be continued for 3 months. The end date will be [**2106-10-24**].
# History of seizures - The patient was maintained on Keppra
throughout his course, with no recurrence of seizures.
# Hydrocephalus - There were no active issues. The
neurosurgical team deferred inpatient removal of his hardware.
The patient will need neurosurgical follow up after the
antibiotic and anti-coagulation courses have finished to
readdress this issue.
# TBI status post motor vehicle accident - The patient's
diminished neurologic status remained unchanged throughout his
course. Baclofen, used to manage his contractures, had been
discontinued in the setting of hypotension. It has since been
restarted and tolerated well.
# Nutrition - The patient was noted to aspirate during a speech
and swallow evaluation. However, an oral diet was continued per
the wishes of the patient's mother. She has been feeding him
since the accident without any complications, and the patient
did not develop any signs of aspiration during his course.
Alternative forms of enteral feeding were deemed not to be
required by the nutrition consult (given that he has been able
to maintain his weight). With his mother's help, the patient
was taking enough calories orally.
#code status - full
Medications on Admission:
BACLOFEN - 20 mg twice a day
LEVETIRACETAM 1500mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
3. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Levetiracetam 500 mg/5 mL Solution Sig: One (1) Intravenous
Q12H (every 12 hours).
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
8. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours) for 33 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnosis:
sepsis
right internal jugular thrombophlebitis
urinary tract infection
Secondary diagnosis:
Traumatic head and neck injury s/p MVC in [**2091**] in Bolivia with
brain and spinal cord damage, s/p shunt and shunt revision.
Baseline non-verbal, spastic quadriparesis. Bites his hands and
has caused scarring from past bites.
- Recurrent complex partial seizures with secondary
generalization s/p MVC, last seizure one year ago
- History of pansensitive Proteus UTI with urinary retention
[**2104-3-18**]
Discharge Condition:
stable and improved, no longer infectious
Discharge Instructions:
You were admitted following a possible episode of choking and
becoming blue in the face, along with a urinary tract infection.
You started receiving an antibiotic for your infection. You
developed another infection in your [**Month/Day/Year **], which was likely due
to the drain in your neck. You needed care in the ICU for a
brief period of time. Treatment was started for your second
infection, you improved and were transferred back to the general
medicine floor. You were found to have a clot in a neck vein,
and you started receiving a [**Month/Day/Year **] thinner medication, which you
will need for 3 months. You continued to do well, and will
require an IV antibiotic for 6 weeks to treat the infection in
your [**Month/Day/Year **]. You were transferred on [**2106-8-5**] to [**Hospital **] Rehab
for further care to receive the antibiotic.
The following changes were made to your medications:
Nafcillin was added
Lovenox was added
You will see Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] infectious disease doctor at the time
below.
Please call your doctor if you develop fevers/chills, or any
other concering vital signs.
Followup Instructions:
DR. [**First Name (STitle) **] [**First Name (STitle) 3143**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2106-9-6**] 9:00
|
[
"348.1",
"401.9",
"451.89",
"038.11",
"599.0",
"344.00",
"285.29",
"345.90",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12354, 12433
|
7993, 11421
|
330, 380
|
12998, 13042
|
4546, 5089
|
14246, 14378
|
2996, 3013
|
11528, 12331
|
12454, 12454
|
11447, 11505
|
13066, 14223
|
3028, 3763
|
241, 292
|
5108, 7970
|
408, 1707
|
3782, 4527
|
12566, 12977
|
12473, 12545
|
1729, 2782
|
2798, 2980
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,750
| 198,981
|
34564
|
Discharge summary
|
report
|
Admission Date: [**2195-7-13**] Discharge Date: [**2195-7-16**]
Date of Birth: [**2135-7-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal and Back Pain
Major Surgical or Invasive Procedure:
UGI with contrast
History of Present Illness:
Pt is a 59 male with 12 hour history of acute onset severe
epigastric and
back pain, followed by nausea. Denies F/C, emesis, hematemesis.
Pt denies alcohol use or trauma. He has a hx of heartburn and
takes aspirin regularly for arthritis. He presented to [**Hospital1 10551**] initially, where a CT showed duodenal perforation at
D2. Has hx of close contacts with PUD
Past Medical History:
GSW to colon/bladder/penis
Osteomyelitis
PSH: Ex Lap with colon resection.
Social History:
No tobacco, occ. ETOH. Not working currently. brother next of
[**Doctor First Name **].
Family History:
[**Name (NI) 79356**]
[**Name (NI) 63650**] CA
Physical Exam:
Vitals on admission: 99.8, 94, 97/64, 18, 95%RA
Gen: NAD, A & O x 3
HEENT: NC/AT, no jaundice
CV: RRR, no murmurs
RESP: decreased breath sounds
Abd: s/ND, epigastric pain with guarding, no rebound. small
ventral hernia. guiac +
Ext: 2+ DP pulse B
Pertinent Results:
[**2195-7-13**] 05:28AM WBC-15.3* RBC-4.95 HGB-14.5 HCT-41.3 MCV-84
MCH-29.3 MCHC-35.1* RDW-13.6
[**2195-7-13**] 05:28AM NEUTS-67 BANDS-18* LYMPHS-11* MONOS-3 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2195-7-13**] 05:28AM ALBUMIN-3.9 CALCIUM-8.9 PHOSPHATE-3.1
MAGNESIUM-1.7
[**2195-7-13**] 05:28AM GLUCOSE-125* UREA N-12 CREAT-0.8 SODIUM-138
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-22 ANION GAP-15
[**2195-7-13**] 05:28AM ALT(SGPT)-19 AST(SGOT)-19 ALK PHOS-41
AMYLASE-61 TOT BILI-1.4
Brief Hospital Course:
Pt was seen in the ED as a transfer from and outside hospital
and admitted to the ICU after a CT outside showed contained
duodenal perforation. He was started on IVF, made NPO, and an
NGT was placed to suction. He was started on IV flagyl,
levaquin, fluconazole for abx. He also received IV octreotide
and protonix. He underwent UGI which showed filling of a
duodenal diverticulum with a
probable small contained perforation adjacently, but no active
contrast
extravasation causing diverticulitis, and that a contained
duodenal perforation from ulceration was felt less likely. The
decision was made to hold off on OR managment and watch
clinically, as a true duodenal perf seemed less likely. A
urology consult was obtained given his altered anatomy from a
GSW, in case he needed a foley placed for the OR.
On HD 2, he continued to do well, and was transferred to the
floor in stable condition. He continued to improve the following
day and was started on a clear liquid diet. His fluids were
stopped, and he was started on PO meds.
By HD 4, he was tolerating a regular diet and had minimal
complaints. He was discharged on Protonix, Levaquin, and Flagyl
in good condition.
Medications on Admission:
ASA 325mg, 4-6 times per day
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*6 Tablet(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*18 Tablet(s)* Refills:*0*
4. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO Q6H:PRN as
needed for pain: No driving on narcotic medication.
Disp:*20 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal diverticulitis with contained perforation
Urethral Sticture
Discharge Condition:
Good
Discharge Instructions:
F/u in Dr.[**Name (NI) 11471**] clinic in 2 weeks.
Please call Dr.[**Name (NI) 11471**] clinic if develop fever > 101, severe
abdominal pain, significant nausea and vomiting, or bloody
stools.
No driving on narcotic medication.
Avoid strenous activity and heavy lifting for 1-2 weeks.
Followup Instructions:
Dr.[**Name (NI) 11471**] clinic in [**1-7**] weeks.
Completed by:[**2195-7-16**]
|
[
"562.01",
"E935.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3761, 3767
|
1821, 2997
|
338, 358
|
3879, 3886
|
1306, 1798
|
4219, 4302
|
976, 1024
|
3076, 3738
|
3788, 3858
|
3023, 3053
|
3910, 4196
|
1039, 1046
|
275, 300
|
386, 757
|
1060, 1287
|
779, 855
|
871, 960
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,407
| 162,578
|
10365
|
Discharge summary
|
report
|
Admission Date: [**2187-9-6**] Discharge Date: [**2187-9-9**]
Date of Birth: [**2113-5-5**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 12077**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 74 yo M with ESRD on HD, CAD s/p CABG, Afib,
elevated PSA, admitted for hypoglycemia following complicated ED
course. Briefly, patient states he went to ED yesterday evening
for back pain and "couldn't get out of chair." Has new
wheelchair with a seat that is sunken in and couldn't get out of
it, called ambulence. States he never had back pain prior to
yesterday. Pain is in lumbar spine. Denies weakness in his
lower extremities. Denies numbness, pain in legs, saddle
anesthesia, bladder/bowel difficulties. Admits to fall approx 1
month ago in which he hit his forehead, no falls since.
In the ED, patient was given pain meds and discharged. He was
brought by ambulence to the nursing home in which he resided in
the past (not where he is currently living). They did not
accept him there [**2-2**] him not being a current resident. Did not
leave the ambulence and brought back to ED. When back at ED,
noted to be more somnolent; FS checked and noted to be 26; given
D50 and glucagon; repeats 46 then 62. Denies having injections
Report of chest pain in ED; however, patient currently denying
current or recent CP. No SOB, dizziness, lightheadedness, HA,
abd pain, fever.
Past Medical History:
1. CAD: s/p CABG x 3 (LIMA-LAD, SVG-OM, SVG-Diag in [**9-4**] at [**Location (un) 7349**]
[**Hospital1 **] after presenting with loss of consciousness). Followed by Dr.
[**First Name (STitle) **] [**Name (STitle) **].
2. s/p MV repair: [**9-4**] (#28 Physio ring)
3. s/p AICD implant: [**9-4**] for VT
4. AFib
5. ESRD: [**2-2**] IgA nephropathy. was on peritoneal dialysis. Now on
HD (since [**10-6**]). Follows with Dr. [**First Name (STitle) 805**]
6. HTN
7. s/p Left-sided CVA
8. dyslipidemia
9. Gout
10. Elevated PSA with enlarged, firm prostate, sclerotic lesions
on CT scan, but bone scan [**9-6**] negative. No prostate bx yet.
Social History:
He emigrated from [**Location (un) 6847**] in [**2172**].
Family History:
His parents are both deceased of unclear cause.
He has two siblings, both deceased of unclear cause. He has
three children.
Physical Exam:
VS: T 97.4, BP 133/75, P 72, R 20, 99%RA. FS: 108, 92 here
General: Thin male, NAD.
HEENT: NC. + soft tissue swelling above L eyebrow, mildly
tender. sclera anicteric. MMM, OP clear.
Chest: clear with few end expiratory crackles
Heart: RRR, S1 S2, loud holosystolic murmur at apex
Abdomen: thin, soft, NT/ND +BS
Back: (limited) no CVA tenderness; +TTP low thoracic and lumbar
spine
Extrem: thin, warm. No edema. L 2nd toe amputation
Neuro: Alert, oriented x 3
Pertinent Results:
[**2187-9-6**]
WBC-3.8* HGB-12.8*# HCT-39.2*# MCV-96# MCH-31.4 MCHC-32.7
RDW-18.0* PLT-94*
NEUTS-83.6* BANDS-0 LYMPHS-9.1* MONOS-5.9 EOS-0.9 BASOS-0.5
HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+
MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-1+
GLUCOSE-285* UREA N-94* CREAT-7.3*# SODIUM-133 POTASSIUM-5.8*
CHLORIDE-97
TOTAL CO2-22 ANION GAP-20
CALCIUM-7.8* PHOSPHATE-6.8*# MAGNESIUM-2.1
CK(CPK)-77 CK-MB-NotDone cTropnT-0.15* (baseline ~0.2)
.
Elbow Xray ([**2187-9-6**]): Cortical irregularity at the medial aspect
of the coracoid process, suspicious for a non-displaced fracture
in the appropriate clinical setting. Please correlate with focal
tenderness in this area.
.
CXR ([**2187-9-6**]) : 1. Stable, bilateral pleural effusions moderate
to large on the right and moderate on the left with bibasilar
atelectasis.
2. No evidence of pulmonary edema.
.
CT head ([**2187-9-6**]) : 1) No evidence of intracranial hemorrhage or
edema. 2) Subcutaneous soft tissue hematoma along the frontal
scalp anteriorly on the left. 3) Small amount of subcutaneous
air within the scalp along the right temporal bone.
.
AXR ([**2187-9-6**]): A relative paucity of gas is again identified
within the abdomen, as seen on the previous exam. Vascular
calcifications are seen. No dilated loops of large or small
bowel are seen.
.
CT chest ([**2187-6-25**]): Interval increase in bilateral pleural
effusions, large on the right and moderate on the left with
lateral left-sided loculated component. No abnormal pleural
enhancement or suggestion of pleural disease. 2. Multifocal
sclerotic lesions within the bones. Differential diagnosis
includes calcified hemangiomas, perhaps related to underlying
renal disease; however, osteoblastic metastatic lesions cannot
be excluded. Suggest correlation with PSA and bone scan if
needed.
Brief Hospital Course:
74 year old male with ESRD on HD, CAD s/p CABG, afib, no history
of diabetes; presents to ED with back pain and hypoglycemia to
26, transferred to MICU for hypotension/hypothermia, he was
transferred to the medical floor on [**2187-9-8**] and signed out
against medical advice on [**2187-9-9**].
Hypotension - Resolved in the MICU. Originally presumed and
treated as septic shock given hypothermia and hypoglycemia. Hct
was stable with normal cortisol levels. Blood pressures were
stable upon call out from MICU. There was no explanation for
initial hypotension. Heart failure was unlikely given clinical
exam, no chest pain, sob, or EKG changes. Patient signed out
Against medical advice the morning after transfer from the MICU.
No further workup done as this patient decided to leave AMA.
Hypothermia - Infectious workup begun in the MICU. Concern was
for sepsis, though patient was without fevers in the MICU.
Blood pressures had also stabilized upon callout from the MICU.
Patient did have sources of infection with right heel ulcer,
left elbow effusion and pleural effusion. On the night of
[**2187-9-8**], one blood culture grew out gram + cocci. Patient was on
ceftriaxone. Vancomycin could not be started given history of
red man syndrome. The following morning, Mr. [**Known lastname **] decided to
sign out AMA. He was told about his likely blood infection and
the possibility of sepsis and death. He stated he understood and
did not want to be treated. Mr. [**Known lastname **] son was present and
agreed with his father. Mr. [**Known lastname **] was given a prescription for
Dicloxacillin and signed out AMA. He was told to follow up with
his PCP [**Name Initial (PRE) 2227**].
Hypoglycemia: Etiology was unclear. [**Name2 (NI) **] was being followed by
endocrine, w/u underway. Differential diagnosis included
prostate cancer, early-onset diabetes, insulinoma. He was told
to follow up with his PCP regarding this matter. He signed out
AMA on [**2187-9-9**] without further workup.
ESRD: Patient is on Hemodyalysis via right arm fistula
(tu/th/sa). HD continued as an inpatient.
Pleural effusions: Patient with bilateral, chronic effusions.
Etiology was unclear, diagnostic pleural tap was being
considered but patient signed out AMA before tap could be done.
Mr. [**Known lastname **] was told to follow up with his PCP regarding this
matter.
Pancytopenia: Mr. [**Known lastname **] was seen by heme/onc who felt pancytopenia
likely represented sepsis vs medications vs prostate ca. Anemia
is at baseline, and is attributed to CKD.
Prostate enlargement: PSA elevated to 40.1, followed by urology
(Dr. [**Last Name (STitle) 770**], has firm prostate on admission exam, will need CT
ABD/PELVIS and bone scan per email from Dr. [**Last Name (STitle) 11189**]. CT TORSO
performed to evaluate for metastatic prostate ca, which found
evidence of extensive sclerotic lesions in the bone. Bone scan
was considered but patient left AMA before further workup could
be pursued. He was told to follow up with his PCP regarding
this matter.
Elevated INR - Patient was given vitamin K for elevated INR.
Patient left AMA before further workup could be initiated.
Back pain: Patient complaining of back pain on admission. It
resolved upon transfer to the medical floor. Patient left AMA
before further workup could be initiated
Elbow pain: Patient with left elbow effusion of unknown
etiology. Mr. [**Known lastname **] left AMA before further workup could be
initiated.
Medications on Admission:
NIFEdipine CR 30 mg PO DAILY
Furosemide 40 mg PO DAILY
FoLIC Acid 1 mg PO DAILY
Multivitamins 1 CAP PO DAILY
Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **]
Pantoprazole 40 mg PO Q24H
Calcitriol 0.25 mcg PO DAILY
Tamsulosin HCl 0.4 mg PO HS
Paroxetine 10 mg PO DAILY
Atorvastatin 40 mg PO DAILY
Amiodarone 200 mg PO DAILY
Metoprolol 100 mg PO TID
Aspirin 325 mg PO DAILY
Clopidogrel Bisulfate 75 mg PO DAILY
Discharge Medications:
Mr. [**Known lastname **] left against medical advice
Discharge Disposition:
Home
Discharge Diagnosis:
Patient left AMA
Hypothermia, hypotension, hypoglycemia
Discharge Condition:
Patient left against medical advice
Discharge Instructions:
Patient left against medical advice
You were admitted with back pain, low blood sugar and
hypothermia. You were treated in the medical intensive care
unit for your low blood pressures and low blood sugars.
Endocrinology was following your blood sugars and recommended
workup which could not be concluded since you have decided to
leave against medical advice.
A blood culture showed possible bacterial blood infection. You
are to take an antibiotic Dicloxacillin 250mg every 6 hours for
14 days.
You were also found to have fluid in your lungs and in your
abdomen. Your prostate as been noted to be enlarged and your
PSA level is elevated, these factors point towards the
possibility of prostate cancer. Please follow up with your
primary care doctor regarding this issue.
Your primary care doctor was notified by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 34382**] about
your admission and regarding your wishes to leave against
medical advice.
If you experience fevers, shortness of breath, chest pain,
abdominal pain, back pain, nausea, vomiting, fainting,
dizziness, lightheadedness, falls or any other concering
symptoms then please call your doctor immediately or report to
the nearest emergency room.
Followup Instructions:
Patient left against medical advice
1. Please call your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on
monday [**2187-9-10**] for a follow up appointment ([**Telephone/Fax (1) 34383**].
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2187-11-13**]
3:00
|
[
"707.07",
"427.31",
"427.1",
"585.6",
"995.93",
"263.9",
"274.9",
"511.9",
"272.4",
"284.1",
"V45.02",
"403.91",
"038.19",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8834, 8840
|
4776, 8287
|
282, 289
|
8941, 8979
|
2910, 4752
|
10267, 10615
|
2287, 2413
|
8756, 8811
|
8861, 8920
|
8313, 8733
|
9003, 10244
|
2428, 2891
|
230, 244
|
317, 1536
|
1558, 2195
|
2211, 2271
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,887
| 182,630
|
25750
|
Discharge summary
|
report
|
Admission Date: [**2199-7-21**] Discharge Date: [**2199-7-31**]
Date of Birth: [**2123-12-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Gallstone pancreatitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 YO female with Hx of Parkinson's disease x-ferred with
gallstone pancreatitis. On the day prior to admission, the pt
developed RLQ pain after eating out with her family. THe pain
then moved to her epigastric and right upper quadrant. She
developed nausea and vomiting at least 5 times. THe pain became
fmore sever and went to OSH ED. In the ED, the patient found to
have Amylase of 3200 and Lipase of 8300 with an abdominal U/S
showing cholelithiasis with mild biliary dilatation common bile
duct 8 mm, no gallbladder wall thickening or pericholecystic
fluid. Pt received morphine for pain. Pt was x-ferred to [**Hospital1 18**]
for possible ERCP and further evaluation.
On admission, the pt is very somnolent- the daughter attributes
to pain. Pt speaks only greek but states abdominal pain is
minimal after having received morphine- daughter is translator.
Deneis CP or SOB. Unable to get Greek interpreter until tomorrow
would have to come to bedside.
Past Medical History:
CHF
HTN
Parkinson's disease
S/P appy
Social History:
Lives with daughter, no EtOH, no tobacco
Family History:
non-contrib
Physical Exam:
On admission:
T: 99.8 (Rectal) HR 78 BP 137/92 RR 20 O2 98% on 3L NC
NAD, lying in bed, speaks only greek, very somnolent
MMM, OP- no teeth, No LAD
Neck FROM but rigid from parkinson's.
RR with no m
CTA-B
Soft, tender in epigastric- voluntary guarding, +BS
No C/C/E, warm
Pertinent Results:
[**2199-7-21**] 03:40PM LIPASE-946*
[**2199-7-21**] 03:40PM CK-MB-12* MB INDX-8.4* cTropnT-0.33*
[**2199-7-21**] 03:40PM WBC-29.9* RBC-4.67 HGB-13.6 HCT-40.9 MCV-88
MCH-29.1 MCHC-33.3 RDW-13.9
CT C/A/P
IMPRESSION:
1. The pancreas is enhancing homogeneously. There are multiple
peripancreatic fluid collections as described above which are
essentially
stable.
2. Small amount of free fluid.
3. Large bilateral pleural effusions with associated
atelectasis are stable.
4. Anasarca
Brief Hospital Course:
A/P: 75F with Hx of Parkinson's admitted with gallstone
pancreatitis and suspected cholangitis.
1. Gallstone pancreatitis/Cholangitis- on admission: [**Last Name (un) 5063**]
criteria- at least 4 points- motality 15-20%. Abdominal U/S
with stones in gallbladder, no stones in CBD, CBD not dilated.
Since the stones had passed, no ERCP was done at this time.
The patient was kept NPO and treated with aggressive IVF
hydration with NS on admission. As her Na rose, free water
boluses were used (free water deficit measured as 2L on [**7-24**]).
She was also treated with Unasyn to cover enterococci, gram
negatives, and anaerobes. A 7 day course was completed. A CT
abd on [**7-25**] showed no necrosis, no hemorrhage, large
peripancreatic fluid, and a small amount of intraabdominal
ascites. Morphine was used for pain control.
2. Tachycardia/afib and HTN:
The patient was maintained on metoprolol 37.5 TID. During her
initial ICU stay, the patient has gone in and out of rapid
atrial fibrillation (HR to 190's). Also with several runs of
sinus tachycardia (to 180's). Usually responsive to Diltiazam.
EKGs during rapid A.Fib showed rate dependent t wave inversions.
(Home HTN meds: metoprolol 25mg TID, lasix 40mg QD, captopriil
25mg TID)
3. Pain was controlled with morphine as needed (meperidine held
b/c of old age and risk of seizure).
4. Hypernatremia: Na trended up to 147 on [**2199-7-26**]. Responsive to
free water boluses through NG tube.
5. [**Name (NI) **] pt had elevated trop- max 0.4 at OSH trended downward,
with negative CK, likely from demand ischemia. Trop down to
0.11 from 0.13 here. An EGK showed no evidence of ischemic
changes. No old EKG available for comparison. Pt was started on
ASA, and low dose BB. Statin was not started as pt was NPO at
this time. Pt was also not heparinized due to risk of
hemorrhagic pancreatitis
6. Tachypnea: pt has been tachypneic with hypercarbia
7. FEN: Had IR placed post-pyloric dobhoff.
8. Parkinson's: held sinemet (Home dose of Sinemet 50/200 QID).
8. PPx- SC heparin, pneumoboots, PPI
9. Glucose control: Insulin SC sliding scale.
10. [**Name (NI) 2638**] HCP is daughter [**State 64162**] Cell: [**Telephone/Fax (1) 64163**]
Home: [**Telephone/Fax (1) 64164**]
PCP is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: [**Telephone/Fax (1) 56152**]
11. Pt was DNR/DNI. On [**7-30**], she was again transferred to
the ICU for fevers, respiratory failure, worsening hypoxemia,
and mental status changes. Following a discussion between the
ICU team and the pt's family, she was made CMO. She expired
shortly thereafter.
Medications on Admission:
Captopril 25mg TID
Lopressor 25mg [**Hospital1 **]
Sinemet50/200 QID
Lasix 40mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2199-9-22**]
|
[
"427.5",
"276.2",
"519.8",
"428.0",
"401.9",
"577.0",
"276.0",
"332.0",
"273.8",
"574.20",
"518.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.69",
"93.90",
"38.93",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
5102, 5111
|
2318, 2455
|
346, 352
|
5174, 5183
|
1803, 2295
|
5235, 5405
|
1482, 1495
|
5074, 5079
|
5132, 5153
|
4963, 5051
|
5207, 5212
|
1510, 1510
|
284, 308
|
380, 1347
|
2469, 4937
|
1369, 1408
|
1424, 1466
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,794
| 185,890
|
8690
|
Discharge summary
|
report
|
Admission Date: [**2168-9-26**] Discharge Date: [**2168-10-8**]
Date of Birth: Sex: M
Service: NSURG
HISTORY OF PRESENT ILLNESS: This is a 66-year-old man who
presented with the worst headache of his life the morning of
[**2168-9-26**]. He was seen in the Emergency Room at approximately
1:30 p.m. by neurosurgery. He was straining while trying to
have a bowel movement. The patient has a history of bad
headaches; however, this time the symptoms were much worse.
PAST MEDICAL HISTORY:
1. Hepatitis C related to transfusion.
2. Benign prostatic hypertrophy.
3. Thrombocytopenia.
4. Atrial fibrillation.
MEDICATIONS ON ADMISSION:
1. Proscar.
2. Tylenol.
3. Lisinopril 5 mg p.o. daily.
4. Nadolol 40 mg p.o. daily.
5. Interferon once a week for hepatitis C.
PAST SURGICAL HISTORY: Gastrectomy 31 years ago.
PHYSICAL EXAMINATION: The vital signs on admission revealed
a blood pressure of 173/70, heart rate 70, respirations 16.
On physical examination, he was awake, alert, oriented times
three. Cranial nerves II through XII were intact. Motor
strength was [**4-27**] in both his upper and lower extremities. He
had no localized motor or sensory deficits.
LABORATORY DATA: White count 3.1, hematocrit 39.8, platelets
63,000. Sodium 141, potassium 4.6, 108 chloride, 25
bicarbonate, 17 BUN, 0.8 creatinine, 117 glucose. His
platelets on admission were 63.
HOSPITAL COURSE: Given that his platelets were 63, he was
transfused with platelets. He was obtained an immediate CTA
which showed a wide neck ACOM aneurysm. He was brought
emergently to cerebral angiogram where he was showed to have
a ruptured wide neck ACOM aneurysm 4-5 mm, a dominant left A1
and minimal filling from the right A1. He was then admitted
to the ICU where his blood pressure was kept at less than 120
at all times. Hematology was consulted and asked to see the
patient for a thrombocytopenia in anticipation of
neurointerventional procedure for the subarachnoid hemorrhage
which they felt that the thrombocytopenia was chronic
secondary to splenic sequestration with moderate splenomegaly
and they recommended transfusing platelets as needed. The
attending from hematology felt that such patients do not
usually bleed spontaneously post surgery and it was okay to
complete the procedure with the use of heparin.
He was monitored in the ICU overnight for his first day of
admission where he was started on nimodipine and Nipride to
keep his blood pressure less than 120. His systolic goal was
100-120. He remained neurologically intact overnight in
anticipation of undergoing a clipping of his ACOM aneurysm.
On [**2168-9-27**], he underwent a clipping where he had without
problems or complaints a vent drain placed without any
difficulties. He continued to be followed by hematology for
his hepatitis C. He also had atrial fibrillation which had
been diagnosed three months prior to his hospitalization and
his rate was well controlled in the 90s. On [**2168-9-29**], his
vital signs were 98.7, blood pressure 118-130s/60s-80s, heart
rate in the 70s, atrial fibrillation, CVP was [**3-8**], ICP 4-17.
He was receiving some Nipride to keep his blood pressure up
at times. He was started with gentle fluids on that day to
keep his goal CVP of 8. He had a chest x-ray to assess for
CHF, and his CVP level was [**8-2**], systolic blood pressure was
in the range of the goal of 160. He was noted to have some
high urine output from possible cerebral salt wasting. His
sodium was 138. He had an echocardiogram which showed normal
ejection fraction, chest x-ray had no acute changes.
On [**2168-9-30**], he remained awake, alert, completely
neurologically intact. His urine input for 24 hours was
5,128, output was 10,100. He was started on one-to-one
repletion therapy with saline due to cerebral salt wasting
and a formal endocrine consult was obtained. His blood
pressure goal of 150-160 was started. Endocrine did not have
any further recommendations other than to continue with his
one-to-one repletion for urine and they followed the patient
with us. His sodiums remained in the 138 range for [**2168-9-30**].
On [**2168-10-1**], an echocardiogram showed a normal ejection
fraction but mild pulmonary hypertension and mild left
ventricular hypertrophy. On [**2168-10-1**], he was awake, alert,
and oriented times three. He was subarachnoid day five. His
EOMs were full. Visual fields were intact. His hematocrit
and platelets were stable. His drain was at 10 cm, put out
36 cc overnight. ICPs were in the 6 range. His drain was
raised at 15 and his systolic blood pressure goals were
increased from 170-180. He was also started on albumin to
increase his CVP greater than 8.
On [**2168-10-2**], he was found to be awake, alert. The face was
symmetric. He had a right drift, grips were [**4-27**]. He
continued to need one-to-one volume repletion for his urine
output. His Decadron doses were decreased. His blood
pressure parameters were kept in the 160-180 range. His
drain was raised to 20.
On [**2168-10-3**], a blood gas showed his pH at 7.44, PC02 24, and
02 of 192. He had crackles at the bases. A chest x-ray
showed pulmonary edema. He was electively intubated for a
low PAC02. He required propofol in order to maintain an
adequate CA02. On [**2168-10-3**], his C02 was 30 even with
propofol and our goal rate was 35-40. He needed significant
sedation to control his respiratory rate in order to get an
adequate PC02 level.
On [**2168-10-4**], the patient required Levophed to keep his blood
pressure goals in the 160-180 range. He was increased to
CPAP plus pressure support of 10 in order to maintain an
adequate C02 and his nimodipine was discontinued in order to
keep his blood pressure in the high range. He eventually had
to be paralyzed on cisatracurium in order to increase his
C02; however, that made his neurologic examination difficult
to assess.
On [**2168-10-4**], he was still receiving a high amount of Levophed
and Neo to maintain his blood pressure but at the same time
he was noted to be cyanotic. His extremities started to
become cyanotic on [**2168-10-3**]. On [**2168-10-4**], it continued with
cyanosis and the ICU noted abdominal distention, worsening
acidemia, rising lactate. The surgery team was asked for
resuscitation for ischemic bowel. He had an emergent CAT
scan of his head and abdomen and also for a four vessel
angiogram which showed minimal vasospasm which were in the
bilateral ICA and PCA territories. His blood pressure
parameters were now weaned down to 110. CT of the abdomen
showed some moderate free fluid, mild rectal thickening, no
pneumonitis or free air. They recommended a colonoscopy to
exclude ischemia of the bowel but they felt more likely he
was having some liver failure, hyperperfusion, or due to the
existing hepatitis C.
On [**2168-10-5**], it appeared that the patient was developing
ARDS. Also, surgery recommended starting him on Levo,
Flagyl, and vancomycin for prophylaxis. His abdomen remained
enlarged and distended. It was difficult to get a
neurological examination on him due to his sedation. His
pupils were equal and reactive to light and accommodation and
his corneal reflexes were intact on [**2168-10-5**] and CVPs were 10-
17. His ICPs were in the 11-15 range. His ventriculostomy
drain continued to work well. His sodium remained in the 147
range. His potassium was noted to be 6.0 and his creatinine
had risen to 1.7. Renal was asked to see the patient
emergently for renal shock and this was felt due to marked
increased phosphate, calcium, and lactate and that he had
dense acute tubular necrosis. They recommended to start
CVVHD/VF and to also replace 150 mEq of bicarbonate per liter
of fluid so he was to receive 300 mEq of bicarbonate per
hour. The liver service also saw the patient and felt that
he did have acute shock liver and acute renal failure. They
felt that he should start on dobutamine and avoid sedation
and that his prognosis was poor, but he was now in multiorgan
failure.
A family meeting was done on [**2168-10-5**] to explain the grim
prognosis due to multiorgan failure to the [**Known lastname 30435**]
family. He was on a bicarbonate drip. His acidosis on
[**2168-10-6**] did seem to improve. He started to receive insulin
and calcium drips and CVVHD. On [**2168-10-6**], he remained
intubated and sedated. On examination, his pupil on the
right was 6 mm, on the left 4 mm. He did not withdrawal to
pain in his extremities. His blood pressure was maintained
in the 100-110 range. He continued on CVVHD. On [**2168-10-6**],
cardiology also saw the patient due to myocardial depression.
They were recommending transitioning his Neo-Synephrine to
Levophed, checking a cortisol, to stop his digoxin, keep his
CVP 10-15 with a PA diastolic of 18-25 and a cardiac index
greater than 2.
On [**2168-10-7**], the patient remained acutely ill with shock
liver, increased acidosis, acute renal failure, multiorgan
failure. He received blood products and factor VII for his
hematocrit of 27 and his platelets of 74, INR of 1.7. He
received lactulose to help increase his bicarbonate.
On the afternoon of [**2168-10-7**], a family meeting was convened
and due to his poor prognosis and multiorgan system failure,
his family requested withdrawal of care. He passed away at
1:05 on [**2168-10-8**].
DISCHARGE DIAGNOSIS:
1. Subarachnoid hemorrhage from ACOM aneurysm.
2. Multiorgan system failure.
3. Shock liver.
4. Hepatitis C.
5. Hypertension.
6. Benign prostatic hypertrophy.
7. Acute renal failure.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 12790**]
MEDQUIST36
D: [**2169-1-5**] 15:13:49
T: [**2169-1-7**] 11:36:13
Job#: [**Job Number 30436**]
|
[
"289.59",
"427.5",
"276.1",
"276.2",
"070.54",
"V58.69",
"995.92",
"518.5",
"286.7",
"289.51",
"401.9",
"038.9",
"584.5",
"557.0",
"570",
"430",
"287.4",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"99.06",
"02.2",
"39.51",
"96.72",
"99.07",
"96.04",
"88.41",
"99.05",
"39.95",
"38.95",
"96.6",
"38.91",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
9423, 9860
|
667, 796
|
1422, 9402
|
820, 847
|
870, 1404
|
161, 500
|
522, 641
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,009
| 134,270
|
37614
|
Discharge summary
|
report
|
Admission Date: [**2190-11-18**] Discharge Date: [**2190-12-1**]
Date of Birth: [**2127-2-1**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Right sided IPH
Major Surgical or Invasive Procedure:
Right Hemicraniectomy
PEG
Trach
History of Present Illness:
63 yo RHF with PMH of Afib, HTN, on coumadin was found
somnolent and lying on floor at about 1-1.30 pm this afternoon
by
her neighbour. She was last seen at her usual state of health
around 12 noon. When her neighbour went in, she was found lying
on the floor, she was apparently talking but felt weak on Left
leg, and hence was unable to get up. Apparently there is no h/o
seizures or trauma but the fall is unwitnessed and the exact
details are not known. At OSH, head CT showed significant ICH an
Right lobar area with midline shift of about 8mm hence was refd
to [**Hospital1 18**]. She was intubated during our initial exam.
Past Medical History:
HTN, afib, ACS 3 years ago with angioplasty
Social History:
lives with husband, 1 [**Doctor Last Name 6654**] per day, smoking- [**3-9**]
packs per day for 20-30 years, quit 3 years ago.
Family History:
strokes in various family members
Physical Exam:
O: T: afeb BP: 96 / 66 HR: 120- 140 R 22 O2Sats 98
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: left 3mm sluggishly reactive, right 1mm sluggish
reactive EOMs - could not be tested , opens eyes
occasionally to commands
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: Irrg Irrg, in Afib. no m/r/g.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: somnolent and intubated, sedated, groans on
painful stimuli, follows some coomands like moving right leg.,
but does not follow commands like move your eyes.
Cranial nerves
Pupils: left 3mm sluggishly reactive, right 1mm sluggish
reactive
No facial asymmetry, gag reflex present.
Motor:
actively moving right side of her body, some movement of left
LL,
miniaml movement of left UL
Reflexes: B T Br Pa Ac
Right 1 1 1 1 -
Left 1 1 1 1 -
Toes upgoing on left side, withdrawal on right
Physical Exam on Discharge:
Opens eyes to voice
PERRL
Follows commands on R side
Withdraws L lower extremity
No movement of L upper extremity to noxious stimuli
Pertinent Results:
[**2190-11-30**] 03:16AM BLOOD WBC-10.2 RBC-2.95* Hgb-7.9* Hct-24.6*
MCV-83 MCH-26.7* MCHC-31.9 RDW-17.3* Plt Ct-317
[**2190-11-30**] 03:16AM BLOOD Plt Ct-317
[**2190-11-18**] 04:25PM BLOOD Neuts-90.6* Lymphs-5.5* Monos-3.1 Eos-0.6
Baso-0.1
[**2190-11-30**] 03:16AM BLOOD Glucose-161* UreaN-23* Creat-0.5 Na-143
K-3.6 Cl-105 HCO3-28 AnGap-14
[**2190-11-22**] 09:17AM BLOOD ALT-8 AST-17 AlkPhos-176* Amylase-20
TotBili-1.2
[**2190-11-22**] 09:17AM BLOOD Lipase-33
[**2190-11-19**] 10:17AM BLOOD CK-MB-NotDone
[**2190-11-30**] 03:16AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.2
[**2190-11-22**] 09:17AM BLOOD Triglyc-126
[**2190-11-30**] 03:36AM BLOOD Type-ART pO2-107* pCO2-42 pH-7.45
calTCO2-30 Base XS-4
[**2190-11-19**] 09:46PM BLOOD Hgb-9.9* calcHCT-30
[**2190-11-30**] 03:36AM BLOOD freeCa-1.15
Brief Hospital Course:
Ms [**Known lastname **] was admitted to the neurosurgery service directly to the
ICU her INR was corrected. She was then taken to the operating
room and went under a right sided hemicraniectomy due to mass
effect of the large frontal IPH the patient had been on
coumadin. She was monitored closely in the ICU with Q 1
neurochecks, she was started on Mannitol to reduce swelling
baseline triponin was negative for MI. The patient was extubated
[**11-23**] but had developed respiratory distress on [**11-26**] requiring
re-intubation and placement of trach and PEG. She was diagnosed
with ventilator associated pneumomia on [**11-29**] and started on
triple antibiotics. Follow up CTs showed decreasing size of
hemorrhage with continued brain herniation through craniectomy
defect. Neurologically the patient would follow commands on the
right side, she is plegic on her left side arm but follow
command on right foot. On exam on [**12-1**], patient was observed to
have left upper extremity edema, an upper extremity utrasound
was ordered to rule out DVT and was read as negative by
radiology.
Medications on Admission:
Avapro 300 mg QDay
Plavix 75 mg QDay
Nexium 40 mg QDay
HCTZ 12.5 mg
Stool softener
Lipitor 80 mg QDay
Toprol XL 100 mg QDay
Digoxin 125 mcg
Coumadin 5 mg Q & Sat, rest of the days 2.5 mg
Lorazepam 0.5 mg QDay, prn
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution [**Month/Year (2) **]: One (1)
Injection ASDIR (AS DIRECTED).
2. Bisacodyl 10 mg Suppository [**Month/Year (2) **]: One (1) Suppository Rectal
DAILY (Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1)
Injection TID (3 times a day).
4. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Acetaminophen 650 mg Suppository [**Month/Year (2) **]: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever.
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours).
8. Irbesartan 300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Qday ().
9. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
10. Propofol 10 mg/mL Emulsion [**Hospital1 **]: One (1) Intravenous TITRATE
TO (titrate to desired clinical effect (please specify)).
11. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
12. Clonidine 0.1 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times
a day).
13. Digoxin 250 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
14. LeVETiracetam 1000 mg IV BID
15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
16. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain
Please hold for oversedation or RR<8
17. Vancomycin 500 mg Recon Soln [**Hospital1 **]: Three (3) Recon Soln
Intravenous Q 12H (Every 12 Hours): Last dose [**2190-12-13**].
18. Ciprofloxacin in D5W 400 mg/200 mL Piggyback [**Month/Day/Year **]: One (1)
Intravenous Q12H (every 12 hours): Last dose [**2190-12-13**].
19. Cefepime 2 gram Recon Soln [**Month/Day/Year **]: One (1) Recon Soln Injection
Q24H (every 24 hours): Last dose [**2190-12-13**].
20. Metoprolol Tartrate 10 mg IV Q4H:PRN tachycardia
Hold SBP < 110, HR < 60
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
IPH
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You 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.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow up with Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 4 weeks with a non-contrast
head CT.
Completed by:[**2190-12-1**]
|
[
"348.5",
"518.81",
"V15.82",
"V45.82",
"401.1",
"V58.67",
"V17.1",
"414.01",
"348.4",
"997.31",
"427.31",
"041.4",
"E879.8",
"431",
"599.0",
"041.11",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"01.25",
"43.11",
"31.1",
"33.24",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6671, 6754
|
3165, 4261
|
333, 367
|
6802, 6826
|
2349, 3142
|
8236, 8380
|
1256, 1292
|
4526, 6648
|
6775, 6781
|
4287, 4503
|
6850, 8213
|
1307, 1662
|
2193, 2330
|
278, 295
|
395, 1027
|
1677, 2165
|
1049, 1094
|
1110, 1239
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,810
| 186,003
|
7255
|
Discharge summary
|
report
|
Admission Date: [**2166-1-13**] Discharge Date: [**2166-1-30**]
Service: PLASTIC
Allergies:
Procainamide
Attending:[**First Name3 (LF) 10416**]
Chief Complaint:
Recurrent ventral hernia repair
Major Surgical or Invasive Procedure:
Left tensor fascia lata/vastus lateralis free flap repair of
recurrent ventral hernia
History of Present Illness:
The patient had failed multiple mesh repairs even prior to
coming to this institution, and the quality of his fascia was so
poor that even with
component separation and mesh repair, he continues to have a
large recurrent hernia. The skin quality is so poor that there
is a large area of skin that will be devascularized with repair.
Thus, new vascularized tissue needs to be
brought into the area in hopes of definitive repair.
Past Medical History:
Coronary artery disease, s/p CABG [**2160**]
Hypercholesterolemia
Hypertension
Peripheral vascular disease
History of previous hernia repairs
Prostatic cancer, s/p TURP
Spinal stenosis with peripheral neuropathy
Bilateral total knee replacement
Social History:
Patient denies alcohol, tobacco and drugs
Family History:
Non-contributory
Physical Exam:
The patient is awake and alert, NAD
RRR, normal S1 and S2 with a 2/6 SEM
CTA b/l
Large ventral hernia with multible obvious ventral wall defects.
There is attenuation of the ventral skin, and abdominal contents
are palpable behind the wall defects.
Pertinent Results:
[**2166-1-30**] 05:01AM BLOOD WBC-7.2 RBC-3.50* Hgb-11.1* Hct-32.7*
MCV-94 MCH-31.9 MCHC-34.0 RDW-13.5 Plt Ct-438
[**2166-1-30**] 05:01AM BLOOD Neuts-69.0 Lymphs-19.3 Monos-8.8 Eos-2.6
Baso-0.3
[**2166-1-30**] 05:01AM BLOOD Plt Ct-438
[**2166-1-28**] 11:00AM BLOOD Glucose-107* UreaN-14 Creat-1.0 Na-138
K-4.3 Cl-105 HCO3-25 AnGap-12
[**2166-1-28**] 11:00AM BLOOD Albumin-2.3* Calcium-8.0* Phos-3.9 Mg-2.1
NON-CONTRAST HEAD CT: No evidence of mass effect or bleed.
PA AND LATERAL CHEST: No acute cardiopulmonary process; improved
aeration of the lungs.
Brief Hospital Course:
The patient was admitted to the hospital and taken to the
operating room on [**2166-1-13**] for a repair of ventral hernia with
lysis of adhesions, reconstruction of abdominal wall with
placement of mesh, combined left vastus lateralis and tensor
fascia lata free flap from left side to abdomen to
gastroepiploic artery and vein, and a split thickness skin graft
right thigh to left thigh measuring 12 x 25 cm for 300 square
centimeters. The patient tolerated this procedure and was taken
to the PACU follow ing surgery for stabilization. Throughout the
hospital course, it should be noted that his flap remained
viable with good pulses, checked routinely. He was noted to be
hypotensive with EKG changes consistent with LBBB, and was seen
by cardiology. An echocardiogram was obtained, and demonstraed
mild LVH, mild aortic regurgitation, and moderate mitral and
tricuspid valve regurgitation. The patient was transferred to
the ICU and extubated on POD#1. On POD#2, the patient was
transfused 2 units of PRBC's for low hematocrit of 26.6. On
POD#3, the patient's cardiac status was improved. A feeding tube
was placed, and was transferred to the floor. On POD#4, the VAC
over the skin graft was taken down. The graft was noted to be
partially intact superiorly, and a xeroform dressing was placed
over the healthy portion of the skin graft. The rest of the
wound was dressed with wet to dry gauze and changed 3 times/day.
The remainder of the hospital course from a surgical standpoint.
Attention was turned to rehabilitation. The patient was acutely
confused following surgery, and was routinely disoriented to
place and time. He was initially given nutrition through a
feeding tube, which was self-removed overnight. The patient was
seen by physical therapy and was out of bed to a chair soon
after being transferred to the floor. Following the removal of
the feeding tube, the nutrition service closely followed the
patient. Calorie counts were obtained, and it was determined
that the patient was adequately taking PO nutrition and that the
replacement of a feeding tube was not necessary. The patient's
mental status slowly improved over the course of his recovery.
The psychiatric service evaluated the patient, and further work
up failed to reveal a pathologic cause to his confusion. On
POD#17, the patient was noted to be vastly improved from a
mental status perspective. He remained afebrile with stable
vital signs. Post-operative pain was well-controlled. His
surgical wounds remained clean, and his flap remained viable. He
was discharged to skilled nursing facility in stable condition.
Medications on Admission:
Pravachol
Trental
Lexapro
Toprol
Neurontin
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
mL Injection TID (3 times a day).
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-1**]
Puffs Inhalation Q4H (every 4 hours) as needed.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) mg
Injection [**Hospital1 **] (2 times a day) as needed for acute aggitation. mg
10. Clindamycin 600 mg IV Q8H
11. Hydralazine HCl 10 mg IV Q6H:PRN
SBP > 180
12. Haloperidol 1 mg IV HS
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Recurrent ventral hernia
Discharge Condition:
Stable
Discharge Instructions:
Please return to the hospital or call Dr.[**Name (NI) 26831**] office if you
experience chills or fever greater than 101.5 degrees F. Please
return if you notice excessive redness, swelling, or tenderness
of your wounds.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] next week. Please call
[**Telephone/Fax (1) 26832**] for an appointment.
|
[
"V45.81",
"401.9",
"568.0",
"276.5",
"293.9",
"414.00",
"272.0",
"553.21",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"86.69",
"83.82",
"54.59",
"96.6",
"53.69",
"54.72",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5700, 5773
|
2020, 4624
|
252, 340
|
5842, 5850
|
1442, 1862
|
6119, 6247
|
1140, 1158
|
4717, 5677
|
5794, 5821
|
4650, 4694
|
5874, 6096
|
1173, 1423
|
181, 214
|
368, 797
|
1871, 1997
|
819, 1065
|
1081, 1124
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,943
| 149,868
|
51910
|
Discharge summary
|
report
|
Admission Date: [**2129-9-9**] Discharge Date: [**2129-9-13**]
Service: NEUROLOGY
Allergies:
Coumadin
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
slurred speech, facial droop, and weakness.
Major Surgical or Invasive Procedure:
Nasogastric tube placement
History of Present Illness:
The pt is an 83 year-old right-handed woman with a past medical
history significant for prior right mesial temporal lobe ([**2122**]),
right insular ([**2125**]), and right cerebellar stroke, HTN, DM,
hypercholesterolemia, CAD s/p CABG [**2113**], and afib recently off
coumadin for nose bleed and who is transferred from an OSH with
slurred speech, facial droop and right hand weakness. The
patient
originally presented to the [**Hospital3 1443**] hospital on
[**2129-9-6**] with slurred speech and some confusion. The differential
on admission was an ischemic stroke or complications of a UTI
noted on UA. She was placed on a heparin ggt. An initial head CT
and a subsquent MRI were negative for acute stroke per report.
The UTI was treated with levofloxacin and the patient's symptoms
seemed
to resolve when she abruptly worsened on [**2129-9-8**]. At that time
she became completely mute, developed a right facial droop, and
some fumbling vs. weakness of her right hand. A stat CT was
performed which revealed no acute bleed. Blood was noted to be
50mmhg systolic and she was transferred to the ICU. Repeat head
CT was negative per report. The patient also had an ECHO while
at the OSH which did no demonstrate any clots and an EF of 40%
mod MR, TR, and pulm HTN. Today's labs at the OSH were notable
for a bicarbonate of 17, creatinine of 1.7, WBC 14.4 and a PTT
that was above the linear range of detection. The patient was
transferred for further stroke management.
ROS
the patient is mute and unable to provide a full ROS.
Past Medical History:
- Atrial fibrillation-3 years
- [**3-/2125**] left L5 radiculopathy with L3-5 lumbar stenosis
- CAD s/p [**2113**] CABG, angioplasty of mid RCA.
- Hypertension - on ccb, bb, acei, nitrate.
- Hypercholestolinemia - not on statin b/c of muscle aches.
- Diabetes II - poorly controlled hgbA1c was 8.8 in [**2128**].
- [**2122**] right mesial temporal CVA with sxs of left sided weakness
Social History:
remote h/o of tobacco, quit years ago. no etoh/drugs. Lives in
an assisted-living facility.
Family History:
NC
Physical Exam:
Physical Exam:
Vitals: T:96.9 P:102 R:16 BP:152/74 SaO2:100% on 2L NC.
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: Irregular. nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, pale cool, difficult to
palpate, but dopplerable DP pulses.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert. Unable to relate history. Does not speak
at all. Appears to understand certain questions but not others.
For example she will close her eyes to command, but doesn't show
2 fingers or a thumb correctly. She had some difficult with left
vs. right. There was no evidence of neglect - able to track
examiner on either side of her body.
-Cranial Nerves: Olfaction not tested. PERRL 2mm and poorly
reactive to light. VF untested. There is no ptosis bilaterally.
Funduscopic exam precluded by small pupils. Normal saccades.
Right facial droop noted. Hearing intact to finger-rub
bilaterally. Palate elevates not visualized. Trapezii and SCM
bilaterally. Tongue deviates to the right.
-Motor: Patient unable to cooperate with formal strength
testing.
She has at least 4- strength in the delts and IPs bilaterally as
I was able to get her to hold each of these limbs high in the
air. No adventitious movements.
-Sensory: Appears to detect light touch in her limbs but can not
report this.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response was flexor bilaterally.
-Gait: not tested.
Pertinent Results:
Admission labs:
Notable for elevated PTT.
WBC 12.2
Bicarnonate 17
Cr 1.6
Glucose 114.
CK 56
CT HEAD W/O CONTRAST [**2129-9-9**] 2:44 PM
FINDINGS: Comparison is made to an MR of the head from [**2125-11-16**].
There are no intracranial hemorrhages.
There is a new hypodensity with loss of the [**Doctor Last Name 352**]/white matter
differentiation as well as some effacement of sulci involving
the left frontal lobe and a small portion of the left insula in
the left middle cerebral artery distribution consistent with a
new acute or subacute infarct.
Again seen is encephalomalacia of the right temporal lobe and
adjacent right insula with ex vacuo dilatation of the temporal
[**Doctor Last Name 534**] of the right lateral ventricle. Also again seen is an old
encephalomalacia of the right inferior cerebellum.
The ventricles are unchanged in size since the prior study.
The visualized orbits show post-cataract surgical changes. There
are extensive carotid siphon arterial calcifications. The
visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. No suspicious bony abnormalities are seen.
IMPRESSION:
1. New acute or subacute infarct of the left middle cerebral
artery distribution.
2. No intracranial hemorrhages.
3. Old infarcts of the right temporal lobe and right inferior
cerebellum.
ECHOCARDIOGRAM:
Conclusions:
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity is unusually small.
Overall left
ventricular systolic function is normal (LVEF 70%). There is no
ventricular septal defect. The right ventricular cavity is
dilated. Right ventricular systolic function appears depressed.
The 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. Moderate
[2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. Compared with the findings of the prior report (images
unavailable for review) of [**2123-10-15**], the left ventricular
ejection fraction is increased.
Brief Hospital Course:
The patient was initially admitted from an OSH to the Neuro ICU
at [**Hospital1 18**]. CT scan of the head confirmed an infarct in the LMCA
territory likely due to atrial fibrillation. She was continued
on a heparin drip and started on Coumadin. The INR target is
2.0-2.5. Given her recent cauterization for epistaxis on
coumadin, an ENT consult was called to place a Doboff tube. The
patient was given humidified air overnight and the tube was
placed without difficulty. She had two swallow evaluations and
it was decided that the patient should remain NPO. The speech
therapist also recommended a PEG tube but the family wanted to
wait to see if the patient's swallowing improved at rehab. The
patient's PTT goal is 50-70 until her Coumadin level is
therapeutic. She finished a 7 day course of Levofloxacin for a
UTI diagnosed on [**9-6**] at an OSH. She was seen by PT and
determined to be suitable to rehab. The patient was given a
follow up appointment to be seen in the [**Hospital 107467**] clinic as well
as the stroke clinic.
Medications on Admission:
Confirmed with son/hcp [**2129-9-9**].
COUMADIN 1MG--One tablet every day and an extra half tablet on
[**Doctor First Name **], sat, and sun.
GLUCOTROL XL 10MG--One tablet every morning
IMDUR 60MG--One every day
LOPRESSOR 50MG--One twice a day
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for angina
NORVASC 5MG--One tablet every day
OMEPRAZOLE 20MG--One every day
SENOKOT 8.6MG--2 tabs at bedtime
TIMOPTIC-XE 0.5%--One drop each eye every day
TRAZODONE 50MG--[**1-11**] tablet with dinner
TRUSOPT 2%--One drop each eye twice a day
TUMS 500MG--[**Hospital1 **]
ZESTRIL 30MG--One every morning
Discharge Medications:
1. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Insulin Lispro 100 unit/mL Solution Sig: please see attached
Subcutaneous ASDIR (AS DIRECTED): Please see attached sliding
scale.
4. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO [**Doctor First Name **], SAT, SUN ().
5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO MON, TUES, WEDS,
[**Last Name (un) **] ().
6. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal
Q1H (every hour).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: Please see attached sliding scale Intravenous ASDIR (AS
DIRECTED): Until Coumadin level between 2.0 - 3.0 .
11. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Isosorbide Mononitrate 20 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
13. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
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. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Cerebral Embolism with infarct
Discharge Condition:
The patient is essentially mute but is awake, alert, and follows
simple commands. The patient does not comply with formal
strength testing but has a right hemiparesis that was improving
at the time if discharge.
Discharge Instructions:
Please call the primary care physician or return to the
emergency room if patient experiences loss of consciousness, new
weakness, inability to eat, difficulty breathing, persistent
fever.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2129-9-19**] 1:15
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], [**Name Initial (NameIs) **].O. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2129-10-10**] 9:00
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"599.0",
"272.0",
"427.31",
"250.00",
"V12.59",
"397.0",
"416.8",
"401.9",
"424.0",
"V45.81",
"434.11"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9651, 9730
|
6478, 7526
|
261, 289
|
9804, 10019
|
4228, 4228
|
10256, 10711
|
2385, 2389
|
8190, 9628
|
9751, 9783
|
7552, 8167
|
10043, 10233
|
3342, 4209
|
2419, 2968
|
177, 223
|
317, 1850
|
4244, 6455
|
2983, 3325
|
1872, 2259
|
2275, 2369
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,930
| 187,593
|
34983
|
Discharge summary
|
report
|
Admission Date: [**2126-12-19**] Discharge Date: [**2126-12-23**]
Date of Birth: [**2054-8-29**] Sex: F
Service: MEDICINE
Allergies:
Lactose / Pollen Extracts / Acetylcysteine
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 yo F with SCC of the throat s/p layrngetctomy preseting with
respiratory distress at home. Prior to the onset of symptoms,
she was seen in the speech and voice clinic. Her prosthesis was
changed due to leaking with an indwelling advantage 10.0 mm
tracheoesophageal puncture voice prosthesis. Additionally she
had her laryngectomy tube in the stoma to hold the trachea open,
maintaining a patent airway without tracheal collapse. Her son
drove her home after her appointment and she felt well when
arriving home. However, she then received nebulizer treatments
with albuterol and acetylcysteine. After receiving her
acetylcysteine neb, the son reports the patient looked pale, and
complained of diffuse pruritus. She quickly became altered,
appearing confused and not responding appropriately to
questions. [**Name (NI) **] son brought her to her bedroom for
humidified oxygen, but patient became agitated and "itchy".
Breathing became worse, and her son removed the laryngotomy tube
to look for mucus plug, which was absent. Son reports the
patient was acutely disoriented, ripping keys off her organ
piano, then engaging in useless activities including organizing
items on her kitchen table and scribbling incoherent sentences.
By the time EMS arrived, the patient continued to be SOB and
disoriented. Per son, this is the 4th time using acetylcysteine.
Of note, the patient has recently been hospitalized for multiple
episodes of mucous plugging and shortness of breath. On [**2126-12-12**]
she had XRT that had to be aborted when she developed severe
respiratory distress and taken to [**Hospital1 3597**] ED. She had a code blue
from a mucous plug and improved once a large mucous plug had
been suctioned from her airway and she was discharged home. On
[**2126-12-13**], XRT and chemo performed and later in the day she had
near-respiratory arrest on arrival to [**Hospital1 1774**] ED. She was
transferred to [**Hospital1 18**] for further care, where CT Chest revealed
effusion with evidence of profound lung and nodal metastatic
disease. She had layrngoscope evalution of her tube, which was
cleaned and replaced. Goals of care discussion on that admission
was to stop chemoradiation and pursue hospice care. Family has
revoked hopsice care within the last week and has pursued VNA
care instead.
Upon arrival to the ED, vitals were T98.3, HR 72, BP 134/56, RR
16, 100% on 15L over stoma. Pt. was still agitated, pulling at
tubing and other surrounding objects. [**Hospital1 **] and urine cultures
were sent. Pt. received morhpine and Roxicet for neck pain, as
well as 5 mg Haldol for atgitation. Had a CXR performed which
showed a stable right sided pleural effussions. Also had a tox
screen performed which was negative.
Upon transfer to the floor vitals were T 98, HR 95, BP 127/53,
RR 15 and 100% on 15L. In the ICU she was observed overnight and
then transferred to the floor. On the floor the patient was
comfortable and back to her baselione.
Past Medical History:
- Metastatic squamous cell cancer of throat. She was originally
diagnosed in [**2121**]. She is s/p resection and radiation therapy.
Recurrence in [**2125**] and underwent resection and multiple repeat
resections including and modified radical neck dissection
9/[**2125**]. She is now known to have recurrence in the mediastinum,
trachea, and the floor of the mouth, as well as multiple
pulmonary mets from PET evaluation in [**2126-9-4**].
- GERD
- Osteoporosis
Social History:
Denies alcohol, tobacco, or illicit drug use. Lives with her
husband. At baseline, can ambulate without assist.
Family History:
Mother with lung cancer. Father with prostate cancer.
Physical Exam:
Physical Exam on arrival to the floor:
General: Elderly appearing woman in NAD.
Vitals: T 99, HR 83, BP 143/76, RR 16 O2100% on 35% blow by.
HEENT: Anicteric sclera. MMM. Poor dentition. Sublingual
leukoplakia occupying most of right sublingual space/ ventral
surface of tongue. Stoma 2cm above jugular notch, without
erythema or exudate. No mucous discharge noted.
Neck: Rest of neck supple. No cervical or supraclaviuclar LAD
noted.
Lungs: CTABL without WRR
Cardiovascular: I/VI pansytostlic murmur across precordium.
Normal S1/S2.
Abdomen: Soft. NBS. NT/ND
Extremities: Trace edema b/l. strong 2+DPP
Neurological: AOx3, CNII-XII intact. No focal deficits in
strength. Gross sensation to touch intact. No cerebellar
defects noted. Gait not assessed. MAE.
Pertinent Results:
ADMISSION LABORTORY STUDIES:
- [**2126-12-19**] 11:50PM [**Month/Day/Year 3143**] WBC-4.6 RBC-3.44* Hgb-9.6* Hct-28.6*
MCV-83 MCH-28.0 MCHC-33.7 RDW-17.1* Plt Ct-209
- [**2126-12-19**] 11:50PM [**Month/Day/Year 3143**] PT-13.0 PTT-26.6 INR(PT)-1.1
- [**2126-12-19**] 11:00PM [**Month/Day/Year 3143**] Glucose-167* UreaN-19 Creat-0.4 Na-136
K-4.4 Cl-102 HCO3-23 AnGap-15 Calcium-8.7 Phos-2.2* Mg-1.7
DISCHARGE LABORTORY STUDIES:
- [**2126-12-22**] 07:10AM [**Month/Day/Year 3143**] WBC-4.0 RBC-4.04* Hgb-11.1* Hct-34.4*
MCV-85 MCH-27.6 MCHC-32.3 RDW-16.5* Plt Ct-236
- [**2126-12-22**] 07:10AM [**Month/Day/Year 3143**] Glucose-111* UreaN-8 Creat-0.4 Na-136
K-4.0 Cl-100 HCO3-27 AnGap-13
CXR ([**2126-12-19**]): Stable examination with small-to-moderate right
pleural effusion. No definite opacity to suggest pneumonia,
though a superimposed process at the right base cannot be
entirely excluded.
Video Swallow Evaluation ([**2126-12-20**])
- ORAL PHASE: Oral phase was for the boluses given.
- PHARYNGEAL PHASE: Swallow initiation was timely without nasal
regurgitation. Propulsion of the thin and thick barium were
reduced with
significant retention. Pt was viewed in multiple positions and
the prosthetic was clearly visualized. A trace amount of barium
was seen leaking through the prosthetic which was consistent
with what was seen at the bedside. No liquid was observed
entering the trachea / airway and there was no evidence of a
fistula at any other location.
- SUMMARY: The exam today confirmed the trace amount of a leak
seen at the bedside yesterday and earlier today on exam, but
this is likely accounted for by recent placement of the TEP and
no liquid was entering the airway. It is likely the skin will
tighten up around the prosthetic over time but she is safe to
resume eating and drinking at this time. She is able to voice
adequately but we will need to ensure frequent care of her stoma
as she accumulates dried secretions quickly which will impact
her respiratory status.
Brief Hospital Course:
Hospital Course: Ms. [**Known lastname 80015**] presented with mental status changes
and respiratory distress. Based on the temporal relationship,
there was concern for a possible allergy to Mucomyst, but it is
also likely this was all from a mucus plug. Of note, there was
concern for possible tracheoesophageal fistulas in addition to
the known tract for the tracheoesophageal prosthesis. Speech and
swallow performed a bedside evaluation that revealed a small
fluid leak around the prosthesis but no other obvious fistulas.
A video swallow confirmed these findings. ENT performed a
laryngoscopy which revealed crusting of the trachea down to the
mainstem bronchi. The patient was treated with moistened
supplemental oxygen, Albuterol nebulizer treatments, frequent
stoma care and tracheal suction to remove the crusting. The
patient's symptoms including delirium resolved. Ms. [**Known lastname 80015**] will
follow-up with her oncologist this week (contact: [**Name (NI) 8214**] [**Last Name (NamePattern1) **]
NP, phone [**Telephone/Fax (1) 80016**]). She will discuss restarting her
palliative course of [**Doctor Last Name **]/Taxol.
Medications on Admission:
1. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3.ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
Disp:*2 weeks* Refills:*2*
9. acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs
Miscellaneous Q6H (every 6 hours) as needed for congestion: for
nebulization.
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: [**1-5**] PO
every four (4) hours as needed for pain.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-5**] Inhalation every four (4) hours as needed
for shortness of breath, wheeze.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Squamous cell carcinoma of the throat
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. [**Known lastname 80015**],
You were admitted after a reaction to Mucomyst nebulizer
treatments. It is unclear whether this was actually an allergic
reaction or from increased secretions and mucus. Regardless, you
can just use the albuterol nebulizer treatments as needed for
shortness of breath. We made no other changes to your
medications although you told us you are no longer taking
anastrozole. You should confirm this with your oncology team.
Followup Instructions:
Please follow-up with your oncologist and [**First Name8 (NamePattern2) 8214**] [**Last Name (NamePattern1) **] within 2
weeks. Phone [**Telephone/Fax (1) 80016**].
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82,627
| 189,323
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39843
|
Discharge summary
|
report
|
Admission Date: [**2180-11-7**] Discharge Date: [**2180-11-16**]
Date of Birth: [**2103-11-12**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Consulted by ED for "ICH"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 87 year-old woman with a history of HTN, AF with
pacer, who was found by her niece this AM on the floor of her
bathroom. She was last known well Sunday evening, when her son
(who calls every night) spoke to her by phone. He was unable to
reach her Monday evening and after failing to reach her this AM,
called his cousin to check in on her. This cousin gained entry
into her appartment with the help of the local constabulary and
found Ms. [**Known lastname **] lying on her R. side, wedged between the toilet
and bathtub. She was awake but non-verbal. She moved her L.
arm with apparent full strength, L. leg with perhaps moderately
decreased strength, and did not move her R. side. In her
niece's estimation she had been lying immobile for quite a while
-
perhaps > 24h.
Ms. [**Known lastname **] was transported via EMS to [**Hospital 8641**] Hospital. There her
CT head demonstrated a 1x3cm L. basal ganglia hemorrhage without
intraventricular or subarachnoid extension. At [**Location (un) 8641**] she was
protecting her airway and maintaining consciousness. However,
because of a hospital protocol mandating intuabation for
particular GCS scores, she was intubated, sedated, and
mediflight trasported to [**Hospital1 18**].
ROS: No known recent symptoms per family.
Past Medical History:
- AFib with pacer, on coumadin
- HTN
- Breast CA, years ago, thought to be in remission
Social History:
The patient lives alone, and is retired. She is functionally
independent and manages her own medical care and finances. She
just returned from a solo trip to West Palm beach.
Family History:
nc
Physical Exam:
<<on admission:>>
- intubated and sedated, off Propofol x 20m:
VS: HR 82 RR 14 OS 100% Riding vent, no spontaneous breaths
during ~10m eval. BP upon arrival 121/85, progressively rising
with time off propofol, 161/84 at high.
General:
Appearance: Intubated and sedated, no spontaneous activity
Skin: Bruising in the R. axilla, R. calvarium, R. flank
HEENT: Intubated. NCAT, MMM
Neck: Supple, No Thyromegaly, No LAD, No bruits
Chest: CTAB with good flow.
CVS: RRR, Nl S1/S2. No M/G/R. No JVD.
Ext: No CCE. DP 2+.
MS:
Gen: Non-responsive to voice. Responds to sternal rub only
with
prolonged stim. Withdraws to modest nailbed pressure in
bilateral toes, no asymmetry. Withdraws to strong L. nailbed
pressure, no response in R. hand. With sternal rub she
localizes
with L. arm, no response on the R
CN:
I: Not tested.
II: Unable to test visual fields. PERRL 2.5mm to 1.5mm, brisk.
No RAPD.
III,IV,VI No spontaneous eye movements, no aversive movements,
in
C-collar so can only do limited occulocephalic but that does
produce equal, slight lateral eye movement.
V: Unable to assess.
VII: R. facial weakness, upper and lower - limited strength to
eye closure, limited grimace with nasal stim.
VIII: No response to shout or clap.
IX,X: Unable to assess
[**Doctor First Name 81**]: SCM and trapezii full.
XII: Unable to assess.
Motor: Normal bulk. Increased tone in the R. hand. Does not
support limbs against gravity. Spontaneously grasps hand with
L.
hand, no response in R. Withdraws bilateral limbs at least
against gravity
Reflex:
[**Hospital1 **] Tri Bra Pat [**Doctor First Name **] Toes
C6 C7 C6 L4 S1
R 1+ 1 1+ - - up
L 2 1+ 1+ - - up
[**Last Name (un) **]: Responds to nailbed pressure in the bilateral toes, L.
hand, but not R. hand. Responds to vigorous sternal rub.
Pertinent Results:
[**2180-11-7**] 02:52PM BLOOD WBC-17.2* RBC-4.76 Hgb-15.3 Hct-45.8
MCV-96 MCH-32.3* MCHC-33.5 RDW-13.8 Plt Ct-247
[**2180-11-16**] 06:40AM BLOOD WBC-8.9 RBC-3.70* Hgb-12.0 Hct-35.7*
MCV-97 MCH-32.5* MCHC-33.6 RDW-14.4 Plt Ct-210
[**2180-11-7**] 02:52PM BLOOD Neuts-91.4* Lymphs-4.0* Monos-3.7 Eos-0.3
Baso-0.5
[**2180-11-7**] 02:52PM BLOOD PT-26.4* PTT-25.8 INR(PT)-2.6*
[**2180-11-16**] 06:40AM BLOOD PT-14.6* PTT-25.1 INR(PT)-1.3*
[**2180-11-7**] 02:52PM BLOOD Glucose-130* UreaN-26* Creat-1.2* Na-143
K-4.4 Cl-106 HCO3-23 AnGap-18
[**2180-11-16**] 06:40AM BLOOD Glucose-86 UreaN-29* Creat-0.9 Na-140
K-3.9 Cl-105 HCO3-27 AnGap-12
[**2180-11-7**] 02:52PM BLOOD CK(CPK)-5055*
[**2180-11-7**] 07:44PM BLOOD CK(CPK)-3749*
[**2180-11-7**] 07:44PM BLOOD CK(CPK)-3613*
[**2180-11-8**] 03:02AM BLOOD CK(CPK)-2535*
[**2180-11-8**] 01:24PM BLOOD CK(CPK)-[**2141**]*
[**2180-11-9**] 02:26AM BLOOD CK(CPK)-1361*
[**2180-11-14**] 08:45AM BLOOD CK(CPK)-91
[**2180-11-7**] 02:52PM BLOOD cTropnT-<0.01
[**2180-11-7**] 07:44PM BLOOD CK-MB-33* MB Indx-0.9 cTropnT-<0.01
[**2180-11-7**] 07:44PM BLOOD CK-MB-33* MB Indx-0.9 cTropnT-<0.01
[**2180-11-7**] 07:44PM BLOOD Calcium-7.9* Phos-2.9 Mg-2.0
[**2180-11-16**] 06:40AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.1
[**2180-11-14**] 04:43PM BLOOD %HbA1c-6.4* eAG-137*
[**2180-11-9**] 02:26AM BLOOD Triglyc-133 HDL-42 CHOL/HD-3.4 LDLcalc-75
OSH CT C-spine:
IMPRESSION: No acute fracture or malalignment.
NCHCT on admission: (read as hemorrhagic infarct, but more
likely was hemorrhagic transformation of ischemic infacrt)
FINDINGS: There is a 3.2 x 1.1 cm focus of parenchymal
hemorrhage within the left basal ganglia, with surrounding
edema. There is mild mass effect on the adjacent lateral
ventricle. A second focus of parenchymal hemorrhage is seen in
the left occipital lobe which approximately measures 2.2 x 1.6
cm (2:15) with associated edema in a pattern suggesting
cytotoxic edema. There are additional areas of hypodensity in
the left occipital lobe, series 2 image 18, suggestive of acute
infarct. Overall, the findings as described are stable from the
outside hospital CT. There is a large right lateral scalp
subgaleal hematoma. No acute fracture is identified. The mastoid
air cells, the imaged paranasal sinuses are clear. Secretions
are seen in the nasopharynx. An endotracheal and nasogastric
tube are in place. There is coiling of the nasogastric tube in
the oropharynx.
IMPRESSION:
1. Stable findings of left basal ganglia, and left occipital
parenchymal
hemorrhage with surrounding edema likely related to HTN and
hemorrhagic
infarction.
2. Right lateral scalp subgaleal hematoma.
3. Coiling of OGT in oropharynx. Please correlate clinically
CTA of the head and neck, [**11-8**]:
IMPRESSION:
1. Slightly increased size of the hyperdense hemorrhagic focus,
located
laterally within the left MCA infarct, without evidence of new
hemorrhagic
focus or active contrast extravasation ("spot sign") to suggest
impending
expansion.
2. Stable appearing left PCA infarct with internal hemorrhagic
conversion.
3. Left fetal PCA, which appears patent with increased distal
flow compared
to the right, possibly secondary to recruitment of flow to this
previously
ischemic territory.
4. Patent left MCA with M1 segment uniformly slightly reduced in
caliber
compared to the right but patent-appearing distal branches.
COMMENT: The overall appearance suggests embolism to the left
MCA and (fetal) PCA from a more central, perhaps cardiac source.
N.B. The cervical vessels were not included in this study. If
evaluation of the more proximal carotid and vertebral arteries
is clinically warranted, dedicated neck CTA is recommended.
ECG on admission:
Cardiology Report ECG Study Date of [**2180-11-7**] 2:50:46 PM
Atrial fibrillation. ST-T wave abnormalities are non-specific.
No previous tracing available for comparison.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 0 92 414/443 0 13 -29
Echo in ICU:
Conclusions
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses and cavity size are
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. The right
ventricular cavity is mildly dilated with borderline normal free
wall function. 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 moderately thickened. The mitral valve shows
characteristic rheumatic deformity. There is moderate thickening
of the mitral valve chordae. There is mild valvular mitral
stenosis (area 1.5-2.0cm2). Moderate (2+) mitral regurgitation
is seen. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Preserved left ventricular systolic function. Mildly
dilated right ventricle with borderline normal function. At
least moderate pulmonary hypertension. Moderate to severe
tricuspid regurgitation. Mild mitral stenosis which may be due
to rheumatic heart disease. Moderate mitral regurgitation.
Video swallow study [**11-14**]:
FINDINGS:
ORAL PHASE: Poor bolus control was demonstrated with delayed
swallowing.
Liquid barium material remained within the valleculae throughout
the oral
phase.
PHARYNGEAL PHASE: Intermittent aspiration was noted with liquid
administration. Moderate amount of penetration was also seen.
IMPRESSION:
1. Intermittent aspiration with liquids and penetration.
2. Moderate impairment during the oral phase, as demonstrated by
poor bolus control and delayed swallowing.
Brief Hospital Course:
76 yr RH WF with hx of a-fib on coumadin, htn was found down on
the floor with decreased mentation and right hemiplegia. She was
awake and arousable and followed simple commands. She had
bruises on her head, right shoulder/arm region and right
hip/lateral right upper leg. Brought to OSH. HCT showed
hypodensity and hyperdensity in left basal ganglia region. It
was first thought that she had a primrary hemorrhage. 10 mg of
Vit K was given and she was transferred to [**Hospital1 18**]. Here she
received 2 units of FFPs. Repeat imaging done. No further
increase in hemorrhage. However, evaluation of hCT by the
attending revealed that she has an ischemic stroke involving the
striatocpasular branches and some patchy lesions in the inferior
division of the MCA as well as the PCA. There was also a
hyperdense sign in the left MCA stem. Her examination in the
UNIT showed impairment in right gaze and dense right hemiparesis
with withdrawal to noxious stimuli in right arm and right foot.
She does have a right facial palsy too. Pupils are equal and
reactive. All brainstem reflexes present. She followed some
simple commands with her left hand. Multiple bruised areas on
her forehead, right shoulder/right arm, right hip. CT is most
consistent wiht an ischemic stroke with hemorrhagic
transformation. She probably has a fetal PCA which might explain
why she has a stroke in MCA and PCA at the same time. Multiple
emboli are possible as well. Hyperdense MCA stem suggests clot
in MCA stem. Her echocardiogram showed no evidence of
thrombosis. Her LDL was 75, total cholesterol was 144. Over the
next few days she became alert and would follow few simple
commands, still with global aphasia amd a dense right
hemiparesis. She was transferred to the floor. She was
re-started on coumadin on [**11-11**]. She started to take a puree
diet on [**11-15**].
Neuro: ischemic stroke involving the striatocpasular branches
and some patchy lesions in the inferior division of the MCA as
well as the PCA with hemorrhagic transformation. Re-started on
coumadin on [**11-11**]. Therapeutic INR goal [**12-22**]. No bridge is
necessary. Continue aspirin. Her LDL was 75, total cholesterol
was 144.
Card: atrial fibrillation; plan to anti-coagulate as above. HTN;
currently on lisinopril 10mg and atenolol 100mg; may titrate BP
medications. SBP should not be higher than 180; PRN hydralizine;
[**Last Name (un) **]
Pulm: no issues
Renal: no active issues
ID: no active issues
GI: currently on ground-solids/nectar-thick liq diet. Caloric
intake improved after d/c concurrent NGT feeds as anticipated.
Speech and Swallow consult service cleared the patient for d/c
on PO intake.
Proph: heparin SC until warfarin/INR therapeutic > 2.0
Medications on Admission:
Synthroid 50mg qDay
Coumadin 5/7.5 alternanting qDay
Digoxin 175 mcg qDay
Lisinopril 5mg qDay
Atenolol 100mg qDay
KCl 20mg qDay
HCTZ/CBRR 37.5/25 qDay
Calcium/Vit D
Multivitamin
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. warfarin 5 mg Tablet Sig: alternate 1.5 and 1.0 pills qod
(7.5/5.0 mg) Tablet PO DAILY (Daily).
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): For DVT-ppx. Please discontinue
this medication once INR is >2.0.
9. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis:
- Large Left-sided MCA+PCA-territory infarction (stroke) with
hemorrhagic conversion
Secondary diagnoses:
- AFib with pacer, on coumadin
- HTN
- CHF
- Breast CA, years ago, thought to be in remission
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted after you were found on the floor. You had a
stroke in two different areas of the left hemisphere of your
brain. You were in the ICU and then transferred to the floor.
After receiving food through [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube, you have been
able to eat a diet by mouth; this diet is specially formulated
to help you swallow without getting food into your lungs
(aspiration), which would cause an infection. You will need to
have close nutrition monitoring. You are being anti-coagulated
(taking a blood thinner called warfarin, aka Coumadin) because
you have atrial fibrillation and warfarin reduces your risk of a
stroke. The A/C was held initially because you had a little
bleeding into the stroke, but this was re-started to reduce the
chances of additional strokes in the future.
Followup Instructions:
1. With PCP
2. With [**Hospital 87680**] clinic: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD
Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2180-12-18**] 2:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2180-11-16**]
|
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] |
[
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13639, 13709
|
9785, 12512
|
332, 338
|
13977, 13977
|
3843, 5276
|
15027, 15377
|
1987, 1991
|
12749, 13616
|
13730, 13730
|
12539, 12726
|
14154, 15004
|
2006, 2008
|
13857, 13956
|
267, 294
|
367, 1662
|
13749, 13835
|
7524, 9762
|
13992, 14130
|
1685, 1777
|
1793, 1971
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,297
| 192,333
|
36396
|
Discharge summary
|
report
|
Admission Date: [**2177-1-20**] Discharge Date: [**2177-1-23**]
Date of Birth: [**2106-1-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Prostate Cancer, scheduled robotic assisted lap prostatectomy
EKG changes post-operatively
Major Surgical or Invasive Procedure:
ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY
Cardiac Catherization
History of Present Illness:
Mr. [**Known lastname **] is a 70-year-old mandarin-speaking male with a past
medical history of hypertension, hyperlipidemia, and T2a [**Doctor Last Name **]
8 prostate cancer s/p robotic prostatectomy under general
anesthesia by Urology on [**2177-1-20**]. There was only 10cc blood
loss during the procedure. Post-operatively in the PACU, he was
noted to be hypotensive to SBP 78-90. He also has an increasing
oxygen requirement, with SaO2 92% on 5L NC. His RN noted
ST-segment changes on telemetry and ECG was performed. He was
found to have new STE in aVR and V1 with STD V2-6, I, and aVL.
At the time, he denied chest, back, arm, or jaw pain, shortness
of breath, nausea, diaphoresis. He only notes pain in his
pelvis, likely related to his surgery. He is Mandarin speaking
only and his daughter is at his bedside assisting with
translation. Patient was started on phenylephrine in PACU and
his pressures recovered and the EKG changes resolved. He
received a full dose aspirin. During this whole episode,
patient states that he has not had any chest pain or difficulty
breathing despite being on 12L face mask and with saturations in
the low 90s.
.
His daughter, Dr. [**First Name (STitle) **] [**Known lastname **], is a cardiologist and notes that
her father had a good functional capacity prior to surgery,
including exercising daily on a treadmill at fast pace. He was
asymptomatic with exertion. He has no history of coronary artery
disease and is a lifelong non-smoker.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
On transfer from [**Hospital Unit Name 153**], vital signs BP 109/50 HR 88 O2 90% on
4LNC. He denied chest pain or any other discomfort.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension, Hyperlipidemia
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
Patellar fracutre and repair in [**2161**]
Benign thyroid nodule - removed
Social History:
Mr. [**Known lastname **] lives in [**Hospital1 392**] and [**Location (un) 5622**], lives with daughters
in both cities. He is a retired physics professor [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) 651**].
Daughter @ [**Doctor Last Name **] is cardiologist, trained at [**Hospital1 **]. Other daughter
in [**Name (NI) 86**] is a consultant for medical consulting firm.
- Tobacco: None
- Alcohol: None
- Illicits: None
Family History:
Mother died of liver cancer at 66. Sister died of lymphoma.
Family members with HTN/ HL. No family hx of heart disease; no
family deaths from MI.
Physical Exam:
Physical Exam on Admission for Urologic Surgery:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, appropriately tender along incisions
Incisions c/d/i w/out evidence hematoma, infection
Extremities w/out edema or pitting and no report of calf pain
Foley catheter in place, secured to medial thigh; urine
yellow/pink and clear
Physical Exam on Admission to Cardiac ICU:
VS: T=96.7 BP=125/62 HR=90 RR=20 O2 sat= 93 (4L)
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. Crackles
posteriorly 1/3 up b/l lung fields. Anterior ronchi.
ABDOMEN: Soft, NTND. Several abdominal port sites clean and
intact. No tenderness to palpation throughout.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Physical Exam on Discharge:
Vitals - Tm/Tc:98/97.6 HR:78-80 BP:125-130/677 RR:18 02 sat:94%
RA
In/Out:
Last 24H:[**Telephone/Fax (1) 82462**]
Last 8H: 100/900
Weight:60.6 (64.2) different scale
.
Tele: SR, no VEA
.
FS: none
.
GENERAL: 70 yo M in no acute distress, lying in bed
HEENT: no lymphadenopathy, JVP non elevated
CHEST: Decreased BS at bases with faint crackles
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, mildly tender, non-distended, BS normoactive. no
rebound/guarding, 4 incision sites D/I with no drainage. Minimal
serosang drng from JP drain.
EXT: wwp, no edema. DPs, PTs 2+.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities.
SKIN: no rash
PSYCH: alert, oriented, conversant
Pertinent Results:
Labs on Admission:
[**2177-1-20**] 08:21PM BLOOD WBC-13.9*# RBC-4.01* Hgb-13.3* Hct-39.8*
MCV-99* MCH-33.1* MCHC-33.3 RDW-13.0 Plt Ct-197
[**2177-1-21**] 03:07AM BLOOD PT-11.3 PTT-25.9 INR(PT)-1.0
[**2177-1-20**] 08:21PM BLOOD Glucose-195* UreaN-19 Creat-0.9 Na-140
K-4.2 Cl-104 HCO3-26 AnGap-14
[**2177-1-22**] 03:32AM BLOOD ALT-36 AST-96* AlkPhos-39* TotBili-0.6
[**2177-1-20**] 08:21PM BLOOD Calcium-8.3* Phos-3.9 Mg-2.2
[**2177-1-22**] 03:32AM BLOOD Albumin-3.5 Calcium-7.9* Phos-2.0* Mg-2.5
[**2177-1-21**] 03:13AM BLOOD %HbA1c-5.8 eAG-120
Cardiac Enzymes:
[**2177-1-20**] 08:21PM BLOOD CK-MB-4 cTropnT-<0.01
[**2177-1-21**] 03:07AM BLOOD CK(CPK)-893*
[**2177-1-21**] 03:07AM BLOOD CK-MB-72* MB Indx-8.1* cTropnT-0.63*
[**2177-1-21**] 10:31AM BLOOD CK(CPK)-1409*
[**2177-1-21**] 10:31AM BLOOD CK-MB-121* MB Indx-8.6* cTropnT-1.84*
[**2177-1-21**] 05:05PM BLOOD CK(CPK)-1240*
[**2177-1-21**] 05:05PM BLOOD CK-MB-80* MB Indx-6.5* cTropnT-1.78*
Imaging:
CXR [**1-20**]:
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Heart is mildly enlarged. Mediastinal vasculature is normal, and
there is no appreciable pleural effusion. Extensive and severe
perihilar pulmonary
consolidation and ground-glass opacification more peripherally.
The stomach is moderately distended with air as is the upper
esophagus. There is no pneumothorax.
TTE [**1-21**]:
The left atrium is normal in size. There is mild regional left
ventricular systolic dysfunction with septal hypokinesis. The
remaining segments contract normally (LVEF = 45%). The aortic
valve leaflets (?#) appear structurally normal with good leaflet
excursion. Mild (1+) aortic regurgitation is seen. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild aortic and mitral regurgitation. Focused emergency
study.
Cardiac Cath [**1-21**]:
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated 2 vessel coronary artery disease. The LMCA had no
angiographically apparent flow-limiting disease. The LAD had
diffuse
proximal 80% stenosis involving the origin of a large D2, also
with
diffuse 70-80% disease. The LCx had serial 60-70% stenosese in
OM1.
The RCA had no angiographically apparent flow-limiting disease.
2. Limited resting hemodyamics revealed normal systemic
arterial
pressures.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Normal systemic arterial pressures.
Carotid US series [**1-22**]:
Impression: Right ICA no stenosis.
Left ICA no stenosis.
Labs on Discharge:
[**2177-1-23**] 07:05AM BLOOD WBC-11.9* RBC-4.49* Hgb-14.5 Hct-43.7
MCV-97 MCH-32.3* MCHC-33.3 RDW-13.0 Plt Ct-207
[**2177-1-22**] 03:32AM BLOOD PT-11.5 PTT-42.7* INR(PT)-1.1
[**2177-1-23**] 07:05AM BLOOD Glucose-126* UreaN-16 Creat-0.7 Na-140
K-4.1 Cl-103 HCO3-25 AnGap-16
[**2177-1-22**] 03:32AM BLOOD ALT-36 AST-96* AlkPhos-39* TotBili-0.6
Brief Hospital Course:
Primary Reason for Hospitalization: Mr. [**Known lastname **] is a 70M with PMH
of hypertension and hyperlipidemia who underwent scheduled
robotic prostatectomy for prostate cancer and subsequent to
procedure developed hypotension and NSTEMI.
Active Diagnoses:
# NSTEMI. ST depression in lateral distribution and STE in avR
and V1 in the setting of hypotension is suggestive of demand
ischemia and underlying coronary artery disease, likely in a
left main territory. Troponins and CK-MB were cycled and also
came back elevated. Initial TTE showed mild regional LV and
septal wall-motion abnormality and LVEF 40%. Patient was started
on a heparin drip, but was not given plavix due to possible need
for CABG. He was intermittently placed on a low dose of
phenylephrine to maintain MAP>70 to prevent further ischemia
associated with hypotension. Subsequent cardiac catherization
showed The LAD had diffuse proximal 80% stenosis involving the
origin of a large D2, also with diffuse 70-80% disease. The LCx
had serial 60-70% stenosese in OM1. Subsequent TTE showed EF
50-55%, LVH, mild AR and mild MR. Heparin drip was stopped 24h
after catherization and patient was continued on ASA 325 and
atorvastatin 80. He was subsequently started on Toprol XL and
lisinoopril as his bp tolerated. He was referred to cardiac
surgery for CABG.
# Pulmonary Edema. Likely developed in the setting of NSTEMI
leading to diastolic dysfunction, which is one of the first
signs of cardiac ischemia. CXR is consistent with pulmonary
edema. In the PACU, patient required face mask to maintain O2
sats in mid-90s. In the [**Hospital Unit Name 153**], was given lasix 20mg IV, put out
500cc by transfer, but blood pressure droped to MAP 55. Was on
4L NC on transfer. Patient continued to be diuresed -2L the
next day and his electrolytes were repleted. His O2 was weaned
as tolerated.
# Hypotension. Patient was transiently hypotensive in PACU, and
again in [**Hospital Unit Name 153**] after diuresis. Could be secondary to general
anesthesia, cytokines, but should rule out infection. CXR
without evidence of pneumonia. Blood and urine cultures were
obtained as part of infectious work-up and were all no growth.
His blood pressure came back up by itself and by the time of
discharge, he had been started on Toprol XL 50mg daily and
Lisinopril 5mg daily and maintaining blood pressures within a
good range.
# Prostate cancer s/p robotic prostatectomy. Surgery proceeded
uneventfully with minimal blood loss. Patient initially
endorsed pelvic pain upon arrival to CCU, but resolved on its
own. Urology team was ok with heparin gtt. Patient developed
hematuria that was wine-colored the day prior to discharge, but
per urology team, this was ok in the setting of post-op and
recent anticoagulation. He was taken off of heparin sq for DVT
prophylaxis and put on pneumoboots. Hematuria resolved on its
own prior to discharge.
# Hyperglycemia. Initial Chemistry glucoses were 190s-230s
despite being NPO, but A1c was not elevated, so this could have
been a stress response.
Transitional Issues:
-Initial studies were obtained for cardiac surgery work-up.
Patient will follow-up on the results of these studies and
schedule a time for surgery with Dr. [**Last Name (STitle) **].
-Patient was discharged home with foley and leg bag and VNA. He
will follow-up with urology regarding further post-op
management.
-Patient will follow-up with PCP regarding LFT check in 6 months
now that he is on high dose statin.
Medications on Admission:
Bisoprolol 5mg qd
Lipitor 20mg qd
Alendronate 70mg qd
ASA 81 held since [**12-2**]
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical
TID (3 times a day).
Disp:*1 tube* Refills:*0*
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
9. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3
days: Start on [**2177-1-30**].
Disp:*6 Tablet(s)* Refills:*0*
10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed.
Disp:*25 tablets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PROSTATE CANCER s/p prostatectomy
ST elevation myocardial infarction
Hypertension
Dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had your prostate removed and had a heart attack after the
operation was complete. A cardiac catheterization showed that
you have 2 major blockages and will need surgery to bypass the
blockages. You will see Dr. [**Last Name (STitle) **] to talk about the surgery.
In the meantime, we have started you on medicine to help your
heart recover from the heart attack and to prevent chest pain.
Please take all of your medicines as prescribed. You also have
been given nitroglycerin to use if you have chest pain at home.
You can take one tablet under your tongue, wait 5 minutes, then
take another tablet if you still have chest pain. Call 911 for
any chest pain that does not go away with nitroglycerin. You can
also call Dr. [**Last Name (STitle) **] or the heartline if you are unsure what to
do for chest pain
.
Surgical instructions:
-Please also reference the additional handout provided by Dr.
[**First Name (STitle) **] with instructions and information about your surgery and
post-operative plan of care.
-Please also review the provided handout w/nursing instructions
on Foley catheter care and leg bag usage
-Resume your pre-admission/home medications except as noted.
Always call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor
-For your safety and the safety of others; PLEASE DO NOT drive,
operate dangerous machinery, or consume alcohol while taking
narcotic pain medications. Do NOT drive while Foley catheter/Leg
bag are in place.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener--it is NOT a laxative.
-You may shower 2 days after surgery, but do not tub bathe,
swim, soak, or scrub incision for 2 weeks
-Bandage strips called ??????steristrips?????? have been applied to close
the wound. Allow these bandage strips to fall off on their own
over time but please REMOVE the gauze dressing in 2 days. You
may get the steristrips wet.
-No heavy lifting for 4 weeks (no more than 10 pounds)
-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
-DO NOT have anyone else other than your Surgeon remove your
Foley for any reason.
-Wear Large Foley bag for majority of time, leg bag is only for
short-term when leaving house.
-Start prescribed antibiotic (Ciprofloxacin) 1 day prior to
scheduled Foley catheter removal and for two subsequent days
-resume your regular home diet and remember to drink plenty of
fluids to keep hydrated and to prevent constipation
[**Hospital 16237**] medical attention for fevers (temp>101.5), worsening pain,
drainage or excessive bleeding from incision, chest pain or
shortness of breath.
.
We have made the following changes to your medicines:
1. START aspirin every day to prevent another heart attack
2. START metoprolol to lower your heart rate and help your heart
recover
3. START lisinopril to lower your heart rate and help your heart
recover
4. START nitroglycerin as needed for chest pain. Please call the
Heartline or Dr. [**Last Name (STitle) **] for any chest pain at home.
5. START Ciprofloxacin, an antibiotic, 24 hours before your appt
with Dr. [**First Name (STitle) **] and continue to take for 48 hours after. This is
to prevent infection.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 10348**]
Specialty: INTERNAL MEDICINE
Location: [**Hospital3 8233**]
Address: [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 61405**]
Phone: [**Telephone/Fax (1) 10349**]
**We were inable to schedule a follow up appointment with your
Primary Care Physician. [**Name10 (NameIs) 357**] contact your PCP office at the
number above to schedule a follow up appointment. It is
recommended you see your PCP [**Last Name (NamePattern4) **] 1 week.**
Department: CARDIAC SERVICES
When: TUESDAY [**2177-3-4**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 127**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
-You will follow up in [**7-1**] days for wound check and Foley
removal. DO NOT have anyone else other than your Surgeon remove
your Foley for any reason.
-Take the prescribed antibiotic (Ciprofloxacin) 1 day prior to
scheduled Foley catheter removal and for two subsequent days
Please call to confirm your follow-up appointment AND if you
have any questions.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 4537**]
Department: [**Hospital **] CANCER CENTER
When: FRIDAY [**2177-1-31**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD [**Telephone/Fax (1) 4537**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: FRIDAY [**2177-1-31**] at 1:30 PM [**Telephone/Fax (1) 327**]
Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SURGERY
When: WEDNESDAY [**2177-2-5**] at 2:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2177-1-24**]
|
[
"E878.6",
"428.21",
"518.0",
"790.29",
"997.1",
"185",
"E849.7",
"458.29",
"410.91",
"428.0",
"401.9",
"272.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"17.42",
"37.22",
"40.29",
"60.5",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
13105, 13111
|
8364, 8609
|
395, 463
|
13250, 13250
|
5355, 5360
|
16818, 19014
|
3325, 3473
|
12013, 13082
|
13132, 13229
|
11906, 11990
|
7811, 7978
|
13401, 16795
|
3488, 4595
|
2744, 2749
|
4623, 5336
|
11463, 11880
|
5918, 7794
|
265, 357
|
7997, 8341
|
491, 2647
|
5374, 5901
|
13265, 13377
|
2780, 2856
|
8627, 11442
|
2669, 2723
|
2872, 3309
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,421
| 193,476
|
18396
|
Discharge summary
|
report
|
Admission Date: [**2109-10-11**] Discharge Date: [**2109-10-17**]
Date of Birth: [**2035-5-4**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: This 74-year-old white male
was asymptomatic and had an old MI on EKG. He had a positive
MIBI for preoperative workup in [**Month (only) 547**] for cataract surgery.
He then had a cardiac catheterization on [**2109-9-25**] which
revealed three vessel coronary artery disease. The MIBI
showed an EF of 50%. His cardiac catheterization revealed
that his LAD was severely diffusely diseased throughout.
Diagonal 1 had 100% occlusion. The left circumflex was
dominant with a 70% stenosis. OM3 had an 80% stenosis. The
RCA was nondominant with 100% proximal occlusion. He is now
admitted for CABG.
PAST MEDICAL HISTORY:
1. Status post cataract surgery in [**2109-3-19**].
2. Status post MI in the past.
3. Status post MIBI.
4. History of peripheral vascular disease and claudication.
5. History of insulin-dependent diabetes for 30 years.
6. Status post PTA of bilateral lower extremities in [**5-20**].
7. Status post CVA in 09/00 with a right carotid
endarterectomy.
8. History of hypertension.
9. History of hypercholesterolemia.
10. History of chronic renal insufficiency.
11. Status post right hip fracture two years ago.
ADMISSION MEDICATIONS:
1. Glyburide 10 mg p.o. q.d.
2. Plendil 50 mg p.o. q.d.
3. Lasix 20 mg p.o. q.d.
4. Atenolol 25 mg p.o. q.d.
5. Zestril 20 mg p.o. q.d.
6. Lipitor 20 mg two times per week.
7. NPH insulin 8 units q.p.m.
8. Aspirin 325 mg p.o. q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] has a 60 pack
year smoking history and quit 30 years ago. He does not
drink alcohol.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: Remarkable for nocturia once per night
and claudication at 50 yards bilaterally.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient is
a well-developed, elderly white male in no apparent distress.
Vital signs: Stable, afebrile. HEENT: Normocephalic,
atraumatic. The extraocular movements were intact. The
oropharynx was benign. Neck: Supple. Full range of motion.
No lymphadenopathy or thyromegaly. Carotids 2+ and equal
bilaterally without bruits. Lungs: Clear to auscultation
and percussion. Abdomen: Soft, nontender, with positive
bowel sounds. No masses or hepatosplenomegaly. Extremities:
Trace bilateral pedal edema. No clubbing or cyanosis.
Pulses were femoral 1+ bilaterally, DP trace bilaterally, PT
1+ bilaterally, and radial 2+ bilaterally.
HOSPITAL COURSE: On [**2109-10-11**], he underwent a CABG times
three with LIMA to the LAD, reverse saphenous vein graft to
OM and RCA. The cross-clamp time was 48 minutes, total
bypass time an hour and 17 minutes. He was transferred to
the CSRU in stable condition on propofol. He was extubated
and had a stable postoperative night.
On postoperative day number two, his creatinine was 2.1. He
had his chest tubes discontinued and was transferred to the
floor in stable condition. He did have rapid atrial
fibrillation and was treated with IV Lopressor and converted.
He continued to have a stable postoperative course.
On postoperative day number six, he was discharged home in
stable condition.
LABORATORY DATA ON DISCHARGE: Hematocrit 32, white count
8,300, platelets 210,000. Sodium 140, potassium 4.4,
chloride 98, C02 30, BUN 42, creatinine 2, blood sugar 170.
DISCHARGE MEDICATIONS:
1. Ecotrin 325 mg p.o. q.d.
2. Percocet one to two p.o. q. four to six hours p.r.n.
3. Colace 100 mg p.o. b.i.d.
4. Lipitor 20 mg p.o. q.d.
5. Glyburide 10 mg p.o. q.d.
6. Lopressor 100 mg p.o. b.i.d.
7. NPH insulin 8 units subcutaneously q.h.s.
FO[**Last Name (STitle) **]P: The patient will be followed by Dr. [**First Name (STitle) 4640**] in
one to two weeks and Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2109-10-17**] 01:23
T: [**2109-10-17**] 14:00
JOB#: [**Job Number 50651**]
|
[
"427.31",
"997.1",
"414.01",
"272.0",
"412",
"593.9",
"401.9",
"250.00",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
1785, 1800
|
3499, 4190
|
2615, 3319
|
1328, 1622
|
3334, 3476
|
1820, 1923
|
1938, 2597
|
788, 1305
|
1639, 1768
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,541
| 187,620
|
2076
|
Discharge summary
|
report
|
Admission Date: [**2133-3-13**] Discharge Date: [**2133-3-22**]
Date of Birth: [**2072-12-20**] Sex: M
Service: NEURO/NMED
HISTORY OF PRESENT ILLNESS: This is a 60-year-old
right-handed gentlemen with coronary artery disease and
peripheral vascular disease who was having difficulty
speaking after a left carotid endarterectomy. The patient
has had high grade bilateral carotid stenosis for at least
[**2-21**], while he was sitting in a chair, he developed sudden
onset of right arm and leg numbness, followed by right arm
and leg weakness. He had also had difficulty speaking. He
was admitted to [**Hospital3 **] and underwent a left
carotid endarterectomy on [**2-26**] and afterwards began
having a severe left-sided headache behind his left eye that
could last for hours and was constant. Never the less, he
visits to [**Hospital1 2436**] for continued headache and nausea and
vomiting. During one of his visits, he had contortion of his
right face and bilateral arm jerking and was started on
Dilantin. He recovered from that event and was again
discharged home.
On [**3-13**], he presented yet again for persistent headaches,
confusion and inability to talk. He new what he wanted to
say, but could not get the words out. He was repeating
phrases and using incorrect words. The wife reported an
incident before they went to [**Hospital1 2436**] in which he asked her
to bring him his Dilantin, but when she brought it, he said
"that is not the pills, then went to a dresser draw and
pulled out a handkerchief and said this is what he was
referring to." At [**Hospital1 2436**], he was not following commands.
Head CT showed a linear hyperintense region in the left
central temporal lobe but also other lesions in the left
posterior parietal hyperintensity spanning 10 images and
slight surrounding hypointensity and a left frontal cortical
hypointensity with a small surrounding region of
hyperintensity. There was slight increase focal effacement
on the left with hypointensity in the left corona radiata as
well. His blood pressure was 188/69 and was treated with
labetalol 40 intravenously. He was then transferred to the
[**Hospital6 256**].
PAST MEDICAL HISTORY:
1. Coronary artery disease. He has not undergone
catheterization. He does not have angina. His ejection
fraction is unknown.
2. Peripheral vascular disease.
3. Carotid disease. Patient had amaurosis fugax in [**2114**]
which lead to a bypass on the innominate artery. In [**2122**], he
was found that he had right carotid 100% occlusion and a high
grade stenosis on the left. He also has
hypercholesterolemia.
MEDICATIONS: His only medication was Dilantin when he
presented to the [**Hospital6 256**].
ALLERGIES: Iodine, unknown reaction.
SOCIAL HISTORY: He lives in [**Location 11277**] with his daughter,
children and grandchildren. He quit cigarette in [**2126**], but
then started smoking five cigars per day until his carotid
endarterectomy. He drinks about one pint of vodka. He is a
former carpenter.
PHYSICAL EXAMINATION: His blood pressure was 97/44 on
admission. Heart rate of 57. Respirations 13, saturating at
98% on room air. In general, he appeared his stated age,
lying in bed in no apparent distress. Head, eyes, ears, nose
and throat: Normocephalic, atraumatic. Sclera were white.
Oropharynx was clear without lesions. Moist mucous
membranes. Left neck with some Steri Strips and appeared to
be healing well. Neck was supple with left carotid bruit.
Lungs were clear to auscultation bilaterally. His
cardiovascular exam showed a regular rate and rhythm, distant
with a soft S1, S2, 2/6 systolic ejection murmur to the left
upper sternal borders. No gallop or rub. Abdomen showed
normal bowel sounds, soft, nontender, nondistended.
Extremities: Warm, no cyanosis, clubbing or edema. He did
have weak pedal pulses.
On neurological exam: Mental status, he was awake, alert and
cooperative. Could not follow multiple step commands.
Months of the year, days of week forward, but not backwards.
He could repeat. Object naming was impaired for low
frequency objects, said F for feather and he said flower for
cactus. He interpreted portions of a complex visual seen
appropriately. Registration was intact, [**11-20**] at five minutes,
[**12-21**] with hint, [**12-21**] with list. Began to follow a three step
command, but touched his tongue instead of his nose on finger
to nose and performed heel to shin in the air without
touching his shin. His [**Location (un) 1131**] was intact, he had difficulty
describing the meaning of words, barn, swallow, he laughed as
though the barn swallowed and then could not explain the
meaning of the sentence. On speech, he had slightly soft and
slurred speech. He was fluent with repetitions. He had
paraphasic errors. He could repeat no ifs, ands or buts. On
cranial nerve testing, he had a left ptosis. His pupils
equal, round and reactive to light.
Extraocular movements were full without nystagmus. His
visual fields were intact. Funduscopic exam revealed normal
vasculature with sharp optic discs. His palate was
symmetric. Tongue was in the midline. Neck and shoulder
shrug power were normal. Motor examination, the patient had
full strength. Bulk and tone were normal. Reflex testing
revealed symmetric reflexes throughout with an upgoing toe on
Babinski testing on the right. There was no angle clonus.
Sensory examination, pinprick, temperature, crude touch were
intact. Vibration slightly decreased in the feet.
Proprioception normal in fingers and toes. Cerebellar exam:
Finger to nose, finger to heel to chin were difficult for him
to perform but no dysmetria. Rapid alternating movements
slightly slow in the right hand. Gait was not assessed in
the unit.
LABORATORY EXAMINATION AT THE OUTSIDE HOSPITAL: Glucose of
128, BUN 21, creatinine 1.5, white blood cell count 17 with a
differential of 78% neutrophils, 15% lymphocytes.
HOSPITAL COURSE: The patient was admitted to the
Neurological Intensive Care Unit and was further examined by
the Stroke Team. It was felt that he had pronation of the
right upper extremity. He had visual spatial abnormalities
and ideomotor apraxia on the right. An MRI showed left
MCA/ACA and left MCA/PCA watershed strokes with acute and
subacute hemorrhagic conversions. It was thought that he had
extended his watershed infarcts after carotid endarterectomy
leading to a carotid hyperperfusion syndrome.
His Intensive Care Unit course was notable for labile blood
pressure requiring labetalol, other times requiring
Neo-Synephrine to achieve a blood pressure in the range of
120-150. His blood pressures from the arm were unreliable
requiring a thigh cuff and arterial line. His blood pressure
settled in this range without pressors or labetalol by [**3-18**].
It was then subsequently determined that he also had a left
ACA stroke one to two weeks prior to his operation.
Given that his blood pressures were under better control, he
was transferred to the Neurology [**Hospital1 **] Service, however, he
developed intermittent episodes of atrial flutter which might
have been old or related to underlying coronary artery
disease. He clearly could not receive anticoagulation given
the size of the bleeds in his head. He was placed on a low
dose of Lopressor and maintained a blood pressure range of
120-140. The patient was maintained on his Dilantin at 200
mg t.i.d. He had no further seizures while in house.
The patient was discharged to a rehabilitation facility. He
will follow-up with Dr. [**Last Name (STitle) 120**], his cardiologist. He will
receive outpatient Holter monitoring and also an outpatient
transthoracic echocardiogram.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSIS: Hyperperfusion syndrome, status post
left carotid endarterectomy.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg po b.i.d.
2. Dilantin 200 mg po t.i.d.
3. Prilosec 40 mg po q.d.
[**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 11278**], M.D. [**MD Number(1) 11279**]
Dictated By:[**Last Name (NamePattern1) 11280**]
MEDQUIST36
D: [**2133-3-25**] 11:00
T: [**2133-3-25**] 11:00
JOB#: [**Job Number 11281**]
|
[
"V45.81",
"272.0",
"427.32",
"780.39",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7743, 7752
|
7864, 8233
|
7774, 7841
|
5976, 7721
|
3057, 3875
|
3895, 5958
|
168, 2185
|
2207, 2760
|
2777, 3034
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,673
| 164,903
|
2823
|
Discharge summary
|
report
|
Admission Date: [**2120-11-13**] Discharge Date: [**2120-11-21**]
Date of Birth: [**2043-11-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
left upper lobe cancer
Major Surgical or Invasive Procedure:
Bronch, Left VATS, LN disection, Left Upper lobectomy sparing
lingula(bisegmentectomy) Leak of PA staple line controlled w/
TeSeal
History of Present Illness:
Ms. [**Known lastname 13784**] is a 76-year-old
woman with a left upper lobe nodule which was confirmed by CT
biopsy to be a likely squamous cell carcinoma. She now
presents for resection.
Past Medical History:
Left bundle branch, emphysema, h/o CVA 4 years ago-resultant
diplopia, PVD, unequal UE bp by cuff by 50 points.
Social History:
lives alone-has supportive daughter
Physical Exam:
general: Thin but well appearing 76 yr old female in NAD.
HEENT: unremarkable
chest: clear bilat.
COR: RRR S1, S2
abd: soft, NT, ND, +BS.
extrem: no C/C/E. 50 point discrepancy in BP in right and left
upper extremity.
neuro: A+Ox3 no focal deficits.
Pertinent Results:
CXR [**2120-11-20**]:
IMPRESSION: Persistent right apical hydropneumothorax with chest
tube in place. Slight increase in amount of fluid compared to
recent study.
CXR [**2120-11-21**]: unchanged- except [**Doctor Last Name **] d/c'd.
Brief Hospital Course:
pt taken to the OR [**2120-11-13**] for VATS thoracic lymph node
dissection, VATS lingula
sparing left upper lobectomy, flexible bronchoscopy.
Refer to operatve note for details of the case.
[**11-13**] post op anterior lead ST elevation -ruled out for MI.
[**11-14**]: rapid A-fib-treated w/ IV lopressor w/ conversion to NSR.
Decreased mental status was noted which prompted a head CT
which was negative. After acute pathology was ruled out mental
status changes were then attibuted to pain medication. Mental
status returned to baseline.
[**11-15**]: CXR revealed left lower lobe collapse. Due to
restrictions regarding CPT d/t intra-op PA disruption pt was
Bronch'd to clear secretions. CX neg
[**11-17**]: Bronch'd- severe edema (LUL, lingula), minimal
secretions.
chest tube placed to water seal w/ stable apical hydroPTX.
[**11-19**] Posterior pleural [**Doctor Last Name **] d/c'd w/o incident. Remaining
pleural [**Doctor Last Name **] kept to water seal.
[**11-20**] [**Doctor Last Name 406**] drain remained to water seal. desat to 84% on room
air w/ ambulation. O2 sat high90's on 2l NP.
[**11-21**] remaining [**Doctor Last Name **] drain d/c'd. CXR unchanged-persistant
effusion.
Medications on Admission:
Aggrenox, Lipitor, Phosphomax
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR
Sig: One (1) Cap PO BID (2 times a day).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 doses.
7. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Left bundle branch, emphysema, h/o CVA 4 years ago-resultant
diplopia, PVD, unequal UE bp by cuff pressure by 50 points..
Discharge Condition:
deconditioned . 02 dependent w/ ambulation.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you develop chest
pain shortness of breath, productive cough, fever, chills,
redness or drainage from your chest incisions.
You may shower on saturday. After showering, remove your chest
tube dressing and cover with a clean bandaid daily until healed.
No tub baths or swimming for 3 weeks.
Take medications as directed.
Followup Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] for a follow up
appointment.
Completed by:[**2120-11-21**]
|
[
"998.2",
"368.2",
"518.0",
"998.11",
"427.31",
"492.8",
"438.7",
"443.9",
"426.3",
"162.3",
"E878.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"32.3",
"33.24",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
3424, 3501
|
1430, 2627
|
347, 480
|
3667, 3713
|
1171, 1407
|
4148, 4273
|
2708, 3401
|
3522, 3646
|
2653, 2685
|
3737, 4125
|
901, 1152
|
285, 309
|
508, 698
|
720, 833
|
849, 886
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,882
| 172,287
|
3386
|
Discharge summary
|
report
|
Admission Date: [**2182-7-5**] Discharge Date: [**2182-7-9**]
Date of Birth: [**2110-6-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillamine / Ampicillin / Penicillins / Spironolactone
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Dyspnea on exertion, pain in calf
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 72-year-old man who complains of [**1-3**] weeks of
dyspnea on exertion, as well as swelling and soreness of his
left calf for approximately one week. He went to his PCP, [**Name10 (NameIs) 1023**]
referred him here to rule out DVT. He also notes some mild lower
abdominal cramping that has been intermittent for approximately
three weeks and that has since resolved, and some nonbloody
diarrhea. The patient has never had any previous DVTs or PEs. He
denies fever, chills, chest pain, pleuritic pain, nausea,
vomiting, hematochezia, melena. The patient deneis any long time
spent immobile, any recent flights.
.
In the ED, initial vital signs were 92 154/72 17 98% RA. The
patient's LENIs demonstrated a significant DVT. The CTA showed a
saddle pulmonary embolism. Though he has been hemodynamically
stable in the Emergency Department, the CTA suggested right
heart strain and atrial enlargement. Because of concern of heart
failure secondary to his saddle PE, the patient was admitted to
the ICU.
.
On the floor, the patient was pleasant, in no acute distress. He
was having continued pain in his left leg and was still
experiencing dyspnea on exertion. He denies any worsening of his
symptoms since his arrival at the hospital.
Past Medical History:
type 2 diabetes
hyperlipidemia
peripheral neuropathy
history of SVT
sleep apnea on CPAP
osteoarthritis of the spine and feet
history of colonic adenoma
obesity
gastroesophageal reflux
hypertension
gout
essential tremor
missing digits s/p snowblower accident
Social History:
He has remote history of prior tobacco use over 30 years ago.
He is a rare and moderate user of alcohol, having perhaps two
drinks over the course of the weekend consisting of red wine.
He is married and has three children and four
grandchildren. They are all healthy.
Family History:
The patient's brother and sister both have Factor V Leiden, and
he suspects his father, who had a history of clotting events,
also did. His 76-year-old older brother has type 2 diabetes. He
lost a sister to smoking-related lung disease last year.
Physical Exam:
Admission:
Vitals: T: 96.4 BP: 156/71 P: 94 R: 16 O2: 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mucous membranes moist, oropharynx
clear and without exudate
Neck: Supple, JVP difficult to appreciate due to body habitus,
no lymphadenopathy plapated
Lungs: Clear to auscultation bilaterally, diffuse wheezes
CV: S1, S2, no murmurs auscultated
Abdomen: Soft, non-tender, bowel sounds positive
GU: No foley
Ext: Warm, well perfused, 2+ pulses in both feet, left calf firm
and warm to touch. Negative [**Last Name (un) 5813**] sign on left and not tender
to palpation.
Pertinent Results:
[**2182-7-5**] 06:20PM WBC-9.7# RBC-4.36* HGB-13.7* HCT-39.7* MCV-91
MCH-31.5 MCHC-34.5 RDW-13.9
[**2182-7-5**] 06:20PM NEUTS-67.5 LYMPHS-22.6 MONOS-6.0 EOS-3.1
BASOS-0.8
[**2182-7-5**] 06:20PM PLT COUNT-219
[**2182-7-5**] 06:20PM cTropnT-<0.01
[**2182-7-5**] 06:20PM GLUCOSE-93 UREA N-22* CREAT-1.1 SODIUM-141
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-17
[**2182-7-5**] 06:51PM PT-12.3 PTT-27.9 INR(PT)-1.0
.
LENIs: Deep venous thrombus involving the left superficial
femoral vein extending to the popliteal. No DVT on the right.
.
CTA: IMPRESSION: Extensive pulmonary embolism with a saddle
emboli. Possible mild right heart strain
Brief Hospital Course:
The patient is a 72-year-old man with a family history of
clotting disorders presenting with known DVT and saddle
pulmonary embolism.
.
# PE/DVT: The patient had a proven saddle embolus on CTA, likely
migrated from the patient's lower left leg, which demonstrated a
DVT. He was started on a heparin drip and transferred to the
ICU. He did well in the ICU and had no hemodynamic instability.
He was bridged to warfarin. On discharge, he will continue
lovenox 1 mg/kg [**Hospital1 **] with coumadin. He will follow-up with PCP
and coumadin clinic for titration. He was provided with patient
education handout on coumadin and frequent medication/diet
interactions. Hematology/oncology was consulted who agreed with
above plan (goal INR [**1-3**], bridge patient to warfarin with
Lovenox 150mg SC q12h, follow-up in [**Hospital3 **]
follow-up for warfarin management). Of note, patient will
follow-up with Dr. [**Last Name (STitle) 15672**] at [**Hospital1 2025**] ([**Telephone/Fax (1) 15673**]) in [**1-3**] months for
discussion of duration of therapy and need for further testing.
He will require at minimum 3-6 months of therapy, and possibly,
life-long therapy. Also of note he has a family history of
factor V, and is in fact heterozygous himself which may be the
etiology.
.
# DVT: The patient has been symptomatic for at least one week
with calf pain and had an extensive clot on the left extending
from the superficial femoral to the popliteal vein. He was
placed on a heparin drip and bridged to warfarin as above.
.
# Sleep apnea: The patient was on CPAP at night throughout his
stay.
.
# Type 2 diabetes: His sugars were controlled on an insulin
sliding scale. His metformin was held in the event that he
needed further imaging. He will continue his oral agents for
diabetes on discharge.
.
# Hypertension: Patient has home regimen of epleronone and
valsartan. These were continued on discharge.
.
# History of possible tachyarrhythmia: continued on digoxin
throughout his stay.
.
# GERD: He continued his home regimen of omeprazole.
.
# Transitional Issues:
- patient to follow-up with [**Hospital3 **] for INR
monitoring
- patient to follow-up with Dr. [**Last Name (STitle) 15672**] at [**Hospital1 2025**] ([**Telephone/Fax (1) 15673**]) in
[**1-3**] months for discussion of duration of therapy and need for
further testing. He will require at minimum 3-6 months of
therapy, and possibly, life-long anticoagulation therapy.
Medications on Admission:
(per OMR)
atorvastatin [Lipitor] 10 mg Tablet
colchicine [Colcrys] 0.6 mg Tablet 1 tab po qday for gout
digoxin 125 mcg Tablet 1 Tablet(s) by mouth once a day
eplerenone 50 mg Tablet 1 Tablet(s) by mouth once a day for htn
Tricor 48 mg Tablet 1 Tablet(s) by mouth once a day
fluticasone 50 mcg Spray, Suspension 1 spray nasal twice a day
glipizide 5 mg Tablet 1 Tablet po qday
metformin 1,000 mg Tablet 1 Tablet(s) by mouth twice a day
omeprazole 20 mg Capsule, Delayed Release 1 po qday
tadalafil 5 mg Tablet [**12-2**] to 1 Tablet(s) by mouth once a day
triamcinolone acetonide 0.1 % Cream prn for pruritus
valsartan 320 mg Tablet 1 po qday
Asprin 81 mg Tablet, Delayed Release (E.C.) 1 po qday
fish oil-fat acid comb.8-hb137 1,200 mg (400 mg-400 mg-400 mg)
Discharge Medications:
1. Lovenox 150 mg/mL Syringe Sig: One [**Age over 90 1230**]y (150) mg
Subcutaneous twice a day.
Disp:*20 syringes* Refills:*0*
2. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. eplerenone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
10. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day.
11. fluticasone 50 mcg/Actuation Disk with Device Sig: One (1)
spray Inhalation twice a day.
12. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. tadalafil 5 mg Tablet Sig: One (1) Tablet PO once a day.
15. fish oil-fat acid comb.8-hb137 1,200 mg Capsule Sig: One (1)
Capsule PO once a day.
16. triamcinolone acetonide 0.1 % Cream Sig: small amount
Topical twice a day as needed for pruritis.
17. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Pulmonary Embolus, Deep Venous Thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 15674**],
It was a pleasure taking care of you at the [**Hospital1 771**].
.
You were admitted to the hospital on [**2182-7-5**] for a
pulmonary embolus, or clot in the arteries of your lungs, and
deep venous thrombosis in your left leg. Both of these findings
were confirmed by imaging and thus you were subsequently
admitted to the Medical Intensive Care Unit for monitoring and
management. Throughout this hospitalization, you remained
stable as your heart rate, heart rhythm and blood pressure were
closely monitored and were always within normal limits.
.
To prevent the formation of further clots, you were started on
intravenous unfractionated heparin in the Intensive Care Unit.
You were kept on this intravenous infusion and were also started
on Coumadin on [**2182-7-8**]. Hematology was consulted to see
you on [**2182-7-9**] for management of your anti-coagulation
given your documented Factor V Leiden mutation and the
unprovoked nature of your clot, and remarked that it was safe to
transition you from unfractionated heparin to low molecular
weight heparin (Lovenox). You underwent Lovenox teaching in the
hospital and were successfully cleared by your nurse. Your
oxygen saturation while walking was within normal limits and
thus we felt that it was safe to discharge you back home.
.
Upon your discharge from the hospital, you will follow-up with
the [**Hospital 2786**] clinic who should call you for intake
tomorrow and follow your Coumadin and clotting levels (INR).
You will also follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Friday
[**7-12**] at 9:40 AM. Finally, within 3 months you should see
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15672**] at [**Hospital6 1129**] for management
of your Coumadin and overall anti-coagulation issues, who should
receive all of the documentation in relation to this hospital
admission.
.
Finally, your blood count was slightly lower than admission. We
advise a repeat hematocrit to be checked by Dr. [**Last Name (STitle) 2483**] at your
upcoming appointment, [**7-12**].
.
We also made the following MEDICATION CHANGES:
- STARTED Coumadin 5 MG daily. You are also being given a
prescription for 2 MG tablets, as advised by [**Hospital 3052**], to allow for a variety of dosing options in the future.
- STARTED Lovenox, 150 MG twice a day, which you should take
until the coagulation clinic tells you to stop
.
You should otherwise continue your medications as before.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2182-7-12**] at 9:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15675**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Finally, within 3 months you should see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15672**] at
[**Hospital6 1129**] for management of your Coumadin
and overall anti-coagulation issues, who should receive all of
the documentation in relation to this hospital admission.
Completed by:[**2182-7-9**]
|
[
"286.3",
"274.9",
"401.1",
"453.41",
"415.19",
"250.00",
"272.4",
"333.1",
"530.81",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8435, 8441
|
3784, 5839
|
351, 357
|
8546, 8546
|
3105, 3761
|
11246, 11872
|
2221, 2471
|
7047, 8412
|
8462, 8462
|
6260, 7024
|
8697, 10854
|
2486, 3086
|
10874, 11223
|
277, 313
|
385, 1635
|
8481, 8525
|
8561, 8673
|
5862, 6234
|
1657, 1917
|
1933, 2205
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,494
| 130,078
|
5141
|
Discharge summary
|
report
|
Admission Date: [**2158-12-20**] Discharge Date: [**2158-12-23**]
Date of Birth: [**2103-6-1**] Sex: F
Service: [**Last Name (un) **]
REASON FOR ADMISSION: The patient was sent to the emergency
room with complaints of abdominal pain, decreased colostomy
output x 24 hours and increased abdominal pain. Denied
vomiting, fevers or chills. She was seen at an outside
hospital, and reportedly had a small-bowel obstruction.
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
female transferred to the ED from outside hospital, [**Hospital6 3622**], with question small-bowel obstruction. Per
report, she has had increasing abdominal pain coinciding with
decreased ostomy output over the past 24 hours. Per her
husband, she had no vomiting, fevers or chills.
PAST MEDICAL HISTORY: Significant for recurrent fungemia;
Klebsiella pneumonia; VRE UTI; mesenteric ischemia;
respiratory failure; end-stage renal disease, on hemodialysis
since [**2158-8-25**], the patient was actually due for
hemodialysis on the day she presented to the ED; breast CA;
status post chemo and radiation therapy; peripheral vascular
disease; CAD; status post MI x 2; hypercholesterolemia;
hypertension; DM; chronic anemia; gout; depression.
PAST SURGICAL HISTORY: Extended right colectomy with
ileostomy in [**2158-4-24**], renal transplant in [**2143**],
transplant nephrectomy in [**2158-10-25**], tracheostomy in
[**2158-4-24**], breast lumpectomy, left BKA, right fem-[**Doctor Last Name **] and
popliteal-to-dorsalis pedis.
PHYSICAL EXAMINATION: Temperature 98.6, heart rate 101, BP
107/53, 93% on room air. The patient was awake, in moderate
distress, with regular rhythm and tachycardia. Lungs were
clear bilaterally with tachypnea. Abdomen was firm,
distended, tympanitic, and diffusely tender to palpation; but
no apparent peritoneal signs. No masses or hernias. Ostomy
appeared pink. There was brown fluid in the ostomy bag
without air. Warm extremities.
LABORATORIES ON ADMISSION: White count 14, hematocrit 32.1,
platelet count 115. Sodium 137, potassium 5.6, chloride 107,
CO2 of 21, BUN 32, creatinine 2, glucose 102, potassium was
3.8 after repletion. Lactate was 3.7. INR was 1.6 in the
ED.
HOSPITAL COURSE: An NG tube was placed at the outside
hospital. An admission, a chest x-ray demonstrated bilateral
large pleural effusions and CHF. A KUB demonstrated mildly
dilated loops of small bowel, likely representing early or
partial obstruction versus ileus with a moderate right
pleural effusion. An abdominal CT with and without contrast
was done. This demonstrated bowel ischemia with pneumatosis
of a loop of small bowel in the right lower quadrant. The
assessment of the SMA was severely limited due to heavy
calcification and the presence or absence of clot in the
superior mesenteric artery, which could not be evaluated.
There was generalized bowel dilatation consistent with ileus.
The evaluation of the gallbladder was limited due to
artifact. Increased bilateral pleural effusions with
bilateral lower lobe collapse was noted, increased from prior
study with mild edema. Endotracheal tube was terminating at
the level of thoracic inlet with possible
tracheobroncomalacia, and atrophic kidneys were noted.
A transplant surgical consult was obtained. The patient was
seen by Dr. [**First Name (STitle) **] [**Name (STitle) **]. The patient was taken to the OR
for urgent laparotomy. She underwent resection of the
ischemic portion of the small bowel under general anesthesia
with minimal EBL. Dr. [**First Name (STitle) **] [**Name (STitle) **], assisted by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 21082**], performed the surgery. Please see operative
report for further details. The abdomen was left open and
was covered with towels and Ioban. The patient was
transferred to the ICU after the procedure. A nephrology
consult was obtained. The patient was intubated in the
surgical intensive care unit, on a fentanyl drip and a
Levophed drip. A heparin drip was also instituted per
vascular for mesenteric ischemia. She was transfused with a
unit of packed red blood cells, and CV VHD was initiated.
On postop day #1, the patient still required pressure support
with multiple fluid boluses for a low blood pressure. The
patient remained on ventilator. She was taken back to the OR
on postop day #1 by Dr. [**First Name (STitle) **] [**Name (STitle) **] for exploratory
laparotomy with small-bowel resection for ischemic bowel. On
the previous day she had 60 cm of gangrenous distal jejunum,
which was resected. The remaining distal bowel looked dusky.
She was brought back for a second look. Please see operative
report for details. It was felt that the patient either had
emboli or low-flow situation. Vascular surgery was
consulted. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was consulted, and the
patient was scheduled for an angiogram. She continued to
receive aggressive resuscitation. It was noted that the
superior mesenteric artery was palpable with a strong
Doppler. The patient continued on CV VHD. Systolic blood
pressures remained in the 90s on Levophed. She received
ultrafiltration, IV antibiotics including vancomycin,
meropenem, Flagyl and fluconazole maintained. Blood cultures
were negative. A swab of the abdomen on [**5-20**] demonstrated
Enterococcus sensitive to vancomycin, resistant to ampicillin
and penicillin. Repeat blood culture on the 28th was
negative.
On [**12-22**], the patient presented for her third
laparotomy for ischemic bowel. Prior to this, vascular
surgery performed an angiogram with stenting of the proximal
superior mesenteric artery stenosis. The patient underwent
reexploration of the abdomen with creation of an ileostomy
and closure of the abdomen for ischemic bowel. [**Month (only) **] was
again Dr. [**First Name (STitle) **] [**Name (STitle) **], assisted by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21082**] and
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Intraop findings demonstrated the
remaining 150 cm of proximal small bowel was pink and viable
upon exploration. The patient returned to the surgical
intensive care unit. While in the surgical intensive care
unit, she remained intubated. CV VHD was reinstituted.
Systolic blood pressure remained in the 110s on pressors.
She remained on a propofol and fentanyl drip. On postop days
#2, 1 and 0, the patient remained sedated. The patient was
in a sinus rhythm with sinus tachycardia with PVCs and PACs.
The patient went into rapid AFib with a rate up to 128.
Systolic BP dropped down to 88 to 94 with a MAP in the low
50s. Levophed was titrated back to 0.3, and a STAT EKG was
done. The patient was noted to be in AFib with a rapid
ventricular response. She was given 25 grams of albumin with
no response. Cardiology was consulted, and the patient was
started on an amiodarone drip. The patient converted back to
a normal sinus rhythm with PACs and PVCs. She continued on a
calcium gluconate drip and potassium drip, per CRRT protocol.
The patient was noted be hypothermic with a temperature of
35.1. A bear-hugger was placed on with a temperature up to
36. She remained on IV heparin. The patient's lactate was
2.3. The patient remained on A/C ventilatory support.
Respiratory rate was down from 20 to 16. ABG demonstrated
moderately severe partially compensated metabolic acidosis
with good oxygenation.
The patient coded in the OR on [**12-22**]. She remained on
Levophed and amiodarone. Systolic dropped down to the 40s.
She reacted to several chest compressions. In the OR, the
patient had loss of ectopy. She was given an amiodarone
drip. Her abdomen was closed, and the ileostomy was
completed. On [**12-23**] - postop day #[**1-25**] - the patient
remained on meropenem, Flagyl, fluconazole and vancomycin.
Blood pressure continued to run on the low side, 97/48 to
113/54, with a heart rate of 117, respiratory rate of 22.
She was on assist control. She reverted to sinus rhythm.
Digoxin was started.
On [**2158-12-23**], the patient's systolic blood pressure
dropped down into the 70s despite pressure support. Her
stoma appeared dusky, and the patient was evaluated by Dr.
[**First Name (STitle) **]. After discussion with the patient's husband and
family, they decided to remove life support. The patient
expired on [**2158-12-23**].
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2159-1-11**] 17:48:52
T: [**2159-1-11**] 19:52:59
Job#: [**Job Number 21083**]
|
[
"V44.2",
"V49.75",
"272.0",
"V10.3",
"557.0",
"458.9",
"250.41",
"585.6",
"403.91",
"412",
"568.0",
"274.9",
"567.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.23",
"45.62",
"00.40",
"39.50",
"00.45",
"39.90",
"99.04",
"54.59",
"39.95",
"46.51",
"38.93",
"99.05",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
2248, 8688
|
1272, 1538
|
1561, 1996
|
474, 789
|
2011, 2230
|
812, 1248
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,198
| 193,360
|
38273
|
Discharge summary
|
report
|
Admission Date: [**2192-6-5**] Discharge Date: [**2192-6-21**]
Date of Birth: [**2120-10-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2192-6-7**]
Mitral valve repair with a 28-mm annuloplasty CG Future
ring & Coronary artery bypass grafting x 1 with reverse
saphenous vein graft to the posterior descending artery
Exploratory laparoscopy
History of Present Illness:
Mr. [**Known lastname 1005**] is a 71 year old male with a complaint of
shortness of breath with exertion and was followed by his
cardiology and primary care physician. [**Name10 (NameIs) **] was admitted for
"heart problems" and underwent cardiac catheterization showing a
total right coronary occlusion and left ventricular function 40%
with severe mitral valve insufficiency. He was discharged home
with plan to follow up with cardiologist. For the past week he
has been feeling more short of breath and not feeling great. He
started to feel acutely short of breath, not resolved with
inhalers and presented to the Emergency Department at an outside
hospital. He was transferred to [**Hospital1 1170**] for surgical evaluation.
Past Medical History:
Coronary artery disease
Chronic obstructive pulmonary disease
Hypertension
Rheumatic mitral valve insufficiency
Depression
Hypercholesterolemia
Cerevascular accident
Myocardial infarction
Atrial fibrillation
Degenerative joint disease
s/p Left inguinal hernia repair
s/p thoracic surgery in past due to gun shot wound
s/p right knee surgery
Social History:
Lives with: alone
Tobacco: currently smoking [**12-17**] cigarettes daily; 80-120 pky
ETOH: occassional
Family History:
non-contributory
Physical Exam:
Admission:
Pulse:82 Resp: 14 O2 sat: 97 on RA
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs scattered rhonchi, crackles at bases
Heart: RRR [] Irregular [x] Murmur 2/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel
sounds+ [x]
Extremities: Warm [x], well-perfused [x] Edema-none
Varicosities: None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
HEPARIN DEPENDENT ANTIBODIES NEGATIVE
[**2192-6-21**] 05:52AM BLOOD WBC-14.6* RBC-3.36* Hgb-9.6* Hct-30.4*
MCV-91 MCH-28.7 MCHC-31.7 RDW-16.9* Plt Ct-502*
[**2192-6-20**] 06:15AM BLOOD WBC-17.2* RBC-3.26* Hgb-9.7* Hct-29.7*
MCV-91 MCH-29.8 MCHC-32.8 RDW-16.9* Plt Ct-420
[**2192-6-21**] 05:52AM BLOOD PT-29.4* INR(PT)-2.9*
[**2192-6-20**] 06:15AM BLOOD PT-23.2* INR(PT)-2.2*
[**2192-6-19**] 01:59AM BLOOD PT-24.3* PTT-36.6* INR(PT)-2.3*
[**2192-6-18**] 07:06PM BLOOD PT-25.2* PTT-31.6 INR(PT)-2.4*
[**2192-6-17**] 08:30PM BLOOD PT-28.8* INR(PT)-2.8*
[**2192-6-16**] 09:00AM BLOOD PT-15.5* PTT-25.5 INR(PT)-1.4*
[**2192-6-20**] 06:15AM BLOOD Glucose-83 UreaN-19 Creat-0.8 Na-137
K-4.1 Cl-104 HCO3-23 AnGap-14
[**2192-6-19**] 01:59AM BLOOD Glucose-92 UreaN-23* Creat-0.7 Na-137
K-4.4 Cl-105 HCO3-24 AnGap-12
[**2192-6-13**] 04:05AM BLOOD Glucose-129* UreaN-31* Creat-1.0 Na-137
K-4.2 Cl-102 HCO3-26 AnGap-13
Brief Hospital Course:
He underwent cardiac catheterization on [**6-6**], was seen by
cardiac surgery and had theusual preoperative workup including
PFT's and dental clearance.
On [**6-7**] he was brought to the Operating Room where mitral valve
repair with a 28-mm annuloplasty CG Future ring and coronary
artery bypass grafting x 1 with reverse saphenous vein graft to
the posterior descending artery were performed. He tolerated the
operation well and was transferred to the cardiac surgery ICU in
stable condition. He was stable in the immediate post-operative
period, anesthesia was reversed and he woke neurologically
intact and was extubated. He continued to do well and was
transferred to the cardiac surgery stepdown floor on POD2. All
tubes lines and drains were removed per cardiac surgery
protocol.
On POD3 his lab work revealed an elevated Creatinine and
platelet count down to 34K. All nephrotoxic meds were stopped
and urine electrolytes were checked and his creatinine
gradually returned to [**Location 213**]. A HIT screen was checked and was
negative. Over the next several days he had increasing abdominal
distention with tenderness and nausea, LFTs/amylase and lipase
were checked and found to be elevated as was the WBC. He was
made NPO, an Abdominal CT was done, General Surgery was
consulted. On [**6-14**] he returned to the Operating Room with Dr
[**First Name (STitle) **] for an exploratory laparoscopy that was essentially
negative. His abdominal exam gradually improved and over several
days his diet was advanced. All lab values trended back toward
normal. The remainder of his hospital stay was uneventful. His
activity was advanced with the assistance of Physical Therapy
and nursing staff.
Coumadin was resumed for his chronic atrial fibrillation. he was
tolerating a heart healthy diet at discharge and his exam was
benign. Diuretics were continued after discharge as he remained
8kgs above his preoperative weight.
On POD 14 he was discharged home with visiting nurses. Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 66039**]) will follow his INR and adjust Coumadin
dosing upon discharge.
Medications on Admission:
Medications at home:
Spiriva 18 micrograms inhaled daily
Advair 100/50 micrograms one puff twice a day
Norvasc 10 mg daily
Coumadin 2.5 mg daily-not compliant per records
Toprol XL 200 mg once a day
Enalapril 20 mg daily
Lipitor 80 mg daily
Aspirin 81 mg daily
Lasix 20 mg daily
Medications on transfer:
albuterol nebs as needed
duoneb three times per day
norvasc 10mg daily
aspirin 81mg daily
atorvastatin 80mg daily
enoxaparin 60mg daily
flovent 1 puff twice per day
lasix 20mg IV daily
lisinopril 20mg daily
toprolol xl 200mg daily
nicotine patch 14mg daily
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
3. Fluticasone-Salmeterol 100-50 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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q 3-4 hrs as
needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*2*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
8. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal
QID (4 times a day).
Disp:*qs 2* Refills:*2*
9. Outpatient Lab Work
Please draw INR/PT on [**2192-6-22**] and then prn and Fax results to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 85296**].
10. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: take daily as oredered by Dr. [**Last Name (STitle) **].
Disp:*50 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
mitral regurgitation
coronary artery disease
s/p mitral valve repair,coronary artery bypass
s/p exploratory laparoscopy
potoperative pancreatitis
Chronic obstructive pulmonary disease
Hypertension
Rheumatic mitral valve insufficiency
Depression
Hypercholesterolemia
h/o Cerebrovascular accident
Atrial fibrillation
Degenerative joint disease
Discharge Condition:
Alert and oriented x3 nonfocal exam
Ambulating, gait steady
Sternal pain managed with Dilaudid
Sternal Incision - healing well, no erythema or drainage
Abdominal wound CDI
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Surgeon Dr. [**Last Name (STitle) **] on [**2192-7-12**] at 3:45 [**Telephone/Fax (1) 170**]
Please call to schedule appointments with:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-17**] weeks ([**Telephone/Fax (1) 66039**])
Cardiologist: Dr. [**Last Name (STitle) 29070**] in [**12-17**] weeks
Please schedule follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (general
surgeon) in [**1-18**] weeks ([**Telephone/Fax (1) 673**])
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
INR to be followed by the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
FAX:[**Telephone/Fax (1) 85296**]. First INR to be drawn [**2192-6-22**] and then QOD.
INR goal for Afib 2-2.5.
First blood draw at [**Hospital6 19155**] on [**2192-6-22**]
Completed by:[**2192-6-21**]
|
[
"394.1",
"305.1",
"401.9",
"794.8",
"577.0",
"414.01",
"412",
"280.0",
"560.1",
"427.31",
"272.0",
"438.20",
"311",
"287.5",
"789.00",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.33",
"88.56",
"37.22",
"36.11",
"39.63",
"54.21",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7435, 7510
|
3371, 5525
|
294, 513
|
7896, 8070
|
2440, 3348
|
8772, 9761
|
1782, 1800
|
6137, 7412
|
7531, 7875
|
5551, 5551
|
8094, 8749
|
5572, 5831
|
1815, 2421
|
235, 256
|
541, 1279
|
5856, 6114
|
1301, 1644
|
1660, 1766
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,790
| 196,135
|
33087
|
Discharge summary
|
report
|
Admission Date: [**2158-12-14**] Discharge Date: [**2158-12-21**]
Date of Birth: [**2084-8-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Type A Aortic Dissection
Major Surgical or Invasive Procedure:
[**2158-12-14**] - 1. Replacement of ascending aorta with a Dacron tube
graft. 2. Total arch replacement with Dacron tube graft. Graft
data: Vascutek Gelweave graft 28 mm in diameter with 10, 8 and 8
mm side branches as well as a separate 8-mm side branch,
reference number [**Numeric Identifier 76915**], lot number [**Serial Number 76916**], serial
number [**Serial Number 76917**]. 3. Resuspension of aortic valve.
History of Present Illness:
74 y/o female s/p endograft stenting of proximal descending
aorta for penetrating ulcer and intramural hematoma on [**2156-1-6**]
presented to [**Hospital3 26615**] Hospital last night c/o back pain,
anterior chest pain, and jaw tightness. Lightheaded. Patient
had had mid upper back pain since previous night. CT scan at
[**Hospital3 26615**] showed dissection of ascending aorta originating in
aortic root and extending to stent. Patient has recurrent chest
pain here in ER. Denies paresis, paresthesia, inability to move
extremities.
Past Medical History:
PMH: PUD,Asthma, Hypothyroid, migranes
PSH: Hyst, Bilat Knee [**Doctor First Name **], Hernia repair, Back surgery(tumor)
Social History:
neg alcohol
neg tobacco
Family History:
n/c
Physical Exam:
PE: T - 100 (rectal) BP - 117/70 HR - 65 (SR) RR - 18
General - appears slightly anxious, answers questions
appropriately, follows instructions
HEENT - EOMI, PERRLA
Neck - FROM
Lungs - CTA
Cardio - RRR, Nl S1 and S2, no S3, S4, murmur
Abdomen - obese, soft, nontender
Extremities - varicosities, warm
Neuro - oriented X 3, follows commands, answers questions
appropriately, moves all extremities on command, able to lift
both legs
Pertinent Results:
[**2158-12-14**] ECHO
Pre bypass: The ascending aorta and arch are moderately dilated.
There are complex (>4mm) atheroma in the aortic arch. There is a
dissection flap in the asending aorta through the mid arch.
There is a communication between the lumens in the mid arch with
flow seen at a postion approximately 3 cm from the left
subclavian. This is suspicous as the probable origin of the
dissection. The flap terminates at the sinotubular junction
wihout involvement of the sinus of valsalva. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a very small pericardial
effusion without evidence for tampanode.
Post bypass: There is a prosthesis seen in the ascending aorta
and arch with normal flow profiles. The aortic valve is native
and has mild aortic insufficiency. LVEF remains normal.
Remaining exam is unchanged. All findings discussed with
surgeons at the time of the exam.
Admission labs:
[**2158-12-20**] 09:30AM BLOOD WBC-9.2 RBC-3.81* Hgb-11.9* Hct-35.5*
MCV-93 MCH-31.3 MCHC-33.5 RDW-14.5 Plt Ct-278
[**2158-12-20**] 09:30AM BLOOD Glucose-130* UreaN-35* Creat-0.7 Na-139
K-3.9 Cl-102 HCO3-27 AnGap-14
[**2158-12-14**] 02:00AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2158-12-14**] 02:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2158-12-14**] 02:00AM PT-13.5* PTT-23.9 INR(PT)-1.2*
[**2158-12-14**] 02:00AM PLT COUNT-174
[**2158-12-14**] 02:00AM WBC-11.1*# RBC-4.10* HGB-13.4 HCT-37.8 MCV-92
MCH-32.6* MCHC-35.3* RDW-14.1
[**2158-12-14**] 02:00AM GLUCOSE-185* UREA N-19 CREAT-0.9 SODIUM-139
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-16
Discharge Labs:
[**2158-12-21**] 04:45AM BLOOD WBC-8.3 RBC-3.59* Hgb-11.1* Hct-34.2*
MCV-95 MCH-30.9 MCHC-32.4 RDW-14.8 Plt Ct-331
[**2158-12-21**] 04:45AM BLOOD Plt Ct-331
[**2158-12-21**] 04:45AM BLOOD UreaN-33* Creat-0.9 Na-139 K-4.6 Cl-100
Radiology Report CHEST (PA & LAT) Study Date of [**2158-12-20**] 3:02 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 76918**]
[**Hospital 93**] MEDICAL CONDITION:74 [**Last Name (un) **] s/p ao arch replacement
Final Report
In comparison with study of [**12-18**], the patient has taken a better
inspiration and there is slightly less opacification at the
bases.
Nevertheless, there is still probable small bilateral pleural
effusions with associated compressive atelectasis. No evidence
of pulmonary vascular
congestion.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2158-12-14**] for emergent
repair of a type A aortic dissection. She was taken directly to
the operating room where she underwent repair of a type A aortic
dissection, resuspension of her aortic valve and replacement of
her ascending aorta and total arch. Please see operative note
for details. Postoperatively she was taken to the intensive care
unit for monitoring. She was transfused for postoperative
anemia. A bronchoscopy was performed for right lower lobe
collapse. On postoperative day two, she awoke neurologically
intact and was extubated. Her blood pressure was strictly
controlled. She had an episode of atrial fibrillation which
converted back to normal sinus rhythm with beta blockade. She
was gently diuresed towards her preoperative weight. The
physical therapy service was consulted for assistance with her
postoperative strength and mobility. On postoperative day four,
she was transferred to the step down unit for further recovery.
Chest tubes and pacing wires were removed per cardiac surgery
protocol. She remained in sinus rhythm with PVC's on the floor.
Lasix was increased for further diuresis. On post operative
day 7 her incisions were healing well, she was tolerating a full
oral diet and she was ambulating with assistance. She was
discharged to rehabilitation at [**Hospital **] Health Care in [**Location (un) 5028**],
MA with all appropriate follow up appointments arranged. She is
to have a CTA of the torso before her appointment with Dr
[**Last Name (STitle) 914**], which has been scheduled.
Medications on Admission:
Levothyroxine, Metoprolol, [**Last Name (LF) 4010**], [**First Name3 (LF) **], Zantac, Fiorinol
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-3**] Sprays Nasal
QID (4 times a day) as needed for dry nares .
7. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day).
8. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) tx Inhalation every four (4) hours as
needed for SOB or wheezing .
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
12. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
13. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
15. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
16. Cepacol Sore Throat + Coating 15-5 mg Lozenge Sig: One (1)
lozenge Mucous membrane every 4-6 hours as needed for sore
throat.
17. ipratropium bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours).
18. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
Port Healthcare Center - [**Location (un) 5028**]
Discharge Diagnosis:
migraines, duodenal ulcer, back surgery [**1-2**] spinal tumor,
hypothyroidism, asthma, TAG of proximal descending aorta for
penetrating ulcer in [**1-3**], hysterectomy [**2129**], pulmonary
embolism
[**2155**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with minimal assistance
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema or drainage
1+ Edema
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**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] Date/Time: [**2159-1-9**] 1:00 PM
** CTA of the torso scheduled prior to your appointment with Dr
[**Doctor Last Name 914**] on [**1-9**] at 9:30 AM - Shipiro 4 Radiology - Nothing
to
eat 3 hrs before CTA **
Cardiologist: ? needs cardiologist
Please call to schedule appointments with your
Primary Care [**Last Name (LF) 3078**],[**First Name3 (LF) **] S [**Telephone/Fax (1) 32949**] in [**3-6**] 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:[**2158-12-21**]
|
[
"424.1",
"441.01",
"519.19",
"V12.71",
"346.90",
"E878.2",
"493.90",
"V12.51",
"244.9",
"512.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.45",
"33.22",
"96.71",
"35.11"
] |
icd9pcs
|
[
[
[]
]
] |
8249, 8325
|
4640, 6246
|
336, 756
|
8581, 8754
|
2009, 3071
|
9728, 10456
|
1532, 1537
|
6393, 8226
|
4254, 4617
|
8346, 8560
|
6272, 6370
|
8778, 9705
|
3853, 4218
|
1552, 1990
|
272, 298
|
784, 1328
|
3087, 3837
|
1350, 1474
|
1490, 1516
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,511
| 130,828
|
51380
|
Discharge summary
|
report
|
Admission Date: [**2187-10-24**] Discharge Date: [**2187-10-28**]
Date of Birth: [**2112-8-6**] 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:
[**2187-10-24**] Coronary Artery Bypass Graft x 4 (Left internal mammary
artery to Left anterior descending, Saphenous vein graft to
Diagonal, Saphenous vein graft to Ramus, Saphenous vein graft to
Posterior descending artery)
History of Present Illness:
75 y/o male with exertional chest pain and abnormal stress echo
who was referred for cardiac cath. Cath revealed severe three
vessel coronary artery disease and he was referred for surgical
revascularization.
Past Medical History:
Hypertension, Hyperlipidemia, Prostate nodule, s/p Bilateral
knee replacements [**2183**], s/p deviated septum repair
Social History:
Retired. Denies Tobacco use. Admits to [**1-23**] glasses of
Scotch/week.
Family History:
Non-contributory
Physical Exam:
At discharge:
VS: 98.3, 97.6, 127/77, 79SR, 20, 95%RA
Gen: NAD, WG, WN [**Male First Name (un) 4746**]
Skin: warm, no rash
HEENT: NCAT, EOMI
Neck: supple
Chest: LCTAB
Heart: RRR, no murmur or rub
Abd: NABS, soft, non-tender, non-distended
Ext: trace edema
Neuro: grossly intact
Incisions: [**Doctor Last Name **]- c/d/i witout erythema or drainage, sternum
stable; LLE EVH- c/d/i without erythema or drainage
Pertinent Results:
[**2187-10-24**] Echo: PRE-BYPASS: 1. The left atrium is mildly dilated.
No spontaneous echo contrast is seen in the body of the left
atrium. No spontaneous echo contrast is seen in the left atrial
appendage. 2. There is mild regional left ventricular systolic
dysfunction in the inferoseptal region at the midpapillary
level. The remaining segments contract normally. Overall left
ventricular systolic function is low normal (LVEF 50-55%). 3.
Right ventricular chamber size and free wall motion are normal.
4. There are simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. 6. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. 7. There is no pericardial effusion. POST
BYPASS: 1. Biventricular systolic function is unchanged. 2.
Aorta intact post decannulation.
[**2187-10-27**] 07:00AM BLOOD WBC-9.7 RBC-3.23* Hgb-10.2* Hct-29.5*
MCV-92 MCH-31.5 MCHC-34.5 RDW-12.6 Plt Ct-156
[**2187-10-27**] 07:00AM BLOOD Glucose-110* UreaN-16 Creat-0.9 Na-137
K-4.4 Cl-100 HCO3-30 AnGap-11
[**2187-10-27**] 07:00AM BLOOD Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 106532**] was a same day admit after undergoing pre-operative
work during previous admission. On [**10-24**] he was brought to the
operating room where he underwent a coronary artery bypass graft
x 4. Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours he was weaned from
sedation, awoke neurologically intact and extubated. He was
found suitable for transfer to telemetry, where he made further
progress. The patient showed excellent strength and balance
with physical therapy before discharge. Chest tubes and pacing
wires were discontinued without incident. The patient did have
an episode of atrial fibrillation for which he was given
amiodarone and beta blocker. He did convert to sinus rhythm,
and would remain in sinus rhythm throughout the hospital course.
By the time of discharge on POD 4, the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics.
Medications on Admission:
Lisinopril 20mg qd, Lipitor 10mg qd, Aspirin 325mg qd, MVI
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
5. 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*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg 2x/day for 1 week, then 200mg 2x/day for 1 week,
then 200mg/day until further instructed.
Disp:*120 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Hypertension, Hyperlipidemia, Prostate nodule, s/p
Bilateral knee replacements [**2183**], s/p deviated septum repair
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) **] in [**12-24**] weeks
Dr. [**Last Name (STitle) 26894**] in [**11-22**] weeks
Completed by:[**2187-10-28**]
|
[
"515",
"401.9",
"427.31",
"272.4",
"E878.2",
"715.31",
"414.01",
"V43.65",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
5309, 5367
|
2698, 3739
|
333, 561
|
5594, 5600
|
1509, 2675
|
6111, 6293
|
1047, 1065
|
3848, 5286
|
5388, 5573
|
3765, 3825
|
5624, 6088
|
1080, 1080
|
1094, 1490
|
283, 295
|
589, 799
|
821, 940
|
956, 1031
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,256
| 162,554
|
7430
|
Discharge summary
|
report
|
Admission Date: [**2118-6-12**] Discharge Date: [**2118-6-13**]
Service: MED
HISTORY OF PRESENT ILLNESS: An 85-year-old male with a
history of COPD, chronic renal insufficiency, congestive
heart failure, previous CVA, atrial fibrillation, dementia,
and a recently diagnosed Pseudomonas urinary tract infection,
who presented to [**Hospital6 4620**] on [**6-12**] after
being found down on the ground at home by his daughter. The
patient lives at home with his wife, who has been bed bound
recently secondary to a pelvic fracture.
He reportedly has a baseline dementia with difficulty
articulating words, according to his daughter. [**Name (NI) **] reportedly
had change in his baseline function over the past two weeks
prior to his fall. There was no evidence of physical trauma.
The patient was brought to [**Hospital6 4620**], where
he reportedly had chest x-ray, C spine films, and pelvic
films that did not show any fracture or any infiltrates. He
also reportedly had a head CT that showed no hemorrhage,
hydrocephalus, or mass effect, and there were bilateral
thalamic lacunar infarcts with a question of a new left
thalamic infarct.
At the Emergency Department at [**Hospital6 4620**], the
patient had an ABG performed that had a pH of 7.27, pCO2 of
70, and a pAO2 of 61. This appears to be the patient's
baseline ABG from previous discharge summary from [**Hospital6 4874**], however, in the Emergency Department at
[**Hospital3 **], he was started on BiPAP and the family was
told that he would need to be transferred to [**Hospital1 346**] Intensive Care Unit for BiPAP. He
was transferred to [**Hospital1 69**],
where he had a chest x-ray in the Emergency Department, which
did not show any infiltrate. He was started on BiPAP and
transferred to the Intensive Care Unit.
PAST MEDICAL HISTORY: COPD with apparent baseline pCO2 in
the 60s.
History of previous CVA with dysphasia.
Dementia.
Chronic renal failure with a baseline creatinine at
approximately 2.5.
Diabetes mellitus.
Gout.
Bipolar disorder.
Congestive heart failure.
Paroxysmal atrial fibrillation status post dual chamber
pacemaker placement.
Sacral decubitus ulcer.
ALLERGIES: Penicillin causing anaphylaxis.
Erythromycin.
MEDICATIONS ON ADMISSION:
1. Digoxin 0.125 mg daily.
2. Lasix 40 mg p.o. b.i.d.
3. Prilosec 20 mg daily.
4. [**Hospital1 **] 75 mg daily.
5. Aspirin 81 mg daily.
6. Nemenda 10 mg b.i.d.
7. Vitamin C daily.
8. Zyprexa 7.5 mg q.h.s.
9. PhosLo 1334 t.i.d. with meals.
10. NPH 17 units q.a.m. and 6 units q.p.m.
11. Regular insulin-sliding scale.
12. Colchicine 0.6 mg daily.
13. Tamsulosin 0.4 mg daily.
14. Neurontin 300 mg p.o. q.h.s.
15. Albuterol and Atrovent nebulizers q.6h.
16. Ciprofloxacin dose unknown.
SOCIAL HISTORY: The patient lives at home with his wife, who
is now hospitalized with a pelvic fracture. The family has
hired a home health worker six hours a day. Patient is
apparently is able to do some of his activities of daily
living.
PHYSICAL EXAMINATION ON ADMISSION TO THE INTENSIVE CARE UNIT:
Temperature 98.0, heart rate 61, blood pressure 110/40,
respiratory rate 16, and oxygen saturation 100 percent on 2
liters of oxygen. General: In no acute distress. Alert and
responsive. Follows simple commands. Speech:
Unintelligible. HEENT: Pupils are equal, round, and
reactive to light, supple neck. Dry mucosal membranes. No
JVD. Anicteric sclerae. Cardiovascular examination:
Regular, rate, and rhythm, distant heart sounds, no murmurs.
Lungs: Coarse breath sounds bilaterally, distant breath
sounds. Abdomen is soft, nontender, and nondistended,
positive bowel sounds. Back: No CVA tenderness. There is a
Stage II to III sacral and bilateral buttock decubitus ulcer
without evidence of infection. Extremities: 1 plus
bilateral lower extremity pitting edema.
LABORATORY DATA ON ADMISSION: White blood cell count 10.2
with a differential of 77 polys, 11 percent lymphocytes,
hematocrit 36.1, platelets 416. Chem-7: Sodium of 147,
potassium 5.0, chloride 109, bicarbonate 25, BUN 85,
creatinine 2.9, glucose 102. Calcium 8.4, magnesium 2.1,
phosphorus 4.4. Total bilirubin 0.4, AST 26, ALT 13,
alkaline phosphatase 60, LDH 312. INR 1.2, PTT 24.1.
Urinalysis was negative for infection without any leukocytes,
blood, nitrites, protein, glucose, ketones. Amylase 21.
Albumin 3.3. Vitamin B12 757. Folate greater than 20, TSH
1.1. Digoxin level 1.2. Lactate 1.0. RPR negative.
Chest x-ray showed hyperinflation without any focal
infiltrates.
HOSPITAL COURSE: The patient was transferred from the
Emergency Department to the Intensive Care Unit on BiPAP. On
arrival, his oxygen saturation was 100 percent peripherally.
His ABG had a pH of 7.27, pCO2 of 76, and a pAO2 of 123. The
patient's pCO2 had worsened with the increased oxygen
provided with BiPAP en route. The BiPAP was discontinued,
and the patient's arterial blood gas several hours later on 2
liters of oxygen had improved to close to his baseline blood
gas with a pH of 7.28, pCO2 of 70, and a pAO2 of 56.
The patient was maintained on 2 liters of oxygen with a goal
peripheral oxygen saturation of 88 percent to 92 percent as
he has a chronic respiratory acidosis from his COPD with CO2
retention and a baseline CO2 of 60-70. He also has a
baseline elevation of his bicarbonate with a bicarbonate in
the low 30s.
The patient has not been on chronic oxygen at home. He may
benefit from very low flow oxygen. However, his oxygen
saturation is in the high 80s to low 90s on room air, he may
not need continuous home O2. It was felt that his
respiratory acidosis was chronic. He was not unchanged from
his baseline and that his chronic stable respiratory acidosis
did not account for his fall or altered mental status.
The etiology of his altered mental status is unclear. The
patient certainly has a component of progressive vascular
dementia, but may have a component of Alzheimer's dementia as
well. He has also recently been diagnosed with a urinary
tract infection. He was initially on ciprofloxacin, however,
on arrival culture and sensitivity data was not available,
and he was given a dose of meropenum for possible Pseudomonas
that was resistant to ciprofloxacin. However, the following
morning the sensitivity data was obtained, and it revealed
intermediate sensitivity to ciprofloxacin. Given the urinary
tract source and high concentration of ciprofloxacin within
the urine, it was felt that a course of ciprofloxacin for two
weeks for a complicated urinary tract infection in this
elderly male would be adequate to cover his Pseudomonal
urinary tract infection.
Other possible etiologies for his altered mental status
included new stroke given the possible finding of a new
lacunar infarct on his head CT at [**Hospital6 4620**].
The patient was continued on his baby aspirin and [**Name (NI) **]. It
was felt that a MRI was not indicated as it would not change
management at this time. The patient had normal B12 and
folate levels, a normal TSH, normal digoxin level, and a
negative RPR. His EKG did not show any ischemic changes and
showed only A-paced rhythm with a right bundle branch block.
It is likely that this patient's failure to thrive and recent
mental status changes represents progression of his end-stage
dementia along with his urinary tract infection and possible
new stroke.
The patient has baseline renal failure with a creatinine,
which appears to be approximately 2.5 on admission. His
creatinine was 2.9 on the transfer to [**Hospital6 27253**]. His creatinine had remained stable at 2.8.
The patient has a diagnosis of diabetes mellitus and was on
NPH as well as sliding scale insulin, however, on admission
to the Intensive Care Unit, the patient had a fingerstick
blood glucose that was 48. At this time, he was also
slightly lethargic. He was given 1.5 and an amp of D50 and
his mental status improved slightly, therefore, his NPH doses
were discontinued. He was followed with fingersticks to
check his blood sugars, and he was given regular insulin
based on a sliding scale.
Sacral decubitus ulcer: The patient has Stage II to III
sacral and right and left buttock decubitus ulcer that is
without any evidence of infection. The wound was clean and
covered with a DuoDerm. The patient will need to be rotated
frequently and will need attentive wound care upon discharge.
The patient has a diagnosis of congestive heart failure. On
presentation, he appeared intravascularly volume depleted,
however, he did have 1 plus lower extremity pitting edema.
He is currently on an aspirin and Lasix 40 mg daily. He is
not on a beta blocker and ACE inhibitor. It is not known
whether his heart failure is systolic or diastolic.
The patient has a history of atrial fibrillation: He has a
dual-chamber pacemaker most likely for his atrial
fibrillation and is not on anticoagulation secondary to his
fall risk.
The patient's code status is do not resuscitate/do not
intubate. The patient's contact is his daughter, [**Name (NI) **]
[**Name (NI) 1968**]. Her cell phone number is [**Telephone/Fax (1) 27254**]. Her home
telephone number is [**Telephone/Fax (1) 27255**]. On the morning of
transfer, the patient spiked a temperature to 102.1, and had
an elevation of his white blood cell count from 10 to 18.
Blood cultures and urine cultures were sent. A chest x-ray
did not show any focal infiltrate. The presumed source of
the patient's Pseudomonas urinary tract infection, possible
bacteremia. This culture data should be followed up after
transfer to [**Hospital6 4620**]. In addition, if the
patient's fevers persist and his mental status does not
improve, a lumbar puncture should be considered to rule out
meningeal infection.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Transfer to [**Hospital6 4620**] for
inpatient care by his primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3065**]
[**Last Name (NamePattern1) 780**], [**Telephone/Fax (1) 8927**].
DIAGNOSES: Complicated urinary tract infection with
Pseudomonas aeruginosa.
Chronic obstructive pulmonary disease with a chronic
respiratory acidosis with a pCO2 in the 60s and a bicarbonate
in the low 30s.
Vascular dementia.
Congestive heart failure.
Atrial fibrillation status post dual-chamber pacemaker
placement.
Renal failure with baseline creatinine approximately 2.5.
Gout.
Bipolar disorder.
Benign prostatic hypertrophy.
History of previous cerebrovascular accidents.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg daily.
2. Colace 100 mg p.o. b.i.d.
3. Senna one tablet p.o. b.i.d.
4. Heparin subQ 5000 units subcutaneously q.8h.
5. Ferrous sulfate 325 mg p.o. daily.
6. Digoxin 0.125 mg daily.
7. Lasix 40 mg p.o. q.a.m.
8. [**Telephone/Fax (1) **] 75 mg daily.
9. Aspirin 81 mg daily.
10. Calcium acetate 1334 mg p.o. t.i.d. with meals.
11. Creon caplets, three caps p.o. t.i.d. with meals
(The patient was on this preadmission).
12. Tamsulosin 0.4 mg p.o. q.d.
13. Multivitamin daily.
14. Gabapentin 300 mg p.o. q.h.s.
15. Olanzapine 7.5 mg p.o. q.h.s.
16. Albuterol nebulizer q.6h.
17. Atrovent nebulizer q.6h.
18. Flovent 110 mcg inhaler two puffs b.i.d.
19. Memantine 10 mg p.o. b.i.d.
20. Ciprofloxacin 500 mg p.o. q.24h. (This dose will
need to be adjusted based on the patient's renal
function).
21. Regular insulin-sliding scale.
[**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 24325**], [**MD Number(1) 24326**]
Dictated By:[**Last Name (NamePattern1) 18139**]
MEDQUIST36
D: [**2118-6-13**] 11:41:49
T: [**2118-6-13**] 12:38:31
Job#: [**Job Number **]
|
[
"707.0",
"496",
"438.12",
"427.31",
"428.0",
"599.0",
"290.40",
"276.2",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9808, 10545
|
10571, 11759
|
2259, 2780
|
4580, 9786
|
118, 1804
|
3901, 4562
|
1827, 2233
|
2797, 3886
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28
| 162,569
|
7187
|
Discharge summary
|
report
|
Admission Date: [**2177-9-1**] Discharge Date: [**2177-9-6**]
Date of Birth: [**2103-4-15**] Sex: M
Service: CSU
REASON FOR ADMISSION: Mr. [**Known lastname 26211**] is a postoperative admit
admitted directly to the Operating Room on [**9-1**]. He
was seen preoperatively on [**8-26**] after cardiac
catheterization.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 26211**] is a 74-year-old man
with known CAD, had an MI and 79 and PTCA of his LAD and RCA
and [**2169**]. He had a stent to his diagonal in [**2175**], reports
dyspnea on exertion over the past several months accompanied
by leg cramps. Denies any chest pain, nausea, vomiting,
diuresis, syncope. Stress echo done recently shows an EF of
25 percent with anterior septal akinesis, septal and anterior
wall ischemia. A cath done at an outside hospital showed
three-vessel disease. Cath on [**8-26**] done at [**Hospital1 **] [**Hospital1 **]
showed an EF of 30 percent with anterior hypokinesis, left
main 60 percent LAD with a complex ostial lesion, left
circumflex with 100 percent OM-2 and RCA with 100 percent
proximal lesion.
PAST MEDICAL HISTORY: CAD status post MI, left bundle branch
block, COPD, hyperlipidemia, claustrophobia, diabetes
mellitus type 2.
PAST SURGICAL HISTORY: None.
ALLERGIES: States allergy to tetanus vaccine which causes
hives.
MEDICATIONS ON ADMISSION:
1. Pravachol 80 once daily.
2. Plavix 75 once daily.
3. Imdur 60 once daily.
4. Lopressor 25 once daily.
5. Ecotrin 325 once daily.
6. Flomax 0.4 at bedtime.
7. Amaryl 1 mg once daily.
8. Lisinopril 5 mg once daily.
9. Advair inhaler b.i.d.
SOCIAL HISTORY: Lives with his wife and [**Name (NI) 26671**]. Retired
police officer. Tobacco: Quit 3 years ago with EtOH rare
use.
FAMILY HISTORY: Has a brother with CAD.
PHYSICAL EXAMINATION: Height 6 feet. Weight 220. Vital
signs: Heart rate 65 sinus rhythm, blood pressure 104/50,
respiratory rate 12, O2 sat 96 percent on room air. General:
Lying flat in bed in no acute distress. Neuro: Alert and
oriented times three. Moves all extremities, nonfocal exam.
Respiratory: Clear to auscultation. Cardiovascular:
Regular rate and rhythm. S1-S2 with no murmurs, rubs or
gallops. No carotid bruits and no edema. Abdomen: Soft,
nontender, nondistended with normoactive bowel sounds.
Extremities are warm and well-perfused with no edema. No
varicosities. Left groin with dry sterile dressing and no
hematoma. Pulses: Radial are two plus bilaterally. Dorsalis
pedis and posterior tibial both one plus bilaterally.
LABORATORY DATA: White count 6.3, hematocrit 35.7, platelets
176, sodium 137, potassium 4.2, chloride 100, CO2 19, BUN 28,
creatinine 1.3, glucose 123, ALT 22, AST 14, alk phos 53,
total bili 0.3, albumin 3.4, PT 14.4, PTT 110.6, INR 1.3.
HOSPITAL COURSE: On [**9-1**], the patient was a direct
admission to the Operating Room. Please see the OR report for
full details. In summary, he had a CABG times five with a
LIMA to the LAD, saphenous vein graft to the PDA with a
sequential graft to OM-2, saphenous vein graft to the
diagonal with a sequential graft to OM-1. His bypass time was
101 minutes with a cross-clamp time of 67 minutes. He was
transferred from the Operating Room to the Cardiothoracic
Intensive Care Unit. At the time of transfer, the patient was
AV paced at 86 beats per minute with a mean arterial pressure
of 58 and PAD of 17. He had propofol at 15 mcg/kg/min,
epinephrine at 0.02 mcg/kg/min and insulin at 2 units per
hour.
The patient did well in the immediate postoperative period.
His sedation was discontinued. His anesthesia was reversed.
He was weaned from the ventilator and successfully extubated
on postoperative day one. The patient continued to be
hemodynamically stable. He was weaned from his epinephrine
infusion. His chest tubes were discontinued. His PA catheter
was removed and he was transferred to the floor for
continuing postoperative care and cardiac rehabilitation.
Once on the floor, the patient had an uneventful
postoperative course. His temporary pacing wires were removed
on postoperative day three. His activity was slowly advanced
with the assistance of the nursing staff as well as the
Physical Therapy staff. On postoperative day four, it was
decided that the patient will be ready and stable for
discharge to home on the following day.
PHYSICAL EXAMINATION: At this time the patient's physical
exam is as follows. Temperature 98.5, heart rate 83 sinus
rhythm, blood pressure 124/54, respiratory rate 18, O2 sat 96
percent on room air. Weight preoperatively was 100 kg, at
discharge is 105.3.
LABORATORY DATA: Sodium 138, potassium 4.7, chloride 101,
CO2 29, BUN 25, creatinine 1.1, glucose 156, magnesium 2.0,
white count 8.5, hematocrit 31.2, platelets 119.
PHYSICAL EXAMINATION: Neurologic: Alert and oriented times
three. Moves all extremities, nonfocal exam. Pulmonary:
Clear to auscultation bilaterally. Cardiac: Regular rate
and rhythm. S1-S2 with no murmur. Abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
Extremities are warm and well-perfused with 1-2 plus edema
bilaterally. Sternal incision: Sternum is stable. Incision
with dry sterile dressing, clean and dry. No erythema. Leg
incision on the left knee with Steri-Strips open to air. The
left leg is somewhat ecchymotic.
CONDITION ON DISCHARGE: The patient's condition at time of
discharge is good.
DISPOSITION: He is to be discharged to home with visiting
nurses.
DISCHARGE DIAGNOSES: CAD status post coronary artery bypass
grafting times five with LIMA to LAD, saphenous vein graft to
the PDA with a sequential graft to OM-2, saphenous vein graft
to diagonal with a sequential graft to OM-1.
COPD.
Hypercholesterolemia.
Diabetes mellitus type 2.
Left bundle branch block.
FOLLOW UP: The patient is to have follow-up with Dr.
[**Last Name (STitle) 26672**] in [**12-24**] weeks and follow-up with Dr. [**Last Name (STitle) 1860**] or Dr.
[**Last Name (STitle) 11679**] in [**12-24**] weeks and finally follow-up with Dr. [**Last Name (STitle) **]
in 4 weeks.
DISCHARGE MEDICATIONS:
1. Colace 100 mg b.i.d.
2. Aspirin 325 mg once daily.
3. Percocet 5/325 1-2 tablets q. 4-6 hours p.r.n.
4. Lisinopril 5 mg once daily.
5. Flomax 0.4 mg at bedtime.
6. Pravastatin 80 mg once daily.
7. Advair inhaler, 2 puffs b.i.d.
8. Amiodarone 400 mg once daily times one week then 200 mg
once daily times 1 month.
9. Metoprolol 25 mg b.i.d.
10. Amaryl 2 mg once daily.
11. Finally, the patient is to take potassium chloride
20 mEq b.i.d. times 7 days then once daily times 2 weeks
and Lasix 20 mg b.i.d. times 7 days and then once daily
times 2 weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2177-9-6**] 14:16:56
T: [**2177-9-7**] 15:58:05
Job#: [**Job Number 26673**]
|
[
"V15.82",
"300.29",
"496",
"V17.4",
"412",
"V45.82",
"411.1",
"250.00",
"414.01",
"426.3",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.61",
"38.91",
"38.93",
"99.05",
"89.64",
"96.04",
"36.15",
"36.14",
"96.71",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
1777, 1802
|
5519, 5812
|
6123, 6939
|
1381, 1624
|
2818, 4359
|
1281, 1355
|
5824, 6100
|
4810, 5349
|
370, 1123
|
1146, 1257
|
1641, 1760
|
5374, 5497
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,462
| 146,176
|
14386+14387
|
Discharge summary
|
report+report
|
Admission Date: [**2174-1-11**] Discharge Date: [**2174-1-14**]
Date of Birth: [**2118-4-4**] Sex: M
Service: NEUROSURGERY
HISTORY OF THE PRESENT ILLNESS: This is a 54-year-old male
with a history of previous SAH and clipping of a right
MCA aneurysm clipping in [**2164**]. He was informed that he harbored
a contralateral aneurysm of the left MCA. He underwent cerebral
angiography which showed an anterior temporal artery origin
aneurysm and a left PComm aneurysm. These aneurysms were wide-
necked and as such were not candidates for coil embolization.
The patient is here today for elective surgical clipping.
PAST MEDICAL HISTORY:
1. CAD.
2. Status post MI on [**2173-6-10**].
3. Stent to the LAD times two.
5. Angina.
6. GERD.
PAST SURGICAL HISTORY: Craniotomy with aneurysmal clipping
in [**2164**].
MEDICATIONS AT HOME: Lopressor 50 b.i.d.
PHYSICAL EXAMINATION ON ADMISSION: The patient was awake,
alert, oriented, speech fluent. EOMs full. No drift. Face
symmetric. Full strength in all extremities. No pertinent
findings on the rest of the physical examination.
HOSPITAL COURSE: On [**2174-1-11**], the patient went to the
OR for a left craniotomy with clipping of the PCOM MCA
aneurysm. He was transferred to the ICU for close
neurological monitoring and BP control. Angiogram done on
postoperative day number one showed a well-clipped aneurysm
with no residual.
The patient was transferred to the floor on postoperative day
number two. He has done well. He is ambulating with a
steady gait. He is eating well.
MEDICATIONS AT DISCHARGE:
1. Dexamethasone 4 mg p.o. b.i.d.
2. Lopressor 50 mg p.o. b.i.d.
3. Percocet one to two tablets p.o. q. four to six p.r.n.
DISPOSITION: Neurologically stable. Discharged to home.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 1132**] in one
month. The staples are to be removed in ten days. The
patient will go home on a Decadron wean of 4 mg b.i.d. times
two, 2 mg b.i.d. times two, 1 mg b.i.d. times two, and 1 mg
q.d. and then off.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2174-1-14**] 08:27
T: [**2174-1-14**] 09:24
JOB#: [**Job Number 19735**]
Admission Date: [**2174-1-11**] Discharge Date: [**2174-1-14**]
Date of Birth: [**2118-4-4**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
gentleman with a history of aneurysm found incidentally.
PAST MEDICAL HISTORY: CAD, status post MI and stenting,
hypertension.
PAST SURGICAL HISTORY: Aneurysm clipping in [**2164**].
PHYSICAL EXAM: BP 136/57, heart rate 71, respiratory rate
13, sat 97%. The patient was awake and alert, oriented x 3.
Pupils equal, round and reactive to light. EOMs full.
Tongue midline. Chest clear to auscultation. Cardiac -
regular rate and rhythm, S1 and S2. Abdomen soft, nontender,
nondistended. Extremities - no edema.
HOSPITAL COURSE: The patient was admitted, status post a
left pterional craniotomy for clipping of a P-COM and MCA
aneurysm without intraop complication. The patient was
monitored in the Neurosurgical Intensive Care Unit postop
where he remained awake, alert, oriented x 3, moving all
extremities, answering questions and following commands with
no drift. Head CT immediately postop showed no acute
changes. The patient was slow to wake-up neurologically,
more awake after CT scan.
On postop day #1, his Foley was DC'd. He was out of bed.
His diet was advanced, and he was transferred to the regular
floor. His vital signs remained stable. He remained stable.
On [**2174-1-12**], he underwent angiogram to evaluate clipping of
the aneurysm which showed good clipping of the left PCA and
left MCA aneurysms without residual. The patient remained
awake, alert, oriented with no drift, answering questions
appropriately, visual fields full, speech fluent.
The patient was then transferred to the regular floor where
he was seen by physical therapy and occupational therapy and
found to be safe for discharge to home.
DISCHARGE MEDICATIONS: Metoprolol 50 mg po bid, colace 100
mg po bid, decadron was weaned to off, nicotine patch 21 mg
topically qd, and percocet 1-2 tabs po q 4 h prn for pain.
CONDITION: Stable at the time of discharge. He will
follow-up with Dr. [**Last Name (STitle) 1132**] in 10 days for staple removal.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2174-2-10**] 10:19
T: [**2174-2-10**] 09:34
JOB#: [**Job Number 4063**]
|
[
"413.9",
"437.3",
"530.81",
"401.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.51"
] |
icd9pcs
|
[
[
[]
]
] |
4169, 4715
|
3038, 4145
|
862, 904
|
2652, 2686
|
2702, 3020
|
1598, 2440
|
2469, 2556
|
919, 1114
|
2579, 2628
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,435
| 140,281
|
39122
|
Discharge summary
|
report
|
Admission Date: [**2185-4-29**] Discharge Date: [**2185-5-10**]
Date of Birth: [**2137-7-23**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Tylenol/Codeine No.3
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Worsening back pain urinary retention
Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion with instrumentation L3-S1
History of Present Illness:
47 year old female w/ PMH sig for chronic back pain s/p L4-5
laminectomy (pt unclear of surgery) in [**2183**] and multiple spinal
injections, HTN, HLD, GERD who presents with worsening back
pain, weakness and urinary retention.
.
Patient states that she suffered a fall ~5years ago and since
then has had chronic lower back pain requiring laminectomy and
multiple spinal injections. 2 days PTA, patient went to pain
services clinic where her physician performed an exam and some
manipulations to her legs and back. Since then she has been
experiency progressively worsening pain. Pain starts in the
mid-thoracic back radiates down around her right side, down the
right groin and down the right leg. Pain is similar to her
usual pain but much more in intensity. She states pain is [**10-7**]
and constant. She went to her PCP who prescribed [**Name9 (PRE) 21330**] which
could not control the pain. She also notices that she had no
sensation to void. She also reports numbness and tingling in
her right heel. She denies any urinary or bowel incontinence.
Her appetite has reduced in the past few days and is eating
less, but no weight loss. She has lightheadedness, no vertigo,
nausea, vomiting, headaches. She denies any fevers, chills,
diarrhea, cough, shortness of breath, lower extremity edema.
.
In the ED, her vitals were 97.3 98 122/85 22 97. Patient c/o
[**10-7**] pain. On bladder scan found to have 1.5L urine, foley
placed w/ 500cc urine voided. Neurology consulted felt patient
had saddle anaesthesia and strength exam was limited by pain.
Imaging done sig for degenerative disease, bulge at L3/4 causing
compression of cauda equina and paracentral disc herniation at
L4-5 on the right affecting the L4 nerve root. Neurosurg
consulted felt that imaging did not explain symptoms and did not
recomend urgent surgical intervention. Patient admitted for
further work up and pain control. She received total of 3mg
dilaudid iv for pain w/o much relief and 2L ivfs.
.
On the floor, patient c/o [**11-6**] pain. States that pain
medications in the ED did not help with pain.
.
Review of sytems:
(+) Per HPI ; She c/o intermittent chest pain during the
evenings for the past 8months. + Weight gain.
(-) Denies fever, chills, night sweats, recent weight loss.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
Past Medical History:
- HTN
- HLD
- GERD
.
Past Surgical History:
- [**2183**] lumbar laminectomy, pt unclear of type of surgery
- Rotator cuff repair
Social History:
She lives at home with her boyfriend and is currently disabled.
She works part-time as an aid for a woman w/ cerbral palsy and
sometimes does lifting during her care. She has been smoking
since the age of 15, continues to smoke [**5-2**] cig per day, and has
occasional alcohol use, denies iv drug use
Family History:
Father w/ diabetes and 2 MIs first was in his 60s. Mother with
GYN related malignancy.
Physical Exam:
General: Patient laying on right side, in distress, complaining
of severe back pain
HEENT: Sclera anicteric, oropharynx clear
Neck: Supple, difficult to assess JVP as patient could not lay
on her back, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes, no jaundice
Neuro: A&Ox3, CN2-12 intact
Motor: 5/5 strength in upper extremity bl. 4+/5 strength in
left lower extremity. Able to lift right leg off but difficult
to assess strength given pain.
Sensation: Facial sensation and upper extremity sensation
intact bl. Reduced sensation to light touch on right lower
extremity.
DTR: +2 patellar reflex on left, reduced reflex on right
Coordination: Not assessed
Gait: Not assessed.
Pertinent Results:
[**2185-4-29**] 01:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2185-4-29**] 01:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2185-4-29**] 01:00AM URINE UCG-NEGATIVE
[**2185-4-29**] 01:00AM URINE HOURS-RANDOM
[**2185-4-29**] 09:10AM SED RATE-9
[**2185-4-29**] 09:10AM PLT COUNT-196
[**2185-4-29**] 09:10AM WBC-6.4 RBC-3.49* HGB-11.6* HCT-35.0*
MCV-100* MCH-33.2* MCHC-33.0 RDW-13.9
[**2185-4-29**] 09:10AM TSH-13*
[**2185-4-29**] 09:10AM VIT B12-235* FOLATE-9.8
[**2185-4-29**] 09:10AM CALCIUM-8.0* PHOSPHATE-3.9 MAGNESIUM-1.6
[**2185-4-29**] 09:10AM LD(LDH)-149
[**2185-4-29**] 09:10AM estGFR-Using this
[**2185-4-29**] 09:10AM GLUCOSE-85 UREA N-11 CREAT-0.6 SODIUM-141
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-25 ANION GAP-14
.
MRI spine:
IMPRESSION:
1. Moderate canal narrowing and intrathecal crowding at L3-4
with extensive
degenerative endplate edema.
2. Severe right foraminal narrowing at L3-4 with likely
compression of the
right L3 root.
3. Potential compression of the right L5 root secondary to a
right
paracentral disc herniation at L4-5.
4. Equivocal signal abnormality in the lower cervical spine for
which a
dedicated cervical spine MRI is recommended.
5. Additional degenerative changes as detailed.
Brief Hospital Course:
47 y/o F w/ chronic back pain s/p L4-5 laminectomy in [**2183**], HTN,
HLD, GERD p/w worsening low back pain, weakness and urinary
retention.
.
# Lower Back Pain/Weakness/Urinary Retention: Exam concerning
for cauda equina however, MRI w/o evidence of this. MRI was
notable for spinal stenosis and in the setting of persistent
pain and urinary retention orthospine was consulted who
recommended decompressive surgery. Patient underwent a
non-diagnostic MRI c-spine. Pain services was consulted and
patient was pain controlled w/ dilaudid pca, valium, tazadine
and gabapentin. Patient was transfered to the Orthopedic Spine
service and taken to surgery on [**2185-5-2**] for an L3-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On [**2185-5-3**] she returned to the operating room for a
scheduled L3-S1 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was low and she was
transfused PRBCs with good effect. She was transfered to the
SICU for low oxygen saturation. Chest x-ray showed a pneumonia
and she was started on antibiotics. She intermittently spiked
fevers for which an incentive spirometer was encouraged. A
bupivicaine epidural pain catheter placed at the time of the
posterior surgery remained in place until postop day one when it
was removed. She was kept NPO until bowel function returned then
diet was advanced as tolerated. The patient was transitioned to
oral pain medication when tolerating PO diet. Foley was removed
on POD#3 from the second procedure. She was fitted with a lumbar
warm-n-form brace for comfort. Physical therapy was consulted
for mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
.
# Low TSH: On admission labs were notable for TSH 13, free T4
0.91. Patient to be followed by outpatient for likely
hypothyroid disease.
.
# Macrocytic anemia: Patient found to be B12 deficient and
started on B12 supplements. MMA was checked and pending.
.
# HTN: Continued home bb
.
# HLD: Continued home statin
.
# GERD: Continued home ppi
Medications on Admission:
- Crestor 40mg qhs
- Prilosec 20mg qhs
- Metoprolol ? 25mg daily
- ASA 325mg
- Trazadone 100mg
- Neurontin 600mg TID
Discharge Medications:
1. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at
bedtime) for 4 days.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for COPD.
12. Clonidine 0.1 mg Tablet Sig: One (1) Tablet 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. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal TID (3 times a day) as needed for rectal discomfort.
15. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for pain.
16. Methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed for pain.
18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
19. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Anxiety.
20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
21. Levothyroxine 25 mcg Capsule Sig: 0.5 Capsule PO once a day.
22. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Health Care Center
Discharge Diagnosis:
Primary:
Lumbar disc degeneration, spondylosis and stenosis
Pneumonia
.
B12 deficiency
Hypothyroid
Discharge Condition:
A&Ox3, pain limiting ambulation
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Out of bed w/ assist
LSO for ambulation; may be out of bed to chair without.
Treatment Frequency:
Please continue to change the dressing daily with dry, sterile
gauze.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 363**] in his clinic in 2 weeks. Call
[**Telephone/Fax (1) **] for an appointment.
Name: [**Last Name (un) **],KARMINA [**Location (un) **] P
Location: [**Hospital6 **]
Address: [**Last Name (un) 59485**], [**Location **],[**Numeric Identifier 21478**]
Phone: [**Telephone/Fax (1) 9674**]
Appt: [**5-9**] at 1:45pm
Completed by:[**2185-5-10**]
|
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icd9cm
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,564
| 153,774
|
24667
|
Discharge summary
|
report
|
Admission Date: [**2190-4-19**] Discharge Date: [**2190-5-14**]
Date of Birth: [**2124-12-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 22401**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
Vascular intervention - stents placed
PICC line placement
Hemodialysis catheter placement
History of Present Illness:
HPI: The patient is a 65 yo woman with DM, HTN, ESRD on HD who
resides at [**Hospital3 2558**] and was admitted for hypotension today
(BPs 70/palp). Per reports she was found to be hypotensive to
the 70s today and had malaise for two days. The patient denies
feeling any different than usual. She denies fevers, dizziness,
chest pain, cough, SOB, abd pain, diarrhea, melena,
hematochezia, dysuria, hematuria, nausea or decreased PO intake.
Her last HD was 2 days ago.
In the ED her SBPs were in the 80s and she was treated with 2 L
of IVFs. She was given levaquin, flagyl,1 gm of vanc and 10 mg
of decadron. Her systolic blood pressures are now in the 160s
and the patient feels well.
.
Past Medical History:
End-stage renal disease on HD
Hypertension
C. diff Colitis [**9-9**]
s/p cholecystectomy
Appendicitis
Asthma
Fluid overload
Hypothyroidism
DM
PNA with parapneumonic effusion s/p VATS with drainage [**10-10**]
Social History:
Nursing home resident. She needs assistance with her ADL's. Next
of [**First Name8 (NamePattern2) **] [**Doctor First Name **] or [**Male First Name (un) **] [**Telephone/Fax (1) 62260**]. Lives at [**Hospital3 2558**] 4th.
At baseline, knows where she is, reads the paper a little
Family History:
Non-contributory.
Physical Exam:
At ED presentation:
VS: T 97.9; HR 80; BP 83/50; RR 18; O2 Sat 100% RA
Currently BP 164/63
GEN: obese, pleasant female in NAD
HEENT: Anicteric sclerae. MMM. OP clear.
Cardio: RRR, nl S1 S2, no m/r/g
LUNGS: CTA B
ABD: obese, soft, NT/ND. +BS. Umbilical hernia, that doesn't
completely reduce, is not painful and is soft
EXT: diminished but palpable DPs 1+ B/L.
Left heel ulcer that has a black eschar and no exudate
Skin: slight erythema above gluteal fold with slight skin
breakdown
Back: No CVA tenderness
Pertinent Results:
[**2190-4-19**] 11:52AM BLOOD WBC-15.8* RBC-3.52* Hgb-11.6* Hct-35.2*
MCV-100* MCH-33.0* MCHC-33.0 RDW-18.3* Plt Ct-257#
[**2190-4-19**] 11:52AM BLOOD Neuts-86* Bands-4 Lymphs-4* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2190-4-19**] 11:52AM BLOOD PT-12.0 PTT-30.9 INR(PT)-1.0
[**2190-5-12**] 04:39AM BLOOD ESR-110*
[**2190-5-3**] 10:40AM BLOOD ESR-71*
[**2190-5-12**] 04:36PM BLOOD Ret Aut-8.2*
[**2190-4-19**] 11:52AM BLOOD Glucose-198* UreaN-47* Creat-6.0*#
Na-131* K-6.2* Cl-92* HCO3-20* AnGap-25*
[**2190-4-19**] 11:52AM BLOOD Calcium-8.8 Phos-4.9* Mg-2.3
[**2190-4-21**] 05:50AM BLOOD calTIBC-191* Ferritn-798* TRF-147*
[**2190-5-5**] 11:42AM BLOOD VitB12-700 Folate-16.7
[**2190-5-12**] 04:36PM BLOOD Hapto-<20*
[**2190-5-5**] 11:42AM BLOOD Free T4-0.8*
[**2190-4-22**] 08:00AM BLOOD PTH-68*
[**2190-5-1**] 11:10PM BLOOD Cortsol-29.9*
.
[**2190-4-19**] 12:30 pm BLOOD CULTURE LINE OR SITE NOT NOTED.
**FINAL REPORT [**2190-4-21**]**
AEROBIC BOTTLE (Final [**2190-4-21**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED FROM ANAEROBIC BOTTLE.
ANAEROBIC BOTTLE (Final [**2190-4-21**]):
REPORTED BY PHONE TO [**Doctor First Name **] PFEIFFER @ 2210 ON [**4-19**] -
FA7A.
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Please contact the Microbiology Laboratory ([**6-/2490**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
PENICILLIN SENSITIVITY AVAILABLE ON REQUEST.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- 1 I
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
.
CT chest [**2190-4-21**]:
CTA CHEST: There is no evidence of filling defects in the
pulmonary arteries bilaterally, concerning for pulmonary
embolus. The heart and great vessels are unremarkable. Multiple
mediastinal and axillary lymph nodes are seen. There are
bilateral pleural effusions with loculated fissural component
along the left major fissure. Again seen is a 7-mm right lower
lobe pulmonary nodule. A vague nodular opacity is seen on series
4, image 49 in the right upper lobe measuring 6 mm.
There are atherosclerotic coronary calcifications. The
visualized portions of the liver and spleen are unremarkable.
There are no suspicious lytic or sclerotic foci.
Multliplanar reformatted images confirm the above findings.
IMPRESSION:
1. No evidence of pulmonary embolus.
2. Right pulmonary nodule.
3. Bilateral pleural effusions with left loculated fissural
component.
4. Calcified mediastinal nodes consistent with old granulomatous
infection.
5. Atherosclerotic coronary calcifications.
.
[**Hospital 93**] MEDICAL CONDITION:
65 year old woman with ESRD on HD, no IV access and clotted off
IJs and subclavians bilaterally
REASON FOR THIS EXAMINATION:
Please check MRV of the chest to evaluate patency of vessels as
it appears bilateral IJs and subclavians are occluded
MRA OF THE CHEST.
CLINICAL HISTORY: Patient with history of multiple venous
catheters secondary to hemodialysis. Currently, inability to
gain central access, evaluate for clot versus stenosis in
central veins.
TECHNIQUE: 3D MRA and MRV post-gadolinium images were acquired.
Time-of- flight and true FISP sequences were also obtained.
Reformatted images were generated at a separate dedicated
workstation and were essential in the evaluation of the central
venous structures.
FINDINGS: Thin linear filling defects are noted in the right
brachicephalic vein and superior vena cava. There is a mild
stenosis present in the right subclavian vein approximately 1.7
cm from its [**Hospital1 **] with the right jugular vein. The veins are
otherwise filled with contrast, however. Collateral vessels are
seen in the region of the stenosis suggesting a chronic process.
This correlates with findings seen on the venogram from [**2190-4-28**].
With the exception of the filling defects, the venous structures
fill with contrast and there is no significant stenosis or
obstruction noted. Non-occlusive thrombus in the left internal
jugular vein is demonstrated. A central catheter appears present
in the left subclavian/brachiocephalic vein with its tip in the
SVC.
The arterial structures of the thorax are unremarkable except
for atherosclerotic changes in the aorta. Limited evaluation of
the upper abdomen is unremarkable. There are small bilateral
pleural effusions left greater than right.
IMPRESSION:
1. Findings consistent with linear thrombus (age indeterminate)
or a fibrin sheath from a prior catheter in the right
brachicephalic vein and superior vena cava. These vessels are
patent and there are no findings which explain the difficulty in
passing a catheter through these venous structures. Perhaps this
thrombus somehow temporarily interfered with passage of the
catheter through the venous structures.
2. Non-occlusive thrombus in the left internal jugular vein.
3. Unremarkable appearance of the arterial structures.
4. Small bilateral pleural effusions.
.
MR [**Name13 (STitle) 6452**] W & W/O CONTRAST; MR CONTRAST GADOLIN
Reason: Please evaluate for epidural abscess and osteomyelitis
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
65 year old woman with concern for L2/L3 disciitis, with fevers,
increasing back pain, and question of abscess.
REASON FOR THIS EXAMINATION:
Please evaluate for epidural abscess and osteomyelitis
CLINICAL INFORMATION: Concern for L2-L3 discitis, fevers, and
increasing back pain.
MRI OF THE LUMBAR SPINE WITH GADOLINIUM
Exam is compared to prior incomplete examination of [**2190-5-2**].
Again is seen the loss of height of the superior endplate of L3.
There is some increased signal within the inferior aspect of L2
and the superior aspect of L3, and there is considerable
contrast enhancement of both these vertebrae consistent with
discitis and osteomyelitis. There is no definite evidence of
paravertebral abscess. There is no evidence of epidural abscess.
There is slight protrusion posteriorly of the L2-L3 disc.
At L4-5, there is moderately large left paracentral disc
protrusion producing some encroachment upon the left lateral
recess and mild central canal stenosis.
At L5-S1, there is also a broad-based left paracentral disc
protrusion producing some encroachment upon the left S1 nerve
root sleeve. There is no evidence of foraminal compromise at any
level. The conus is not remarkable.
IMPRESSION: Findings consistent with discitis and osteomyelitis
at L2-L3. Disc protrusions at L4-5 and L5-S1 with features as
discussed above.
.
Tunneled HD catheter placement:
[**Hospital 93**] MEDICAL CONDITION:
65 year old woman with ESRD on HD needs permanent hemodialysis
catheter; Catheter recently removed from LIJ b/c of MSSA
bacteremia. Blood cultures have been clear since [**4-23**]. Recent
attempt at temporary access were complicated by patient's rigt
sided vessels being clotted.
REASON FOR THIS EXAMINATION:
TUNNELLED HEMODIALYSIS CATHETER; attempt right side first, if
unable may use the left
HISTORY: 65-year-old woman with end-stage renal disease
requiring permanent hemodialysis catheter.
PHYSICIANS: [**First Name8 (NamePattern2) **] [**Doctor Last Name 26181**] and [**First Name8 (NamePattern2) **] [**Doctor Last Name 380**] with Dr. [**Last Name (STitle) 380**], the
attending radiologist, present and supervising during the
procedure.
PROCEDURE: Following written informed consent, the patient was
positioned supine on the angiography table. A preprocedure
timeout was performed to confirm patient, procedure, and site.
Standard sterile prep and drape of the left base of the neck,
upper chest, and left upper extremity. Local anesthesia with 5
cc of 1% lidocaine in the left arm. Initial ultrasound
evaluation demonstrated the left internal jugular vein to be
thrombosed. Limited ultrasound evaluation of the left upper
extremity demonstrated the left brachial vein to be patent and
compressible. Using realtime ultrasound guidance, a 21-gauge
needle was advanced into the left brachial vein. A 0.018-inch
guide wire was advanced through the needle into the brachial
vein and then the needle was exchanged for the inner 3 French
stiffener of the micropuncture sheath. Left upper extremity
venography was performed through the sheath with imaging of the
arm and thorax. The tip of the catheter was in the axillary vein
at the time of venography. This demonstrated patency of the
axillary vein, left subclavian vein, left brachiocephalic vein,
and superior vena cava. Mild stenosis of the left
brachiocephalic vein was present, however, no collateral veins
were visualized; therefore, this is likely not a hemodynamically
significant stenosis. Based on the findings of the diagnostic
venogram, it was determined that the patient would be a suitable
candidate for a left subclavian vein tunneled hemodialysis
catheter. Note that a previously performed venogram from the
right side, dictated separately under clip # [**Clip Number (Radiology) 62262**],
demonstrated occlusion of the right brachiocephalic vein. Local
anesthesia with 10 cc of 1% lidocaine in the left upper chest.
Using realtime ultrasound guidance, a 21-gauge needle was used
to puncture the left subclavian vein. A 0.018-inch guide wire
was advanced through the needle into the superior vena cava
using fluoroscopic guidance. Needle was exchanged for the
micropuncture sheath. A subcutaneous tunnel was created in the
left upper chest using the tunneling device. A 14.5 French
double lumen hemodialysis catheter was placed through the tunnel
after being bathed in orthopedic solution. A 0.018-inch guide
wire was exchanged for a 0.035-inch guide wire, and then the
micropuncture sheath was exchanged for 10 French dilator, 12
French dilator, and then peel-away introducer sheath. The guide
wire was removed, and the catheter was placed through the
peel-away sheath and positioned with its tip in the superior
vena cava. The peel-away sheath was removed. It was noted on
fluoroscopy that as the peel-away sheath was removed, the
dialysis catheter tip flipped into the azygos vein. Therefore,
an Amplatz guide wire was placed through the catheter, and the
catheter tip was repositioned in the superior aspect of the
right atrium using fluoroscopy. Both lumens of the catheter
flushed and aspirated well, were capped and heplocked. The
catheter was sutured in place with 2-0 silk sutures, and a
sterile transparent dressing was applied. Final limited chest
radiograph confirmed catheter tip position in the superior
aspect of the right atrium. The catheter can be used
immediately. Note that a 27-cm long cuff-tip catheter was
utilized.
There were no immediate complications.
Total of 30 cc of Optiray radiographic contrast was utilized.
IMPRESSION:
1. Mild stenosis of the left brachiocephalic vein with no
collateral veins, therefore, it is likely not of hemodynamic
significance. The left axillary vein, subclavian vein, and the
superior vena cava are patent.
2. Successful placement of a 27 cm long cuff-tip 14.5 French
double lumen hemodialysis catheter by way of the left subclavian
vein with tip in the superior aspect of the right atrium. The
catheter can be used immediately.
.
EXAM ORDER: Left foot.
HISTORY: Heel ulcer. Rule out osteomyelitis.
Left foot: Three views show soft tissue defect at the posterior
aspect of the calcaneus. Since the previous examinations of [**2189-12-30**] and [**2190-4-3**], there is no significant change
in the appearance of the underlying bone. No definite evidence
of osteomyelitis, osteopenia. Fragments of a needle are seen in
the first web space as noted on the previous examinations. A
small inferior calcaneal spur is seen.
IMPRESSION: No radiographic evidence of osteomyelitis.
.
CT abdomen [**2190-5-12**]
INDICATION: Recent angiography with 8-point hematocrit drop.
Query retroperitoneal bleed.
TECHNIQUE: MDCT was used to obtain contiguous axial images from
the lung bases to the pubic symphysis without oral or IV
contrast. The study was compared with [**2190-5-1**].
CT ABDOMEN WITH IV CONTRAST: A small amount of fluid adjacent to
the major fissure on the right, which was not included in the
field of view on the previous study. There is a small left
pleural effusion with associated compressive atelectasis which
is slightly increased compared to the previous study. No
pericardial effusion is present. There are aortic mural
calcifications.
Liver, spleen, pancreas, adrenals are within normal limits.
There are abdominal vascular calcifications seen throughout.
Renal calculi are seen bilaterally. There is no evidence of
obstruction. There is stranding seen around the kidneys;
however, there is no free fluid in the abdomen. No findings to
suggest retroperitoneal bleed. No free air. Small lymph nodes
are seen in the retroperitoneum and mesentery, none of which are
pathologically enlarged.
CT PELVIS WITHOUT IV CONTRAST: Fat-containing umbilical hernia
is again identified. Fibroid uterus is again seen. There is a
Foley within the collapsed bladder. Evaluation of the deep
pelvic structures is limited by the left hip prosthesis.
However, no free fluid is identified. There are heavy vascular
calcifications. High-density material within the distal bowel is
probably due to previous oral contrast administration. No
lymphadenopathy is identified.
Extensive soft tissue subcutaneous stranding is seen indicating
anasarca. In addition to the fat-containing umbilical hernia,
there are several nodular densities in the anterior abdominal
wall, the largest measuring 11 mm, of uncertain clinical
significance.
Bone windows show no suspicious sclerotic or lytic lesions.
There is again noted a compression fracture of the L3 vertebral
body and probably of T10.
IMPRESSION: No retroperitoneal hematoma. Findings were discussed
with Dr. [**First Name (STitle) **] by telephone at the time of interpretation.
Otherwise, no significant interval change.
Brief Hospital Course:
65 yo female with DM, ESRD on HD and HTN who presented with
hypotension and UA suggestive of UTI, found to have MSSA
bacteremia.
1) MSSA bacteremia/fevers: The patient was initially admitted
with hypotension after HD. Her UA was c/w a UTI so she was
initially thought to have urosepsis and started on levaquin.
Urine culture showed only genital contamination. Blood cultures
showed growth of G+ cocci so she was started on vancomycin.
Further speciation showed MSSA and she had her HD line removed
on [**4-20**]. Blood cultures on [**4-21**] were still positive for MSSA but
surveillance cultures were negative after that. She was also
changed to nafcillan from vancomycin when her sensitivities
returned. She had a temporary femoral HD catheter placed b/c the
vessels in her chest were difficult to access. She had a
tunnelled HD line placed by IR on [**4-28**]. They had difficulty
placing this line and also had difficulty placing a midline b/c
of clot in the vessels. An MRV was subsequently done and showed
thrombus in several vessels. She remained afebrile for most of
her hospital course but on [**5-1**] she became more lethargic,
hypotensive to the 70s and had a low grade temp to 100.3. Her
WBC also trended up to 24. She was treated with IVFs and sent to
the MICU. ID was consulted and thought this could be [**1-7**] to
c.diff, even though the pt did not have diarrhea at the time.
She was started on flagyl and had copious amts of diarrhea while
in the ICU. She completed a 14 day course of metronidazole for
her presumed c. difficile. Her c. difficile toxin A and B were
negative. She also had an MRI of her L spine that showed
osteomyelitis and disciitis at L2/L3. She was being treated with
vancomycin and cefepime, which was discontinued in favor of
nafcillin, to be continued for a minimum of [**5-13**] weeks for high
grade bacteremia and osteomyelitis. She was also found to have a
pseudomonal urinary tract infection, sensitive to cefepime, and
she received a 7 day course of treatment for this as well. She
will follow up with infectious diseases as an outpatient, and
will have course of therapy determined by them. Patient's blood
cultures from [**4-23**] onward were negative for infection. Her
cortisol stimulation test was negative.
.
2) ESRD on HD (T/Th/Sa): The patient was continued on her
regularly scheduled dialysis on T/Th/Sa. She was continued on
renagel and nephrocaps. As mentioned above, she had her HD line
removed on [**4-20**] and received dialysis through a temporary
femoral line for several days. She had a new tunnelle line
placed by IR on [**4-28**]. She had hypophosphatemia during her
hospital stay, and required adjustment of her phosphate binders.
.
3) DM: Patient's blood sugars were well controlled and she was
continued on 7 units of NPH at breakfast and 4 units at dinner.
She required a slight adjustment in this regimen during her stay
and was also covered with a RISS.
.
4) Hyponatremia: Pt was hyponatremic at admission and this
resolved after fluid was removed during HD. Her sodium was
followed during her stay.
.
5) Necrotic left heel: She has a left heel ulcer, likely [**1-7**] to
DM, that was noted at previous admissions. Ulcer did not appear
infected at this admission. She was continued on multipodus
boots, zinc, ascorbic acid and received wound care. Wound care
was consulted, and recommended podiatry consult. Podiatry
consult debrided left heel ulcer, and took deep wound cultures,
which grew pseudomonas. Patient was felt to be colonized, not
infected at the time. However, doppler studies were performed,
which showed minimal perfusion to the LLE, and patient was taken
by vascular surgery to angiography where stents were placed in
the left external iliac and superior femoral arteries, with
repeat doppler studies showing improved flow. Patient was kept
nonweight bearing on the heel, and received local wound care.
She will continue high dose atorvastatin and clopidogrel.
.
6) Umbilical hernia: Pt was noted to have an umbilical hernia at
admission that was not clearly reducible and has been noted in
prior discharge summaries but has never been imaged. An abd CT
was ordered for further evaluation but pt was refusing this test
b/c did not want to drink the contrast.
.
7) Bilateral pleural effusions: Pt had a left sided effusion
with loculated component. She is s/p VATS in fall [**2188**]. Spoke
with [**First Name4 (NamePattern1) 3065**] [**Last Name (NamePattern1) **] from IP who said no further intervention
necessary at this time.
.
8) Hyperlipidemia: Continued on lipitor 80 mg qd.
.
9)Hypothyroidism: Patient normally takes 175 mcg Synthroid qd as
an outpatient. A TSH was checked on [**4-4**] and was 81. Patient's
Synthroid dose was increased to 200 mcg qd prior to discharge 3
weeks ago. Her thyroxine level was found to be low on this
admission and her dose was increased to 225 mcg daily, with
repeat thyroid studies to be checked as an outpatinet in six
weeks.
.
10) H/o asthma: Continued albuterol nebs
.
11) Diet: diabetic, renal, low salt diet.
.
12) Code status: full code
.
13) Access: Patient had new hemodialysis tunnelled line placed
on [**4-28**]. Patient also had PICC line placed during admission.
.
14) Witnessed aspiration: Patient was noted to aspirate and
choke on her food. A speech and swallow evaluation was obtained
and recommended dietary modifications, which patient was
unwilling to comply with. After discussion of risks and
benefits, patient was ordered a regular diet.
.
15) Anemia. Patient was noted to have anemia of chronic disease.
She also developed acute blood loss anemia after her vascular
intervention. She received 2u pRBC for her hematocrit of 21, and
had an appropriate increase in hematocrit. She remained guaiac
negative. Hemolysis labs were significant for a low haptoglobin
and an elevated reticulocyte count, which was thought to be
consistent with recent vascular intervention. She had no other
signs of hemolysis.
.
16) Bilateral upper extremity clots. Due to concern for high
clot burden in bilateral upper extremities, patient was placed
on anticoagulation with coumadin. She was briefly taken off
coumadin for her vascular procedure, and at time of discharge,
awaiting therapeutic INR with goal 2.0 to 3.0.
.
17) PPx: Prilosec, SC heparin, bowel regimen
.
18) Dispo: Patient was discharged to her rehabilitation
facility.
Medications on Admission:
-Levothyroxine 200 mcg qd
-Atorvastatin 80 mg qd
-Lisinopril 20 mg Tablet, One (1) Tablet PO 4 times per
week: four times a week, q Sun/M/W/Fri.
-Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection ASDIR (AS DIRECTED): at dialysis.
-Senna 8.6 mg [**Hospital1 **] PRN
-Aspirin 325 mg PO qd
-Metoprolol Tartrate 50 mg PO BID
-Sevelamer 800 mg TID
-Albuterol Sulfate 0.083 % Solution q6 hrs PRN
-Zinc Sulfate 220 mg PO qd
-Prilosec 20 mg PO qd
-B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
-Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
-Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
-Heparin (Porcine) 5,000 unit/mL Solution TID
-Insulin NPH Ten (10) units Subcutaneous q breakfast.
-Insulin NPH 6 units Subcutaneous q dinner.
-Vitamin C 250 mg Tablet Sig: One (1) Tablet PO once a day.
-Insulin sliding scale
-Ultram 50 mg PO q 12 hrs PRN backpain
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) dose
Injection ASDIR (AS DIRECTED): with dialysis.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours) as needed.
5. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig:
for goal ptt 50-70 Intravenous ASDIR (AS DIRECTED): until
coumadin therapeutic, with INR 2.0 to 3.0.
6. 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.
7. Levothyroxine 200 mcg Tablet Sig: Two [**Age over 90 **]y Five
(225) mcg PO DAILY (Daily).
8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Papain-Urea 830,000-10 unit/g-% Spray, Non-Aerosol Sig: One
(1) Appl Topical [**Hospital1 **] (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. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
13. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
15. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
16. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) gm
Intravenous Q4H (every 4 hours): Course will be determined by
infectious diseases.
17. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Seven
(7) units Subcutaneous qAM: and 4u qPM per sliding scale.
18. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
19. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1. Osteomyelitis of the spine
2. Thoracic compression fracture
3. MSSA sepsis
4. Upper extremity clots (IJ, subclavian, brachiocephalic)
5. Hemodialysis catheter line infection
6. Left heel ulcer requiring vascular intervention
7. Pseudomonas urinary tract infection
8. C. difficile colitis
9. Aspiration
10. Anemia, acute blood loss and chronic renal disease
associated
11. Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
If you develop nausea, vomiting, shortness of breath, fevers,
chills, chest pain, or drainage or pus around your hemodialysis
catheter site, please call your doctor or go to the emergency
room.
|
[
"276.1",
"995.92",
"585.6",
"285.1",
"440.23",
"041.7",
"453.8",
"722.90",
"403.91",
"707.14",
"V58.67",
"785.52",
"038.11",
"996.62",
"730.28",
"451.84",
"250.40",
"008.45",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"00.42",
"00.47",
"39.50",
"39.95",
"39.90",
"88.72",
"88.42",
"88.48",
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
25770, 25840
|
16398, 22778
|
343, 435
|
26274, 26283
|
2264, 5111
|
1702, 1721
|
23816, 25747
|
9075, 9355
|
25861, 26253
|
22804, 23793
|
26307, 26503
|
1736, 2245
|
277, 305
|
9384, 16375
|
463, 1152
|
1174, 1385
|
1401, 1686
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,522
| 179,349
|
47571
|
Discharge summary
|
report
|
Admission Date: [**2143-2-13**] Discharge Date: [**2143-2-26**]
Date of Birth: [**2060-2-12**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Intramural [**First Name3 (LF) 8813**] hematoma.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
83-year-old female was transferred from [**Hospital1 **] with a
diagnosis of intramural [**Hospital1 8813**] hematoma, as seen on CT scan
performed for initial complaints of abdominal pain. Yesterday
morning she noted that the room was spinning. She had
associated vomiting. Had been feeling unwell and unsteady fot a
couple of days prior to this. Has had similar episodes in the
past and diagnosed with Meniere's disease. Later that day, she
complained of epigastric pain radiating to the back at 10/10
severity, no chest pain, no diaphoresis and no shortness of
breath. On arrival at [**Hospital1 18**], she c/o dull aching abdominal
pain. Otherwise asymptomatic. No fever.
Past Medical History:
Hyperlipidemia, Hypertension, GERD, Renal Insufficiency,
Hypothyroidism, Degenerative Joint Disease, Anxiety/Depression,
Meniere's disease
PSH:
Detached Left Retina, h/o colon perforation with colonoscopy,
s/p R ear stapedectomy, Coronary Artery Bypass Graft x 3 (LIMA
to LAD, SVG to OM, SVG to RCA) [**2138**], Mitral Valve Replacement
(27mm pericardial tissue valve), [**Year (4 digits) **] Valve Replacement (23mm
pericaridial tissue valve), Ascending Aorta Replacement (28m
gelweave graft), [**2139-6-10**] Mediastinal exploration with evacuation
Social History:
Artist. Denies tobacco. Rare wine.
Family History:
Mother with RHD.
Physical Exam:
Neuro/Psych: Oriented x3, Affect Normal.
Neck: No right carotid bruit, No left carotid bruit.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear.
Gastrointestinal: Non distended, No masses.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No LLE Edema, No varicosities, No skin changes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
LUE Radial: P.; Femorals palpable bilateral, Popliteals palp
bilaterally; PT/DP dopplerable bilaterally.
Pertinent Results:
[**2143-2-13**] 02:25AM PT-21.2* PTT-32.8 INR(PT)-2.0*
[**2143-2-13**] 02:25AM WBC-12.5* RBC-6.85*# HGB-15.7# HCT-47.5#
MCV-69*# MCH-22.9*# MCHC-33.0 RDW-15.3
[**2143-2-13**] 02:25AM PLT COUNT-197
[**2143-2-13**] 02:25AM CK-MB-NotDone cTropnT-<0.01
[**2143-2-13**] 02:25AM ALT(SGPT)-19 AST(SGOT)-31 CK(CPK)-88 ALK
PHOS-96 TOT BILI-1.2
[**2143-2-13**] 02:25AM LIPASE-22
[**2143-2-13**] 02:25AM GLUCOSE-139* UREA N-17 CREAT-0.9 SODIUM-135
POTASSIUM-3.1* CHLORIDE-97 TOTAL CO2-24 ANION GAP-17
[**2143-2-13**] 09:44AM CK-MB-3 cTropnT-<0.01
[**2143-2-13**] TTE showed:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). The
right ventricular cavity is mildly dilated with normal free wall
contractility. A bioprosthetic [**Month/Day/Year 8813**] valve prosthesis is
present. The transaortic gradient is normal for this prosthesis.
Trace [**Month/Day/Year 8813**] regurgitation is seen. The mitral valve leaflets
are mildly thickened. A bioprosthetic mitral valve prosthesis is
present. The mitral prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. No 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 mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
Patient is an 83 y/o female who initially presented with
dizziness, found to have an [**Month/Day/Year 8813**] hematoma whose course has
been complicated hyponatremia and a UTI.
.
#) [**Month/Day/Year **] Hematoma: Patient was initially admitted with
abdominal pain and dizziness, found to have an [**Month/Day/Year 8813**] hematoma.
She was initially admitted to the CVICU for strict blood
pressure control, managed on a nitroglycerin gtt with a goal SBP
of 90 to 120. A TTE was done that showed that her cardiac
function was intact, when she was found to be hemodynamically
stable, she was transferred to the CICU on [**2-15**]. Her coumadin
was held due to concern for possible progression of her
hematoma, and in case she needed future operative management.
Her blood pressure regimen was adjusted to keep her goal BP
under 120/80 if possible, at the time of discharge her blood
pressure was mainly in the 120's systolic on her regimen of
metoprolol 100mg TID, amlodipine 10mg daily and valsartan 160mg
daily. A repeat CTA was done that showed her hematoma was
stable, and vascular felt that she was safe for discharge with
outpatient follow up with Dr. [**Last Name (STitle) **]. If her blood pressure is
not at goal during her rehab stay, would avoid hydralazine and
start low dose lisinopril to help with better BP management.
She had also previously been on HCTZ 25mg daily, which would be
another option as long as her sodium is stable.
.
#) Hyponatremia: on [**2-17**] patient was first noted to be
hyponatremic with a serum Na of 128, she was initially treated
with lasix and fluid restriction. Over the next few days her
serum sodium did not improve and she was transferred to the
medicine service for further management. Her serum sodium
improved with normal saline over the next few days as she was
hypovolemic, hyponatremic.
.
#) Urinary Tract Infection: on [**2-17**] patient complained of
dysuria, a urinalysis was done that was suggestive of infection
and she was initially started on cipro, a culture was done that
grew pan-sensitive enterococcus and she was treated with a 4 day
course of augmentin.
.
#) Altered Mental Status: on [**2-21**] patient was noted to be more
somnolent, a CT of her head was done that showed a question of
an old infarct, so neurology was consulted. After their
evaluation, an MRI was recommended but due to prior stapedectomy
she was unable to undergo the MRI, it was decided that since the
lesion seen on the CT was old, she did not need an MRI. Her
mental status improved over the next few days, and it was
thought that her dehydration and hyponatremia were likely
contributing her altered mental status. She will follow up with
neurology as an outpatient.
.
#) Atrial Fibrillation: restarted home warfarin at 5mg daily,
uptitrated metoprolol for blood pressure control
.
#) Hypothyroidism: continued home synthroid
.
#) GERD: continued home omeprazole
Medications on Admission:
asa 81mg
celebrex 200mg
claritin 10mg
coumadin 5mg
detrol 2mg qhs
diovan/HCTZ 160/25
ergocalciferol 5000 qweek
nasonex
omeprazole 20mg
synthroid 100mcg
toprol 50mg
simvastatin 10mg
cymbalta 60mg
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
10. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
The Blare House
Discharge Diagnosis:
Intramural hematoma in aorta
Hyponatremia
Altered Mental Status
Hypertension
Discharge Condition:
Vital Signs Stable
Mental status: Alert/Oriented x 3, NAD
Ambulating without assistance
Discharge Instructions:
Ms. [**Last Name (Titles) **], it was a pleasure taking care of you at [**Hospital1 18**].
You were admitted with a clot in the wall of your aorta. It is
important that your blood pressure is controlled adequately.
During your stay we also found that you sodium level was low,
which was due to dehydration, your sodium level improved with IV
fluids. You were also treated for an urinary tract infection
during your staty. After you leave the hospital you will need
close follow up with both your primary care provider and Dr.
[**Last Name (STitle) **] the vascular surgeon who was helping care for you in the
hospital.
.
We made some changes to your medications while in the hospital,
1. INCREASED Metoprolol to 100mg three times per day
2. ADDED Amlodipine 10mg daily
3. STOPPED HCTZ 25mg daily
Please continue to take all other medications as previously
prescribed
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**0-0-**] for blood pressure
control, please call the office to make an appointment in the
next week.
You will also need to follow up with Dr. [**Last Name (STitle) **] after you leave
the hospital, we made an appointment for you, you will get a CT
scan to look at the blood clot in your aorta prior to seeing Dr.
[**Last Name (STitle) **].
Department: RADIOLOGY
When: TUESDAY [**2143-3-26**] at 1:30 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: VASCULAR SURGERY
When: TUESDAY [**2143-3-26**] at 2:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROLOGY
When: [**2143-4-9**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital 830**]
Campus: East
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"427.31",
"780.97",
"V58.66",
"041.04",
"V45.81",
"599.0",
"272.4",
"V58.61",
"428.33",
"V42.2",
"401.9",
"244.9",
"276.1",
"441.02",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8129, 8171
|
3817, 5957
|
316, 324
|
8292, 8311
|
2220, 3794
|
9298, 10564
|
1680, 1698
|
6979, 8106
|
8192, 8271
|
6759, 6956
|
8405, 9275
|
1713, 2201
|
228, 278
|
352, 1036
|
8326, 8381
|
1058, 1611
|
1627, 1664
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,315
| 119,437
|
36036
|
Discharge summary
|
report
|
Admission Date: [**2159-5-1**] Discharge Date: [**2159-5-22**]
Date of Birth: [**2119-9-6**] Sex: M
Service: SURGERY
Allergies:
Erythromycin Base / Amoxicillin
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
evaluate for splenic rupture
Major Surgical or Invasive Procedure:
Splenectomy and distal pancreatectomy [**2159-5-2**]
History of Present Illness:
The patient is a 39-year-old male who has a complicated
series of recent events summarized below:
* 9 days ago, had chills/rigors
* 8 days ago, presented to [**Hospital 5450**] Hospital (?[**Doctor First Name **]). Lipase
found to be 1100, admitted, made NPO, treated conservatively for
presumed pancreatitis
* 7 days ago, several episodes of bilious emesis that stopped 6
days ago; also had dizziness and syncope
* over the past 3 days, has been febrile to Tmax of 103F
* yesterday, asked Dr. [**Last Name (STitle) **] to facilitate transfer to [**Hospital1 18**];
arrived in ED. Eventually, he underwent a CT scan which showed a
large splenic lesion concerning for bleed. A surgery consult was
initiated.
Last BM was yesterday. Upon arrival in ED, v/s were: 98.9 110
143/95 16 96RA. He received about 2.5 liters of fluid and
vanco/levoflox/flagyl. A repeat Hct showed a drop from 32.3 ->
27.2. A unit of pRBCs was ordered.
Past Medical History:
PMH: recurrent episodes of acute pancreatitis, about 22 in all
.
PSH: s/p appy
s/p CCY
pseudocyst drainage procedure - ?cyst gastrostomy ([**Hospital **]
Hospital)
Social History:
SH: Single, mother lives with him. Works as a controller of [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 5450**]-based company; never smoked, rare EtOH, denies
history
of abuse/dependence.
Family History:
FH: Father died of brain cancer at age 52; mother alive and well
at 60. Only child, no children of his own.
Physical Exam:
98.9 110 143/95 16 96RA
Gen: elderly male, appears younger than stated age, NAD,
diaphorectic, +scleral icterus, dyspneic
HEENT: NC/AT, EOMI, PERRLA bilat., MMM, without cervical LAD
on my exam
Cor: RRR without m/g/r, no JVD, no bruits
Lungs: CTA bilat.
[**Last Name (un) **]: +BS, soft, no masses, palpable reducible ventral/umbilical
hernia, distended without tympany, ++tender at LUQ with
guarding,
tender at L flank and LLQ, mild percussion tenderness, no
rebound
Ext: warm feet, no edema
Brief Hospital Course:
The patient was taken to the operating room on [**2159-5-2**] and again
on [**2159-5-9**]. His hospital course will be outlined in a system
format below:
Neuro: Post-operatively, the patient's pain was managed via a
PCA. He did well. He reported that his pain was well
controlled. On POD [**4-22**], the patient started c/o increasing
abdominal pain. He became febrile and tachycardic. In addition
he became acutely delirous resulting in a code purple.
Psychiatry was consulted for acute agitation. It was discovered
that the patient had a enteric leak causing the agitation.
After being re-operated on, the patient did not have further
episodes of agitation or confusion. His pain was once again
managed on a PCA and eventually transitioned to PO pain
medications. No further psychiatry input was required.
CV: Post-operatively, the patient did well. He was
hemodynamically stable. He did not require any pressors.
However on POD [**4-22**], the patient became tachycardic [**12-18**] enteric
leak. After the second operation, the patient did not have
futher episodes of tachycardia. He is hemodynamically stable at
the time of discharge.
Resp: The patient was successfully extubated in the OR. He was
placed on nasal cannula post-operatively. On POD 4, the patient
had acute respiratory distress requiring admission to the [**Hospital Unit Name 153**].
W/U was negative for LE DVT but POSITIVE for left upper lobe
subsegmental PEs and a large left pleural effusion. The
effusion was seen pre-operatively, likely [**12-18**] to his
pancreatitis, thus the decision was made not to perform a
thoracocentesis. He was anticoagulated appropriately and started
on aggressive chest PT/incentive spirometry. His oxygen
requirements decreased slowly and eventually he was weaned off
supplemental O2. Serial CXRs were done to evaluate the left
pleural effusion. Because the patient went down to IR for an
abdominal drainage procedure, they also performed a
thoracocentesis, effectively draining 500 cc of straw colored
fluid. Post-procedure CXR shows a small loculated PTX and the
CT was placed on wall suction. He has no respiratory issues.
Eventually his CT had little drainage, was placed on water seal
and eventually discontinued. He continues to maintain his
saturation in the mid-90's on RA.
GI: After arriving to the ED, a CT scan of the abdomen and
pelvis with p.o. and
IV contrast showed a large hypodense mass within the spleen with
blood tracking posterior to the spleen and into the pelvis.
Findings were consistent with a subcapsular hematoma of the
spleen which had ruptured. He was taken to IR for urgent
embolization and then taken to the OR for a hematoma evacuation
and distal pancreatectomy and total splenectomy. His
post-operatively course was c/b a leak for which he was taken
back to the OR on POD 7. A large leak seen on the Roux Limb was
identified. It was repaired, a J-tube was placed, and his
abdomen was irrigated and closed. Post-operatively the patient
required IR drainage of a fluid collection adjacent/at the site
of surgery. He continued to be NPO and his tube feeds were
advanced through his J-tube. He tolerated this well to goal.
On POD 19/12, the patient started on a regular diet to see if
there was a pancreatic leak of some sort. There did not appear
to be an increase in drain output.
Renal: The patient UOP was adequate throughout his
hospitalization course. His creatinine was stable. His foley
was eventually discontinued and he voided without difficulties.
ID: The patient was cultured numerous times throughout his
hospitalization course given his fevers. In addition OR
cultures were also obtained. While awaiting cultures, the
patient was placed on broad spectrum antibiotics. The only
positive blood culture was on [**2159-5-8**] 1/2 bottles for
STAPHYLOCOCCUS, COAGULASE NEGATIVE. Further blood
cultures/surveillence cultures were negative. Cultures intraop
as well as from the abdominal drains grew out HAEMOPHILUS
SPECIES NOT INFLUENZAE (HEAVY GROWTH, repeat culture shows
sparse growth), [**Female First Name (un) **] ALBICANS (SPARSE GROWTH), and
LACTOBACILLUS SPECIES (RARE GROWTH). Multiple C-difficle were
negative. Urine culture showed no growth multiple times. After
a long duration of antibiotics, all his antibiotics were
discontinued on [**2159-5-18**]. He was afebrile > 48 hours and his
post-splenectomy vaccines were administered on [**2159-5-20**].
Heme: The patient was anticoagulated for his PE. During a
bedside ultrasound for CVL placement, a clot was noted in his L
IJ, which may have been the source of his PE. He was
therapeutic on a heparin gtt of 2050 Units. He was given
Coumadin and his INR became therapeutic [**Female First Name (un) **] dose of 7.5 mg. His
hep gtt was stopped thereafter.
From [**Date range (1) 81787**], he continued to recover. His diet was
advanced to regular, and he tolerated this well without increase
in output from either of his JP drains or from his pigtail
catheter, situated in the splenic bed. Because the drain outputs
did not appear to increase after food, we surmised that the
pancreatic fistula had healed to an extent, and we removed one
of the JP drains. Because he tolerated a regulat diet, we
stopped his supplemental tube feeds.
He continued on warfarin for his PE/DVT. He is discharged on a
regular diet, on oral pain medication, able to care for himself.
He has received drain care and has been deemed competent to take
care of his drains, as has his mother. [**Name (NI) **] will be sent home with
the pigtail, JP drain and J-tube in place. He is to follow up in
office with Dr. [**Last Name (STitle) 1924**] in [**11-17**] weeks.
Medications on Admission:
Viokase prn with meals
Vicodin prn
Discharge Medications:
1. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO Q8H (every 8 hours).
Disp:*90 Cap(s)* Refills:*2*
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks: Please do
not take more than 4000mg of acetaminophen in 24 hrs.
Disp:*45 Tablet(s)* Refills:*0*
3. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: Your PCP will adjust dose as needed. .
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 for 1 months: take with
pain meds.
Disp:*60 Capsule(s)* Refills:*0*
5. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8117**] VNA
Discharge Diagnosis:
Chronic pancreatitis with subcapsular hematoma of the spleen.
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled with oral medication.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your 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.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Steri-strips will be applied and will fall off on their own.
Please remove any remaining strips 7-10 days after application.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Drain Care:
-Please continue to assess drain sites for s/s of infection.
-Please continue to assess and record drain outputs daily.
-Please continue to change dressings daily or as needed.
.
Coumadin:
-You were started on this medication while in the hospital
secondary to a Pulmonary Embolis
-You will need to have your lab work drawn at least once a week
to check your INR.
-You will have this done at your local hospital and your PCP
will adjust the dose as needed.
-You should take 6mg today and until your PCP tells you
otherwise. (2 2.5 mg tablets and 1 1 mg tablet)
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1924**] ([**Telephone/Fax (1) 55864**]
.
Scheduled Appointments :
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2159-9-10**] 11:45
Completed by:[**2159-5-22**]
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icd9cm
|
[
[
[]
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] |
[
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72,557
| 197,150
|
38380
|
Discharge summary
|
report
|
Admission Date: [**2114-6-30**] Discharge Date: [**2114-7-11**]
Date of Birth: [**2073-1-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Fever, lymphadenopathy
Major Surgical or Invasive Procedure:
Intubation/Mechanical Ventilation
Lymph Node Fine Needle Aspiration
History of Present Illness:
41 y/o previously healthy female with 2wk history of painful
cervical [**Doctor First Name **]. She was first seen by ENT on [**6-20**], given a
course of Augmentin without improvement. LAD worsened to involve
anterior and posterior chains on both sides of neck. A steroid
taper was initiated and an FNA was then done, and was
??????nondiagnostic??????, but they empirically added valtrex to her
regimen. A mono screen and cat scratch disease screening was
negative. On Weds. night [**6-27**], she developed headache and neck
pain, and was referred to the [**Hospital 8641**] Hospital ER, where she was
admitted. Initial CBC showed WBC of 11.7 with 30% bands, Hct 30,
Plt 97. ALT was 129, AST 77. Cr was normal. CRP elevated to 277.
An LP was performed, which revealed no cells. CT head was neg.
Her hospital course since then is notable for [**Doctor First Name **] that has been
progressive, and continued fevers. ID was consulted, thought a
viral syndrome, sent off multiple seroligies (see labs).
Initially treated with zosyn and azithromycin, and eventually
added vancomycin. She continued to spike was worsen clincially.
On [**6-29**], she became more SOB. CXR performed, had progressed from
clear to bibasilar infiltrates. She had increasing hypoxemia,
with ABG showing 3.39/40/55 on NRB. Antibiotics broadened to
include levofloxacin. She was intubated on [**6-30**] for hypoxemia.
Intesivist added doxy today. Echo showed EF 35-40% and small
pericardial effusion. Central access was obtained and she was
transferred to [**Hospital1 18**] for further workup.
Hospital course also significant for development of bilateral
parotiditis. Mumps IgG+, but IgM still pending.
No recent travel. No exposure to pets, animals, farms, no sick
contacts. Review of systems is unable to be obtained [**3-13**] patient
is intubated, sedated.
Past Medical History:
None
Social History:
No smoking, very rare alcohol. She is an avid runner. Married
with 2 children, works as an on-line editor.
Family History:
Breast cancer.
Physical Exam:
(Physical Exam on Admission)
Vitals: T: 99.0 BP: 109/73 P: 109 RR: 18 O2: 100% on A/C
500/12/10/0.8
General: intubated, easily rousible and following commands
HEENT: Sclera anicteric
Neck: diffuse erythema and LAD in all submandibular chains. LAD
also present in bilaterally axillary chains.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, 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
[**2114-6-30**] 08:01PM BLOOD WBC-13.4* RBC-3.30* Hgb-10.2* Hct-29.6*
MCV-90 MCH-30.9 MCHC-34.4 RDW-12.5 Plt Ct-89*
[**2114-6-30**] 08:01PM BLOOD Neuts-82* Bands-9* Lymphs-3* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-2* Myelos-2* NRBC-1*
[**2114-6-30**] 08:01PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-1+ Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL Tear
Dr[**Last Name (STitle) **]1+
[**2114-6-30**] 08:01PM BLOOD PT-15.3* PTT-29.5 INR(PT)-1.3*
[**2114-6-30**] 08:01PM BLOOD Glucose-97 UreaN-9 Creat-0.6 Na-126*
K-3.9 Cl-96 HCO3-26 AnGap-8
[**2114-6-30**] 08:01PM BLOOD ALT-107* AST-103* LD(LDH)-380*
CK(CPK)-485* AlkPhos-357* Amylase-301* TotBili-2.0*
[**2114-6-30**] 08:01PM BLOOD Albumin-2.2* Calcium-6.5* Phos-1.9*
Mg-2.0
Other Labs:
[**2114-7-5**] 06:55AM BLOOD Fibrino-295
[**2114-7-1**] 03:48AM BLOOD calTIBC-113* Ferritn-1120* TRF-87*
[**2114-7-5**] 06:55AM BLOOD Triglyc-260*
[**2114-7-1**] 03:48AM BLOOD Osmolal-268*
[**2114-7-1**] 03:48AM BLOOD TSH-2.3
[**2114-7-5**] 06:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2114-7-6**] 06:30AM BLOOD Vanco-11.9
[**2114-7-5**] 06:55AM BLOOD HCV Ab-NEGATIVE
Microbiology:
toxoplasma negative
urine strep antigen negative
Q fever: pending
mycoplasma pending
Influenza A and B pending
HIV negative
EBV PCR negative
CMV negative
[**Location (un) **] PND
Chlamydia trachomatis and psittica PND
Lyme serology PND
syphilis negative
dsDNA PND
[**Doctor First Name **] negative
RF negative
CSF enterovirus and lyme PND
B. HENSELAE IGG SCREEN - Negative
FRANCISELLA TULARENSIS SEROLOGY Results Pending
LEPTOSPIRA ANTIBODY Results Pending
[**2114-6-30**] 9:56 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2114-7-1**]):
[**12-3**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2114-7-3**]):
SPARSE GROWTH Commensal Respiratory Flora.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2114-7-2**] 9:35 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2114-7-2**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2114-7-4**]):
SPARSE GROWTH Commensal Respiratory Flora.
[**2114-7-5**] 8:42 am FLUID,OTHER Source: lymph node r/o
enterovirus.
GRAM STAIN (Final [**2114-7-5**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): *PENDING*
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2114-7-6**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
VIRAL CULTURE (Preliminary): *PENDING*
CXR ([**2114-6-30**]) - FINDINGS: There are no old films available for
comparison. The ET tube is 5.5 cm above the carina. The NG tube
is slightly high with the proximal port just above the GE
junction. There are bilateral lower lobe infiltrates and
probable small right effusion. The heart is mildly enlarged.
RUQ U/S ([**2114-7-1**]) - IMPRESSION:
1. No evidence of CBD dilation or stones.
2. Non-dilated gallbladder, free of stones. Moderate amount of
pericholecystic fluid and mild gallbladder wall edema may be
compatible with diffuse liver process such as hepatitis, even in
the absence of focal
intrahepatic ultrasound abnormalities.
3. Mild splenomegaly
CT NECK W CONTRAST ([**2114-7-1**]) - IMPRESSION:
1. Extensive bilateral cervical lymphadenopathy, particularly in
the
jugulodigastric and posterior cervical triangles. These findings
may be
reactive.
2. Slightly hyperenhancing and heterogeneous appearance of the
parotid glands bilaterally, may reflect reported history of
parotiditis. No discrete fluid collection or abscess identified.
3. Diffuse infiltration of the subcutaneous [**Last Name (LF) **], [**First Name3 (LF) **] reflect
anasarca.
4. Large bilateral pleural effusions, partially imaged, better
assessed on
concurrent chest CT.
CT CHEST W/O CONTRAST ([**2114-7-1**]) - IMPRESSION:
1. ET tube appropriately positioned.
2. Side port of the gastric tube is positioned at the GE
junction.
3. Moderate-sized bilateral pleural effusions with neighboring
compressive
atelectasis. An underlying consolidative process cannot be
excluded.
4. Enlarged bilateral axillary lymph nodes, with no evidence of
mediastinal
or hilar lymphadenopathy.
5. Small pericardial effusion.
ECHO ([**2114-7-2**]) - The left atrium and right atrium are normal in
cavity size. The estimated right atrial pressure is 10-20mmHg.
Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the basal half of the anterior and
anteroseptal walls. The remaining segments contract normally
(LVEF = 40 %). Transmitral and tissue Doppler imaging suggests
normal diastolic function, and a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is mild pulmonary artery systolic hypertension. There is a
very small anterior pericardial effusion without evidence of
hemodynamic compromise.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction in a distribution that is atypical
for CAD and suggests myocarditis or other process (cannot fully
exclude CAD). Mild pulmonary artery systolic hypertension.
NECK U/S ([**2114-7-4**]) - IMPRESSION: Numerous bilateral lymph nodes
diffusely prominent but with largely preserved normal
morphology; a level 4 node on the left shows an expanded cortex
and could potentially be targeted for fine needle aspiration.
CXR ([**2114-7-2**]) - Previous interstitial abnormality and vascular
engorgement in the upper lungs has cleared, but there is still
considerable consolidation at the lung bases, left greater than
right. Small to moderate bilateral pleural effusions remain.
Overall sequence of findings could be due to aspiration during
an episode of pulmonary edema progressing to bibasilar
pneumonia, or the succession of bacterial to previous viral
pneumonia. Heart size is normal.
CARDIAC MRI - [**2114-7-6**]
1. Normal left ventricular cavity size with mildly depressed
global left
ventricular function. The LVEF was mildly depressed at 53%. The
effective
forward LVEF was mildly depressed at 47%. No CMR evidence of
prior myocardial scarring/infarction. There was increased T2
signal of the myocardium consistent with possible myocarditis.
2. Normal right ventricular cavity size and systolic function.
The RVEF was normal at 58%.
3. Moderate sized circumferential pericardial effusion.
4. Mild mitral regurgitation.
5. Biatrial enlargement.
6. Bilateral pleural effusions and atelectasis as described
above.
Image quality was limited due to difficulty with breath-holding
and a high
heart rate. If clinically indicated, a repeat study when her
clinical
condition improves may provide better diagnostic results.
STUDIES TO BE FOLLOWED UP:
- Culture Data from LN Bx
Brief Hospital Course:
41F with progressive fevers, cervical/axillary lymphadenopathy
who has now developed hypoxic respiratory failure.
1. Hypoxic Respiratory Failure - Possible etiologies included
infectious vs inflammatory reaction. Also possible is extrinsic
airway compression from the progressive LAD, but history without
stridor, etc. Improved rapidly with diuresis and chest x-ray
revealed resolution of vascular congestion and effusions.
Extubated [**2114-7-1**] without difficulty. Supplemental oxygen
weaned over several days until room air on [**2114-7-3**]. Respiratory
status stable at the time of discharge.
2. Lymphadenopathy - Etiology unclear, but after extensive
evaluation most likely appears to be viral syndrome. Initial
differential included infectious (esp viral) etiologies,
autoimmune/inflammatory etiologies, and malignancy. Extensive
infectious work-up was begun at OSH prior to transfer with all
results being negative. Also with prior FNA without evidence of
malignancy, and [**Doctor First Name **]/RF negative, with dsDNA negative.
Inflammatory markers elevated on admission which was consistent
with physical exam. Initial serologies from [**Hospital 8641**] hospital
were followed daily without any positive results prior to
tranfer out of the ICU. ENT was consulted for potential
lymphnode biopsy but felt that nodes were too deep. U/s on
[**2114-7-4**] revealed accessible lymphnodes and on [**7-5**] patient
underwent FNA of her lymphnode. FNA was negative for malignancy
and all culture results were negative to date by time of
discharge. Pending serologies at the time of discharge include
tularemia and leptospirosis.
3. Parotiditis - Etiology unclear. Constellation of symptoms
could be consistent with mumps, but differential diagnosis
includes enterovirus, paraflu 3, influenza A, acute HIV,
bacterial (S. Aureus most common, but also gram negatives), drug
reaction, tumor, Sjogrens or sarcoid. Infectious work-up
negative (Mumps serology IgG +, IgM NEG). HIV serology was
negative. Treated symptomatically with lozenges, [**Doctor Last Name 84857**] and
hydration. Also continued on antibiotic coverage with Vanco (in
case of MRSA), Zosyn (gram negative coverage) and Levofloxacin
(atypical coverage) x 14 days. Infectious disease was consulted
and followed patient throughout her hospitalization. At the
time of discharge, extensive infectious work-up as thus far
negative (see above). The patient will follow up with ENT and
infectious disease as an outpatient.
4. Cardiomyopathy - Echo at OSH with EF 30-35% compared to Echo
in [**11-17**] with 60-65%. Likely viral in etiology as no risk
factors for CAD. Iron studies and TSH within normal limits.
Volume overload on initial chest x-ray but this improved through
auto-diuresis and Lasix. Cardiac MRI was performed and showed
LVEF of 53%, moderate sized pericardial effusion, and findings
consistent with myocarditis. Patient will have repeat echo as
an outpatient to reassess LVEF and resolution of effusions.
5. Abnormal LFTs - Likely due to viral process, especially with
normal ultrasound. LFTs were trended and did rise slightly at
first. Hepatitis serologies were negative. LFT's were improving
at the time of discharge and will be followed as an outpatient.
6. Hyponatremia - Initially presented with hyponatremia to 126
in the setting of intravascular volume overload. Diuresed with
Lasix and improved to 133. Then redeveloped hyponatremia. This
was attributed to hypovolemia given high insensible losses and
large volume urine output although urine lytes and osmolality
consistent with inappropriate ADH secretion. Patient continued
to have intermittent mild hyponatremia throughout hospital stay
which did not improve significantly with fluid resuscitation.
7. Tachycardia - Presented with tachycardia > 100. EKG revealed
sinus tachycardia. Contributing factors including fever,
anxiety, pain and hypovolemia. Intermittently improved to 80s
with fluid or lorazepam but not with a clear pattern. Monitored
on telemetry for 5 days while in ICU. Tachycardia improved
furhter after pt was called out to the floor.
8. Fevers - Patient with persistent fevers upwards of 103
despite Acetaminophen dosing and broad spectrum antibiotics.
Infectious work-up as above. Fevers were improved at the time
of discharge.
9. Anemia - Admitted with initial Hct 29.6. Iron studies not
consistent with deficiency. Likely due to acute inflammatory
response. Hct was trended and was relatively stable.
Medications on Admission:
Home Medications: None
Transfer Medications:
Vancomycin 1g IV q12h
Levofloxacin 750 IV q24
Zosyn 3.375g IV q6h
Compazine
Benadryl 25mg IV q6h prn (not used)
Toradol 30mg IV q6h
Oxycodone 10 po q3h prn
OxyconTIN 20mg po q12h
Pantoprazole 40mg IV daily
Zofran 4mg IV q4h prn nausea
Colace
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Do not exceed 4gm per day. .
2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Anxiety.
Disp:*15 Tablet(s)* Refills:*0*
3. Outpatient [**Name (NI) **] Work
Pt should have the following weekly labs drawn: CBC, Chem 7,
LFTs, ESR, CRP. Results should be faxed to [**Telephone/Fax (1) 85465**] (Attn:
[**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 1352**]).
4. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical ASDIR
(AS DIRECTED).
Disp:*1 bottle* Refills:*2*
5. Outpatient Physical Therapy
prolonged illness, evaluation and treatment for endurance
training
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Cervical lymphadenopathy
- Cervical rash
- Bilateral parotiditis
- Hypoxic Respiratory Failure
- Acute systolic heart failure
- Moderate pericardial effusion
- Hepatitis
- Fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
You were transferred to [**Hospital3 **] with respiratory distress
requiring intubation and with swelling in the lymph nodes in
your neck. You were also found to have depressed cardiac
function. You respiratory status gradually improved, and you
were able to successfully be extubated. It was felt that your
lymph node swelling and your rash were likely related to an
infectious process. However, an extensive infectious work-up was
sent, which was negative. You are now being discharged to home
after completing a 14-day course of antibiotics.
You will need to follow up with the infectious disease
specialist and otolaryngologist. You will also need to have
another ultrasound of your heart to ensure that cardiac function
is returning to normal.
CHANGES TO YOUR MEDICATIONS:
- continue ativan as needed for anxiety until you see your
primary care physician
[**Name Initial (PRE) **] [**Name10 (NameIs) **] using Lac Hydrin lotion as needed for the exfoliation
of skin over your neck and arms
It was a pleasure taking part in your medical care.
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 85466**], MD
Specialty: Primary Care
When: Wednesday [**7-18**] at 10:30am
Address: [**Location (un) 85467**], [**Location (un) **],[**Numeric Identifier 30816**]
Phone: [**Telephone/Fax (1) 85468**]
You should also follow-up with the [**Hospital **] clinic at [**Hospital3 **]
within 1 week of discharge. You should follow-up in the ID
urgent care clinic to ensure that you are seen in a timely
manner. The number for this clinic is [**Telephone/Fax (1) 457**].
You also need to schedule an ECHO, or ultrasound of the hear in
[**3-14**] weeks. Please call [**Telephone/Fax (1) 85469**] to schedule an appointment
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,630
| 100,808
|
8413
|
Discharge summary
|
report
|
Admission Date: [**2194-8-18**] Discharge Date: [**2194-8-27**]
Date of Birth: [**2108-10-18**] Sex: F
Service: SURGERY
Allergies:
Lisinopril / Metformin
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Bright red [**First Name3 (LF) **] per rectum
Major Surgical or Invasive Procedure:
[**2194-8-19**] SMA arteriogram, selective ileocolic arteriogram
exploratory laparotomy with extended right colectomy.
[**2194-8-20**] end ileostomy
History of Present Illness:
85 year old female h/o afib with RVR on pradaxa with BRBPR x
several weeks with increased amount of [**Month/Day/Year **] this week. Patient
reports the increased bleeding was also associated with
suprapubic pain accompanied by dysuria and some fevers, chills,
nausea and vomiting. Patient previously diagnosed with UTI and
has been taking Nitrofurantoin with improvement of her symptoms.
Patient additionally noted chest pain prior to presentation to
ED. The chest pain resolved without intervention and she is
currently chest pain free. Initially an EKG showed afib without
any acute changes. SBP 100, not lightheaded or dizzy.
In ED patient noted to be mildly tachycardic, with increasing
heart rate after volume resuscitation with 2L NS. Patient
underwent CTA of the abdomen which showed active venous
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
Atrial fibrillation
Hypothyroidism
Osteoarthritis, s/p bilateral knee replacements in [**2182**]
Depression
Asthma, diagnosed in [**2184**]
C-sections in past
Social History:
Husband died many years ago. Patient lives with her
granddaughter who is her proxy. Smoked 36 years x 1 ppd, quit in
[**2181**], remote social ETOH.
Family History:
Family history of CVA/CAD.
Physical Exam:
Physical Exam upon presentation:
Vitals: 97.4 111 127/78 17 100% RA
GEN: A&O to self, appropriate, resting comfortably, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregular, rate controlled, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, minimally tender, no rebound or
guarding, normoactive bowel sounds, no palpable masses
DRE: normal tone, guiac positive, no gross [**Year (4 digits) **]
Ext: No LE edema, LE warm and well perfused. R femoral sheath
intact.
Physical Exam upon discharge:
VS:97.6, 95, 125/58, 20, 99/RA
GEN: Arousable to voice, NAD.
HEENT:HEENT: No scleral icterus, mucus membranes moist
CV: Irregular, rate controlled. No M/R/G.
PULM: Faint expiratory wheezes bilaterally. No rales/rhonchi.
ABD: Soft, nondistended, nontender. Ileostomy + fecal output.
EXT: + 1 pitting edema all four extremities. No Cyanosis,
clubbing. WWP.
Pertinent Results:
[**2194-8-18**] 08:10PM [**Month/Day/Year 3143**] WBC-8.0 RBC-2.76*# Hgb-8.7*# Hct-26.9*#
MCV-97# MCH-31.4 MCHC-32.3 RDW-15.2 Plt Ct-204
[**2194-8-19**] 01:17AM [**Month/Day/Year 3143**] WBC-7.8 RBC-2.32* Hgb-7.2* Hct-22.1*
MCV-96 MCH-31.1 MCHC-32.5 RDW-15.5 Plt Ct-164
[**2194-8-19**] 06:03AM [**Month/Day/Year 3143**] WBC-10.5 RBC-2.97*# Hgb-8.6* Hct-26.3*
MCV-89# MCH-29.0 MCHC-32.8 RDW-16.7* Plt Ct-124*
[**2194-8-19**] 11:00AM [**Month/Day/Year 3143**] Hct-29.0*
[**2194-8-19**] 03:01PM [**Month/Day/Year 3143**] WBC-8.9 RBC-3.06* Hgb-9.1* Hct-26.4*
MCV-90 MCH-29.8 MCHC-33.2 RDW-16.5* Plt Ct-124*
[**2194-8-19**] 07:18PM [**Month/Day/Year 3143**] Hct-28.5*
[**2194-8-20**] 01:53AM [**Month/Day/Year 3143**] WBC-5.4 RBC-2.96* Hgb-9.1* Hct-26.4*
MCV-89 MCH-30.8 MCHC-34.5 RDW-15.1 Plt Ct-71*
[**2194-8-20**] 05:26AM [**Month/Day/Year 3143**] WBC-12.7*# RBC-3.57* Hgb-11.3* Hct-31.3*
MCV-88 MCH-31.5 MCHC-35.9* RDW-15.3 Plt Ct-92*
[**2194-8-20**] 09:25AM [**Month/Day/Year 3143**] Hct-30.3*
[**2194-8-20**] 01:38PM [**Month/Day/Year 3143**] Hct-26.7*
[**2194-8-20**] 03:24PM [**Month/Day/Year 3143**] Hgb-9.9* Hct-29.0*
[**2194-8-21**] 12:50AM [**Month/Day/Year 3143**] WBC-13.0* RBC-2.63*# Hgb-7.8* Hct-23.4*
MCV-89 MCH-29.8 MCHC-33.6 RDW-16.0* Plt Ct-104*
[**2194-8-21**] 04:02AM [**Month/Day/Year 3143**] Hct-26.9*
[**2194-8-21**] 09:31AM [**Month/Day/Year 3143**] Hct-25.5*
[**2194-8-21**] 01:05PM [**Month/Day/Year 3143**] Hgb-8.3* Hct-23.6*
[**2194-8-21**] 05:05PM [**Month/Day/Year 3143**] Hct-22.0*
[**2194-8-21**] 09:44PM [**Month/Day/Year 3143**] Hct-27.1*
[**2194-8-22**] 02:47AM [**Month/Day/Year 3143**] WBC-8.0 RBC-2.99* Hgb-9.1* Hct-26.4*
MCV-88 MCH-30.4 MCHC-34.5 RDW-16.0* Plt Ct-105*
[**2194-8-22**] 07:22AM [**Month/Day/Year 3143**] Hct-19.8*
[**2194-8-22**] 09:30AM [**Month/Day/Year 3143**] Hct-25.5*#
[**2194-8-22**] 04:00PM [**Month/Day/Year 3143**] WBC-5.8 RBC-2.97* Hgb-9.1* Hct-26.2*
MCV-88 MCH-30.5 MCHC-34.5 RDW-16.5* Plt Ct-113*
[**2194-8-18**] 08:10PM [**Month/Day/Year 3143**] PT-19.8* PTT-33.9 INR(PT)-1.9*
[**2194-8-19**] 01:17AM [**Month/Day/Year 3143**] PT-18.7* PTT-47.9* INR(PT)-1.8*
[**2194-8-19**] 03:27PM [**Month/Day/Year 3143**] PT-15.6* PTT-38.1* INR(PT)-1.5*
[**2194-8-19**] 09:50PM [**Month/Day/Year 3143**] PT-17.9* PTT-43.0* INR(PT)-1.7*
[**2194-8-20**] 01:53AM [**Month/Day/Year 3143**] PT-18.2* PTT-43.2* INR(PT)-1.7*
[**2194-8-21**] 12:50AM [**Month/Day/Year 3143**] PT-20.4* PTT-46.7* INR(PT)-1.9*
[**2194-8-22**] 02:47AM [**Month/Day/Year 3143**] PT-18.0* PTT-53.8* INR(PT)-1.7*
[**2194-8-22**] 04:00PM [**Month/Day/Year 3143**] PT-15.6* PTT-46.8* INR(PT)-1.5*
[**2194-8-18**] 08:10PM [**Month/Day/Year 3143**] Glucose-154* UreaN-42* Creat-1.8* Na-139
K-4.1 Cl-104 HCO3-18* AnGap-21*
[**2194-8-19**] 01:17AM [**Month/Day/Year 3143**] Glucose-121* UreaN-39* Creat-1.5* Na-141
K-3.6 Cl-110* HCO3-19* AnGap-16
[**2194-8-19**] 06:03AM [**Month/Day/Year 3143**] Glucose-165* UreaN-38* Creat-1.2* Na-143
K-3.3 Cl-113* HCO3-19* AnGap-14
[**2194-8-20**] 01:53AM [**Month/Day/Year 3143**] Glucose-168* UreaN-34* Creat-1.1 Na-146*
K-3.5 Cl-120* HCO3-17* AnGap-13
[**2194-8-21**] 12:50AM [**Month/Day/Year 3143**] Glucose-218* UreaN-36* Creat-1.4* Na-145
K-4.9 Cl-118* HCO3-14* AnGap-18
[**2194-8-21**] 09:31AM [**Month/Day/Year 3143**] Glucose-166* UreaN-34* Creat-1.3* Na-144
K-4.0 Cl-115* HCO3-19* AnGap-14
[**2194-8-22**] 02:47AM [**Month/Day/Year 3143**] Glucose-118* UreaN-28* Creat-0.7 Na-144
K-3.7 Cl-116* HCO3-19* AnGap-13
[**2194-8-22**] 04:00PM [**Month/Day/Year 3143**] Glucose-114* UreaN-23* Creat-1.1 Na-144
K-3.3 Cl-115* HCO3-20* AnGap-12
[**2194-8-19**] 07:43PM [**Month/Day/Year 3143**] Lactate-1.2
[**2194-8-19**] 09:56PM [**Month/Day/Year 3143**] Glucose-124* Lactate-2.4* Na-141 K-3.7
Cl-119*
[**2194-8-19**] 11:37PM [**Month/Day/Year 3143**] Glucose-247* Lactate-2.0 Na-142 K-4.1
Cl-115*
[**2194-8-20**] 01:01AM [**Month/Day/Year 3143**] Glucose-189* Lactate-2.1* Na-140 K-3.8
Cl-119*
[**2194-8-20**] 02:02AM [**Month/Day/Year 3143**] Glucose-153* Lactate-2.7* Na-139 K-3.5
Cl-120*
[**2194-8-20**] 10:02PM [**Month/Day/Year 3143**] Lactate-3.5* K-4.1
[**2194-8-21**] 12:56AM [**Month/Day/Year 3143**] Lactate-5.0* K-4.7
[**2194-8-21**] 04:09AM [**Month/Day/Year 3143**] Lactate-3.0* K-4.2
[**2194-8-21**] 09:39AM [**Month/Day/Year 3143**] Lactate-2.1*
[**2194-8-21**] 01:19PM [**Month/Day/Year 3143**] Lactate-1.8
[**2194-8-21**] 05:16PM [**Month/Day/Year 3143**] Lactate-1.7
[**2194-8-21**] 08:49PM [**Month/Day/Year 3143**] Lactate-1.6
[**2194-8-22**] 02:56AM [**Month/Day/Year 3143**] Lactate-1.0
[**2194-8-27**] 05:46AM [**Month/Day/Year 3143**] WBC-8.0 RBC-2.68* Hgb-8.2* Hct-25.6*
MCV-96 MCH-30.8 MCHC-32.2 RDW-16.9* Plt Ct-249
[**2194-8-26**] 05:54AM [**Month/Day/Year 3143**] WBC-8.2 RBC-2.76* Hgb-8.7* Hct-25.9*
MCV-94 MCH-31.4 MCHC-33.5 RDW-16.8* Plt Ct-230
[**2194-8-27**] 05:46AM [**Month/Day/Year 3143**] Glucose-185* UreaN-17 Creat-0.9 Na-141
K-3.5 Cl-108 HCO3-27 AnGap-10
[**2194-8-26**] 06:21PM [**Month/Day/Year 3143**] Glucose-211* UreaN-16 Creat-0.9 Na-144
K-3.8 Cl-110* HCO3-26 AnGap-12
[**2194-8-27**] 05:46AM [**Month/Day/Year 3143**] Calcium-7.7* Phos-2.3* Mg-1.8
[**2194-8-26**] 06:21PM [**Month/Day/Year 3143**] Calcium-8.5 Phos-2.1* Mg-2.0
[**2194-8-18**] Mesenteric CTA abdomen/pelvis
ABDOMEN: Focal area of scarring in the right middle lobe base
is similar to prior exam (3A:3). The liver shows no intrahepatic
biliary dilatation. A 4-mm focus of arterial enhancement in the
left lobe of the liver persists during the venous phase, likely
making this a small hemangioma as opposed to more aggressive
lesion with washout features; its appearance is similar to prior
chest CTA (3B:206). The gallbladder is distended, but shows no
stones or wall edema. The CBD is prominent in diameter,
measuring up to 11 mm in diameter and tapering to 5 mm more
distally. The spleen is normal in size. The pancreas and
adrenal glands show no masses.
The kidneys enhance with and excrete contrast symmetrically
without evidence of hydronephrosis. A small hypodensity in
right upper pole is too small to characterize and likely
represents a simple cyst and measures 6 mm in diameter (3B:211).
In the mid pole of the left kidney is an area of cortical
thinning, likely representing scarring from either prior
infection or infarct (3B:222). Incidental note is made of a
fat-containing ventral wall hernia (3B:279). The small and large
bowel show no evidence of obstruction or wall edema. The right
colon contains liquid stool with peripheral aerosolized
contents. No pneumatosis or portal venous gas is present. A
focal blush of intraluminal contrast is present within the right
colon during the venous phase (3B:253). There is no free air,
free fluid, or lymphadenopathy.
PELVIS: The bladder is decompressed around a Foley balloon.
The uterus
demonstrates calcified fibroids. The rectum is unremarkable.
There is no
free fluid or lymphadenopathy. A lipoma is incidentally noted
anterior to the right hip, measuring 5 x 3 cm in the axial plane
(3B:339). Sigmoid diverticulosis is present without
diverticulitis.
CTA/CTV: The aorta is of a normal caliber along its course.
The origins of the celiac and SMA are narrowed but patent. The
renal arteries demonstrate calcified atherosclerotic disease at
their origins, but are also patent. The [**Female First Name (un) 899**] is open. The iliac
and femoral arterial branches are also patent. In the venous
phase, the portal vein, splenic vein, and SMV are all patent.
Again is noted a blush within the lumen of the right colon on
this phase.
IMPRESSION:
1. Focal blush of intraluminal contrast in the right colon
during the venous phase concerning for active hemorrhage
2. No evidence of pneumatosis or portal venous gas or bowel
wall edema.
3. Sigmoid diverticulosis without evidence of diverticulitis.
4. Prominent CBD raises the question of a stenotic sphincter of
Oddi -
correlate with LFT's.
[**8-19**] SMA arteriogram, Selective ileocolic arteriogram
Using a combined palpatory and fluoroscopic guidance and
following
administration of local anesthetic, the right common femoral
artery was
accessed with a 19-guage single wall puncture needle. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**]
wire was
easily advanced into the lower order and the needle exchanged
for a 5 French [**Last Name (un) 2493**]-Tip vascular sheath. A Cobra catheter was
then advanced over the [**Last Name (un) 7648**] wire and the SMA selectively
calculated. An initial nonselective SMA DSA run in 2
projections demonstrated a normal anatomy of the SMA branches,
specifically with no evidence of active extravasation in the
area of the cecum (area of hemorrhage on previous CTA). The same
procedure for a selective DSA run with a microcatheter inserted
into
the ileocolic artery. Wires and catheters were withdrawn. Given
an INR of 1.8 and Pradaxa use, the sheath was left in place to
be withdrawn after successful correction of coagulopathy.
IMPRESSION:
Normal appearance of SMA branches, specifically without evidence
of active
extravasation in the area of the cecum (site of extravasation on
prior CTA). Given an INR of 1.8 and Pradaxa use, the sheath is
left in place and should be continuously flushed until removed
in the setting of corrected coagulopathy.
[**2194-8-21**] Echocardiogram
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF 65%). The right ventricular cavity is dilated with
depressed free wall contractility. There is abnormal septal
motion/position. The ascending aorta is mildly dilated. There
are focal calcifications in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion. There
is an anterior space which most likely represents a prominent
fat pad.
Compared with the findings of the prior study (images reviewed)
of [**2191-5-6**], the heart rate is increased, the left ventricle
is smaller (underfilled), with persistent right ventricular
dysfunction.
[**2194-8-20**] OR pathology R colon - pending
Brief Hospital Course:
Ms. [**Known lastname 3647**] was initially admitted to the MICU service with
BRBPR in the setting of chronic atrial fibrillation on pradaxa.
CTA positive for blush in right colon, mesenteric angiogram
negative for active extravasation. On [**8-19**], hospital day 2, GI
was planning to perform a colonoscopy to evaluate for a possible
source of the bleed. The patient was unable to tolerate the prep
and was becoming increasingly tachycardic with a worsening
abdominal exam. She continued to pass maroon stools and received
4 units of [**Month/Day (4) **] that day. In the evening, she became more
diffusely tender with concern for peritonitis and was taken to
the OR for exploratory laparotomy, found to have ischemic areas
throughout the transverse and right colon, as well as an
abnormal cecal appendage. There was a significant amount of
[**Month/Day (4) **] throughout the ascending and transverse colon. She
underwent an extended right colectomy, end ileostomy. She
received 3 more units of [**Month/Day (4) **] and 2 units of FFP during the
case. She was transferred to the SICU intubated and sedated.
On [**8-20**], the patient had periods of atrial fibrillation with RVR
to 130's alternating with sinus tachycardia 120-130. A diltiazem
gtt was started and an a-line was placed. Her BP did not
tolerate the drip and it was stopped as she remained mostly in
sinus. She continued to pass old [**Month/Day (1) **] per rectum and her urine
dropped to 15/hour. She was given a 1L bolus. IR removed her
right groin sheath at the bedside. Her hematocrit was ranging
between 26 and 30 on serial checks and no transfusion was given.
On [**8-21**], she continued to be tachycardic, in and out of afib, and
her hematocrit drifted to 23. She was transfused 1 unit of [**Month/Day (4) **]
and bumped to 26.9. She was given albumin 500cc 5% x 3 and 1L of
LR for ongoing tachycardia. Hematocrit down again throughout the
day to 22.4 and was given a second unit of [**Month/Day (4) **], up to 27.1.
Her diltizem drip was restarted for better rate control and a
right IJ CVL was placed to assess CVP which was found to be >20.
Heparin prophylaxis was restarted. Ileostomy teaching was
initiated by the Wound/Ostomy nurse.
On [**8-22**], Ms. [**Known lastname 3647**] was extubated without difficulty and weaned
to room air, lasix 10 x 1 given. She was having scant ostomy
output at this point, tube feeds were started on [**8-23**] and
advanced to goal, tolerated well, low residuals. On [**8-23**], the
ostomy output started to pick up. Diltiazem was transitioned to
enteral via NG route and heart rates remained in atrial
fibrillation, 70-90 range.
On [**8-24**], the patient was transferred to the surgical floor in
stable condition.
0n [**8-25**], the patient was experiencing inspiratory wheezes, lasix
20mg IV was given. She had a Speech and Swallow evaluation,
however she was too sleepy to be able to have a thorough
evaluation, and they recommended keeping patient NPO for the
time being. Her nasogastric tube remained in place for tube
feeds, which were being transfused at goal. Her hematocrit
remained stable at 25.
On [**8-26**], the patient's foley was discontinued and she voided
large quantity of urine. Her mental status improved and she was
more alert. She became tachycardic to the 130s and complained of
chest pain. An EKG revealed she was in atrial fibrillation. She
was given IV Lopressor and an adult dose aspirin. An ABG was
drawn which showed hypoxia, so the patient also received 40mg IV
lasix to improve her pulmonary function. A CXR also revealed a
presentation consistent with congestive heart failure. A foley
catheter was replaced for urine output monitoring. Patient's
chest pain resolved; troponins and CKMBs were drawn and were
negative. Physical therapy evaluated patient and they
recommended a rehab facility.
On [**8-27**], the patient passed her speech and swallow evaluation
and was advanced to a puree diet and nectar thickened fluids.
She was able to tolerate PO medications. Her nasogastric tube
was discontinued. She was restarted on her all her home
medications, including Pradaxa. She was still exhibiting signs
of fluid overload and received 40mg IV lasix x 2. Foley remained
in place for urine output monitoring. Vitals remained stable,
and patients heart rate was controlled with Metoprolol.
Medications on Admission:
1. Isosorbide Mononitrate 30 mg PO QDAILY
2. Furosemide 40 mg PO DAILY
3. GlyBURIDE 2.5 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Valsartan 160 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Pravastatin 40 mg PO DAILY
8. Allopurinol 100 mg PO BID
9. Oxybutynin 5 mg PO BID
10. Dabigatran Etexilate 150 mg PO BID
11. Colchicine 0.6 mg PO PRN arthritis
12. Diltiazem Extended-Release 240 mg PO DAILY
Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. Levothyroxine Sodium 112 mcg PO DAILY
3. Pravastatin 40 mg PO DAILY
4. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
5. Pantoprazole 40 mg PO Q24H
6. Allopurinol 100 mg PO BID
7. Colchicine 0.6 mg PO PRN arthritis
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
9. Gabapentin 300 mg PO Q12H
10. Diltiazem Extended-Release 240 mg PO DAILY
11. GlyBURIDE 2.5 mg PO DAILY
12. Isosorbide Mononitrate 30 mg PO QDAILY
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Oxybutynin 5 mg PO BID
15. Valsartan 160 mg PO DAILY
16. Ipratropium Bromide Neb 1 NEB IH Q6H
17. Insulin SC
Sliding Scale
Fingerstick q 6
Insulin SC Sliding Scale using REG Insulin
18. Dabigatran Etexilate 75 mg PO BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Lower Gastrointestinal bleed
Atrial fibrillation
Acute [**Hospital6 **] Loss Anemia
Acute on chronic pulmonary edema
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital with rectal bleeding. You lost a
significant amount of [**Last Name (LF) **], [**First Name3 (LF) **] you were taken to the OR for an
exploratory lapartomy in order to find the source of your
bleeding, and underwent a Right colectomy and ileostomy
placement. You had a nasogastric tube which was used to give you
tube feedings, but before you were discharged we were able to
start a puree diet. Pathology results are still pending of your
colon.
Please follow up in [**Hospital 2536**] clinic at the appointment sdcheduled for
you below. Your staples will be removed at this appointment.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Hospital 5059**] at your next visit.
Don't lift more than 20-25 lbs for 4-6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the staples. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red [**Name2 (NI) **] or foul smelling discharge coming from the
wound
- an increase in drainage from the wound.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 249**]
[**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 1, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2010**]
Date/Time:[**2194-10-20**] 10:50
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2194-9-18**] at 1 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2194-8-28**]
|
[
"274.9",
"585.9",
"599.0",
"567.89",
"V15.82",
"562.10",
"287.5",
"997.1",
"V43.65",
"244.9",
"427.31",
"403.90",
"584.9",
"V13.02",
"568.0",
"411.89",
"493.90",
"569.89",
"557.9",
"285.1",
"272.4",
"458.9",
"250.00",
"518.51",
"331.83",
"311",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"38.97",
"46.23",
"54.59",
"96.71",
"38.91",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
18791, 18857
|
13232, 17575
|
329, 480
|
19018, 19018
|
2670, 13209
|
24317, 25012
|
1716, 1744
|
18049, 18768
|
18878, 18997
|
17601, 18026
|
19198, 24294
|
1759, 2265
|
244, 291
|
2295, 2651
|
508, 1316
|
19033, 19174
|
1338, 1533
|
1549, 1700
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,114
| 170,048
|
1037
|
Discharge summary
|
report
|
Admission Date: [**2137-12-10**] Discharge Date: [**2137-12-17**]
Date of Birth: [**2077-8-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine-131 / Epinephrine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
Minimally Invasive Mitral Valve Repair with 30mm [**Doctor Last Name 405**] Band
on [**2137-12-10**]
History of Present Illness:
60 y/o female with h/o mitral vlave prolapse for 40 yrs. Has had
increased dyspnea on exertion this year with an episode of
congestive heart failure [**9-16**]. Recent echo showed 4+ mitral
regurgitation with severe prolapse/myxomatous leaflets. Was then
referred for surgery.
Past Medical History:
Mitral Valve Prolapse
Congestive Heart Failure
Hypercholesterolemia
Hypertension
Anxiety
Uterine Fibroids
Osteoarthritis
Irritable Bowel Syndrome
?Meniere's Syndrome
Bilat. Carpal Tunnel syndrome
s/p Left Hernia Repair
s/p Multiple Dilation and Curretage
Social History:
Lives alone and has a friend as her caretaker
DPH Inspector
Never smoked tobacco. Drinke wine 3x/wk
Family History:
Father with CHF
Physical Exam:
VS: 80 18 172/90 156/82 5'4: 160#
General: NAD, somewhat anxious
Skin: Unremarkable without lesions
HEENT: PERRLA, EOMI, Nonicteric
Neck: Supple, FROM, -JVD, -Bruit
Chest: CTAB -w/r/r
Heart: RRR, +S1S2, [**4-17**] murmur
Abd: Soft, NT/ND, +BS
Neuro: Nonfocal, MAE, A&O x 3
Brief Hospital Course:
Pt. was a same day admit and on [**2137-12-10**] pt was brought to the
operating room where she underwent a minimally invasive mitral
valve repair. Please see op note for surgical details. Pt was
transferred to the CSRU in stable condition. Later on op day pt
was weaned from mechanical ventilation and sedation and
extubated. She was neurologically intact. Inotropic support was
weaned off by post-operative day one. Pt received 1 unit pRBC's
on post-op day 1 for a hematocrit of 24.4. Diuretic and
b-blockers were started per protocol. Pt was transferred to the
telemetry floor on post-op day one. On post op day 2 the
patient's chest tube was removed, subsequently the patient
developed subcutaneous emphysema. On post op day three a chest
tubed was inserted into the right chest and placed on suction
inorder to treat a small pleural leak. The patient's crepitus
and subcutaneous air was much improved with the chest tube
treatment. On post op day seven her chest tube was removed, two
repeat chest xrays did not show any residual evidence of a
pneumothorax. The patient felt great on post day 8. She was
discharged home with services.
Medications on Admission:
1. ASA 81mg qd
2. Antivert 25mg [**Hospital1 **]
3. Ortho-Est
4. HCTZ 25mg qd
5. Xalatan 0.005% 1gtt OU qhs
6. Vit C 500mg qd
7. Ativan 1mg q4am, q5am
8. Calcium/Citracal/Vit. D
8. MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 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:*2*
4. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Mitral Regurgitation/Prolapse s/p Minimally Invasive Mitral
Valve Repair
Congestive Heart Failure
Hypercholesterolemia
Hypertension
Anxiety
Discharge Condition:
good
Discharge Instructions:
[**Month (only) 116**] take shower. Wash incisions with warm water and gentle soap.
Gently pat dry. Do not bath
If you notice and redness or drainage from incisions or
experience fever greater than 101, please contact office
immediately.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks ([**Telephone/Fax (1) 917**]
Dr. [**Last Name (STitle) **] in [**2-14**] weeks
Dr. [**Last Name (STitle) 410**] in [**1-13**] weeks
|
[
"401.9",
"428.0",
"272.0",
"300.00",
"346.80",
"998.81",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"99.04",
"35.12",
"88.72",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
3592, 3667
|
1460, 2601
|
312, 414
|
3850, 3856
|
1131, 1148
|
2836, 3569
|
3688, 3829
|
2627, 2813
|
3880, 4119
|
4170, 4348
|
1163, 1437
|
253, 274
|
442, 720
|
742, 998
|
1014, 1115
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,617
| 179,233
|
17190+17191+56832
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2178-4-23**] Discharge Date: [**2178-5-10**]
Date of Birth: [**2129-5-19**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: Miss [**Known lastname **] is a 48 year old woman
with a past medical history of hypothyroidism carrying the
diagnosis of systemic lupus erythematosus who presents from
[**Hospital3 35813**] Center in [**Doctor Last Name 792**]with Group A beta
hemolytic Strep sepsis, rash, anopsia, myalgia, arthralgia and
hypoxia, and respiratory failure requiring intubation.
She initially presented to [**Hospital3 35813**] Center on the evening
of [**4-19**], complaining of upper extremity pain and fever to 102.0
F. The pain was most severe in her left axilla and shoulder.
Four weeks prior to admission, she began having upper extremity
swelling and stiffness particularly in her hands. She was
prescribed Vioxx for her symptoms.
On the 1st, she was referred to a rheumatologist who prescribed
Prednisone 20 mg q. day and then she presented to the outside
hospital on the 4th complaining of fever, diarrhea, stiff joints
and puffiness in her hands. She decided to go the Emergency
Department particularly because her left arm and shoulder had
increased in pain.
She had an outside hospital course notable for increased
erythematous rash on the left arm, neck, and chest, increased
white blood cell count to 22.0 with bandemia approximately 10 to
12%, positive blood cultures, four out of four bottles drawn
on the 4th for Group A beta hemolytic strep. She initially was
started on Rocephin which was changed to penicillin and
clindamycin.
On [**5-22**], she developed wheezing, hypoxia and shortness of
breath. She was transferred to the Medical Intensive Care Unit.
She was intubated on the 7th. Chest x-rays showed evidence of
pulmonary edema but she had a normal transthoracic
echocardiogram, normal ejection fraction and no evidence of
vegetations at the outside hospital. She had a chest CT scan
that showed significant lymphadenopathy in the mediastinum,
axillae, retroperitoneum and supraclavicular regions with some
question of mediastinal fluid.
The patient has a distant history of a malar rash especially
related to photosensitivity, sun exposure. Her [**Doctor First Name **] was positive
1 to 320 at the outside rheumatologist's office on the first. The
CRP and ESR were also elevated, CRP to 144 and the ESR to 74.
There was some concern at the outside hospital, but at [**Hospital1 1444**] her platelets were normal. Her
INR was normal. Her fibrinogen was 653. On the date of
transfer to [**Hospital1 69**], the patient was
given one dose of intravenous IG at 36 grams times one. On
transfer she was hemodynamically stable without need for
pressors.
PAST MEDICAL HISTORY:
1. Hypothyroidism.
2. Systemic lupus erythematosus.
No coronary artery disease, diabetes mellitus, pulmonary or
renal disease.
MEDICATIONS ON TRANSFER:
1. Synthroid 50 micrograms intravenous q. day.
2. Zantac intravenously q. 12.
3. Heparin subcutaneously.
4. Clindamycin 900 mg intravenous q. eight.
5. Intravenous IG 36 grams times one.
6. Ativan 2 to 4 grams intravenously.
7. Morphine sulfate 2 to 4 gram intravenous p.r.n.
8. At home the patient was taking Vioxx and Synthroid 100
micrograms q. day.
ALLERGIES: The patient denies any allergies, however, the
patient did have a rash to Dilaudid at the outside hospital.
LABORATORY: Microbiological data drawn on the [**5-20**], the
patient had four out of four bottles of Group A beta hemolytic
strep at the outside hospital.
EKG sinus tachycardia, normal axis, normal intervals. The
patient had ultrasound of the left upper extremity which revealed
no deep venous thrombosis; this was on the [**5-20**] at the
outside hospital.
The patient had a chest x-ray at the outside hospital on [**4-23**]
with parenchymal changes consistent with low grade edema,
vascular engorgement, congestive heart failure. The patient had a
CT scan of the chest as noted on the 5th, adenopathy in
mediastinum, retroperitoneal, axilla, supraclavicular regions
with small pericardial effusion. Possible question of
mediastinal fluid/mediastinitis.
Pertinent laboratory data at transfer: Lyme serology negative.
Hepatitis B, Hepatitis C negative. Parvovirus B19 negative.
Antistreptolysin 46, P-ANCA negative. Rheumatoid factor 19. [**Doctor First Name **]
positive 1:320, homogenous, anticentromere antibody negative. CRP
1 in 44; ESR 74; antismooth antibody negative. Ferritin 759.
Hemoglobin 9.1, hematocrit 27.4, white count 14.6 with 7 bands,
82 PMNs, one meta. INR 1.2, platelets 196. Sodium 131,
potassium 4.3, chloride 99, bicarbonate 21, anion gap 11, BUN 26,
creatinine 1.0, glucose 96. Albumin 2, total bilirubin 1.0, SGOT
62, down from 200; SGPT 40, down from 131.
CBC from the outside hospital on the 4th: her white blood
cell count was 22 with 11 bands. This decreased to 15.6 on
the day prior to transfer to 14.6 on the day of transfer.
Platelets on presentation were 219 the day prior to transfer,
196 on the day of transfer. TSH was 12.8, T4 was 6.6.
Ventilation settings at the time of transfer was AC-550 by
14, 50%, PEEP of 5 with an arterial blood gas of 7.33, 44,
151. She was on 15 of Propofol for sedation.
PHYSICAL EXAMINATION: Pulse 78; blood pressure 120/70; 97%
on the above stated ventilator settings. Her intakes and
outputs were roughly on presentation the first 12 hours one
liter in and one liter out. Temperature at presentation was
99.8 F.; temperature maximum of 100.4 F.; she was sedated and
intubated. She had erythema in her right neck
supraclavicular region as well as her left breast and left
medial aspect of her arm. There is petechiae in her right
ankle. There was swelling and warmth in her shoulder,
deltoid and axilla region on the left hand side. Upon
palpation of these areas the patient would grimace, bite down
the ETT tube and become hypertension and tachycardic implying
pain in the region. HEENT: Pupils equally round and
reactive to light and accommodation. Neck with no jugular
venous distention. No bruit. Lungs were clear to
auscultation anteriorly however, there were scattered wheezes
bilaterally. Regular rate and rhythm. S1, S2. There is a I
to II systolic ejection murmur at the apex to axilla.
Abdomen was soft, normoactive bowel sounds, no
hepatosplenomegaly. Abdomen was mildly distended. Plus two
upper extremity edema in hands as well as plus one in the
feet. As stated earlier, the patient was sedated.
Ventilator settings at [**Hospital1 69**]
on presentation were AC40%, 550 by 16, volume approximately
8.8, PEEP of 8.
ASSESSMENT: This is a 48 year old woman with Group alpha beta
hemolytic strep sepsis transferred from the outside hospital.
She was hemodynamically stable, not on pressors, with report of
toxic shock syndrome but with normal renal and end-organ function
with the exception of Pulmonary status at presentation, with left
arm axilla pain at presentation.
HOSPITAL COURSE:
1. BETA HEMOLYTIC STREP SEPSIS: Unclear at the entry for
the source of the Group A beta hemolytic strep. The patient
denies symptoms of pharyngitis, however, there were reports later
on after discussion with the patient of excoriations and possibly
a dermatological portal of entry.
The infectious disease service was consulted, and the patient was
continued on penicillin and Clindamycin until the [**2178-5-3**], at which time penicillin was discontinued. The patient's
white count decreased to 6.4 on the 18th with no bands and 76
PMNs.
Given the patient's pain and significant adenopathy and CT scan
from the outside hospital, it was felt that the left shoulder was
indeed the portal source for the bacteremia. The patient had an
MRI on the [**4-25**] which showed edema and enhancement about
the left shoulder girdle, prominent tracking along the subclavian
and axillary vessels and in the subacromial and subdeltoid bursa,
fat and along the superficial surface of the deltoid and within
the anterior fibers of the deltoid. These findings are
consistent with inflammation making this highly suspicious for
soft tissue infection including focal myositis of the deltoid.
Both the Surgical and Orthopedic Teams felt that given the
patient's improvement clinically in terms of a white count and
examination of the left shoulder, that there was no indication to
have a surgical intervention. There was no focal collection of
fluid and although the patient seemed to have evidence of mild
myositis, there was no evidence of necrotizing fasciitis on
clinical examination.
The patient will require a total of three weeks of Clindamycin,
at which time the patient should get a repeat MRI to evaluate the
left shoulder, and then follow-up at Infectious Disease clinic
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
2. FEVER: The patient's fever curve generally improved.
Although her baseline temperature was low grade 99 to 100.0
F., she had spike to 102.0 F. Multiple blood cultures were
drawn. The patient has blood cultures from the 19th, two
sets; 15th two sets; 12th two sets; 11th one set; 10th two
sets; 9th two sets. Only positive cultures were coagulase
negative Staphylococcus on the [**2178-4-30**].
The patient had had a PICC line on the [**2178-4-27**].
This PICC line was associated with hypotension and ventricular
tachycardia. The PICC line was placed at the bedside. The
patient had runs of ventricular tachycardia with blood pressure
into the 80s. The patient was bolused intravenous fluids. The
line was pulled back 8 cm with resolution of the abnormal heart
rhythm. Further x-ray was done which showed the tip of the
catheter PICC line still in the right ventricle. This was pulled
back an additional 4 cm. Due to the prolonged exposure of the
PICC line to the environment, when patient spiked on the 15th,
the PICC line was promptly removed. However, the patient
continued to have fevers even after this line was discontinued.
Despite a general improvement in her swelling of her left arm
and left soft tissues, continued maintenance of a white count in
the 6.0 range as well as good urine output and no focal symptoms,
one possibility was the Clostridium difficile infection, the
patient did not have diarrhea and had two negative cultures for
Clostridium difficile on the 12th. However, given the treatment
with clindamycin, this placed the patient at a high risk for
Clostridium difficile and it is noted that the patient should be
monitored for Clostridium difficile infections. If she has any
continued fevers, high white counts or diarrheal symptoms, that
Clostridium difficile toxin should be sent and empiric coverage
with Flagyl should be considered. A possible source of
the patient's fever was a reaction to beta lactate antibiotics,
particular penicillin. The patient had a maculopapular rash on
her left arm as well as on her flanks associated with fever
spikes in the context of taking penicillin with her clindamycin.
The patient had a urine culture on the [**4-24**] which showed
extended spectrum beta lactamase E. coli. Unclear whether this
was a colonizer or a pathogen but the patient had a Foley
catheter in place. The patient was treated with Ciprofloxacin
for five days and repeat urine cultures thereafter were negative.
3. HYPOXEMIC RESPIRATORY FAILURE: The patient was intubated
at the outside hospital. Shortly after being transferred to [**Hospital1 1444**], she was switched from AC to
pressure support and did well. The patient eventually did well
on the spontaneous breathing trial. The cuff was taken down and
the patient did not have a cuff leak around the balloon,
suggesting airway edema. The patient also had expiratory
wheezes. Given the patient's chest x-ray it was hypothesized the
wheezes might be secondary to volume overload as the patient
did not have any asthma history or reactive airway history.
The patient was given empiric treatment with intravenous
Lasix, but this did not improve the cuff leak around the ET tube.
However, it should be noted that the patient's pulmonary
edema/infiltrates that were reported at the outside hospital
improved as her infection improved after treatment course
progressed, most likely suggesting some degree of capillary leak
at the outside hospital.
The patient was brought to the Operating Room for extubation.
She had no supplemental oxygen requirement after four additional
days.
4. SYSTEMIC LUPUS ERYTHEMATOSUS: The patient has a past
medical history consistent with possible systemic lupus
erythematosus.
Please see the next discharge summary for further details
regarding the patient's continued care.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36
D: [**2178-5-5**] 14:50
T: [**2178-5-5**] 16:50
JOB#: [**Job Number 48209**]
Admission Date: [**2178-4-23**] Discharge Date: [**2178-5-6**]
Date of Birth: [**2129-5-19**] Sex: F
Service:
ADDENDUM: The previous dictation was cut off at hospital
course, point being systemic lupus erythematosus.
HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED):
1. SYSTEMIC LUPUS ERYTHEMATOSUS ISSUES: The patient has
numerous parts of her medical history consistent with
systemic lupus erythematosus including joint pain,
photophobic rash, positive antinuclear antibody, pericardial
effusion on the outside hospital computerized axial
tomography, and proteinuria on her initial urinalysis.
However, further urinalysis showed only trace protein when
the patient was not afebrile. The initial urinalysis showed
protein; however, the patient was febrile at that time.
Antinuclear antibody of 1:1280, being very suspicious for
connective tissue disease; although, this was in the context
of an acute infection. The patient's streptolysin was very
elevated; consistent with a strep infection at the patient's
presentation. BSI and anti-SNRP/anti-double stranded DNA
antibodies were negative. However, the patient will require
further outpatient workup regarding systemic lupus
erythematosus. The patient had seen a rheumatologist as an
outpatient prior to admission at the outside hospital, who
discussed with the patient the need for followup regarding
this matter when she leaves rehabilitation and is over her
acute infection so further laboratory work and examination
can be done.
2. LYMPHADENOPATHY ISSUES: The patient had a computerized
axial tomography on presentation with a very impressive
lymphadenopathy. This needs to be re-evaluated as an
outpatient following the resolution of her acute infection.
The differential diagnosis included connective tissue disease
or malignancy; however, it was most likely secondary to an
acute infection the patient presented with as well as the
toxic shock-like syndrome that was prior to this infection.
3. ANEMIA ISSUES: The patient presented from an outside
hospital with a hematocrit of approximately 27. Her ferritin
was markedly elevated; making iron studies in the acute
setting of an acute phase reactant less than useful on the
presentation to [**Hospital1 69**].
When she presented, there was some question of whether her
low blood count could be secondary to hemolysis secondary to
the toxic shock-like syndrome of her strep infection;
however, her total bilirubin was not elevated. Her LDH was
within normal limits. Her haptoglobin was also normal. It
was possible that her anemia is possibly secondary to
systemic lupus erythematosus or possible hemolysis that
occurred prior to presentation to [**Hospital1 190**]. Her nadir was 23.6 in the Medical Intensive
Care Unit. Her hematocrit was 26.8 on [**5-5**] without a
transfusion.
4. ACCESS ISSUES: The patient initially came with
peripheral intravenous lines and was noted to require
long-term intravenous antibiotics. The peripherally inserted
central catheter mentioned earlier was placed at the bedside
and was removed. Later a peripherally inserted central
catheter was placed under Interventional Radiology on [**5-5**]
without complications. The tips from the peripherally
inserted central catheter line that was removed did not grow
out any organisms.
While intubated, the patient received tube feeds. Status
post extubation, the patient was able to take normal oral
intake and did not have any problems swallowing pills, or
solids, or liquids and was leaving the hospital on a regular
oral intake diet.
5. COMMUNICATION ISSUES: The patient's primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 48210**] was called regarding her
presentation and course by the Medical Intensive Care Unit
intern.
Also, the patient's family was frequently informed about not
only her condition but plan, and general outlook, and
followup regarding the patient's care.
6. PROPHYLAXIS ISSUES: The patient was initially on
lansoprazole solution via orogastric tube. This was changed
to famotidine 20 p.o. twice per day when she was taking oral
intake. She was subcutaneous heparin three times per day and
then was getting physical therapy status post extubation.
The patient was transferred to the floor on [**2178-5-4**] with
a disposition to a [**Hospital 3058**] rehabilitation.
DISCHARGE DIAGNOSES:
1. Group A beta-hemolytic strep sepsis.
2. Soft tissue infection of the left shoulder.
3. Possible systemic lupus erythematosus.
4. Diffuse lymphadenopathy.
6. Mediastinal retroperitoneum, subauricular region axilla.
7. Fever likely secondary to a febrile reaction from
beta-lactam antibiotic; specifically penicillin.
8. Hypoxic respiratory failure; status post intubation and
extubation.
MEDICATIONS ON DISCHARGE:
1. Clindamycin 900 mg intravenously q.8h. (to complete
three weeks of treatment).
2. Usaryn apply twice per day to affected area.
3. Ibuprofen 600 mg p.o. q.8h. as needed.
4. Levothyroxine sodium 100 mcg p.o. once per day.
5. Albuterol/ipratropium bromide nebulizer solution inhaled
q.6h. as needed.
6. Albuterol 1 to 2 puffs inhaled q.6h. as needed.
7. Combivent meter-dosed inhaler q.6h. as needed.
8. Atarax 25 mg p.o. q.4-6h. as needed (for itching).
9. Senna one tablet p.o. twice per day as needed.
10. Tylenol 325 mg to 650 mg p.o. q.4-6h. as needed (for
fever).
11. Heparin 5000 units subcutaneously q.8h. (for deep venous
thrombosis prophylaxis if the patient is not ambulating).
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed regarding the need for
intravenous antibiotics and then follow up with a magnetic
resonance imaging as an outpatient after she is finished with
her antibiotic course and then follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
at the Infectious Disease Clinic at [**Hospital1 190**] approximately one week after the magnetic
resonance imaging.
2. The patient was also instructed to follow up with her
rheumatologist as an outpatient following her discharge from
[**Hospital 3058**] rehabilitation.
3. The patient was also instructed to follow up with her
primary care physician to help coordinate her care regarding
these subspecialty matters.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36
D: [**2178-5-5**] 15:04
T: [**2178-5-5**] 16:57
JOB#: [**Job Number 48211**]
Name: [**Known lastname **], [**Known firstname **] A Unit No: [**Numeric Identifier 8902**]
Admission Date: [**2178-4-23**] Discharge Date: [**2178-5-10**]
Date of Birth: [**2129-5-19**] Sex: F
Service:
This addendum is to the original Intensive Care Unit dictation.
These are the events on the Medical floor.
When the patient got to the Medical floor, blood cultures were
obtained on [**2178-5-4**]. When these blood cultures were negative
for 24 hours, a PICC line was placed so that the patient could
get IV clindamycin. The patient continued to have fevers of 101
and persistent left shoulder pain. Therefore, a MRI of the left
shoulder was reimaged showing interval decrease in extensive
edema and enhancement surrounding the left rotator cuff muscles
and left deltoid muscle. There is a slight increase in the
enhancement of synovium in the joint capsule and plenty amount of
fluid in the joint has not increased in the interval since the
last MRI of the left shoulder.
Patient was sent down to Interventional Radiology for possible
tap of the left shoulder, but the tap was not successful. The
Infectious Disease team was reconsulted, and they felt that the
patient could be switched over to po clindamycin for three weeks.
The patient's left shoulder then did improve after the imaging of
it. However, her fevers persist.
A chest x-ray was obtained showing no evidence of pneumonia.
Urine culture was obtained which showed mixed bacterial flora.
Her fevers were felt secondary to possible lupus or a healing
myositis. She is to have followup with Rheumatology on an
outpatient basis for her lupus and continue on her oral
clindamycin until she follows for her infectious disease doctor,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3769**]. She is also to have a reimaging of her left
shoulder prior to seeing her infectious disease doctor. She was
instructed to return if any further additional persistent fevers
or increasing pain in the left shoulder.
DISCHARGE DIAGNOSES:
1. Group A beta hemolytic Streptococcus bacteremia.
2. Hypoxic respiratory failure / adult respiratory distress
syndrome.
3. Lupus.
4. Anemia of chronic disease.
5. Hypothyroidism.
DISCHARGE MEDICATIONS:
1. Levothyroxine 100 mcg po q day.
2. Clindamycin 450 mg po qid through [**2178-5-25**].
3. Hydroxyzine 25 mg po q4-6h prn pruritus.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Home.
FOLLOWUP:
1. The patient is to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
Infectious Disease on [**2178-5-25**] at 1:30 pm on [**Hospital Ward Name 257**] 11th
floor, phone #[**Telephone/Fax (1) 496**].
2. The patient is to followup with Dr. [**Last Name (STitle) 8903**] in
Rheumatology on [**2178-7-9**] at 1 pm on the [**Hospital **] Medical
Building, Fourth Floor, [**Hospital Unit Name 8904**], phone #[**Telephone/Fax (1) 8905**].
3. The patient is to schedule a followup MRI prior to seeing
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3769**].
[**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D.
Dictated By:[**Last Name (NamePattern1) 4387**]
MEDQUIST36
D: [**2178-5-12**] 12:28
T: [**2178-5-12**] 13:12
JOB#: [**Job Number 8906**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,317
| 143,562
|
28740
|
Discharge summary
|
report
|
Admission Date: [**2150-6-25**] Discharge Date: [**2150-7-29**]
Date of Birth: [**2096-5-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
direct admit from OSH for transplant work-up
Major Surgical or Invasive Procedure:
Paracentesis
Placement of tunnel line for hemodialysis
History of Present Illness:
Pt is 54 yo male with alcoholic cirrhosis, h/o esophageal
varices, who has had multiple recent admissions to Southern
[**Hospital 1727**] Medical Center for ascites and hepatic encephalopathy. Pt
presented recently to the OSH with encephalopathy, and developed
oliguric ARF, severe hyponatremia, and severe hyperkalemia. He
also had a transaminitis on admission to OSH, which improved
during his hospital stay. He had diarrhea, and was found to be
positive for C.dif (presumably [**1-1**] recent Abx treatment for
SBP), and was placed on flagyl. He was treated with octreotide,
midodrine, and albumin for likely HRS. He was initially treated
with levofloxacin, but this was d/c'd after a negative urine cx.
Pt also reportedly underwent therapetuic paracentesis (12 L
removed) 1 week ago. Pt was evaluated for TIPS procedure,
however this was deferred until pt could be transferred to [**Hospital1 18**]
for further evaluation.
.
Pt currently complains only of feeling "bloated". He denies
abdominal pain, fevers, chills, nausea, vomiting, chest pain,
SOB.
Past Medical History:
cirrhosis ([**1-1**] EtOH)
h/o hepatic encephalopathy
h/o SBP
h/o esophageal varices (EGD [**2148**])
C.diff positive (currently on Flagyl)
likely HRS
Diabetes
Social History:
h/o EtOH abuse (reports being sober x 6 months).
+ smoker (1ppd).
Divorced, has 2 children.
lives with female friend who helps take care of him
Family History:
alcoholism
Physical Exam:
Vitals: T 95.8 BP 100/64 HR 60 RR 18 O2 98% RA
Gen: NAD, pleasant
HEENT: PEERL. Sclera icteric
Neck: Supple. R IJ in place without erythema.
Cardio: RRR, nl S1S2, no m/r/g
Resp: CTAB anteriorly
Abd: distended, + fluid wave, +BS. Mild sensitivity, but no
focal tenderness
Ext: 2+ pitting edema BL LE
Neuro: A&0x3. Has tremor, but no asterixis.
Pertinent Results:
DUPLEX DOPP ABD/PEL [**2150-6-26**] 2:01 PM
IMPRESSION:
1. Patent portal vein, with waveforms suggestive of stagnant
flow, without specific evidence of intraluminal thrombus.
2. Please see report from previous ultrasound regarding
description of left hepatic mass.
.
[**2150-6-26**] ABD U/S: [**2150-6-26**] 8:06 AM
IMPRESSION:
1. 2.2 cm hypoechoic mass in left hepatic lobe that is
concerning for hepatocellular carcinoma.
2. Ascites marked for paracentesis at right lower quadrant.
3. Splenomegaly.
.
[**2150-6-29**] MRI ABD:
IMPRESSION:
1. Cirrhosis and evidence of portal hypertension given
portosystemic collaterals, splenomegaly, and large volume
ascites.
2. 1.7 cm lesion within segment VIII with unusual enhancement
characteristics; however, which does contain an 8 mm peripheral
nodule which contains some microscopic fat, early hepatocellular
carcinoma cannot be excluded. A hemangioma would be much less
likely.
3. No portal venous enhancement on the post-contrast images,
these findings are suspicious for portal vein thrombosis.
.
[**2150-7-1**] ABD U/S:
IMPRESSION:
No flow seen within the portal vein. It may represent
thrombosis.
Lesion in right lobe of liver, which may represent
hepatocellular carcinoma and previously identified on ultrasound
and MR.
Ascites. Splenomegaly. Splenic varices.
.
[**2150-7-3**] ABD U/S:
CONCLUSION:
Thrombosis of intrahepatic portal vein. Ascites. Approximately
2.5 cm area of low echogenicity in relation to the right lobe of
liver which may represent a hepatocellular CA. Splenomegaly.
Splenic varices.
.
[**2150-7-16**] ABD CT:
IMPRESSION:
1. Cirrhosis.
2. Large amount of ascites.
3. Portal vein thrombosis extends 1-cm into the superior
mesenteric vein and 1.5-cm into the splenic vein.
4. Large right pleural effusion with atelectasis of the right
lower lobe.
5. Ileus.
.
[**2150-7-17**] Portable abdomen:
ABDOMEN, SINGLE AP SUPINE PORTABLE VIEW.
The lateral aspects of the abdomen are not included on this
film, nor are the obturator foramina. Residual oral contrast is
present in portions of the colon. There are multiple air-filled
dilated loops of small bowel in a stepladder configuration.
Nonethe less, air is seen throughout much of the colon. No
supine film evidence of free air is identified. No bowel wall
thickening is detected and no intramural emphysema is seen. Note
that many forms of hemorrhage would not be evident
radiographically.
.
There appear to be rib fractures in the left posterior ninth and
tenth ribs and question eleventh rib near the costovertebral
junction. The possibility of metastatic lesions in these areas
cannot be excluded.
.
Residual contrast is noted in the bladder.
.
[**2150-6-27**] Head CT:
IMPRESSION: No acute intracranial pathology identified,
including no evidence of intracranial hemorrhage.
.
[**2150-7-2**] CHEST CT:
IMPRESSION:
1) 4 mm right lower lobe pulmonary nodule. 3 month follow up
chest CT is recommended in this patient with possible
hepatocellular carcinoma.
2) Small bilateral pleural effusions with associated mild
compressive atelectasis.
3) Bilateral upper lobe peripheral ground glass opacities are
likely inflammatory in etiology or due to resolving pulmonary
edema.
4) Cirrhosis with portal hypertension.
.
[**2150-7-3**] CXR:
IMPRESSION: Stable mild pulmonary edema and small right pleural
effusion.
.
[**2150-7-2**] BONE SCAN:
IMPRESSION: 1) Increased tracer activity in region of right
sternoclavicular joint may be degenerative. If isolated osseous
metastasis is considered, then correlation with CT may be of
value. 2) Ascites. 3) If additional characterization of liver
lesion is desired, then a blood pool study may be useful in
evaluation of a possible hemangioma.
.
[**2150-7-8**] RENAL U/S:
RENAL ULTRASOUND: The right kidney measures 10.3 cm, and the
left kidney measures 10.8 cm. There is limited evaluation of the
lower pole of the right kidney. There are no renal masses,
stones, or hydronephrosis. The echogenicity of the kidneys is
normal. Ascites is noted in the right upper and lower quadrants.
The bladder is partially collapsed.
There is a small nodular liver consistent with known cirrhosis.
IMPRESSION: No hydronephrosis. Ascites.
.
[**2150-7-8**] RENAL U/S:
Conclusions:
Suboptimal study.
.
1. The left atrium is mildly dilated. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. The LV is not well seen but
limited views demonstrate normal regional left ventricular wall
motion.. Overall left ventricular systolic function appears
normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation
5.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
6.There is no pericardial effusion.
.
[**2150-7-16**] TUNNELLED HD PLACED:
IMPRESSION:
1. Status post successful placement of tunneled hemodialysis
catheter in exchange for a previous positioned left internal
jugular post-temporary hemodialysis catheter. See above
description. The catheter is ready to employ.
.
MICRO:
Peritoneal fluid:
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, monocytes, lymphocytes and neutrophils.
.
PERITONEAL FLUID:
#[**12-2**]-->*FINAL REPORT [**2150-7-3**]**
GRAM STAIN (Final [**2150-6-27**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2150-6-29**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2150-7-3**]): NO GROWTH.
.
BLOOD CULTURE-NO GROWTH X12 BOTTLES FROM [**Date range (1) 69470**]
**FINAL REPORT [**2150-7-21**]**
AEROBIC BOTTLE (Final [**2150-7-21**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2150-7-21**]): NO GROWTH.
.
Source: Right IJ.
**FINAL REPORT [**2150-7-12**]**
WOUND CULTURE (Final [**2150-7-12**]): No significant growth.
.
[**2150-7-12**] 2:29 pm URINE Source: CVS.
**FINAL REPORT [**2150-7-17**]**
URINE CULTURE (Final [**2150-7-17**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE, PRESUMPTIVELY NOT S.
SAPROPHYTICUS. >100,000 ORGANISMS/ML..
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE,
PRESUMPTIVELY
|
GENTAMICIN------------ 1 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- 32 S
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
.
[**2150-7-2**] 8:53 pm Toxoplasma Antibodies
**FINAL REPORT [**2150-7-3**]**
TOXOPLASMA IgG ANTIBODY (Final [**2150-7-3**]):
EQUIVOCAL FOR TOXOPLASMA IgG ANTIBODY BY EIA.
5 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
.
[**2150-7-2**] 8:53 pm IMMUNOLOGY **FINAL REPORT [**2150-7-7**]**
HCV VIRAL LOAD (Final [**2150-7-7**]):
HCV-RNA NOT DETECTED.
Performed by RT-PCR.
HCV GENOTYPE (Final [**2150-7-7**]):
HCV-RNA not detected by HCV viral load assay.
.
[**2150-7-2**] 8:53 pm EBV IgG/IgM/EBNA Antibody Panel
**FINAL REPORT [**2150-7-6**]**
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2150-7-6**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2150-7-6**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2150-7-6**]):
NEGATIVE <1:10 BY IFA.
.
[**2150-7-2**] 8:53 pm CMV Antibodies **FINAL REPORT [**2150-7-3**]**
CMV IgG ANTIBODY (Final [**2150-7-3**]):
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
< 4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2150-7-3**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
.
PERTINANT LABS:
AT DISCHARGE:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2150-7-24**] 05:14AM 5.7 2.10* 7.0* 20.5* 98 33.2* 34.1 21.1*
39
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2150-7-24**] 05:14AM 144* 22* 4.0* 128* 3.5 92* 24 16
.
LFTs:
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili
[**2150-7-23**] 06:05AM 33 67* 109 3.7*
[**2150-7-5**] 05:30AM 7.2* 3.1* 4.1
[**2150-6-25**] 09:41PM 59* 36 169 76 3.1
.
COAGS:
PT PTT Plt Smr Plt Ct INR(PT)
[**2150-7-24**] 05:14AM 17.9* 53.3* 1.7
.
HEME:
Hapto Ferritn TRF
[**2150-7-10**] 05:20AM <20*
[**2150-7-5**] 05:30AM <20*
[**2150-7-3**] 05:20AM <20*
[**2150-6-26**] 04:49AM 103* 450* 79*
.
HEP:
HBsAg HBsAb IgM HBc IgM HAV
[**2150-7-22**] 10:20AM NEGATIVE POSITIVE NEGATIVE
[**2150-7-2**] 08:53PM NEGATIVE POSITIVE NEGATIVE NEGATIVE
.
HCV Ab
[**2150-7-22**] 10:20AM NEGATIVE
HEPATITIS C VIRUS RNA BY PCR, QUALITATIVE
Test Result Reference
Range/Units
HCV RNA, QUAL, PCR NOT DETECTED
.
CEA PSA AFP
[**2150-7-2**] 08:53PM 6.2*1 0.11
HIV SEROLOGY HIV Ab
[**2150-7-2**] 08:53PM NEGATIVE
.
HERPES SIMPLEX (HSV) 2, IGG
TEST RESULT
REFERENCE RANGE
---- ------
---------------
Herpes II (IgG) Antibody 5.79
NEGATIVE
HSV (IgG) Interpretation ANTIBODIES TO BOTH
HSV TYPE 1 AND HSV
TYPE 2 DETECTED
.
[**2150-7-2**] 08:53PM
CA [**62**]-9
Test Result Reference
Range/Units
CA [**62**]-9 16 0-37 U/ML BY
[**Doctor Last Name **] CENTAUR
Brief Hospital Course:
54 yo M w/ETOH cirrhosis, portal vein thrombus, DM, ARF p/w
ascites, hepatic encephalopathy and w/u for liver transplant
.
# CIRRHOSIS: Patient's cirrhosis most likely secondary to
alcohol and patient was admitted with multiple complications.
Ultrasound at OSH demonstrated possible portal vein thrombosis,
although this finding was not present on 1st doppler study at
[**Hospital1 18**]. Patient underwent therapeutic paracentesis many times
during this admission. He was always negative for SBP. He was
continued on cipro for SBP prophylaxis. Pt's initial U/S was
unremarkable for portal vein thrombus, subsequent Abd U/S with
doppler as well as CT and MRI, notable for Portal vein thrombus.
Anticoagulation was contraindicated given his thrombocytopenia,
pt also developed some oozing around temporary central lines.
His clot then extended into SVC and was no longer a candidate
for transplant surgery. Further transplant work up stopped and
pt was made DNR/DNI given no further options for treatment.
.
# RENAL FAILURE: Patient was admitted with oliguric renal
failure. Patient's renal function decreased rapidly during this
episode of hepatic decompensation, suggesting hepatorenal
syndrome although likely compounded by intravascular depletion
and increased intra-abdominal pressure. Patient was started on
octreotide, midodrine, and albumin at the OSH. Patient's SBP
dropped during HD from base line BP of 90's to low 80's. He was
then transferred to the ICU for CVVH. He tolerated several
sessions of HD. Plan for continued HD as outpatient as pt would
like to continue HD. Plan was to provide HD as outpatient close
to home. The patient was admitted to the MICU for ongoing CVVHD
given his pressures were prohibitive for traditional HD. The
patient was maintained on midodrine and octreotide for possible
hepatorenal syndrome and was additionally treated with IV
albumin, which was discontinued on [**2150-7-11**]. Midodrine was
increased to 12.5mg [**Hospital1 **]. The patient's pressures tolerated CVVHD
well and his creatinine decreased from 5.9 to 2.5. He has
required dialysis, though, since being transferred from the MICU
to the floor, and his renal function has not improved.
Unfortunately, given his coagulopathy, he has had issues with
bleeding from the dialysis catheter site following dialysis. He
did not bleed following his last course of hemodialysis and was
deemed safe to go home.
.
# COAGULOPATHY: Pt developed some oozing around line sites. Labs
showed picture consistent with DIC but this could also be from
underlying liver disease. He received FFP/Cryo before
procedures. He recieved several units of PRBC for low HCT but
remained stable. Had some bleeding from tunneled line. Was given
conjugated estrogen and Vitamin K x 3 doses.
.
# HEPATIC ENCEPHALOPATHY: During this admission, patient had
waxing and [**Doctor Last Name 688**] mental status, suggesting likely hepatic
encephalopathy. Patient's mental status much improved with
lactulose therapy. The patient was maintained on lactulose for
encephalopathy. He was noted to have some fluctuation in mental
status but was generally appropriate and oriented.
.
# LIVER MASS: Patient also noted to have hepatic mass on
abdominal ultrasound, suggestive for possible HCC although AFP
only 2.9. Unclear etiology of mass.
Medications on Admission:
MEDS (at OSH):
Lactulose 30 ml PO TID
Maalox [**9-28**] ml PO Q6H PRN
Metronidazole 500 mg PO
Albumin 5% 50 gm IV DAILY
Midodrine HCl 7.5 mg PO TID
Calcium Carbonate 500 mg PO QID PRN
Multivitamins 1 CAP PO DAILY
Octreotide Acetate 200 mcg SC Q8H
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): according to sliding
scale.
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*qs for 1 month ml* Refills:*2*
4. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day) as needed for hemorrhoids.
Disp:*1 tube* Refills:*0*
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-1**]
Drops Ophthalmic PRN (as needed).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*90 Cap(s)* Refills:*2*
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching.
Disp:*1 bottle* Refills:*0*
8. 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:
[**Hospital6 486**] [**Location (un) 69471**]
Discharge Diagnosis:
End Stage liver disease
End stage renal disease requiring hemodialysis
Diabetes mellitus with complications
C. difficile infection
Anemia
Thrombocytopenia
Discharge Condition:
Fair, ambulating, tolerating PO diet, requiring hemodialysis
Discharge Instructions:
Call your doctor if you develop chest pain, shortness of breath,
nausea, vomiting, abdominal pain or any other worrisome
symptoms.
Followup Instructions:
Please arrange for hemodialysis three times weekly.
.
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 63296**] at
[**Telephone/Fax (1) 69472**] for a follow up appointment if you are not feeling
well.
|
[
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"511.9",
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"286.6",
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"139.8",
"518.0",
"289.51",
"E871.4",
"303.01",
"780.79",
"572.2",
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"E849.7",
"572.3",
"287.5",
"585.6",
"560.1",
"789.5",
"276.1",
"571.2",
"041.04",
"807.03",
"999.9",
"041.19",
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"572.4",
"428.0",
"E879.1",
"456.20",
"453.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"98.02",
"99.04",
"99.07",
"39.95",
"38.95",
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
17126, 17202
|
12455, 15758
|
358, 415
|
17401, 17464
|
2253, 4933
|
17643, 17895
|
1862, 1874
|
16056, 17103
|
17223, 17380
|
15784, 16033
|
17488, 17620
|
1889, 2234
|
10643, 12432
|
274, 320
|
443, 1501
|
4942, 10629
|
1523, 1685
|
1701, 1846
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,141
| 147,751
|
29864
|
Discharge summary
|
report
|
Admission Date: [**2178-3-21**] Discharge Date: [**2178-3-25**]
Date of Birth: [**2134-6-30**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Betadine / Grapefruit
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
rectal cancer work-up
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43 year old male with history of poorly differentiated laryngeal
cancer with known metastasis to bone (lymphoepithelioma),
recently completed XRT for bone mets presented to an OSH [**3-4**]
for abdominal distention and pain. Scans revealed rectal
narrowing and liver lesions by CT scan. Patient underwent
colonoscopy which showed changes consistent with radiation
proctitis and subsequently started on steroids. Despite this
therapy symptoms persisted and the patient underwent repeat
colonoscopy, which was concerning for rectal narrowing [**3-20**]
extrinsic mass. By report, surgery thought patient may need
resection with diverting colostomy.
The patient as reported to have urinary urgency at the outside.
Eval revealed normal post-void residual but evidence of moderate
outflow obstruction. CT scan revealed bladder wall thickening
likely related to radiation injury. Patient's management at OSH
was additionally complicated by renal failure with a Cr bump
from 1.1 to 2.7, thought possibly to be [**3-20**] contrast nephropathy
from CT on [**3-18**]. WBC trend previous 2 wks at OSH [**10-28**] (18 one
one day). By report, patient requested transfer to tertiary care
facility for further work-up.
Past Medical History:
1. Laryngeal cancer (primary in epiglottis)
- neo-adjuvant chemotherapy prior to surgery (regimen unknown)
- radical neck dissection [**2177-5-17**], metastasis to thoracic/L3
regions of spine, sacrum, ribs, R and L pelvis (PET scan -
[**2177-11-16**])
- radiation therapy to lumbar and thoracic regions
2. Back surgeries due to trauma
Social History:
SH: Heavy smoking history, quit last year. Married, wife at
bedside.
Family History:
FH: Lung cancer in sister, breast cancer in sister.
Physical Exam:
PE: T: 99.4, BP: 146/86 HR: 107 RR: 20 93% O2 % RA
Gen: NAD, pale appearing, tremulous male. Nervous, anxious
appearing. Cried once when discussing prognosis.
HEENT: No conjunctival pallor, no icterus. Dry MM. OP clear.
NECK: Right neck with surgical changes/thin, left neck with
non-demarcated mass left superior anterior triangle. No JVD
appreciated.
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, no crackles appreciated.
ABD: Soft, NT, ND. No HSM. Tympanetic. +bs
EXT: bil 2+ pitting edema, pulses intact bil sym.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3 but with thought finding difficulties. Somewhat
somnolent. Waxing and [**Doctor Last Name 688**] mental status changes +. CN 2-12
grossly intact. Preserved sensation throughout. 5/5 strength
throughout. [**2-17**]+ reflexes, equal BL. Normal coordination. Gait
assessment intact.
Pertinent Results:
[**2178-3-21**] 09:45PM GLUCOSE-104 UREA N-50* CREAT-5.6* SODIUM-134
POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-21* ANION GAP-21*
[**2178-3-21**] 09:45PM estGFR-Using this
[**2178-3-21**] 09:45PM CALCIUM-8.6 PHOSPHATE-3.9 MAGNESIUM-2.3
[**2178-3-21**] 09:45PM WBC-9.0 RBC-2.75* HGB-8.7* HCT-24.2* MCV-88
MCH-31.7 MCHC-35.9* RDW-15.8*
[**2178-3-21**] 09:45PM PLT SMR-VERY LOW PLT COUNT-54*
[**2178-3-21**] 09:45PM PT-17.4* PTT-36.3* INR(PT)-1.6*
[**2178-3-21**] 09:45PM FIBRINOGE-459*
.
[**2178-3-24**] 03:00AM BLOOD WBC-12.1* RBC-2.64* Hgb-8.2* Hct-23.5*
MCV-89 MCH-31.1 MCHC-35.0 RDW-16.4* Plt Ct-38*
[**2178-3-24**] 03:00AM BLOOD Plt Ct-38*
[**2178-3-24**] 03:00AM BLOOD PT-17.2* PTT-31.3 INR(PT)-1.6*
[**2178-3-24**] 03:00AM BLOOD Glucose-82 UreaN-80* Creat-8.6* Na-136
K-5.1 Cl-99 HCO3-19* AnGap-23*
[**2178-3-24**] 03:00AM BLOOD ALT-35 AST-138* LD(LDH)-9850*
AlkPhos-297* Amylase-36 TotBili-0.7
[**2178-3-24**] 03:00AM BLOOD Albumin-2.7* Calcium-7.8* Phos-5.1*
Mg-2.5 UricAcd-17.7*
[**2178-3-24**] 05:34AM BLOOD Type-ART Temp-36.6 O2 Flow-4 pO2-90
pCO2-46* pH-7.32* calTCO2-25 Base XS--2 Intubat-NOT INTUBA
[**2178-3-24**] 05:34AM BLOOD Lactate-3.9*
.
[**2178-3-21**] CXR: IMPRESSION: AP chest reviewed in the absence of
prior chest radiographs:
I see no radiopaque central venous line. Heart size is normal. A
region of heterogenous opacification just to the right of the
upper mediastinum could be due to a mass or region of
consolidation. Followup and/or cross sectional imaging advised.
There is no pleural effusion.
.
[**2178-3-22**] Portable abdomen. IMPRESSION: AP view of the abdomen
shows gaseous distension of the large bowel, but no appreciable
small bowel distension. This may represent distal colonic
obstruction. There is no free intraperitoneal gas.
.
[**2178-3-22**] Renal Ultrasound. IMPRESSION: Mild hydronephrosis within
the left kidney. Right kidney appears unremarkable.
.
[**2178-3-23**] CT-Torso-w/o contrast:
IMPRESSION:
1. Patchy bilateral ground glass opacities. The appearance is
more suggestive of atypical infection, cryptogenic organizing
pneumonia or a drug- related pneumonitis, as opposed to
metastatic disease
2. Diffuse involvement of the osseous structures with mixed
sclerotic and lytic metastases, including prior rib fractures.
There is also a recent or acute non-displaced right
posterolateral eighth rib fracture, and findings suggestive of
acute on chronic injury of the left lateral sixth rib, again
without displacement.
3. Persistent contrast opacification of the renal cortices
bilaterally with mild bilateral hydronephrosis.
4. Diffuse involvement of the liver with metastatic disease.
5. Dilatation of the transverse colon, probably reflecting
partial obstruction by a rectal mass, which is demonstrated as
diffuse thickening of the rectum on images performed with rectal
contrast opacification of the lumen. The appearance includes
rectal edema, soft tissue and nodularity, probably reflecting
small suspicious lymph nodes.
.
[**2178-3-23**] CT-head w/o contrast:
IMPRESSION:
1. No evidence of hemorrhage or shift of normally midline
structures.
2. Diffuse lytic lesions seen throughout the calvarium.
3. Increased soft tissue density seen at the posterior orbits
bilaterally, possibly representing metastatic disease. Clinical
correlation recommended.
Brief Hospital Course:
The Patient was admitted on [**2178-3-21**], transfered to the medical
intensive care unit on [**2178-3-23**], made "comfort measures only",
transfered back to the floor on [**2178-3-24**], and passed away on
[**2178-3-25**].
.
The patient arrived at the [**Hospital1 18**] in renal failure and oliguric.
This was felt likely due to the bilateral hydronephrosis seen on
CT scan.
.
Prior to transfer to the MICU the patient had a rapidly
developing oxygen requirement, going from RA to 3-4L NC in the
course of about 12 hours. He was noted to be febrile to 101.8
and tachycardic to the 130s.
.
The patient had severe constipation which was felt to be due to
radiation associated colitis, metastatic obstruction, or
narcotic side effect. The true contribution of each of these
factors was never defined. Plans were made for a diverting
colostomy, but the patient was converted to "comfort measures
only" status instead.
.
The patient's mental status was noted to be altered. He was not
oriented to place on transfer to the MICU. On transfer to the
floor from the MICU he was no longer able to communicate.
.
CT Torso and CT head both showed diffuse osteometastatic
disease.
.
In the end the patient's pain was managed with concentrated
morphine and an IV morphine drip. The patient's wif reported
that his last moments were peaceful.
Medications on Admission:
1. Oxycodone CR 80 q8
2. Oxycodone 20 q3 prn
3. Mesalamine 1000 qAM pr
4. Ultram 50 q6 prn
5. Flagyl 500 tid - started [**3-14**]
6. Levaquin 500 qd - started [**3-14**]
7. Methylprednisolone 30 q12
8. Hydrocort 60mL qhs PR
9. Bisacodyl 10 [**Hospital1 **] pr
10. Docusate 200 [**Hospital1 **]
11. Senna 4 [**Hospital1 **]
12. PEG 17 q4 hours prn
13. Zofran 4 q6
14. Hydroxyzine 100 q6 prn
15. Tolterodine 4 qhs
16. Tamsulosin 0.4 qd
17. Lorazepman 1 q8hrs
18. Metoclopromide 10 q8iv prn
19. Buproprion XL 150 qid
20. Protonix 40 qd
21. Proctofoam HC pr [**Hospital1 **]
Discharge Medications:
None. Patient passed away during this admission.
Discharge Disposition:
Expired
Discharge Diagnosis:
Diffusely metastatic laryngeal cancer.
Discharge Condition:
Patient passed away during this admission.
Discharge Instructions:
Patient passed away during this admission.
Followup Instructions:
Patient passed away during this admission.
Completed by:[**2178-3-29**]
|
[
"287.5",
"569.9",
"584.5",
"591",
"276.2",
"V10.21",
"560.89",
"285.22",
"198.5",
"197.6",
"564.00",
"518.81",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8361, 8370
|
6326, 7666
|
314, 320
|
8452, 8496
|
2986, 6303
|
8587, 8660
|
2017, 2071
|
8288, 8338
|
8391, 8431
|
7692, 8265
|
8520, 8564
|
2086, 2967
|
253, 276
|
348, 1555
|
1577, 1915
|
1931, 2001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,148
| 113,780
|
36430
|
Discharge summary
|
report
|
Admission Date: [**2165-5-24**] Discharge Date: [**2165-5-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
84 yo M w/ PMH of CHF, afib, LGIB, gastric ulcer s/p clipping,
gallstone pancreatitis and cholecystitis p/w abd pain, elevated
amylase/lipase and GNR bacteremia for ERCP from OSH in NH. Pt.
was initially admitted in early [**Month (only) **] to the OSH with
abdominal pain and diagnosed with cholecystitis and gallstone
pancreatitis. He reportedly had an NSTEMI during this episode
and so was only treated with antibiotics as surgery was too
risky. He was also admitted in [**Month (only) **] w/ GIB and had gastric
ulcer clipped. Most recently, he was watching a red sox game on
[**5-21**] when he began having abdominal pain then nausea and
vomitting. He had some blood in his emesis but at OSH his Hct
remained stable and his vomiting resolved. His amylase and
lipase were elevated in the 1000 range and his LFTs and Tbili/AP
were elevated as well. He was tachycardic and moderately
hypotense to 96/67. He was planned for MRCP but this was not
done given recent ulcer clipping w/ metal clip and he was
transfered to [**Hospital1 18**] for ERCP and close monitoring from the ICU
at St. [**Hospital 11042**] Hospital in [**Location (un) 8117**], NH.
.
On presentation to the ICU, he continued to complain of
abdominal pain which he says was only improved with dilaudid but
returns to the same baseline pain in between doses. He was
immediately taken for ERCP where stone fragments with frank pus
were drained.
Past Medical History:
Atrial fibrillation off coumadin [**3-18**] GIB
CHF
AAA s/p remote repair
COPD emphysema on Home O2 2L
Bladder CA s/p surgery and BCG
PVD s/p fem-[**Doctor Last Name **]
Cholecystitis
Gallstone pancreatitis
CAD
Duodenal AVM s/p large bleed
Spinal stenosis
Prinzmetal angina
Sleep apnea
Urosepsis
Social History:
Lives at home w/ wife and oldest daughter. Quit smoking in [**2152**]
but had smoked 52yrs x 2.5PPD. Previous heavy ETOH, but only
occasional now.
Family History:
Father died of CAD at age 47
Mother had breast CA
Physical Exam:
VS - Temp 96.6F, BP 104/81, HR 117, R 20, O2-sat 94% 4l
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - sclerae anicteric, MM dry
NECK - JVD to Ear lobe
LUNGS - Decreased breath sounds diffusely. Crackles half way up
the back.
HEART - Irregular rhythm, II/VI systolic murmur
ABDOMEN - BS+, soft, moderately tender in LUQ and LLQ but not in
RUQ. Midline well healed laparotomy scar.
EXTREMITIES - DP and PT pulses not palpable, warm/WP, 1+ pedal
edema
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, appropriately conversant
Pertinent Results:
[**2165-5-24**] ERCP
Normal major papilla
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique
Contrast medium was injected resulting in complete opacification
of the biliary tree. There were few filling defects that
appeared like sludge at the lower third of the common bile duct.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire
Sludge, few small stone fragments, and purulent bile in small
amount were extracted successfully using a 8.5 mm balloon.
Successful placement of a 10Fr 9cm biliary stent.
Otherwise, the caliber and course of the the common bile duct,
common hepatic duct, right and left hepatic ducts, and
intrahepatic bile ducts were normal.
Normal limited pancreatogram
[**2165-5-24**] AP CXR:
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Lungs are clear, heart top normal size, and pulmonary
mediastinal vasculature engorged. Pleural effusion is minimal if
any. No pneumothorax.
[**2165-5-24**] 05:52PM GLUCOSE-72 UREA N-21* CREAT-1.3* SODIUM-139
POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-22 ANION GAP-12
ALT(SGPT)-132* AST(SGOT)-81* LD(LDH)-163 ALK PHOS-247*
AMYLASE-447* TOT BILI-2.0* LIPASE-773* ALBUMIN-3.0*
CALCIUM-7.7* PHOSPHATE-3.0 MAGNESIUM-2.2 NEUTS-84.6*
LYMPHS-7.8* MONOS-2.5 EOS-5.0* BASOS-0.1PLT COUNT-226 PT-17.4*
PTT-37.2* INR(PT)-1.6*
Brief Hospital Course:
84 yo M w/ CHF, Afib not anticoagulated, known cholelithiasis,
presents from OSH with gallstone pancreatitis and pansensitive
E.coli bactermia for ERCP.
#. E.coli bacteremia: Patient remained hemodynamically stable
throughout hospital course with good urine output. Given history
of known CHF he was carefully given IV fluid support and his
home lasix dose was initially held. OSH cultures from blood grew
E.coli pan sensative and he was switched from Zosyn to
ciprofloxacin on hospital day #2. He will finish a 14-day course
(last day [**6-5**]). Surveillance blood cultures were negative as of
day of discharge. He will follow up with ERCP in 6 weeks for
stent removal. The recommendation of the ERCP team that he be
considered for early cholecystectomy was discussed with the PCP
by both the [**Hospital Unit Name 153**] team and hospitalist, and the PCP prefers to
hold off for now given his significant cardiovascular and
pulmonary comorbidities.
#Gallstone pancreatitis s/p ERCP: Pus drained from bile ducts
with sphincterotomy and stent placement. Patient improved
clinically and was advanced to regular diet without difficulty.
He will follow up with the ERCP team in 6 weeks for stent
removal.
#. Hx of GIB: Hct stable on admission but then began to trend
downward after recieving fluids, did not have any s/s of GIB and
his Hct eventually trended back towards the value at admission.
#. CHF/CAD: Appeared mildly volume overloaded on admission, but
given borderline BP in setting known bacteremia home lasix was
held and IVF given prn. As he recovered, spironolactone, then
lasix were resumed. Given brisk diuresis on home lasix and
increased dose of metoprolol, Lasix was decreased to 20mg daily
to allow blood pressure room. Continued on BB, imdur, statin,
not on aspirin at home [**3-18**] GI bleed; restarting coumadin as
below but would observe on this before adding ASA (can be done
as outpatient).
.
#. Afib: Afib: Presented from OSH in RVR. Controlled with one
dose of IV metoprolol 5mg. He was continued on PO metoprolol for
rate control and increased on hospital day #3 due to persistent
heart rate in the 130s, likely related to increased activity on
transfer to the medical floor (now walking independently, out of
bed). His metoprolol was titrated up to 75mg [**Hospital1 **] with good
effect. He remained asymptomatic throughout all tachycardic
episodes. His PCP has been holding coumadin given recent GI
bleed but had planned to restart this on [**5-27**], so he was started
on 2mg warfarin daily, to be followed by his PCP (discussed with
PCP)
Medications on Admission:
Home
ocuvite 2tabs daily
Omeprazole 20mg daily
isosorbide dinitrate 20mg [**Hospital1 **]
Simvastatin 40mg daily
doxazosin 2mg QHS
Metoprolol tartrate 25mg [**Hospital1 **]
Furosemide 40mg daily
spironolactone 25mg Daily
nitroquick 0.4mg PRN
.
On transfer
Pip/tazo 2.25g Q6hours day 1=[**5-23**]
Pantoprazole 40mg IV daily
ondansetron 4mg Q6 PRN
Hydromorphone 0.5-1mg Q4PRN
Metoprolol 2.5mg IV Q8hours
Metronidazole 500mg Q12 hours
Heparin SC Q12
Discharge Medications:
1. Outpatient Lab Work
INR check on [**2165-5-29**], please fax results to Dr. [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) **]
office (phone # [**Telephone/Fax (1) 82541**]) per standing order.
2. Ocuvite 1,000-60-2 unit-unit-mg Tablet Sig: Two (2) Tablet PO
once a day.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual q5min up to three times.
11. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 8117**] Home Health and Hospice
Discharge Diagnosis:
Primary: gallstone pancreatitis, atrial fibrillation
Secondary: coronary artery disease, chronic systolic heart
failure
Discharge Condition:
good, stable, ambulating independently
Discharge Instructions:
You were transferred for an ERCP for gallstone pancreatitis and
your abdominal pain improved. You should continue to take
antibiotics as directed. You had a very fast heart rate
afterwards that may have been partially due to the infection,
and your metoprolol dose was increased.
If you have lightheadedness, chest pain, shortness of breath,
episodes of loss of consciousness, fevers, chills, abdominal
pain, or any other concerning symptoms, call your doctor or seek
medical attention immediately.
Followup Instructions:
Dr.[**Name (NI) 2798**] office will call you to schedule a follow up ERCP
for stent removal in [**5-20**] weeks. If you do not hear from them,
you can call them at ([**Telephone/Fax (1) 10532**].
You should follow up with your primary care physician [**Name Initial (PRE) 176**] 1
week; call Dr.[**Name (NI) 82542**] office at [**Telephone/Fax (1) 82541**] to make an
appointment.
You should have your INR checked tomorrow. Have your labs drawn
as per your prior routine and Dr.[**Name (NI) 82542**] office will call you
with any changes to your coumadin dose.
|
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icd9cm
|
[
[
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[
"51.88",
"51.87",
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icd9pcs
|
[
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8600, 8674
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2861, 4273
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,773
| 153,515
|
42968
|
Discharge summary
|
report
|
Admission Date: [**2121-8-8**] Discharge Date: [**2121-8-12**]
Date of Birth: [**2061-7-4**] Sex: F
Service: MEDICINE
Allergies:
Dilantin / Nsaids
Attending:[**First Name3 (LF) 3574**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 YO F with a history of SLE, pulmonary embolism currently on
coumadin who presents with chest pain. She was in her normal
state of health until 4 days ago when one day after doing some
packing she developed lower back pain, generalized malaise,
fatigue. She took tylenol and back pain improved but continues
to feel very tired. She reports intermittent substernal chest
pain that is worse when position (moving from sitting to lying
down), not exertional or pleuritic, not associated with
shortness of breath, nausea, vomiting, diaphoresis. She is not
currently having this chest discomfort now. She has never had
this pain before. She saw PCP today in clinic today. She also
experienced an episode of lightheadedness 2 days before
admission and some epistaxis. Her INR this week was noted to be
subtherapeutic at 1.6 on [**8-6**], prompting patient to take extra 5
mg of coumadin that day. Of note, vitals in her PCP's office was
T: 99.5 100/60 104. She also reports decreased PO intake today
due to her office visits and transfer to the ED. She also
self-discontinued her plaquenil in [**Month (only) 404**], only re-started 2
days ago.
.
In the ED, initial vs were: 98.3 86 107/75 100. Then noted to
have Temperature of 99.5. Labs notable for HCT 29.1 (down from
low thirties), creatinine of 1.7 (worse than baseline) and INR
of 1.5. Troponin 0.04 --> 0.01. EKG unchanged. CXR unremarkable.
Concern for PE, no CTA due to ARF, wanted to get VQ scan but
unable to O/N. Blood pressure to 70s after got 3L of IVF,
asymptomatic. Bedside cardiac U/S by ED senior without
pericardial effusion. UA with bacteruria without pyuria. Lactate
of 1.7. Got Lovenox 80mg, ceftriaxone, ciprofloxacin, aspirin.
Vitals: BP: 86/53 HR: 74. Has 1 PIV for access and now putting
in CVL. Getting blood and urine cultures.
.
On the floor, patient denies any chest pain. ROS is positive as
detailed above. Negative for syncope, palpitations, abdominal
pain, diarrhea, cough, shortness of breath, dysuria, nausea,
vomiting, lower extremity edema, blood in stools.
Past Medical History:
- SLE with membranous nehpritis, leukopenia, anemia, rash,
fever, vasculitis lesions toes, pulmonary embolism, non-ruptured
cerebral aneurysm; (+Ro, +RNP/[**Doctor Last Name **], negative dsDNA)
- hypothyroidism
- hyperparathyroidism
- history of breast cancer
- pulmonary embolism
- Chronic renal insufficiency (cr 0.94 in [**2121-5-10**])
Membranous Glomerulonephritis
- Back pain
- unilateral adrenalectomy
Social History:
Works at [**University/College 15564**]in fundraising. Lives by herself.
Previously married, currently divorced. Has 2 adult children. No
EtOH, tobacco, or illicit drugs,
Family History:
No family history of lupus or clotting disorders
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.2 76 87/56 99% on RA
General: African American female, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 5cm at 30 degrees, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: S1, S2 regular rhythm, normal rate, no murmurs
Abdomen: soft, NTND, no guarding, no rebound, left surgical scar
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
CXR [**2121-8-8**]:
UPRIGHT PA AND LATERAL VIEWS OF THE CHEST: Multiple surgical
clips are
present within the left upper quadrant of the abdomen. The heart
size is
normal. The hilar and mediastinal contours are within normal
limits. Linear opacities at the lung bases are reflective of
mild bibasilar atelectasis. There is no pneumothorax or pleural
effusion. No focal consolidations are seen.
IMPRESSION: No acute intrathoracic process.
TTE [**2121-8-9**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Transmitral and
tissue Doppler imaging suggests normal diastolic function, and a
normal left ventricular filling pressure (PCWP<12mmHg). There is
no ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. An eccentric, posteriorly
directed jet of Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild, posteriorly directed, mitral regurgitation. Mild pulmonary
artery systolic hypertension.
Bilateral lower extremity vein US [**2121-8-9**]: No evidence of DVT in
bilateral lower extremity veins.
Admission Labs:
[**2121-8-8**] 02:35PM BLOOD WBC-4.3 RBC-3.18* Hgb-9.9* Hct-29.1*
MCV-91 MCH-31.2 MCHC-34.1 RDW-13.7 Plt Ct-166
[**2121-8-8**] 02:35PM BLOOD Neuts-58.0 Lymphs-35.4 Monos-5.4 Eos-0.2
Baso-0.9
[**2121-8-8**] 02:35PM BLOOD PT-16.8* PTT-28.9 INR(PT)-1.5*
[**2121-8-8**] 02:35PM BLOOD Glucose-102* UreaN-27* Creat-1.7* Na-128*
K-4.0 Cl-94* HCO3-26 AnGap-12
[**2121-8-8**] 02:35PM BLOOD CK(CPK)-292*
[**2121-8-8**] 02:35PM BLOOD cTropnT-0.04*
[**2121-8-8**] 02:35PM BLOOD CK-MB-2 proBNP-2606*
Other Pertinent Results:
[**2121-8-11**] 05:40AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2121-8-11**] Fibrino-496*
[**2121-8-9**] ESR-105*
[**2121-8-11**] Ret Aut-0.8*
[**2121-8-11**] Hapto-214*
[**2121-8-8**] 02:35PM BLOOD CK(CPK)-292*
[**2121-8-9**] 03:56AM BLOOD CK(CPK)-265*
[**2121-8-11**] 05:40AM BLOOD LD(LDH)-239 CK(CPK)-180
[**2121-8-8**] 02:35PM BLOOD CK-MB-2 proBNP-2606*
[**2121-8-8**] 02:35PM BLOOD cTropnT-0.04*
[**2121-8-8**] 11:00PM BLOOD cTropnT-0.01
[**2121-8-9**] 03:56AM BLOOD CK-MB-2 cTropnT-LESS THAN
[**2121-8-9**] FSH-31* LH-16 Prolact-8.1
[**2121-8-9**] TSH-0.12*
[**2121-8-9**] Free T4-0.94
[**2121-8-9**] 03:56AM BLOOD Cortsol-5.7
[**2121-8-11**] 06:10AM BLOOD Cortsol-18.7
[**2121-8-11**] 06:10AM BLOOD Cortsol-23.3*
[**2121-8-11**] 06:40AM BLOOD Cortsol-21.1*
[**2121-8-9**] dsDNA-NEGATIVE
[**2121-8-9**] C3-137 C4-24
Discharge Labs:
[**2121-8-12**] 06:50AM BLOOD WBC-3.4* RBC-2.88* Hgb-8.8* Hct-26.5*
MCV-92 MCH-30.6 MCHC-33.4 RDW-13.8 Plt Ct-211
[**2121-8-12**] 06:50AM BLOOD PT-23.1* PTT-73.9* INR(PT)-2.2*
[**2121-8-12**] 06:50AM BLOOD Glucose-94 UreaN-10 Creat-0.8 Na-139
K-3.9 Cl-108 HCO3-25 AnGap-10
[**2121-8-12**] 06:50AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.1
Brief Hospital Course:
60yo female with h/o DVT, PE, and SLE who presented with low
grade fevers, back pain, chest pain and hypotension and was
found to have a sub-thereapeutic INR.
.
#CHEST PAIN: The DDx for her chest pain included PE, ACS,
pleuritis, and myocarditis/pericarditis. It is also possible
the pain was musculoskeletal in nature, as she was packing boxes
in the days prior to admission. She ruled out for an MI based
on unchanged ECG and negative cardiac enzymes. A TTE did not
reveal a perdicardial effusion or RV strain. She was seen by
rheumatology, who did not feel she was having an acute lupus
flare. A CXR did not reveal any acute process. She was started
on Lovenox briefly given suspicion for DVT/PE, then switched to
a heparin gtt given her h/o renal disease. Bilateral lower
extremity US was negative for DVT. She did not have a VQ scan
or CTA chest to evaluate for PE, as it was felt it would not
change management. Given her h/o DVT and PE, as well as her SLE
which puts her at risk for hypercoaguability, she will likely
need to be on lifetime coumadin. She was continued on a heparin
gtt bridge to a therapeutic INR, and her daily coumadin dose was
increased from 4.5mg to 5mg daily. Her CP resolved and she did
not have any additional episodes. She will f/u in
[**Hospital3 **] and with her PCP for further monitoring.
.
#HYPOTENSION: SBP in 80s on day of admission and most likely
secondary to hypovolemia as the patient responded to fluids.
The DDx included sepsis, obstruction (concern for PE,
tamponade), cardiogenic hypotension, and adrenal insufficiency
in addition to hypovolemia. She did not meet SIRS criteria, and
blood cultures remained negative to date at time of discharge.
Urine culture was negative. A TTE did not reveal evidence of
pericardial effusion or RV stain, and ECG was unchanged. She
had a cortisol level that was low, but repeat testing indicated
normal cortisol levels and adrenal insufficiency was unlikely.
She has a history of hypothyroidism and had a low TSH, but free
T4 level was normal. Additional testing given some concern for
panhypopituitarism revealed normal prolactin, normal LH, and FSH
within appropriate range for a post-menopausal woman. The
patient was initially transferred to MICU, and BP had stabilized
after receiving 3L of fluid initially. She required one
additional 1L fluid bolus, and SBP then remained stable. Per
records, baseline SBP around 100. Her lisinopril, which she
takes for proteinuria, was held given her hypotension.
.
#BACTERURIA: Bacteruria without pyuria noted on admission UA,
and the patient was briefly treated with ceftriaxone and cipro
given concern for possible infection. Urine culture was
negative and patient remained asymptomatic, and antibiotics were
discontinued.
.
#SLE: Patient has known history of SLE with multiple
complications including PE, hematologic dysfunction, cerebral
aneurysms, renal dysfunction, and vasculitis. It was thought
symptoms could be secondary to SLE flare, and the patient had
recently stopped taking her plaquenil. She was seen by
rheumatology, who felt this was unlikely to be an SLE flare, and
they recommended re-starting her Plaquenil. On testing, dsDNA
was negative and C3 and C4 levels were within normal limits.
She will f/u with her rheumatologist as an outpatient for
further monitoring.
.
#ACUTE ON CHRONIC RENAL INSUFFICIENCY: Patient has known Stage
II CKD with membraneous glomerulonephritis, Cr 0.9 at baseline.
Cr peaked at 1.7 during this admission, most likely [**2-11**] to
pre-renal etiology in setting of dehydration, as Cr trended back
down to baseline after fluid administration. Cr 0.8 at time of
discharge. Patient on lisinopril as outpt for proteinuria, but
this was held given patient's hypotension during admission.
.
#HYPERTHRYOIDISM: TSH low, but free T4 normal. Patient continued
on home dose of levothyroxine.
.
# NORMOCYTIC ANEMIA/CHRONIC PANCYTOPENIA: Pt has chronic
pancytopenia likely [**2-11**] SLE. Per Atrius records baseline Hct
around 30. HCT around baseline on admission, but decreased to
25.0 in setting of IVF administration. HCT remained stable, and
patient was hemodynamically stable at time of discharge. Retic
count low, suggesting inappropriate response to anemia and some
degree of bone marrow suppression. Haptoglobin levels were
slightly above normal, suggesting hemolysis unlikely. Patient
had colonoscopy 3-4 years ago which showed only benign polyps,
and was guiac negative. WBC and platelet counts low but stable
during admission.
Medications on Admission:
1. Levothyroxine 125mcg 5X per week
2. Lisinopril 20mg daily
3. Warfarin 4.5 mg daily
4. Hydroxychloroquine 400mg daily
5. Calcium and vitamin D
6. Multivitamin
Discharge Medications:
1. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO 5X/WEEK
(MO,TU,WE,TH,FR).
3. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
5. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. Outpatient Lab Work
Please have INR checked on Thursday [**2121-8-14**]
7. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Hypovolemia, Acute Kidney Injury,
Hypotension, Atypical chest pain
Secondary Diagnosis: SLE, DVT/PE, Hypothryoidism
Discharge Condition:
AAOx3, satting high 90s on room air, systolic blood pressure
100s-120s
Discharge Instructions:
You were admitted to the hospital with chest pain, low blood
pressure and kidney impairment. Your INR (Coumadin level) was
found to be low. You were initially admitted to the ICU and
started on a heparin blood thinning medication while we waited
for your coumadin level to be within range. Your blood pressure
and kidney impairment improved with IV fluids so you were likely
quite dehydrated when you came to the hospital. We also stopped
one of your medications as below, called lisinopril, which can
lower your blood pressure.
We made the following changes to your medications
1. We stopped your lisinopril
2. We increased your coumadin from 4.5mg to 5mg daily
Please take all of your medications as prescribed and follow up
with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. You should have your INR, or
coumadin level checked on Thursday [**2121-8-14**].
Followup Instructions:
Department: Primary Care
Name: [**Last Name (LF) 54468**],[**First Name3 (LF) 54469**] B.
Location: [**Hospital **] [**Hospital 92749**] MEDICAL ASSOCIATES [**Location (un) **],
[**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
When: Thursday [**8-14**] at 10:50am
Department: Rheumatology
Name: [**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **]
Location: [**Location (un) 2274**]-[**Location (un) 2277**] [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
When: Monday [**8-18**] at 2:30pm
|
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icd9cm
|
[
[
[]
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[] |
icd9pcs
|
[
[
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|
6955, 11486
|
287, 293
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17,891
| 175,303
|
24614
|
Discharge summary
|
report
|
Admission Date: [**2121-5-6**] Discharge Date: [**2121-6-24**]
Date of Birth: [**2075-12-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
eval for liver transplant
Major Surgical or Invasive Procedure:
[**5-13**] EGD
R thoracotomy
LP done through IR
History of Present Illness:
45 yo m with h/o cryptogenic cirrhosis, end stage liver disease,
frequent episodes of hepatic encephalopathy exacerbations. He
presented on [**5-4**] to [**Hospital **] hospital after being found unconscious
[**12-18**] to missing a lactulose dose. He was given lactulose by NGT
in the ER and his mental status cleared. The patient underwent a
diagnostic tap in the ED there, but there was not sufficient
fluid to send to cell count. He was tapped again on [**5-6**] at OSH
and this tap showed increased cell count to 9045, 83% PNMs c/w
SBP therefore he was started on cefotaxime. The patient reported
blood in stools (patient thought this was from his hemorrhoids),
therefore he underwent an upper and lower endoscopy. Upper
showed grade I varices, gastropathy, and gastric varices. Lower
showed diverticulitis, polyp (not clipped [**12-18**] to increase INR),
and internal hemorrhoids. He was hypotensive after the procedure
to systolic of 80's (had been 120 - 150) which responded to
fluid boluses. Also significant was the fact his Cr increased
from 1.8 to 2.6 during his short hospital stay, thought to be
due to acute renal failure [**12-18**] bowel prep vs. hepatorenal
syndrome. He was transferred to [**Hospital1 18**] for transplant eval on
[**5-6**].
At [**Hospital1 **]:
# End stage liver failure: The cause of his liver failure is
currently unknown and his MELD score was 30 on admission. He
underwent a workup for a liver transplant - echo, PFTs, viral
studies. He had multiple episodes of encephalopathy when not
taking lactulose. He was continued on lactulose while here.
Neomycin, which was started at RIH, was stopped for concern of
nephrotoxicity. His diuretics were held [**12-18**] low BP. Pt.
scheduled for transplant but chest CT showed nodules (SEE lung
nodule hx below); intubated for surgery and weaned off on [**5-19**] in
SICU...transplant deferred.
.
# Acute renal failure: His baseline Cr was 1.5 - 1.8 and he has
had a sudden increase of his Cr from 1.8 -> 3.1 in a matter of 3
days. Of note, his Cr began to increase before he became
hypotensive and before any procedure was done at the OSH. This
is worrisome for hepatorenal failure exacerbated by infection
and intravascular volume depletion [**12-18**] to colonoscopy prep. He
was given 50mg of albumin x2 on admission and started on
octreotide and midodrine. and renal consulted; transfused for
improved forward flow and his creatinine improved. On txf from
SICU, creat. trended down to 1.8.
.
# SBP: This was diagnosed on the day of admission at RIH and he
was started on cefotaxime there. He was switched to ceftriaxone
here. His cultures at RIH are currently not growing anything. He
was gently hydrated on the night of admission for concern that
his hypotension was [**12-18**] to infection (though he had a normal
lactate). Switched from ceftriaxone to oral cipro for SBP
therapy ([**5-10**]) - to end on ([**5-22**])
.
# Hypotension/anemia: This is likely multifactorial . His
initial BP at the OSH was between 120 - 150 and decreased after
the colonoscopy. Perforation unlikely since has no pain.
Possibly [**12-18**] to SBP, volume depletion from colonoscopy prep, or
arterial and vasodilatation from HRS. on hospital day 2, his HCT
dropped from 25.7 on [**5-6**] to 18 on [**5-7**]. It was thought that he
was bleeding into his peritoneum from the paracentesis on [**5-6**]
or from his gastric varices. (He did not have abdominal pain,
vomiting, or BRBPR). His INR was 4.3 on [**5-7**] as well. He was
given 2 units PRBC and 2 units FFP for this HCT drop and
coagulopathy. His BP on transfer from ICU.
.
# Rectal bleeding at OSH: The patient underwent a colonoscopy
and EGD on [**5-6**] that did not show evidence of active bleeding.
He does have gastric varices therefore at high risk for bleeding
event. Resolved on transfer to medicine.
.
# Lung nodules - Chest CT on [**5-8**] showed scattered small
pulmonary opacities within both lungs, of varying sizes and
morphologies, suggestive of an acute infectious or inflammatory
process. Bronchoscopy performed [**5-9**] - normal on visual
inspection, but BAL ctx grew out sensitive enterobacter and
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] sensitive to caspo/vori. Tx c caspo c plan for
transplant after treatment of yeast infection in lungs.
Continue caspo * 2 weeks ([**5-18**]) with repeat CT to assess for
interval change.
.
# Panniculitis - tx c IV vancomycin. Swab sent for MRSA screen
and pending; currently being treated with vancomycin.
Past Medical History:
cryptogenic cirrhosis
right inguinal hernia - cannot repair [**12-18**] to liver disease
Social History:
No longer working but used to work as a chef. live with his
mother, not married or has children. Does not drink or smoke
Family History:
positive for diabetes but no known history of iron overload.
His father died of small cell carcinoma of the lung
Physical Exam:
vs: HR 60, BP 110/48, O2 sat 99%, 99.1 at 12:00, CVP 5
HEENT: EOMI, sclerae anicteric, oropharynx clear c no lesions
Lungs: CTA at apices/bases
Heart: RRR, S1, S2, no r/m/g
Abd: soft, + splenomegaly, NT, obese, + striae
Ext: [**11-17**] + edema to ankles b/l
Skin: large area ecchymoses over L shoulder. No spider angiomas
noted, + gynecomastia.
Pertinent Results:
Labs from outside hospital on morning of admission:
Na 136, K 3.5, Cl 118, Bicarb 11, BUN 23, Cr 2.6 up from 1.8 on
admission to RI, Glu 116. INR 2.3 up from 1.8 on admission.
Tbili 40. up from 1.8, HCT 26, WBC 14.8 with 90% neutrophils
Ascites: fluid cloudy yellow, Nu cells [**Pager number **], RBCs 675, 89%
Neutrophils therefore 7000 nuc cells.
.
Admission labs at [**Hospital1 **]:
[**2121-5-7**] 06:35AM BLOOD WBC-3.6* RBC-1.99* Hgb-5.9* Hct-18.2*
MCV-92 MCH-29.7 MCHC-32.4 RDW-16.1* Plt Ct-65*
[**2121-5-7**] 06:35AM BLOOD PT-25.6* PTT-57.8* INR(PT)-4.3
[**2121-5-7**] 06:35AM BLOOD Glucose-139* UreaN-31* Creat-3.1* Na-135
K-3.6 Cl-114* HCO3-10* AnGap-15
[**2121-5-7**] 06:35AM BLOOD ALT-37 AST-41* AlkPhos-98 TotBili-1.4
[**2121-5-7**] 06:35AM BLOOD Albumin-3.5 Calcium-8.1* Phos-4.7* Mg-1.7
Iron-47
[**2121-5-7**] 06:35AM BLOOD calTIBC-88* VitB12-1342* Folate-11.5
Ferritn-348 TRF-68*
[**2121-5-7**] 06:35AM BLOOD TSH-1.4
[**2121-5-7**] 02:04AM BLOOD Lactate-1.5
.
[**2121-5-8**] CT Chest and Abdomen: Patents portal and hepatic veins.
IMPRESSION: 1. Scattered small pulmonary opacities within both
lungs, of varying sizes and morphologies, suggestive of an acute
infectious or inflammatory process. An additional area of
fibronodular thickening within the right lung apex may be
secondary to chronic lung disease, but could also be associated
with the above described smaller nodular opacities. Correlation
with the patient's clinical exam and follow up of these nodules,
to document their stability or resolution, is recommended. Given
the patient's history, a neoplastic process cannot be entirely
excluded.
2. New bilateral pleural effusions, smaller in size.
3. Prominent mediastinal and axillary lymph nodes, none meeting
the size criteria for pathologic enlargement, which may related
to the above described process within the lung parenchyma.
4. Stable perihepatic and perisplenic ascites.
5. Gynecomastia.
.
[**2121-5-8**] Echo: The left atrium is markedly 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. Overall left ventricular systolic function is normal
(LVEF 60-70%). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated. The ascending aorta is mildly
dilated. 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 estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
.
[**2121-5-7**] blood cultures neg. x 2
[**2121-5-8**] RPR neg, VZV IgG pos, EBV IgG pos, EBV IgM neg, Toxo IgG
neg, Toxo IgM neg, CMV IgG pos, CMV IgM neg,
[**2121-5-8**] 05:37AM BLOOD HIV Ab-NEGATIVE
[**2121-5-10**] 07:40AM BLOOD PEP-NO SPECIFIC ABNORMALITIES.
[**2121-5-9**] 11:53 am BRONCHOALVEOLAR LAVAGE GRAM STAIN positive for
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO
MICROORGANISMS SEEN.
RESPIRATORY CULTURE positive for ENTEROBACTER CLOACAE, ~[**2115**]/ML,
but not considered a pathogen unless >=10,000 cfu/ml.
BAL FUNGAL CULTURE (Preliminary): YEAST, PRESUMPTIVELY NOT C.
ALBICANS. FURTHER IDENTIFICATION TO FOLLOW.
ACID FAST SMEAR negative, ACID FAST CULTURE (Pending):
[**5-19**] repeat chest CT
1. Thick walled, irregular right upper lobe cavitary lesion.
Differential considerations include an infectious process such
as reactivation TB, particularly given the lymphadenopathy.
Vasculitis, such as Wegener's, can have a similar appearance and
be associated with tracheal thickening as seen on this study. A
cavitary neoplasm is considered less likely given the irregular
shaped of the cavity.
2. Bibasilar consolidation and pleural effusions, right greater
than left.
Pleural Fluid [**5-28**]
GRAM STAIN (Final [**2121-5-29**]): 1+ (<1 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
ACID FAST SMEAR (Final [**2121-5-29**]): NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR. ACID FAST CULTURE (Pending):
FLUID CULTURE (Final [**2121-5-31**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
Lung Tissue [**5-27**]
rare growth coag (-) staph, oxacillin resistant, no ctx growth -
anaerobes, legionella, fungus, AFB
.
Histo Urinary Ag - P
.
LP [**6-19**]-->WBC, CSF 0 #/uL
CLEAR AND COLORLESS
PERFORMED AT WEST STAT LAB
RBC, CSF 71* #/uL 0 - 0
PERFORMED AT WEST STAT LAB
Polys 25 %
4 CELL DIFFERENTIAL
PERFORMED AT WEST STAT LAB
Lymphs 25 %
Monocytes 50 %
..
[**6-22**] CXR: There is continued large right pleural effusion, which
is unchanged since the previous study. The previously identified
mild congestive heart failure has been slightly improving. The
right-sided PICC line remains in place. No pneumothorax is seen.
Brief Hospital Course:
This patient, who had initially seen Dr. [**Last Name (STitle) 497**] and transplant
social work a few weeks ago, was transferred to [**Hospital1 18**] for an
expedited liver transplant workup because he developed acute
renal failure and SBP; was about to receive liver txp which was
aborted because of lung infxn; currently undergoing tx for
cavitary lesion in lung prior to txp.
.
End stage liver failure; followed by liver service. He was
continued on octreotide and midodrine until his creatinine came
down; he was considered to be out of hepatorenal syndrome and
octreotide/midodrine stopped. Prior to R lobectomy, pt. was
diuresed aggressively in anticipation of large amount of blood
products during surgery. He was kept on lactulose with a goal
of [**1-17**] BM daily. He was on cipro for SBP prophylaxis and
protonix for gastritis/prophylaxis. Post lobectomy we continued
to diurese him aggressively with lasix, spironolactone and
repleted his electrolytes accordingly. It was determined the
week of [**6-9**] that the pt. actually has cryptococcus in the RUL
specimen, not histoplasmosis based on mucicarmine stain and
Fontana-Masson1 stain. As a result, he had a w/u for CNS crypto
which included an LP performed under fluoroscopy. However, this
procedure was complicated by patient's coagulopathy, and pt
required multiple transfusions of FFP and platelets. In
addition, patient required 4800mcg of Factor VII, which was
given immediately prior to procedure and successfully reversed
his INR. As a result of the blood products, pt became fluid
overloaded and developed a R sided pleural effusion. This was
treated with aggressive IV diuretics in addition to his oral
aldactone. Pt was kept in negative balance of at least 1.5L
daily, and his weight was tracked as well. His creatinine
remained between 1.3-1.4. Diuresis was slowly decreased once
patient able to breathe comfortably on room air and his weight
decreased by a few pounds. He was changed over to oral lasix
and continued on the spironolactone.
.
SBP; this resolved with a 2 week course of cipro/ceftriaxone.
He was kept on prophylaxis with cipro and did not c/o any
increasing abdominal pain.
.
Lung nodules/cavitary lesion RUL; prior to R lobectomy, he was
ruled out for TB with three negative induced sputums. He
underwent R lobectomy and path showed large palisading caseating
granulomas with many yeast forms ([**1-18**] microns) in the caseous
material. Post lobectomy, he was treated with ambisome IV. A
discussion whether he needed a w/u for disseminated histo
occurred and it was decided that the w/u should include a MRI to
assess for meningeal involvement as well as a BM biopsy/aspirate
culture. This was considered necessary as it may impact his
prognosis should he go for emergent liver txp as well as his
relative response to a non-cidal [**Doctor Last Name 360**] (itraconazole) should he
not tolerate ambisome. As of [**6-6**] he had a negative MRI and a
BM aspirate culture was going to be done [**6-6**]. The BM was never
done b.c. of high risk and possibility to treat empirically.
Concurrently (see above) it was determined that he had
cryptococcus, not histoplasmosis. This was based on fungal
stains. As a result, he requires a LP to r/o CNS crypto. The
LP was to be done under fluoroscopy because he has such poor
landmarks and he is a high risk candidate, because of this, the
[**Hospital1 **] protocol for LP, which is that the procedure service must
attempt, then neurology, then the pain service, and then IR as a
last resort; was bypassed. The LP was negative for crypto, at
which point the patient was changed from ambisome to oral
fluconazole, 400mg daily, to complete an eight week course per
ID recommendations.
.
Panniculitis; treated with IV vancomycin and this resolved;
vanco stopped [**5-23**].
.
Central line; pt. central line placed [**2121-5-15**]; plan was to
remove central line [**6-6**] AM and position 2 peripheral IVs.
Central line removed, tip (-) ctx, PICC placed for plan for
outpt. abx, however, as patient did not require IV antibiotics,
this PICC was removed prior to discharge.
.
Pt was also followed by thoracic service for management of chest
tubes. Drained for nearly 1 week post surgery. Chest tubes
pulled when drainage < 400 cc/24 hr. Pt. continued to have
sporadic drainage usually worsened by activity. Pt. had ostomy
bag intermittently applied over chest tube site to control
drainage. Tramadol and oxycodone used for pain control and pt.
able to use incentive spirometer. Stitch over CT site applied
by thoracic team. As of [**6-14**], his chest tube site was draining
minimal fluid and was covered with dry gauze. Staples over his
incision site were removed 2 days prior to discharge and covered
with steri-strips.
.
Patient was evaluated by PT/OT and was cleared for discharge to
his home. VNA was arranged for the patient prior to discharge.
After a stable dose of lasix was determined that would provide
patient with optimal diuresis, patient was cleared for discharge
to home with services. Patient was scheduled for follow-up
appointments with Dr. [**Last Name (STitle) 497**], Dr. [**Last Name (STitle) 4334**], and Dr. [**Last Name (STitle) 724**]. On day of
discharge, patient was ambulating, afebrile, hemodynamically
stable, and tolerating a house diet. Patient was given a
prescription for all of his medications as he stated that he did
not have any at home. However, a few days after discharge,
patient called needing clarification with two of the
prescriptions, at which point he was [**Name (NI) 653**], but stated that
the problem had already been resolved.
Medications on Admission:
on transfer:
albumin 40mg IV q8
cefotaxime 2g q24
neomycin 500mg q6
lactulose 20 po q6
aldactone 50 po qam
Discharge Medications:
1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for legs.
Disp:*1 * Refills:*1*
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
Disp:*1 * Refills:*2*
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 * Refills:*1*
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*112 Tablet(s)* Refills:*0*
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Doctor Last Name **]
Discharge Diagnosis:
cryptococcal pneumonia
cryptogenic cirrhosis
end stage liver disease
Discharge Condition:
stable
Discharge Instructions:
Please take all of your medications as prescribed.
Please maintain all of your follow up appointments listed below.
Please call your doctor or return to the hospital if you develop
fevers, chills, nausea or vomiting, or develop chest pain or
shortness of breath.
Followup Instructions:
1.Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 3126**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2121-7-2**] 3:20
2.Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2121-7-17**] 10:30
3.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Where: LM [**Hospital Unit Name 3126**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2121-8-12**] 10:00
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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17694, 17755
|
10712, 16364
|
297, 347
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17868, 17876
|
5666, 8967
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5031, 5153
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,722
| 150,767
|
47411
|
Discharge summary
|
report
|
Admission Date: [**2145-6-12**] Discharge Date: [**2145-6-29**]
Date of Birth: [**2083-2-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
62 YO female with Hx of Developmental delay, Bipolar D/O,
epilepsy, admitted to the ICU after being found unresponsive and
in respiratory failure on the floor. Per pt's sister and
previous notes , [**Name (NI) **] was in her USOH, but has slowly become
more agitated since this change, but has been functioning at
home and shopping/balancing her checkbook w/o difficulty.
Approximately 3 weeks ago her Lithium was changed to Lithobid by
CVS b/c of a med shortage. For approximately 1-2 weeks [**Known firstname **]
has been increasingly agitated, with some tremors and has been
dropping things. She may have had some right arm stiffness as
well. She has some also been quite sleepy recently, and has been
unable to go to her day care program. Her breathing has also
been labored recently, and was placed on Singular for allergies.
She has also had ~1 week of coughing and hoarseness.
In the ED, the pt received a wrist/foremarm/chest X-ray, head
CT, neck CT, and chest CTA to r/o PE. She was placed back on
Lithium and Seroqel, and given Ativan as well as 7.5mg of Haldol
for agitation.
She was started on Levaquin/flagyl for possible PNA yesterday
and was evaluated by psych for MS changes and an EEG report is
pending. Pt was at baseline [**Name8 (MD) **] RN until found patient
unresponsive at 0400. ABG was done 7.08/115/131 and pt was
emergently intubated with no medications for respiratory failure
and brought to [**Hospital Unit Name 153**]. Pt was borderline hypotensive MAP 50-60 so
started on phenylepherine.
PCP--> Dr [**Last Name (STitle) **]
Psychiatrist--> Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at Mass Mental
Past Medical History:
Asthma
Developmental delay
Temporal lobe epilepsy, ? in past. neuro did not agree with dx
[**Location (un) 3484**] Disease
Hypertension 2nd to cushings
s/p CCY
OA
Social History:
Patient lives in [**Hospital3 **] in [**Location (un) **], and has visiting
services and family members help out as well. She is able to do
her ADL's as well as balancing her chechbook, etc. She attends a
day care program. No history of tobacco abuse.
Physical Exam:
T=98.0, BP=78/55, HR=79, RR=20, O2=96% on NC
GEN: Pt responds to painful stimuli, morbidly obese
HEENT: nonicteric, mmm, PERRL, Nasal and OP is bloody from
intubation.
CHEST: diffuse rhonchi and no wheezing
CV: RRR, no murmers noted
ABD: obese, NT, +BS
EXT: trace LE edema bilaterally
NEURO/PSYCH: moves all 4 extremities and responsive to painful
stimuli.
Pertinent Results:
CTA CHEST [**2145-6-13**] - IMPRESSION: 1. Limited examination showing
no central or segmental pulmonary embolus. 2. Bilateral patchy
airspace opacities consistent with an infectious process, less
likely congestive heart failure. Clinical correlation is
recommended. 3. Aortic calcifications.
CXR- ETT at [**Female First Name (un) 5309**], left lung fluffy iniltrates and right lung
also looks worse compared to admission CXR.
ECHO [**2145-6-14**] The left atrium is mildly dilated. The right atrium
is moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Left ventricular systolic function
appears grossly preserved but views are technically suboptimal.
Right ventricular chamber size and free wall motion are probably
normal but views are suboptimal. The ascending aorta is mildly
dilated. The aortic valve leaflets are mildly thickened. There
is a minimally increased gradient consistent with minimal aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
EEG [**2145-6-13**] This is an abnormal portable EEG due to the presence
of a
slow and disorganized background rhythm in the delta frequency
range
with occasional generalized delta frequency slowing. These
findings
suggest deep, midline subcortical dysfunction and are consistent
with an
encephalopathy. Common causes include medications, infection,
and
metabolic derangements. No lateralizing or epileptiform
abnormalities
were seen.
Brief Hospital Course:
1. Respiratory Distress-The etiology of the patients repiratory
distress was unclear. The differential diagnosis initially
included seizure activity, ishemic cardiac event, hypercapnia
from asthma, viral pulmonary infection as initial insult,
congestive heart failure given increased weight gain for 3 weeks
prior to admission.
To address our cardiac concerns, cardiac enzymes were ordered
and she ruled out for an MI. An ECHO was performed and due to
patients size was a suboptimal study, but results that were
obtained did not indicate severe diastolic or systolic
dysfunction.
Because of a history of temporal lobe epilepsy, it was
originally thought that the patients unresponsiveness prior to
ICU transfer may have been from seizure activity. An EEG was
performed and no seizure activity was seen.
Blood and sputum cultures were sent, and the patient was started
on Levoquin and Flagyl empirically. Because of a history of
epilepsy, the patient was switched to ceftriaxone and
azithromycin. Because of extensive lung opacities on both CXR
and CT Thorax that were not improving, a bronchoscopy was
performed and BAL send for extensive cultures. Bronchoscopy neg
on [**6-15**]. Sputum cx from [**6-18**] showed gram MRSA on final culture
report. MRSA felt to be consistent with ventilator associated
pneumonia and she was placed on 10 day course of Vancomycin.
Other antibiotics were discontinued. She completed Vanco on [**6-29**]
and has remained afebrile and hemodynamically stable without
localizing symptoms.
After much investigation, the etiology of her respiratory
failure remains unclear. The leading differentital is
hypercapnia from underlying longstanding hypercapnic/hypoxic
state (i.e. asthma vs. obesity related), possible viral
pulmonary infection as initial insult, and ?congestive heart
failure given increased weight gain for 3 weeks prior to
admission. We have continued aggressive asthma treatment with
around the clock albuterol and ipratropium nebulizers + flovent
nebs. In addition she is continued on montelukast. In addition,
we have treated her clinical volume overload with diuresis on
lasix. Upon discharge she is on 20mg PO lasix per day and low
dose Ace-I.
She will benefit from a referral to pulmonary medicine for
pulmonary function tests and CT scan and f/u CXR to further
evaluate the nature of her underlying lung disease and the
progression of her current illness. PFT's are scheduled as
outlined on the discharge planning paperwork.
2. Hypotension - Upon transfer to the ICU the patient was
borderline hypotensive with MAP 50-60. She was started on
phenylepherine. She was weaned off within 24 hours and
continued to maintain her pressure the remainder of her hospital
course.
3. Transaminitis - on admission AST/ALT were 120/54 and trended
down during her time in the ICU. No further w/u indicated at
this time.
4. Increased Lithium level-On admission patients lithium level
was 1.4. As per psychiatry's recommendations, two doses were
held and she was restarted on 450mg/day (which was lower than
her dosage on admission). Her last level was 0.5 (goal 0.7-1.0),
but this level was felt to be appropriate per psychiatry,
therefore she was continued on 150mg TID.
5.FEN - Lactose free healthy heart diet. Monitoring lytes while
on lasix, Ace-I
6.Prophylaxis -SQ heparin, pneumatic boots, H2 blocker, and
bowel regimin.
7.Code: Full Code as discusses with sisters on this hospital
stay
Medications on Admission:
Lithobid 300mg [**Hospital1 **]
Seoquel 550mg HS
Lisinopril 40mg QD
MVI
Singular
Premarin 0.3 QD
Discharge Medications:
1. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Quetiapine Fumarate 200 mg Tablet Sig: Two (2) Tablet PO QHS
(once a day (at bedtime)).
6. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) as needed for agitation.
7. Benztropine Mesylate 0.5 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours) as needed for with Haldol.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Haloperidol 1 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation [**Hospital1 **] (2 times a day).
11. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
12. Lithium Carbonate 150 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] health center
Discharge Diagnosis:
Respirator Failure, hypercarbic
MRSA Ventilator acquired pneumonia
Bipolar Disease
Temporal Lobe Epilepsy
Discharge Condition:
Stable, extubated. HCO3 38 post extubation. unclear baseline. At
the time of discharge O2 sats on room air wer 93%
Discharge Instructions:
Please make all follow up appointments. If you have any
increased trouble breathing, please call Dr. [**Last Name (STitle) **]
immediately.
You have completed a 10 day course of antibiotics for MRSA
pneumonia.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 2204**] to schedule a follow up appointment
within a week of discharge. You should have a referral to a
pulmonologist for pulmonary function testing and CT scan and
follow up CXR to further evaluate your underlying lung disease
as listed below.
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2145-7-8**]
1:10
Provider: [**Name10 (NameIs) 1571**] EXAM ROOM IS (NO CHARGE) Where: IS (NO
CHARGE) Date/Time:[**2145-7-8**] 1:30
Provider: [**Name Initial (NameIs) **]/[**Doctor Last Name **],TCC Date/Time:[**2145-7-8**] 1:30
|
[
"458.9",
"296.7",
"345.40",
"493.20",
"482.41",
"V09.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
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] |
icd9pcs
|
[
[
[]
]
] |
9804, 9865
|
4605, 8052
|
279, 305
|
10015, 10131
|
2850, 4582
|
10390, 11056
|
8199, 9781
|
9886, 9994
|
8078, 8176
|
10155, 10367
|
2472, 2831
|
232, 241
|
333, 2000
|
2022, 2187
|
2203, 2457
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,819
| 177,491
|
34989
|
Discharge summary
|
report
|
Admission Date: [**2164-9-8**] Discharge Date: [**2164-9-21**]
Date of Birth: [**2106-6-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Aortic Valve Replacement ( 27mm [**Company 1543**] porcine) [**9-17**]
History of Present Illness:
The patient presented to an outside hospital with recurrent
shortness of breath. He had been treated with diuretics
earlier, but symptoms persisted. He was treated for congestive
failure and diuresis was continued. He was transferred here for
further workup and treatment.
Past Medical History:
hypertension
chronic renal insufficiency
Social History:
Tobacco history: Currently smoking
ETOH: Denies
Illicit drugs: Denies
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
Admission
VS 97.5 HR83 BP186/85 RR24 O2sat 99% nonrebreather Ht68"
Wt200
Gen NAD
Neuro A&Ox3
Heent PERRL/EOMI anicteric. MMM, neck supple
CV RRR, S1-S2 4/6 SEM,
Pulm Bilat rales 1/3way up
Abdm soft, NT/ND, +BS
Ext warm, no CCE
Discharge
VS T98 BP 122/85 RR18 O2sat 93%-RA Wt 100.4K
Gen NAD
Neuro nonfocal exam
CV RRR, no murmur. Sternum stable incision CDI
Pulm CTA-bilat
Abdm soft, NT/ND/+BS
Ext warm well perfused. trace edema
Pertinent Results:
[**2164-9-8**] 06:56PM GLUCOSE-242* UREA N-25* CREAT-1.6* SODIUM-140
POTASSIUM-2.7* CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
[**2164-9-8**] 06:56PM ALBUMIN-3.3* CALCIUM-7.5* PHOSPHATE-4.2
MAGNESIUM-1.7
[**2164-9-8**] 05:06PM CK(CPK)-159
[**2164-9-8**] 05:06PM CK-MB-5 cTropnT-0.09*
[**2164-9-8**] 11:18AM URINE HOURS-RANDOM UREA N-276 CREAT-39
SODIUM-110
[**2164-9-8**] 11:18AM URINE OSMOLAL-289
[**2164-9-8**] 09:32AM %HbA1c-5.8
[**2164-9-8**] 01:55AM WBC-5.8 RBC-4.49* HGB-13.8* HCT-39.6* MCV-88
MCH-30.7 MCHC-34.8 RDW-13.4
[**2164-9-8**] 01:55AM PLT COUNT-180
[**2164-9-8**] 01:55AM PT-13.5* PTT-24.9 INR(PT)-1.2*
[**2164-9-21**] 05:00AM BLOOD WBC-6.9 RBC-3.05* Hgb-9.4* Hct-26.8*
MCV-88 MCH-30.9 MCHC-35.2* RDW-12.9 Plt Ct-199
[**2164-9-21**] 05:00AM BLOOD Plt Ct-199
[**2164-9-17**] 12:00PM BLOOD PT-15.1* PTT-43.7* INR(PT)-1.3*
[**2164-9-21**] 05:00AM BLOOD Glucose-94 UreaN-28* Creat-1.4* Na-134
K-3.9
Radiology Report CHEST (PA & LAT) Study Date of [**2164-9-20**] 9:06 AM
[**Hospital 93**] MEDICAL CONDITION:
58 year old man with
REASON FOR THIS EXAMINATION:
??ptx
Preliminary Report !! PFI !!
No significant interval change. No pneumothorax.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
PFI entered: [**Doctor First Name **] [**2164-9-20**] 11:52 AM
Radiology Report RENAL U.S. Study Date of [**2164-9-19**] 4:15 PM
[**Hospital 93**] MEDICAL CONDITION:
58 year old man with
REASON FOR THIS EXAMINATION:
renal doppler to r/o renal artery stenosis
Final Report
HISTORY: 58-year-old male with renal Doppler to evaluate for
renal artery
stenosis.
COMPARISON: None available.
RENAL ULTRASOUND: The right kidney measures 11.0 cm, and the
left kidney
measures 9.8 cm. There is no evidence of stones, mass, or
hydronephrosis.
Doppler waveform analysis of the renal arteries was performed to
evaluate for renal artery stenosis. The right kidney
demonstrates normal arterial
waveforms throughout, with normal resistive indices of
0.62-0.68.
The left renal arteries are difficult to evaluate despite
scanning with
multiple accoustic windows and in multiple patient positions.
However, a
waveform tracing obtained from the upper pole was normal, with a
normal
resistive indicex of 0.69.
The bladder is visualized and is unremarkable.
IMPRESSION:
1. No evidence of stones, mass, or hydronephrosis.
2. No evidence of renal artery stenosis on the right.
3. Despite slight limitation on the left, no evidence of renal
artery
stenosis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name 3900**]
DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 275**] [**Hospital1 18**] [**Numeric Identifier 80024**]Portable TEE
(Complete) Done [**2164-9-10**] at 10:15:54 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] S.
[**Hospital1 **] C
[**Location (un) 830**], E/RW-453
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2106-6-3**]
Age (years): 58 M Hgt (in): 68
BP (mm Hg): 140/65 Wgt (lb): 213
HR (bpm): 83 BSA (m2): 2.10 m2
Indication: Aortic valve disease. ? Aortic dissection.
ICD-9 Codes: 428.0, 424.1
Test Information
Date/Time: [**2164-9-10**] at 10:15 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]: Cardiology
Fellow
Doppler: Full Doppler and color Doppler Test Location: West CCU
Contrast: None Tech Quality: Suboptimal
Tape #: 2008W000-0:00 Machine: Vivid i-4
Sedation: Versed: 1.5 mg
Fentanyl: 50 mcg
(See comments below for other sedation.)
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Descending Thoracic: *3.3 cm <= 2.5 cm
Findings
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Symmetric LVH. Normal LV cavity size.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Mildly dilated descending aorta.
Simple atheroma in abdominal aorta. No thoracic aortic
dissection.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
masses or vegetations on aortic valve, but cannot be fully
excluded due to suboptimal image quality. Moderate (2+) AR.
Eccentric AR jet directed toward the anterior mitral leaflet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No masses
or vegetations on mitral valve, but cannot be fully excluded due
to suboptimal image quality. Mild (1+) MR.
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 monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was
provided by benzocaine topical spray. The posterior pharynx was
anesthetized with 2% viscous lidocaine. 0.2 mg of IV
glycopyrrolate was given as an antisialogogue prior to TEE probe
insertion. No TEE related complications. Image quality was
suboptimald - poor esophageal contact. Resting tachycardia
(HR>100bpm). MD caring for the patient was notified of the
echocardiographic results by e-mail. Echocardiographic results
were reviewed with the houseofficer caring for the patient.
Conclusions
Technically suboptimal study due to poor contact.
The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is prominent symmetric left ventricular
hypertrophy with normal cavity size. There are simple atheroma
in the abdominal aorta. The descending aorta is mildly dilated.
.No thoracic aortic dissection is seen. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. There is no aortic valve stenosis. An
eccentric jet of moderate (2+) aortic regurgitation is seen
directed towards the anterior mitral leaflet. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Moderate aortic regurgitation with thickened
leaflets but without discrete vegetation. Dilated descending
aorta without evidence of aortic dissection. Mild mitral
regurgitation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2164-9-10**] 19:24
Brief Hospital Course:
58yoM presented to [**Hospital3 4107**] with increasing shoertness of
breath, found to be in hypertensive crisis and transferred to
[**Hospital1 18**] for further care. Patient treated initially by cardiology
service. during work up patient was found to have Aortic
insufficiency and cardiac surgery was consulted. He was accepted
for surgery and on [**9-17**] was brought to the operating room for
an aortic valve replacement. Please see OR reportr for details,
in summary he had and AVR with #27 [**Company 1543**] porcine valve. His
bypass time was 86 minutes with a crossclamp of 61 minutes. He
tolerated the operation well and was transferred to the ICU in
stable condition. He remained hemodynamically stable in the
immediate post-op period, anesthesia was reversed he woke
neurologically intact and he was extubated. On POD1 he was
transsferred from the ICU to the stepdown floor.
The remainder of his hospitalization was uneventful. His
activity level was advanced his antihypertensives were titrated
and on POD 4 he was discharged home with visiting nurses.
Medications on Admission:
ASA 325mg
Hydralazine 50mg QID
Labetolol 200mg [**Hospital1 **]
Discharge Medications:
1. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
aortic iinsufficiency
s/p aortic valve replacement(27mm [**Company 1543**] porcine)
hypertension
Chronic renal insufficiency
Acute systolic heart failure
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any fever more than 100.5
report any redness of, or drainage from incisions
report any weight gain greater than 2 pounds a day or 5 pounds a
week
no driving for 6 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
Followup Instructions:
wound clinic in 2 weeks
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1637**] in 2 weeks ([**Telephone/Fax (1) 14655**])
Completed by:[**2164-9-21**]
|
[
"414.01",
"428.21",
"E915",
"225.2",
"933.1",
"305.1",
"428.0",
"424.1",
"585.9",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"88.72",
"37.23",
"37.78",
"39.61",
"88.42",
"88.56",
"88.50",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
10973, 11031
|
8681, 9751
|
326, 399
|
11229, 11236
|
1406, 2406
|
11604, 11850
|
872, 932
|
9869, 10950
|
2901, 2922
|
11052, 11208
|
9777, 9846
|
11260, 11581
|
947, 1387
|
279, 288
|
2954, 8658
|
427, 703
|
725, 768
|
784, 856
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,467
| 143,803
|
40507
|
Discharge summary
|
report
|
Admission Date: [**2129-5-2**] Discharge Date: [**2129-5-11**]
Date of Birth: [**2053-10-26**] Sex: F
Service: SURGERY
Allergies:
Amoxicillin / Lovenox
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
hypotension after exploratory laparotomy
Major Surgical or Invasive Procedure:
[**2129-5-9**] CT guided drainage of abdominal abscess
History of Present Illness:
75 F s/p umbilical hernia repair on [**4-28**] for incarcerated
umbilical hernia c/b intra-abdominal bleed s/p ex-lap now
transferred from OSH for further management The patient had
undergone repair of her umbilical and was recovering from this
when she became hypotensive. A CT was performed that
demonstrated
significant amount of blood in the abdomen. The patient was
taken
to the or for an emergent exploratory laparotomy.
Postoperatively
she had a ph of 7.03 and was then transferred to [**Hospital1 18**]>
Past Medical History:
PMH: HTN, HL, OA, Obesity, CAD (No MIs), TIA, NIDDM, AF on
coumadin, COPD, OSA, EtOH abuse.
PSH: Hysterectomy, THA, umbilical hernia repair as above
Social History:
+ Tobacco remote
+ ETOH
Family History:
non contributory
Physical Exam:
Temp 99.2 123AF BP 127/69 RR 20 100 CMV 400x17p5@40%
Alert, responds appropriately, Intubated.
CTAB
Irreg Irreg
Abd Soft, diffusely tender, no rebound/guarding.
1+ edema BLE
Pertinent Results:
[**2129-5-9**] CT Abd/pelvis :
1. No findings of bowel obstruction. Small-to-moderate sized
fluid
collection within the subcutaneous tissues and peritoneal cavity
along the
lateral right abdominal wall/flank. This appears predominantly
simple by
Hounsfield unit attenuation and contains internal locules of
gas, presumably related to the recent surgery. There is
incomplete rim enhancement and underlying superinfection not
excluded. If there remains a high clinical concern for
infection, collection should be amenable to percutaneous
aspiration.
2. Moderate atherosclerotic disease and marked mitral annular
calcification.
3. Moderate right and small left pleural effusion. Trace
pericardial
effusion. Mild amount of intra-abdominal ascites.
4. High-density material within the gallbladder may reflect
vicarious
excretion of previously administered intravenous contrast or
biliary sludge. The gallbladder is moderately distended, likely
related to n.p.o. status. However, if there remains a high
clinical concern for acalculous
cholecystitis, suggest correlation with HIDA examination.
5. Significant bladder distention at time of examination. Please
correlate
for any clinical symptoms of urinary retention. Small amount of
gas within
the bladder likely reflects recent instrumentation/Foley
catheter.
6. Slight asymmetrical positioning of the femoral head within
the acetabular component of the right hip arthroplasty. This may
simply reflect patient positioning, but can be better assessed
with dedicated pelvic radiograph to evaluate for uneven
acetabular wear.
7. Incompletely characterized left adrenal mass. In a patient
without any
history of malignancy, this is almost certainly a benign
adenoma. Current
guidelines do suggest correlation with biochemistry to assess
for a functional adenoma and repeat imaging in 12 months to
exclude growth if there are no prior imaging is available to
document stability.
[**2129-5-9**] CT guided drainage of abdominal abscess :
Technically successful CT-guided aspiration and drainage of a
right lateral abdominal collection yielding clear dark brownish
red fluid
suggestive of subacute to chronic hematoma/seroma. 6 French
catheter left to
bag and gravity drainage. Specimen sent to microbiology for
further analysis.
[**2129-5-2**] 02:23PM WBC-32.2* RBC-3.12* HGB-10.1* HCT-28.3*
MCV-91 MCH-32.4* MCHC-35.8* RDW-16.5*
[**2129-5-2**] 02:23PM PLT COUNT-232
[**2129-5-2**] 02:23PM PT-24.6* PTT-33.5 INR(PT)-2.3*
[**2129-5-2**] 02:23PM ALT(SGPT)-780* AST(SGOT)-1157* LD(LDH)-[**2047**]*
CK(CPK)-633* ALK PHOS-51 TOT BILI-0.8
[**2129-5-2**] 02:23PM GLUCOSE-180* UREA N-26* CREAT-1.6* SODIUM-137
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
[**2129-5-2**] 02:28PM LACTATE-4.6*
[**2129-5-2**] 07:14PM WBC-31.9* RBC-3.12* HGB-10.2* HCT-28.0*
MCV-90 MCH-32.5* MCHC-36.3* RDW-17.2*
[**2129-5-2**] 07:14PM GLUCOSE-137* UREA N-30* CREAT-1.9* SODIUM-141
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16
[**2129-5-2**] 07:14PM ALT(SGPT)-956* AST(SGOT)-1364* LD(LDH)-1619*
ALK PHOS-54 TOT BILI-0.7
[**2129-5-2**] 07:38PM LACTATE-2.7*
[**2129-5-9**] 1:56 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2129-5-9**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
4/27/11WBC 12.1 HCT 31.6 PLT CT 418K
Brief Hospital Course:
Mrs. [**Known lastname **] was evaluated by the Acute Care service in the
Emergency Room and admitted to the SICU for further management.
She was intubated and sedated and required voluminous fluid
resuscitation to correct her acidosis. Her renal function
gradually improved and over a 24 hour period she was weaned and
extubated from the respirator. Her WBC on admission was 32K but
that gradually decreased and she remained afebrile. Her
hematocrit drifted to 21 and following two units of packed red
blood cells she stabilized.
Following transfer to the Surgical floor she began to progress.
She was gradually tolerating a regular diet but unfortunately
failed two voiding trials requiring replacement of the Foley
catheter. Her abdominal wound was healing well. She was
evaluated by the Physical Therapy service who recommended a
short term rehab prior to returning home to help increase her
mobility and stamina.
Of note, she remained in rate controlled atrial fibrillation and
her Coumadin was not resumed due to her prior bleeding. Her PCP
can decide after she's fully recovered if she should resume it.
She did have 1 episode of chest pain during her admission with
negative enzymes and no ischemic changes on her EKG. This
happened just prior her developing an abdominal wound
collection.
On [**2129-5-9**] her WBC started to rise again and she had increased
abdominal pain. An abdominal CT was done which noted a fluid
collection along the right flank and subsequently she underwent
percutaneous drain placement which resolved her pain. She was
also placed on Cipro and Flagyl. Her diet was resumed and she
was feeling much better. Her drain is putting out about 50 cc of
dark bloody fluid daily and her hematocrit is stable at 31. Her
creatinine is now down to her baseline of 0.5. The preliminary
cultures on the abdominal fluid are negative.
Mrs. [**Known lastname **] will be discharged to rehab on [**2129-5-11**] and will
follow up in the [**Hospital 2536**] Clinic next week.
Medications on Admission:
[**Last Name (LF) **], [**First Name3 (LF) **], Fosamax, Lopresser, Fentanyl patch, Percocet,
NItro patch, Senna, Spiriva, VitD, Betagen eye drops.
Discharge Medications:
1. senna 8.6 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): hold for diarrhea.
3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection TID (3 times a day).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): for pain.
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): thru [**2129-5-23**].
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): thru [**2129-5-23**].
10. nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
11. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
12. Betagan 0.5 % Drops Sig: One (1) drop Ophthalmic once a day:
both eyes.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]-[**Location (un) **]
Discharge Diagnosis:
1. Abdominal wound abscess
2. Urinary retention
3. Chronic atrial fibrillation
4. Acute renal failure
5. Acute blood loss anemia
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 underwent a repair of your abdominal hernia which was
complicated by bleeding into your abdomen. You underwent a
exploration of your abdomen. You were transferred here because
you had a large fluid requirement and abnormal electrolytes and
there was a concern for infection. You were admitted to the
intensive care unit for monitoring. Your bleeding stopped and
your electrolytes normalized. Unfortunately your pain increased
due to an abdominal abscess. The area has been drained and the
tube will stay in for now. You will continue antibiotics until
your follow up appointment. You will need a short term rehab
stay prior to returning home to increase your strength and
mobility.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-24**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
* Your staples will be removed at rehab.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 1 week. Bring a record of the daily drainage
from your abdominal drain with you.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2129-5-11**]
|
[
"250.00",
"285.1",
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"707.22",
"272.4",
"401.9",
"327.23",
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"E878.8",
"788.20",
"998.12",
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] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.91",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8208, 8276
|
4852, 6858
|
321, 378
|
8449, 8449
|
1382, 4693
|
11153, 11462
|
1150, 1168
|
7057, 8185
|
8297, 8428
|
6884, 7034
|
8625, 10775
|
10791, 11130
|
1183, 1363
|
241, 283
|
406, 920
|
4776, 4829
|
8464, 8601
|
942, 1093
|
1109, 1134
|
4725, 4740
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,629
| 178,164
|
20520
|
Discharge summary
|
report
|
Admission Date: [**2122-4-22**] Discharge Date: [**2122-5-6**]
Service: MEDICINE
Allergies:
Amoxicillin / Tegretol / Dilantin Kapseal / Heparin Agents /
Benzodiazepines
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Reason for MICU admission: Chronic ventillation
Major Surgical or Invasive Procedure:
Rigid Bronchoscopy for Y-stent placement
Rigid Bronchoscopy for Y-stent removal
Central Venous Line Insertion
Sigmoidoscopy
History of Present Illness:
Mr. [**Known lastname 34384**] (a.k.a. "[**Doctor Last Name **]") is an 86 M with a history of CVA
with chronic right-sided weakness, seizure disorder subsequent
to CVA, hypertension now off meds, CHF with unknown current LVEF
(last 75% in [**2117**]), recent ED visit for urinary retention
secondary to urethral stricture who presents for a planned
admission for re-evaluation of the airways following Y-stent
removal at his last hospitalization on [**2122-3-21**].
.
During his last hospital admission, he was found to have a
post-obstructive pneumonia presumed secondary to partial
tracheal stent occlusion noted on bronchoscopy. The Y-shaped
stent was removed and granulation tissue debrided from the left
mainstem bronchus. He was then discharged to [**Hospital 100**] Rehab, where
he has been chronically ventillated (his baseline prior to his
last admission was ventillation only overnight from 10 PM - 6
AM). He is readmitted now for rigid bronchoscopy to assess
airway and determine need for replacement airway stent. Because
he is on the ventillator he requires ICU admission.
.
Per [**Hospital 100**] Rehab paperwork, recent active issues include fevers,
thrombocytopenia, edema, diarrhea, and variable mental status.
According to his daughter, his baseline functional status prior
to his last admission was on ventillator at night only, out of
bed to wheelchair in the day though no longer walking (left
"good" leg is too weak to support his weight, though he can move
his foot), living at home with his wife and full-time nursing
aides. He has expressive aphasia since his stroke and at his
best can speak only a few words at a time; recently he has had
significant secretions when the vent is capped so he has not
been speaking, but can nod yes/no to questions and communicate
with facial expressions.
.
ROS: Given aphasia, complete review of systems is not possible.
His aide who is with him and was with him at rehab confirms that
he has had recent watery diarrhea, which has been improving
since Monday. He denies any pain including abdominal pain.
Denies uncomfortable breathing.
Past Medical History:
1) Tracheomalacia, status post stent x 2 with failure secondary
to stent migration. Status post trach revision [**3-27**]. Status
post T-tube removal on [**2115-6-26**]. [**2119-11-9**]: Silicone Y-stent
revision and replacement. Tracheostomy stoma revision.
2) Status post stroke in [**2109**] with TIA; right upper extremity
weakness resulting.
3) Hypertension.
4) Seizure disorder.
5) History of MRSA.
6) Hemorrhoids.
7) Arthritis.
8) Depression.
9) History of CHF.
10) CRI
Social History:
Married and lived at home with wife (also with medical problems)
with full-time private nursing care prior to this recent
hospitalization and stay at [**Hospital 100**] Rehab. Forced to retire in
[**2109**] following CVA from his work as businessman (had an Exxon
franchise). Has three children; his two daughters [**Name (NI) 553**] [**Last Name (NamePattern1) 54905**]
and [**First Name8 (NamePattern2) 54906**] [**Name (NI) 54907**] serve as his co-health care proxies; he also
has a son involved in his care. He has a remote history of
social smoking but never a heavy smoker. No recent alcohol.
Caregivers provide all ADLs. Prior to this admission, he would
occasionally take some puree by mouth for pleasure but TF
provide nutrition.
Family History:
NC
Physical Exam:
ADMISSION
VS: Temp: 97.7 BP: 128/70 HR:70 RR:21 O2sat 100% on FiO2 0.3
GEN: Appears comfortable, NAD, following commands, nodding head
yes/no
HEENT: PERRL, anicteric, MMM, op without lesions though
difficult to visualize back of mouth as patient cannot open
fully
Neck: Supple, no JVD
RESP: Diminished BS at left base, referred ventillation noises,
no wheeze or rales
CV: RR, S1 and S2 wnl, no m/r/g
ABD: Mildly distended, +b/s, soft, nt, no masses or
hepatosplenomegaly
EXT: Non-pitting edema of feet and right hand (per aide,
unchanged since arriving at rehab). 2+ DP pulses.
NEURO: Able to squeeze hand on left though weak grip. Can move
left foot though very weak. Not moving right side which is
baseline. Facial droop also baseline.
Pertinent Results:
TTE [**4-27**]:
The left atrium and right atrium are moderately dilated. There
is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>65%).
Right ventricular chamber size and free wall motion are normal.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. The estimated pulmonary artery systolic
pressure is high normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Moderate mitral regurgitation.
Moderate tricuspid regurgitation. Mild aortic regurgitation.
Compared with the prior study (images reviewed) of [**2117-10-29**], the
multivalvular regurgitation is now seen and there now appears to
be lack of atrial systolic function. In the absence of a history
of systemic hypertension, these raise the suggestion of an
infiltrative process such as amyloid cardiomyopathy.
CT a/p [**4-27**]
1. Proctitis, without evidence of megacolon.
2. Multi-segmental collapse of the bilateral lower lobes, with
foci of ground
glass opacity in the aerated lung, consistent with aspiration or
infection.
There are associated moderate-sized simple pleural effusions.
3. Mediastinal lymphadenopathy, likely reactive.
4. Nonspecific renal hypodensities might represent cysts though
ultrasound
evaluation is suggested for further characterization when
clinically
appropriate.
Bronch [**4-27**]
Severe granulation tissue formation at distal end of left limb
of the Y-stent. Thick putrulent secretions sent for microbilogy.
Y-stent removed without difficulty.
[**2122-4-25**] 10:10 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2122-4-30**]**
GRAM STAIN (Final [**2122-4-26**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2122-4-30**]):
MODERATE GROWTH Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
GRAM NEGATIVE ROD #3. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ 8 I
MEROPENEM------------- 8 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
[**2122-4-27**] 6:49 pm BRONCHIAL WASHINGS
**FINAL REPORT [**2122-5-4**]**
GRAM STAIN (Final [**2122-4-27**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2122-5-4**]):
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # 319-3364S ON
[**2122-4-25**].
KLEBSIELLA PNEUMONIAE. ~3000/ML.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml. FURTHER WORKUP ON REQUEST ONLY.
DR. [**First Name (STitle) 13258**], S ([**Numeric Identifier 13259**]) REQUEST FOR WORK UP ON [**2122-4-29**].
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
PROTEUS MIRABILIS. ~1000/ML.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml. FURTHER WORKUP ON REQUEST ONLY.
DR. [**First Name (STitle) 13258**], S ([**Numeric Identifier 13259**]) REQUEST FOR WORK UP ON [**2122-4-29**].
sensitivity testing performed by Microscan.
CIPROFLOXACIN (>=2 MCG/ML), SULFA X TRIMETH (>=2
MCG/ML),
MEROPENEM (<=1.0 MCG/ML).
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. ~1000/ML.
SENSITIVE TO CHLORAMPHENICOL (<=8 MCG/ML) Intermediate
TO
TIMENTIN (64 MCG/ML).
CEFTAZIDIME , CHLORAMPHENICOL , TIMENTIN sensitivity
testing
performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| PROTEUS MIRABILIS
| |
STENOTROPHOMONAS (XANTHOMON
| | |
AMIKACIN-------------- 32 I
AMPICILLIN------------ =>16 R
AMPICILLIN/SULBACTAM-- =>32 R <=8 S
CEFAZOLIN------------- =>64 R 16 I
CEFEPIME-------------- R 4 S
CEFTAZIDIME----------- =>64 R <=1 S =>16 R
CEFTRIAXONE----------- R <=4 S
CIPROFLOXACIN--------- =>4 R R
GENTAMICIN------------ <=1 S =>8 R
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S S
NITROFURANTOIN-------- =>64 R
PIPERACILLIN/TAZO----- I <=8 S
TOBRAMYCIN------------ =>16 R =>8 R
TRIMETHOPRIM/SULFA---- <=1 S R <=1 S
Flex Sig:
Patchy areas of mild erythema and granularity were seen in the
rectum.
Impression: Abnormal mucosa in the colon
Otherwise normal EGD to sigmoid colon
Recommendations: Healing Proctitis Noted
Likely due to ischemia though distribution unusual.
No psudomembranes seen, no mass lesion seen.
Brief Hospital Course:
86 M with history of tracheobronchomalacia s/p tracheostomy and
stent placement on ventillator overnight at baseline with recent
admission for post-obstructive left-sided pneumonia followed by
removal of stent who presented for planned rigid bronchoscopy.
His hospital course was prolonged by sepsis secondary to
pseudomonas pneumonia, illeus and protitis.
1. Tracheobronchomalacia s/p Y-stent removal [**2-/2122**]: Since his
prior admission for post-obstructive pneumonia during which his
Y-stent was removed (see operative report note above), he has
been chronically ventillated in rehab. Y stent placed under
rigid bronchoscopy by IP during admission. Patient initially did
well on trach mask, but then developed copious secretions
concerning for a VAP. He was covered with ceftazadine and
vancomycin and sputum grew pseudomoas. He progressively worsened
(see shock below) and ultimately Y-stent was removed in OR by IP
on [**2122-4-27**] without intraoperative complication. Mr. [**Known lastname 34384**]
remained on the vent for several more days and was aggressively
diuresed. He tolerated trach mask on [**4-25**] and [**5-4**].
2. Septic Shock/ventilator associated pneumonia - While in the
ICU for monitoring after his Y-stent placement, Mr. [**Known lastname 34384**]
developed worsening pulmonary secretions and chest x-ray was
concerning for pneumonia/VAP. He was started empirically on
Vancomycin and Cefepime. He developed worsening hypotension
with transient requirement of pressors. He was aggressively
resuscitated with 9L IVF with improvement in blood pressure.
Cefepime was changed to Ceftazadime based on previous
sensitivities for pseudomonas. Mr. [**Known lastname 34384**] [**Last Name (Titles) 54908**] over the
course of [**2-26**] days. Repeat sputum culture grew Pseudomonas,
Klebsiella and stenotrophomonos. The pseudomonas was the only
organism that grew with >10,000 cfu. The others were felt to be
colonizers. **His 14-day course of ceftazidine will complete on
[**5-11**].
2. Hematachezia - On hospital day 4, Mr. [**Known lastname 34384**] was found to
have hematachezia. His hematocrit was stable. In the presence
of dilated bowel loops on KUB and grimmacing to abdominal
palpation; surgery was consulted for concern of obstruction vs.
other acute process. He was placed on bowel rest. CT abdomen
and pelvis showed no obstruction, concern for proctitis. He had
a flexible sigmoidoscopy which showed resolving proctitis,
perhaps secondary to ischemia. There was no active bleed and no
psuedomembranes. C. diff swab was negative x 3. Symptoms were
most likely [**2-25**] proctitis and associated ileus.
3. History of C. Diff - Recent diarrhea at reheab, C. difficile
culture negative per report in rehab paperwork, remaining
bacterial stool studies cancelled. On admission, was continued
on PO Vancomycin. After worsening abdominal symptoms, he was
started on IV Flagyl as well. Remained C. Diff negative
throughout admission. The flagyl was stopped but we elected to
continue the po vancomycin for the duration of the ceftazidine
course.
4. Seizure disorder. Developed post-CVA per daughter. Continued
phenobarbital during admission.
5. CHF. Most recent echocardiogram in our system is from [**2117**],
with preserved systolic function and LVEF of 75%.
6. Hypervolemia - Mr. [**Known lastname 34384**] is ~10L positive for his hospital
admission, diuresing as tolerated with IV Lasix. On day of
discharge, he was recieving Lasix 40 mg IV BID with plans to
diurese 2L in 24h period. He should continue to be diuresed
with IV Lasix as tolerated.
Medications on Admission:
- Albuterol/ipratropium inhaler 8 puff Q6H
- Chlorhexidine 5 ml TID swish & spit
- Nystatin 5 mL [**Hospital1 **] swish & spit
- Phenobarbital 240 mg G-tube QHS
- Tamsulosin 0.4 mg PO QHS
- Vancomycin 125 mg PO QID
- Acetaminophen 650 mg G-tube Q6H for pain or fever
- Bisacodyl 5 mg PO daily PRN constipation
- Senna 8.6 mg PO QHS PRN constipation
- Bacitracin topical ointment apply daily
Discharge Medications:
1. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): Continue for 2 weeks after completion of antibiotics.
2. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day): swish and spit.
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO at bedtime.
4. ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q12H (every 12 hours): LAST DAY [**5-11**].
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for SOB/wheezing.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for consitpation.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Eight
(8) Puff Inhalation Q4H (every 4 hours).
10. phenobarbital 20 mg/5 mL Elixir Sig: Sixty (60) mL PO HS (at
bedtime): (dose =240mg qHS).
11. furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Tracheobronchmalacia
Respiratory Failure
Pneumonia
Proctitis/Lower GI Bleed
Atrial Fibrillation with Rapid Ventricular Response
Hypernatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital after an elevtive procedure to
place a new stent in your airway for treatment of
tracheobronchomalacia. After the procedure you developed a
pneumonia as well a low blood pressure. Your stent was removed
and you were given antibiotics and supportive therapy with IV
fluids. You also developed a lower GI bleed (blood per rectum).
Surgery and Gastroenterology evaluated you and CT scan of your
abdomen showed Proctitis (inflammation of the very distal
bowel). You were treated empirically for C. Diff infection.
You improved without intervention.
You are being discharged to a long term facility for further
care since you require intermittant time on the ventilator (at
night).
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please arrange to see your outpatient physicians once you are
discharged from the hospital.
|
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icd9cm
|
[
[
[]
]
] |
[
"96.72",
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] |
icd9pcs
|
[
[
[]
]
] |
16791, 16857
|
11585, 15190
|
331, 457
|
17043, 17043
|
4636, 11562
|
18009, 18104
|
3859, 3863
|
15631, 16768
|
16878, 17022
|
15216, 15608
|
17178, 17986
|
3878, 4617
|
244, 293
|
485, 2584
|
17058, 17154
|
2606, 3086
|
3102, 3843
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,013
| 135,842
|
3053
|
Discharge summary
|
report
|
Admission Date: [**2127-2-13**] Discharge Date: [**2127-2-21**]
Service: MEDICINE
Allergies:
Morphine / Levaquin
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
Repair of R common femoral artery, PTCA and stent
History of Present Illness:
86 F with PMH HTN presented on [**2127-2-12**] with SSCP x 3 days.
Started [**2-10**] when dusting. Pain is dull ache, substernal and
radiates to jaw. No other associated symptoms. Did take an
aspirin. From [**2-10**] to [**2-12**] the pain progressed to occur with
minimal exertion. On [**2-13**], she noticed a marked increase in the
severity of the pain. She waited 5 hours, then called EMS. Went
to OSH and found to respond to sl ntg. Received lovenox X 1 and
plavix 600mg X 1.
Past Medical History:
HTN
Bilateral total hip replacement
Polio as child w/ residual facial droop
Osteoarthritis
Social History:
-----
Family History:
Mother with CAD
Physical Exam:
PE: AF 117/66 67 14 95%RA
Gen: NAD, A&O X3
Heent: EOMI, R-sided facail droop (old)
Neck: No JVD
Heart: Distant RRR no mrg
Lungs: CTAB anterior
Abd: Benign
Ext: R groin with 3X 2cm soft hematoma. 2+ peripheral pulses.
Pertinent Results:
Labs (OSH): Cr 1.4, Ck 175 MB 5.5 TnI 0.33
CXR: Neg
ECG: NSR, 1st degree delay, normal QRS/QT, nl [**Doctor Last Name 1754**], no ST-T
changes, no Q's
.
[**2127-2-13**] 08:24PM GLUCOSE-129* UREA N-28* CREAT-1.2*
POTASSIUM-3.8
[**2127-2-13**] 08:24PM CK(CPK)-127
[**2127-2-13**] 08:24PM CK-MB-4 cTropnT-0.11*
[**2127-2-13**] 08:24PM MAGNESIUM-1.5*
[**2127-2-13**] 08:24PM HCT-31.1*
[**2127-2-13**] 08:24PM PLT COUNT-211
.
Upper GI with barium:
IMPRESSION: Evaluation for ulceration is limited by patient
debility. No evidence of esophageal stricture or web, although
there is a large impression of the heart upon the esophagus.
There is an ineffective primary peristaltic wave.
.
Femoral R US:
CONCLUSION: Superficial hematoma without evidence of
pseudoaneurysm or AV fistula.
.
Cardiac Cath:
1. Selective coronary angiography of this right dominant system
demonstrated two (2) vessel coronary artery disease. The right
coronary
artery demonstrated an 80% ostial lesion along with a proximal
95%
lesion. The left main coronary artery demonstrated no
angiographic
evidence of flow limiting lesions. The left circumflex
demonstrated no
obstructive lesions. The left anterior descending artery
contained a
30% lesion along with a 1st diagonal with an 80% lesion.
2. LV ventriculography was deferred
3. Limited resting hemodynamics demonstrated an elevated
central
filling pressure with a pressure of 180/82.
4. Successful PTCA and stenting of the ostial and proxmal RCA
with
overlapping 3.0 x 8 mm and 3.0 x 28 mm Cypher DES which were
postdilated
to 3.5 mm (see PTCA comments).
5. A 6 French Angioseal device was deployed in the right common
femoral
arteriotomy and was complicated by hematoma formation (see PTCA
comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful placement of 2 drug-eluting stents in the RCA.
3. Failed Angioseal
Brief Hospital Course:
86 F with PMH HTN, with Inferior NSTEMI and R groin hematoma.
.
# Inferior NSTEMI and R groin hematoma:
Pt initially presented to OSH with substernal chest pain, ruled
in for an NSTEMI (peak CK 354), and was sent to [**Hospital1 18**] for
cardiac cath. Pt had 2 x stent placed in RCA. The post cath
course was complicated by a R groin bleed with transient
hypotension (SBP 50 and briefly on dopamine on floor). After
this incident of hypotension, the pt remained hemodynamically
stable. Physical exam revealed femoral bruit and R groin
enlarging hematoma. Femoral US of R groin showed no
pseudoaneurysm or AV fistula at the puncture site. AM PTT found
to be 108.8 on only heparin SC, so pt was not placed on heparin
products for the remainder of admission (pneumoboots for ppx).
Pressure was held at the groin for >1 hr, she was given 25 mg
protamine.
.
Pt's hematoma remained stable for 3 days, but pt continued to
have frequent belching and epigastric and chest discomfort. She
was placed on PPI IV BID and carafate, and upper GI series with
barium swallow was normal.
.
After the UGI series with barium procedure, the pt's R groin
hematoma began to re-bleed, and pt lost approximately 3 units
into her R groin. Hematoma was evacuated by vascular surgery,
during which there was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in one of the veins of the legs
more distal to the puncture site for cath. Pt did well after
evacuation of the hematoma, with resolution of pain. Pt received
a total of 6U RBC.
.
During [**Hospital **] hospital course, she was placed on ASA, plavix x1yr,
statin, metoprolol, lisinopril, and was discharged on these
meds. TTE showed EF=70%, [**12-16**]+ MR, 2+ TR, moderate PA systolic
HTN. Pt remained in NSR, with no events on tele.
.
# Shortness of breath:
Patient had SOB only overnight after cardiac cath, then
resolved. Was likely from anxiety. Per pt, she has a history of
sleep apnea (also evidenced on ECHO with mod pulmonary HTN). PND
also on differential given large amounts of fluid received
during her hypotensive episode, although per ECHO pt w/ good EF.
But does have [**12-16**]+ MR. Currently appears euvolemic, with no
crackles in lungs, no other signs fluid overload. Therefore
likely slight apneic episode contributed to by anxiety.
.
# GI upset:
After cath, pt complained of nausea associated with dry heaving,
some "gas" feeling in abdomen, some feeling as though food gets
stuck in lower esophagus. Also + constipation. No evidence of
aspiration. Likely sxs related to GERD being in hospital w/
more time spent in supine position and not ambulating, also with
consitpation. Pt was placed on protonix QD, GI cocktail, tums,
anzemet prn. She was also placed on bowel regimen (colace and
senna [**Hospital1 **], lactulose PRN). Upper GI series w/ barium swallow
found no gastric erosions, esophageal strictures
.
# Hypotension:
Occurred immediately post-cath, then resolved, likely due to
mildly prolonged vagal response after sheath pull and RCA x2
DES, as well as hemorrhage in groin post-cath.
.
# HTN: ACE and BB had been held [**1-16**] hypotension post-cath, but
was restarted.
.
# OA: Tylenol prn
.
# CODE: Full
Medications on Admission:
Medications on Admission:
ASA 325
colace
serax
atenolol 50
norvasc 10
hctz 25
Vit D
Pepcid 20
Lisinopril 10
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One [**Age over 90 1230**]y
(150) mg PO BID (2 times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
10. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q8H
(every 8 hours) for 6 days.
11. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q4-6H
(every 4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] at [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis:
DES to RCA x2
R groin hematoma
.
Secondary Diagnosis:
HTN
Discharge Condition:
Good, VSS stable, R groin hematoma stable, Hct stable.
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please keep all appointments below.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 14527**] (vascular surgery), [**Telephone/Fax (1) 14528**], [**2127-3-12**] 2:45 PM, [**Last Name (NamePattern1) **], [**Location (un) 442**], [**Hospital Unit Name 3269**], Room 5B.
.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**] (primary care), [**Telephone/Fax (1) 14529**], in 1 week.
.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] (cardiology), [**Telephone/Fax (1) 14530**], [**2127-5-11**] 3:30 PM, [**Street Address(2) 14531**], [**Hospital1 1474**], MA.
Completed by:[**2127-2-21**]
|
[
"599.0",
"138",
"998.2",
"401.9",
"997.5",
"998.12",
"780.6",
"780.57",
"536.8",
"414.01",
"E870.6",
"715.95",
"410.71",
"V43.64",
"272.4",
"458.29",
"041.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"00.46",
"36.07",
"99.04",
"88.56",
"00.40",
"88.48",
"37.22",
"39.31",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
7441, 7515
|
3131, 6327
|
242, 294
|
7636, 7693
|
1227, 2970
|
7828, 8471
|
958, 975
|
6485, 7418
|
7536, 7536
|
6379, 6462
|
2987, 3108
|
7717, 7805
|
990, 1208
|
188, 204
|
322, 805
|
7609, 7615
|
7555, 7588
|
827, 919
|
935, 942
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,224
| 164,126
|
3399+55460
|
Discharge summary
|
report+addendum
|
Admission Date: [**2102-12-20**] Discharge Date: [**2103-1-2**]
Service: [**Location (un) 2655**] - Medicine
CHIEF COMPLAINT: Progressive dyspnea.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 15747**] is a 77
year-old Russian speaking woman with past medical history
significant for papillary cancer of the thyroid and is
status post resection and radiation therapy who was admitted
with respiratory failure secondary to an obstructing
endobronchial metastasis from her papillary cancer of her
thyroid. Patient was taken to the Medical Intensive Care
Unit where patient was intubated and had a rigid bronchoscopy
that was done in the operating room by Dr. [**First Name (STitle) **] [**Name (STitle) **].
During the procedure the patient was provided with some
relief of obstruction by placing a stent and then patient was
extubated and hopsital course was complicated by a post
obstructive pneumonia. Patient was on ceftazidine and
Levaquin after the extubation and was transferred to the
medical floor prior to discharge. Patient's prognosis was
found to be very poor as per the interventional pulmonology
attending and as per the oncology attending.
PAST MEDICAL HISTORY: 1) Papillary cancer of the thyroid.
2) Total abdominal hysterectomy, bilateral
salpingo-oophorectomy. 3) Atrial fibrillation. 4)
Constipation.
HOSPITAL COURSE: 1) Pulmonology: Patient presented with a
progressive dyspnea and had a rigid bronchoscopy that was
done in the operating room and was found to have an
obstructing causing her symptoms. Her obstruction was from a
mass secondary to the metastases from her primary cancer of
her thyroid gland. At that time Dr. [**Last Name (STitle) **] placed a stent
providing some relief of the obstruction but the overall
prognosis was found to be very poor. Initially after
discussion with the family the family wanted the patient to
be in full code ad had requested that if patient did
decompensate patient be reintubated. However, after
extensive discussion between Dr. [**Last Name (STitle) **], [**Doctor Last Name **] who is Russian
speaking and the family it was decided that the best course
of action for the patient would be that if she would
decompensate under any circumstances then patient should be
made comfortable and should not be intubated or resuscitated.
From the pulmonary point of view nothing more can be done
and no further intervention can be provided.
2) Cardiology: Patient has a history of atrial fibrillation
and was in atrial fibrillation during her hospital course but
was rate controlled. No intervention was done in terms of
her anticoagulation. However, patient was also on Procardia
for her hypotension and her blood pressure appeared to be
well controlled with Procardia 20 mg p.o. t.i.d. Patient is
to continue the same.
3) Infectious disease: Patient did not have post obstructive
pneumonia and was started on ceftazidime 1 gram intravenous q
12 hours and Levaquin 250 mg intravenous q 24 hours. In
addition during her hopsital course patient became febrile
and it was thought that she probably developed some infection
from her groin line. At that time her groin line was pulled
and was sent for culture and patient was started on
Vancomycin 1 gram intravenous q 12. However, the blood
cultures came back to negative and the Vancomycin was
stopped.
4) Gastrointestinal: Patient's diet is consist of pureed
honey thick liquids and is to be advanced as tolerated.
DISCHARGE DIAGNOSIS:
1. Metastatic papillary cancer of the thyroid.
2. Hypertension.
3. Atrial fibrillation.
4. Status post stent placement to her bronchus to
relieve some obstruction.
DISCHARGE MEDICATIONS: 1) Procardia 20 mg p.o. t.i.d., 2)
senna 1 tablet p.o. b.i.d. p.r.n., 3) Dulcolax 10 mg
p.o./p.r. q.d. p.r.n., 4) Colace 100 mg p.o. b.i.d. p.r.n.
5) Tylenol 325 mg p.o. q 4 to 6 hours p.r.n., 6) Albuterol 1
to 2 puffs inhaler q 6 hours p.r.n., 7) Atrovent 2 puffs
inhaler q.i.d., 8) morphine 1 to 2 mg intravenous q 4 to 6
hours p.r.n., 9) Please see page 1 for her other medications.
DISCHARGE STATUS: Patient is fair at the time of discharge
and is expected to be discharged to [**Hospital3 2558**].
Please note that this discharge summary is not very complete
as patient is primarily Russian speaking and most of the
information was obtained by reviewing the old charts which
are also not very clear as the patient had a complicated
Medical Intensive Care Unit course followed by being
transferred to the regular floor prior to her placement to a
skilled nursing facility. Should you have any questions
please feel free to page Dr. [**First Name (STitle) **] [**Name (STitle) **] or myself, Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **], at [**Telephone/Fax (1) 2756**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) 251**] 12-988
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2103-1-1**] 20:13
T: [**2103-1-1**] 20:51
JOB#: [**Job Number 15748**]
Name: [**Known lastname 2477**], [**Known firstname 308**] Unit No: [**Numeric Identifier 2478**]
Admission Date: [**2102-12-20**] Discharge Date: [**2103-1-2**]
Date of Birth: [**2023-4-20**] Sex: F
Service:
ADDENDUM: Please note that during the last two days of the
hospital course the patient became more conversant, and after
an extensive discussion with her family members, the
interpreter, and the social workers the patient decided that
she wanted to be full code.
At that time the do not resuscitate/do not intubate code
status was reversed, and the patient was sent to the [**Hospital3 959**] with a code status of full code. The patient clearly
indicated that if the patient was to decompensate the patient
would want everything done to her.
[**Name6 (MD) 116**] [**Name8 (MD) 117**], M.D. [**MD Number(1) 118**]
Dictated By:[**Name8 (MD) 2479**]
MEDQUIST36
D: [**2103-1-4**] 16:15
T: [**2103-1-4**] 16:31
JOB#: [**Job Number 2480**]
|
[
"427.31",
"584.9",
"486",
"785.59",
"038.9",
"518.81",
"250.01",
"V10.87",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.24",
"38.91",
"38.93",
"33.22",
"93.90",
"89.62",
"32.01",
"96.72",
"96.05",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3704, 6049
|
3487, 3680
|
1364, 3466
|
139, 161
|
190, 1177
|
1200, 1346
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,505
| 160,619
|
6694
|
Discharge summary
|
report
|
Admission Date: [**2129-6-29**] Discharge Date: [**2129-7-4**]
Date of Birth: [**2076-7-29**] Sex: F
Service: MEDICINE
Allergies:
Latex / Neurontin / Morphine / Percocet / Augmentin / Shellfish
/ Iodine / Red Dye / Dilaudid (PF)
Attending:[**First Name3 (LF) 25518**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52 yo IDDM on insulin pump with recently discharged from [**Hospital1 18**]
on [**2129-5-20**] after admission for poorly controlled DM and recent
discharge from psych facility after diagnosed with depression w/
psychotic features presents from OSH with concern for NSTEMI,
but found to be in DKA. According to patient she has been
urinating 10-12 times per day for a day or 2. She has been
drinking a lot of ice tea and other liquids as well because she
is thristy. Yesterday afternoon the patient noticed her FSG was
greater than 600. She said that prior to yesterday afternoon,
her readings were not that high. She bolused herself with an
insulin pump and recheck continued to be greater than 600. She
had been doing really well with the pump, but had it changed
over the weekend because her old one was scratched. She did not
notice that the pump was having any error signals or not working
properly. She went to bed the night prior to admission and woke
up around 1am with CP. She took nitro and her pain improved.
She fell back asleep and then woke up at 3am and had recurrent
CP. She had some N/V took nitro and her pain improved, but she
went to [**Hospital3 **] for further evaluation. At LGH trop
0.13 and FSG 800's. She was sent here for further management of
possible NSTEMI.
.
In the ED, initial vitals were 98.8 101 121/66 20 100% 2L. Labs
and imaging significant for Na: 132, HCO3 13, Glu 666, AG 24,
WBC 20.3 ( N:91.6 L:6.8 M:1.4 E:0 Bas:0.2), urine glucose 1000,
ketones 80, lactate of 4.0. She was initially transferred for
NSTEMI, and prior to her labs returning, she had bradycardia to
the 40's eyes rolled to back of head, no pulse, asystolic,
within 10 seconds pulse again, awake, alert. She had persistent
hypotension and RIJ placed and started on levophed. She was
also noted to have EKG changes in the ED with STE in aVR and V1
and depressions in I, II, V4-6 thought to be demand ischemia in
setting of DKA. Insulin drip was started in the ED and 4.5L of
NS was given. Given bradycardia, hypotension and EKG changes,
she will be admitted to the CCU for further management. Prior
to transfer due to sustained hypotension, she was started on
dopamine. Cipro and calcium gluconate was also given in the ED
for unclear reasons at this time.
.
On arrival to the floor, patient awake, alert, very thirsty, but
otherwise feeling well.
.
REVIEW OF SYSTEMS
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
Coronary artery disease, multivessel CABG [**2113-7-10**]
Angiography showing stable disease [**7-/2116**]
Negative stress-nuclear study [**4-13**]
Minimal inferoposterobasal endocardial sclerosis (Echo, [**4-13**])
? angina (effort and stress [**5-16**])
3. OTHER PAST MEDICAL HISTORY:
PVD with distal occlusive disease LLE
Right ophthalmic artery occlusion
Hypotension, prob vasoregulatory, with small vessel
hypoperfusion
Diabetes mellitus, insulin-dependent, brittle, non-ketotic [**2089**]
- diffuse vasculopathy
- peripheral neuropathy, mild, but with autonomic dysfunction
- Retinopathy, advanced
- nephropathy, mild
Cataracts
NLD
Bronchospastic disease
"Spastic colitis" / Celiac Dz / ischemic bowel Dz;
dermatitis herpetiformis
Disseminated Zoster [**5-14**]
Hypothyroidism; possible subacute thyroiditis
Social History:
Lives alone, husband died 8 years ago. Has sister who is
involved in her care. No cigarettes, EtOH, illicit drugs.
Family History:
Family history of heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. conjunctiva were
dry/pink, oral mucosa dry
NECK: Supple, JVP not visualized.
CARDIAC: tachycardic, normal S1, S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use.
adventitious breath sounds throughout, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS
[**2129-6-29**] 12:50PM [**Month/Day/Year 3143**] WBC-20.3*# RBC-3.54* Hgb-11.3* Hct-35.2*
MCV-100*# MCH-31.9 MCHC-32.0 RDW-13.0 Plt Ct-285
[**2129-6-29**] 12:50PM [**Month/Day/Year 3143**] Neuts-91.6* Lymphs-6.8* Monos-1.4* Eos-0
Baso-0.2
[**2129-6-29**] 12:50PM [**Month/Day/Year 3143**] PT-11.0 PTT-26.0 INR(PT)-1.0
[**2129-6-29**] 12:50PM [**Month/Day/Year 3143**] Glucose-666* UreaN-34* Creat-1.5* Na-132*
K-5.1 Cl-95* HCO3-13* AnGap-29*
[**2129-6-29**] 12:50PM [**Month/Day/Year 3143**] ALT-35 AST-44* CK(CPK)-140 AlkPhos-101
TotBili-1.0
[**2129-6-29**] 12:50PM [**Month/Day/Year 3143**] Lipase-408*
[**2129-6-29**] 12:50PM [**Month/Day/Year 3143**] Albumin-3.9 Calcium-8.7 Phos-4.0 Mg-2.4
[**2129-6-29**] 10:29PM [**Month/Day/Year 3143**] TSH-23*
[**2129-6-29**] 10:29PM [**Month/Day/Year 3143**] T4-4.1*
[**2129-6-30**] 01:54PM [**Month/Day/Year 3143**] T4-3.4* Free T4-0.71*
[**2129-6-29**] 12:26PM [**Month/Day/Year 3143**] Lactate-3.9*
[**2129-6-29**] 02:40PM [**Month/Day/Year 3143**] Lactate-4.0*
[**2129-6-29**] 01:35PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.017
[**2129-6-29**] 01:35PM URINE [**Month/Day/Year **]-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2129-6-29**] 01:35PM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
CARDIAC ENZYMES
[**2129-6-29**] 12:50PM [**Month/Day/Year 3143**] CK-MB-9
[**2129-6-29**] 12:50PM [**Month/Day/Year 3143**] cTropnT-0.32*
[**2129-6-29**] 06:31PM [**Month/Day/Year 3143**] CK-MB-32* MB Indx-5.8 cTropnT-3.06*
[**2129-6-30**] 12:27AM [**Month/Day/Year 3143**] CK-MB-81* MB Indx-6.4* cTropnT-7.68*
[**2129-6-30**] 05:43AM [**Month/Day/Year 3143**] CK-MB-91* MB Indx-6.8* cTropnT-8.22*
IMAGING:
TTE [**2129-6-29**]:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC
diameter (<=2.1cm) with <50% decrease with sniff (estimated RA
pressure (5-10 mmHg).
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Severe regional LV systolic dysfunction. No LV mass/thrombus. No
VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Emergency study performed by the cardiology
fellow on call.
Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is 5-10 mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
severe regional left ventricular systolic dysfunction with mid-
and distal anterior/anteroseptal/apical hypokinesis, as well as
hypokinesis of the basal inferior/inferoseptal segments. There
is milder hypokinesis of the remaining segments (LVEF = 25-30%).
No masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with mild global free wall hypokinesis. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w multivessel CAD. Mild right ventricular
systolic dysfunction. Mild mitral regurgitation. Moderate
tricuspid regurgitation.
[**2129-6-29**] CXR: FINDINGS: A new right internal central jugular
venous catheter terminates in the uppermost part of the atrium.
The patient is status post coronary artery bypass graft surgery.
The cardiac, mediastinal, and hilar contours appear unchanged.
There is no evidence for pneumothorax or pleural effusion. New
streaky left basilar opacities suggest minor atelectasis.
Otherwise, the lungs appear clear.
IMPRESSION: New right internal central jugular venous catheter
protruding
slightly into the right atrium; no evidence for pneumothorax.
Brief Hospital Course:
Ms. [**Known lastname 19075**] [**Known lastname **] is a 52 year old female with diabetes mellitus
on insulin pump and coronary artery disease (CAD) status post
bypass surgery (CABG) who presented to [**Hospital1 18**] from OSH with
diabetic ketoacidosis (DKA) and concern for demand ischemia. Her
course was complicated by vagal-mediated asystole and subsequent
decreased ejection fraction on echo with cardiac enzyme
elevation.
# Hypotensive Shock: Patient with hypotensive shock on
admission. Infectious work up negative except leukocytosis
which was attributed to DKA and resolved with metabolic
improvement. Clinical findings and HPI concerning for
hypovolemic shock in the setting of DKA, poor PO intake and
vomiting. She was aggressively volume resuscitated and had
resolution of hypotension. Was briefly on pressors but these
were weaned off within the first 24 hours as volume
resuscitation continued.
# DKA: Patient with DM on insulin pump. As per her last
admission in [**5-/2129**], she had difficulty controlling her sugars
with wide ranges of FSG from 50's - 500s. Her glucose control
is complicated by psychiatric issues. [**Last Name (un) **] has seen her in
the past and made adjustments to her pump, but she seems to have
been undertreating her elevated Finger sticks at home and it is
possible that her pump has not been functioning properly since
it was changed over the weekend. She was managed [**First Name8 (NamePattern2) **] [**Last Name (un) **]
protocol with insulin gtt transitioned to SC insulin and
electrolyte repletion with resolution of her acidosis and
elevated suagrs within the first 24 hours. [**Last Name (un) **] saw the
patient and we transitioned her back on to her pump on HD 2.
She did well on the pump with some minor adjustments to her
basal rate. She will follow up with Dr. [**Last Name (STitle) **] in the outpatient
setting for further management of her IDDM.
# CAD s/p CABG: Patient with history of ischemic heart disease
who had new EKG changes after asystolic event in the ED.
Concern for demand ischemia in the setting of hypotension and
DKA. She had known CAD with many plaques and her EKG was most
consistent with global hypoperfusion rather than unstable
plaques. Her outpatient cardiologist was contact[**Name (NI) **] to discuss
catheterization as an inpatient versus outpatient. Given global
hypokinesis on her ECHO despite EKG changes and increase in
cardiac enzymes, it was felt that there was likely some cardiac
stunning in the setting of DKA, acidosis and asystolic event.
Repeat ECHO 3 days after her admission to the hospital showed
improvement in her ejection fraction. She was continued
aspirin, plavix durin her hospital stay. Once her [**Name (NI) **]
pressures normalized and she was off pressors, she was given
Cozaar 25mg, but this caused some relative hypotension and she
was symptomatic with lightheadedness and dizziness. Her Cozaar
was lowered to 6.25mg PO Daily. She was started on metoprolol
tartrate while in the hospital, but upon discharge she was
continued on her home bisoprolol 2.5mg PO BID. She will follow
up with Dr. [**Last Name (STitle) 13114**] for further management of her CAD.
# Elevated WBC: likely elevated in the setting of DKA.
Infectious work up negative with [**Last Name (STitle) **] cultures pending. She is
afebrile and while has had some recent sick contacts, is not
having any symptoms concerning for infection. Nausea and
vomiting was likely related to her hyperglycemia. She was given
cipro/flagyl in the ED, but not continued in the ICU. Her WBC
trended down and normalized within 48 hours.
# Hypothyroidism: TSH elevated to 23 with low T4 so increased
Levothyroxine to 175 mcg DAILY.
# Behavioral changes: patient had recently discharged from psych
facility for depression with psychotic features. She is
currently stable from psychiatric standpoint. Continued
aripirazole 2 mg daily, diazepam 2 mg TID
# Asthma: provided PRN albuterol, Atrovent.
.
sister [**Name (NI) **] - [**Telephone/Fax (1) 25519**]
TRANSITIONAL ISSUES
- Continued management of IDDM and insulin pump by
endocrinologist
- CAD management as per Dr. [**Last Name (STitle) 13114**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientPharmacy.
1. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]:PRN SOB
Takes as needed due to trouble controlling [**Hospital1 **] sugars
2. Aspirin 81 mg PO DAILY
3. Cozaar 25 mg PO DAILY:PRN SBP>150
Patient takes as needed due to hypotension with daily use.
4. Diazepam 2 mg PO TID:PRN anxiety, dizziness
5. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL Injection as needed
anaphylaxis
6. HumuLIN R *NF* (insulin regular human) 100 unit/mL Injection
per sliding scale
7. Clopidogrel 75 mg PO DAILY
8. Albuterol Inhaler [**1-10**] PUFF IH Q6H:PRN SOB
9. Montelukast Sodium 10 mg PO DAILY:PRN allergies
10. Levothyroxine Sodium 150 mcg PO DAILY
11. Zebeta *NF* (bisoprolol fumarate) 5 mg Oral [**Hospital1 **]
12. Aripiprazole 2 mg PO QHS
13. Ranitidine 150 mg PO DAILY
14. Hydrochlorothiazide 25 mg PO DAILY:PRN leg swelling
Discharge Medications:
1. Aripiprazole 2 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Losartan Potassium 6.25 mg PO DAILY
Hold for SBP<100
5. Diazepam 2 mg PO TID:PRN anxiety, dizziness
6. Levothyroxine Sodium 175 mcg PO DAILY
7. Ranitidine 150 mg PO DAILY
8. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal Rates:
Midnight - 0600: .3 Units/Hr
0600 - 1500: .35 Units/Hr
1500 - 1800: .3 Units/Hr
1800 - 2330: .35 Units/Hr
2330 - 2400: .3 Units/Hr
Meal Bolus Rates:
Breakfast = 1:15
Lunch = 1:15
Dinner = 1:15
Snacks = 1:15
High Bolus:
Correction Factor = 1:15
Correct To 170 mg/dL
MD acknowledges patient competent
MD has ordered [**Name6 (MD) **] consult
MD has completed competency
9. Albuterol Inhaler [**1-10**] PUFF IH Q6H:PRN SOB
10. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]:PRN SOB
Takes as needed due to trouble controlling [**Hospital1 **] sugars
11. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL Injection as needed
anaphylaxis
12. Hydrochlorothiazide 25 mg PO DAILY:PRN leg swelling
13. Montelukast Sodium 10 mg PO DAILY:PRN allergies
14. Outpatient Lab Work
Please check complete metabolic panel (electrolyte panel), as
well as creatinine.
15. Zebeta *NF* (bisoprolol fumarate) 2.5 Oral [**Hospital1 **]
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Diabetic ketoacidosis
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 19075**],
You were admitted to the hospital because you were in diabetic
ketoacidosis. You had a temporary stop in your heart beat which
we think was caused by stunning of your heart from the acido in
your [**Known lastname **]. You do have significant blockages of the arteries
in your heart, which are old, and so when your heart is under
stress from other metabolic causes you have relative decreased
[**Name2 (NI) **] flow. Your [**Name2 (NI) **] pressure was low on admission to the
hospital, and it was thought to be due to this heart stunning.
While in the hospital, your acidosis was corrected with insulin
and intravenous fluids. You were seen by the [**Hospital **] Clinic who
helped adjust your insulin needs for your insulin pump. Please
make sure you continue to use your insulin pump as directed, and
keep your follow up appointment with the [**Hospital **] Clinic.
Please see your attached medication sheet to review any changes
that have been made to your medications while at the hospital.
The following medications were CHANGED:
Cozaar 25mg Daily ---> Cozaar 6.25mg ([**1-12**] pill) by mouth Daily
Zebeta 5mg twice a day ---> Zebeta 2.5mg by mouth twice a day
It has been a pleasure taking care of you!
It is very important for you to keep all of your follow-up
appointments listed below. Bring your medications to each
appointment so that your doctors [**Name5 (PTitle) **] adjust [**Name5 (PTitle) 4319**] as needed.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Department: Endocrinology- [**Last Name (un) **] Diabetes Center
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**]
When: Thursday [**2129-7-7**] at 12:30 PM
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Department: Cardiology
Name: Dr. [**First Name8 (NamePattern2) 5987**] [**Last Name (NamePattern1) 13114**]
When: Friday [**2129-7-22**] at 11:00 AM.
Location: DOCTORS [**Name5 (PTitle) **] & VINCH CARDIOLOGY, PC
Address: [**Street Address(2) **], STE 703W, [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 25520**]
|
[
"414.00",
"369.4",
"362.01",
"337.1",
"276.1",
"V58.67",
"427.5",
"250.43",
"440.20",
"440.4",
"785.59",
"272.4",
"V45.81",
"583.81",
"250.53",
"412",
"493.90",
"250.13",
"244.9",
"401.9",
"250.63",
"V45.85",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
15872, 15878
|
9358, 13555
|
370, 377
|
15986, 15986
|
4958, 9335
|
17693, 18405
|
4400, 4433
|
14536, 15849
|
15899, 15965
|
13581, 14513
|
16137, 17670
|
4473, 4939
|
3436, 3692
|
320, 332
|
405, 3333
|
16001, 16113
|
3723, 4252
|
3355, 3416
|
4268, 4384
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,354
| 129,795
|
6443
|
Discharge summary
|
report
|
Admission Date: [**2198-12-20**] Discharge Date: [**2198-12-25**]
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD- friability in lower third of esophagus and gastroesophageal
junction.
History of Present Illness:
83 year-old male nursing home resident with DM, CRI, CHF, CAD
and PVD on aspirin and Plavix, history of CVA, presents to [**Hospital1 18**]
ED with 3-4 episodes of coffee ground emesis and possible
aspiration with one of the episodes of vomiting.
In the ED, temp 99.8. NG lavage positive for coffee ground,
Cleared after 1L of lavage. Initially, briefly hypotensive to
80/40, but quickly resolved with IVF. Started on Levofloxacin,
but developed a rash with infusion according to ED note.
Infusion was stopped and patient was instead given Ceftriaxone,
Azithromycin and Flagyl for community-acquired/aspiration
pneumonia. Urine cloudy.
ROS: denies fever, chills, chest pain, palpitations, c/o cough
x1mo, denies abd pain, diarrhea, c/o dysuria and constipation
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease
s/p inferior MI in [**2196**] post-op of toe amputation,
(taken to cardiac cath with PTCA c/b CVA)
2. ischemic cardiomyopathy (LVEF 35-40% on [**2197-6-24**] Echo)
[**2197-6-24**] Echo showed hypokinetic mid anteroseptal, mid
inferoseptal, basal inferior, mid inferior, anterior apex,
septal apex, inferior apex, and apex.
3. CVA following cardiac catheterization in [**2196**] with
residual right hemiparesis.
4. Diabetes type 2 with neuropathy.
6. Hypertension.
7. Hypercholesterolemia.
8. Chronic renal insufficiency (baseline creatinine 1.6-1.7).
9. Aspiration pneumonia in [**2196**].
10. Benign prostatic hypertrophy.
11. MRSA.
12. Peripheral vascular disease.
13. Hypothyroidism.
.
PAST SURGICAL HISTORY:
1. Left BK [**Doctor Last Name **]-AT with reverse saphenous vein graft in [**2191**].
2. Right [**Doctor Last Name **]-DP with nonreverse saphenous vein graft done in
[**2194**].
3. Amputation of right first toe in [**2194**], right second toe in
[**2196**], left first and second toes in [**12-31**], left transmetatarsal
amputation in [**3-1**].
4. [**Date Range 24785**] of the left hip in [**2192**].
5. Removal of hardware in the left hip in [**2196**] at [**Hospital6 11896**].
6. G tube placement in [**2196**] post-CVA.
7. Right cataract surgery.
8. Laparoscopic cholecystectomy.
Social History:
Married but now lives [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Nursing Home for two months
Wheelchair bound at baseline
Quit tob 25 years ago, previous 20 pack-yr hx
No current EtOH use, but reports previously drinking 3 beers/day
Family History:
parents d. "old age"
no known h/o DM, CVD, cancers
Physical Exam:
T 95.6 HR 75 BP 116/43 RR18 98%RA
Gen: comfortable, NAD
HEENT: PERRL, anicteric, conjunctiva pink, mm dry, OP with
blood posteriorly
Neck: supple, no LAD
CV: RRR, no mrg, 1+DP pulses (L>R)
Resp: CTA apices, decreased breath sounds B bases
Abd: obese, +BS, soft, NT, ND, no HSM, no masses
Back: no CVA tenderness
Ext: s/p L distal foot amputation, s/p R toe 1 and 2
amputation, no edema
Skin: erythematous plaque in groin
Neuro: A&O, CN II-XII intact, strength 4-/5 RUE, [**5-2**] LUE, 4+/5
RLE, [**5-2**] LLE, sensation intact grossly to fine touch but
decreased distally
Pertinent Results:
Brief Hospital Course:
Assessment and Plan: 83 year-old male with coronary artery
disease and peripheral vascular disease on aspirin and plavix,
DM, CRI, CHF, and multiple other medical problems who presents
with upper gastrointestinal bleeding, possible aspiration
pneumonia and UTI.
.
Upper GI bleed: EGD showed friability in GE junction and lower
third of the esophagus. Protonix 40 PO BID for acid suppression
and Sucrulfate 1g QID recommended by GI. Aspirin can be
restarted in 3 days and Plavix in 1 week per GI recommendations.
The patient is to have a follow up EGD in 4 weeks to assess for
Barrett's or underlying malignancy. HCT has been stable after
initial episode requiring MICU admission for monitoring.
UTI: suggested by WBC in urine but UCx had No growth. WBC most
likely from chronic foley. Pt was initially treated with Cipro
and did well.
aspiration pneumonia: pt with reported aspiration event with
hematemesis, but no infiltrate on CXR. Treated empirically in ED
with CTX, Azithro, Flagyl but was discontinued b/c patient did
well after Upper GI bleed stabilized.
ARF on CRI: Initially Creatinine 1.9 up from 1.6-1.7 baseline,
but returned to baseline with hydration.
.
CAD/PVD: -continued metoprolol, lipitor, and lisinopril. Will
restart Aspirin in 3 days and Plavix in 1 week per GI
recommendations.
.
s/p CVA: Will restart Aspirin in 3 days and Plavix in 1 week
per GI recommendations.
.
TIIDM: patient on insulin sliding scale at nursing home and was
continued in .
Access: piv x ii large bore
.
Communication: with pt, [**Name (NI) **] [**Name (NI) 7749**] wife is HCP
.
Code status: DNR/DNI- after discussions with patient and family.
Medications on Admission:
Insulin-sliding scale.
Colace 100 mg p.o. q.p.m.
Multivitamin one tablet p.o. q.d.
trazadone 25mg PO QPM
Levoxyl 25 mcg p.o. q.d.
terazosin 1mg PO QD
metoprolol 25mg p.o. b.i.d.
Aspirin 325 mg p.o. q.d.
Plavix 75 mg p.o. q.d.
Lipitor 10 mg p.o. q.h.s.
Lasix 20mg PO QD
Lisinopril 5mg PO QD
.
[**Hospital1 **] Protonix started [**2198-12-20**]
dulcolax started [**2198-12-20**]
Discharge Medications:
1. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Multivitamin Capsule Sig: One (1) Cap 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) as needed.
5. Terazosin HCl 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. Insulin Regular Human 100 unit/mL Solution Sig: as directed
units Injection ASDIR (AS DIRECTED): Regular Insulin Sliding
scale as directed.
7. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime).
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for bowel movement.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Carafate 1 g Tablet Sig: One (1) Tablet PO four times a day:
Give 1Hour before meals and QHS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Upper GI bleed
Discharge Condition:
[**Name (NI) 24789**] pt unable to perform ADLs and cannot ambulate.
Discharge Instructions:
Pt will continue to take medications as prescribed.
Pt will restart Aspirin in 3 days and Plavix in 1 week per
gastroenterology recs. The pt is to have a repeat EGD in 4
weeks.
Followup Instructions:
Pt will follow up with PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], at Nursing home.
The pt is to have a repeat EGD in 4 weeks to assess for
Barrett's or underlying malignancy.
|
[
"530.82",
"272.0",
"276.5",
"600.00",
"593.9",
"584.9",
"414.01",
"250.60",
"401.9",
"357.2",
"112.84",
"428.0",
"443.9",
"507.0",
"438.21",
"599.0",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
6794, 6867
|
3476, 5132
|
232, 309
|
6926, 6996
|
3453, 3453
|
7223, 7428
|
2779, 2831
|
5559, 6771
|
6888, 6905
|
5158, 5536
|
7020, 7200
|
1895, 2485
|
2846, 3433
|
181, 194
|
337, 1106
|
1150, 1872
|
2501, 2763
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,753
| 181,847
|
43575+58634
|
Discharge summary
|
report+addendum
|
Admission Date: [**2179-1-7**] Discharge Date: [**2179-1-16**]
Date of Birth: [**2100-5-29**] Sex: F
Service: MEDICINE
Allergies:
Beta-Adrenergic Blocking Agents / Calcium Channel Blocking
Agents-Benzothiazepines
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Found down, delta MS
Major Surgical or Invasive Procedure:
1. Intubation
2. A-line
3. RIJ temporary pacer wire
4. Permanent pacemaker placed
History of Present Illness:
This is a 78 yof pmh HTN, CABG x 1 vessel [**2148**], hyperlipidemia,
hypothyroidism, BRCA s/p lumpectomy/XRT [**2167**] and thyroid nodule
excision who presents s/p being found down by her family at
home. Unclear whether there was head trauma however pt was so
lethargic and bedridden that family decided to bring her into
[**Hospital1 18**].
In the ED, patient grew increasely unresponsive and was
subsequently intubated for airway protection. Given atropin,
kayexalate, vanco/levo/flagyl. Patient was found to have a
junctional rhythm and HR in 30's consistent with complete heart
block. He had a PPM placed emergently in the ED and was
transferred to the CCU for further care.
Past Medical History:
1. BRCA s/p lumpectomy and XRT [**2167**]
2. Thyroid nodule excision
3. HTN
4. CABG x 1 vessel [**2148**]
5. Hyperlipidemia
6. Hypothyroidism
Social History:
Lives with her husband, very distant [**Name (NI) **] hx, neg EtOH.
Family History:
Sister ovarian cancer, brother MI at 60
Physical Exam:
T 90.6 HR 79 BP 72/48 RR20 O2SAT 100%RA
AC 14x500 FiO2 1.00 PEEP 5
Gen: Patient intubated lying in the bed, diffuse anarsarca
HEENT: NCAT, grossly edematous conjunctivae, pupils dilated 4mm
NECK: supple no LAD
CHEST: crackles bilaterally, +wheezes
CV: distant heart sounds, RRR, II/VI holosystolic murmur
AB: soft nontender, +BS
EXT: no CCE
Neuro: spontaneously moving all four limbs
Pertinent Results:
[**2179-1-15**] 09:45AM BLOOD PT-16.8* PTT-26.9 INR(PT)-1.9
[**2179-1-6**] 10:22PM BLOOD pO2-189* pCO2-36 pH-7.04* calHCO3-10*
Base XS--20
[**2179-1-7**] 01:21am
Na 136 Cl 108 BUN 36 Gluc 306
Potassium 5.4 HCO3 10 Creatinine 2.8
CK: 129 MB: Pnd Trop-*T*: Pnd
Ca: 6.9 Mg: 1.3 P: 6.0 D
ALT: 51 AP: 47 Tbili: 0.9 AST: 71 LDH: 338 [**Doctor First Name **]: 75 Lip: 30
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Hapto: Pnd
Triglyc: Pnd
WBC 28.2 D Hgb 12.7 plat 192 Hct 37.8
PT: 15.3 PTT: 32.6 INR: 1.6
Fibrinogen: 241
Imaging:
[**1-5**] Left shoulder x-ray: Calcific tendinitis of the left
shoulder.
[**1-6**] CXR: prominent pulmonary vasculature, consistent with an
element of fluid overload. asymmetric perihilar haziness, and
faint opacity in the left lower lung zone.
[**1-6**] abd CT/pelvic CT: extensive retroperitoneal fluid and
stranding, which appears to center around the pancreas, with
extension along Gerota's fascia, and adjacent to the second and
third parts of the duodenum. Additionally, there is marked
bowel wall edema of the entire duodenum, and to a lesser degree,
of the proximal jejunum. There is secondary gallbladder wall
edema, and free intraperitoneal fluid. The pancreatic contour,
however, does appear well circumscribed. These findings may
represent changes from pancreatitis, or alternatively, this may
represent a focal duodenitis, with secondary changes in adjacent
organs.
[**1-6**] non-con head CT: negative for ICH.
[**1-7**] RUQ US: 1. Gallbladder wall edema, without any gallbladder
distention. This appearance is highly suggestive of changes
relating to a non-gallbladder related etiology, such as third
spacing of fluid, or inflammation of adjacent organs.
2. No cholelithiasis.
[**1-7**] ECHO
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Left
ventricular systolic function is hyperdynamic (EF 70-80%). The
right ventricular cavity is dilated. Right ventricular systolic
function is borderline normal. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] Severe [4+]
tricuspid regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior report (tape
unavailable for review) of [**2178-6-2**], the tricuspid
regurgitation is significantly increased.
[**2179-1-9**] CXR: Right central venous catheter has been placed with
the tip in the right atrium and no PTX. A retrocardiac density
remains unchanged. There are no new consolidations and the
pulmonary vascular markings may be subtlely increased versus
prior. Less density over the right lower lung is noted and
likely due to positioning influencing pleural fluid
distribution.
CHEST (PA & LAT) [**2179-1-14**]
1. Unchanged appearance of pacemaker. No evidence of
pneumothorax.
2. Stable left retrocardiac density.
UNILAT LOWER EXT VEINS LEFT [**2179-1-16**] 8:52 AM
No DVT in the left lower extremity.
Brief Hospital Course:
This is a 78 yof pmh CAD, hypothyroidism, h/o br ca p/w
junctional escape rhythm, unresponsive requiring intubation,
hyperkalemic, in severe acidosis and ARF. Temp wire was placed
now unpaced and wire removed. Pt extubated. ARF resolved. Now
with new afib w/RVR. PPM placed on [**2179-1-13**].
.
#Low grade fevers for 2 days (100.3)- Patient completed 1 week
of levofloxacin/flagyl for possible abdominal or pulmonary
infections contributing to her shock on admission. Patient is
three days out from pacer placement. Received 3 doses IV
vancomycin periprocedurally. Pt will complete 7 day course of
keflex in the setting of new pacemaker placed until [**1-22**].
.
## CARDIAC:
#Ischemic - h/o CABG x1 vessel. Pt with elevated enzymes thought
to be secondary to demand. There were no ST changes seen on EKG.
Outpatient BP meds were held in setting of acute renal failure
and junctional escape rhythm (incl atenolol, cozaar, aldactone,
cardizem/cardura). Patient was started metoprolol and cozaar in
setting of afib w/RVR. Continue lipitor.
.
#Pump - Shock most likely either cardiogenic versus septic.
Patient was hypotensive requiring dopamine and levophed drips
despite being positive approximately 4-5L of fluid and fluid
overloaded on CXR. Minimal UOP, fluid third spacing. Hospital
day #2 (HOD #2) patient was weaned off pressors and unpaced in
60's. HOD #3 patient successfully extubated. Given rapid
turnaround more likely cardiogenic shock [**3-11**] combination of
dehydration, renal insufficiency and renally cleared nodal
blockers (bb, ccb). No clear source of sepsis. Corstim test was
negative however given less likely septic picture, stress dose
steroids were held and patient was monitored closely.
#Arrhythmia - temp pacer wire placed [**3-11**] to junction escape
rhythm/sinus node arrest upon admission. Has had PR prolongation
on past EKGs. Now pacer wire removed and patient in NSR 70's
with PR interval 220. Patient went into afib w/RVR HR 140's
without chest pain on [**1-11**]. Pt started on metoprolol which was
titrated up. EP placed PPM on [**2179-1-13**] to facilitate treatment of
afib by rate controlling agents.
# Acidosis: Initially, mixed gap and respiratory acidosis with
elevated lactate and ARF contributing to anion gap acidosis.
Increased respiratory rate while ventilated, fluid bolused
aggressively and received 4amps of bicarb until pH>7.1.
Patient's acidosis resolved quickly over the course of first
night of admission and was likely secondary to increased
perfusion.
.
# Respiratory compromise: Patient extubated easily. Repeat CXR
suggests retrocardiac atelectasis tx'd with abx. ISS to bedside.
Now on room air.
.
# Abnormal abd findings on CT/?etiology of sepsis: Possible
pancreatitis v duodenitis seen on abd CT. RUQ US was negative
for stones. Amylase, lipase and LFTs wnl. no intrabd free air.
Given negative enzymes, less likely acute abdominal process.
Surgery was consulted, no need for emergent surgery and
recommended outpatient EGD as follow-up of abd CT findings.
Patient completed 1 week course of levoquin and flagyl to cover
abdominal and pulm organisms.
.
# S/P fall/found down: concern for head bleed given hx of SAH
and hx from family that pt might have hit head prior to change
in mental status this admission. Head CT negative for large ICH
however pt received IV dye load for abd CT which may obscure
smaller bleeds. Per family patient at baseline MS.
.
# ARF: baseline 1.1. Was 3.9 on admission and oliguric. Likely
component of prerenal azotemia. Now better than baseline at 0.9.
.
# FEN: mildly hypernatremic/hyperchloremic likely [**3-11**] to NS
fluid resuscitation continue diuresis with lasix as needed,
advance cardiac healthy low sodium diet as tolerated, replete
lytes.
.
# Access: PIV
.
# PPX: heparin SC, Protonix
.
# Dispo: PT consulted and being screened for rehab
.
#Contact:
[**Name (NI) **] [**Name (NI) 1726**] ([**Last Name (un) **]) ([**Telephone/Fax (1) 93735**]
[**First Name5 (NamePattern1) 66110**] [**Last Name (NamePattern1) 93736**] (daughter) ([**Telephone/Fax (1) 93737**]
Medications on Admission:
1. atenolol
2. cozaar
3. aldactone
4. cardizem/cardura?
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4-6H (every 4 to 6 hours) as needed.
5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Three (3)
Tablet Sustained Release 24HR PO once a day.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: Not to exceed 4g/day.
8. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please give at 5pm.
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days: until [**2179-1-22**].
12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Diltiazem HCl 180 mg Tablet Sustained Release 24HR Sig: One
(1) Tablet Sustained Release 24HR PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Primary Diagnosis:
1. Tachy-brady syndrome
2. Atrial fibrillation
Secondary Diagnosis:
3. CAD s/p CABG
4. Hypertension
5. Hyperlipidemia
6. Hypothyroidism
7. h/o breast cancer
Discharge Condition:
Good
Discharge Instructions:
Please take medications as prescribed.
Please keep your follow-up appointments.
You have had a permanent A-V pacer placed for tachy-brady
syndrome.
You have been started on a new medication called warfarin which
is a blood thinner for your new atrial fibrillation. Please
check labs (INR/PT) daily. Adjust coumadin dose accordingly for
goal INR between 2 to 3.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2179-1-20**]
11:30am
Provider: [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 1968**], MD Phone:[**Telephone/Fax (1) 3329**]
Date/Time:[**2179-1-19**] 3:30pm Location: [**Location (un) **], [**Location (un) 16824**], MA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2179-1-16**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 14796**]
Admission Date: [**2179-1-7**] Discharge Date: [**2179-1-16**]
Date of Birth: [**2100-5-29**] Sex: F
Service: MEDICINE
Allergies:
Beta-Adrenergic Blocking Agents / Calcium Channel Blocking
Agents-Benzothiazepines
Attending:[**First Name3 (LF) 949**]
Addendum:
ADDENDUM-Patient was started on diltiazem XR 180mg QD to help
treat atrial fibrillation by rate control. Tolerated well with
pacer.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 204**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 205**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 950**] MD, [**MD Number(3) 951**]
Completed by:[**2179-1-16**]
|
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"276.7",
"428.0",
"276.2",
"244.9",
"785.51",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.78",
"96.04",
"37.83",
"38.91",
"96.71",
"37.72",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
12340, 12630
|
5191, 9262
|
363, 447
|
10867, 10874
|
1892, 3348
|
11287, 12317
|
1427, 1469
|
9368, 10488
|
10667, 10667
|
9288, 9345
|
10898, 11264
|
1484, 1873
|
303, 325
|
475, 1159
|
10755, 10846
|
3357, 5168
|
10686, 10734
|
1181, 1325
|
1341, 1411
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,195
| 135,955
|
28999
|
Discharge summary
|
report
|
Admission Date: [**2112-4-10**] Discharge Date: [**2112-4-14**]
Date of Birth: [**2058-4-15**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
hypoxic respiratory distress
Major Surgical or Invasive Procedure:
[**2112-4-11**]: fluoroscopy-guided replacement of old right arm
venous catheter (38.5 cm) with a new 4 French 38 cm single-lumen
PICC, and with its tip in the lower SVC confirmed on CXR.
History of Present Illness:
Ms. [**Known lastname 69887**] is a 53 year old woman with MR, tracheomalacia (s/p
tracheostomy [**2107**]), PVD, multiple aspiration PNAs, and DM who
presents from her nursing facility with increased tracheal
secretions, fever and hypoxemia. The patient is able to answer
yes or no questions, but not able to provide a detailed history.
Therefore much of the history was compiled based upon records
sent over from the nursing facility. According to their report,
she had been in her usual state of health until last night when
she developed temp of 100 and O2 sat decreased to 79% on 35%
FiO2. This morning her temp rose to 101, RR 30, Pulse 120 BP
120/76. O2 sat decreased to 77% on 40% FiO2. She was then sent
to the ED for further evaluation.
In the ED, initial VS were: 97.2 124 144/62 24 98% 10L Trach
mask. She underwent CXR showing ? RLL opacification and labs
notable for WBC of 12.5K w/ left shift, Na 123, K 4.8, Cl 89,
CO2 29, Cr 0.9, lactate of 2.2, UA notable for pyuria,
bacteriuria trace leucocytes. She received Vanco 1g, Cefepime
2g, Flagyl 500mg IV. She was then admitted to the [**Hospital Unit Name 153**] for
further management. VS prior to transfer were 154/57 98 22 92%
on 10L TM.
On arrival to the [**Hospital Unit Name 153**], patient's VS 97.3 105 134/67 23 98% on
50% FiO2. The patient denies feeling short of breath, chest
pain, nausea, vomiting, diarrhea or constipation.
Of note, the patient was seen in the ED ~6 weeks ago after
desaturating to 70s, which resolved with suctioning. She was
diagnosed as having a mucus plug but treated with a course of
levaquin to be safe.
Past Medical History:
Past Medical History:
Mental retardation
tracheomalacia s/p tracheostomy
h/o aspiration pneumonia
E.Coli bacteremia [**10-23**]
diabetes mellitus
h/o C. difficile infection
glaucoma
hypertension
HLD
osteoarthritis
depression/anxiety,
constipation
psychosis
PAST SURGICAL HISTORY:
Tracheostomy and PEG [**2107**],
R total knee replacement
R hip replacement
Right common iliac artery stent placement and right external
iliac recanalization with stent placement x2. [**1-/2111**]
Social History:
lives at nursing home
Father and Brother are [**Name2 (NI) **]-guardians
Family History:
unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.3 105 134/67 23 98% on 50% FiO2.
General: Opens eyes to voice.
HEENT: Sclera anicteric, MMM, Exotropia of right eye. PERRL
Neck: Trach collar in place. JVP not elevated, no LAD
CV: Tachycardic. normal S1 + S2, no murmurs, rubs, gallops
Lungs: Coarse upper airway sounds throughout
Abdomen: PEG tube. soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation
GU: foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally
.
DISCHARGE
140/50 100 o2 SAT OF 98% FIO@ 35%
Wgt (current): 71 kg (admission): 75.2 kg
General: Opens eyes to voice.
HEENT: Sclera anicteric, MMM, Exotropia of right eye. PERRL
Neck: Trach collar in place. JVP not elevated, no LAD
CV: normal S1 + S2, no murmurs, rubs, gallops
Lungs: diffuse rhonchi
Abdomen: soft, non-distended, bowel sounds present
GU: foley
Ext: Warm, well perfused, 2+ pulses
Pertinent Results:
ADMISSION
[**2112-4-10**] 11:33AM BLOOD Neuts-74.8* Lymphs-14.2* Monos-10.2
Eos-0.6 Baso-0.3
[**2112-4-10**] 11:33AM BLOOD WBC-12.3* RBC-3.75* Hgb-10.9* Hct-34.0*
MCV-91 MCH-29.1 MCHC-32.2 RDW-15.8* Plt Ct-215
[**2112-4-10**] 10:30AM BLOOD Glucose-137* UreaN-16 Creat-0.9 Na-128*
K-5.7* Cl-89* HCO3-29 AnGap-16
[**2112-4-10**] 11:30PM BLOOD Calcium-8.8 Phos-2.4* Mg-1.9
.
PERTINENT
[**2112-4-10**] 10:30AM BLOOD CK-MB-2
[**2112-4-10**] 10:30AM BLOOD cTropnT-0.04*
[**2112-4-10**] 11:30PM BLOOD CK-MB-2 cTropnT-0.03*
[**2112-4-11**] 03:52AM BLOOD CK-MB-2 cTropnT-0.04*
[**2112-4-10**] 10:30AM BLOOD TSH-4.8*
[**2112-4-11**] 03:52AM BLOOD Free T4-0.74*
[**2112-4-13**] 06:31AM BLOOD Vanco-36.2*
[**2112-4-14**] 03:12AM BLOOD Vanco-26.4*
[**2112-4-11**] 04:15AM BLOOD Type-[**Last Name (un) **] pO2-79* pCO2-53* pH-7.42
calTCO2-36* Base XS-7
[**2112-4-13**] 08:43PM BLOOD Type-MIX Temp-38.4 pO2-45* pCO2-66*
pH-7.31* calTCO2-35* Base XS-3
[**2112-4-14**] 05:46AM BLOOD Type-ART Temp-37.8 pO2-110* pCO2-66*
pH-7.35 calTCO2-38* Base XS-8 Comment-AXILLARY04/29/12 10:32AM
BLOOD Lactate-2.2* K-4.8
[**2112-4-14**] 05:46AM BLOOD Lactate-0.9
.
DISCHARGE
[**2112-4-14**] 03:12AM BLOOD WBC-7.6 RBC-3.02* Hgb-9.1* Hct-27.8*
MCV-92 MCH-30.1 MCHC-32.7 RDW-15.5 Plt Ct-148*
[**2112-4-14**] 03:12AM BLOOD Neuts-58 Bands-5 Lymphs-23 Monos-13*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2112-4-14**] 03:12AM BLOOD Glucose-169* UreaN-14 Creat-0.8 Na-135
K-4.6 Cl-99 HCO3-31 AnGap-10
[**2112-4-14**] 03:12AM BLOOD Calcium-8.6 Phos-1.9* Mg-2.4
.
CXR [**2112-4-13**]
Consolidation in the right mid lung is more pronounced today,
most likely
pneumonia. Vascular congestion of both hilar pulmonary arteries
and
mediastinal veins suggest cardiac decompensation, although
moderate
cardiomegaly is chronic. Tracheostomy tube has a relatively
short
intratracheal excursion, but projects over the tracheal lumen.
Right PIC line ends 5.5 cm below the carina, 2 cm below the
superior cavoatrial junction. No pneumothorax.
.
CT CHEST [**2112-4-13**]
IMPRESSION:
1. Findings suggesting tracheomalacia.
2. Multifocal consolidations and areas of mucus plugging,
particularly
extensive in the right lung, worrisome for pneumonia.
3. Trace pleural effusions.
.
[**2112-4-10**] 3:00 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2112-4-10**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2112-4-13**]):
SPARSE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
MEROPENEM------------- 2 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Brief Hospital Course:
Ms. [**Known lastname 69887**] is a 53 year old woman with MR, tracheomalacia (s/p
tracheostomy [**2107**]), PVD, multiple aspiration PNAs, and DM who
presented with fever, tachypnea, and increased O2 requirement.
#) Hypoxemia, Psedomonal HCAP:
Fever, leukocytosis, increase in sputum production and evolution
of infiltrates on lung imaging were consistent with purulent
tracheobronchitis and pneumonia. The patient was initially
started on Cefepime and Vancomycin for HCAP coverage given
residence in nursing home. Patient's sputum culture grew
pseudomonas sensitive to cefepime. The patient was continued on
Cefepime with plan for total of 14 day course of antibiotics.
The patient should have repeat imaging in about six weeks to
evaluate for resolution of multifocal consolidations.
Patient was hypoxic on admission with increased oxygen
requirement secondary to pneumonia and mucous plugging. The
patient initially required aggressive pulmonary toilet with
hourly suctioning. As the patient improved, she required less
frequent suctioning and returned to her baseline oxygen
requirement of 35-40% via trach mask.
#) Hypertension/Tachycardia
Patient was noted to have sinus tachycardia with paroxysmal
elevations in blood pressure. She was treated initially with
labetolol with good response. However, this ultimately led to
hypotension. Labetolol was discontinued and BP normalized.
Paroxysmal abnormalities in vitals were correlated with episodes
of respiratory discomfort and normalized as the patient
improved.
#) Hyponatremia:
Mild, likely representative of SIADH in the setting of pulmonary
process. Resolved prior to discharge.
#) Hypothyroidism:
TSH elevated and FT4 decreased. Left levothyroxine at current
dose given HTN /tachycardia at the time of presentation and
acute illness. Patient should follow up with repeat labs in the
outpatient setting.
#) Peripheral Vascular Disease:
Continued ASA 325mg daily.
#) Diabetes:
Continued home lantus, NPH, ISS.
#) Mental Retardation/Psychosis:
Patient noted at times to be somewhat more lethargic, so home
anti-psychotics were held. This was likely secondary to delerium
in the setting of acute illness. Prior to discharge patient was
easily arousable and interactive. Her home antipsychotics,
seroquel and valproic acid, should be resumed upon discharge.
Medications on Admission:
1 aspirin 325 mg Tablet daily
2 ipratropium nebs 0.02% inh every 8 hrs prn wheeze
3 Albuterol 0.083 neb q8hrs as needed for congestion
4 cholecalciferol (vitamin D3) 400 unit Tablet daily
5 valproic acid (as sodium salt) 250 mg/5 mL Syrup 750mg qHS,
500mg qAM
6 quetiapine 250mg tid
7 milk of magnesia 30cc qday PRN constipation
8 fenofibrate 54 mg Tablet Sig: One (1) Tablet PO once a day.
9 calcium carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension 5mL
daily
10 Lantus 100 unit/mL Solution Sig: 40 units SC qHS
11 Insulin NPH 100unit/mL, 4 units sc qday at 12 noon.
12 Insulin Humun regular 100units/mL QAC SC as directed per
ISS
13 levothyroxine 25 mcg qDaily
14 lactobacillus acidophilus 100 million cell Capsule Sig: daily
15 acetaminophen 650 mg q4hrs prn
16 Miralax 17gm daily
17 multivitamin with minerals daily
18 loperamide prn
19 lorazepam 1mg q6hrs for anxiety
20 Latanoprost 0.05% opth 1 drop qAM both eyes
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. ipratropium bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation every 4-6 hours
as needed for shortness of breath or wheezing.
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. valproic acid (as sodium salt) 250 mg/5 mL Solution Sig: Five
Hundred (500) mg PO QAM (once a day (in the morning)).
6. quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO PRN (as needed) as needed for constipation.
8. fenofibrate micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
9. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Forty
(40) units Subcutaneous at bedtime.
10. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
13. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
14. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
15. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic QAM
(once a day (in the morning)).
16. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
One (1) PO DAILY (Daily).
17. valproic acid (as sodium salt) 250 mg/5 mL Solution Sig:
Seven [**Age over 90 1230**]y (750) mg PO QHS (once a day (at bedtime)).
18. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
19. cefepime 2 gram Recon Soln Sig: Two (2) grams Injection
every eight (8) hours for 10 days.
Disp:*30 syringes* Refills:*0*
20. NPH insulin human recomb 100 unit/mL Suspension Sig: Four
(4) units Subcutaneous once a day: at noon.
21. insulin regular human 100 unit/mL Solution Sig: as directed
Injection QAC: as directed per
ISS
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Healthcare associated Pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms [**Known lastname 69887**],
You were admitted to the hospital because you were having fevers
and difficulty with your breathing. We did some tests which
showed that you have a pneumonia. We started you on antibiotics
and you improved. You will need to complete a total of 14 days
of antibiotics.
Medication changes:
START cefepime
Followup Instructions:
Please schedule an appointment with your primary care doctor
within one week of discharge:
Name: [**Last Name (LF) 69883**],[**First Name3 (LF) **] J
Location: [**Doctor Last Name **] REGION SERVICES
Address: [**Street Address(2) 69889**], [**Hospital1 **],[**Numeric Identifier 26328**]
Phone: [**Telephone/Fax (1) 69884**]
Fax: [**Telephone/Fax (1) 69890**]
|
[
"293.0",
"934.9",
"311",
"E941.3",
"443.9",
"458.29",
"V44.1",
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"300.00",
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"365.9",
"V43.65",
"272.4",
"482.1",
"253.6",
"250.00",
"519.19",
"244.9",
"V43.64",
"401.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
12701, 12772
|
7228, 9551
|
335, 525
|
12848, 12848
|
3837, 7205
|
13393, 13757
|
2774, 2793
|
10522, 12678
|
12793, 12827
|
9577, 10499
|
13028, 13334
|
2467, 2667
|
2808, 3818
|
13354, 13370
|
266, 297
|
553, 2164
|
12863, 13004
|
2208, 2444
|
2683, 2758
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,732
| 155,489
|
18798
|
Discharge summary
|
report
|
Admission Date: [**2163-7-6**] Discharge Date: [**2163-7-21**]
Date of Birth: [**2101-4-26**] Sex: F
Service: [**Doctor First Name 147**]
Allergies:
Morphine / Demerol / Penicillins
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Benign obstruction of the ampulla of vater
Major Surgical or Invasive Procedure:
Exploratory celiotomy
Extended adhesiolysis
Introperative ultrasound
Open cholecystectomy
Transduodenal ampullary sphincteroplasty
Placement of jejunostomy feeding tube
History of Present Illness:
62 yo female with a long history of pancreaticobiliary problems
including an episode of acute pancreatitis this year. Her
pancreatitis is attributed to a benign stricture of the ampulla
of vater identified by MRCP. Her course has been complicated by
nutritional marasmus requiring preoperative TPN for several
months.
Past Medical History:
Peptic ulcer disease s/p Billroth II 20 years ago.
Nutritional marasmus requiring tpn.
Reflex sympathetic dystrophy fo the right upper extremity
Emphysema
Social History:
none
Family History:
none
Physical Exam:
Neuro: awake, alert, in no apparent distress
General: cachectic
HEENT: sunken temples
Chest: clear breath sounds; breathing easily at rest on nasal
cannula
Cor: RRR with no murmurs, rubs, or gallops
Abd: Open subcostal incision with fibrinous exudate at the
base. Moderate
amount of healthy appearing granulation tissue.
Ext: warm.
Pertinent Results:
[**2163-7-11**] 04:30AM BLOOD WBC-19.6*# RBC-3.72* Hgb-10.3* Hct-31.0*
MCV-83 MCH-27.6 MCHC-33.0 RDW-14.4 Plt Ct-198
[**2163-7-18**] 06:00AM BLOOD Glucose-125* Creat-0.6 Na-129* K-4.5
Cl-87* HCO3-35* AnGap-12
[**2163-7-9**] 10:11PM BLOOD O2-100 pO2-54* pCO2-39 pH-7.48*
calHCO3-30 Base XS-5 AADO2-637 REQ O2-100 Intubat-NOT INTUBA
Comment-NON-REBREA
Brief Hospital Course:
Following an uncomplicated transduodenal sphincteroplasty, the
patient was admitted to the surgical inpatient floor. The
patient's immediate postoperative progress was hampered by
difficulty achieving adequate analgesia despite consultation
with the Acute Pain Service. This led to poor pulmonary toilet.
On POD #2 she had a temperature elevation to 102.3 as well as
decreased oxygen saturation to 88%. Additionally, a CXR showed
evidence of pulmonary edema, basilar atelectasis, and possible
pneumonia.
The patient was therefore transferred to the ICU for intensive
pulmonary support including chest physiotherapy, high flow
oxygen, and empiric iv antibiotics. At her worst she had an A-a
gradient of >500 and required oxygen by non-rebreather mask to
acheive a oxygen saturation in the low 90's. The patient never
required intubation.
Pulmonary medicine consultation was obtained. Diagnostic
evaluation of her respiratory problems included CT angiogram to
rule out pulmonary embolism and cardiac ultrasound to r/o
noncardiogenic pulmonary edema. Both were negative however,
changes consistent with emphysema (previously undiagnosed), were
found on the chest ct.
Over the following week, the patient had a slow recovery of her
pulmonary function through judicious diuresis and aggressive
pulmonary toilet. By POD #9, she was back to nasal cannula at
2lpm without respiratory distress, saturating in the mid to
upper 90's.
On POD #5, a wound infection was discovered that involved the
entire skin incision. There was no involvement of the subjacent
fascia. This was treated with twice daily wet to dry dressing
changes through the remainder of the hospital course. Cultures
of the wound yielded sparse E.Coli, sensitive to multiple
agents, and coag neg. staph. She was treated with appropriate
antibiotics.
By POD #11, Ms. [**Known lastname 51471**] displays a marked improvement overall
though she still has a small oxygen requirement. Her pain is
well controlled, her wound is improving, and she is tolerating a
regular diet supplemented by full strenght tube feeds through
her jejunal tube. She will be transferred to a rehab facility
for an anticipated 1 week for additional help with pulmonary
toilet, wound care, and physical therapy.
Medications on Admission:
Topamax
Tegretol
Oxycontin
Elavil
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation three times a day.
Disp:*2 puffs* Refills:*2*
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation three times a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Benign stricture of the ampulla of vater
Pulmonary emphysema
Acute Pancreatitis
Respiratory failure due to pneumonia and underlying lung disease
Wound infection
Nutritional marasmus
Discharge Condition:
Good
Discharge Instructions:
none
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**1-14**] weeks
|
[
"261",
"576.2",
"492.8",
"575.11",
"998.59",
"577.1",
"486",
"401.9",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"51.83",
"99.04",
"99.15",
"96.6",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
5066, 5143
|
1849, 4111
|
353, 524
|
5369, 5375
|
1475, 1826
|
5428, 5481
|
1089, 1095
|
4195, 5043
|
5164, 5348
|
4137, 4172
|
5399, 5405
|
1110, 1456
|
271, 315
|
552, 873
|
895, 1051
|
1067, 1073
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,630
| 139,230
|
47112
|
Discharge summary
|
report
|
Admission Date: [**2166-2-3**] Discharge Date: [**2166-2-7**]
Date of Birth: [**2096-1-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Worsening mental status and respiratory failure.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
70 M with multiple lung co-morbidities including severe
kyphoscoliosis resulting in severe restrictive physiology,
severe sleep disordered breathing, hypoventilation syndrome,
severe pHTN, chronic dHF who presents with worsening confusion
over the past 4 weeks which prompted her daughters to bring her
into the ER by 911 this evening. History is taken through
daughter's who state their mother has become more confused
throughout the past 4 weeks. They state she denies any dyspnea,
fever, cough, URI symptoms, and that she takes her medications
on her own. They state she has refused to wear the BiPaP machine
since it was brought into the household in [**Month (only) 1096**] after she
was diagnosed with the severe sleep disordered breathing.
In the ER she was tachypneic into the 30s and had decrease in O2
saturation into 70s, she was given multiple neb treatments with
minimal improvement. An ABG was drawn 7.13/107/38 and she was
then placed on BIPAP and transferred to the ICU. Vitals prior to
ICU arrival were 129/64, 92, 20s, 86-96% on bipap, only on 10
minutes.
Upon arrival the patient has no complaints and is able to state
her name, the year, and her location. When asked regarding her
code status she is not able to express understanding.
Past Medical History:
Severe kyphoscoliosis s/p operative repair in [**2140**]
Severe sleep disordered breathing
Hypoventilation syndrome due to severe restrictive lung disease
Asthma
Chronic hypercapneic, hypoxic respiratory failure- resting ABG
pH of 7.40 and PCO2 of 85 on continuous home oxygen
Chronic diastolic heart failure
Pulmonary hypertension
Large hiatal hernia
GERD
Hypertension
h/o severe skin burns as child
Osteoporosis
h/o hip and back pain
Social History:
Prior smoke (X 11 years) but quit in [**2138**]. No alcohol. Lives
with daughter and performs own ADLs (bathing, dressing,
cooking). Previously worked as a home health aide. Widowed.
Family History:
Father died of liver cancer. Daughter with breast cancer at 45.
Also history of colon cancer. No history of pulmonary disease.
Physical Exam:
General Appearance: Respiratory distress; tachypneic. Cachectic.
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, normal appearances.
MMM.
Cardiovascular: Dual sounds with fixed split of S2, no M/R/G
Respiratory / Chest: Very severe kyphosis. Diminished sounds and
very little expansion. Clear with some crackles only at left
base.
Abdominal: Soft, non-tender, bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Warm
Neurologic: Attentive, Oriented to name, year, hospital. CN
II-XII intact. Movement: Purposive. Tone: Normal.
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present). Some venous statis.
Pertinent Results:
Admission Labs:
[**2166-2-3**] 09:55PM BLOOD WBC-5.4# RBC-3.58* Hgb-10.4* Hct-35.7*
MCV-100* MCH-29.2 MCHC-29.3* RDW-16.2* Plt Ct-182
[**2166-2-3**] 09:55PM BLOOD Neuts-75.8* Lymphs-17.7* Monos-5.0
Eos-1.1 Baso-0.4
[**2166-2-3**] 09:55PM BLOOD PT-11.7 PTT-28.2 INR(PT)-1.0
[**2166-2-3**] 09:55PM BLOOD Glucose-97 UreaN-21* Creat-1.0 Na-150*
K-4.5 Cl-95* HCO3->50
[**2166-2-3**] 09:55PM BLOOD CK(CPK)-81
[**2166-2-3**] 09:55PM BLOOD cTropnT-0.02*
[**2166-2-4**] 12:02AM BLOOD Type-ART pO2-38* pCO2-107* pH-7.13*
calTCO2-38* Base XS-1
[**2166-2-3**] 10:04PM BLOOD Lactate-0.8
On Transfer to the Floor:
[**2166-2-5**] 03:27AM BLOOD WBC-4.9 RBC-3.50* Hgb-10.0* Hct-33.7*
MCV-96 MCH-28.7 MCHC-29.8* RDW-16.3* Plt Ct-151
[**2166-2-5**] 03:27AM BLOOD Glucose-95 UreaN-20 Creat-1.1 Na-143
K-3.9 Cl-93* HCO3-46* AnGap-8
[**2166-2-4**] 03:39AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2166-2-5**] 03:27AM BLOOD Calcium-9.5 Phos-2.6*# Mg-2.3
[**2166-2-5**] 03:32AM BLOOD Type-ART pO2-50* pCO2-101* pH-7.33*
calTCO2-56* Base XS-21
Echo [**2166-2-4**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is unusually
small. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). There is no ventricular septal defect.
The right ventricular free wall is hypertrophied. The right
ventricular cavity is mildly dilated with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. Trace aortic
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is severe pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2165-2-14**], the
degree of pulmonary hypertension detected has increased.
CXR [**2166-2-5**]:
COMPARISON: [**2166-2-3**].
FINDINGS: As compared to the previous radiograph, the
transparency of the right lung has improved. At both the right
lung base and in the entire left lung, however, small scattered
areas of opacity are seen, most likely caused by chronic
infection. Elevation of the left hemidiaphragm. Borderline size
of the cardiac silhouette, no evidence of overt pulmonary edema.
Unchanged position of [**Location (un) 931**] stabilization device, unchanged
sternal wires.
Brief Hospital Course:
Respiratory Failure
Contribtors include severe kyphoscoliosis resulting in severe
restrictive physiology, severe sleep disordered breathing,
hypoventilation syndrome, severe pHTN, chronic dHF. Because of
tenuous respiratory status and initial infiltrate was started on
course of Levoquin. Given hypercarbia and hypoxia, work toward
NC when awake and NIPPV when asleep. Formulation is worsening of
underlying diseases - spinal and pulmonary hypertension (worse
on echo), possible central drive failure (particularly at
night). Aim for permissive pCO2 80-90. Initally treated with
fluticasone, ipratropium, salmeterol and albuterol, with
continuation of the latter two, as per her home regimen. Appears
euvolemic at present but will restart home Lasix and observe.
Altered Mental Status
TSH, folate, B12 came back within normal limits. Simple
toxicology negative. Patient with episodes of visual/audio
hallucination on [**2-4**] (seeing people not in the room and hearing
a baby) during the afternoon and evening when off CPAP and on
nasal cannula. ABG obtained in the morning with her on nasal
cannula. Patient was placed back on CPAP titrated to mental
status. Likely contributors were compasine, hypercarbia and
underlying neurodegenerative disorder possible.
Osteoporosis
Continued vitamin D and Ca supplementation.
Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 nebulizer inh q4-6h as needed for shortness of
breath or wheezing
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs(s) inhaled four times a day as needed for shortness of
breath or wheeze
ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth once
a week take first thing in am with water, do not eat for 30-60
min after taking, sit upright after taking pill
FEXOFENADINE [[**Doctor First Name **]] - 180 mg Tablet - 1 Tablet(s) by mouth
daily During allergy season
FLUOCINONIDE - 0.05 % Cream - apply to affected area once a day
FLUTICASONE - 50 mcg Spray, Suspension - [**1-11**] spray(s) each
nostril daily
FLUTICASONE [FLOVENT HFA] - (Dose adjustment - no new Rx) - 220
mcg Aerosol - 1 puffs(s) inhalation twice a day
FUROSEMIDE [LASIX] - 40 mg Tablet - 2 Tablet(s) by mouth once a
day
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day at
night
METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth 30 mins
before meals and hs for reflux esophagitis
NAPROXEN - 250 mg Tablet - [**1-11**] Tablet(s) by mouth twice a day as
needed for pain up to 3 days a week
OVERNIGHT OXIMETRY - - Please perform on 2L O2 via NC; Fax
results to Dr. [**Last Name (STitle) 217**] at [**Telephone/Fax (1) 9730**]. Thank you!
OXYGEN MONITORING - - Please check O2 sats while ambulating
with portable unit on pulsed 2L to ensure O2 sats are maintained
>90%.
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth daily no substitutions
POWER OPERATED SCOOTER -
SALMETEROL [SEREVENT DISKUS] - 50 mcg Disk with Device - 1 puff
inhaled at bedtime
Medications - OTC
CALCIUM - (OTC) - Dosage uncertain
CALCIUM CARBONATE [TUMS] - (OTC) - 300 mg (750 mg) Tablet,
Chewable - 2 Tablet(s) by mouth daily
COENZYME Q10 - (OTC) - 50 mg Capsule - 1 Capsule(s) by mouth
daily
DOCUSATE [**Telephone/Fax (1) 11516**] [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC) - Dosage
uncertain
MULTIVITAMIN WITH IRON-MINERAL - Tablet - 1 Tablet(s) by mouth
daily
OMEGA-3 FATTY ACIDS-FISH OIL - (OTC) - 360 mg-1,200 mg Capsule
-
1 Capsule(s) by mouth daily
OXYGEN-AIR DELIVERY SYSTEMS - Device - Use as directed with
nasal cannula. 2L/min with activity, 1 L/min at rest and while
sleeping. Please assess for oxygen conservation device.
POLYETHYLENE GLYCOL 3350 - (OTC) - 17 gram (100 %) Powder in
Packet - 1 packet by mouth daily with juice
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) inh Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
3. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week: take
first thing in am with water, do not eat for 30-60 min after
taking, sit upright after taking pill .
4. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): during allergy season.
5. Fluocinonide 0.05 % Cream Sig: One (1) application Topical
asdir.
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**1-11**]
sprays Nasal once a day: to each nostril daily.
7. Flovent HFA 220 mcg/Actuation Aerosol Sig: One (1) inh
Inhalation twice a day.
8. Lasix 80 mg Tablet Sig: One (1) Tablet PO asdir: hold dose on
[**2166-2-8**], resume taking on [**2166-2-9**].
9. Reglan 10 mg Tablet Sig: One (1) Tablet PO asdir: 1 Tablet(s)
by mouth 30 mins before meals and hs for reflux esophagitis.
10. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. Naproxen 250 mg Tablet Sig: 1-2 Tablets PO asdir: [**1-11**]
Tablet(s) by mouth twice a day as needed for pain up to 3 days a
week.
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) puff
Inhalation at bedtime.
14. Docusate [**Month/Day (2) **] 100 mg Capsule Sig: One (1) Capsule PO once
a day.
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
17. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet w/ juice PO DAILY (Daily).
18. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Home Oxygen
Please continue your regular home oxygen.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Hypercarbic respiratory failure
SECONDARY DIAGNOSES:
-Severe kyphoscoliosis s/p operative repair
-Severe sleep disordered breathing
-Hypoventilation syndrome due to severe restrictive lung disease
-Asthma
-Chronic hypercapneic, hypoxic respiratory failure
-Chronic diastolic heart failure
-Pulmonary hypertension
-Large hiatal hernia
-GERD
-Hypertension
-Osteoporosis
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2166-2-3**] with confusion because you
weren't using your BiPAP machine. You were in the intensive care
unit because you were so sick. IT IS EXTREMELY IMPORTANT THAT
YOU USE YOUR BIPAP MACHINE EVERY NIGHT! We spoke with you
daughter about this, and she will help you remember to put it on
every night so you can get used to the machine, even though it
is uncomfortable.
Please don't take your lasix tomorrow (Saturday, [**2166-2-8**])
because you are slightly dehydrated. You can restart taking it
on Sunday [**2166-2-9**]. Have labwork checked at your appointment with
Dr. [**Last Name (STitle) 2185**] on Monday [**2166-2-10**].
Please keep all of your appointments as listed below.
Call your doctor if you become short of breath or gain more than
3 pounds in 3 days. Restrict your [**Month/Day/Year **] intake to less than 2
grams per day. Do not drink more than 1500 mL of fluid in one
day.
Followup Instructions:
Provider: [**Name10 (NameIs) 191**] POST [**Hospital 894**] CLINIC Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2166-2-10**] 4:30. See Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] on the [**Location (un) **] in
the [**Hospital Ward Name 23**] building to follow-up on your hospital course and to
follow up labs.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2166-3-3**] 3:00
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2166-3-3**] 3:00
Provider: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 10476**], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2166-3-3**] 3:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"780.59",
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"327.26",
"401.1",
"733.00",
"V46.2",
"293.0",
"428.32",
"737.39",
"276.4",
"276.0",
"518.84",
"493.22",
"530.81",
"553.3",
"428.0",
"416.8",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
11797, 11803
|
5924, 7245
|
362, 369
|
12238, 12238
|
3260, 3260
|
13384, 14240
|
2332, 2462
|
9810, 11774
|
11824, 11824
|
7271, 9787
|
12415, 13361
|
2477, 3241
|
11900, 12217
|
274, 324
|
397, 1654
|
3276, 5901
|
11843, 11879
|
12252, 12391
|
1676, 2115
|
2131, 2316
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,160
| 133,975
|
31566
|
Discharge summary
|
report
|
Admission Date: [**2184-9-27**] Discharge Date: [**2184-10-12**]
Date of Birth: [**2113-8-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9157**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Bronchoscopy
Central Line Placement
History of Present Illness:
Mr [**Known lastname 6359**] is a 71M with hx of CAD s/p cabg, sCHF (EF 25-30%),
vtach on mexilitene/sotalol who p/w SOB, found to be hypoxic.
The pt states that he had been "feeling crappy" for a week, with
predominant symptoms being SOB, fatigue, cough productive of
white to rusty colored sputum. He endorsed increased dyspnea on
exertion, orthopnea, a day of chills, and decreased appetite. He
denied fevers, nightsweats, chest pain, LE edema, n/v/diarrhea.
He endorsed taking his home meds and denied any dietary
indiscretions.
The pt presented to clinic today complaining of dyspnea x1 wks,
was found to be hypoxic, satting 88%RA. He was sent to the ED
where was he found to be 99.3 75 138/62 24 97%4Lnc. He continued
to be tachypneic and was increased to a non-rebreather and then
bipap. He had an abg 7.49/32/187/25. Trop <0.01. He had a cxr
showing diffused pulmonary edema, L>R with obscuration of the
cardiac borders, no focal opacity, no effusions. He was given
lasix 20mg IV, CTX 1g IV, and azithro 500mg PO. He also received
ntg sl x1 and lorazepam 2mg IV x1.
In the MICU the pt was 99/1 67 130/64 22 97% on bipap. He was
given another dose of lasix 20mg IV and continued on
ctx/azithro. He was weaned from bipap to nrb with stable sats in
the upper 90s, continued RR in the 20s-30s. The pt stated he
felt markedly improved.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
CAD s/p CABG x 3 in [**2162**] s/p redo CABG in [**2180-9-2**] (LIMA
to
LAD, SVG to OM and RIMA to the diagonal arteries)
Hypertension
Hyperlipidemia
Systolic Heart Failure (EF 25-30%) [**2184-6-19**]
Gout
TIA in [**2170**]
s/p lap cholecystectomy
s/p B inguinal hernia repair
hx vtach resistent to epicardial cardioversion on mexilitene and
sotalol
Social History:
He is currently working part time helping out in a bar. He is a
former smoker and quit 30 years ago. He smoked about 1-2 packs a
day for 20 years. He denies any alcohol or other drug use.
Family History:
He had a brother who had an MI when he was 55 y/o and had a
CABG. His father had oral cancer.
Physical Exam:
ADMISSION EXAM
General: Alert, oriented, somewhat uncomfortable on bipap
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVD to earlobe
Lungs: L sided crackles throughout, r sided basilar crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM
VS: 97.6 124/60 50 16 94% on 2L, down to 85% while walking off
oxygen
GEN: elderly man, in no acute distress, comfortable
HEENT: MMM, no lymphadenopathy
CV: RRR no m/r/g
LUNGS: bronchial breath sounds, worse on the lower left
ABD: soft NT ND
EXT: no edema
SKIN: warm and dry
NEURO: A+Ox3, occasionally confused particularly at night
Pertinent Results:
[**2184-9-29**] TTE
The left atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is severe regional left ventricular
systolic dysfunction with akinesis of the inferolateral and
inferior walls and hypokinesis of the anterior wall, apex, and
lateral wall (EF 20-25%). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-4**]+)
mitral regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Moderately dilated left ventricular cavity. Severe
regional left ventricular systolic dysfunction c/w multivessel
CAD. Mild to moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2184-6-19**],
left ventricular cavity is more dilated. Regional dysfunction is
more severe with hypokinesis of the anterior wall. There is more
mitral regurgitation.
DISCHARGE LABS
[**2184-10-12**] 06:45AM BLOOD WBC-9.2 RBC-3.89* Hgb-11.2* Hct-33.9*
MCV-87 MCH-28.7 MCHC-33.0 RDW-13.1 Plt Ct-365
[**2184-10-10**] 02:26AM BLOOD PT-14.1* PTT-31.5 INR(PT)-1.2*
[**2184-10-12**] 06:45AM BLOOD UreaN-40* Creat-1.5* Na-135 K-4.1 Cl-100
HCO3-25 AnGap-14
[**2184-10-8**] 02:54AM BLOOD ALT-105* AST-62* AlkPhos-109 TotBili-0.6
[**2184-10-10**] 02:26AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.5
MICROBIOLOGY:
GRAM STAIN (Final [**2184-10-6**]):
[**10-26**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Brief Hospital Course:
71M with hx of CAD s/p cabg, sCHF (EF 20-25%), vtach on
mexilitene/sotalol who p/w SOB and eventually developed hypoxic
respiratory failure requiring an extended period of mechanical
ventilation complicated by ARDS and VAP.
ACUTE ISSUES:
# ACUTE HYPOXIC RESPIRATORY FAILURE: On presentation patient
with O2 sats in the 80s on RA, tachypneic to the 30s-40s.
Patient initially covered for CAP with CTX and azithro and was
aggressively diuresed. Antibiotics were broadened to
vanc/cefepime/azithro after respiratory decompensation and
intubation. His CXR at that time showed dramatic worsening of
bilateral pulmonary edema. Though he has severe CHF with a TTE
showing worsening systolic function (20-25%), there was probably
a component of ARDS leading to his respiratory decompensation.
He completed a CAP course of CTX/azithro while ventilated. About
8 days into ventilation on [**10-4**], he developed a VAP. Antibiotics
were broadened to vancomycin/cefepime/tobramycin. He was
extubated on [**10-7**]. Vancomycin was stopped on [**10-8**] due to low
MRSA suspicion. He completed 8 days of tobramycin and cefepime.
His oxygen requirement gradually improved and he was transferred
to the general medicine floor. On the medicine floor, he
remained somewhat hypoxic off oxygen and while walking, but had
an O2 sat in the mid-90s on 2L NC. He had completed his
antibiotic course prior to discharge.
# SHOCK: Septic and cardiogenic. From pneumonia as above,
briefly required pressors. EF decreased to 25% in setting of
acute illness.
# [**Last Name (un) **]: In the MICU, Cr increased to 1.5 and was assume to be
acute kidney injury from tobramycin. Tobramycin was stopped as
course was almost completed. Creatinine remained stable but
elevated at 1.5. Losartan and lasix were both held but should be
restarted when creatinine has improved.
# GOUT: He complained of knee pain that was similar to pain
experienced with gout. He was treated with tylenol PRN.
CHRONIC ISSUES:
# CHF: A repeat TTE during this hospitalization showed worsening
ejection fraction of 20-25%. CHF may have contributed to
worsening of respiratory status. On discharge, medications were
unchanged except losartan and lasix were held pending
improvement of creatinine.
# VENTRICULAR TACHYCARDIA: Patient with hx of vtach not resolved
with epicardial ablation, currently stable on mexiletine and
sotalol. Patient with increasing runs of Vtach during
hospitalization. Aggressively repleted lytes with improvement in
ectopy.
# CAD s/p CABG. Patient continued on home carvedilol, plavix,
aspirin and simvastatin. Losartan was held due to [**Last Name (un) **]. Should be
restarted when creatinine improves.
# BPH: flomax continued
# HYPERLIPIDEMIA: Held simvastin given interaction with azithro
and risk for rhabdo; after azitro completed statin held in the
setting of transamintitis. Restarted on transfer to the medical
floor and continued as outpatient.
TRANSITIONAL:
# [**Last Name (un) **] - Please check creatinine 3x per week and restart losartan
25mg daily and lasix 20mg PO daily when creatinine has improved
to 1.2.
Medications on Admission:
CARVEDILOL [COREG] - 12.5 mg Tablet - 1 Tablet(s) by mouth twice
a day
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - Tablet(s) by mouth once a day
FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - 20 mg
Tablet - Tablet(s) by mouth once a day
LOSARTAN - 25 mg Tablet - 1 Tablet(s) by mouth daily - No
Substitution
MEXILETINE - 250 mg Capsule - 1 Capsule(s) by mouth every eight
(8) hours
RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth daily
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet -
Tablet(s) by mouth once a day
SOTALOL - 80 mg Tablet - 1.5 Tablet(s) by mouth twice a day
TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg
Capsule, Ext Release 24 hr - Capsule(s) by mouth once a day
ASPIRIN [ASPIRIN [**Hospital1 **]] - (Prescribed by Other Provider) -
81 mg Tablet, Chewable - Tablet(s) by mouth once a day
Discharge Medications:
1. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. mexiletine 250 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. sotalol 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Community Acquired Pneumonia
CHF Exacerbation
Ventilator Acquired Pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 6359**],
It was a pleasure caring for you at [**Hospital1 18**]. You were admitted to
the hospital with a pneumonia and worsening of your heart
failure. You had a prolonged stay in the Intensive Care Unit
requiring intubation and antibiotics. You also acquired a
pneumonia from your ventilator that required more antibiotics.
You were then transferred to the general medical floor and
monitored prior to discharge to a rehab facility.
Medication changes:
# stop LOSARTAN temporarily due to kidney damage, this can be
restarted when your creatinine improves
# stop LASIX temporarily due to kidney damage, this can be
restarted when your creatinine improves
Followup Instructions:
Please contact your primary care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**]
appointment after you leave rehab.
These appointments have already been scheduled for you at [**Hospital1 18**]:
Department: CARDIAC SERVICES
When: TUESDAY [**2184-11-23**] at 8:00 AM
With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE Best Parking: None
Department: CARDIAC SERVICES
When: WEDNESDAY [**2185-3-9**] at 3:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2185-3-9**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"995.92",
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"E930.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.23",
"96.72"
] |
icd9pcs
|
[
[
[]
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] |
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|
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2153, 2505
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2521, 2711
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,016
| 138,584
|
151
|
Discharge summary
|
report
|
Admission Date: [**2109-11-13**] Discharge Date: [**2109-11-25**]
Date of Birth: [**2032-8-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Hytrin
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 77 yo M with h/o CHF c/o dyspnea and 23lb wt.
gain in last 10 days. The patient was discharged from [**Hospital1 18**] 10
days ago. He has been followed closely by VNA and his
cardiolgoist. His lasix doses have been progressively increased
but his weight has been going up and he has been having
worsening SOB. Denies CP, SOB, fevers, chills.
.
In the ED, initial vitals were 97.7 94 125/69 24 83%4L. O2 sat's
improved to the high 90's on NRB. BNP >3000. He received a total
of lasix 80mg IV x 1 and had 1900cc urine output.
.
In the MICU, the patient was started on Bumex IV 2mg prn dosing
for goal I/O of 1-2L negative daily with good effect. He was
restarted on spironolactone as well and has continued to diurese
with improvement in his symptoms. His verapamil was transiently
stopped on [**11-16**], and patient subsequently developed atrial
tachycardia, thought to be MAT,(which it was not)and was started
on a dilt drip and digoxin loaded. Dilt was transitioned to PO
verapamil, and he has been continued on the dig. HR appears to
be well controlled at this time. Additionally, he developed
increased erythema of his left lower extremity at the site of
his prior cellulitis, and blood cultures from that day grew coag
neg staph 2 out of 2. He was initially started on Vanc IV and
this was changed to tetracycline as a result of the patient's
allergies. He is currently on day 3 of 7.
.
The patient reports he is feeling much better, though not quite
to baseline. His SOB is much improved and he feels his ascites
is reduced. He denies fevers, chills, night sweats, headache,
chest pain, diarrhea, dysuria, melena or hematochezia. He does
report abdominal distention which is improved. Has 2 pillow
orthopnea at baseline and denies PND [**12-21**] using BiPAP at night.
Additionally, denies stroke, TIA, DVT, PE, joint pains,
hemoptysis or exertional buttock or calf pain. He does report a
chronic dry cough which is at his baseline.
.
Past Medical History:
-- Hypertension
-- Hyperlipidemia
-- BPH; s/p turp x2
-- Gout
-- Impaired glucose tolerance
-- Interstitial lung disease with diminished DLCO (thought [**12-21**]
to pulmonary fibrosis and emphysema as per Pulmonary). B/L
pleural thickening and honeycombing on CT
-- CHF/ Cor pulmonale
-- Obesity.
-- Diabetes mellitus 2, diet controlled
-- hiatal hernia
-- sleep apnea
-- R sided renal lesion
-- CKD - baseline creatinine is 1.6-1.7
Social History:
Lives at home with his wife of 49 years. Stays on the [**Location (un) 453**]
of the house (can't climb stairs [**12-21**] SOB). Has 6 children and
15 grandchildren-all healthy. Quit smoking 20 yrs ago (1ppd x
35 yrs), rare ETOH, no drug use.
Family History:
Non-Contributory
Physical Exam:
Vitals - T 97.3 BP 100/55 HR 83 R 20 92% on 4L NC
General - well appearing male, sitting up in chair in NAD
HEENT - NCAT, PERRL, oropharynx clear, dry MM
Neck - supple, JVP elevated to angle of jaw (though has 4+ TR)
CV - distant heart sounds, RRR, faint [**11-24**] murmur at
Lungs - decreased breath sounds at bases, crackles 2/3 up
posteriorly on left, 1/2 up on right
Abdomen - distended, nontender, soft, + BS
Ext - b/l venous statsis changes/PVD, 1+ pitting edema
bilaterally, well-healed scar over left shin at site of prior
cellulitis, no open areas
.
Pertinent Results:
Imaging:
[**2109-11-13**] CXR - No significant change with persistent
cardiomegaly and likely bibasilar effusions/atelectasis. No
overt CHF.
[**2109-11-13**] KUB - Gas distended stomach. No evidence of
obstruction.
[**2109-11-13**] Ct Abdomen - Slight interval increase in small right
pleural effusion and intra-abdominal ascites. Otherwise, stable
CT appearance of the abdomen and pelvis.
[**2109-11-15**] Port abd - No dilated air-filled loops of bowel to
suggest obstruction
[**2109-11-16**] CXR - A single portable view of the chest is compared
to prior examination dated [**2109-11-13**]. The cardiomediastinal
silhouette is enlarged, but stable. Current examination reveals
increasing patchy opacities at the bases bilaterally, right
slightly greater than left. Also, blunting of the right
costophrenic angle is noted, suggesting pleural effusion.
Probable underlying copd.
[**2109-11-17**] CXR - Cardiomegaly and residual CHF with small
effusions. Interval improvement compared with one day earlier.
.
EKG [**11-17**]: Rhythm is sinus tachycardia with atrial premature
complexes. There is borderline low voltage in both the limb
leads and precordial leads. There is an RSR' pattern in lead V1
as well as right axis deviation. There are diffuse ST-T wave
changes. Overall configuration suggests pulmonary disease. When
compared with prior tracing of [**2109-11-13**] the rate has increased,
though it is quite similar to tracing of [**2109-10-25**].
.
Urine:
[**2109-11-15**] 11:53PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2109-11-15**] 11:53PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2109-11-15**] 11:53PM URINE RBC-[**4-29**]* WBC-0 Bacteri-0 Yeast-NONE
Epi-0
.
Labs:
[**2109-11-13**] 12:00PM BLOOD WBC-7.4 RBC-4.30* Hgb-13.5* Hct-39.6*
MCV-92 MCH-31.5 MCHC-34.1 RDW-16.6* Plt Ct-241
[**2109-11-14**] 04:54AM BLOOD WBC-6.6 RBC-3.61* Hgb-11.4* Hct-32.9*
MCV-91 MCH-31.5 MCHC-34.6 RDW-16.8* Plt Ct-222
[**2109-11-15**] 03:33AM BLOOD WBC-6.2 RBC-3.91* Hgb-11.9* Hct-36.1*
MCV-93 MCH-30.5 MCHC-33.0 RDW-16.0* Plt Ct-224
[**2109-11-18**] 03:06AM BLOOD WBC-6.8 RBC-3.70* Hgb-11.6* Hct-35.1*
MCV-95 MCH-31.5 MCHC-33.2 RDW-16.8* Plt Ct-255
[**2109-11-19**] 05:09AM BLOOD WBC-6.7 RBC-3.75* Hgb-11.7* Hct-35.3*
MCV-94 MCH-31.1 MCHC-33.1 RDW-16.9* Plt Ct-249
[**2109-11-20**] 04:53AM BLOOD WBC-5.8 RBC-3.54* Hgb-11.0* Hct-32.6*
MCV-92 MCH-31.1 MCHC-33.8 RDW-15.9* Plt Ct-220
[**2109-11-21**] 05:30AM BLOOD WBC-7.8 RBC-3.74* Hgb-11.7* Hct-34.6*
MCV-92 MCH-31.2 MCHC-33.8 RDW-15.9* Plt Ct-238
[**2109-11-22**] 05:35AM BLOOD WBC-8.2 RBC-4.22* Hgb-12.7* Hct-39.9*
MCV-95 MCH-30.1 MCHC-31.9 RDW-15.9* Plt Ct-263
[**2109-11-23**] 05:30AM BLOOD WBC-7.1 RBC-3.82* Hgb-11.8* Hct-35.6*
MCV-93 MCH-30.9 MCHC-33.2 RDW-16.1* Plt Ct-254
[**2109-11-25**] 05:35AM BLOOD WBC-6.5 RBC-3.62* Hgb-10.9* Hct-32.9*
MCV-91 MCH-30.2 MCHC-33.2 RDW-16.6* Plt Ct-255
[**2109-11-13**] 12:00PM BLOOD Neuts-78.8* Lymphs-11.2* Monos-7.5
Eos-2.1 Baso-0.3
[**2109-11-15**] 03:33AM BLOOD Neuts-63.6 Lymphs-19.2 Monos-11.3*
Eos-5.7* Baso-0.3
[**2109-11-13**] 12:00PM BLOOD PT-16.2* PTT-24.7 INR(PT)-1.5*
[**2109-11-14**] 04:54AM BLOOD PT-15.4* PTT-26.2 INR(PT)-1.4*
[**2109-11-15**] 03:33AM BLOOD PT-16.7* PTT-27.7 INR(PT)-1.5*
[**2109-11-16**] 04:27AM BLOOD PT-17.0* PTT-32.7 INR(PT)-1.5*
[**2109-11-17**] 01:58AM BLOOD PT-16.4* PTT-29.3 INR(PT)-1.5*
[**2109-11-18**] 03:06AM BLOOD PT-15.5* PTT-29.9 INR(PT)-1.4*
[**2109-11-21**] 05:30AM BLOOD PT-15.2* PTT-30.0 INR(PT)-1.3*
[**2109-11-23**] 05:30AM BLOOD PT-14.9* PTT-27.2 INR(PT)-1.3*
[**2109-11-13**] 12:00PM BLOOD Glucose-137* UreaN-24* Creat-1.5* Na-136
K-3.9 Cl-98 HCO3-31 AnGap-11
[**2109-11-14**] 04:54AM BLOOD Glucose-97 UreaN-22* Creat-1.5* Na-135
K-3.5 Cl-98 HCO3-29 AnGap-12
[**2109-11-14**] 02:21PM BLOOD Glucose-123* UreaN-24* Creat-1.6* Na-137
K-3.4 Cl-98 HCO3-28 AnGap-14
[**2109-11-15**] 03:33AM BLOOD Glucose-92 UreaN-27* Creat-1.7* Na-138
K-4.1 Cl-102 HCO3-28 AnGap-12
[**2109-11-16**] 04:27AM BLOOD Glucose-127* UreaN-36* Creat-2.1* Na-140
K-4.1 Cl-101 HCO3-29 AnGap-14
[**2109-11-17**] 01:58AM BLOOD Glucose-138* UreaN-36* Creat-1.9* Na-139
K-3.7 Cl-102 HCO3-26 AnGap-15
[**2109-11-17**] 01:31PM BLOOD Glucose-128* UreaN-34* Creat-1.7* Na-138
K-3.2* Cl-100 HCO3-27 AnGap-14
[**2109-11-18**] 03:06AM BLOOD Glucose-127* UreaN-31* Creat-1.7* Na-138
K-4.2 Cl-101 HCO3-28 AnGap-13
[**2109-11-18**] 05:25PM BLOOD UreaN-29* Creat-1.6* Na-139 K-3.9 Cl-101
HCO3-29 AnGap-13
[**2109-11-19**] 05:09AM BLOOD Glucose-100 UreaN-27* Creat-1.6* Na-138
K-3.8 Cl-101 HCO3-29 AnGap-12
[**2109-11-19**] 04:17PM BLOOD Glucose-109* UreaN-29* Creat-1.7* Na-138
K-3.9 Cl-97 HCO3-30 AnGap-15
[**2109-11-20**] 04:53AM BLOOD Glucose-90 UreaN-28* Creat-1.6* Na-137
K-3.6 Cl-99 HCO3-31 AnGap-11
[**2109-11-22**] 05:35AM BLOOD Glucose-98 UreaN-26* Creat-1.8* Na-138
K-3.9 Cl-94* HCO3-32 AnGap-16
[**2109-11-24**] 06:03AM BLOOD Glucose-93 UreaN-28* Creat-1.9* Na-136
K-4.0 Cl-94* HCO3-31 AnGap-15
[**2109-11-25**] 05:35AM BLOOD Glucose-108* UreaN-27* Creat-1.9* Na-137
K-3.7 Cl-93* HCO3-31 AnGap-17
[**2109-11-13**] 12:00PM BLOOD ALT-28 AST-45* CK(CPK)-65 AlkPhos-197*
Amylase-107* TotBili-1.1
[**2109-11-13**] 06:25PM BLOOD CK(CPK)-58
[**2109-11-14**] 04:54AM BLOOD CK(CPK)-56
[**2109-11-21**] 05:30AM BLOOD GGT-245*
[**2109-11-13**] 12:00PM BLOOD CK-MB-NotDone cTropnT-0.02* proBNP-3634*
[**2109-11-13**] 06:25PM BLOOD cTropnT-0.02*
[**2109-11-14**] 04:54AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2109-11-13**] 12:00PM BLOOD Albumin-3.6 Calcium-8.8 Phos-2.9 Mg-2.3
[**2109-11-14**] 04:54AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.1
[**2109-11-15**] 03:33AM BLOOD Calcium-8.5 Phos-4.5 Mg-2.3
[**2109-11-16**] 04:27AM BLOOD Calcium-8.3* Phos-4.8* Mg-1.9
[**2109-11-17**] 01:58AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9
[**2109-11-17**] 01:31PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.8
[**2109-11-18**] 03:06AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.2
[**2109-11-19**] 05:09AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.1
[**2109-11-19**] 04:17PM BLOOD Calcium-8.8 Phos-3.6 Mg-1.9
[**2109-11-21**] 05:30AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9
[**2109-11-23**] 05:30AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.2
[**2109-11-24**] 06:03AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.0
[**2109-11-25**] 05:35AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1
[**2109-11-24**] 06:03AM BLOOD TSH-11*
[**2109-11-25**] 05:35AM BLOOD Free T4-1.1
Brief Hospital Course:
# CHF, acute on chronic diastolic dysfunction - Patient admitted
with SOB likely [**12-21**] to CHF exacerbation, has severe diastolic
dysfunction with pulmonary hypertension and severe TR.
Difficulty balancing diuresis and renal function as an
outpatient. He was initially started on Bumex IV with signficant
diuresis. He was then transitioned to PO Lasix and has
continued to diurese on this regimen. Appears to maintain even
Is/Os on Lasix 80mg PO BID. He will be discharged on this
regimen with follow up to determine the most appropriate
long-term regimen for him. His baseline oxygen requirement is
4L NC satting 88-92%. Additionally, he uses BiPAP overnight. He
is satting low-mid 90s on 3L NC at the time of discharge. He was
continued on his Metoprolol at 12.5 [**Hospital1 **], Spironolactone was
added at 25mg PO daily. He was also discharged on Verapamil.
His weight was 207.6 pounds on discharge.
.
# Atrial tachycardia: Some concern that patient was having MAT
while in the MICU, however, unable to find evidence of MAT in
patient's ECG. He appears to be in an atrial tachycardia.
Verapamil was increased to 180mg daily, and he was continued on
Metoprolol 12.5mg [**Hospital1 **]. He was rate controlled with HR in the
80s on this regimen.
.
# COPD/Interstitial Lung Disease: Recent admission in early
[**Month (only) 1096**], patient had workup for worsening ILD. Echo readings of
severe pulmonary hypertension (not new), worsening dilated RV,
and worsening TR found. Patient had a trial of sildenafil
however, it was stopped secondary to side effects of
hypotension, tachycardia, and dizziness. No plan for further
sildenafil. He was started on prn inhalers and continued on his
home oxygen regimen. He will require continued outpatient
pulmonary follow-up.
.
# ID/Cellulitis: During his recent hospital admission (dc'd
[**2109-10-27**]), patient completed a 7 day course of clindamycin for L
shin cellulitis. During his stay in the MICU, patient developed
by report increasing erythema of his L shin and spiked a fever.
He was initially started on vancomycin for positive blood
cultures. These subsequently grew GPC/coag neg staph. No further
positive blood cultures. He was transitioned to tetracycline for
his cellulitis. He received 4 days. His antibiotics were
discontinued as he did not appear to have further evidence of
cellulitis, remained afebrile and had no leukocytosis. Baseline
erythema of PVD remained unchanged for the duration of his
admission.
.
# CAD: Clean coronaries on cath in [**7-27**]. Continued on
Metoprolol, Verapamil, Atorvastatin.
.
# Anemia: Baseline appears to be around 35. Range of 32-39
during admission with no evidence of bleed. Last iron studies in
[**10-26**] showing iron 53, TIBC 368, Ferritin 40, TRF 283. Likely
secondary to chronic kidney disease.
.
# Hypothyroid: Pt complaining of cold intolerance. TSH found to
be 11. Free T4 1.1. Likely subclinical hypothyroidism. Started
low dose thyroid supplementation on discharge. Patient should
follow with PCP.
.
# Coagulopathy: INR elevated at 1.4 since [**2109-3-19**]. Unclear
etiology. AST wnl, ALT slightly elevated at 45. [**Month (only) 116**] be
nutritional though albumin is 3.6. Can be monitored as an
outpatient.
.
# DM: On oral medications at home. On ISS during admission.
Restarted on home regimen on discharge.
.
# CKD: Baseline creatinine is 1.6-1.7. Slight increase in
creatinine to 1.9 during admission, likely a result of
aggressive diuresis. Stable over several days.
.
Code - FULL
Medications on Admission:
Allopurinol 100 mg DAILY
Aspirin 325 mg DAILY
Atorvastatin 10 mg DAILY
Hexavitamin DAILY
Prilosec OTC 20 mg once a day
Glimepiride 1 mg once a day.
HOME o24L NC
Metoprolol 12.5mg TID
Verapamil 120 mg SR DAILY
Lasix 40mg M-W-F; 30mg T-Th-Sat-Sun
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Tablet PO once a day.
5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
7. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] (2 times a day): Take as you were prior to
admission.
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-20**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing/SOB.
Disp:*1 months supply* Refills:*0*
11. Home O2
3-4L NC
12. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day.
13. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
14. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Tablet PO once a day.
5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
7. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] (2 times a day): Take as you were prior to
admission.
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-20**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing/SOB.
Disp:*1 months supply* Refills:*0*
11. Home O2
3-4L NC
12. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day.
13. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
14. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Acute on chronic severe right heart systolic failure
Severe COPD, Pulmonary Hypertension (PA systolic 72 mm hg)
Ascites secondary to right sided CHF
Interstitial Pulmonary Fibrosis and emphysema
Secondary diagnoses:
Hypertension
Hyperlipidemia
Type 2 Diabetes Mellitus
Sleep Apnea
Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a worsening of your heart failure. A
significant amount of fluid was removed, and you are now back to
your baseline weight with improvement of your breathing.
It is very important that you take your Lasix (furosemide) as
directed. This should keep the fluid from re-accumulating. In
addition, it is very important that you use your BiPAP at night
as this will keep your oxygen levels up while you sleep.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere
to 2 gm sodium diet. Please try not to drink too much fluid
after discharge.
.
In addition, while you were here, your thyroid hormone levels
were found to be low. We have started you on a low dose of
thyroid replacement hormone (levothyroxine). You should have
your thyroid levels rechecked in [**2-23**] weeks.
.
Please take all your medications as directed and keep all follow
up appointments.
Followup Instructions:
Please follow up with your cardiologist, Dr. [**Last Name (STitle) **], early next
week.
Please follow up with your primary care doctor in the next 2
weeks as well.
|
[
"780.57",
"250.00",
"244.9",
"428.0",
"285.21",
"416.9",
"585.9",
"428.33",
"682.6",
"785.0",
"789.59",
"416.8",
"403.90",
"286.9",
"515",
"272.4",
"278.00",
"496",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16543, 16600
|
10042, 13561
|
310, 316
|
16940, 16949
|
3662, 10019
|
17907, 18076
|
3048, 3066
|
13857, 16520
|
16621, 16816
|
13587, 13834
|
16973, 17884
|
3081, 3643
|
16837, 16919
|
267, 272
|
344, 2309
|
2331, 2768
|
2784, 3032
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,877
| 165,171
|
53905
|
Discharge summary
|
report
|
Admission Date: [**2188-3-24**] Discharge Date: [**2188-4-3**]
Date of Birth: [**2110-10-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
77 year old Male with HTN/HL/COPD/HCV and recent diagnosis of
PNA, who was admitted to [**Hospital1 3278**] MC 3 wks prior to admission,
d/ced to rehab ([**Location (un) **] HC), where he was found to have
progressively worsening gait abnormality, ? urinary retention
and/or incontienence, who was transferred to [**Hospital1 18**] for
evaluation of dyspnea from [**Hospital1 1501**]. No further history is available,
above obtained from son.
On arrival to the ED SBPs initially in 100s, pt. on CPAP of 5cm.
.
In the ED, initial VS were: 136 77/58 23 98% RA. ECG w/
regualr WCT. Initial labs Na:127, K:8.7, Cl:95, TCO2:13,
Glu:264, Lactate:2.2. Received 2 amps CaCl, 1 amp Bicarb,
Insulin (10UR)/D50, kayexalate and 100mg IV hydrocortisone and
started on Levophed. Pt. was intubated 7.5 ETT
(etomidate/rocuronium/fentaly/versed), with ABG 7.22/52/439.
Repeat labs notable for WBC of 12K, HCT 33%, INR 1.0, PTT46,
chem 7 of 128/9/89/13/243/18. Renal was consulted who
recomended initiation of emergent dialysis. Currently on
levophed 0.2 mcg/kg SBP 127/85, HR 103, 100% on 20x380x5x50%.
Noted to have frank blood per rectum and had coffee grounds. Of
note, upon foley insertion, noted to have 3L output.
.
In addition, OG lavage showed "dark blood" and pt. was noted to
have frank blood per rectum. Was started on PPI gtt w/ 80mg IV
bolus. GI was consulted who recommended conservative management.
While in the MICU, as mentioned, he underwent emergent HD, foley
placement and received finasteride with complete recovery of
renal function (Cr 0.6 today). He only received one HD session.
Given concern for PNA, he was started on vancomycin and
levofloxacin (cefepime discontinued on [**3-26**]), for which he will
complete an 8 day course (day 1- [**3-24**]). Given his hypotension,
he underwent and ECHO which revealed an interatrial septal
aneurysm. Cardiology was consulted and recommended aspirin and
statin. Neurology also consulted and agree with cardiology.
Neurology also following for recent history of left arm
weakness, for which they recommend a c-collar and MRI c-spine.
There was a question of cauda [**Month/Year (2) 43561**] so he was started on
methylprednisolone. On [**3-26**], the patient coughed up a pill that
was stuck in his oropharynx. Given this, he was made NPO and
S/S was consulted. They are planning to do a video swallow
evaluation on [**3-28**]. He was maintained on IV PPI [**Hospital1 **] while in
the MICU with an equivocal H.pylori. In addition, while pulling
his central line yesterday, the patient became hypotensive and
hypoxic secondary to an air embolus. ECHO at that time was
stable. He was given lasix 10mg IV x 2 with 1.2L urine output
and resolution of symptoms. He is being transferred to the
medicine floor for further management
On arrival to the floor, vital signs were T- 97.9, BP- 158/96,
HR- 90, RR- 18, SaO2- 99% on 2L NC. The patient was comfortable
and AAO x 2 (person, place, "[**2132**]").
Past Medical History:
- Coronary artery disease
- PMR on Prednisone
- "Thickened bladder"
- Benign prostatic hypertrophy
- AAA 3.7 cm on [**2188-3-24**] at [**Hospital1 18**] u/s
- COPD
- Hyperlipidemia
- Hypertension
- Hep C
- Pneumonia
Social History:
Lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], divorced, wife still visits him at
home and [**Name (NI) 1501**]. Prior to recent hospitalization at [**Hospital1 3278**],
ambulated independently, not on home O2. Was able to do his own
bills up to 1mo ago, had HHA x2/wk and meals on wheels. Former
restaurant chef.
- Tobacco: 30 yrs ago, prior extensive.
- Alcohol: denies
- Illicits: denies
Family History:
Mother w/ skin cancer, brother with brain cancer and MI in 80s.
Physical Exam:
Admission physical exam:
General: Intubated, sedated, not following commands.
Malnourished and chornically ill appearing man.
HEENT: Sclera anicteric, dMM
Neck: supple, JVP flat
CV: Regular rate, normal S1 + S2, no murmurs or rubs
Lungs: Clear to auscultation bilaterally, poor air movement.
Abdomen: soft, scaphoid, non-distended, bowel sounds present, no
organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:
Intubated, sedated, not following commands.
PER, 1.5mm minimally reactive, intact corneals b/l, intact
oculocephalics, + gag. No withdrawal to noxious.
.
Discharge physical exam:
VS: Tm 98.0 Tc97 BP 130/78 (118-150/70s-80s) HR 90s-100s RR18 O2
95-100% 2L
Gen: emaciated elderly gentleman, awake, alert, appropriate,
follows simple commands
HEENT: sclera anicteric, moist MM, oropharynx clear, poor
dentition
Neck: supple
CV: prominent PMI, RRR, nl s1/s2, no murmurs, rubs
Pulm: CTAB, no rhonchi, rales or wheezes
Abd: +BS, non-tender, non-distended, no guarding/rebound
GU: + foley, flexiseal
Ext: warm, well perfused, 2+ ankle edema, 1+ upper extremity
edema
Neuro: follows commands, CN2-12 intact, moves all four
extremities spontaneously
Pertinent Results:
Admission labs:
[**2188-3-23**] 10:21PM WBC-12.7* RBC-3.25* HGB-10.1* HCT-33.3*
MCV-102* MCH-31.0 MCHC-30.3* RDW-13.8
[**2188-3-23**] 10:21PM GLUCOSE-297* UREA N-243* CREAT-18.0*
SODIUM-128* POTASSIUM-9.1* CHLORIDE-89* TOTAL CO2-13* ANION
GAP-35*
[**2188-3-23**] 10:21PM ALT(SGPT)-17 AST(SGOT)-15 ALK PHOS-44 TOT
BILI-0.2
[**2188-3-23**] 10:21PM PT-11.2 PTT-46.6* INR(PT)-1.0
[**2188-3-23**] 10:33PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2188-3-23**] 10:33PM URINE RBC-9* WBC-6* BACTERIA-NONE YEAST-NONE
EPI-<1
[**2188-3-24**] 03:23AM URINE OSMOLAL-373
[**2188-3-24**] 03:23AM URINE HOURS-RANDOM UREA N-574 CREAT-80
SODIUM-30 POTASSIUM-44 CHLORIDE-22
[**2188-3-23**] 10:54PM TYPE-ART TEMP-36.1 TIDAL VOL-400 PEEP-5
PO2-439* PCO2-52* PH-7.22* TOTAL CO2-22 BASE XS--6
INTUBATED-INTUBATED
[**2188-3-24**] 03:03AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE
[**2188-3-24**] 03:03AM TSH-1.3
[**2188-3-24**] 03:03AM HCV Ab-NEGATIVE
[**2188-3-24**] 03:03AM calTIBC-170* VIT B12-1496* FOLATE-11.6
FERRITIN-1033* TRF-131*
[**2188-3-24**] 03:03AM ALBUMIN-3.3* IRON-150
[**2188-3-24**] 03:03AM CK(CPK)-71
[**2188-3-24**] 04:05AM CK-MB-6 cTropnT-0.05*
[**2188-3-24**] 04:05AM CK(CPK)-64
[**2188-3-24**] 01:37PM CK-MB-5 cTropnT-0.02*
[**2188-3-24**] 01:37PM CK(CPK)-48
[**2188-3-24**] 01:49PM LACTATE-0.8
.
[**2188-3-23**] CXR:
1. No evidence of acute disease.
2. Endotracheal tube terminating approximately 7 cm above the
carina. If
clinically indicated, advancing the tube by 2-3 cm could be
considered for
more optimal positioning.
3. Moderate relative elevation of the right hemidiaphragm.
.
[**2188-3-24**]: Renal ultrasound:
IMPRESSION:
1. Mild bilateral hydronephrosis.
2. Slightly small kidneys, both less than 10 cm in size.
3. No evidence for renal artery stenosis.
.
[**2188-3-24**] RUQ ultrasound:
IMPRESSION:
1. No evidence for cirrhosis.
2. Moderate bilateral hydronephrosis.
3. Aneurysmal dilatation of abdominal aorta which measures 3.7cm
in maximal diameter.
.
[**2188-3-24**] CT head:
IMPRESSION: No evidence of hemorrhage or infarction. Partial
opacification of bilateral sphenoid sinuses as well as bilateral
mastoid air cells
.
[**2188-3-24**]: MR [**Name13 (STitle) **]
FINDINGS:
There is normal anatomic alignment and vertebral body height.
There are
degenerative-type endplate changes at multilevel more evident at
L3-4 level. Schmorl's nodes are noted at the inferior endplate
of L1 and superior endplate of L4. The spinal cord terminates at
L1-2 level, with normal distribution of the cauda [**Name13 (STitle) 43561**] nerve
roots. There are bilateral renal cysts vs. dilatation of the
right renal pelvis. There is atrophy of the paraspinal muscles.
At T11-T12 level, there is no significant disc bulge, spinal
canal stenosis, or neural foraminal narrowing.
At T12-L1 level, there is a disc bulge, asymmetric to the right
as well as
mild bilateral facet arthrosis causing mild narrowing of the
right neural
foramen.
At L1-2 level, there is a diffuse disc bulge, bilateral facet
arthrosis and ligamentum flavum thickening causing mild right
and moderate left neural foraminal narrowing as well as mild
spinal canal stenosis.
At L2-3 level, there is a disc bulge, bilateral facet arthrosis
and ligamentum flavum thickening causing moderate right and
severe left neural foraminal narrowing as well as mild spinal
canal stenosis.
At L3-4 level, there is a diffuse disc bulge, bilateral facet
arthrosis and ligamentum flavum thickening causing moderate to
severe narrowing of the bilateral neural foramina and moderate
to severe spinal canal stenosis.
At L4-5 level, there is a disc bulge, bilateral facet arthrosis
and ligamentum flavum thickening causing severe narrowing of the
right neural foramen, moderate narrowing of the left neural
foramen and moderate spinal canal stenosis.
At L5-S1 level, there is a disc bulge and bilateral facet
arthrosis causing severe narrowing of the bilateral neural
foramina and mild to moderate spinal canal stenosis. A small
annular tear is noted.
IMPRESSION:
Multilevel degenerative changes of the lumbar spine as described
above. No evidence of fracture.
.
[**2188-3-25**] EGD: duodenitis, gastritis, gastric ulcer
Recommend Omeprazole 40 mg daily for gastritis
H. pylori serology and treat if positive.
.
[**2188-3-26**] Echo:
IMPRESSION: Suboptimal image quality as patient could not be
repositioned due to concern for air embolism. Right ventricle is
normal in size and has borderline normal free wall motion (apex
not well-visualized). The patient is tachycardic with frequent
premature atrial contractions. Hypermobile, aneurysmal
interatrial septum. Borderline pulmonary artery systolic
hypertension.
.
MRI C-spine ([**2188-3-28**]):
Images are degraded by motion artifact. There is normal anatomic
alignment and vertebral body height. The bone marrow signal is
within normal limits. Limited evaluation of the paraspinal soft
tissues is grossly unremarkable. The posterior fossa is within
normal limits.
At C2-3 level, there is a posterior disc bulge touching the
spinal cord as well as bilateral uncovertebral and facet
arthrosis causing severe right and moderate left neural
foraminal narrowing.
At C3-4 level, there is a posterior disc bulge asymmetric to the
right,
deforming the spinal cord as well as bilateral uncovertebral and
facet
arthrosis causing severe spinal canal stenosis and severe
bilateral neural foraminal narrowing.
At C4-5 level, there is a posterior disc bulge, deforming the
spinal cord as well as bilateral uncovertebral and facet
arthrosis causing moderate right and severe left neural
foraminal narrowing and moderate-to-severe spinal canal
stenosis.
At C5-6 level, there is a posterior disc-osteophyte complex
asymmetric to the left as well as bilateral uncovertebral and
facet arthrosis causing moderate narrowing of the right neural
foramen, severe narrowing of the left neural foramen, anterior
deformity of the spinal cord with moderate spinal canal
stenosis.
At C6-7 level, there is a posterior disc bulge touching the
spinal cord as well as bilateral uncovertebral and facet
arthrosis causing mild right and moderate-to-severe left neural
foraminal narrowing.
At C7-T1 level, there is a posterior disc bulge indenting the
thecal sac as well as bilateral uncovertebral and facet
arthrosis, but no significant spinal canal stenosis and neural
foraminal narrowing.
There is abnormal cord signal at C3-4 and C4-5 level, related to
the severe spinal canal stenosis.
IMPRESSION:
1. No evidence of acute fracture or ligamentous injury.
2. Multilevel severe degenerative changes of the cervical spine,
worse at
C3-4 level with severe spinal canal stenosis and abnormal spinal
cord signal.
[**2188-3-30**] CTA Abd/Pelvis: 1. No evidence for active extravasation
on this examination. High-density material within bowel loops
may represent ingested material versus blood products from known
GI bleed. 2. Moderate atherosclerotic calcification of the aorta
and its branching vessels with an infrarenal aortic aneurysm and
aneurysm of the left common iliac artery. 3. Bilateral small
effusions with associated atelectasis.
[**2188-4-1**] CXR: The right PICC terminates in the mid to lower SVC.
There is no pneumothorax. NG tube terminates in the stomach.
Elevation of the right hemidiaphragm, dilated bowel gas pattern,
and basilar atelectasis are unchanged from [**3-30**]. Subcutaneous
gas has resolved.
[**4-3**] Video Swallow Study: Barium passes freely through the
oropharynx into the upper esophagus without evidence of
obstruction. There was penetration with thin liquids,
nectar-thick liquids and ground solids. No gross aspiration was
seen.
[**4-2**] Colonoscopy: Diverticulosis of the Left side colon. Terminal
ileal mucosa normal. Stool in the Solid stool in left side colon
and liquid stool in right side colon. Otherwise normal
colonoscopy to cecum and terminal ileum.
DISCHARGE LABS:
[**2188-4-3**] 05:54AM BLOOD WBC-4.4 RBC-2.65* Hgb-8.2* Hct-26.4*
MCV-100* MCH-30.9 MCHC-31.0 RDW-15.9* Plt Ct-179
[**2188-4-3**] 12:41PM BLOOD Hct-26.4*
[**2188-4-1**] 02:16AM BLOOD PT-11.6 PTT-28.9 INR(PT)-1.1
[**2188-4-3**] 05:54AM BLOOD Glucose-130* UreaN-7 Creat-0.5 Na-145
K-3.8 Cl-106 HCO3-36* AnGap-7*
[**2188-4-3**] 05:54AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.9 Cholest-112
[**2188-4-3**] 05:54AM BLOOD Triglyc-98 HDL-PND
Brief Hospital Course:
77 yo M w/ COPD, HTN/HL, CAD, who p/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], hypotension tx for
obstructive uropathy w/ foley, urgent HD, with hospital course
complicated by [**Company 191**] pneumonia and GIB initially [**1-31**] gastritis and
subsequently diverticular in nature.
# Hypotension, Adrenal Insufficiency
The patient's hypotension was likely multifactorial and
secondary to a combination of hypovolemia from GI bleed,
infection from pneumonia, and unstable tachycardia. See below
for treatment of each of these problems. The patient also
received stress dose steroids, but was ultimately transitioned
back to his home prednisone as he stabilized. Cardiac enzymes
were not suggestive of MI. The patient was resuscitated fully
and left the MICU slightly hypertensive because he was NPO and
could not take his home nifedipine. While on the medicine
floor, the patient had no episodes of hypotension and did well
on his home metoprolol dose. His home nifedipine was held, but
this can be gradually restarted if his pressures require it.
#Bacterial Pneumonia:
The patient's X-ray on admission showed a RLL opacity. Unclear
if chronic or new, infectious vs. malignant, based on old
records. The patient was treated for HCAP with vancomycin,
cefepime, and levofloxacin, which was tailored back to
vancomycin and levofloxacin as the patient stabilized. He
completed an 8 day course- last day was [**2188-4-1**]. He continued to
have a 2L oxygen requirement which was attributed to atelectasis
in the setting of deconditioning. He will benefit from continued
physical therapy and incentive spirometry.
# Acute Renal Failure due to Urinary Retention
This was due to obstructive uropathy, given large amount (3L) of
UOP after Foley placement in ED. He was uremic with extensive
electrolyte abnormalities and acidosis. His initial EKG showed
changes consistent w/ his hyperkalemia. The patient's ultrasound
suggested bilateral hydronephrosis. The patient was emergently
hemodialyzed in one two hour session. He did not require further
dialysis. Between the placement of a Foley catheter and the
dialysis, the patient's renal function rapidly improved and his
creatinine was normal by the time he left the ICU. He was
started on finasteride and tamsulosin and foley was kept in
place. Urology recommended foley for at least two weeks with
outpatient follow-up for a voiding trial.
# Etiology of urinary obstruction. Multiple possibilities, the
most concerning of which was cauda [**Month/Day/Year 43561**] syndrome. An MRI
showed no cauda [**Last Name (LF) 43561**], [**First Name3 (LF) **] stress dose steroids for possible
cauda [**First Name3 (LF) 43561**] were stopped. Thought to be caused by benign
prostatic hyperplasia. Urology consult was placed and they
recommended foley for at least two weeks with outpatient
follow-up for a voiding trial. They did not see an indication
for any acute urologic intervention during the hospitalization.
# Acute Blood Loss Anemia due to Diverticulosis with Bleeding:
The patient was was initially given DDAVP 0.4mcg/kg over 10
mins. a PPI drip, and resuscitation with fluids. The patient
underwent endoscopy, which showed gastritis, gastric ulcer,
duodenitis. He was then started on PPI [**Hospital1 **]. His H pylori
serology was equivocal, stool antigen was ultimately negative.
He was called out to the floor but returned to the ICU following
additional episodes of hypotension and bright red blood per
rectum. He required transfusions of red blood cells (4 units).
His CTA abdomen was negative, but his colonoscopy showed
left-sided diverticulosis which was believed to be the etiology
of his bleed. He will require GI follow up (scheduled) with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for repeat EGD given concern for gastric metaplasia
in the setting of his gastritis.
# Severe Malnutrition/aspiration risk:
On second to last day of patient's initial ICU stay, the patient
coughed up a large pill that was stuck in his posterior throat.
He was made NPO, his medications were switched to IV. On [**3-28**],
S/S team felt the patient was high risk for aspiration so he
remained NPO, failing multiple trials until [**4-3**] when he passed a
video swallow and was started on a nectar thick liquids, pureed
solids diet. After completion of GI studies and resolution of
the bleed, patient was given tube feeds for nutrition. These
will need to be continued while his swallowing mechanism is
still improving and nutritional status poor. We would recommend
nutrition to follow him and perform calorie counts to help
decide when to discontinue tubefeeds. Would recommend monitoring
for refeeding syndrome given severe malnutrition and several
days w/o food in setting of GI bleed.
# LUE weakness:
On [**2187-3-26**], the patient was seen not using his left arm.
Neurological exam showed biceps and triceps weakness, with no
obvious sign of shoulder dislocation. Strength in hand was [**5-3**],
though patient had some swelling of dorsum of left hand. UE
ultrasound was scheduled, but patient refused that test on [**3-27**].
Neurology was called. They recommended soft cervical collar and
MRI spine. MR [**Name13 (STitle) **] performed on [**3-28**], which showed
degenerative changes, posterior disc bulge throughout w/ severe
spinal stenosis. He may benefit from neurology follow up as an
outpatient.
# Possible air embolism:
Shortly after the patient's HD line was removed, he had
hypotension and destauration. This was thought to be secondary
to an air embolism. The patient was placed on his left lateral
decubitus. An echo was obtained that did not suggest right heart
strain or pulmonary embolism. The patient's condition slowly
improved until he only needed 2L nasal cannula. This can
continue to be weaned as tolerated.
# Intraatrial septal aneurysm:
Incidental finding on echocardiography. Following discussion
with Cardiology and Neurology, the patient may be placed on
aspirin once he is out of the window of his acute GI bleed.
# CAD:
Echo w/ EF 55%, no wall motion abnormality, though notable for
interatrial septal aneurysm. Per cardiology and neurology
recommended aspirin and statin. We have been holding aspirin
given his recent bleed but this can be restarted if hcts remain
stable and no signs of further bleed. He was continued on his
metoprolol and restarted on his statin on discharge.
# Polymyalgia Rheumatica:
He briefly received stress dose steroids as above, but then was
switched tot methylpred 4mg iv daily. On discharge he was
restarted on his home prednisone 5 mg daily.
The patient will need to establish care with a PCP and is
interested in doing so at the [**Hospital1 18**]. He will need to follow up
with urology and GI as detailed in the discharge instructions.
He had extensive code status discussions during this
hospitalization and he decided to be DNR/DNI. His health care
proxy is son [**Name (NI) **] [**Name (NI) 166**] ([**Telephone/Fax (1) 110571**].
Medications on Admission:
- Colace
- Lactulose prn constipation
- ASA 81
- Metoprolol succ 50mg daily
- Lisinopril 20mg daily
- Doxycycline 100mg [**Hospital1 **]
- Cyclobenzaprine 10mg TID prn
- nifedipine 60mgdaily
- prednisone 5mg daily (per [**Hospital1 3278**] records, 10 mg daily)
- herbal supplements
- simvastatin 10 mg daily
- MV daily
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. multivitamin Tablet Sig: One (1) Tablet PO once a day.
3. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) **]
Discharge Diagnosis:
Primary- Respiratory failure
Health Care Associated Pneumonia
Diverticular bleed
Gastritis
Renal failure
Secondary- Coronary artery disease
Hyperlipidemia
Hypertension
COPD
BPH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 166**],
You were admitted to the hospital with kidney and lung failure.
While here, you were admitted to the ICU and placed on a
breathing machine. You underwent hemodialysis due to the kidney
failure. You were treated with IV antibiotics for a pneumonia
and also developed two GI bleeds, one that was secondary to
inflammation in your stomach and a second that was related to a
diverticulum in your colon. You were treated with an
acid-blocking medication and bowel rest. You did well in the
ICU and were transferred to the medicine floor for further
management. You had no further bleeding and passed a swallowing
exam so are being trialed on a soft diet. You will continue to
get feeds by the [**Last Name (un) **]-gastric tube until you are stronger and
eating well. You are being discharged to rehab.
The following changes were made to your medications:
1. START omeprazole 40mg by mouth twice daily
2. START finasteride 5mg daily
3. START tamsulosin 0.4 mg qHS
4. STOP aspirin until otherwise instructed by a doctor
5. STOP nifedipine until otherwise instructed by a doctor
6. STOP cyclobenzaprine
7. STOP doxycycline
8. STOP lisinopril
9. START lidocaine patch as needed for pain
Please continue your other medications as prescribed by your
outpatient providers.
You will need to keep the foley catheter in for at least 2 weeks
and will need to see a urologist as an outpatient for further
evaluation of your urinary obstruction. You will also need to
follow up with gastroenterology.
It was a pleasure taking care of you. We wish you a speedy
recovery.
Followup Instructions:
**Please discuss with the staff at the facility the need for a
follow up appointment with a Primary Care Physician when you are
ready for discharge. If you need assistance obtaining a new PCP
at [**Hospital1 18**], you can contact our Find A Doctor line and
[**Telephone/Fax (1) 70946**]. They are available Monday - Friday from 8:30AM -
5:00PM.**
Please follow up at the appointments below:
Name: [**Last Name (LF) 163**], [**First Name3 (LF) 161**] K. MD
Specialty: UROLOGY
Location: [**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 3RD FL, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 921**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) **] [**Last Name (STitle) 176**]
1-2 weeks. You will be called at home with the appointment. If
you have not heard from the office within 2 days or have any
questions, please call the number above.**
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2188-4-29**] at 1 PM
With: [**First Name8 (NamePattern2) 4503**] [**Last Name (NamePattern1) 4504**], 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
Completed by:[**2188-4-3**]
|
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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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22246, 22315
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13788, 20804
|
311, 325
|
22617, 22617
|
5327, 5327
|
24431, 25755
|
4029, 4095
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21174, 22223
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22336, 22596
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20830, 21151
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22801, 24408
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4135, 4720
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264, 273
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353, 3327
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5343, 7419
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22632, 22777
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3349, 3567
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3583, 4013
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4745, 5308
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