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47142
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Discharge summary
|
report
|
Admission Date: [**2168-10-9**] Discharge Date: [**2168-10-13**]
Service: NEUROLOGY
Allergies:
Colchicine / Omeprazole / Doxazosin / Cipro I.V. / Lipitor
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
headaches
Major Surgical or Invasive Procedure:
arterial line [**2168-10-9**]
History of Present Illness:
[**Age over 90 **]y F with history notable for bilateral SDH s/p evac here at
[**Hospital1 18**] in [**2166**] as well as chronic, recurrent non-migrainous
headaches, hypertension, and remote h/o migraine HA. who returns
to our ED for the second time in two weeks for
persistent/recurrent headache. I saw Ms. [**Known lastname 1968**] a little over a
week ago in our ED ([**9-30**], Friday) for her headache, which was
similar to now and similar to several previous presentations. At
that time, her headache had started one day after she started a
new medication (amlodipine at a low dose). It had been going on
for several days at that time, with only partial relief from
Fioricet and Motrin, and a one-day spell of relief during a
brief
stay at [**Hospital1 **] where she got Reglan. There, NCHCT was
unremarakable (both the report and the images, which I reviewed
at that time) and a carotid doppler U/S of the carotids study
was
reportedly without e/o stenosis. We recommended f/u with her
outpatient Neurologist (Dr. [**Last Name (STitle) **] has been following her since
[**2166**]), and stopping the medication that may have triggered the
HA
(amlodipine) and follow up with her PCP [**Name9 (PRE) 2678**] to try a different
anti-hypertensive [**Doctor Last Name 360**] because her BP was 170/x at that time
(despite the amlodipine). Also recommended giving Reglan, which
had worked at [**Hospital1 **].
Pt tells me now that the headache went away for a day or less
after the Reglan she got here last week, but returned, again
present every day at the same intensity or worse, no full relief
from the aforementioned analgesics. Stopping the amlodipine did
not seem to have any effect on the HA. She followed up with Dr.
[**Last Name (STitle) **] this past Monday ([**10-3**]), and he recommended trying
verapamil extended-release 120mg daily for the BP and headaches
in lieu of the amlodipine. She checked with her Cardiologist,
who
said this was OK, and has been taking it for a few days now, but
no relief from the [**Last Name (LF) **], [**First Name3 (LF) **] she returned to the ED. Here, her BP
has ranged from 190s-250s systolic over 70s to 110s diastolic,
and did not respond well to labetalol or hydralazine. The ED
staff planned to admit to Medicine ICU ([**Hospital Unit Name 153**]) for blood pressure
control, but Dr. [**Last Name (STitle) **] noticed that she was in the ED and
visited and recommended that we could admit to our Neuro-ICU
service since we are familiar with the patient and he is
attending on the inpatient service this week.
On my interview with her, she gave the details as listed above
and says that nothing else has changed since our last encounter
except that she is frustrated that the headache won't stay away.
Her daughter is concerned about the situation and there is some
disagreement between her and the patient about the desired
amount
of diagnosis and treatment -- patient requests DNR/DNI and does
not want, e.g., CTA or potential coil/clipping if she were found
to have an aneurysm. She also takes off the BP cuff and refuses
BP cuff measurments because she says it hurts her arm. She says
she will allow a-line placement and IV managment of her BP.
ROS: negative except as above and as noted in previous ED
consult
note from [**9-30**] (no changes).
Past Medical History:
1. remote h/o migraine HAs
2. bilateral SDH/hygromas [**4-/2166**] s/p evacuation and resolution;
no Neurologic sequelae except intermittent vertex HAs since that
time, including this week.
3. h/o DM2, but this was apparently related to hydrocortisone
use
for her low back pain; her daughter explained that the patient
stopped requiring any diabetes medications since discontinuing
the hydrocortisone (and also lost 10-20lbs recently).
4. Obesity
5. Hypertension on [**Last Name (un) **], BB, and recently started on CCB (the day
before the headache started).
6. Chronic anemia, on FeSO4 (not taking) and EPO injections
(taking).
7. Depression, on SSRI
8. Hyperlipidemia, no longer taking statin (adverse reaction to
atorvastatin)
9. h/o Gout
10. h/o melanoma
11. h/o "spastic colon" on mesalamine
12. remote surgical history of gastrectomy, T&A, hysterectomy,
"bladder lift"
13. hypothyroidism
14. Low back pain, chronic - takes tramadol ("my favorite"),
formerly experienced better relief with hydrocortisone.
15. Chronic renal failure, which her daughter says was [**2-10**]
adverse reaction to Prilosec. Recently discontinued from
furosemide by Nephrologist due to uremia (per dtr.).
- denies any h/o stroke, TIA, MI, CAD
Social History:
no tobacco, ETOH
Family History:
Family History is notable for many relatives esp. women living
into 90s or 100+ years old.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital signs:
T 98.6F
HR 86, reg
BP 196/119 --> 180-190 / 74 on my exam
RR 24 --> teens on my exam
SaO2 100%
General: Lying in ED stretcher in trauma bay, daughter sitting
next to her. Smiling, remembers me from last week. Appears
comfortable, in NAD.
HEENT: Normocephalic and atraumatic. Surgical pupils
bilaterally.
No scleral icterus. Mucous membranes are moist. No lesions noted
in oropharynx.
Neck: Supple, with minimally restricted range of motion; no
rigidity. No bruits. No lymphadenopathy.
Pulmonary: Lungs CTA. Non-labored.
Cardiac: RRR, normal S1/S2, soft systolic murmur @USB.
Abdomen: Obese. Soft, non-tender, and non-distended.
Extremities: Obese. Warm and well-perfused, no clubbing,
cyanosis, or edema. 2+ radial, DP pulses bilaterally. c/o pain
at
both UE from BP cuff.
*****************
Neurologic examination:
Mental Status exam:
Oriented to person, [**2168**], [**Month (only) 359**], location, reason for
treatment. Some difficulty relating some historical details, as
before; daughter fills in the rest. Attentive, able [**Doctor Last Name 1841**] forward
and backward. Speech was not dysarthric. Repetition was intact.
Language is fluent with intact repetition and comprehension,
normal prosody, and normal affect. There were no paraphasic
errors. Naming is intact to both high and low frequency objects
(watch, band, pen, stethescope). Anterograde memory excellent
[**3-10**]
--> [**3-10**] as before. No evidence of apraxia or neglect or
ideomotor
apraxia; the patient was able to reproduce and recognize
brushing
hair with right hand; used fingers/hand to represent toothbrush
on brushing teeth with left hand. Calculation intact (answers
seven quarters in $1.75 and $0.32). Left-right confusion as
before; touched her left ear with
her left hand instead of R ear with Left hand.
-Cranial Nerves:
I: Olfaction not tested.
II: Surgical, non-reactive pupils bilaterally (old cataracts
procedure). Visual fields are full. Disc sharp and vessels
normal
on the Right; cannot visualize left fundus at this time.
III, IV, VI: EOMs full and conjugate with no nystagmus. No
saccadic intrusion during smooth pursuits. Normal saccades.
V: Facial sensation intact and subjectively symmetric to light
touch V1-V2-V3.
VII: No ptosis, no flattening of either nasolabial fold. Brow
elevation is symmetric. Eye closure is strong and symmetric.
Normal, symmetric facial elevation with smile.
VIII: Hearing intact and subjectively equal to finger-rub
bilaterally; worse hearing loss on Left vs. extinguishes on
Left.
IX, X: Palate elevates symmetrically with phonation.
[**Doctor First Name 81**]: [**5-12**] equal strength in trapezii bilaterally.
XII: Tongue protrusion is midline.
-Motor:
No pronator drift, and no parietal up-drift bilaterally.
Mild resting tremor Left>right, less pronounced than 1wk ago. No
asterixis. Normal muscle bulk and tone, no flaccidity. Mild
hypertonicity of RLE.
Delt Bic Tri WE FF FE IO | IP Q Ham TA [**Last Name (un) 938**] Gastroc
L 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 4* 5 4* 5 5 5
* pain-limited (causes pain in Right lower back)
-Sensory:
No gross deficits to light touch, pinprick, cold sensation
sensation in either upper or distal lower extremity.
Joint position sense minimally impaired in both both great toes
and subtly in RUE (missed nose initially; may have been [**2-10**]
compression from BP cuff which I just deflated before test).
- Cortical sensory testing:
No agraphesthesia or astereoagnosia. No extinction.
-Reflex examination (left; right):
Biceps (++;++)
Triceps (++;++)
Brachioradialis (++;++)
Quadriceps / patellar (++;++)
Gastroc-soleus / achilles (0;0)
Plantar response was mute bilaterally.
-Coordination:
Finger-nose-finger testing with no dysmetria or intention
tremor,
mild tremor. Heel-knee-shin testing with no dysmetria. No
dysdiadochokinesia.
-Gait: deferred, given the labile BP and pt preference
______________________________________________________________
Discharge Examination:
No change from initial examination except for variable
orientation: oriented to name and place but not month, year, or
hospital name.
Pertinent Results:
ADMISSION LABS:
[**2168-10-9**] 08:30AM BLOOD WBC-5.8 RBC-3.96* Hgb-11.8* Hct-33.4*
MCV-84 MCH-29.8 MCHC-35.3* RDW-15.1 Plt Ct-173
[**2168-10-9**] 08:30AM BLOOD Neuts-60.1 Lymphs-26.1 Monos-4.7 Eos-8.6*
Baso-0.6
[**2168-10-10**] 03:59AM BLOOD PT-11.5 PTT-21.7* INR(PT)-1.0
[**2168-10-9**] 08:30AM BLOOD Glucose-138* UreaN-34* Creat-1.4* Na-139
K-5.2* Cl-109* HCO3-20* AnGap-15
[**2168-10-10**] 03:59AM BLOOD ALT-12 AST-14 CK(CPK)-288* AlkPhos-112*
TotBili-0.3
[**2168-10-10**] 03:59AM BLOOD Albumin-4.2 Calcium-10.2 Phos-2.6* Mg-2.0
[**2168-10-10**] 03:59AM BLOOD TSH-4.9*
DISCHARGE LABS:
Na 139, K 4.5, Cl 107, HCO3 20, BUN 35, Cr 2.2
WBC 5.2, Hgb 10.3, Plt 139
IMAGING:
CT HEAD [**2168-10-9**]:
IMPRESSION:
1. Post-SDH evacuation changes in the bilateral frontal
calvarium.
2. No intracranial hemorrhage.
CXR [**2168-10-9**]:
Heart size is normal. Mediastinum is normal. Lungs are
essentially clear.
There is no pleural effusion or pneumothorax. Elevation of left
hemidiaphragm is unchanged.
Brief Hospital Course:
[**Known firstname 2127**] [**Known lastname 1968**] is a [**Age over 90 **] yo woman with PMHx of bilateral SDH/hygromas
in [**2166**] s/p evacuation and resolution, DM, HTN, HL and
hypothyroidism who presented with HA x2 weeks and hypertensive
urgency, thought to be causing the headaches.
.
# Neurologic: patient was initially on a nicardipine gtt, but
this was able to be stopped on [**10-10**]. We initially continued her
on verapamil SR 120mg that was started prior to her admission as
well as her home valsartan. We increased her toprol XL dose and
restarted her on lasix 20mg to help control her BP. She refused
BP checks with a cuff because they were "too painful".
Therefore, we kept her in the ICU to have her BP monitored with
an A-line. She was started on clonidine as well for blood
pressure management and was transferred from the ICU to the
floor. She developed orthostasis the next day, but this resolved
quickly with intravenous fluids and the holding of her blood
pressure medications. We decided on a final regimen of
metoprolol succinate (50mg XL), clonidine (0.1 [**Hospital1 **]), and
valsartan (home dose, 320 mg daily) for her blood pressure
management.
# Cardiovascular: she did not have any events on telemetry
while here. Her HR remained stable in the 70's after we
increased her Toprol XL dose from 25->50mg QD. We restarted her
lasix after discussing this with her outpatient nephrologist
(who was previously prescribing it). This helped to control her
BP and her HA's.
# Infectious Disease: pt had a U/A with WBCs and leukocytes but
no bacteria, so we waited to see if the UCx grew anything before
considering ABx as she was not symptomatic.
# Hematology/Oncology: patient has known mild anemia, is on EPO
as an outpatient. Her HCT remained stable throughout this
hospitalization.
# Endocrine: we continued patient's L-thyroxine, however her TSH
was mildly elevated at 4.9. Her free T4 was 1.2 (normal).
# Nephrology/Urologic: pt has known chronic kidney disease,
which began with Prilosec treatment and per daughter plateaued
and improved after withdrawal of this medication. We monitred
her potassium and BUN/Cr, which remained increased after
starting furosemide, likely also with a contribution of volume
depletion. We stopped her furosemide and will not restart this
medication at this time.
# CODE/CONTACT: DNR/[**Name2 (NI) 835**] requested by pt; daughter [**Telephone/Fax (1) 99907**]
TRANSITIONAL CARE ISSUES:
[ ] She will need her BP monitored and her BUN + Cr monitored to
ensure that they stay within her baseline ranges.
[ ] Please recheck her electrolytes to monitor her potassium and
creatinine.
[ ] She will be going to rehab for a short course for physical
therapy to improve her gait stability.
Medications on Admission:
1. verapamil SR 120mg daily (started earlier this week)
2. Procrit
3. Fiorinal 50/325/100 - PRN for headaches (takes < 1/day)
4. Motrin ?600mg OTC - PRN for headaches (takes 1+ per day q8+h)
5. tramodal 50mg PRN for back pain (takes < 1/day)
6. valsartan (Diovan) for HTN 320mg daily
7. sertraline (Zoloft) for mood 25mg daily
8. ondansetron (Zofran) 4mg PRN for nausea (took a few this wk)
9. metoprolol-succinate (XR) 25mg daily (?for HTN)
10. mesalamine 400mg q8h for GI discomforts
11. pantoprazole (Protonix) 40mg daily
12. folic acid 1mg daily
13. MVI daily
14. vit D qSun
15. levothyroxine 100mcg daily
* [ amlodipine 5mg daily --> started this past Monday, [**2168-9-28**] ]
* [ furosemide 40mg qod discontinued 2wks ago by nephrologist
due
to uremia, per daughter ]
* [ gemfibrozil 400mg tid & glipizide 5mg daily discontinued
recently by PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) 8472**] [**Name Initial (NameIs) **] while ago due to improved blood
sugar and A1c down to 6% after stopping hydrocortisone for back
pains ]
Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for low back pain (home med).
2. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
as needed for hypertension (home med/dose).
3. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for mood (home med).
4. mesalamine 250 mg Capsule, Extended Release Sig: Four (4)
Capsule, Extended Release PO TID (3 times a day) as needed for
GI discomfort (home med).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for home med.
6. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) as needed for hypothyroidism (home med/dose).
7. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK ([**Doctor First Name **]).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for gerd.
9. Ondansetron 4 mg IV Q8H:PRN nausea
(takes 4mg ODT at home PRN)
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for home med.
11. clonidine 0.1 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day: for management of
blood pressure.
12. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: for
control of blood pressure.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Care - [**Location (un) 47**]
Discharge Diagnosis:
Primary: Hypertensive Urgency
Secondary: Chronic Headaches, History of Subdural Hematomas
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic: Oriented to name and place but not hospital name or
month/year. Otherwise no focal deficits.
Discharge Instructions:
Dear Ms. [**Known lastname 1968**],
You were seen in the hospital because of headaches and high
blood pressure. While here we controlled your blood pressure,
initially on intravenous medications, and then on oral
medications. Your blood pressure improved, and when this
happened, your headaches also improved.
We made the following changes to your medications:
1. We would like you to continue taking VALSARTAN 320 MG by
mouth DAILY for control of your blood pressure.
2. We would like you to take a higher dose of metoprolol. The
new dose will be METOPROLOL SUCCINATE (extended-release) 50 MG
by mouth DAILY.
3. We would like you to take a new blood pressure medication
called CLONIDINE 0.1 MG by mouth TWICE DAILY. This is a very
strong blood pressure medication. It is very important to adhere
to the twice daily scheduling of this medication as not taking
this medication can cause a quick rise in your blood pressure.
4. Please STOP taking the medication FUROSEMIDE.
5. Please STOP taking the medication VERAPAMIL.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
Department: NEUROLOGY
When: WEDNESDAY [**2168-11-9**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"585.9",
"300.00",
"V15.81",
"V49.86",
"276.50",
"564.1",
"244.9",
"403.90",
"276.7",
"530.81",
"784.0",
"285.21",
"311",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
15544, 15632
|
10313, 12755
|
286, 318
|
15766, 15766
|
9289, 9289
|
17365, 17721
|
4953, 5046
|
14163, 15521
|
15653, 15745
|
13102, 14140
|
16059, 16395
|
9881, 10290
|
6912, 9270
|
5086, 5892
|
16424, 17342
|
237, 248
|
12781, 13076
|
346, 3652
|
9306, 9864
|
15781, 16035
|
5917, 6895
|
3674, 4902
|
4918, 4937
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,624
| 183,092
|
43895
|
Discharge summary
|
report
|
Admission Date: [**2125-12-15**] Discharge Date: [**2125-12-19**]
Date of Birth: [**2063-10-15**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 60-year-old man with
type 2 diabetes, history of high cholesterol and a recent
admission in [**Month (only) 359**] for DKA, who was brought to the
Emergency Room after being found by landlord (patient has no
family and minimal social support). Per patient, he
are unclear. The patient states there was no loss of
consciousness but he was found lethargic, somewhat obtunded,
did not take pills or insulin for the last 36 hours before
admission. The patient was brought to the Emergency Room.
Initially white count 12, 89% polys, anion gap of 21. New
acute renal failure with creatinine of 6.4. ABG equalled
7.25, 32 and 70, CK 9,419, MB 81, troponin negative.
acetone. A Foley was placed with urine output of 900 cc.
The initial blood sugar was 309. The patient was started on
insulin drip. Overnight the patient continued to have anion
gap acidosis with decreasing blood sugar. Large amount of
acetone in serum as well. The patient received 7 liters of
normal saline with 3 liters of output. The patient was
hypertensive and tachycardic on admission.
PAST MEDICAL HISTORY: Type 2 diabetes mellitus and secondary
neuropathy, history of DKA in [**2125-10-2**], high cholesterol,
hypertension, chronic low back pain, depression, atypical
chest pain status post t mibi in [**10-3**] which showed an EF of
55% and normal perfusion. Question of rheumatic fever.
Neurogenic bladder.
MEDICATIONS: Glucophage 500 mg [**Hospital1 **] , Propranolol 40 mg [**Hospital1 **],
NPH 30 units q h.s., Regular insulin sliding scale, Paxil 60
mg q d, Gemfibrozil 600 mg [**Hospital1 **] and Percocet [**1-3**] q 4-6 hours
prn.
ALLERGIES: Penicillin, Sulfa, Erythromycin and iodine.
PHYSICAL EXAMINATION: Temperature 98.7, pulse 120, blood
pressure 164/100, respiratory rate 20, O2 saturation 95% on
room air. In general, the patient was awake, alert and
oriented to person, place and time but waxes and wanes per
staff. HEENT: Pupils equal, round and reactive to light,
mucus membranes dry, oropharynx clear. Neck, JVP at 8 cm,
right IJ catheter in place. Heart, tachycardic, normal S1
and S2 and a 2/6 systolic murmur at the lower sternal border.
Lungs, scattered crackles, decreased breath sounds in the
left lower lobe. Abdomen, obese, nontender, nondistended,
normal active bowel sounds, no hepatosplenomegaly.
Extremities, mild bilateral lower extremity edema. Neuro,
mild asterixis. Motor [**5-6**] bilaterally in all extremities.
Reflexes brisk knee jerk.
LABORATORY DATA: Revealed on discharge a hematocrit of 31.5,
white count of 7.7, platelet count 451,000, INR 1.0, PT 12.4,
PTT 21.3, creatinine 1.3 on discharge, however, it had peaked
at 6.6 and progressively decreased. BUN 25 on discharge.
Potassium 3.9. The last CK was 851, downtrending from the
9,419. GGT 13, calcium 8.2, phosphorus 2.5, magnesium 1.5
but repleted, TSH 0.12, free T4 0.8, T3 pending. Hep surface
antigen negative. Hep surface antibody positive. Hepatitis
A antibody positive. Hep C antibody negative. Blood
cultures showed no growth. Urine culture contaminated. CT
on admission showed no evidence of intracranial hemorrhage
and chest x-ray on admission showed left lower lobe
consolidation suggestive of pneumonia. A renal ultrasound on
[**2125-12-15**] showed hydronephrosis of the right kidney but a
follow-up renal ultrasound on [**2125-12-18**] showed no evidence of
hydronephrosis in either kidney and a simple cyst in the
right kidney.
HOSPITAL COURSE: The patient was treated in the MICU for DKA
and as the anion gap resolved, the patient was discharged to
the floor on [**2125-12-16**]. The patient also had evidence of
rhabdomyolysis with high CK and a flat MB and troponin. The
patient had acute renal failure probably secondary to
hypovolemia from DKA as well as post obstructive from
neurogenic bladder and unable to urinate and in addition,
probably toxicity from rhabdo. The patient's creatinine
continued to fall with hydration and was 1.3 on discharge.
The patient's blood sugar remained somewhat elevated
throughout the admission and the patient was started on
Glargine and titrated up to 35 units q h.s. On discharge the
patient also remained on a regular insulin sliding scale.
For the patient's pneumonia the patient started on a 7 day
course of Levaquin 250 mg po q d which can be titrated up
according to improved renal function. The patient can also
be restarted on his ACE inhibitor prior to discharge as he
has now normal renal function.
For the neurogenic bladder the patient has been extensively
worked up for this and usually straight caths himself at
home. A Foley was kept in place throughout the admission and
will be discontinued in rehab.
The patient was also found to have elevated hepatic enzymes
with an ALT of 217, AST 123, alkaline phosphatase 56, total
bilirubin of 0.3 on [**2125-12-15**]. The patient's hepatitis
serologies were sent. The patient appears to have been
infected with hepatitis A at some point. This is unknown
whether this infection had been recent and had contributed to
the patient's presentation or not. The patient's TSH was
also checked and found to be .12. However, the free T4 was
low normal. These TFTs should be followed as an outpatient.
As for the rhabdomyolysis, it resolved with hydration and the
patient's CKs were downtrending. The patient was in good
condition on discharge and will follow-up with Dr. [**Last Name (STitle) **]
as an outpatient. The patient is discharged to rehab on
[**2125-12-19**].
DISCHARGE MEDICATIONS: Guaifenesin 10 ml q 6 hours prn,
Senna one tablet q d, Colace 100 mg [**Hospital1 **], Tylenol q 4-6 hours
prn, Trazodone 25 mg q h.s. prn, Protonix 40 mg q d, Glargine
35 units q h.s., Regular insulin 10 units at dinner, Regular
insulin sliding scale, Percocet 1-2 tabs q 4-6 hours prn,
Propranolol 40 mg tid and Levofloxacin 250 mg po q d through
[**2125-12-22**] to complete a 7 day course.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**]
Dictated By:[**Last Name (NamePattern1) 23892**]
MEDQUIST36
D: [**2125-12-18**] 17:33
T: [**2125-12-18**] 19:30
JOB#: [**Job Number 94240**]
|
[
"250.10",
"728.89",
"486",
"584.9",
"357.2",
"276.5",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5699, 6376
|
3640, 5675
|
1876, 3622
|
162, 1235
|
1258, 1853
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,174
| 135,414
|
42599
|
Discharge summary
|
report
|
Admission Date: [**2127-11-25**] Discharge Date: [**2127-11-30**]
Date of Birth: [**2077-7-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tree Nut
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
decline in activity tolerance
Major Surgical or Invasive Procedure:
s/p coronary artery bypass grafting x4 (left internal mammary
artery ->Left anterior descending/saphenous vein
grafted->diagnal/Obtuse Marginal/posterior descending artery)on
[**2127-11-25**]
History of Present Illness:
50 year old male with a strong family
history of heart disease reports symptoms of acid reflux dating
back twenty years. He describes his symptoms as a powerful knot
felt around the middle of the neck near the collarbone and
tightness in the upper epigastric area. He has not had these
symptoms in the past year. He also describes a decline in
activity tolerance compared to a year ago. A nuclear ETT dated
[**2127-11-6**] was positive for ST changes, frequent ectopy and an LVEF
of 30% with evidence of both infarct and ischemia. He was
referred for left heart catheterization. He was found to have
three vessel disease and is now being referred to cardiac
surgery
for revascularization.
Past Medical History:
Inferior MI
Hyperlipidemia
GERD
Rhinitis
Cervical disc disease/stenosis
Obesity
Right inguinal hernia (to have consultation on [**2127-11-19**])
Intermittent migraines with blurred vision
Hit by a car [**2098**] since has had occasional Right knee edema
Past Surgical History:
Laparoscopic appendectomy
Social History:
Race:Caucasian
Last Dental Exam: [**2127-5-30**]
Lives with:wife
Contact: [**Name (NI) 717**] [**Name (NI) 3175**] (wife) [**Telephone/Fax (1) 92157**]
Occupation:Attorney
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-6**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Family History:Premature coronary artery disease- Father had an
MI at age 62. 50 year old brother had an MI about one year ago,
s/p failed CABG. He underwent heart transplant 8-9 months later.
Physical Exam:
Admission Physical Exam:
Pulse:61 Resp:16 O2 sat:100/RA
B/P Right:138/85 Left:128/72
Height:6'1" Weight:221 lbs
General:NAD, alert, 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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left:+1
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +1 Left:+1
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2127-11-28**] WBC-8.1 RBC-3.78* Hgb-11.6* Hct-33.0* MCV-87 MCH-30.7
MCHC-35.2* RDW-12.5 Plt Ct-160
[**2127-11-25**] WBC-7.8 RBC-3.62* Hgb-11.2* Hct-31.4* MCV-87 MCH-31.1
MCHC-35.8* RDW-12.6 Plt Ct-162
[**2127-11-26**] PT-13.3* PTT-29.9 INR(PT)-1.2*
[**2127-11-25**] PT-16.4* PTT-28.7 INR(PT)-1.5*
[**2127-11-28**] UreaN-12 Creat-0.8 Na-141 K-3.6 Cl-106
[**2127-11-25**] UreaN-11 Creat-0.8 Na-143 K-4.1 Cl-113* HCO3-24
[**2127-11-30**] Na-142 K-4.8 Cl-107 Mg-2.3
Echocardiographic Measurements [**2127-11-25**]
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *7.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 25% to 30% >= 55%
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Severely depressed LVEF.
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is severely depressed
(LVEF= 25 - 30 %). There is global HK, with akinesis of the
inferior wall.
The RV is mildly dilated and is mildly HK.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is A-Paced, on no inotropes.
Biventricular systolic fxn is unchanged.
Aorta intact.
Brief Hospital Course:
On [**2127-11-25**] Mr.[**Known lastname 13130**] was taken to the operating room and
underwent coronary artery bypass grafting x4 (left internal
mammary artery ->Left anterior descending/saphenous vein
grafted->diagnal/Obtuse Marginal/posterior descending
artery)with Dr.[**Last Name (STitle) **]. Please see operative report for further
details. Cross clamp time=65 minutes. Cardiopulmonary bypass
time:79 minutes. He tolerated the procedure well and was
transferred to the CVICU intubated and sedated. He awoke
neurologically intact and weaned to extubation. All lines and
drains were discontinued per protocol. He was started on
beta-blocker/statin/aspirin and diuresis. On POD#1 he was
transferred to the step down unit for further monitoring. He was
started on a 7 day course of Indomethicin and Colchine for
pericarditis. Physical Therapy was consulted for evaluation of
strength and mobility. He continued to progress. The remainder
of his hospital course was essentially uneventful. On POD5 he
was discharged to home with VNA. All follow up appointments were
advised.
Medications on Admission:
FLUTICASONE 50 mcg Spray, Suspension - 1 spray PRN
LISINOPRIL 5 mg Daily
METOPROLOL SUCCINATE 25 mg Daily
NITROGLYCERIN 0.4 mg Tablet, Sublingual- 1 Tablet sublingually
every five minutes for chest discomfort. Call 911 if pain
persists longer than 15 minutes
OMEPRAZOLE 40 mg Daily
ROSUVASTATIN [CRESTOR] 20 mg Daily
ASPIRIN 81 mgDaily
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. 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*
4. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*5 Tablet(s)* Refills:*0*
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day): take 40
mg twice daily for 1 week then 40 mg daily.
Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 1 weeks.
Disp:*21 Capsule(s)* Refills:*0*
9. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*5 Tablet(s)* Refills:*0*
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**3-5**]
hours as needed for pain/temp.
11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**3-5**]
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day for 5 days.
Disp:*5 Capsule, Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p coronary srtery bypass grafting x4
Coronary artery disease
Inferior MI
Hyperlipidemia
GERD
Rhinitis
Cervical disc disease/stenosis
Obesity
Right inguinal hernia (to have consultation on [**2127-11-19**])
Intermittent migraines with blurred vision
Hit by a car [**2098**] since has had occasional Right knee edema
Past Surgical History:
Laparoscopic appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
**Please call 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: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2128-1-7**] at 1:00 [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
Cardiologist: Yamini Levitzky on [**12-26**] at 2:40
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 68410**] in [**12-1**] 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:[**2127-11-30**]
|
[
"412",
"278.00",
"414.01",
"530.81",
"428.22",
"413.9",
"723.0",
"423.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
7808, 7857
|
4846, 5925
|
307, 501
|
8267, 8494
|
2837, 4823
|
9263, 9890
|
1919, 2100
|
6312, 7785
|
7878, 8195
|
5951, 6289
|
8518, 9240
|
8218, 8246
|
2140, 2818
|
237, 269
|
529, 1220
|
1242, 1496
|
1563, 1888
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,059
| 139,329
|
34981
|
Discharge summary
|
report
|
Admission Date: [**2108-10-20**] Discharge Date: [**2108-10-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
L TLC Central Line placement
History of Present Illness:
Ms. [**Known lastname 61106**] is a [**Age over 90 **] year old female with a PMH significant for
dementia, HTN, colon CA s/p colectomy admitted on [**10-20**] for
bilateral shoulder pain for several days and tachycardia to 120s
with associated lightheadedness. On initial presentation to the
ED, she was noted to be in atrial fibrillation with RVR with an
old LBBB and received IV diltiazem with conversion to NSR.
.
Since her admission, the patient has ruled in for NSTEMI with
peak cardiac biomarkers of CK 379, MB 61, and TnT 1.43 ([**10-20**],
11:55 pm). She was started on ASA, plavix, heparin gtt,
metoprolol, losartan, plavix, and atorvastatin. In addition,
the patient was noted to be hypertensive to SBP 170s, so was
placed on a nitro gtt. Of note, initial family was held with
the decision for the patient to be made DNR/DNI with medical
management and no cardiac catheterization. This morning, the
patient was noted to have a hematocrit of 35.4 from 40, and this
evening she was noted to several large grossly blood bowel
movements with associated hypotension with a SBP nadir in the
60s with a hct of 29.2. She was also noted to have
approximately 50 cc of hematemesis. After discussion with the
family, the patient was initially confirmed to be DNR/DNI with
the additional decision for no escalation of care. However,
this was changed upon further discussion with the [**Hospital1 1516**] team with
the decision to place a CVL and consult GI for possible
endoscopy/colonscopy. She received 4L IVF and 2 units PRBC on
the floor with improvement in her BP from 90s/60s to 180/100,
and was transferred to the CCU for further management.
.
Currently, the patient is resting comfortably without
complaints. Denies any CP/SOB,f/c/s, n/v/d, abd pain, HA.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias. She
denies recent fevers or chills. All of the other review of
systems negative.
.
Cardiac review of systems was significant for absence of dyspnea
on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema.
Past Medical History:
1. CARDIAC RISK FACTORS: +Hypertension
2. CARDIAC HISTORY:
-CABG: None reported
-PERCUTANEOUS CORONARY INTERVENTIONS: None reported
-PACING/ICD: None reported
3. OTHER PAST MEDICAL HISTORY:
-history of Colon CA (s/p colectomy)
-hypertension
-hard of hearing
-osteoarthritis
-mild dementia
-MR [**First Name (Titles) **] [**Last Name (Titles) **].
Social History:
Has lived in [**Hospital 100**] Rehab for the past 14 months.
-Tobacco history: Reports a remote tobacco history; quit smoking
in her 40's.
-ETOH: Socially; hasn't had a drink in a while
Family History:
Brother with a CVA; another brother colon CA; a sister with
unspecified colon problems. Reports no FHx of heart disease or
DM.
Physical Exam:
VS: 99.5 83 200/95 26 97%2L nc
Gen: Age appropriate female.
HEENT: PERRL, EOMI, sclerae anicteric. MMM, OP clear without
lesions, exudate, or erythema. Neck supple without
lymphadenopathy.
CV: Regular S1+S2, III/VI late peaking systolic murmur
throughout the precordium loudest at the RUSB radiating to the
carotids. II/VI diastolic murmur at the apex.
Pulm: Bilateral early inspiratory crackles at the base
Abd: S/NT/ND +bs
GU: Deferred given grossly bloody BM on floor
Ext: No c/c/e, 1+ dp/pt bilaterally
Neuro: Oriented to person.
Pertinent Results:
On admission:
WBC-8.8 RBC-4.30 Hgb-12.9 Hct-40.5 MCV-94 MCH-30.0 MCHC-31.8
RDW-14.7 Plt Ct-170
NEUTS-88.9* LYMPHS-8.4* MONOS-2.2 EOS-0.2 BASOS-0.3
PT-12.4 PTT-22.6 INR(PT)-1.0
Glucose-128* UreaN-22* Creat-1.1 Na-140 K-4.1 Cl-104 HCO3-23
AnGap-17
CK-MB-61* MB Indx-16.1* cTropnT-1.43*
On discharge:
WBC-10.7 RBC-3.77* Hgb-11.7* Hct-34.6* MCV-92 MCH-31.1 MCHC-33.9
RDW-15.0 Plt Ct-137*
Glucose-119* UreaN-25* Creat-0.9 Na-140 K-3.7 Cl-113* HCO3-20*
AnGap-11
Calcium-7.4* Phos-1.5* Mg-1.5*
CK-MB-13* MB Indx-5.7 cTropnT-0.81*
Triglyc-103 HDL-49 CHOL/HD-2.4 LDLcalc-46
Type-ART pO2-94 pCO2-28* pH-7.44 calTCO2-20* Base XS--3
Imaging:
ECHO [**2108-10-22**]
The left atrium is mildly dilated. The interatrial septum is
aneurysmal. The estimated right atrial pressure is 0-5 mmHg.
There is moderate 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%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is a mild resting left ventricular outflow
tract obstruction. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output
and increased stroke volume due to aortic regurgitation. Mild to
moderate ([**1-27**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is moderate thickening of
the mitral valve chordae. There is systolic anterior motion of
the mitral valve leaflets. Mild to moderate ([**1-27**]+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a fat pad.
IMPRESSION: Moderate left ventricular hypertrophy with normal
systolic function. There is a mild left ventricular resting
outflow gradient. Mild to moderate aortic regurgitation. Mild to
moderate mitral regurgitation. Moderate estimated pulmonary
artery systolic hypertension.
CT Head [**2108-10-23**]
1. No evidence of acute intracranial abnormalities.
2. Small chronic lacunar infarction in the left lentiform
nucleus. Moderate chronic small vessel ischemic disease.
CXR [**2108-10-24**]
FINDINGS: As compared to the previous examination, today's
radiograph shows slightly increased interstitial markings as
well as newly appeared Kerley B lines. Overall, the changes
suggest increased interstitial fluid content consistent with
moderate pulmonary edema. The size of the cardiac silhouette is
unchanged. On the right, the costophrenic sinus is blunted,
there might be a small pleural effusion. No newly acquired focal
parenchymal opacity suggesting pneumonia. Unchanged course and
position of the central venous access line.
Brief Hospital Course:
Pre-ICU Course:
[**Age over 90 **] y/o F with PMHx significant for HTN, colon CA (s/p
colectomy), hearing loss, and mild dementia who presented with
new-onset atrial fibrillation that was noted at [**Hospital 100**] Rehab on
the morning of presentation. Converted back to sinus rhythm
after administration of IV diltiazem.
# Atrial Fibrillation / NSTEMI - On arrival to the floor, the
patient was back in sinus rhythm. The patient denied any
current or previous chest pain. A TSH was sent and was within
normal limits. Additionally, cardiac enzymes were followed.
The first set of cardiac enzymes showed a slight elevation of
troponin to 0.10, which was initially attributed to demand
ischemia in the setting of a.fib with RVR. However, overnight,
the patient's second set of cardiac enzymes showed a significant
rise. Troponin was now 1.43. The patient was loaded with
plavix, started on a heparin drip, and started on a high-dose
statin. The following morning, the patient triggered for
hypertension to the 210's. She was given IV labetalol and
started on a nitroglycerin drip. Her pressure then decreased to
the 90's, but she was asymptomatic. Nitroglycerin drip was
stopped. The [**Hospital 228**] medical situation was discussed with the
family and the decision was made to likely not pursue cardiac
catheterization and to treat the patient medically. Later in
the afternoon, the patient triggered for hypotension,
diaphoresis, and weakness while she was walking back from the
urinating in the bathroom. The hypotension quickly resolved
with positioning the patient in the Trendelenberg position.
This episode was initially thought to be vagal in nature.
Several hours later, however, the patient was noted by nursing
to have a large, loose bloody stool, with subsequent drop in SBP
to the 70's. At that point, all of the patient's
antihypertensives as well as her heparin drip and plavix with
stopped. She was ultimately transferred to the CCU for further
management (see GI bleed section below)....
# GI Bleed - Overnight, on the night of admission, the patient
ruled in for ACS and was loaded with plavix and started on a
heparin drip. In the afternoon of the following day, the
patient was noted by her nurse to have a large, loose bloody
bowel movement with subsequent drop in SBP to the 70's. At that
point, the patient was given NS at a maximal rate and the IV
nurse [**First Name (Titles) **] [**Last Name (Titles) **] to obtain better IV access. After several
attempts, the best access obtainable by the IV nurse was one 20G
IV in the right forearm. The CCU team was also called. The
family was called and consented to administration of blood
products but said that they did not want further escalation of
care (including a central line). The decision was made at that
point to keep the patient on the floor. During this time, the
patient had several large dark bloody liquid stools. She also
had an episode of hematemesis of approximately 50 cc. On
further discussion after the patient's family arrived, the
became amenable to CVL placement, endoscopy, and possible
administration of pressors. By that point, the patient had
received 2 L NS and was receiving her 1st unit of blood. She
was transferred to the CCU for further management....
.
CCU COURSE -
In the CCU, patient was transfused 4 units of PRBCs and
rescuscited with 5LNS. The patient's pressures stabilized as
well as did her hematocrit. An EGD was done, which was negative
for bleed. ICU course was complicated by labile hypertension
with SBP in 200s that needed to be controlled with a nitro gtt.
Because the patient's hematocrit remained stable >72 hours, a
colonscopy was deferred to be done as an outpatient. The patient
returned to the floor with stable vitals, stable hematocrits.
POST ICU COURSE
GIB: Pt without significant bleeding. Hct remained stable for
>48 hours.
Coronaries: Pt remained without chest pain the remainded of the
admission.
Rhythm: Pt back in sinus with atrial ectopy, suggestive pre
atrial fibrillation. If patient converts to a fib again, would
recommend considering amiodarone. Pt currently on Carvedilol
25mg PO BID for rate and BP control.
HTN: Pt with longstanding labile hypertension, intractable to
multiple medications. Was treated with Carvedilol 25mg PO BID
and then bottomed out to 70s/40s, asymptomatic. Was given some
IVF and BP responded nicely.
Pump: However, after 1.5L of NS for hypotension, pt was a bit
fluid overloaded with elevated JVP and pulmonary edema on CXR.
Was given Lasix 20mg IV on day of discharge with improvement of
symptoms, however could still benefit from further diuresis.
Headache: Pt with headache in setting of significant HTN.
Neurologic exam completely normal. CT head negative for e/o
bleed. HA resolved with tylenol/codeine.
DNR/DNI: Pt and family still interested in minimally invasive
procedures such as colonoscopy and EGD.
Medications on Admission:
MEDICATIONS (Home):
losartan 150 mg daily
metoprolol succinate 50 mg daily
poly iron 150 mg daily
tylenol [**Hospital1 **] 975
ca carbonate 1300 mg daily
vitamin D2 once a week (last time 21st)
sodium fluoride 10 ml swish and spit at bedtime
.
MEDICATIONS (Transfer):
Acetaminophen 325-650 mg PO Q6H:PRN pain
Atorvastatin 80 mg PO DAILY
Calcium Carbonate 1250 mg PO DAILY
Iron Polysaccharides Complex 150 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO once a day.
2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Tylenol 325 mg Tablet Sig: Three (3) Tablet PO twice a day.
5. Fluorigard 0.05 % Solution Sig: Ten (10) mL Dental at
bedtime.
6. Poly-Iron 150 mg Capsule Sig: One (1) Capsule PO once a day.
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
10. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary:
A fib in rapid ventricular rate
Non-ST elevation myocardial infarction
Lower gastrointestinal tract bleed
Labile Hypertension
Discharge Condition:
Stable vitals, afebrile.
Discharge Instructions:
You came to the emergency department for shoulder pain. You were
found to have a very fast and irregular heart rate called atrial
fibrillation and were admitted to the cardiology floor. During
this time, you were also found to have a small heart attack. You
were treated medically with blood thinners, however during this
treatment you developed bleeding from your gastrointestinal
tract. You received 4 units of blood and 5 liters of IV fluids.
An upper gastrointestinal (GI) scope was negative for a source.
Because your blood counts remained stable for more than 72
hours, and because the blood thinners were stopped, the acute
bleed was thought to have ceased and you are to follow up with
GI in 4 weeks.
We have made several changes to your medications:
STOP taking Metoprolol 50mg by mouth daily
STOP taking Losartan 150mg by mouth daily
START taking Aspirin 81mg by mouth daily
START taking Carvedilol 6.25mg by mouth twice a day
START taking Furosemide (Lasix) 10mg by mouth once a day
START taking Potassium 20mEq by mouth once a day
If you develop any chest pain, shortness of breath, fevers, or
any symptoms that are concerning to you, please come to the
emergency department immediately.
Followup Instructions:
You have an appointment with Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2108-11-13**] 9:40 on [**Last Name (NamePattern1) 439**]
[**Location (un) **] of [**Hospital Unit Name **].
Dr.[**Name (NI) 80012**] office has been in touch with [**Hospital 100**] Rehab and
will call you there to set up a follow up cardiology appointment
for you.
Completed by:[**2108-10-25**]
|
[
"396.3",
"427.31",
"414.01",
"578.9",
"428.33",
"428.0",
"V10.05",
"410.71",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
13021, 13086
|
6858, 11775
|
273, 303
|
13265, 13292
|
3729, 3729
|
14543, 14999
|
3030, 3158
|
12242, 12998
|
13107, 13244
|
11801, 12219
|
13316, 14047
|
3173, 3710
|
2519, 2619
|
4033, 6835
|
14076, 14520
|
224, 235
|
331, 2438
|
3744, 4018
|
2650, 2809
|
2460, 2499
|
2826, 3014
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,443
| 156,106
|
17480
|
Discharge summary
|
report
|
Admission Date: [**2198-3-28**] Discharge Date: [**2198-4-18**]
Date of Birth: [**2145-8-24**] Sex: M
Service: [**Hospital1 **]
CHIEF COMPLAINT: Fall/compartment syndrome.
HISTORY OF THE PRESENT ILLNESS: The patient is a 52-year-old
male with a history of seizure disorder, history of DVT, history
of hypertension, cellulitis, lower extremity peripheral edema,
who is status post fall on his left leg. He presented with a
large anterolateral hematoma on the leg in the setting of an INR
of 5.0.
The patient had been evaluated by Orthopedics. He had lateral
compartment syndrome and had a compartment syndrome release. The
release was stable but there was still a question of recurrent
anterior and lateral compartment pressure.
The patient has a history of deep venous thrombosis but not
being anticoagulated.
PAST MEDICAL HISTORY:
1. Seizure.
2. DVT.
3. Hypertension.
4. Cellulitis.
5. Lower extremity edema.
ALLERGIES: The patient has no known drug allergies.
HOME MEDICATIONS:
1. Atenolol 50 mg p.o. q.d.
2. K-Dur 20 mg p.o. b.i.d.
3. Tegretol 600 mg p.o. b.i.d.
4. Lasix 50 mg p.o. b.i.d.
5. Coumadin, dose unclear.
HOSPITAL COURSE: The patient was transferred to Medicine. Of
note, the patient has a IVC filter in place. He had been spiking
temperatures to 101.5 and cultures were drawn through the course
for administration. During the hospital admission, the chest x-
ray was normal. Urinary tract infection with Pseudomonas was
treated with Ceftaz times seven days.
On [**2198-4-3**], the patient went to the OR for debridement of his
left lower leg wound. On [**2198-4-5**], the patient continued to be
febrile. He was continued on antibiotics, status post incision
and drainage and VAC dressing placement following the
debridement.
On [**2198-4-9**], the patient was noted to have mechanical SBO on CT
and NG tube was placed. The patient was hydrated and his
electrolytes were replaced. In addition, a Dilantin loading dose
was provided on [**2198-4-9**].
On [**2198-4-12**], the patient continued to be febrile. On [**2198-4-13**],
the patient went to the OR for draining of his left knee hematoma
and the placement of a graft. At that time, his central line was
placed given the possible source of infection.
On [**2198-4-13**], the patient was afebrile. On [**2198-4-18**], the
VAC was removed and the patient was cleared by Plastics to
ambulate for 15 minute intervals four to five times per day, to
sit in a chair with leg elevated above the heart.
DISCHARGE STATUS: The patient is discharged to rehabilitation.
DISCHARGE CONDITION: Fair.
DISCHARGE DIAGNOSIS: Compartment syndrome, status post graft
placement.
DISPOSITION: The patient was discharged to rehabilitation.
DISCHARGE MEDICATIONS:
1. Phenytoin 300 mg p.o. t.i.d.
2. Promethazine HCL 25 mg p.o. q. six hours.
3. Carbamazepine 60 mg p.o. b.i.d., [**4-13**]
4. Morphine sulfate 2-6 mg IV q. four.
5. Ascorbic acid 500 mg p.o. b.i.d.
6. Ondansetron 8 mg IV q. six hours p.r.n. nausea.
7. Heparin 5,000 units subcutaneously q. eight.
8. Percocet one to two tablets p.o. q. four to six.
9. Tylenol 325 to 650 mg p.o. q. [**4-29**].
10. Atenolol 50 mg p.o. q.d.
11. Heparin 50 mg p.o. q.d.
DISCHARGE INSTRUCTIONS/RECOMMENDATIONS: See page 1.
FOLLOW-UP:
1. The patient is to follow with Plastics on [**2198-5-1**]
between 9:00 a.m. and 11:00 a.m.
2. Check Dilantin levels and adjust Dilantin biweekly.
3. Ambulate 15 minutes q. five times a day.
4. Wound care per nursing instructions.
5. Physical therapy and OT therapy recommended.
DISCHARGE CONDITION: Stable.
Of note, the patient has a cousin who makes his decisions for
him.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 4814**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2198-5-6**] 05:34
T: [**2198-5-6**] 19:34
JOB#: [**Job Number 48827**]
|
[
"780.39",
"560.9",
"682.6",
"958.8",
"317",
"E888.9",
"285.1",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"83.14",
"86.69",
"83.45",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
3605, 3919
|
2771, 3583
|
2635, 2748
|
1177, 2585
|
1013, 1159
|
163, 835
|
857, 995
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,632
| 154,010
|
14298
|
Discharge summary
|
report
|
Admission Date: [**2199-7-5**] Discharge Date: [**2199-7-10**]
Date of Birth: [**2123-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
CHF/Edema
Major Surgical or Invasive Procedure:
[**2199-7-5**] - Aortic valve replacement with 25-mm,
[**Last Name (un) 3843**]-[**Doctor Last Name **] bovine pericardial valve.
History of Present Illness:
75 year old man who presented to the mergency department with
ankle swelling. He was diagnosed with CHF and transferred to the
[**Hospital1 18**] for diuresis and a cardiac catheterization. He was found
to have non-obstructive coronary disease and severe aortic
stenosis. Given the severity of his aortic stenosis, he was
referred to the cardiac surgical service for surgical
management. He now presents for same day admission with aortic
valve replacement.
Past Medical History:
-CAD: anterior MI s/p PTCA approximately 20 years ago; Taxus and
Cypher stents to distal RCA and Cypher stent to proximal RCA in
[**2197-8-30**] (done for ETT-MIBI suspicious for ischemia of the
mid-distal lateral wall extending to the inferolateral junction)
-Syncope, found to have monomorphic VT s/p ICD [**2193-6-10**]
-Hypertension
-Hypercholesterolemia
-Mild aortic stenosis
-AAA
-CRI with Cr 1.8
-Atrial flutter/fibrillation, on Amiodarone
-Asthmatic bronchitis
-Remote right shoulder dislocation
-Tonsillectomy
-Cholecystectomy
-Bleeding Ulcers
-Small bowel resection for SBO
-Diverticulitis
-Cataracts
Social History:
Social history is significant for the absence of current tobacco
use. He formerly smoked 1 ppd X 50 years, but quit smoking [**6-11**]
years ago. He does have a history of alcohol abuse, and
currently drinks 2 vodka and [**Location (un) 2452**] juice/day. He previously
drank 4-5 drinks/day especially when he lived in [**State 531**]. He is
married and lives with his wife in [**Name (NI) **]. He is a retired
sales manager for GE, and currently works part time for [**Company 42451**] during tax season.
Family History:
There is no family history of premature coronary artery disease
or sudden death. His father had an MI in his 70s and HTN. Father
and uncles with gastric cancer.
Physical Exam:
66 SR 18 176/75 71" 290lbs
GEN: Obese, NAD
SKIN: Unremarkable
HEENT: NCAT, PERRL, OP Benign
NECK: Supple with FROM
LUNGS: Clear
HEART: RRR, NlS1-S2, IV/VI SEM
ABD: Benign
EXT: Warm, well perfused, 1+ edema, no varicosities.
NEURO: Grossly intact
Pertinent Results:
[**2199-7-10**] 05:33AM BLOOD Hct-22.2*
[**2199-7-9**] 06:05AM BLOOD WBC-10.6 RBC-2.52* Hgb-7.7* Hct-23.6*
MCV-94 MCH-30.6 MCHC-32.7 RDW-15.2 Plt Ct-241
[**2199-7-8**] 03:02AM BLOOD WBC-11.0 RBC-2.46* Hgb-7.5* Hct-23.2*
MCV-94 MCH-30.4 MCHC-32.4 RDW-15.0 Plt Ct-195
[**2199-7-10**] 05:33AM BLOOD UreaN-53* Creat-2.0* K-4.2
[**2199-7-9**] 06:05AM BLOOD Glucose-111* UreaN-48* Creat-2.0* Na-136
K-4.9 Cl-104 HCO3-23 AnGap-14
[**2199-7-8**] 03:02AM BLOOD Glucose-89 UreaN-39* Creat-2.1* Na-135
K-4.8 Cl-105 HCO3-24 AnGap-11
[**2199-7-7**] 04:50PM BLOOD UreaN-39* Creat-2.3* K-5.1
[**2199-7-5**] 11:51AM BLOOD UreaN-21* Creat-1.4* Cl-113* HCO3-20*
[**2199-7-5**] ECHO
PRE CPB No spontaneous echo contrast is seen in the body of the
left atrium. No atrial septal defect is seen by 2D or color
Doppler. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded. There
is moderate global left ventricular hypokinesis (LVEF = 35-40
%). The right ventricle displays borderline normal free wall
function. The ascending aorta is mildly dilated. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
= 0.8cm2). Mild to moderate ([**2-6**]+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is a
prolapsed segment of the posterior leaflet which is more
calcified and displays somewhat limited mobility. The mitral
valve leaflets are not well seen. Based on vena contracta width,
moderate (2+) mitral regurgitation is likely though the jet
color area is more consistent with mild to moderate mitral
regurgitation. Dr. [**Last Name (STitle) **] was notified in person of the results
in the operating room at the time of the study.
POST CPB The patient is being atrially based and is receiving
epinephrine by infusion. Normal right ventricular systolic
function. Improved left ventricular systolic function with an
ejection fraction of about 50%. There is a well seated
bioprosthesis in the aortic position. The leaflets are only
poorly seen. There is trace aortic regurgitation that appears
valvular thought the exact source is difficult to determine. The
effective orifice area is about 2 cm2. The peak gradient through
the aortic valve is 27 mm Hg with a mean gradient of 14 mm Hg at
a cardiac output of 5 l/m. The mitral regurgitation may be
slightly improved. Mild to moderate tricuspid regurgitation is
seen. The thoracic aorta appears intact.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2199-7-5**] for surgical
management of his aortic valve disease. He was taken directly to
the operating room where he underwent an aortic valve
replacement using a 25mm CE Bovine Pericardial Valve. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring. The Electrophysiology
service was consulted to interogate his Pacemaker and ICD which
was found to functioning within normal limits. On postoperative
day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was
extubated. Aspirin, amiodarone and a statin were resumed. He
required pulmonary toiletting over the next two days for
wheezing and pulmonary edema. On postoperative day three, he was
transferred to the step down unit for further recovery. He was
gently diuresed towards his preoperative weight. Diuresis had to
be held at times due to an elevated creatinine. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. He was ready for discharge
to rehab on POD #5.
Medications on Admission:
Aspirin
Plavix 75mg QD
Tricor 145mg QD
Amiodarone 200mg Daily
Pravachol 20mg QD
Toprol XL 75mg QD
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
10. Albuterol 90 mcg/Actuation Aerosol Sig: [**2-6**] Inhalation
qid:prn.
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: then reassess need for diuresis.
Discharge Disposition:
Extended Care
Facility:
The Cliffer Home
Discharge Diagnosis:
AS s/p AVR
HTN
CAD s/p PTCA and Stenting
Chronic systolic Heart failure
AAA
CRI (Baseline Creatinine 1.8)
AF
Asthma
Syncope
Hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 24717**] in [**2-6**] weeks. [**Telephone/Fax (1) 24721**]
Completed by:[**2199-7-10**]
|
[
"424.1",
"285.21",
"493.90",
"428.0",
"428.22",
"278.00",
"403.90",
"585.9",
"427.31",
"272.4",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"39.63",
"35.21",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
7646, 7689
|
5329, 6465
|
330, 462
|
7872, 7881
|
2571, 5306
|
8624, 8842
|
2124, 2286
|
6613, 7623
|
7710, 7851
|
6491, 6590
|
7905, 8601
|
2301, 2552
|
281, 292
|
490, 949
|
971, 1584
|
1600, 2108
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,702
| 157,559
|
6937
|
Discharge summary
|
report
|
Admission Date: [**2129-4-18**] Discharge Date: [**2129-10-27**]
Date of Birth: [**2048-10-16**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Direct admit from Nursing Home for malnutrition and chronic
aspiration, plan to have jejunostomy tube placement.
Major Surgical or Invasive Procedure:
[**5-12**] open jejunostomy tube placement
[**6-2**], open jejunostomy tube placement following dislodged
previously placed tube
[**6-21**], [**Month (only) 26092**] IR jejunostomy change (attempted change of
10Fr to larger size)
[**7-4**], unable to fundoplicate via Esophagogastroduodenoscopy
(EGD)
[**8-16**], Tracheostomy under local and change of J-tube to 14
Fr tube
History of Present Illness:
80M with dysphagia supported on TPN who presents for feeding
jejunostomy placement. Prior to admission he was reported to
have fever and (+)blood cultures from rehabilitation center.
Past Medical History:
1. A gastrointestinal bleed in the [**2091**], treated with a
Billroth II surgery.
2. Atrial fibrillation since the [**2101**] for which the patient
was placed on anticoagulation with Coumadin.
3. Gastric adenocarcinoma discovered in [**2119**] after a
recurrent gastrointestinal bleed, treated with partial
esophagogastrectomy. This adenocarcinoma is stage IB. The
patient's Coumadin was discontinued at that time.
4. History of stroke in [**2121-4-12**]. The patient was placed
back on Coumadin at this time. He has been on Coumadin
since.
5. Hypertension.
6. Osteoarthritis.
7. large GI bleed in [**2124**], so off all anti-platelets or
anti-thrombotics
8. hx of mantle cell lymphoma treated with five cycles of
R-CHOP,in remission.
9. recent perianal lymph node biopsy for ? lymphoma (uptake on
recent PET scan) on [**3-25**] with complication of urinary retention.
bx results showed poorly-circumscribed leiomyoma
10. reflux, which is likely largely due to bile reflux given his
past history of a vagotomy and partial gastric resection
Social History:
quit tobacco 30years ago (10 pack year hx)
few beers daily
no illicit drug abuse
has 6 children, lives with wife
retired gas serviceman/car inspector
Family History:
Mother -cva, htn
Father - died of heart condition
Physical Exam:
Admission PE- [**2129-4-18**]
98.4 86 102/62 18 98%RA
weight: 54.11kg, Height: 68inches
Gen: Alert and in NAD; cachectic
PERRL. Nonicteric. Neck supple. No [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3495**]: Irregular (+)M
Lungs: left insp/exp wheeze; (+)cough
Abd: soft, ND, NT (+)bs
Ext: wwp; 2+DP; right PICC- no erythema
GU: foley with cloudy yellow urine
Pertinent Results:
[**2129-5-2**] 2:21pm - RADIOLOGY Final Report
FLUORO GUIDED PLCT/REPLCT/REMOVE CENTRAL LINE
Reason: PICC line placement- IV nurse [**First Name (Titles) **] [**Last Name (Titles) 26092**];
needs TPN
.
RADIOLOGIST: Drs. [**Last Name (STitle) 380**] and [**Name5 (PTitle) 26093**] the procedure. Dr.
[**Last Name (STitle) 380**], the attending radiologist was present and supervising
throughout.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
double lumen PICC line placement via the left brachial venous
approach. Final internal length is 36 cm, with the tip
positioned in SVC. The line is ready to use.
.
[**2129-5-2**] 1:17pm
VIDEO OROPHARYNGEAL SWALLOW PO
Reason: ? Aspiration
VIDEO FLUOROSCOPIC SWALLOW EVALUATION: Study done in conjunction
with speech and swallow division. Multiple consistencies of
barium were administered to the patient under constant video
fluoroscopy. Oral phase demonstrates severely impaired bolus
formation, bolus control, and tongue movement. Premature
spillover was consistently seen prior to initiation of swallow.
The pharyngeal phase was characterized by moderate delay in
initiation of pharyngeal swallow. Significant residue remained
in the valleculae and piriform sinuses after swallow.
Penetration and aspiration were seen with multiple consistencies
of barium.
.
[**2129-5-16**] 8:25pm
RADIOLOGY Final Report CTA HEAD W&W/O C & RECONS
Reason: NEW APHASIS, RIGHT UPPER WEAKNESS - ASSESS FOR VASCULAR
INJURY
Comparison is made to prior MRI dated [**2128-4-3**] and prior
CT dated [**2128-4-2**].
NON-CONTRAST HEAD CT
There are areas of encephalomalacia from previously identified
right MCA distribution stroke involving the right frontal,
temporal, and subinsular region with bilateral old lacunar
infarcts involving the basal ganglia. Evidence of acute major
vascular territory stroke, hydrocephalus, shift of midline
structures, or hemorrhage. Osseous structures and soft tissues
appear unremarkable. Paranasal sinuses and mastoid air cells are
well aerated.
CTA OF THE HEAD AND NECK
Please note there was very poor contrast opacification of the
neck and intracranial vessels due to infiltrated IV during bolus
injection. This poor opacification makes accurate interpretation
on the CTA not possible. Mild atherosclerotic disease is noted
bilaterally at the regions of the carotid bifurcation.
IMPRESSION:
Areas of encephalomalacia from old right MCA distribution stroke
and bilateral basal ganglia lacunar infarcts. No evidence of
acute major vascular territorial infarct or hemorrhage.
CTA uninterpretable due to suboptimal bolus from IV
infiltration. The patient may return to the department for a
repeat CTA if clinically needed at no additional cost.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] DR. [**First Name (STitle) **] [**Name (STitle) 12563**]
Approved: [**Doctor First Name **] [**2129-5-19**] 5:13 PM
.
[**2129-5-17**] 9:16 AM
CAROTID SERIES COMPLETE / Reason: Assess for carotid stenoses.
INDICATION: New right-sided hemiparesis, history of stroke.
Carotid ultrasound examination was performed bilaterally.
RIGHT SIDE: There is mild plaque at the distal common carotid
artery and proximal internal carotid artery with respective peak
systolic velocities 61 cm/sec, and 51 cm/sec. The peak systolic
velocity in the external carotid artery 86 cm/sec. ICA/CCA ratio
0.84. The flow in the vertebral artery is in antegrade
direction.
LEFT SIDE: There is mild plaque in the distal common carotid
artery and proximal internal and external carotid arteries with
respective peak systolic velocities 52 cm/sec, 33 cm/sec, and 79
cm/sec. ICA/CCA ratio is 0.63. The flow in the vertebral artery
is in antegrade direction.
IMPRESSION: Less than 40% stenosis of the proximal internal
carotid arteries bilaterally. This is a baseline examination at
the [**Hospital1 18**].
.
[**2129-5-18**] Neurophysiology Report EEG
OBJECT: 80-YEAR-OLD MAN WITH RIGHT UPPER EXTREMITY WEAKNESS AND
HX OF
STROKE, NOW WITH WAXING AND [**Doctor Last Name **] MENTAL STATUS. PLEASE
EVALUATE FOR
SEIZURES. REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
FINDINGS:
ABNORMALITY #1: The background is slow and disorganized and
reached a
maximum of 6.5-7 Hz posteriorly during wakefulness.
ABNORMALITY #2: There were bursts of generalized delta frequency
slowing occasionally better appreciated on the left side.
HYPERVENTILATION: Contraindicated.
INTERMITTENT PHOTIC STIMULATION: Was not performed as this was
requested as a portable study.
SLEEP: No normal transitions between wakefulness and sleep were
seen.
CARDIAC MONITOR: An irregular cardiac rhythm was noted with an
average
heart rate of 78 bpm.
IMPRESSION: This is an abnormal portable EEG due to the slow and
disorganized background with bursts of generalized slowing
suggestive of
an encephalopathy. Infection, toxic metabolic disturbances, and
medication effects are among the most common causes. No clear
epileptiform features were seen and no electrographic seizures
were
seen.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 7495**] B.
[**2129-5-18**] 11:14am Cardiology Report ECHO Portable TTE
Indication: Atrial fibrillation/flutter. Cerebrovascular
event/TIA. Conclusions:
The left atrium is dilated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are moderately thickened. There is mild to moderate
aortic valve stenosis ). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**12-14**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
No cardiac source of embolus other than presence of atrial
fibrillation
identified (cannot definitively exclude).
Compared with the prior study (images reviewed) of [**2128-4-6**],
estimated
pulmonary artery systolic pressure is now higher. Aortic valve
gradient is now higher.
Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD on [**2129-5-18**] 12:09.
.
[**2129-5-18**]
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
HEAD MRI.
TECHNIQUE: Multiplanar T1, T2, and diffusion-weighted sequences
were
obtained.
FINDINGS: There are scattered areas of restricted diffusion,
also with low signal on the ADC map, consistent with evolving
infarction within the left middle cerebral artery territory
distribution, mostly centered within the subcortical and deep
white matter of the left prefrontal region and left temporal
lobe. Many of these lesions demonstrate increased T2 and FLAIR
signal indicating that they are subacute in nature. There is
diffusely increased T2 and FLAIR abnormality in a region of
previously noted right MCA distribution infarct consistent with
probable underlying gliotic or malacic changes from a chronic
infarct. No significant areas of susceptibility artifact are
identified. No evidence of hydrocephalus, shift of midline
structures, or abnormal signal void within the
vasculature. The paranasal sinuses and mastoid air cells appear
normal.
MRA OF THE CIRCLE OF [**Location (un) **].
TECHNIQUE: 2D and 3D Time-of-flight multiplanar imaging was
obtained.
FINDINGS: No significant flow-limiting stenoses or aneurysmal
dilatation is identified. The distal branches of the left middle
cerebrl artery appear unremarkable. Within the limits of the
study, there is no evidence of AV malformation.
IMPRESSION:
1. Subacute left middle cerebral distribution infarct involving
multiple
areas, mostly within the left prefrontal and temporal lobes,
probably embolic in nature.
2. Unremarkable MR angiogram of the circle of [**Location (un) 431**].
[**2129-6-1**] 7:45am - RADIOLOGY Final Report
FISTUOGRAM/SINOGRAM W/DR. [**Last Name (STitle) **]
[**Name (STitle) **]: Assess J-tube tract; patient had a surgically placed
jejunostomy tube which fell out yesterday.
PHYSICIAN: [**Name10 (NameIs) **] procedure was performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**] in
the Interventional Radiology Suite.
PROCEDURE: Attempts were made to advance small catheters through
the jejunostomy tract followed by contrast injection. Contrast
injection delineated what appeared to be a small bowel loop,
however, no peristalsis was identified. A guide wire was
advanced into this loop, but due to the lack of normal
peristalsis, catheter and guide wire were removed. The procedure
was discontinued.
DR. [**First Name (STitle) **] [**Name (STitle) **]
.
[**2129-6-9**] 9:06 AM - SMALL BOWEL ONLY (GASTROGRAF)
Reason: TO STUDY J TUBE AND TO ASSESS BOWEL WALL FOR THUMB
PRINTING /EDEMA
INDICATION: Assess for small bowel ischemia.
SMALL BOWEL FOLLOWTHROUGH: Contrast was administered through the
J-tube. There is a normal passage of contrast through the small
bowel into the large bowel. There is no evidence of wall edema
or bowel dilatation. A normal appendix is appreciated.
IMPRESSION: Normal small bowel followthrough.
DR. [**First Name (STitle) 21827**] [**Name (STitle) 21828**]
[**2129-7-1**] 2:11pm ABDOMEN (SUPINE & ERECT) PORT
Reason: mildly distended abdomen, need KUB
s/p partial esophagogastrectomy for gastric CA. abdomen mildy
distended. need KUB
FINDINGS: Normal gas pattern is observed in the bowel loops. No
evidence of air-fluid levels. No evidence of free air. There is
left-sided total arthroplasty.
IMPRESSION: No evidence of acute obstruction. No evidence of
perforation.
[**2129-6-22**]
G/GJ TUBE CHECK PORT
15ml Gastrograffin injected into J tube by surgical md [**First Name (Titles) **] [**Last Name (Titles) **]
taken. Comparison is made to prior UGI series and abdominal
radiograph dated [**2129-6-9**]. A J tube was noted entering the
left lower quadrant with contrast noted within loops of small
and large bowel. There is no evidence of focal leak on this
limited examination or pneumoperitoneum. No evidence of bowel
obstruction. There is diffuse patchy opacities noted within the
visualized lungs--chest examination reported separately.
[**2129-8-25**]
ABDOMEN U.S.
FINDINGS: Sagittal and transverse grayscale images were
obtained portably. Despite diligent effort, no mesenteric
vasculature was identifiable due to the large amount of
overlying bowel gas.
IMPRESSION: Mesenteric vasculature not visualized on this exam
as described above.
[**2129-9-4**]
G/GJ TUBE CHECK
Contrast is seen in the left lower quadrant through a J-tube.
It lies within the small bowel. Consolidation of the left lower
lobe is again noted. There is no evidence of obstruction.
IMPRESSION: Contrast within small bowel. No leakage seen.
[**Date range (1) 26094**]
BEDSIDE EEG WITH VIDEO, EKG
IMPRESSION: This is a mildly abnormal 24-hour video EEG
telemetry due
to the mildly slow background rhythm suggestive of a mild
encephalopathy. This may be seen with medication effect, toxic
metabolic abnormalities, or infections. No epileptiform
discharges and
no electrographic seizures were noted.
[**2129-10-18**]
TTE
The left atrium is dilated. The right atrium is dilated. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets are
moderately thickened. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a fat pad. Compared with the
prior study (images reviewed) of [**2129-5-18**], estimated pulmonary
artery systolic pressure is now lower.
[**2129-10-18**]
RENAL ULTRASOUND
The right kidney measures 11.7 cm. The left kidney measures
13.1 cm. There is minimal right-sided hydronephrosis. There
are no renal stones. The main renal arteries and veins are
patent. A Foley catheter is seen within a distended bladder.
IMPRESSION:
1. Foley catheter within a filled, distended bladder.
2. Minimal right-sided hydronephrosis which may be secondary to
reflux from the distended bladder.
Brief Hospital Course:
[**Known firstname 2092**] [**Known lastname 5239**] was admitted preoperatively to the surgery service on
[**2129-4-18**] under the care of Dr. [**Last Name (STitle) 957**]. The plan was to place a
feeding jejunostomy tube, as he had failed multiple swallowing
evaluations and coverage for continued TPN in the presence of
functional bowel was in question. On admission (+)blood culture
results were reported from the rehabilitation center. He was
(+)UTI. WBC count was 6.2. His urinary catheter was exchanged
and he was started on Vancomycin/Zosyn for empiric coverage. CXR
was negative for acute process. The PICC line was removed. He
was supported on PPN. Outside blood cultures were positive for
coag (-)staph and VRE. PICC tip culture was (+)coag (-) staph.
Urine culture was (+) for coag(-) staph and enterococcus.
Sputum culture was (+) E. coli. Abx coverage was changed to
Zosyn/Linezolid. At HD 6 he was afebrile; serial blood cultures
were negative for growth. A PICC line was placed; TPN was
restarted. At HD 12 a repeat video swallow evaluation was
completed which showed that he was unable to tolerate anything
PO without aspiration. At HD 19 he was afebrile and doing well.
Antibiotics were discontinued. Transferrin was low at 189; Alb
2.6. At HD 23 iron dextran was given x 3 doses. Hibiclens
washes were started.
On HD25 he was taken to the OR where he underwent a feeding
jejunostomy placement. He tolerated the procedure well and was
returned the floor after recovery in the PACU. On POD2 tube
feedings were being tolerated. Coumadin was started for a. fib
prophylaxis. POD4 pt was noted to have R arm weakness and was
unable to talk. Stroke team was present on scene shortly
thereafter and CT demonstrated LMCA ischemic defect without
hemorrhage. IV tPA was administered with consent of the family.
TEE demonstrated no mural thrombus, carotid u/s with <40%
stenosis bilaterally. On POD 5 the patient was started on a
heparin gtt and Coumadin, with a therapeutic goal of [**1-15**], as
well as a statin. MRI of the brain was performed on POD 7, which
confirmed the L MCA distribution subacute stroke affecting the
prefrontal and temporal region, appearing to be embolic in
nature. On the evening of postoperative day 8, the patient
experienced a 20-beat run of ventricular tachycardia, which was
asymptomatic. Cardiac enzymes were sent and an EKG was
performed, all of which were inremarkable. Low dose
beta-blockade was initiated at that time. The patient had showed
slow, but gradual improvement following the CVA until POD 10
when it was noted that the patient vomited and aspirated,
resulting in transient hypoxia.
Following placement of the patient's J-tube for enteral feedings
and subsequent embolic CVA, the [**Hospital 228**] hospital course was
complicated by chronic aspiration and bile reflux resulting in
numerous bouts of aspiration pneumonia. This was complicated by
the fact that the patient required aggressive diuresis to avoid
CHF exacerbation, which also occured multiple times during his
course. This resulted in hypoperfusion of his bowel causing
worsening of his bile reflux and subsequent aspirations.
Throughout his course he was treated with multiple broad
spectrum antibiotic regimens. Multiple cultures were performed
throughout his long course and the pathogens remained constant.
Sputum cultures grew Pseudomonas and E. Coli multiple times.
Urine cultures grew VRE and yeast on multiple occassions. His
blood also grew coagulase negative Staph on a number times,
treated with line changes and appropriate antibiotics.
Aspiration events were treated with similar regimens, this
included: aspiration precautions (ie sitting patient upright),
stopping TF, NT suctioning, aggressive pulmonary toilet,
hydrocortisone lavages, NGT decompression, and nebulizers. Once
the patient improved, the NGT was discontinued (usually after
24-48 hours) and TF were restarted and advanced as tolerated
until the next aspiration event. Nutritional support was
provided by TPN and varying rates of TF's. The patient was
transferred in and out of the ICU multiple times, always being
transferred back to the ICU following aspiration and resulting
in transient hypoxia. Multiple interventions were performed
during his hospitalization, including multiple therapeutic
bronchoscopies and multiple studies and manipulations of his
jejunal feeding tube. Please separate section for dates and
details of these interventions. Interventional GI was consulted
during his hospitalization to assess for possible endoscopic
fundoplication to try and resolve his chronic aspiration.
However given his prior gastric surgeries, it was deemed that he
was not a candidate based on the small gastric remnant (he was
s/p BII) and friable mucosa noted on EGD. He would tolerate a
general anesthetic for laparoscopic or open surgical
intervention to accompish this procedure. Later in his course,
on HD 120, the patient underwent tracheostomy placement with
local anesthesia to see if this would help to avoid further
aspirations. He continued to aspirate despite this intervention,
more so when he underwent Passe-Muir valve trials, which were
eventually discontinued. The patient remained on therapeutic
anticoagulation following his CVA caused by AF/embolism. The
regimen initially consisted of Heparin gtt and coumadin, and for
a brief period, Lovenox. Rate control was maintained with beta
blockade, Amiodarone, and Digoxin. The patient also received
multiple blood transfusions and was treated with Epogen and iron
for anemia of chronic disease. The wound care nurse was also
following the patient for sacral decubitus ulceration.
The patient remained chronically ill, but relatively stable with
marginal respiratory status dictating whether he was monitored
on the floor or the ICU. His final decompensation and eventual
decline resulting in death started with his final transfer to
the ICU on HD 144. Tracheostomy secretions were noted to be
increased and CXR was consistent with aspiration pneumonia. His
WBC was also elevated to 32K. Sputum cultures again grew
Pseudomonas and urine cultures grew yeast. Antibiotic coverage
consisted of Zosyn and Gent at that time. PMV trials were
discontinued on HD 148. During the next few weeks he continued
to aspirate despite the aggressive measures as outlined above.
More aggressive diuresis was performed to avoid volume overload.
Albumin was given on multiple occasions, only for a CVP less
than 4 as it was felt a CVP at or around 4 was the optimal
volume on his Starling curve. Later in the course his
antibiotics were changed to Vancomycin, Tobramycin, Fluconazole
and Ciprofloxacin and his WBC had decreasaed to 10.3 by HD 176.
It was around this time that the patient's BUN began to rise and
urine output to decrease, requiring increasing doses of diuretic
to try and maintain euvolemia. He thus diagnosed with ARF, which
would ultimately lead to his demise. On HD 177, the patients BUN
was 46 and Cr 0.9, however his BUN and Cr subsequently steadily
increased and urine output gradually decreased. On HD 182 the
patient was noted to have 200cc of blood suctioned from his
trach and received a 1 unit pRBC transfusion. Anticoagulation
was discontinued at this time. Cr at that was noted to have
risen to 1.4 and would continue to rise. Nephrology was
consulted and it was recommended that the tobramycin be
discontinued and to avoid diuresis if possible. Cardiac enzymes
were cycled and the Troponion was noted to be elevated to 0.18
on HD 183. Cardiology was consulted and the troponin increase
was thought to be due to demand ischemia. A TEE performed on
[**10-18**] showed normal LVEF, dilated R and L atria, mild valve
dysfunction, and normal pulmonary pressures. Gentle diuresis was
recommended, however his ARF obviously complicated the treatment
plan.
Full work up of his renal failure ruled out post-renal
obstruction, as well as allergic interstitial nephritis. His
volume status was in question, but at this point the patient's
family did not want to pursue further invasive interventions,
such as a PA catheter. TPN was adjusted to provide only
essential amino acids to avoid exacerbating the rising BUN. ON
HD 184 it was noted that the patient's WBC had again gradually
increased, reaching 39K. No new pathogens were identified on
cultures. We continued to try and diurese him, however his
kidneys failed to respond adequately, as his ARF continued to
worsen. The patient's mental continued to gradually decline and
the patient had become progressively non-verbal and eventually
minimally responsive to stimulation. Multiple discussions were
had with the family regarding the plan of care given the
patient's inability to participate. HD was offered to the family
given the worsening ARF, however they did not believe that that
would be consistent with his wishes given that it was unlikely
that he would ever make it out of the ICU. The patient was
eventually made DNR/DNI by the familyl after multiple
discussions. His renal failure progressed, with his potassium
eventually rising to 7.0 despite aggressive treatment with
calcium, bicarbonate, and glucose/insulin. His creatinine at
that time peaked at 5.8. On 193 the patient became progressively
more bradycardic, reaching 20s-30s and was found to be in a
junctional rhythm. He eventually became progressively more
hypotensive and then was asystolic around 11:55 PM. His family
was present and he pronounced dead at that time.
Medications on Admission:
Enoxaparin 40q 12h
Aranesp 60mcg q 7 days
Pantoprazole 40mg qd
Ferrous sulfate 15mg/0.6ml 3gtts q 12h
Discharge Medications:
None, patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Chronic aspiration
2. Aspiration pneumonia
3. Congestive heart failure
4. Acute renal failure
5. L-sided prefrontal/temporal stroke
6. Respiratory failure
7. Malnutrition
8. Failure to thrive
9. s/p feeding jejunostomy
10. s.p tracheostomy
11. line sepsis
12. UTI
Discharge Condition:
expired
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
|
[
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icd9cm
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[
[
[]
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[
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icd9pcs
|
[
[
[]
]
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25127, 25136
|
15454, 24927
|
386, 760
|
25447, 25456
|
2692, 15431
|
25519, 25536
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2221, 2272
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25080, 25104
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24953, 25057
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25480, 25496
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234, 348
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788, 973
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995, 2037
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2053, 2205
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,959
| 184,941
|
41713
|
Discharge summary
|
report
|
Admission Date: [**2145-10-23**] Discharge Date: [**2145-10-29**]
Date of Birth: [**2107-1-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
endotracheal intubation
mechanical ventilation
History of Present Illness:
Mr. [**Known lastname 47097**] is a 38 year old man with h/o OSA on CPAP, HTN, HLD,
anxiety, who was transferred from an OSH s/p intubation for
hypercarbic respiratory failure.
Patient presented to the OSH yesterday with worsening shortness
of breath. Per the patient's girlfriend, the patient has been
ill for the past 2-4 weeks. He has seen several doctors and was
[**Name5 (PTitle) 75629**] with bronchitis and URI, given Albuterol inhaler and
steroid taper. Three days prior to admission, he had to leave
from work because he was feeling ill. Two days ago, he was
having difficulty breathing while walking around the mall with
his girlfriend. [**Name (NI) **] finished the prednisone taper the day prior
to presentation. Yesterday, the patient was increasingly short
of breath at rest, so his girlfriend dropped him off at the
[**Hospital6 3105**] ED. In the OSH ED, patient was
initially satting 72% on RA, up to 98% with 3LNC. Initial CXR
showed cardiomegaly, but otherwise was unremarkable. The patient
was awaiting bed availability/admission to cards for further
evaluation of CP and SOB with EKG showing TWI in inferolateral
leads and ST depressions in V2-5. He was noted to be obtunded
this AM while satting 99-100% on CPAP/FiO2 75% and could not be
aroused. ABG done at that time showed pH 7.05, pCO2 170, pO2 99.
He was intubated at this point - intubation was difficult [**1-20**] to
anatomy and required 2 operators. Post-intubation CXR with
diffuse air-space disease, concerning for ARDS vs pulmonary
edema, with no clear consolidations. Flu swab was negative per
OSH. Patient was given a dose of Levaquin, duonebs, IV
Solumedrol, Vecuronium, started on Propofol gtt, and transferred
to [**Hospital1 18**] ED via [**Location (un) **]. Patient was bolused with Fentanyl
during the flight because sedation noted to be light.
In the ED, patient noted to be agitated on Propofol gtt, so was
bolused Propofol 50mcg. Initial gas 7.38/68/68 on 100% FiO2.
Labs notable for WBC 14. Repeat gas 7.51/47/75 on 100% FiO2 and
PEEP 5. Bedside ECHO showed no e/o RHS. CTA chest prelim read
with no e/o large PE. Sedation changed from Propofol to
Midazolam given decreased BP in the ED. Also re-dosed with
Vecuronium prior to the CTA chest. Patient was given Vanc,
Flagyl (in addition to Levaquin that he received at the OSH).
Also given a dose of Tamiflu. Blood and urine cultures drawn,
flu swab sent. Vitals prior to transfer: HR 60 BP 115/88 RR 24
O2sat 100% on mechanical ventilation.
On the floor, the patient is intubated and sedated. FiO2 now
down to 50% with increased PEEP to 12.
Review of systems:
Unable to assess
+weight gain recently per girlfriend
Past Medical History:
Sleep apnea on CPAP, does not use it every night
GERD
HTN
HLD
Anxiety
Arthritis (hips)
Back pain
Obesity
Social History:
Lives with his girlfriend [**Name (NI) **]. [**Name2 (NI) 1403**] at [**Company **]'s.
- Tobacco: past use
- Alcohol: none
- Illicits: none
Family History:
Patient was adopted
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.3 BP:157/105 P: 63 R: 24 O2: 96% on ventilator
General: intubated, sedated
HEENT: pinpoint pupils, Sclera anicteric, ETT and OG tube in
place
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles at bases bilaterally, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended, firm, hypoactive bowel sounds
GU: foley in place
Ext: warm, well perfused, 2+ pulses, 2+edema b/l, cracked thick
calluses on b/l feet
Neuro: sedated
DISCHARGE EXAM:
Vitals: T98.5F, BP120/82, HR:80, RR:18, O2sat: 93&RA
General: NAD, breathing comfortably on room air
HEENT: oropharynx clear
LUNGS: CTAB
GU: foley removed
NEURO: alert, nonfocal
Exam otherwise uncanged from admission
Pertinent Results:
ADMISSION LABS:
[**2145-10-23**] 01:05PM BLOOD WBC-14.0* RBC-5.11 Hgb-13.4* Hct-44.9
MCV-88 MCH-26.2* MCHC-29.9* RDW-14.1 Plt Ct-238
[**2145-10-23**] 01:05PM BLOOD Neuts-92.2* Lymphs-4.4* Monos-3.1 Eos-0.2
Baso-0.1
[**2145-10-23**] 01:05PM BLOOD PT-12.4 PTT-21.0* INR(PT)-1.0
[**2145-10-23**] 01:05PM BLOOD UreaN-30* Creat-1.2 Na-141 K-5.2* Cl-96
HCO3-37* AnGap-13
[**2145-10-23**] 01:05PM BLOOD ALT-88* AST-27 LD(LDH)-264* CK(CPK)-146
AlkPhos-51 TotBili-0.7
[**2145-10-23**] 01:05PM BLOOD CK-MB-8
[**2145-10-23**] 01:05PM BLOOD cTropnT-0.06*
[**2145-10-23**] 01:05PM BLOOD Albumin-4.0 Calcium-8.7 Phos-3.4 Mg-2.2
[**2145-10-23**] 12:57PM BLOOD Type-ART Rates-24/ Tidal V-500 FiO2-100
pO2-68* pCO2-68* pH-7.38 calTCO2-42* Base XS-11 AADO2-589 REQ
O2-95 -ASSIST/CON Intubat-INTUBATED
[**2145-10-23**] 12:57PM BLOOD Lactate-2.8*
URINE:
[**2145-10-23**] 01:05PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2145-10-23**] 01:05PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2145-10-23**] 01:05PM URINE RBC-3* WBC-1 Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
[**2145-10-23**] 01:05PM URINE CastHy-3*
OTHER PERTINENT STUDIES:
TSH 2.4
DISCHARGE LABS:
[**2145-10-29**] 04:47AM BLOOD WBC-6.9 RBC-5.68 Hgb-14.8 Hct-46.0
MCV-81* MCH-26.1* MCHC-32.3 RDW-15.0 Plt Ct-200
[**2145-10-29**] 04:47AM BLOOD Glucose-96 UreaN-21* Creat-1.2 Na-133
K-4.6 Cl-94* HCO3-30 AnGap-14
[**2145-10-29**] 04:47AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.3
MICRO:
[**2145-10-23**] BCx: Blood Culture, Routine (Final [**2145-10-29**]): NO
GROWTH.
[**2145-10-23**] UCx: NO GROWTH.
[**2145-10-23**] RSV screen:
Respiratory Viral Culture (Final [**2145-10-27**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2145-10-25**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
[**2145-10-23**] MRSA screen: No MRSA isolated.
STUDIES:
[**2145-10-23**] CXR:
1. Intubated patient with the tip of the endotracheal tube 2.3
cm from the
carina; this might be withdrawn for optimal positioning.
2. Low lung volumes with left greater than right basilar
opacities, likely
atelectasis, though infection cannot be excluded.
CXR [**2145-10-26**]:
FINDINGS: Bilateral lung volumes are low. Right lower lung
atelectasis has
improved, but there is new minimal fluid in the right minor
fissure.
Increased retrocardiac density reflecting left lower lung volume
loss is
unchanged. Both upper lungs are clear. Endotracheal tube and
orogastric tube are in standard position. No evidence of pleural
effusion.
The study and the report were reviewed by the staff radiologist.
[**2145-10-23**] CT chest:
IMPRESSION:
1. No evidence of PE or acute aortic injury.
2. Bilateral opacification may represent aspiration versus
pneumonia in the current clinical setting versus bibasilar
atelectasis associated with lower airway inflammation. Some
tree-in-[**Male First Name (un) 239**] appearance, especially within the right lung may
represent reactive/small airway disease or an infectious process
involving small airways.
TTE [**2145-10-25**]:
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is a small inferolateral
pericardial effusion without evidence of hemodynamic compromise.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Small
inferolateral pericardial effusion.
PFT'w: mild mixed obstructive and restrictive defect, decreased
MIPs and MEPs, final interpretation pending.
Discharge ABG:
[**2145-10-29**] 02:19PM BLOOD Type-ART pO2-71* pCO2-46* pH-7.44
calTCO2-32* Base XS-5
Brief Hospital Course:
Primary Reason for Hospitalization: Mr. [**Known lastname 47097**] is a 38 year old
man with h/o OSA, HTN, HLD, who was transferred from [**Hospital3 12748**] with hypercarbic respiratory distress, s/p
intubation, and presented to the MICU. He was started on
Levofloxacin for pneumonia, and CPAP at night for obstructive
sleep apnea. He was evaluated by physical therapy, with
recommendations for rehabilitation.
.
#. Hypercarbic/Hypoxic respiratory failure: Patient with initial
hypoxia on presentation to the OSH ED, with quick improvement on
2-3LNC. He then acutely decompensated while on FiO2 75% on CPAP.
Given his underlying sleep apnea, he may have been over
oxygenated, causing the patient to lose his respiratory drive
and become obtunded. Could also have component of obesity
hypoventilation as well. There was also concern for CHF, as
patient had had several weeks of increasing LE edema. TWI and ST
changes on EKG suggest possible coronary event, but CK remain
flat at this time. TTE showed intact systolic function. Given
concern for viral infection, he was initially started on
oseltamivir, but this was discontinued once viral screen
returned as negative. He treated with levofloxacin, with planned
7-day course.
His oxygenation and mental status improved after intubation, but
he required very high PEEPs. He diuresed well with IV lasix in
the MICU. His viral antigen screen was negative for flu, so
oseltamivir was stopped. Sputum cultures were negative.
He was extubated on [**2145-10-26**]. OSH records of a sleep study were
obtained showing severe sleep apnea. He endorsed a history of
severe daytime sleepiness prior to admission. He was started on
nighttime CPAP. On transfer to the floors, pulmonary was
consulted. He had PFT's which showed mild mixed obstructive and
restrictive defect. ABG showed mildly elevated CO2. MIP's were
low, but no evidence of skeletal weakness otherwise.
.
#. Chest pain: On admission, patient had T-wave inversions and
ST depressions inferolaterally, mildly improved since initial
OSH EKG. Trop and CK flat at OSH. Trop 0.06 here, but CK/MB
remained flat. Troponin leak was likely due to fluid overload
and respiratory failure. He had no more chest pain on the
medicine floors.
.
#. Acute Renal Failure: Cr 1.6 at OSH, improved to 1.2 here on
admission. Creatinine was trended, and was 1.2 on the day of
discharge. Lisinopril was initially held, but was restarted
prior to discharge.
Transitional issues:
1. CODE: FULL
2. Medical management:
- Start CPAP at night
3. Pending studies:
- Final PFT's interpretation pending at time of discharge
4. Follow-up:
- Pulmonary as an outpatient
- Sleep as outpatient
- Repeat sleep study as outpatient
- Repeat PFT's as an outpatient in [**3-24**] weeks
Medications on Admission:
Omeprazole 20mg PO BID
Lisinopril 10mg PO daily
Ibuprofen 500mg PO BID
Prednisone - s/p pred taper for bronchitis
Albuterol inhaler
Ammonium lactate lotion
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
mL Injection TID (3 times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
5. ipratropium bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for sob/wheezing.
6. CPAP
machine to be used nightly. Auto-set
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q6H (every 6
hours) as needed for sob/wheezing.
8. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
9. lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours: do not take more than 4 grams per day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Hypoxic, hypercarbic respiratory failure
Secondary: Obstructive Sleep apnea
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 47097**],
You were admitted to the hospital for shortness of breath and
confusion and were found to have a low blood oxygen level and a
high blood carbon dioxide level. These required you to be
intubated to help you breathe and you stayed in the ICU. Your
breathing improved and we were able to take you off the
ventilator and eventually back to room air. We feel that your
obstructive sleep apnea plays a role in why this happened, but
we will have to sort out the exact cause for this event with a
pulmonologist and sleep specialist. In the hospital we did lung
function tests and blood tests. These showed that your level of
carbon dioxide was slightly high but improved and that your
lungs show slight impedement of air movement both in and out.
This could be related to your acute illness and should be
followed up with repeat testing in [**3-24**] weeks and with evaluation
as an oupatient with a sleep pulmonologist and a general
pulmonologist.
Please make the following changes to your medications:
1. START taking acetaminophen 325-650mg by mouth every 6 hours
as needed for pain. DO NOT exceed 4gm per day.
2. STOP taking ibuprofen
3. START taking benzonatate 100mg by mouth three times daily as
needed for cough
4. START heparin 5000 units by subcutaneous injection 3 times
daily while in a healthcare facility
5. START senna 8.5 mg. Take 1 tab by mouth twice daily as needed
for constipation
6. START Docusate 100mg by mouth twice daily
7. START bisacodyl 10mg rectally daily as needed for
constipation
8. START ipratropium bromide nebulizer treatment every 6 hours
as needed for shortness of breath
9. START albuterol nebulizer treatment every 6 horus as needed
for shortness of breath
10. START using your CPAP machine nightly. Auto-set
Please take other medications as prescribed and dispose of old
or expired medications properly.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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"571.8",
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icd9cm
|
[
[
[]
]
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[
"38.91",
"33.24",
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icd9pcs
|
[
[
[]
]
] |
13141, 13240
|
8845, 11284
|
281, 329
|
13369, 13369
|
4133, 4133
|
3325, 3346
|
11801, 13118
|
13261, 13348
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11621, 11778
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13552, 14559
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5359, 8822
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3361, 3879
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3895, 4114
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11305, 11595
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14588, 15561
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2968, 3024
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234, 243
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357, 2949
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4149, 5343
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13384, 13528
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3046, 3152
|
3168, 3309
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,606
| 153,230
|
35516
|
Discharge summary
|
report
|
Admission Date: [**2111-3-24**] Discharge Date: [**2111-4-2**]
Date of Birth: [**2054-9-9**] Sex: F
Service: SURGERY
Allergies:
Ace Inhibitors / Losartan / Darvon / Iodine; Iodine Containing /
Demerol / Shellfish Derived / Pentazocine
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
bleeding gastric mass
Major Surgical or Invasive Procedure:
Total gastrectomy, feeding jejunostomy.
History of Present Illness:
Pt is a 56F, Jehovah's Witness, who has had a history of
anemia. She presented to the [**Hospital 8641**] Hospital yesterday with
weakness and dark, bloody stools. She felt well until 2-3 days
ago when she developed abdominal cramps and passed a large
bright
red clot from her rectum. This progressed to melena over the
next days until presenting to [**Location (un) 8641**] ED. She was taken from the
ED to the endoscopy sweet where an EGD was performed. A large,
5cm, fungating and ulcerated mass with oozing bleeding was found
in the cardia. Vaporization was performed with argon beam and
hemostasis was obtained. She was evaluated by a surgeon at
[**Location (un) 8641**] who felt the case should be referred to [**Hospital1 18**] as the
surgery would be high risk is this patient who refuses blood
transfusions.
The [**Location (un) 8641**] records indicate her HCT on [**2111-3-6**] was 32.8, 24.9 at
1530 on [**2111-3-23**]. Has been hemodynamically stable at [**Location (un) 8641**].
Patient reports she had an MI in [**2110-10-22**] when her HCT was
18. She was reportedly guaiac negative at the time and a GI
work-up was not undertaken as cardiology would not clear her.
Her anemia was attributed to her CKD & iron deficiency. She was
started on Epo & iron supplements. Colonoscopy in [**2105**]
demonstrated only two tubular adenomas which were removed.
Denies abdominal pain, N/V. Has had increasing gastric reflux
and possibly some early satiety. Had lost 10lbs at the time of
her MI, but had since gained that back. Prior to 3 days ago and
never seen blood in her stool or emesis. Denies lightheadedness
or dizziness.
ALL: ace inhibitor (difficulty breathing) / losartan (rash,
trouble breathing) / darvon (arrhythemia) / iodine
(swelling/breathing problems) / demerol (sizziness/vomiting) /
lobster (angioedema) / pentazocine (drowsiness/sedation/rash) /
tolwin (psychotic reaction)
ROS: see HPI. Denies LE edema, SOB, CP
Past Medical History:
1. anemia - both [**Doctor First Name **] & CRI
2. MI [**10/2110**] while HCT was 18 - patient reports her EF was as
low as 20-25% at the time of her MI, but increased to 30-35%.
She was to see her cardiologist again next week.
3. DM-I
4. recurrent UTI
5. recurrent kidney stones
6. h/o colonic polyps
7. HTN
8. hyperlipidemia
9. Stage 3 chronic kidney disease -- baseline Cr 2.3 (per pt)
10. panic attacks
11. treated Hashimoto thyroiditis
12. diabetic nephropathy
13. diabetic neuropathy
14. s/p tonsillectomy
15. E Coli sepsis (no known etiology)
16. PTSD
Social History:
SocHx: Jehovah's Witness, refuses all blood products. Married,
works as an artist. Rare EtOH. no tobacco
Family History:
NC
Physical Exam:
PE: 97.6 90 160/90 16 100%2L
NAD, pale. [**Last Name (un) **]. AOx3. Knowledgable about her medical
history and treatments
no jaundice or icterus
CTA B/L
RRR
Abd soft, ND, ND.
No LE edema. ext warm, well perfused.
Pertinent Results:
[**2111-3-24**] 12:20AM BLOOD WBC-6.5 RBC-3.09* Hgb-8.7* Hct-26.5*
MCV-86 MCH-28.1 MCHC-32.7 RDW-17.6* Plt Ct-209
[**2111-3-24**] 08:00AM BLOOD WBC-6.7 RBC-2.69* Hgb-8.1* Hct-22.6*
MCV-84 MCH-30.2 MCHC-35.9* RDW-17.9* Plt Ct-113*
[**2111-3-25**] 03:08AM BLOOD WBC-11.7*# RBC-2.60* Hgb-7.5* Hct-22.2*
MCV-86 MCH-28.7 MCHC-33.5 RDW-17.6* Plt Ct-197#
[**2111-3-26**] 03:20AM BLOOD WBC-10.1 RBC-2.41* Hgb-7.0* Hct-21.4*
MCV-89 MCH-29.0 MCHC-32.6 RDW-17.9* Plt Ct-178
[**2111-3-27**] 01:18AM BLOOD WBC-12.9* RBC-2.32* Hgb-6.8* Hct-21.2*
MCV-92 MCH-29.2 MCHC-32.0 RDW-17.5* Plt Ct-210
[**2111-3-28**] 03:10AM BLOOD WBC-11.8* RBC-2.42* Hgb-7.0* Hct-21.7*
MCV-90 MCH-28.8 MCHC-32.2 RDW-17.2* Plt Ct-240
[**2111-3-29**] 05:40AM BLOOD WBC-7.9 RBC-2.22* Hgb-6.7* Hct-20.5*
MCV-92 MCH-30.0 MCHC-32.6 RDW-17.3* Plt Ct-220
[**2111-4-1**] 06:35AM BLOOD WBC-7.4 RBC-2.44* Hgb-7.2* Hct-21.9*
MCV-90 MCH-29.4 MCHC-32.8 RDW-17.3* Plt Ct-247
[**2111-3-24**] 12:20AM BLOOD Glucose-144* UreaN-47* Creat-2.3* Na-142
K-4.2 Cl-111* HCO3-24 AnGap-11
[**2111-3-24**] 08:00AM BLOOD Glucose-185* UreaN-40* Creat-2.0* Na-142
K-4.3 Cl-110* HCO3-21* AnGap-15
[**2111-3-26**] 03:20AM BLOOD Glucose-153* UreaN-32* Creat-2.8* Na-147*
K-4.6 Cl-116* HCO3-24 AnGap-12
[**2111-3-27**] 01:18AM BLOOD Glucose-241* UreaN-38* Creat-3.0* Na-149*
K-5.1 Cl-118* HCO3-21* AnGap-15
[**2111-3-28**] 03:10AM BLOOD Glucose-127* UreaN-44* Creat-2.9* Na-147*
K-4.5 Cl-117* HCO3-22 AnGap-13
[**2111-3-29**] 05:40AM BLOOD Glucose-168* UreaN-48* Creat-2.8* Na-148*
K-5.1 Cl-116* HCO3-21* AnGap-16
[**2111-3-24**] 12:20AM BLOOD Calcium-10.1 Phos-3.1 Mg-2.3 Iron-46
[**2111-3-24**] 08:00AM BLOOD Calcium-9.8 Phos-2.5* Mg-2.1
[**2111-3-25**] 03:08AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.8
[**2111-3-26**] 03:20AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9
[**2111-3-27**] 01:18AM BLOOD Calcium-9.5 Phos-3.0 Mg-2.4
[**2111-3-28**] 03:10AM BLOOD Calcium-10.1 Phos-2.7 Mg-2.3
[**2111-3-29**] 05:40AM BLOOD Calcium-9.8 Phos-3.3 Mg-2.1
[**2111-4-1**] 06:35AM BLOOD Iron-22*
[**2111-3-24**] 12:20AM BLOOD calTIBC-322 Ferritn-17 TRF-248
[**2111-4-1**] 06:35AM BLOOD calTIBC-241* VitB12-1725* Folate-GREATER
TH Ferritn-61 TRF-185*
[**2111-3-24**] 11:41PM BLOOD Type-ART pO2-350* pCO2-43 pH-7.38
calTCO2-26 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2111-3-25**] 01:00AM BLOOD Type-ART pO2-393* pCO2-38 pH-7.41
calTCO2-25 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2111-3-24**] 11:41PM BLOOD Glucose-239* Lactate-1.1 Na-142 K-4.3
Cl-108
[**2111-3-25**] 01:00AM BLOOD Glucose-305* Lactate-1.3 Na-142 K-4.0
Cl-111
Imaging:
[**3-24**] CXR: No acute cardiopulmonary process.
[**3-24**] CT Abd/Pelvis:
1. Ulcerating mass in the fundus of the stomach without definite
evidence of local invasion or metastatic disease on this
non-contrast exam. However, several adjacent lymph nodes are
borderline enlarged and lymphatic extension cannot be excluded.
2. 2 cm left renal hypodensity likely represents a cyst, but is
incompletely characterized.
3. Cholelithiasis without evidence of cholecystitis.
[**3-24**] CT Chest: The lungs are clear without effusion,
consolidation, or nodule. Heart size is normal. Scattered
mesenteric and axillary nodes either have a fatty hilum or are
below size criteria for enlargement. Moderate coronary
atherosclerotic calcifications are most prominent in the left
anterior descending artery. There is trace pericardial effusion.
[**2111-3-27**] CXR:
Since [**2111-3-24**], surgical cutaneous clips are new. A
nasogastric tube was installed with its sideholes near the
gastroesophageal junction. A drain is in the upper abdomen.
Interstitial markings are more prominent, could be due to
interstitial edema or overhydration. Pleural effusion, if any
would be minimal. Note that the left costophrenic angle was
excluded. Heart size is overall unchanged.
[**2111-3-30**] Upper GI:
IMPRESSION: No evidence of anastomotic leak. Patent
esophagojejunal
anastomosis.
Brief Hospital Course:
Gastrectomy: Patient was admitted to the surgery service and had
a total gastrectomy. Postoperatively, she was admitted to the
ICU. On [**2111-3-27**] she was stable and transferred to the floor.
Her NG tube was pulled on [**2111-3-30**] and she had an upper GI study
which showed no leak. The JP drain was removed on [**2111-3-31**].
She reported dark stools, but did not have an abrupt drop in
hematocrit as evidence in labs.
Diabetes: Her sugars were controlled with sliding scale
insulin, and the doses of long-acting insulin were increased as
her tube feeds were advanced and as her diet was advanced. Her
tube feeds were discontinued on [**2111-3-31**].
Anemia: Patient's hematocrit was intermittently monitored,
reaching a low of 20.5 on [**2111-3-29**]. Effort was made to minimize
the frequency of blood draws. She had a hematology consult on
[**3-31**] while inpatient for recommendations on IV iron. She
received IV iron on [**2111-4-1**] with no complications. She was
continued on iron and B12, and epoetin alpha while inpatient.
She complained of occasional lightheadedness while inpatient,
but this resolved prior to discharge.
She was restarted on her home medications prior to discharge.
She was discharged to home with services in stable condition.
She was tolerating a diet, ambulating, and her pain was
controlled.
Medications on Admission:
Armour thyroid 90
cod liver oil
MVI
herbal supplements
coreg 6.25''
ISS
Humulin N 14units qam, 13units qpm
imdur 30
iron 18
procrit 40,000U q3 weeks
protonix 40mg daily
Discharge Medications:
1. Thyroid 30 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
2. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) injection
Injection once a month.
7. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Insulin NPH & Regular Human Subcutaneous
10. 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 With Service
Facility:
[**Location (un) 8300**] VNA
Discharge Diagnosis:
Gastric Cancer
Upper gastrointestinal hemorrhage
Anemia
Type 1 diabetes
Discharge Condition:
Stable. Anemic.
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.
* 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.
Other:
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Incision Care:
-If your staples were removed and steri-strips were placed, they
will fall off on their own. Please remove any remaining strips
7-10 days after surgery.
-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.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**3-25**] weeks. Call his
office ASAP to make your appointment. ([**Telephone/Fax (1) 1483**].
Please coordinate your vitamin B12 (monthly) and iron injections
with your primary care physician.
|
[
"151.0",
"593.9",
"585.3",
"357.2",
"578.9",
"250.61",
"300.01",
"309.81",
"V13.02",
"285.21",
"276.0",
"280.9",
"412",
"250.41",
"196.2",
"V12.72",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.99",
"96.6",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
9817, 9876
|
7338, 8690
|
387, 429
|
9991, 10008
|
3397, 7315
|
11585, 11838
|
3142, 3146
|
8909, 9794
|
9897, 9970
|
8716, 8886
|
10032, 11179
|
11194, 11562
|
3161, 3378
|
325, 349
|
457, 2418
|
2440, 3001
|
3017, 3126
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,143
| 101,985
|
11011
|
Discharge summary
|
report
|
Admission Date: [**2118-8-5**] Discharge Date: [**2118-8-25**]
Date of Birth: [**2094-5-3**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 24-year-old male with
past medical history significant for bilateral PE with
bilateral pleural effusions and pericardial effusions in [**2118-6-3**] requiring extensive MICU stay and prolonged
hospitalization. Since discharge, the patient had been
reasonably well, however, over the week prior to admission he
developed onset of pleuritic right sided anterior chest pain
associated with exertional dyspnea. Emergency Room
evaluation done at that time revealed no new clot by CTA but
revealed a right atrial abnormality. Follow-up echo showed
echo dense space intimately associated with either the
pericardium or the pleural space. The patient was
hemodynamically stable without pulses paradoxus or tamponade.
Repeat echo 7 days later was done with stability in the
patient's symptoms. Echo at this time showed increased size
of the right sided loculated pericardial effusion with
diastolic compression of the RV. Chest x-ray showed increase
in heart size. In clinic on the day of admission the patient
was hemodynamically stable. EKG showed ST elevations in 2,
3, and AVF with PR depressions in 3 and a pulsus paradoxus of
10. The patient was sent to the Emergency Room for
admission.
PAST MEDICAL HISTORY: Pericardial effusion status post
drainage with pigtail catheter in [**2118-6-3**] with negative
rheumatologic malignant and infectious work-up. Bilateral
pleural effusion status post pigtail drainage of the right
with negative work-up as well for rheumatologic infectious
disease and malignancy, bilateral pulmonary emboli diagnosed
in [**2118-6-3**], treated with Heparin initially and currently
anticoagulated on Coumadin, history of heterozygosity for
factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12843**] mutation.
MEDICATIONS: Coumadin 8 mg q day, Tylenol 650 mg prn.
ALLERGIES: None known.
SOCIAL HISTORY: He is a heterosexual male in a monogamous
relationship. He denies tobacco, denies drug use, used
alcohol in the past prior to his [**Month (only) **] hospitalization of
greater than 30 beers per week. He is from Great [**Last Name (un) 35668**]
and is a sailor.
FAMILY HISTORY: Grandfather had [**Name2 (NI) 499**] cancer and also a
grandparent with lung cancer.
PHYSICAL EXAMINATION: Temperature 99.0, heart rate 90-106,
blood pressure 128/76, respirations 12, satting 99% on room
air. In general, in no apparent distress sitting in bed.
HEENT: Pupils equally round and reactive to light, moist
mucus membranes, JVD approximately 4-5 cm above the right
atrium. Cardiovascular, regular rate and rhythm, no murmurs,
rubs, gallops. Respirations clear to auscultation
bilaterally. Abdomen soft, nontender, normoactive bowel
sounds. Extremities, no clubbing, cyanosis or edema.
Neurologically alert and oriented times three, grossly non
focal.
LABORATORY DATA: On admission, white count 6.3, neutrophils
58, 0 bands, 33 lymphs, 7 monos, 2 eos, hematocrit of 34.1,
platelet count 270,000, sodium 141, potassium 4.6, chloride
105, CO2 21, BUN 12, creatinine 0.9, glucose 93. Chest x-ray
as dictated in the HPI. EKG showed normal sinus rhythm, left
and right atrial abnormalities, 1-2 mm ST segment elevations
in leads 2, 3, and F, PR depression in 2. ST elevations were
new compared to EKG from [**6-3**].
HOSPITAL COURSE: The patient was admitted initially to the
medicine service where cardiothoracic consultation was
obtained for his pericardial effusion. Initially this was
thought secondary to recurrent pericarditis. Plans were made
for going to the OR for pericardial window. On [**2118-8-9**] the
patient was taken to the operating room by cardiothoracic
surgery for pericardial window. At the time of surgery,
transesophageal echocardiogram was performed and showed
abnormality in the right atrium consistent with perforation
with overlying clots and fluid loculated on pericardial
effusion. At this time plans were suspended for pericardial
window with plans for medial sternotomy in [**1-4**] days for
repair of right atrial abnormality. The patient was
transferred to the Coronary Care Unit overnight where he
remained hemodynamically stable. He was taken to the
operating room again on [**2118-8-11**] where the patient underwent
median sternotomy with exploration of his cardiac anatomy.
At the time of surgery multiple tumor nodules were noted
within the pericardium and eroding into the right atrium.
Major debulking occurred at the time. The right atrium was
closed and pericardial partial stripping was performed.
Hemostasis was achieved. The patient was transferred in
stable condition from the OR to the cardiac surgery Intensive
Care Unit where he remained intubated for 24 hours. He was
extubated on [**2118-8-12**] without complication. His postoperative
course was complicated by significant blood loss requiring a
number of blood transfusions to maintain a hematocrit between
25 and 30. His chest tubes and mediastinal tubes were
removed without complication on postoperative day #3. On
postoperative day #4 anticoagulation for history of bilateral
pulmonary emboli was reinitiated with IV unfractionated
Heparin without a bolus. Within 8-10 hours of reinstitution
of anticoagulation the patient became tachypneic, tachycardic
and hypoxic. At that time it was noted to have a large
re-accumulation of fluid in his right hemithorax on chest
x-ray as well as a small pneumothorax. Cardiothoracic
surgery inserted 32 French chest tube at the bedside without
complication. Drainage of 2 liters of bloody fluid was
yielded. Patient's anticoagulation was stopped and reversed
with Protamine at that time. The patient obtained
hemodynamic stability and his chest tubes were discontinued
without complications on postoperative day #7. Follow-up
chest x-ray throughout the remainder of the hospital course
showed resolution of the patient's pneumothorax and stability
in a small right sided pleural effusion. Follow-up CAT scan
revealed abnormality consistent with tumor and postoperative
changes along the right cardiac border with bilateral
atelectasis. No pulmonary metastases. Follow-up staging
abdominal CT was performed during this hospitalization which
revealed no evidence of metastases, showed a small right
inguinal seroma.
Infectious Disease: The patient began spiking fevers on
postoperative day #1, up to 104 degrees. Multiple cultures
were obtained which remained negative. Infectious disease
was consulted initially. The patient was placed briefly on
Vancomycin and Ceftaz but after pan CT revealed no evidence
of fluid collection or infectious etiology, these antibiotics
were discontinued. The patient's fever curve trended down
throughout his admission without any evidence of bacterial
etiology to his fevers. The thought was the fevers were
secondary to tumor fever. Upon discharge the patient's fever
curve had been trending down with occasional low grade
temperatures.
Heme: The patient's anticoagulation was initially restarted
but after re-complication with hemopneumothorax, was
discontinued and not restarted. The risks and benefits of
anticoagulation were weighed. Given the remainder of tumor
still involved in the cardiac tissue and the risk of bleed,
it was decided not to re-anticoagulate the patient for
several weeks, if ever. The patient required several blood
transfusions, platelet transfusions, FFP and cryoprecipitates
during his surgery and occasionally after to maintain
hematocrit between 25-30. Upon discharge the patient's
hematocrit was stable for 4-5 days at 26??????. He had no signs
of bleeding. He will avoid non steroidals as they may
increase his risk of bleeding.
Cardiovascular: As above. The patient developed a new
pericardial friction rub during this admission after his
operative course. Echocardiogram was performed on [**8-21**] to
evaluate this pericardial friction rub which revealed no
pericardial effusion, stable LV and RV function. The patient
had some tachycardia that resolved by discharge.
Pain: The patient had significant chest discomfort during
this hospitalization which initially required PCA. He was
transitioned to OxyContin with Percocet for breakthrough and
was discharged on 30 mg q a.m., 20 mg of OxyContin q p.m. and
Percocet for breakthrough.
Renal: The patient's kidney function remained stable
throughout this hospitalization.
Pulmonary: The patient had to rule out the possibility of
DVT leading to PE secondary to concerns over his chest pain.
This was negative on [**2118-8-24**]. The patient will not be
re-anticoagulated secondary to concerns of his bleed. The
patient's oxygen saturation was maintained between 94 and 95%
on room air at the time of discharge.
Fluids, Electrolytes & Nutrition: The patient was tolerating
full diet on discharge. He required intermittent
electrolytes repletion during his hospitalization.
Heme/Onc: Patient's tumor at resection was sent to
pathology. Pathologic diagnosis revealed angiosarcoma of low
grade type. Heme/Onc was consulted immediately
postoperatively. Plans were made for chemotherapy as an
outpatient vs transfer back to the United Kingdom for
treatment there. The patient will follow-up with Dr. [**First Name8 (NamePattern2) 189**]
[**Last Name (NamePattern1) **] on [**2118-9-2**] for arrangement of his chemotherapy at a
time when he is fully healed from his cardiothoracic surgery.
Social Work: The patient was seen extensively by social work
and case management during this hospitalization. Plans were
made for living situation upon discharge as the patient is
from Great [**Last Name (un) 35668**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 35669**] was instrumental in
arranging this. Patient was discharged on [**2118-8-25**] to home.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSIS:
1. Angiosarcoma of cardiac origin.
2. Right atrial perforation secondary to tumor.
3. Pericardial effusion causing tamponade physiology.
4. Anemia secondary to blood loss as a complication of
cardiothoracic surgery.
5. History of bilateral pulmonary embolus.
6. Status post hemopneumothorax.
7. Postoperative chest pain.
DISCHARGE MEDICATIONS: OxyContin 30 mg q a.m., 20 mg q p.m.,
Percocet 5/325 1-2 tablets po q 4-6 hours prn for
breakthrough pain, Colace 100 mg [**Hospital1 **], Zantac 150 mg [**Hospital1 **] and
Bacitracin topically to affected areas tid.
FOLLOW-UP: He will follow-up with his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3640**] on [**2118-9-9**] at 3:30 p.m. in the
clinical center, [**Hospital Ward Name 23**] Bldg., [**Location (un) **]. He will also
follow-up with Dr. [**First Name8 (NamePattern2) 189**] [**Last Name (NamePattern1) **] on [**2118-9-2**] in the
clinical center, [**Location (un) **].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 35670**]
MEDQUIST36
D: [**2118-8-26**] 10:00
T: [**2118-8-30**] 16:07
JOB#: [**Job Number **]
|
[
"780.6",
"164.1",
"V12.51",
"286.3",
"512.1",
"285.1",
"998.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.23",
"37.31",
"37.4",
"34.04",
"37.33",
"88.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
2314, 2400
|
10327, 11270
|
9974, 10303
|
3467, 9953
|
2423, 3449
|
164, 1369
|
1392, 2015
|
2032, 2297
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,655
| 115,606
|
37628
|
Discharge summary
|
report
|
Admission Date: [**2167-12-2**] Discharge Date: [**2167-12-16**]
Date of Birth: [**2120-12-21**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Vancomycin-D5w
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
right ankle pain
Major Surgical or Invasive Procedure:
[**2167-12-3**]: s/p:
1. Treatment of right tibia nonunion with iliac crest bone
graft and free fibula graft.
2. Application multiplanar external fixator, right leg.
3. Deep bone biopsy, right tibia.
History of Present Illness:
47 yo male with infected non [**Hospital1 **] distal tibia s/p orif and
revisions of distal tibial fx
Past Medical History:
chronic pancreatitis
GERD
Right tibia fracture [**9-/2166**]
Social History:
Construction worker
Stopped smoking prior to non-[**Hospital1 **] repair on [**3-/2167**]
Family History:
non-contributory
Physical Exam:
VS: 100.0 99.8 98/60 96 16 94RA
GEN: pleasant, nad
HEENT: PERRL, EOMI, sclerae anicteric, neck supple, MMM, no
ulcers/lesions/thrush
CV: RRR, normal S1, S2, no M/G/R
PULM: decreased breath sounds in bases
BACK: no focal tenderness, no CVAT
GI: normoactive BS, soft, non-tender, distended, no rebound
MSK:
- operative
EXT: warm and well perfused, no edema, 2+ DP pulses palpable
bilaterally
LYMPH: no cervical, axillary, or inguinal lymphadenopathy
SKIN: no rashes, no jaundice
NEURO: AAOx3, CN 2-12 intact, 5/5 strength b/l, reflexes 1+
bilaterally, normal sensitivity
PSYCH: non-anxious, normal affect
Pertinent Results:
[**2167-12-15**] 10:47AM BLOOD WBC-5.2 RBC-2.91* Hgb-9.4* Hct-27.5*
MCV-94 MCH-32.3* MCHC-34.2 RDW-13.6 Plt Ct-438
[**2167-12-13**] 08:35AM BLOOD WBC-4.6 RBC-2.71* Hgb-9.0* Hct-25.5*
MCV-94 MCH-33.2* MCHC-35.3* RDW-13.9 Plt Ct-352
[**2167-12-11**] 06:48AM BLOOD WBC-5.7 RBC-2.58* Hgb-8.7* Hct-24.4*
MCV-94 MCH-33.5* MCHC-35.5* RDW-14.1 Plt Ct-305
[**2167-12-8**] 04:01AM BLOOD WBC-4.2 RBC-2.50* Hgb-8.6* Hct-23.9*
MCV-95 MCH-34.3* MCHC-36.1* RDW-13.9 Plt Ct-204
[**2167-12-7**] 09:19AM BLOOD WBC-5.3 RBC-2.64* Hgb-8.9* Hct-25.1*
MCV-95 MCH-33.7* MCHC-35.5* RDW-14.4 Plt Ct-179#
[**2167-12-4**] 06:15AM BLOOD WBC-6.7 RBC-2.59*# Hgb-8.9* Hct-25.1*#
MCV-97 MCH-34.2* MCHC-35.3* RDW-14.3 Plt Ct-98*
[**2167-12-3**] 02:58AM BLOOD WBC-10.2 RBC-3.54* Hgb-11.8* Hct-33.9*
MCV-96 MCH-33.4* MCHC-34.8 RDW-15.0 Plt Ct-126*
[**2167-12-2**] 04:45PM BLOOD WBC-9.4# RBC-4.22* Hgb-14.7 Hct-41.7
MCV-99* MCH-34.9* MCHC-35.4* RDW-12.7 Plt Ct-193
[**2167-12-15**] 10:47AM BLOOD Plt Ct-438
[**2167-12-13**] 08:35AM BLOOD Plt Ct-352
[**2167-12-11**] 06:48AM BLOOD Plt Ct-305
[**2167-12-7**] 09:19AM BLOOD Plt Ct-179#
[**2167-12-2**] 04:45PM BLOOD Plt Ct-193
[**2167-12-11**] 06:48AM BLOOD Glucose-110* UreaN-8 Creat-0.6 Na-137
K-4.1 Cl-101 HCO3-26 AnGap-14
[**2167-12-7**] 09:19AM BLOOD Glucose-136* UreaN-7 Creat-0.6 Na-137
K-3.9 Cl-104 HCO3-24 AnGap-13
[**2167-12-4**] 06:15AM BLOOD Glucose-112* UreaN-7 Creat-0.6 Na-139
K-3.6 Cl-103 HCO3-31 AnGap-9
[**2167-12-3**] 02:58AM BLOOD Glucose-142* UreaN-9 Creat-0.8 Na-144
K-4.5 Cl-109* HCO3-25 AnGap-15
[**2167-12-11**] 06:48AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.9
[**2167-12-7**] 09:19AM BLOOD Calcium-8.6 Phos-3.7# Mg-1.8
[**2167-12-4**] 06:15AM BLOOD Calcium-7.9* Phos-1.9*# Mg-1.8
Brief Hospital Course:
Mr. [**Known lastname 449**] presented to the [**Hospital1 18**] on [**2167-12-2**] for plans for a
right tibia non-[**Hospital1 **] repair. Prior to surgery he was prepped
and consented. He was taken to the operating room and underwent
a right free fibula transfer. Due to the length of the surgery
he remained intubated and was transferred to the ICU
post-operatively on [**2167-12-3**] from the operating room. He was
started post operatively on IV Vancomycin per infectious
disease. Later on [**2167-12-3**] he was weaned and extubated without
difficulty. He was then transferred to the floor for further
care. On [**2167-12-4**] his vancomycin was stopped and he was started
on Daptomycin per infectious disease. On [**2167-12-5**] he had a PICC
line placed for long term antibiotics. On [**2167-12-10**] he returned
to the operating room and underwent an adjustment of his
external fixator, revision of screws, and split thickness skin
graft with VAC placement.
The rest of his hospital stay was uneventful with his lab data
and vital signs within normal limits and his pain controlled.
He is being discharged today in stable condition.
Medications on Admission:
CREON, ESOMEPRAZOLE MAGNESIUM [NEXIUM], HYDROMORPHONE 2 mg, [**Last Name (un) **]
VITAMIN B COMPLEX, SULFAMETHOXAZOLE-TRIMETHOPRIM, ACETAMINOPHEN,
ASCORBIC ACID, CALCIUM CARBONATE, ERGOCALCIFEROL, GARLIC,
MULTIVITAMIN, VITAMIN A, ZINC
Discharge Medications:
1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous Q 24H (Every 24 Hours) for 4 weeks.
Disp:*30 syringe* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily) for 4 weeks.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
4. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
5. daptomycin 500 mg Recon Soln Sig: One (1) 600mg Intravenous
once a day for 4 weeks: End date [**2168-1-14**].
Disp:*qs bag soln* Refills:*0*
6. Outpatient Lab Work
Weekly CBC, BUN/Cr, LFTs, CK, ESR, CRP.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]
7. PICC Line
PICC line, Non-heparin dependent line
Normal Saline Flush 5-10cc daily/PRN/SASH
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] Home Infusions
Discharge Diagnosis:
Right tibial non-[**Hospital1 **] with bone defect.
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:
Wound Care:
-Keep wound dry.
-Do not soak the wound in a bath or pool.
-Keep pin sites clean and dry.
Activity:
-Continue to be non weight bearing on your right leg.
-Elevate right leg to reduce swelling and pain.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- Continue taking the antibiotic as directed.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so 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 narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Physical Therapy:
Right lower extremity non-weight bearing.
Treatments Frequency:
Pin care daily to right external fixator with half strength
hydrogen peroxide.
Followup Instructions:
2 weeks in the [**Hospital **] clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP.
Please call [**Telephone/Fax (1) 1228**] to make this appointment.
Please follow up with Dr. [**Last Name (STitle) 23606**] in...........please call his
office at [**Telephone/Fax (1) 26564**], to schedule that appointment.
Infectious Disease Follow Up:
[**2167-12-30**] 11:30a Dr. [**Last Name (STitle) 13895**], phone [**Telephone/Fax (1) 457**]
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
[**2168-2-3**] 10:00a Dr. [**Last Name (STitle) 13895**], phone [**Telephone/Fax (1) 457**]
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
Completed by:[**2167-12-25**]
|
[
"288.00",
"577.1",
"996.78",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"78.67",
"78.17",
"77.79",
"86.69",
"77.47",
"78.07",
"77.87",
"78.47"
] |
icd9pcs
|
[
[
[]
]
] |
5742, 5810
|
3239, 4392
|
298, 504
|
5906, 5906
|
1506, 3216
|
7669, 8028
|
843, 861
|
4677, 5719
|
5831, 5885
|
4418, 4654
|
6089, 6089
|
876, 1487
|
7502, 7544
|
7566, 7646
|
8039, 8409
|
242, 260
|
6101, 7484
|
532, 635
|
5921, 6065
|
657, 719
|
735, 827
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,296
| 160,944
|
39577
|
Discharge summary
|
report
|
Admission Date: [**2180-12-13**] Discharge Date: [**2180-12-15**]
Date of Birth: [**2119-7-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
61 year old male with GERD, SCLC dx'd [**8-/2180**] and metastatic to
the mediastinum and brain, s/p brain radiation and 4 cycles of
chemo and begun on thoracic radiation within the last week, who
has had an increasing pericardial effusion which was initially
noted on CT in [**Month (only) 359**] of this year. The patient had an echo on
[**12-12**] that revealed a large pericardial effusion with possible
tamponade physiology. He was scheduled to come in for elective
pericardiocentesis today but awoke with much worse SOB, was BIBA
to the [**Hospital1 18**] ED. He went to the cath lab where 300ccc
serosanguinous fluid was drained from a loculated effusion. He
tolerated the procedure well without complication and a
pericardial drain was placed for continued drainage. In the CCU,
he reports not being sure if he is feeling better given his
ongoing pain related to the procedure. Denies significant SOB or
dizziness.
.
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 dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations,
syncope or presyncope. Endorses mild pedal edema b/l for the
last few days.
Past Medical History:
-SCLC diagnosed [**8-/2180**] with mets to brain and mediastinum
-laryngeal cancer in [**2169**] s/p radiation therapy
-GERD
-s/p partial colectomy for diverticulitis with ostomy, now s/p
takedown of ostomy
-s/p hernia repair
-s/p cataract removal
Social History:
- Tobacco history: former smoker, quit 6 months ago, "many
years"
- ETOH: denies
- Illicit drugs: denies
-Lives in apt [**Location (un) 6409**] with fiancee (HCP), 2 flights of
stairs that he can climb slowly. Worked as millwright.
Family History:
No history of malignancy. Mother alive age 87. Father died at 48
unknown causes. No cardiac history.
Physical Exam:
VS: T=98.1 BP=140/67 HR=95 RR=26 O2 sat=99% 2L NC Pulsus=6
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Chronically
ill-appearing, whispers. Mildly tachypneic at times.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
CHEST: Pericardial drain in place w/ drsg c/d/i.
NECK: Supple with no JVD while upright.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. Decreased
BS at L base, crackles at R base.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: Trace pitting edema b/l to mid calf. No femoral
bruits.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
Labs on admission:
[**2180-12-13**] 10:00AM BLOOD WBC-10.5 RBC-3.22* Hgb-9.1* Hct-27.4*
MCV-85 MCH-28.3 MCHC-33.3 RDW-17.3* Plt Ct-416
[**2180-12-13**] 10:00AM BLOOD Neuts-77* Bands-3 Lymphs-6* Monos-12*
Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-1*
[**2180-12-13**] 10:00AM BLOOD PT-15.8* PTT-26.5 INR(PT)-1.4*
[**2180-12-13**] 10:00AM BLOOD Glucose-104* UreaN-20 Creat-0.9 Na-140
K-4.5 Cl-100 HCO3-26 AnGap-19
[**2180-12-13**] 10:00AM BLOOD LD(LDH)-535*
[**2180-12-13**] 10:00AM BLOOD cTropnT-<0.01
[**2180-12-13**] 10:00AM BLOOD TotProt-6.5 Albumin-3.2* Globuln-3.3
[**2180-12-14**] 05:10AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.3*
Pericardial fluid:
[**2180-12-13**] 04:45PM OTHER BODY FLUID WBC-[**2169**]* RBC-[**Numeric Identifier 87357**]*
Polys-21* Lymphs-64* Monos-6* Plasma-1* Macro-8*
[**2180-12-13**] 04:45PM OTHER BODY FLUID TotProt-4.5 Glucose-76
LD(LDH)-1338 Amylase-28 Albumin-2.3
Fluid cytology - no malignant cells
Labs on discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2180-12-15**] 05:45 7.2 3.20* 9.2* 26.7* 84 28.6 34.3 17.0* 348
BASIC COAGULATION PT PTT INR(PT)
[**2180-12-15**] 05:45 15.5* 27.6 1.4*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
[**2180-12-15**] 05:45 87 18 0.9 133 4.8 98 28
CHEMISTRY Calcium Phos Mg
[**2180-12-15**] 05:45 8.3* 4.1 1.8
Microbiology:
[**2180-12-13**] 4:45 pm PERICARDIAL FLUID.
GRAM STAIN (Final [**2180-12-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2180-12-14**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
[**2180-12-13**] 4:45 pm PERICARDIAL FLUID.
Fluid Culture in Bottles (Preliminary): NO GROWTH.
Imaging / other studies:
TTE (prior to drainage):
The estimated right atrial pressure is 10-20mmHg. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Right ventricular chamber size
is normal. with mild global free wall hypokinesis. The aortic
valve leaflets are mildly thickened (?#). The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is moderate pulmonary
artery systolic hypertension. There is a large pericardial
effusion measruing 2.5cm around the apex and 2cm along the
lateral and distal third of the left ventricle. There is minimal
anterior to the right ventricle and right atrium. There is
significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, c/w impaired ventricular filling
and increased pericardial pressure/tamponade physiology.
Compared with the prior study (images reviewed) of [**2180-9-19**],
the effusion is larger with increased pericardial
pressure/tamponade now suggested. The heart rate is also now
greater.
TTE (s/p drainage):
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). with normal free wall
contractility. There is a trivial echodense pericardial
effusion, primarily around the RV apex.
IMPRESSION: No clinically-significant residual pericardial
effusion.
Compared with the prior study (images reviewed) of [**2180-12-12**],
pericardial effusion has been successfully drained.
TTE (1 day s/p drainage):
Overall left ventricular systolic function is normal (LVEF>55%).
Mild (1+) mitral regurgitation is seen. There is a small
pericardial effusion. The effusion appears circumferential. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade.
IMPRESSION: poor echo windows. There is a small amount of
residual fluid seen. There is an echodense mass at the apex and
lateral wall of the left ventricle (see in particular image #8).
This is probably collapsed lung outside the pericardium rather
than echo dense material in the pericardium. No echo evidence of
tamponade.
Compared with the prior study (images reviewed) of [**2180-12-13**],
the previously seen pericardial fluid has been drained.
CXR:
IMPRESSION:
1) Findings compatible with interval development of
post-obstructive pneumonia and left lower lobe collapse.
2) Known mediastinal mass and right pulmonary nodule.
Brief Hospital Course:
61yo M with SCLC diagnosed in [**8-/2180**] c/b CNS and mediastinal
metastases with known prior pericardial effusion, presents with
increasing dyspnea, with pericardiocentesis prior to admission
to CCU.
.
# Pericardial effusion: Known small effusion from [**9-/2180**] CT
chest. Increased to moderate size on a recent CT, but then
appeared even larger on TTE done on admission with concern for
tamponade physiology due to his presenting symptoms.
Pericardiocentesis was performed and a drain was placed. Fluid
studies were notable for large amount of RBCs and protein/LDH
ratios that satisfied Light's criteria for exudate. After the
procedure, there was no evidence of tamponade on exam and his
blood pressures remained stable. Though the effusion was
reported as loculated, the decision was made to defer a
pericardial window at this time due to his comorbidities, good
drainage, and symptomatic relief. His drainage site pain was
controlled with long-acting oxycontin and oxycodone for
breakthrough. Follow-up TTEs did not show reaccumulation of the
effusion and frequent checks were negative for pulsus paradoxus.
The drain was pulled prior to discharge. He will be discharged
with pain medications for the drainage site pain.
# Healthcare associated pneumonia: Based on the CXR finding of
post-obstructive pneumonia and bandemia, we gave levofloxacin
for coverage of a presumed pneumonia. He should continue these
antibiotics for 7 days, to end on [**12-19**].
# Anemia: Hct reached a nadir of 24.8. Since the patient has a
large tumor burden and will be getting XRT on the Monday
following discharge, Hematology/Oncology recommended transfusion
and he was given 1 unit pRBCs prior to discharge with Hct of
26.2.
Medications on Admission:
-Omeprazole 40mg daily
-Acetaminophen prn
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain for 7 days.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Pericardial effusion
Secondary diagnosis:
Metastatic small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 37393**],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted with increasing shortness of
breath and an enlarging fluid collection around your heart. You
underwent a procedure to drain this fluid so that your heart
could work more efficiently. A drain was placed so that the
fluid did not re-collect and we gave you medications to help
control the pain associated with the procedure. We also gave
you some blood because your blood count was a little low during
your stay. We pulled out the drain before you left. We have
also provided you with some medication to help control your pain
around the drainage site. Keep the drain site dry and leave the
dressing in place for the next 24 hours.
You should continue to use your oxygen at home as you need it.
If you have a recurrence of your symptoms, such as shortness of
breath, chest pain, or dizziness/fainting, please be sure to
inform your doctors and return to the Emergency Department.
We have made the following changes to your medications:
1) START levofloxacin 750mg daily until [**2180-12-19**]
2) START oxycodone 5mg every 4 to 6 hours as needed for pain.
YOU SHOULD NOT DRIVE OR PARTICIPATE IN HAZARDOUS ACTIVITIES
WHILE TAKING THIS MEDICATION.
Followup Instructions:
Please follow-up with your outpatient center for radiation
therapy on Monday.
You have the following appointment scheduled for you at [**Hospital1 18**]:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2181-1-23**] at 9:30 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**0-0-**] / [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) 4913**], MD
[**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"423.0",
"530.81",
"V10.21",
"197.1",
"198.3",
"285.22",
"485",
"162.9",
"423.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
10149, 10155
|
7861, 9591
|
314, 334
|
10295, 10295
|
3365, 3370
|
11739, 12297
|
2390, 2492
|
9683, 10126
|
10176, 10176
|
9617, 9660
|
10446, 11477
|
2507, 3346
|
5086, 7838
|
5027, 5050
|
11506, 11716
|
267, 276
|
4309, 4898
|
362, 1853
|
10238, 10274
|
10195, 10217
|
3385, 4290
|
4980, 4994
|
10310, 10422
|
1875, 2124
|
2140, 2374
|
4930, 4944
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,872
| 131,850
|
11900
|
Discharge summary
|
report
|
Admission Date: [**2110-11-30**] Discharge Date: [**2110-12-15**]
Service: CCU
HISTORY OF PRESENT ILLNESS: An 86-year-old Chinese male with
a past medical history significant only of hypertension who
presents with a 2-day history of decreased p.o. intake, the
feeling of cold, and increased thirst but denying any pain.
Beginning in [**Month (only) 216**], the patient developed abdominal cramps,
decreased appetite, intermittent low-grade temperatures, and
weight loss. He denies nausea, vomiting, diarrhea,
dysphagia, or hematemesis. In [**Month (only) 359**] he was seen in a
doctor's office with a productive cough when a thoracentesis
was done for unknown reason.
A week and a half prior to admission, the patient noted pedal
edema. The patient also with decreased mobility, walking
with cane due to fatigue and shortness of breath. He denied
any associated chest pain, lightheadedness, headache, or back
pain. At the time of admission the patient was without cough
or sick contacts. [**Name (NI) **] history of pets. No recent travel.
The patient just emigrated from [**Country 651**] within the last two
years.
PAST MEDICAL HISTORY: Hypertension and hard of hearing.
MEDICATIONS ON ADMISSION: Norvasc, Zantac, and Tylenol.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No alcohol. The patient was a smoker until
20 years ago. The patient emigrated from southern [**Country 651**]
seven years ago. He lives with his son who still smokes, and
the patient used to be a rice farmer.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed afebrile, vital signs were stable. In
general, Chinese speaking, hard of hearing male, comfortable,
alert. Head, eyes, ears, nose, and throat revealed
extraocular muscles were intact. Mucous membranes were dry.
The oropharynx was clear. No lesions. Cardiovascular
revealed irregularly irregular, a 3/6 systolic ejection
murmur throughout the precordium with radiation to the
axilla. No third heart sound or fourth heart sound. Lungs
revealed decreased breath sounds at the bilateral bases; left
greater than right, with associated crackles. Also, crackles
in the left anterior apex and dullness to percussion
basilarly. No E to A changes. The abdomen was mildly
distended, soft, tender to moderate palpation in the right
upper quadrant, left upper quadrant, and epigastrium. The
liver edge was smooth. Negative [**Doctor Last Name **] sign. Occult-blood
negative. Extremities revealed ankle edema of 2 to 3+.
PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell
count of 4, hematocrit of 33, platelets of 142 (89% polys, no
bands, 7% lymphocytes, 2.6% monocytes, 0.9% eosinophils).
Sodium of 129; and electrolytes were within normal limits.
Coagulations were normal. Liver function tests revealed ALT
of 39, AST of 83, alkaline phosphatase of 442, amylase of 88,
lipase of 81, total bilirubin of 1.9, LDH of 527, albumin
of 2.7.
RADIOLOGY/IMAGING: Chest x-ray showed right lower and middle
lobe with interstitial honeycomb pattern, right-sided
mediastinal shift, and a left lower lobe effusion; likely
loculated.
Electrocardiogram showed wondering atrial pacemaker with a
normal axis, small Q wave in I, V5 and V6, right
bundle-branch block, poor R wave progression, and T wave
inversions in V1 and V2.
CT showed no definite mass and left pleural loculated
effusion, question of left lower lobe collapse and
adenopathy, right-sided increase in interstitial markings,
and right pleural thickening.
HOSPITAL COURSE: On [**12-2**], the patient had nonsustained
ventricular tachycardia on the floor and ST elevations was
transferred to the Coronary Care Unit for acute myocardial
infarction versus pericarditis. An echocardiogram showed an
ejection fraction of 25% with anterior hypokinesis, and the
patient was started on heparin.
The patient underwent cardiac catheterization on [**12-3**]
which showed clean coronaries. The patient became
hypotensive and tachypneic and required intubation. On chest
CT a miliary pattern suspicious for tuberculosis was seen
throughout the lungs. The patient was started on antibiotic
coverage for tuberculosis, per Infectious Disease, on
isoniazid, rifampin, patient-controlled analgesia, and SM
ethambutol.
The patient underwent bronchoscopy as part of his
tuberculosis workup which revealed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 564**] albicans
pneumonia with necrotic areas throughout the bronchi. The
patient was also started on intravenous fluconazole. The
patient also with an episode of DIC, and ultimately sepsis.
The patient was also started on ceftazidime when the patient
was unable to maintain adequate blood pressure. It was
believed that he was becoming septic. Unfortunately, the
patient then expired and resuscitation was not attempted
since the patient was do not resuscitate/do not intubate, per
the family's request.
DATE OF EXPIRATION: [**2110-12-15**]. The family refused
autopsy.
DR.[**Last Name (STitle) 2052**],[**First Name3 (LF) 2053**] 12-462
Dictated By:[**Name8 (MD) 15885**]
MEDQUIST36
D: [**2111-2-26**] 17:16
T: [**2111-2-27**] 07:25
JOB#: [**Job Number 37498**]
|
[
"427.1",
"286.6",
"112.4",
"789.5",
"584.5",
"276.2",
"570",
"785.51",
"018.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.04",
"88.53",
"88.56",
"96.72",
"96.56",
"37.23",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
1225, 1294
|
3552, 5236
|
118, 1140
|
1163, 1198
|
1311, 3534
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,071
| 198,309
|
16037
|
Discharge summary
|
report
|
Admission Date: [**2198-5-13**] Discharge Date: [**2198-5-29**]
Date of Birth: [**2136-7-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Bacitracin / Aminoglycosides
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**5-17**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag,
SVG to OM, SVG to PDA)
[**5-14**] Cardiac Cath
History of Present Illness:
61 yo M with DM, HTN, end-stage hypertensive nephropathy s/p
living-related renal transplant in [**2197-8-27**] on chronic
immunosuppressives transferred from OSH with acute MI for
cardiac catheterization. He was admitted to [**Hospital **] hospital on
[**2198-5-11**] with dyspnea and found to have congestive heart failure.
Cath revealed 20% LM, 95% LAD, CX 50%, OM 3 70%, LPL 50%, OM 6/
LPL 60%, RCA 80-90%, RPDA 90%. Referred for CABG.
Past Medical History:
Hypertension, Diabetes Mellitus w/ Retinopathy (legally blind),
Carotid Artery Disease, End Stage Renal Disease s/p Renal
Transplant c/b delayed graft function and wound healing,
Obesity, Osteoporosis, CVA, s/p Bilat. Victrectomies, s/p
Cataract surgery, s/p Renal Transplant c/b delayed graft
function and wound healing, s/p AV Fistula placement, GERD
Social History:
Married, lives with wife. [**Name (NI) **] tobacco, rare alcohol, no IVDU
Family History:
Colon CA, sibling with lymphoma. Sister with DM
Physical Exam:
PE: 97.9F HR 76 BP 132/75 20 95RA
5'9" 110.7 kg
Gen: awake, alert, pleasant, obese male in no acute distress
Skin: Abd. Incision healed with 4cm area open wound
HEENT: PERRL, anicteric sclera, OP clear, MMM
CV: RRR. S1, S2 -c/r/m/g
Pulm: CTAB -w/r/r
Abd: Normoactive bowel sounds, soft, obese, nontender, no HSM
appreciated
Ext: WWP, no edema , mild bilat varicosities below knee
Neuro: R-sided weakness LE>UE
Pertinent Results:
[**5-14**] Cath: 1. Selective coronary angiography of this co-dominant
system revealed multi vessel disease. The LMCA was mildly
calcified with a distal 20% lesion. The LAD showed moderate
calcification; proximal ulcerated 90% at d1; d1 origin 95%; mid
70%; diffuse mid-distal 80-90% at modest d3. The LCX showed
moderate calcification; proximal tubular 50%; major om2 diffuse
disease in both branches to 70%; OM5/LPL proximal 50% then 60%
in lower pole; major OM6/LPL proximal 60%; diffusely diseased
LPDA. The RCA showed diffuse disease throughout to 50% mid, 50%
mid-distal; 80-90% at RPDA, with diffuse disease to 80% in RPDA.
2. LVEDP was elevated with a mean pressure of 23mmHg. 3. Of
note, access was via the left radial approach.
[**5-15**] Head CT: No evidence of acute hemorrhage or edema. Sequelae
of chronic small vessel infarction as described.
[**5-17**] Echo: PRE-BYPASS: The left atrium is moderately dilated.
The left atrium is elongated. 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. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. No left ventricular
aneurysm is seen. There is severe regional left ventricular
systolic dysfunction consitent with coronary artery disease more
severely affected LAD territory. There is moderate global left
ventricular hypokinesis. Right ventricular chamber size and free
wall motion are normal. There are focal calcifications in the
aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**11-28**]+) mitral regurgitation is seen.
There is no pericardial effusion. POST-BYPASS: Normal RV
systolic function. Overall improvement of LV systolic function
with improvement of LAD territory functions as well. LVEF 45%
Trace to Mild MR [**First Name (Titles) **] [**Last Name (Titles) **] TR. Ascending aorta intact.
[**2198-5-13**] 11:55PM BLOOD WBC-4.8 RBC-4.21* Hgb-11.7* Hct-33.4*
MCV-79*# MCH-27.8 MCHC-35.1* RDW-15.3 Plt Ct-233
[**2198-5-17**] 03:05PM BLOOD WBC-8.5 RBC-3.23* Hgb-9.0* Hct-26.0*
MCV-80* MCH-27.8 MCHC-34.7 RDW-16.3* Plt Ct-181
[**2198-5-22**] 06:45AM BLOOD WBC-7.5 RBC-3.61* Hgb-10.2* Hct-31.1*
MCV-86 MCH-28.2 MCHC-32.8 RDW-16.5* Plt Ct-246#
[**2198-5-13**] 11:55PM BLOOD PT-11.9 PTT-32.5 INR(PT)-1.0
[**2198-5-17**] 03:05PM BLOOD PT-13.1 PTT-31.9 INR(PT)-1.1
[**2198-5-13**] 11:55PM BLOOD Glucose-121* UreaN-31* Creat-1.9* Na-142
K-3.3 Cl-100 HCO3-27 AnGap-18
[**2198-5-22**] 06:45AM BLOOD Glucose-99 UreaN-27* Creat-2.0* Na-140
K-3.7 Cl-104 HCO3-22 AnGap-18
[**2198-5-18**] 12:04PM BLOOD ALT-23 AST-40 LD(LDH)-334* AlkPhos-46
TotBili-0.8
[**2198-5-28**] 06:05AM BLOOD WBC-9.6 RBC-4.18* Hgb-11.6* Hct-34.7*
MCV-83 MCH-27.9 MCHC-33.6 RDW-16.7* Plt Ct-440
[**2198-5-28**] 06:05AM BLOOD Plt Ct-440
[**2198-5-28**] 06:05AM BLOOD Glucose-118* UreaN-19 Creat-1.4* Na-140
K-4.5 Cl-106 HCO3-22 AnGap-17
[**2198-5-28**] 06:05AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.0
[**2198-5-14**] 06:50AM BLOOD Triglyc-222* HDL-46 CHOL/HD-4.4
LDLcalc-114
[**2198-5-14**] 10:30AM BLOOD %HbA1c-7.1*
[**2198-5-14**] 10:30AM BLOOD VitB12-491
[**2198-5-23**] 04:21PM BLOOD Ammonia-21
[**2198-5-28**] 06:05AM BLOOD FK506-10.2
Cardiology Report ECHO Study Date of [**2198-5-17**]
PATIENT/TEST INFORMATION:
Indication: Unstable agina
Height: (in) 69
Weight (lb): 225
BSA (m2): 2.17 m2
BP (mm Hg): 110/60
HR (bpm): 72
Status: Inpatient
Date/Time: [**2198-5-17**] at 10:56
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW04-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.7 cm (nl <= 5.2 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.5 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 25% to 30% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A Ratio: 1.33
Mitral Valve - E Wave Deceleration Time: 242 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement. Elongated LA. No
spontaneous echo
contrast or thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
No LV
aneurysm. Severe regional LV systolic dysfunction. Moderate
global LV
hypokinesis.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid
anteroseptal -
hypo; anterior apex - hypo; septal apex - hypo; inferior apex -
hypo; lateral
apex - hypo; apex - akinetic;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending
aorta. Normal aortic arch diameter. Focal calcifications in
aortic arch.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. The MR
vena contracta is
<0.3cm. Mild to moderate ([**11-28**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. The patient appears
to be in sinus
the patient.
See Conclusions for post-bypass data
Conclusions:
PRE-BYPASS:
The left atrium is moderately dilated. The left atrium is
elongated. 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.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size
is normal. No left ventricular aneurysm is seen. There is severe
regional left
ventricular systolic dysfunction consitent with coronary artery
disease more
severely affected LAD territory. There is moderate global left
ventricular
hypokinesis.
Right ventricular chamber size and free wall motion are normal.
There are focal calcifications in the aortic arch. There are
simple atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**11-28**]+) mitral
regurgitation is seen. There is no pericardial effusion.
POST-BYPASS:
Normal RV systolic function.
Overall improvement of LV systolic function with improvement of
LAD territory
functions as well. LVEF 45%
Trace to Mild MR [**First Name (Titles) **] [**Last Name (Titles) **] TR.
Ascending aorta intact
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD on [**2198-5-17**]
14:12.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 45894**])
RADIOLOGY Final Report
CHEST (PA & LAT) [**2198-5-26**] 9:19 AM
CHEST (PA & LAT)
Reason: please evaluate pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
61 year old man s/p CABG
REASON FOR THIS EXAMINATION:
please evaluate pleural effusions
STUDY: PA and lateral chest, [**2198-5-26**].
HISTORY: 61-year-old man status post CABG. Evaluate pleural
effusions.
FINDINGS: Comparison is made to previous study from [**2198-5-23**].
Median sternotomy wires and cardiomegaly is seen. The lungs are
clear, without pulmonary edema, focal infiltrates. On the
lateral view, bilateral pleural effusions are identified.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2198-5-26**] 3:51 PM
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 9035**] was transferred from OSH
w/ NSTEMI for cardiac cath. Cardiac catheterization showed
significant 3 vessel disease and he was referred for surgical
revascularization. During the following few days, he had a
pre-op workup by CT surgery, including a CXR and echocardiogram.
He was also seen by nephrology, neurology and had a head CT.
His diabetes regimen was optimized and on hospital day five (
[**5-17**]) 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 CSRU for invasive monitoring in stable condition. He
remained intubated until post-operative day three when he was
weaned from sedation and extubated. He also remained on
inotropes for several days post-operatively. He was eventually
weaned from them and started on pre-op meds along with beta
blockers and diuretics. He was gently diuresed towards his
pre-op weight. He was also started on Amiodarone for frequent
PVC's and bigeminy.
On post-operative day five he was transferred to the SDU for
further care.
His chest tubes and epicardial pacing wires were removed per
protocol. Foley removed on POD #5. Intermittent confusion
necessitated haldol and periodic sitters. ID and renal services
continued to consult. Beta blockade titrated. Neuro consult done
and no organic reason found for delirium. Several runs of A
Flutter converted back to NSR. Seen by Dr. [**Last Name (STitle) **] of EP
service. Psychiatry consultation also done to help with
management of delirium. Urine, sputum, and blood cultures no
growth as of [**5-28**]. Cleared for discharge to rehab on POD
#........
Medications on Admission:
From osh:
Plavix 75 mg daily
Bactrim one daily
Aspirin 81 mg daily
Celexa 20 mg daily
CellCept [**Pager number **] mg twice daily
prograf 2mg [**Hospital1 **]
Zocor 10mg daily
Avandia 8mg daily - held at OSH
Rapamune 2mg daily - held at OSH **** (changed to prograf
because of assoc volume overload)
Glipizide 5mg tablet daily
lasix 40mg qday (was getting 60mg iv bid at OSH)
mucomyst 3mg po bid
procrit 40,ooo sc
heparin gtt
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime
for 3 days.
14. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours): level three times a week 12 hours after last
dose, just prior to am dose .
15. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Hypertension, Diabetes Mellitus w/ Retinopathy (legally
blind), Carotid Artery Disease, End Stage Renal Disease s/p
Renal Transplant c/b delayed graft function and wound healing,
Obesity, Osteoporosis, CVA, s/p Bilat. Vitrectomies, s/p
Cataract surgery, s/p Renal Transplant c/b delayed graft
function and wound healing, s/p AV Fistula placement
Discharge Condition:
Good
Discharge Instructions:
Patient should shower daily, no baths.
No creams, lotions, ointments. or powders 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 cardiac
surgeon if start to experience fevers, sternal drainage and/or
wound erythema.
Staples in bilateral calfs, bilateral knees, and right thigh -
please remove [**6-7**] if at rehab - if discharged from rehab please
call [**Hospital Ward Name **] 2 to come in for wound check [**Telephone/Fax (1) 3633**]
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Dr.[**Name (NI) 43096**] after discharge from rehab [**Telephone/Fax (1) 45895**]
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Nephrology [**Telephone/Fax (1) 673**] Mon [**6-4**] at 1:30pm [**Doctor First Name **] floor 7
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2198-10-9**] 1:30
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Date/Time:[**2198-10-9**] 1:00
Labs: BUN/Cr qweekly and FK506 (tacro)mon/wed/fri 12 hours after
last dose prior to am dose - results to Dr [**Last Name (STitle) **] Fax #
[**Telephone/Fax (1) 21335**]
Completed by:[**2198-5-29**]
|
[
"997.1",
"362.01",
"414.01",
"401.9",
"427.32",
"V42.0",
"250.50",
"369.4",
"293.9",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
13967, 14039
|
10332, 12065
|
302, 421
|
14494, 14500
|
1868, 2617
|
15114, 15942
|
1373, 1422
|
12542, 13944
|
9703, 9728
|
14060, 14473
|
12091, 12519
|
14524, 15091
|
5373, 9468
|
1437, 1849
|
255, 264
|
9757, 10309
|
449, 890
|
9503, 9666
|
2626, 5347
|
912, 1266
|
1282, 1357
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,958
| 172,079
|
47520
|
Discharge summary
|
report
|
Admission Date: [**2196-9-21**] Discharge Date: [**2196-10-1**]
Date of Birth: [**2130-5-14**] Sex: M
Service: MEDICINE
Allergies:
Ativan / Morphine / Iodine-Iodine Containing
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
66 year old male with history of bicuspid aortic valve s/p AVR
in [**2187**], complicated by prosthetic valve endocarditis requiring
redo AVR, presented initially to floor with dyspnea. Upon
arrival to floor, patient experienced acute worsening dyspnea,
without associated symptoms. BP was noted to be in 180s-190s
systolic range. Patient triggered and was transferred to
cardiac care unit. Upon arrival to unit, patient was anxious,
tachypneic, no chest discomfort, and hypertensive to 210s
systolic. A nitro drip and lasix IV were given immediately,
with good effect. See hospital course for further details.
ROS notable for increasing lower extremity edema over past few
weeks while self-limiting diuretic use.
Past Medical History:
HTN
bicuspid aortic valve s/p AVR
prosthetic valve endocarditis s/p redo AVR
chronic renal insufficiency
Social History:
no tobacco or alcohol use
Family History:
Father died of a heart attack at 76 years
old and had prostate cancer. Mother died of lung cancer in
her 70s. There is a positive family history of diabetes
mellitus.
Physical Exam:
initial vital signs notable for oxygen saturation in the mid 90s
on [**3-9**] liters nasal cannulu, with BP, as noted before, as high
as 210s/90s
GENERAL: well nourished, anxious, tachypneic
HEENT: PERRLa, NCAT, clear oropharynx, MMM, no thyromegaly
CV: RRR, S1, S2, no S3 or S4, II/VI SEM at left upper sternal
border, JVD not elevated, 2+ pulses throughout
PULM: bibasilar rales
ABD: soft, NT, ND, active BS, no HSM
EXT: no rash, [**1-8**]+ pretibial pitting edema
NEURO: CNs II-XII intact, strength and sensation grossly
intact, no cerebellar deficits
SKIN - no rash or evidence of chronic venous stasis
exam at discharge:
BP 130s-140s/70s
lungs were clear to auscultation
edema had resolved
Pertinent Results:
Labs at discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
9.7 3.20* 8.5* 26.8* 84 26.5* 31.7 15.9* 411
PT 15.3* PTT 31.1 INR 1.3
Glucose UreaN Creat Na K Cl HCO3 AnGap
175* 104 3.3* (peak 4.7) 137 3.6 100 23 18
Calcium Phos Mg
8.6 5.5 2.2
TTE: Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. Mild to
moderate mitral regurgitation. Mild pulmonary hypertension.
ECG: Sinus rhythm. A-V conduction delay. Prior anteroseptal
myocardial infarction. Compared to the previous tracing of
[**2190-10-9**] sinus rhythm is now recorded. The anterolateral ischemic
appearing ST-T wave changes have improved. Sinus rhythm with A-V
conduction delay is now present. The rate has slowed.
Admission CXR:
1. Patchy focal consolidation within the left mid-lung. Followup
to resolution is recommended.
2. Small-to-moderate size right pleural effusion, with
associated
opacification of the lung base, may reflect atelectasis.
Underlying
consolidation not excluded.
3. Stable mild cardiomegaly
Renal ultrasound:
1. Normal acceleration time in the right main renal artery with
no evidence of right renal artery stenosis.
2. Nondiagnostic left renal artery waveforms.
3. Normal appearance and size of both kidneys.
4. Morphological appearance of mild benign prostatic
hyperplasia.
Cardiac cath:
1. Elevated right and left sided filling pressures.
2. Moderate to severe pulmonary hypertension.
3. Moderate systemic hypertension.
4. High cardiac output state.
Resting hemodynamics revealed elevated right sided and left
sided filling pressure with an RVEDP of 17 mmHg and a PCWP mean
of 27 mmHg. There was severe pulmonary hypertension with a pasp
of 65/27 mmHg. There was a high output cardiac index of 4.37
L/min/m2. The femoral arterial pressure was moderately elevated
with a pressure of 163/55 mmHg which correlated with the
noninvasive cuff pressure.
CT Chest, Abdomen, Pelvis:
1. Diffuse bilateral central pulmonary opacities with associated
fissural
fluid and pleural effusions, large on the right and moderate on
the left
side, favoring pulmonary edema with superimposed infection.
Pulmonary
hemorrhage cannot be ruled out.
2. No additional source of infection or acute process identified
in the
abdomen or pelvis.
Brief Hospital Course:
66 year old male with history of bicuspid aortic valve s/p AVR
in [**2187**], complicated by prosthetic valve endocarditis requiring
redo AVR, presented initially to floor with dyspnea. Upon
arrival to floor, patient experienced acute worsening dyspnea,
without associated symptoms. BP was noted to be in 180s-190s
systolic range. Patient triggered and was transferred to
cardiac care unit. Upon arrival to unit, patient was anxious,
tachypneic, no chest discomfort, and hypertensive to 210s
systolic. A nitro drip and lasix IV were given immediately,
with good effect. The patient continued to receive aggressive
IV diuresis, and was maintained on a nitro drip until blood
pressure was better controlled with long-acting nitrates and,
arterial vasodilators, and non-specific beta blockers, in
addition to his home regimen. It was thought that the patient
presented in flash pulmonary edema secondary to severe
hypertension, and an underlying pulmonary infection could not be
ruled out. Bronchoscopy was entertained but ultimately not
pursued given likelihood of pulmonary edema as etiology of
radiographic lung findings. There was no evidence of myocardial
ischemia as the etiology. No diastolic murmur was noted on
exam, there was a low suspicion for recurrent endocarditis, and
TTE did not show any vegetation, see above. A cardiac
catheterization was done to evaluate the patient's refractory
hypertension, and both the BP cuff pressure and central pressure
correlated well. Initial antibiotic therapy covering
community-acquired pneumonia was soon discontinued after patient
did not develop additional signs/symptoms of infections. It was
thought that poor renal perfusion in the setting of likely
chronic hypertensive/diabetic nephropathy contributed to the
patient's acute renal failure. Renal ultrasound did not show
any evidence of obstruction. Following improved blood pressure
control, the patient's renal function slowly recovered.
Hemodialysis was never indicated. The patient also received two
units of packed red blood cells with an appropriate response.
The patient was maintained on a basal/bolus insulin regimen. He
was discharged on [**2196-10-1**] with improved BP control and clear
lungs. See below for medication changes.
Medications on Admission:
Benicar and Lisinopril
Furosemide and Metolazone PRN
Bisystolic
Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for insomnia.
Folgard 0.8-10-115 mg-mg-mcg Tablet Sig: One (1) Tablet PO once
a day.
Clonidine 0.3 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly
Transdermal QSUN (every Sunday).
Lantus 100 unit/mL Solution Sig: 20-26 units Subcutaneous at
bedtime: Please titrate to blood sugars.
Novolog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous four times a day
Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Doxazosin 1 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours.
Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily). Disp:*60 Tablet Sustained
Release(s)* Refills:*2*
Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Outpatient Lab Work
Please check Chem-7, Ca, Mag, Phosphate on [**2196-10-4**] at Dr. [**Name (NI) 100470**] office. Results to Dr. [**Last Name (STitle) 1407**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 721**]
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three
times a day: take before meals.
Disp:*90 Tablet(s)* Refills:*2*
7. Folgard 0.8-10-115 mg-mg-mcg Tablet Sig: One (1) Tablet PO
once a day.
8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly
Transdermal QSUN (every Sunday).
9. Lantus 100 unit/mL Solution Sig: 20-26 units Subcutaneous at
bedtime: Please titrate to blood sugars.
10. Novolog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous four times a day.
11. Hydralazine 100 mg Tablet Sig: 1.5 Tablets PO three times a
day.
Disp:*135 Tablet(s)* Refills:*2*
12. Carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
13. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
15. Nifedipine 90 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
16. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
Disp:*150 Tablet(s)* Refills:*2*
17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
18. Metolazone 5 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute Kidney Injury
Acute on Chronic Diastolic Congestive Heart Failure
SEcondary Diagnosis:
Hypertension
Hyperlipidemia
Diabetes Mellitus type 2
Anemia
Discharge Condition:
hemodynamically stable, creat 3.3. Afebrile.
Discharge Instructions:
You had high blood pressure that led to fluid overload and
kidney failure. Your kidney function is slowly improving and
your fluid status is better after medication adjustment. You
will need to follow up with your nephrologist and Dr. [**Last Name (STitle) **]
after you go home. You should see a dietician for counseling on
a renal diet if your creatinine is still high. Your goal blood
sugar is 80-120 but it is important that the number stays below
150, goal A1C is < 7.0. Your goal systolic BP is 120-130.
For now, avoid High Phosphorus foods:
-dairy products such as milk, cheese,
yogurt, ice cream and pudding
-nuts and peanut butter
-dried beans and peas such as kidney
beans, split peas and lentils
-beverages such as cocoa, beer and
dark cola drinks
.
Medication changes:
1. STOP taking Benicar and Lisinopril
2. START taking Hydralazine to lower your blood pressure
3. Take 100 mg of Furosemide twice a day and Metolazone 2.5 mg
once a day
4. START Sevelamer, one tablet before meals to lower your
phosphate level.
5. START Imdur to lower your blood pressure
6. Take Nifedipine CR instead of Amlodipine to lower your blood
pressure
6. Use Carvedilol instead of Bisystolic to lower your blood
pressure.
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 1407**] if weight > 3 lbs
in 1 day or 6 pounds in 3 days.
Adhere to 2 gm sodium diet, a diabetic diet and the phosphorus
restrictions noted above.
Call Dr. [**Last Name (STitle) 1407**] if you notice increased swelling in your legs,
trouble lying flat, decreased appetite or shortness of breath.
.
If you experience worsening shortness of breath, fever, chills,
chest pain, palpitations, dizziness, or increased swelling of
your extremities, please call 911 or your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1407**].
Followup Instructions:
Dermatology:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 4961**], MD Phone:[**Telephone/Fax (1) 2309**]
Date/Time:[**2196-10-3**] 3:45
Nephrology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 721**] Date/Time: Office will
call you at home with an appt.
.
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) 20**] R. Phone: [**Telephone/Fax (1) 1408**] Date/Time: Tuesday [**10-4**]
at 3:30pm.
.
Cardiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/Time: Please call
to schedule an appt in 1 month
|
[
"272.4",
"416.8",
"404.91",
"799.02",
"584.5",
"V43.3",
"428.33",
"486",
"274.9",
"V58.67",
"250.00",
"285.29",
"585.9",
"300.4",
"414.01",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
9948, 9954
|
4551, 6816
|
313, 339
|
10170, 10217
|
2186, 2186
|
12075, 12734
|
1276, 1447
|
7915, 9925
|
9975, 9975
|
6842, 7892
|
10241, 11002
|
1462, 2082
|
2096, 2167
|
11022, 12052
|
266, 275
|
2206, 4528
|
367, 1089
|
10087, 10149
|
9994, 10066
|
1111, 1217
|
1233, 1260
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,304
| 165,523
|
11723
|
Discharge summary
|
report
|
Admission Date: [**2193-2-18**] Discharge Date: [**2193-3-19**]
Date of Birth: [**2138-10-6**] Sex: M
Service:
HISTORY: This was a 54-year-old male with past medical
history significant for non-Hodgkin lymphoma status post
chemotherapy and status post mini-allogeneic BMT complicated
by graft versus host disease for skin, liver, GI, and lungs.
He was originally admitted on [**2193-2-18**] for shortness of
breath, increasing edema, and change in mental status to the
Medicine Service. His hospital course was complicated by
atrial fibrillation and new flutter status post DC
cardioversion on [**2193-2-22**]. The patient had recurrence of his
aflutter on [**2193-2-26**] on amiodarone associated with
hypertension and was transferred to the CCU. The patient had
aflutter ablation done on [**2193-2-27**] and a right- and left-
sided cardiac catheterization on [**2193-2-28**] revealed
hemodynamics consistent with constrictive pericarditis. The
patient was started on Natrecor and Lasix with minimal
diuresis complicated by hypertension and Natrecor was
discontinued. On [**2193-3-4**], the patient had a cardiac MRI
which post MRI was complicated by a respiratory arrest
requiring intubation, transferred to the MICU.
The patient was eventually extubated on [**2193-3-7**] and placed
intermittently on BiPAP for hypercapnia and fatigue. Due to
the patient's constrictive pericarditis possibly secondary to
his graft versus host disease, a pericardial stripping was
performed on [**2193-3-12**] for improvement in hemodynamics by
cardiothoracic surgery. The patient did well post
pericardial stripping with excellent diuresis. The patient
was transferred to the CCU for further diuresis after his
pericardial stripping. The patient's phone numbers were
followed closely after stripping with improvement of cardiac
output over the next several days. The patient occasionally
needed BiPAP for respiratory fatigue and hypercapnia. The
patient was complaining of some difficulty swallowing and
sore throat on [**2193-3-17**] and his tube feeds were held due to
his difficulty swallowing and his need for BiPAP. The
patient was noted on [**2193-3-18**] to have a desaturation in the
morning to 70 percent on 40 percent facemask, suctioned and
blood with some thin secretions were suctioned and the
patient's O2 saturations increased after suctioning.
It was felt that the patient may had an aspiration event and
was started on Flagyl and a speech and swallow evaluation was
ordered. Given the patient's difficulty with his respiratory
status, it was unable to perform a swallowing study and the
patient was closely monitored with holding of tube feeds.
The patient required emergent intubation in the evening of
[**2193-3-18**] for respiratory distress. Copious thin secretions
were removed. The patient was noted to have secretions of
400 to 500 cc of bloody tube feeds. The patient became more
difficult to arouse and blood pressure continued to drop and
the patient's oxygen saturations also declined. The patient
was placed on multiple blood pressure support medications
including dopamine and Neo-Synephrine drips. A stat
echocardiogram was obtained which showed no evidence of
tamponade. Prior to placing his Swan-Ganz catheter to
evaluate likely septic physiology, the patient went into a
systolic arrest. ACLS was performed with multiple
epinephrine, bicarbonate, atropine x20 minutes without
success. The patient expired at 12:34 a.m. likely from
sepsis from aspiration event. The family was informed of
events of the night and declined postmortem exam.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30311**], [**MD Number(1) 30312**]
Dictated By:[**Last Name (NamePattern1) 37098**]
MEDQUIST36
D: [**2193-7-18**] 16:40:43
T: [**2193-7-18**] 20:18:53
Job#: [**Job Number 37099**]
|
[
"427.5",
"511.9",
"202.80",
"423.2",
"428.0",
"427.32",
"996.85",
"428.31",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"89.64",
"37.29",
"37.34",
"37.23",
"34.91",
"99.60",
"37.26",
"88.56",
"88.72",
"00.13",
"37.27",
"96.04",
"37.31"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,663
| 111,039
|
49550
|
Discharge summary
|
report
|
Admission Date: [**2109-4-19**] Discharge Date: [**2109-4-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]yoW with diastolic CHF, pulmonary fibrosis, htn, recently
hospitalized at [**Hospital1 **] [**Location (un) 620**] for sob thought possibly due to
pneumononia (ambiguous cxr) presents to [**Hospital1 18**] ED with sob, htn >
200/100. Admitted to ICU for BP control.
Past Medical History:
pulmonary fibrosis
htn
chf (diastolic)
mild as
1+MR
Social History:
lives on [**Location (un) **] in apartment, daughter [**Name (NI) **] [**Name (NI) 103645**] very
involved in care
Family History:
nc
Physical Exam:
On arrival to ICU:
T 100.2 BP 113/52 HR 73 RR 22 Sat 96% on 4 L/min nc
Gen: thin elderly woman thrashing around in bed
HEENT: dry MM, no OP lesions
Neck: supple, unable to assess JVP due to lack of pt cooperation
Chest: fine bibasilar rales, several inches up from the bases;
no wheezes/ronchi; exam limited by patient's lack of cooperation
in sitting up and sitting still
CV: rrr, nl s1s2, no m/r/g
Abd: soft, nondistended, no grimacing with deep palpation,
normal BS, no masses/HSM
Extr: warm, 2+ DP pulses, no edema
Skin: warm, dry, no rashes or jaundice
Neuro: thrashing around in bed, localizes vision to verbal
stimuli, EOMI, PERRL, moving all extremities equally
Brief Hospital Course:
1)Fever: Unclear whether this was due to pneumonia or viral URI.
CXR cleared quicly after diuresis in ICU. Sputum grew MRSA, but
pt appeared well. It was felt in discussion with the pulmonary
team that this likely represented colonization rather than MRSA
pneumonia. She was treated conservatively for course of
possible community acquired pneumonia.
2)SOB: Hypoxia on arrival to ICU. Improved shortly there after.
Unclear whether represented pulmonary edema in setting of htn
or pneumonia. Diuresed to 4 pounds below normal weight
(euvolemic weight approx 98-100 lbs). Once on the floor
diuresis was discontinued as pt had developed hyponatremia.
Case was discussed with pt's cardiologist, pulmonologist, and
[**Name (NI) 3390**]. [**Name10 (NameIs) 3390**] asked to send pt home on prn lasix regimen - lasix 20
mgs po only if gains weight from one day to next. Echo
unchanged.
3)Htn: Pt continued on atenolol 50, imdur 60. She had recently
had losartan dc'd by her cardiologist, who recommended
restarting as her SBPs continued to be in the 140s-150s. This
was restarted, she did have morning htn to 150s/80s just before
receiving morning meds but was otherwise well controlled
throughout the day. Cardiologist, Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] see her
in 2 weeks and decide whether losartan needs to be increased.
4)Frequent urination at night. Post void residual bladder scan
was normal. This was when pt was not receiving lasix. Pt
referred to outpt urology.
Send home with telemonitoring and VNA.
Daughter [**First Name4 (NamePattern1) **] [**Known lastname 103645**] had multiple concerns throughout the
hospital course, including concern that patient was not safe for
home. Meeting required with case management and myself due to
inflammatory comments and behavior by pt's daughter to nursing
and physician [**Name Initial (PRE) **]. At end of meeting, daughter seemed
satisfied with discharge plan.
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 1 days: Take on [**2109-4-28**].
Disp:*3 Tablet(s)* Refills:*0*
7. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: Only
take if patient has gained more than 4 pounds in 48 hours.
11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
pneumonia
diastolic heart failure
hypertension
Discharge Condition:
stable
Discharge Instructions:
Please call Dr. [**Last Name (STitle) **] with any concerning delerium, problems
breathing, or other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2109-5-23**] 2:25
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2109-5-23**] 2:45
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2109-5-23**] 2:45
[**5-29**] at 10:50am with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital6 733**].
Recommend scheduling this for sooner, within next 2 weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2109-5-1**]
|
[
"428.0",
"293.0",
"733.00",
"515",
"428.32",
"401.1",
"276.1",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4528, 4586
|
1524, 3477
|
266, 273
|
4677, 4686
|
4856, 5590
|
809, 813
|
3500, 4505
|
4607, 4656
|
4710, 4833
|
828, 1501
|
223, 228
|
301, 586
|
608, 661
|
677, 793
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,929
| 185,185
|
18853
|
Discharge summary
|
report
|
Admission Date: [**2162-8-22**] Discharge Date: [**2162-8-26**]
Date of Birth: [**2081-3-18**] Sex: F
Service: MEDICINE
Allergies:
Feldene
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
: 81yo previously active & ambulatory woman with DM2, HTN,
hypothyroid, ESRD on HD x 9 months (MWF, last done [**8-20**]).
Admitted to OSH on [**2162-8-12**] with MSSA line infection, line
removed, treated with nafcillin, defervesced on [**8-15**], never
septic. Subsequently developed severe neck/back pain. MRI whole
spine negative for abscess, discitis, fracture, or
osteomyelitis, but patient continues to not be able to speak or
walk. Mental Status is distinctly decreased from beginning of
hospitalization per family. She denies chest pain, abdominal
pain, or difficulty breathing. Remains alert &
hemodynamically stable. MRI brain showed 2 acute infarcts R & L
parietal areas. Family requesting transfer to [**Hospital1 18**] for further
evaluation.
Past Medical History:
1. Type 2 DM (diet controlled)
2. ESRD on HD MWF
3. HTN
4. Hypothyroidism
5. Anemia
6. Depression
7. Breast Cancer s/p mastectomy [**2156**]
Social History:
lives with her husband. Up until this illness, was shopping,
cooking, driving. Daughters [**Name (NI) **] and [**Name2 (NI) 4457**] involved in care.
tob: none etoh: none other drugs: none
Family History:
non-contributory
Physical Exam:
Vitals- Tm 99.1 BP 118/50 HR 81 R 16 O2sat 95%2L FSBG 128
General- thin woman, moaning, skin icteric
HEENT- +scleral icterus, pinpoint pupils, full lateral gaze
Neck- tender to palpation posteriorly
Pulm- limited exam secondary to pain, clear anteriorly
CV- RRR, [**4-12**] holosystolic murmur
Abd- soft, non-tender, +bs
Extrem- no edema, dp pulses intact bilaterally
Neuro- A&OX1, follows some simple, one step commands, difficult
to understand speech, moves all extremities equally, babinski:R
upgoing. [**4-11**] motor strength upper extremities, L>R
Pertinent Results:
MRI head: Acute infarct in high R and high L parietal areas
.MRI C-spine: bulges C5/C6, no impingement, no abcess.
.MRI T/L spine showed no osteomyelitis, mulitlevel
spondylolisthesis, disc bulging L5-S1, narrowing of canal.
EGD ([**2162-8-13**]): gastroenteritis
U/S LE ([**2162-8-20**]): bilat DVT
TTEcho ([**2162-8-20**]): EF 60%, no evidence of vegetations
.
Brief Hospital Course:
A/P: 81F with h/o ESRD on HD, hypertension, DM2, transferred
from OSH with mental status changes, line infection, and back
pain. Now with acute bilateral vision loss thought secondary to
b/l occipital strokes.
.
#. Septic shock:
On arrival to the ICU, patient hypotensive and tacchycardic
overnight (alternating with rapid rate with RBBB and LBBB).
Despite frequent fluid boluses patient and being on 2 pressors,
she was persistently hypotensive. The patient was started on
broad spectrum abx vanc/levo/ flagyll and naficillin. During her
ICU course, she continued to require pressors and her pressor
needs escalated to the point of requiring a 3rd pressor for
hypotension.
# Acute Vision Loss
- MRI showed new bilateral occipital strokes thought to be [**3-11**]
hypotension. Neurology was consulted, but in the setting of
patient's septic picture, neuro exam was deferred because of
ongoing shock.
.
# Mental Status Change: Neuro felt that AMS could be due to
vascular insults, infarcts and extensive small vessel disease;
other etiologies that could be contributing are infection or
other metabolic disturbances.
.
# Line infection: from central dialysis catheter, dxed and
removed at osh on [**2162-8-12**]. Blood cultures grew MSSA - hence
patient was placed on nafcillin. Blood cultures here from [**8-22**]
and [**8-24**] were pending on date of death.
.
# Abd Pain- with diarrhea, may be infectious.
-- cdif ordered
-- kub- no free air
.
# Back pain: severe from recent fall. An MRI C-spine showed
bulges at C5/C6, no impingement and no abcess. MRI T/L spine
showed no osteomyelitis, mulitlevel spondylolisthesis, disc
bulging L5-S1, narrowing of canal. No evidence of acute
fracture. PAtient placed on morphine for pain.
.
# ESRD on HD, mon/wed/fri schedule.
.
# Anemia, likely from CKD (36-->28-->27 since admission),
unclear why drop but has how been stable. iron studies
consistent with chronic disease. no signs of active bleeding.
Hcts stable through rest of stay.
.
# Hypertension: held antihypertensives because of recent
infarcts and need for pressor support. Neuro recommended BPs to
be in the 130s.
.
After an extensive discussion with the patien's family on [**8-26**]
(daughters and husband) the decision was made to make the
patient CMO. Pulm fellow, residents, sw and nurse were all
present. Pressors were discontinued and later this evening,
patient expired. Family was at bedside. Autopsy was offered, but
declined by daughters.
.
Medications on Admission:
Atenolol 75mg PO daily
Hectorol 2.5 micrograms
Hydralazine 25mg PO TID
Lisinopril 2.5mg daily
Rocaltrol 0.25 micrograms daily
synthroid 100mcg Qday
senna
protonix 40mg QD
nephrocaps
nafcillin 2gm IV Q6hr
morphine 1-2mg IV Q4hr
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2162-8-26**]
|
[
"244.9",
"584.9",
"285.21",
"V66.7",
"263.9",
"403.91",
"995.92",
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"996.62",
"250.00",
"585.6",
"785.52",
"369.00",
"038.11",
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
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icd9pcs
|
[
[
[]
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2475, 4935
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289, 295
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5300, 5310
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2087, 2452
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
109
| 124,657
|
14804
|
Discharge summary
|
report
|
Admission Date: [**2142-1-14**] Discharge Date: [**2142-1-20**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
HD
History of Present Illness:
Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant
HTN admitted with mild headache, mild shortness of breath and
consistent abdominal pain at the site of her known left
abdominal wall hematoma in the setting of hypertension. Her
last HD was yesterday.
.
Upon arrival to the ED, her vitals were BP 240's systolic, HR
90's, 93% on RA. A head CT scan was done which showed no acute
process. An abdominal CT was done given her femoral line pain,
which also was normal. She was given nitropaste X2 initially,
then switched to labetalol 100mg x2, then 200mg x2, then finally
started on nicardipine drip when she showed benefit with a
decrease in her BP to 170/123 and improvement in her headache.
.
Upon arrival to the MICU, patient denies any current symptoms.
She reports that her headache, shortness of breath and abdominal
pain all resolved with blood pressure management and pain
medications.
.
Pt was transferred to the floor when blood pressure was
controlled.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**] but refused it as of [**2140**], has
survived despite this
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] that resolved
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy: may be etiology of episodes of
worse hypertension given appears quite labile
12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**],
Straight CPAP/ Pressure setting 7
PSHx:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**]
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
VS: HR 96 BP 171/111 RR 12 O2 98% on RA
Physical Exam:
General in NAD
HEENT NC, AT, EOMI, PERRLA, MMM
CVS RRR, 3/6 systolic murmur in all heart fields
RESP CTA BL, no crackles or wheezes
ABD soft, hematoma raised on left anterior abdominal wall, +BS,
mildly tender over hematoma
EXT left sided femoral HD line in place, no erythema, no edema
NEURO A+Ox3, CN2-12 intact, pt has left sided artificial eye,
motor and sensory intact
Pertinent Results:
***LABS ON ADMISSION***
[**2142-1-13**] 07:03AM WBC-5.2 RBC-2.79* HGB-8.5* HCT-26.3* MCV-94
MCH-30.3 MCHC-32.2 RDW-19.2*
[**2142-1-13**] 07:03AM PLT COUNT-154
[**2142-1-13**] 07:03AM PT-29.5* PTT-49.2* INR(PT)-3.0*
[**2142-1-13**] 07:03AM GLUCOSE-94 UREA N-53* CREAT-7.0* SODIUM-136
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
[**2142-1-13**] 07:03AM CALCIUM-8.8 PHOSPHATE-5.0* MAGNESIUM-1.9
[**2142-1-14**] 12:00PM PT-43.8* PTT-56.1* INR(PT)-4.9*
[**2142-1-14**] 12:00PM LIPASE-42
[**2142-1-14**] 12:00PM ALT(SGPT)-12 AST(SGOT)-43* ALK PHOS-96 TOT
BILI-0.4
[**2142-1-14**] 03:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2142-1-14**] 03:25PM URINE RBC-[**3-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-[**3-15**]
[**2142-1-14**] 12:00PM BLOOD PT-43.8* PTT-56.1* INR(PT)-4.9*
[**2142-1-19**] 06:40AM BLOOD PT-18.6* PTT-38.7* INR(PT)-1.7*
.
***LABS ON DAY OF DISCHARGE***
[**2142-1-20**] 06:35AM BLOOD WBC-5.7 RBC-2.39* Hgb-7.1* Hct-22.1*
MCV-93 MCH-29.8 MCHC-32.2 RDW-18.6* Plt Ct-136*
[**2142-1-20**] 06:35AM BLOOD Glucose-107* UreaN-34* Creat-4.8* Na-137
K-5.2* Cl-101 HCO3-27 AnGap-14
[**2142-1-20**] 06:35AM BLOOD PT-22.8* PTT-42.3* INR(PT)-2.2*
.
IMAGING
[**2142-1-14**] EKG
Sinus rhythm. Possible left atrial abnormality. Borderline
voltage criteria
for left ventricular hypertrophy. Inferolateral ST-T wave
changes may be
related to left ventricular hypertrophy. Compared to the
previous tracing
of [**2142-1-8**] there is no significant diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
99 190 86 368/436 13 100 24
[**2142-1-14**] CT ABD/PELV
IMPRESSION:
1. Interval decrease in size to subcutaneous anterior abdominal
wall
hematoma.
2. Infectious versus inflammatory process within the right lower
lobe of the
lung. Small right simple pleural effusion.
3. Cardiomegaly with slight decrease in size of moderate
pericardial
effusion.
4. Right lobe liver hemangioma, unchanged.
[**2142-1-14**] CT HEAD
IMPRESSION:
1. Mildly limited study given administration of small amount of
IV contrast
material. However, no evidence of hemorrhage or mass effect.
NOTE ADDED AT ATTENDING REVIEW: This patient was administered
contrast for the
abdominal CT, and the head CT was performed after part of this
dose.
Therefore, this is neither a noncontrast examination, nor a
proper contrast
CT.
[**2142-1-14**] CXR
CONCLUSION:
Persistent cardiomegaly and mild pulmonary edema.
Brief Hospital Course:
24 yo woman with hx of SLE, ERSD on HD, admitted with
hypertensive urgency.
.
# Hypertensive Urgency: Pt with extensive history of
hypertension. Patient's BP improved with nicardipine drip.
Became increased yesterday when the patient missed a dose of
oral nicardipine, but came down after a replacement dose.
Restarted all home oral antihypertensives including nicardipine
30 Q8H, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine
100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses.
Blood pressure remains labile and renal continues to follow
patient.
Pt was transferred to the floor as blood pressure stabilized.
BP has remained stable with systolics 140s-170s. In the MICU,
Nifedipine extended release was added in place of Nicardipine as
pt's blood pressures seemed to rise prior to Nicardipine doses.
.
# Hyperkalemia: Ocurred on the day after admission. Resolved
with administration of kayexalate. Pt continued hemodialysis on
TuThSat.
.
# Left abdominal wall hematoma: Abd CT showed a mild decrease
in the size. Pt reported that morphine did not help pain, and
was switched to dilaudid PO in the MICU. However, given pt's
recent prior admission required narcan following sensitivity to
narcotics, dilaudid was d/c'ed on the floor. Pt was continued on
gabapentin, tylenol around the clock, and low-dose Morphine as
needed for pain. Narcotics should be avoided in the future. Pain
should also resolve in the next few weeks as hematoma resolves.
.
# SLE: Pt was continued on prednisone at 4 mg PO daily.
.
#ESRD: Renal was following during her stay. She continued HD on
her T, Th, Sat schedule.
# Anemia: Hct was mildly decreased from baseline during
admission. This is likely secondary to AOCD and in the setting
of renal failure.
.
# SVC thrombus: Patient is on anticoagulation, likely lifelong.
Patient was supratherapeutic on coumadin on admission and
coumadin was subsequently held. Then INR became subtherapeutic,
so heparin gtt was used to bridge. On day of discharge, INR
became therapeutic, and pt was discharged home on Coumadin 4mg
PO daily, with INR to be checked next at hemodialysis
.
# HOCM: Pt has evidence of myocardial hypertrophy on recent
Echo. She was not symptomatic during her stay. She was continued
on her beta blocker.
.
# Depression/anxiety. She was continued on celexa and clonazepam
PRN.
.
# OSA: CPAP for sleep with 7 pressure.
.
# FEN: repleted lytes prn / regular diet
.
# PPX: coumadin, bowel regimen
.
# ACCESS: PIV/ permanent dialysis cath L fem
.
# CODE: FULL
.
# CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**]
Medications on Admission:
Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday
Hydralazine 100mg PO q8H
Labetalol 900mg PO TID
Morphine 7.5mg Q8H PRN
Nicardipine 30mg PO TID
Aliskiren 150 [**Hospital1 **]
Prednisone 4mg PO qday
Clonazepam 0.5 mg [**Hospital1 **]
Celexa 20mg PO qday
Gabapentin 300 mg [**Hospital1 **]
Acetaminophen 325 mg q6H PRN
Ergocalciferol (Vitamin D2) 50,000 unit PO once a month
Coumadin 4 mg daily
Discharge Medications:
1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8)
hours as needed for breakthrough pain for 2 weeks.
2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*1*
13. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times
a day.
[**Hospital1 **]:*260 Tablet(s)* Refills:*1*
14. Respiratory Therapy
Please adjust settings of CPAP machine to a lower volume as it
is uncomfortable for the patient.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive urgency
Discharge Condition:
Good, hemodynamically stable, afebrile, pain controlled
Discharge Instructions:
You were admitted for headaches and very high blood pressures.
You were started on an IV medication for your blood pressure
which controlled it. You were then started back on your home
medications with improvement of your blood pressure. One new
medication was added as your hypertension was difficult to
control.
You were also started on a heparin drip while restarting your
coumadin since you have a known clot in your veins. You will
need to continue your Coumadin at 4mg daily and have your INR
checked AT DIALYSIS next week.
Please take all medications as prescribed. It is important that
you do not miss doses of your medications since your blood
pressure is very sensitive to missed doses. Please keep ALL
scheduled appointments.
Medications changes include:
1. STOP NICARDIPINE
2. Start Nifedipine CR 90mg by mouth daily
3. INCREASE Labetalol to 900mg by mouth 3 times daily
4. Continue at Warfarin 4mg by mouth daily
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: fevers, chills, chest pains,
shortness of breath, nausea, vomiting, or headaches.
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up
a follow-up appointment in 1-2weeks.
Please continue your HD TuThSat.
Completed by:[**2142-1-20**]
|
[
"V12.51",
"V58.61",
"425.1",
"403.01",
"451.84",
"585.6",
"710.0",
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icd9cm
|
[
[
[]
]
] |
[
"39.95"
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icd9pcs
|
[
[
[]
]
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291, 295
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,976
| 105,492
|
46871
|
Discharge summary
|
report
|
Admission Date: [**2169-6-8**] Discharge Date: [**2169-6-14**]
Date of Birth: [**2105-6-4**] Sex: F
Service: MEDICINE
Allergies:
Haldol / Darvon
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
Femoral CVL
PICC
History of Present Illness:
64 y.o. female with Hep C/etoh cirrhosis, history of GIBs and
monoclonal gammopathy who presented to the ED after suffering a
fall at home. Patient ambulates with a walker at home and per
daughter and HCP, is not fully independent with her ADLs. She
reportedly was trying to maneuver her walker and fell backwards
hitting her head and it is unclear if she loss consciousness.
Per the patient's daughter who does not live with her and did
not witness the fall, the patient was reportedly sleepy after
her fall and slept through the night. Once the fall was learned
of this morning, the patient was brought to the ER for further
evaluation. Upon arrival in the [**Hospital1 18**] ER, vitals were stable and
the patient was complaining of back pain and right wrist and
shoulder pain. CT head, c-spine and torso as well as plain films
of the hips, right wrist and shoulder revealed a T3 burst
fracture without spinal cord involvement, but otherwise showed
chronic, insignificant injuries. Patient was seen by trauma
surgery and neurosurgery, both of whom felt that surgery was not
indicated. Incidentally, patient was found to have a Hct of 17,
down from 24 a month prior. She denied any melena, hematochezia
or hematemesis. She was given 2 units of FFP and 10 of vitamin K
for an INR of 2.9 and then written for 2 units of PRBCs, one of
which she received prior to coming to the unit for further
management.
.
In the ICU, patient was hemodynamically stable and lying in bed
comfortably, denying chest pain, SOB, palpitations,
lightheadedness/dizziness.
Past Medical History:
- ?Etoh/ HCV cirrhosis with recurrent hepatic encephalopathy
- Iron deficiency anemia
- GI bleed - hemorrhoids, s/p TIPS; also w/ known portal
gastropathy
- Sigmoid diverticulosis
- Schatzki's ring
- Duodenal polyps and duodenitis
- Monoclonal gammopathy of undetermined significance
- Psychotic disorder on olanzapine
- Polysubstance abuse - etoh, cocaine, marijuana
- COPD
- Temporal lobe epilepsy (per daughter no seizure in 30 yrs)
- Subcutaneous variceal rupture s/p hematoma exploration in LLQ
- Chronic kidney disease (baseline Cr ~1.4)
- Fractures: clavicle and pubic rami
Social History:
Lived in nursing home but recently discharged home with hospice
(1/[**2169**]). History of tobacco, EtOH and drug abuse. She is
originally from [**State 3908**]. She worked as an administrative
assistant when she was younger, but is now on SSDI (for
?schizophrenia and seizure disorder). Patient's daughter,
[**Name (NI) 4850**], is heavily involved in care.
Family History:
Mother: asthma, grandmother with diabetes, HTN. No family
history of liver disease or bleeding disorders. Great aunt with
epilepsy.
Physical Exam:
Vitals: T: 96.4, BP: 92/52, P: 89, R: 17, O2: 100% 2L
General: Awake, alert, NAD, resting in a hard neck collar
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB
CV: S1, S2 nl, no m/r/g appreciated
Abdomen: Soft, NT, ND, + BS; multiple surgical incisions noted
on abdomen
Ext: No c/c; 2+ pitting edema b/l in LEs
Pertinent Results:
[**2169-6-8**] 06:00PM BLOOD WBC-3.9*# RBC-1.83* Hgb-5.8* Hct-17.9*#
MCV-98# MCH-31.6 MCHC-32.4 RDW-16.7* Plt Ct-90*
[**2169-6-8**] 04:25PM BLOOD PT-28.8* PTT-92.2* INR(PT)-2.9*
[**2169-6-8**] 04:25PM BLOOD Glucose-65* UreaN-10 Creat-1.4* Na-127*
K-4.9 Cl-96 HCO3-23 AnGap-13
[**2169-6-8**] 04:25PM BLOOD ALT-21 AST-36 CK(CPK)-73 AlkPhos-119*
TotBili-2.5*
[**2169-6-8**] 04:25PM BLOOD Albumin-1.7* Calcium-8.4 Iron-33
[**2169-6-8**] 04:25PM BLOOD calTIBC-26* Ferritn-925* TRF-20*
[**2169-6-11**] 03:54AM BLOOD Hapto-<20*
[**2169-6-8**] 04:33PM BLOOD Lactate-2.1*
[**2169-6-11**] 08:48AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.023
[**2169-6-11**] 08:48AM URINE Blood-LG Nitrite-POS Protein-TR
Glucose-NEG Ketone-TR Bilirub-MOD Urobiln-4* pH-6.5 Leuks-SM
[**2169-6-11**] 08:48AM URINE RBC->50 WBC->50 Bacteri-MANY Yeast-NONE
Epi-0-2
Images:
CT C-Spine
IMPRESSION:
1. Possible acute compression fracture of T3 involving anterior
and posterior
columns with posterior retropulsion of the fragmented vertebral
body. The
thecal sac is indented. Evaluation of cord injury, posterior
longitudinal
ligament complex, and possible extra-axial hematoma at this site
is incomplete
with CT and would recommend MRI for better evaluation.
2. Chronic fracture of the spinous processes of C7, T1, and T2.
In addition,
there is anterior widening between the vertebral bodies of C6
and C7. All
these findings may represent sequela of a prior hyperextension
injury;
however, acute injury of the anterior longitudinal ligament at
C6/C7 cannot be
fully excluded. MRI would be better for evaluation.
3. Degenerative changes in the cervical spine, most notably at
C4/C5, C5/6
with loss of intervertebral disc space height and posterior disc
osteophyte
complexes.
4. As the T3 vertebral body fractures incompletely assessed on
this study,
one cannot exclude additional vertebral body injuries below this
level and
would recommend further imaging to better evaluate.
CT Head:
IMPRESSION: No acute pathology.
.
CXR:
IMPRESSION: Feeding tube in place.
.
CT Chest/Abdomen/Pelvis
IMPRESSION:
1. Age-indeterminate compression fractures at T3 and T8. Chronic
compression
fracture at T11. Old spinous process fractures at T3 and T4.
Chronic
posterior right eleventh and twelfth rib fractures. Likely
chronic sacral
insufficiency fracture. A bone scan may be useful for further
evaluation.
2. Cirrhotic-appearing liver with stable TIPS catheter. Slightly
increased
volume of abdominal and pelvic ascites.
3. Enlarged ptotic gallbladder without wall thickening or
gallstones to
suggest cholecystitis.
4. No retroperitoneal collections to suggest hematoma.
5. Marked biapical emphysema.
6. Dense atherosclerotic calcifications, however, the abdominal
vasculature
appears patent.
7. Secretions within the thoracic trachea put the patient at
increased risk
for aspiration.
.
Lower ext U/S
IMPRESSION: No DVT. Right groin hematoma without vascular flow.
No AV
fistula.
Brief Hospital Course:
64 y.o. female with Hep C/etoh cirrhosis, history of GIBs and
monoclonal gammopathy who presented to the ED after suffering a
mechanical fall at home.
Hospitalization was complicated by GI bleeding, aspiration event
with progressive hypoxia and hypotension in spite of agressive
antibiotic and supportive therapy. Given lack of improvement
patient was made CMO on [**2169-6-14**]. She expired later that
afternoon. Below is a problem based summary leading to her
death.
# T3 Burst Fracture: She hit her head on fall, but denied LOC.
In the ED the patient's vitals were stable. CT head, c-spine and
torso as well as plain films of the hips, right wrist and
shoulder revealed a T3 burst fracture without spinal cord
involvement, but otherwise showed chronic, insignificant
injuries. Patient was seen by trauma surgery and neurosurgery,
both of whom felt that surgery was not indicated.
# Anemia/Hct Drop: Patient has a history of GIB and now presents
with a Hct of 17, down from 24.5 one month ago. Last EGD in
2/'[**68**] without varices. Patient was found to have a Hct of 17 on
admission, down from 24 a month prior. She was transfused 2U
([**6-8**]), 4U ([**6-9**]) and 2U ([**6-10**]). The patient had a right femoral
line that was pulled and showed hematoma on U/S. No evidence of
fistula or aneurysm. She was evaluated by vascular surgery and
recommended supportive care. Her Hct increased to 28 on [**6-11**],
but then again dropped to 21 the evening of [**6-11**]. The patient
underwent CT-scan of her abd/pelvis that did not show evidence
of RP bleed. She had guaiac positive brown stool. On [**2169-6-14**]
frank blood was aspirated from oropharynx.
.
#. Aspiration pneumonia: Pt with likely aspiration on [**6-11**] and
CXR showed questionable RML pneumonia. The patient was started
on Vanco/Unasyn and maintained on broad spectrum antibiotics,
later changing to Vanc/ Meropenem, although with progressive
decline.
#UTI: The patient had a postive UA that eventually grew E. coli
which was treated Unasyn given her aspiration pneumonia.
# Cirrhosis: Her liver disease is secondary to EtOH and HCV.
Patient is followed at liver center by Dr. [**Last Name (STitle) 497**]. She was
continued on lactulose, rifaxamin, and ursodiol, and still felt
not to be a transplant candidate.
.
# CKD: On admission the patient's Cr was 1.4, which was near her
baseline. Her creatinine trended down to 1.3.
.
# Goals of care: Pt made DNR/DNI. Discussed goals of care with
daughter and patient, with ongoing deterioration patient was
made CMO
.
Prophylaxis: SCDS, PPI, lactulose
Access: PICC
Code: DNR/DNI
Communication: Patient and her daughter, [**Name (NI) 4850**] [**Name (NI) 99446**] (HCP):
[**Telephone/Fax (1) 99373**]
Medications on Admission:
1. Rifaximin 400 mg PO TID
2. Ursodiol 300 mg PO BID
3. Camphor-Menthol 0.5-0.5 % Lotion QID PRN
4. Olanzapine 5 mg PO BID
5. Lactulose 30 ML PO Q6H
6. Keppra 750 mg PO BID
7. Tramadol 50 mg PO Q4H
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
T3 Fracture
Anemia
Right thigh hematoma
Aspiration Pneumonia
UTI
Secondary:
Etoh/ HCV cirrhosis
MGUS
COPD
Chronic kidney disease
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"070.70",
"799.02",
"E888.9",
"584.9",
"305.00",
"805.2",
"287.5",
"571.2",
"345.90",
"507.0",
"348.39",
"585.9",
"041.4",
"599.0",
"285.1",
"785.0",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"99.05",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9398, 9407
|
6387, 9117
|
282, 300
|
9590, 9599
|
3414, 5373
|
9655, 9665
|
2878, 3011
|
9366, 9375
|
9428, 9569
|
9143, 9343
|
9623, 9632
|
3026, 3395
|
234, 244
|
328, 1880
|
5382, 6364
|
1902, 2486
|
2502, 2862
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,218
| 114,284
|
49185
|
Discharge summary
|
report
|
Admission Date: [**2190-5-22**] Discharge Date: [**2190-5-31**]
Date of Birth: [**2110-1-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4963**]
Chief Complaint:
MI/LGIB
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is an 80 year old male with a past medical history of
colitis and diverticulosis with history of bleeds, who was
recently admitted at [**Location (un) 620**] with a diverticular bleed
(discharged day before admission here), represented to the OSH
today with sudden onset dyspnea and acute on chronic epigastric
discomfort and was found to have ST changes consistent with
acute MI (not stemi criteria). Hct was 33 on discharge now back
to 27. EKG with old RBBB, but clear new lateral ST depressions
and ST elevation in III. First set of cardiac enzymes were CK
333 MB 11.8 TnT 1.13. Patient presented hypotensive to low 80s,
but now 95-100 with fluid; HR 90s. Is transferred to [**Hospital1 18**] for
further management. A unit of packed red cells was hung on
transfer.
.
In the ED, the patient remained with stable blood pressures,
dropping only as low as 102 systolic. His initial vitals were
98.7 102/70 20 96%4L. The blood that was hung on transfer
continued to run throughout his ED course and he received an
additional 1L NS. An EKG was rechecked which confirmed the
initial findings, and another troponin was 1.12. He was guaiac
negative, but given his recent history of LGIB and relative
hypotension, he was unable to be anticoagulated or beta blocked.
.
The case was discussed with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] from Cardiology, who
said to medically manage with ASA (which he received x 1 in the
ED) and blood, and admit to the floor and allow the MI to run
it's course as long as he remains asymptomatic. Given his recent
LGIB and initial hypotension, however, he is admitted to the
MICU for further management and monitoring.
.
On ROS, the patient says that he feels much better and denies
chest pain or shortness of breath. He denies dizziness,
abdominal pain or palpitations.
.
Past Medical History:
Diverticulosis s/p recent bleed (treated at [**Location (un) 620**]), and a
prior bleed in [**2188**]
Ulcerative colitis
Hypertension
Dementia
Osteoarthritis
Status post hip replacement in [**2188-2-20**]
Anxiety
Social History:
Lives at home alone. He is independent in all of activities of
daily living. However, he is somewhat forgetful. He denies
tobacco, alcohol or illicit drug use.
Family History:
NC
Physical Exam:
O: Vital signs: 96.9/96.1, 108/60 (96-115/50-71), 85 (80-92),
18, 96%RA
I/O: 1240/1350 +BM
Tele: PVCs
GEN: Resting quietly in bed, pleasant.
HEENT: PERRL, mucus membranes moist. No lymphadenopathy.
CV: Distant heart sounds: RRR, no m/r/g appreciated. JVP appears
mildly elevated, unchaged at 8-10cm. Radial pulses symmetric and
2+.
PULM: URI congestion, but moving air in both lung fields, clear
to auscultation.
ABD: Soft, NTND, + BS.
EXT: Warm and well perfused. [**12-23**]+ pitting edema.
Pertinent Results:
[**2190-5-22**] 11:40PM cTropnT-1.12*
[**2190-5-22**] 11:40PM CK(CPK)-328*
[**2190-5-22**] 11:40PM CK-MB-19* MB INDX-5.8
[**2190-5-22**] 11:40PM WBC-6.6 RBC-3.41* HGB-10.4* HCT-30.8* MCV-91
MCH-30.4 MCHC-33.6 RDW-14.2
[**2190-5-22**] 11:40PM GLUCOSE-86 UREA N-21* CREAT-0.8 SODIUM-135
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-20* ANION GAP-13
Brief Hospital Course:
# NSTEMI: Patient had atypical chest discomfort (acute on
chronic epigastric pain, has history of Barrett's) with EKG
changes and positive biomarkers, likely in the setting of recent
LGIB. He was managed medically because of the recent bleeding
with aspirin, low dose beta blocker, low dose ace inhibitor and
simvastatin. Echo demonstrated EF of 25-30% with severe global
LV hypokinesis. His BP remained SBP 90-110. He developed volume
overload from blood transfusions and volume resuscitation for
his hypotension at admission and was gently diuresed.
# LGIB: Presented to outside hospital with bright red blood per
rectum. Hematocrit was 37.4 to OSH initially, underwent an EGD
and a colonoscopy. Colonoscopy revealed diverticulosis and
incidental tiny polyp, otherwise, it was normal with no evidence
of active colitis or bleeding. He then underwent an EGD which
revealed Barrett's esophagus, but no evidence of upper
gastrointestinal bleeding. His hematocrit drifted down to a
nadir of 28 during his stay at the OSH and was stable at 33
prior to discharge. He did not require blood tranfusions there.
Upon this presentation, with a HCT of 27 and active cardiac
ischemia he was transfused 2 units of blood and subsequetly
maintained stable blood counts. He was repeatedly guaiac
negative.
# HTN - Systolic blood pressure after the MI ranged 90-110s. He
was treated with low dose beta blocker and low dose
ace-inhibitor (started [**2190-5-30**]) and intermittent lasix. His
outpatient medications were stopped.
# Fluid overload/ Hyponatremia - Pulmonary edema present on
admission improved with gentle diuresis (Lasix 10mg IV bolus
prn). Appeared vol overloaded on exam based on peripheral edema,
elevated JVP, and cephalization/ small pleural effusions from
CXR on [**5-27**]. Received 10mg IV lasix but diuresis persistently
difficult to quantify given urine spills and incontinence. Urine
electrolytes showed he is salt avid (FeNa = 0.1%); likely
hypervolemic hyponatremia from CHF and possibly SIADH from
stress of hospitalization. Fluid restriction to 1.5L/day.
Appeared euvolemic despite persistent LE edema on day of
discharge. Weight upon discharge 77 KG.
.
# Upper respiratory infection: Cough accompanied by [**Last Name (un) 1993**]
production and upper respiratory congestion. Pt remained afebile
without an oxygen requirement throughout stay. Given
Azithromycin Day 1 ([**2190-5-29**] day 1. To complete 5 days)
guaifensein, encoraged spirometry, OOB.
# Depression - continued celexa
#CODE: FULL
Medications on Admission:
Celexa 40 mg daily
Asacol 400 mg two tablets three times a day
lisinopril 20 mg daily
hydrochlorothiazide 12.5 mg daily (stopped on [**2190-5-21**])
Prilosec 20 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Prilosec 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. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 doses.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
Non ST-segment elevation myocardial infarction
Diverticular bleed-lower gastrointestinal bleed
Systolic congestive heart failure
[**Last Name (un) 27191**] esophagitis
Hypertension
Osteoarthritis
Anxiety
Discharge Condition:
Stable, tolerating normal diet, on room air.
Discharge Instructions:
You were admitted to the hospital with a heart attack and low
blood pressures. You were given 1 unit of blood on transfer here
and 1 additional unit of blood when you arrived. You were
treated with medications for your heart attack. You had no
further bleeding. It was determined that you need rehabilitation
to help your body recover.
Please call your doctor or return to the hospital if you
developing any bleeding from your rectum, chest pain, shortness
or breath, dizziness, or any other concerning symptoms.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 49718**], a cardiologist,on [**6-14**]
at 11:30 at [**Hospital1 18**]-[**Location (un) 620**] for follow-up of your heart attack.
Please arrive at least 15 minutes early to fill to register and
fill out paperwork. Please call his office at [**Telephone/Fax (1) 19946**] if
you need to reschedule this appointment for another time within
the next 2-3 weeks.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 5057**] within 1-2 weeks after discharge from rehabilitation. Her
office can be reached at [**Telephone/Fax (1) 5763**].
Completed by:[**2190-5-31**]
|
[
"556.9",
"280.0",
"401.9",
"V43.64",
"426.4",
"465.9",
"530.85",
"458.9",
"410.71",
"428.21",
"788.30",
"E879.8",
"428.0",
"999.8",
"780.09",
"300.4",
"276.1",
"211.3",
"715.90",
"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7116, 7157
|
3540, 6057
|
323, 331
|
7405, 7452
|
3167, 3517
|
8015, 8726
|
2634, 2638
|
6277, 7093
|
7178, 7384
|
6083, 6254
|
7476, 7992
|
2653, 3148
|
276, 285
|
359, 2204
|
2226, 2441
|
2457, 2618
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,671
| 184,923
|
43087
|
Discharge summary
|
report
|
Admission Date: [**2192-1-17**] Discharge Date: [**2192-1-20**]
Date of Birth: [**2134-9-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
57 year old male with HTN, hypercholesterolemia, OSA, who
presents with one week of cough and shortness of breath with
exertion for 2 days. He also complains of one episode of nausea,
vomiting and 3-4 days of watery diarrhea, denies any blood in
emesis or stool. He was seen in [**Location (un) **] Urgent Care Clinic
and sent here. Patient reports cough has been non-productive,
but coughing to the point of dry heaves. No known fevers or
chills at home. Denies muscle aches or pains, able to go to work
for the past few days, but became very concerned when he became
dyspneic with minimal exertion at work. Denies any associated
chest pain, dizziness, or feeling LH with the SOB. No recent
antibiotics, no recent travel, multiple sick contacts at home.
Did receive the flu vaccine this year. Remembers having a stress
test over five years ago, believes he had an echo within the
past two years, cannot recall specific results.
.
ED vitals: HR 110's, O2 sat 100%/3L. The patient given dose of
Levofloxacin and aspirin, CXR with small left pleural effusion.
Blood cultures sent.
Past Medical History:
HTN
hypercholesterolemia
OSA
GERD
Social History:
Lives with his wife, two children, and father in law. Works as a
bus driver for mass transit. Non-smoker, occasional ETOH, no
illicits
Family History:
Mother deceased from a MI at age 75, Father deceased from
pneumonia at 81
Physical Exam:
V: 99.7/ bp 143/72/ hr 107/ rr 22/ 90% on RA-> 96% on 2L
Gen: obese male, speaking full sentences but w/ labored
breathing
HEENT: atraumatic, anicteric, EOMI, dry mucosa
Neck: no JVP, no LAD
CV: tachy, no murmurs or rubs appreciated
Pulm: decreased BS on left with rhonchi, mild wheeze throughout
Abd: soft, nt, nd, nabs
Ext: warm, dry. Mild trace pretibial edema, DP pulses full and
symmetric B/L
Pertinent Results:
.
EKG:
.
Labs:
142.|.100.|.24 111
--------------
3.5.|.29.|.0.9
.
WBC 11.1 Hct 32.4 Plt 359
N:70.4 L:20.7 M:7.7 E:0.5 Bas:0.6
.
[**1-17**] 7:45p.m. CK: 136 MB: Pnd Trop < 0.01
.
Lactate:2.7
.
Studies:
[**1-17**] CXR: Cardiomegaly with small left pleural effusion.
.
Echo:
Left ventricular wall thickness, cavity size, and systolic
function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion
abnormality cannot be fully excluded. 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. There is a
small
pericardial effusion subtending the posterolateral wall. The
effusion is echo
dense, consistent with blood, inflammation or other cellular
elements. There
are no echocardiographic signs of tamponade.
.
Pericardial fluid:
GRAM STAIN (Final [**2192-1-19**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2192-1-22**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2192-1-25**]): NO GROWTH.
ACID FAST SMEAR (Final [**2192-1-19**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
NEGATIVE FOR CMV IgM ANTIBODY BY EIA
Brief Hospital Course:
A/P: 57 year old male with HTN, hypercholesterolemia presents
with cough x 1 week, SOB x 2 days.
.
# SOB- Patient was found to have pericardial effusion. No
tamponade physiuology observed. The fluid was drained and a
drain was placed. Pt's breathing improved a lot after the fluid
was removed. The echo was repeated after the drainage. It showed
decreased amount of fluid as compared to the previous ECHO. Pt
was on O2 by NC during the day and was using his CPAP machine
during night. He was monitored on telemetry. The pt remained
stable after pericardial drain removal, required no oxygen and
was discharged in stable condidtion. A follow up cardiology
appointment and a follow up echo was scheduled. The CXR showed
LLL infiltrate. Hence he was treated with a course of
levofloxacin
.
# [**Name (NI) 3674**] pt had normocytic anemia. unclear baseline hct. Pt did
not report any signs or symptoms of GIB, reported having a
colonoscopy three years ago that was normal.
.
# hypercholesterolemia- continued statin
.
# OSA- CPAP overnight
.
# FEN- heart healthy diet
.
# Proph- heparin SC
Medications on Admission:
Lipitor 20 daily
Colace 100 [**Hospital1 **]
Lisinopril 5 daily
Ranitidine 150 mg [**Hospital1 **]
Aspirin 81 daily
Ibuprofen
HCTZ 25 daily
Nafazodone 150 mg [**Hospital1 **]
CPAP- does not know his settings
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
5. Nefazodone 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 1 weeks.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
pericardial effusion
.
Secondary
hypercholesterolemia
OSA uses CPAP
GERD
chronic blood loss anemia
obesity
psoriasis
Discharge Condition:
Stable
Discharge Instructions:
You had fluid accumulation around your heart. We removed the
fluid. You need to follow up with your cardiologist. You also
need to get an [**Hospital1 461**] before seeing your cardiologist.
The appointments for both these things have been made.
.
We stopped you lisinopril and HCTZ. Your PCP needs to assess
your BP and decide whether to restart these medications.
.
You need to get a test known as PPD. Please talk to your PCP
regarding this.
.
If you have chest pain, shortness of breath, dizziness,
palpitaions, nausea, vomitting, pain in stomach please call your
doctor or go to the emergency room
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2192-2-8**]
2:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2192-1-30**]
9:00
Please make a follow up appointment with your primary care
provider Dr [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **] early next week. You need to get a
test known as PPD. Please talk to your PCP regarding this. Also
we stopped you lisinopril and HCTZ. Your PCP needs to assess
your BP and decide whether to restart these medications.
Completed by:[**2192-2-1**]
|
[
"327.23",
"530.81",
"272.0",
"280.0",
"276.51",
"420.91",
"401.9",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
5598, 5604
|
3605, 4695
|
335, 356
|
5773, 5782
|
2203, 3417
|
6433, 7065
|
1692, 1768
|
4954, 5575
|
5625, 5752
|
4721, 4931
|
5806, 6410
|
1783, 2184
|
3483, 3582
|
3450, 3450
|
275, 297
|
384, 1465
|
1487, 1523
|
1539, 1676
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,447
| 169,239
|
5277
|
Discharge summary
|
report
|
Admission Date: [**2110-8-22**] Discharge Date: [**2110-9-3**]
Date of Birth: [**2052-9-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Fatigue and pancytopenia
Major Surgical or Invasive Procedure:
Bone marrow biopsy
History of Present Illness:
Mr. [**Known lastname 21540**] is a 57 year old with a PMH significant for HIV
with a recent admission at [**Hospital1 34**] for pancytopenia. Per nightfloat
admission History and Physical, the patient states that he
initially started experiencing symptoms of dry cough and fatigue
at the end of [**Month (only) **]. Prior to this he has felt otherwise well in
good health. The patient has been HIV positive since [**2099**],
stable until 3 weeks ago when presented to S. [**Hospital **] hospital
with fevers and pancytopenia. He also endorses low grade fever
at that time. He denies having [**Last Name (LF) **], [**First Name3 (LF) **], sinus congestion, CP,
n/v/d, abd pain, rash, or lower ext swelling. He thus presented
to S [**Hospital **] Hosp on [**2110-7-31**]. There he was found to be pancytopenic
with WBC 1.9, Hct 16.5, Plt 11. His bili, AST/ALT were also
mildly elevated. He was therefore admitted there for 2+ weeks
for further work up. He presumably underwent bronch which was
neg for PCP (per patient). CT chest/abd was only notable for
fatty infiltration of the liver, spenomegaly, and mild
atelectasis. Other infectious work up was neg. He received
multiple transfusions, and underwent a bone marrow biopsy before
being discharged home. His bone marrow bipsy was thought to be
myelodysplasia. Upon follow up on [**8-20**], he was found to be
persistently pancytopenic. After discussion with Dr. [**Last Name (STitle) **] and
his PCP, [**Name10 (NameIs) **] was thus transferred for further work up. Of note,
he denies travel though he lives on [**Location (un) **]. He denies sick
contacts. [**Name (NI) **] has lost 10lbs since this began. While there, he
received multiple transfusions, bone marrow bx preliminary dx
was myelodysplasia and he was discharged to home approximately a
week ago.
Repeat labs performed the day prior to admission at [**Hospital1 34**]
demonstrated WBC 1000 (WBC 1000 - 23 poly, 65 lymph, 12 mono, 1
nuc.rbc), hgb 7.9, hct 22.8, platelets 21. He was readmitted and
transferred to [**Hospital1 18**] for further evaluation of pancytopenia. Of
note, bone marrow biopsy slides were sent to [**Hospital1 112**] for further
read.
In the ED, T 98.1, HR 100, BP 107/70, RR 18, 96%RA. Labs
confirmed pancytopenia/neutropenia. Pt subsequently spiked to
101.3. Pt was given Cefepime 2g IV x1, vanco added upon initial
transfer to the floors.
Currently, he states that he is fatigued but otherwise resting
comfortably without complaints. On further questioning, he
states that he has been febrile in the past week up to 101-102.
Past Medical History:
HIV since [**2099**], [**5-6**] CD4 471 vl <50 cop/ml
h/p PCP PNA six [**Name9 (PRE) 1686**] ago
HTN
Hyperlipidemia
? of childhood blood disorder
Social History:
Currently unemployed. Denies tobacco, admits to occational EtOH,
denies recreational drug use/IVDU. MSM. Currently lives on [**Location (un) 21541**]
Family History:
Both parents died of lung ca. Sibling is alive and well.
Physical Exam:
VS Tm 99.3 Tc 100.7 105/26 92 20 99%RA
Gen: NAD, lipodystrophy changes
HEENT: perrl, eomi, sclerae anicteric, MMM, op clear without
lesions, erythema, or exudate. Neck supple.
CV: Nl S1+S2, no m/r/g
Pulm: CTAB
Abd: S/NT/ND +bs, spleen tip palpable.
Ext: 1+ dp b/l, no c/c/e
Skin: No rashes or other observed lesions.
Pertinent Results:
STUDIES:
CXR
The cardiomediastinal silhouette is unremarkable. The lungs are
clear. There are mild degenerative changes seen in the mid
thoracic spine.
EKG: NSR, nl axis, intervals, early R wave progression,
non-specific STT changes. No priors for comparision
Bone Marrow bx [**2110-8-5**]: hypercellular marrow showing erythro
hyperplasia with left shift, myeloid left [**Hospital1 **] shift. NO
evidence of lymphoma. CD117 focally positive. GPH-A postive
TTE [**8-28**]: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%) Transmitral and tissue Doppler
imaging suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. 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. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
LABS:
[**2110-8-22**] 06:43PM GLUCOSE-103 UREA N-10 CREAT-0.6 SODIUM-137
POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16
[**2110-8-22**] 06:43PM LD(LDH)-1258* TOT BILI-1.5
[**2110-8-22**] 06:43PM HAPTOGLOB-<20*
[**2110-8-22**] 06:43PM LACTATE-2.2*
[**2110-8-22**] 06:43PM WBC-1.4*# RBC-2.55* HGB-7.9*# HCT-21.1*#
MCV-83# MCH-30.8# MCHC-37.3* RDW-17.1*
[**2110-8-22**] 06:43PM NEUTS-6* BANDS-0 LYMPHS-91* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2110-8-22**] 06:43PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-1+
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2110-8-22**] 06:43PM PT-16.1* PTT-29.6 INR(PT)-1.4*
[**2110-8-22**] 06:43PM FIBRINOGE-664* D-DIMER-1102*
[**2110-8-22**] 06:43PM GRAN CT-270*
[**2110-8-22**] 06:43PM RET AUT-0.6*
[**2110-8-22**] 06:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0
LEUK-NEG
Brief Hospital Course:
A/P: Mr. [**Known lastname 21540**] is a 57 year old gentleman with a PMH
significant for HIV diagnosed in [**2098**] transferred from [**Hospital1 34**] for
further diagnostic evaluation of pancytopenia found to have
leukemia.
# Pancytopenia: The patient was intially worked up for multiple
infectious etiologies and a bone marrow biospy was reobtained to
evaluate for cancer. He had an inital bone marrow biospy at the
OSH which was inconclusive. Leading diagnoses included
Ehrlichiosis (so he was started on doxycyline empirically while
the test was pending) and parvovirus (for which he received two
treatments of IVIG). During workup for pancytopenia, DIC labs
were sent and were negative, as were peripheral smear for
schistocytes, as well as hemolysis labs which were consistent
with a moderate amount of hemolysis. PCR of parvovirus returned
negative and IgG Ab was found to be positive and IgM was
negative. Ehrlichiosis serologies were still pending at time of
admission from OSH records. Smear for babesia x 3 was negative.
On [**8-28**] the bone marrow biopsy results returned without evidence
of parvovirus infection and with evidence of erythroleukemia so
he was transferred to the oncology service for initiation of
chemotherapy.
# Neutropenic fevers: The patient was intially started on
cefepime for his fevers, however ID felt this was not needed and
it was stopped.
# SOB/Hypoxia: Likely secondary to anemia versus pulmonary
process. A chest CT in the OSH has shown no airway disease. The
patient was transfused two times since admission for a Hct less
than 21. He remained only mildly symptomatic on exertion. Pt
progressively became more hypoxia, requiring 4L O2 by NC at one
point. On [**8-30**], pt underwent bronchoscopy for the evolving
hypoxia. On [**8-31**], pt became acutely dyspneic while maintaining
his sats. ABG performed at the time was relatively unchanged
from prior, showing a respiratory alkalosis and possibly
worsened A-a gradient (PO2 83.) CXR showed no
consolidation/pneumothorax. Pt wa placed on a NRB and given
nebulizer treatment with improvement of dyspnea. He was
transferred to the [**Hospital Unit Name 153**] for further management. In the [**Hospital Unit Name 153**], he
transitioned back to 4LNC, satting 96% with reassurance by his
partner and nursing, suggesting a likely anxiety component to
his acute SOB, as respiratory rate improved from 40s to high
20s. CTA was obtained to rule out PE. Unfortunately, he again
became increasingly hypoxic and chest x-ray on [**2110-9-2**] showed
rather rapid progression of bilateral parenchymal densities and
his respiratory state decompensated to the point of needing
intubation and vent dependency. He also became extremely
confused and agitated likely secondary to extreme hypoxic state.
After intubation. During this time he also had dramatic ARF
indicated by rapidly rising BUN/Cr and LDH levels >[**Numeric Identifier 7923**] and
markedly rising LFTs indicating rapid multi-system organ
failure. The patient's family had several meetings with the
attending physician and residents in [**Hospital Unit Name 153**] during this difficult
time and ultimately the patient's partner and family decided
that the patient should be made comfortable and CMO / Comfort
Measures Only routine care was adopted. Patient was made
comfortable with pain medications, all transfusions and IVFs
were stopped and patient expired on [**2110-9-3**].
# HIV: HAART therapy was initially continued.
# Hyperlipidemia: The patient was continued on zetia.
Medications on Admission:
Atripla 600mg/200mg/300mg Daily
Zetia 10mg daily
Atenolol 50mg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired on [**2110-9-3**] while in ICU shortly after CMO
decision was made by patient's HCP and partner.
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
none
Completed by:[**2110-11-11**]
|
[
"300.00",
"205.00",
"276.4",
"518.81",
"238.75",
"272.4",
"348.30",
"427.89",
"401.9",
"414.01",
"486",
"042",
"780.6",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.14",
"33.24",
"38.93",
"99.25",
"99.04",
"96.71",
"41.31",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9547, 9556
|
5886, 9428
|
339, 359
|
9712, 9729
|
3725, 5863
|
9793, 9829
|
3315, 3373
|
9577, 9691
|
9454, 9524
|
9753, 9770
|
3388, 3706
|
275, 301
|
387, 2963
|
2985, 3132
|
3148, 3299
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,856
| 178,397
|
29527
|
Discharge summary
|
report
|
Admission Date: [**2163-9-11**] Discharge Date: [**2163-9-14**]
Date of Birth: [**2107-5-26**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
"Hemoptysis"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 year old male with history of interstitial lung disease
(?Asbestosis), multiolobar PNA in ?[**2159**], hypertension,
hyperlipidemia, GERD, obstructive sleep apnea and ocular
pemphigoid who presents from [**Hospital6 3105**] with
hemoptysis. The patient has had intermittent hemoptysis since
[**2162-12-22**], which prompted work-up that resulted in his ILD
diagnosis (all performed at [**Hospital3 **]). The patient
developed fevers (101F), severe coughing with hemoptysis,
lightheadedness two days ago. When he presented to OSH ED
yesterday, he was mildly febrile at 100.6F, tachycardic 90-100s,
hypoxic to 84% on room air and confused (alert and oriented X2).
He had labs drawn with mild leukocytosis (WBC 11.9), Hct 27.9
(unclear baseline), platelets 180. Na 139, K 4.1, BUN 56,
Creatinine 1.5. He responded to 4L nasal cannula --> O2 sat 94%.
CTA was performed which ruled out pulmonary emboli but
demonstrated ground glass opacities and a calcified granuloma in
the right apex. He did not receive antibiotics prior to transfer
but was transfused one unit and volume resuscitated for
hypotension with BP initially 70-85/39-44, then SBP90s. He also
received 1 gram tylenol for his fever. Of note patient reports
occasional night sweats drenching sheets, cough productive of
yellowish-grey sputum and sharp chest pain which is worse with
inspiration. He denies recent travel or sick contacts.
Upon arrival to the [**Hospital1 18**] ED, initial VS: T99.5, HR80, BP106/66,
RR16, 98% on 4L. His hematocrit post-transfusion was 29.0. He
was hemodynamically stable with systolics in 110s-120, and was
treated for community-acquired pneumonia with ceftriaxone and
azithromycin; blood and urine cultures drawn. The patient was
guaiac negative. Interventional Pulmonary was made aware and had
no recommendations at this time. Vital signs upon transfer:
T99.4, HR80, BP118/64, 94% on 4L NC.
.
Past Medical History:
* Interstitial lung disease
* Hypertension
* Ocular pemphigoid
* Anziety/depression
* Neck/lower back disc disease with chronic pain
* GERD
* Hyperlipidemia
* Obstructive sleep apnea
* Severe community acquired pneumonia [**2158-12-22**] requiring
ICU admission (left AMA secondary to lack of sleep, general
uneasiness in ICU setting)
* Recurrent aspiration pneumonias
Social History:
- Lives with his girlfriend and previously works as an
electrician with possible exposure to asbestosis.
- No recent travel, no incarceration.
- Tobacco: Never
- Alcohol: Denies
- Illicits: Denies
Family History:
Family History: Mother died of lung cancer in her 50s, was life
long smoker.
Physical Exam:
ADMISSION EXAM:
Vitals: T:99.9 BP:155/76 P:86 R:18 O2:96% RA
General: Alert, oriented, no acute distress. Coughing, bedside
cup has sputum with yellowish-grey discoloration, no frank blood
or streaking.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Course breath sounds over basilar posterior lung fields
with occasional expiratory wheezes
CV: Regular rate and rhythm, S1 S2 clear and of good quality, 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
DISCHARGE EXAM:
GEN: Sitting up in bed in NAD..
HEENT: EOMI, OP clear. PERRL.
NECK: Supple, no LAD, no JVD.
COR: +S1S2, RRR, no m/g/r.
PULM: Coarse breath sounds halfway up lung field with monophonic
expiratory wheeze.
[**Last Name (un) **]: +NABS in 4Q. Soft, NTND
EXT: Warm, well-perfused. DP+ bilaterally. No c/c/e.
Pertinent Results:
ADMISSION LABS:
[**2163-9-11**] 01:05AM BLOOD WBC-9.2 RBC-3.53* Hgb-10.1* Hct-29.0*
MCV-82 MCH-28.7 MCHC-34.9 RDW-14.8 Plt Ct-188
[**2163-9-11**] 08:15AM BLOOD Neuts-85.6* Lymphs-10.4* Monos-1.9*
Eos-1.9 Baso-0.2
[**2163-9-11**] 01:05AM BLOOD PT-14.1* PTT-24.8 INR(PT)-1.2*
[**2163-9-11**] 01:05AM BLOOD Glucose-110* UreaN-46* Creat-1.1 Na-143
K-4.0 Cl-107 HCO3-26 AnGap-14
[**2163-9-11**] 08:15AM BLOOD Calcium-8.7 Phos-1.2* Mg-2.0
[**2163-9-11**] 08:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2163-9-11**] 02:05AM BLOOD Lactate-1.2
DISCHARGE LABS:
[**2163-9-12**] 04:00AM BLOOD WBC-6.6 RBC-3.69* Hgb-10.6* Hct-29.9*
MCV-81* MCH-28.6 MCHC-35.4* RDW-14.4 Plt Ct-208
[**2163-9-13**] 07:35AM BLOOD WBC-5.5
[**2163-9-13**] 07:35AM BLOOD Ret Aut-2.3
[**2163-9-13**] 07:35AM BLOOD Na-135 K-4.2 Cl-97
[**2163-9-13**] 07:35AM BLOOD Iron-30*
Imaging:
[**9-11**] CXR PA/Lat: IMPRESSION: Non-specific subtle increase of
opacity in the left lower lobe, could represent either early
infection or small amount of alveolar hemorrhage.
[**9-11**] CT Chest W/O Contrast:
1. Diffuse peribronchial ground-glass opacities are visualized
at all lobes
of both lungs, but greatest throughout the left lower lobe.
These findings
are suggestive of an infectious or inflammatory process.
Atypical infections,
including mycobacterial infections, are included as differential
considerations.
2. Esophageal thickening with a small hiatal hernia, suggestive
of an
inflammatory process.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
56yo M PMHx of uncertain interstitial lung disease, obstructive
sleep apnea p/w fevers reporting "hemoptysis", found to not have
any signs of hemorrhagic process, nor any signs of blood in
sputum, started on a rule out for TB and transferred to the
floor.
ACTIVE DIAGNOSES:
# Multifocal pneumonia: Patient has reports of hemoptysis, but
sputum during stay yellowish-grey, guaiac negative. Given his
radiographic findings and outpatient fever, the patient was
treated with empiric cefpodoxime and azithromycin. His case was
discussed with interventional pulmonology and reviewed CT of his
chest, a bronchitis was most likely etiology but given apical
granuloma (see below on pulmonary imaging) it was felt that the
patient warranted a TB rule-out. Upon transfer from the MICU to
the floor the patient was saturating in the low 90s on room air
and his productive cough had improved. He was discharged on
cefpodoxime & azithromycin (to complete a 10-d course).
# Apical granulomas: Patient w h/o L apical granuloma on prior
CT chest ([**2159**]) and on wet read of admission chest CT. He
appeared to have a small right apical granuloma. Given his
prior stay in prison & his presenting symptoms, it was felt that
he should be ruled out for active TB. He had 3 AFB negative
sputum samples at the time of discharge.
# Iron deficiency anemia: Mr. [**Known lastname 70832**] was found to have heme
occult positive brown stools, but H/H remained stable at 29-31.
Iron saturation was ~10% with ferritin in the 80s. He had
undergone recent colonoscopy and EGD so this was not pursued.
Repeat HCT should be checked in follow-up.
# Esophageal thickening: Noted on CT scan. Patient reported some
intermittant GERD symptoms. EGD done 1 month prior was normal by
his report.
CHRONIC DIAGNOSES:
# Interstitial lung disease: The patient reports that he has
asbestosis and is being followed by an outpatient pulmonologist.
He was encouraged to discuss his recent admission with his
pulmonologist after discharge.
# Hypertension: The patient was continued on Amlodipine and
Atenolol
# Psychiatric Disorder NOS: Patient was noted to have pressured
speech, flight of ideas, and tangential thinking during his
admission. He was continued on his home medications including
clonazepam, soma, cymbalta, and ambien.
TRANSITIONAL ISSUES:
# Follow-Up: The patient should follow-up with his outpatient
pulmonologist in [**2-24**] weeks as well as his primary care
physician. [**Name10 (NameIs) **] discharge, he was given an appointment for
outpatient pulmonary function tests.
Medications on Admission:
* Gemfibrozil 600mg daily
* Atenolol 25mg daily
* Amlodipine 10mg daily
* Prilosec 40mg daily
* Clonazepam 0.1mg three times daily
* Soma 350mg three times daily
* Cymbalta 60mg daily
* Ambien 10mg daily
* Morphine 30mg PO three times daily
* Trazodone 50mg daily
* Motrin 800mg three times daily
Discharge Medications:
1. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO twice a day
for 8 days.
Disp:*32 Tablet(s)* Refills:*0*
2. azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
3. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO three times a day: This medication may
sedate you, please only take as prescribed by your PCP and do
not drive while on this medication.
10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Senna Lax 8.6 mg Tablet Sig: 1-2 Tablets PO once a day.
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every six (6) hours as needed for
shortness of breath or wheezing: please discuss how to use with
pharmacist.
Disp:*1 inhaler* Refills:*0*
14. ibuprofen Oral
15. Soma Oral
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pneumonia
2. Interstitial lung disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 70832**], you were admitted for pneumonia. You had a CT of
your chest which showed an atypical pneumonia and findings
possible of TB. You were treated with IV and then PO antibiotics
with great improvement in your symptoms. You were ruled out for
active tuberculosis by induced sputums.
Your ambulatory oxygen at discharge was 88% on room air. You
were asymptomatic with this. If this gets lower you may need
home oxygen. Please discuss this with your primary care
physician and pulmonologist.
You should take azithromycin for an additional 3 days and
cefpodoxime for an additional 8 days. You were written for an
albuterol inhaler. Please discuss with your pharmacist and
primary care physician how to use this medication.
No other changes were made to your medications.
Followup Instructions:
Please contact your primary care physician tomorrow and set up
an appointment for within the next 1 week. His name and number
are [**Last Name (LF) 70833**],[**First Name3 (LF) 177**] C. [**Telephone/Fax (1) 50168**]. Please discuss your
pneumonia and GI symptoms.
You should also follow up with your pulmonogist in the next
couple of weeks. If you would like, appointments were made for
our pulmonary physicians. If you wish to cancel them please call
the numbers below to cancel.
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2163-10-3**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: MONDAY [**2163-10-3**] at 1:30 PM
Department: MEDICAL SPECIALTIES
When: MONDAY [**2163-10-3**] at 1:30 PM
With: DR. [**Last Name (STitle) **] / DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"965.09",
"401.9",
"530.81",
"584.9",
"280.9",
"515",
"E850.2",
"272.4",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9882, 9888
|
5488, 5781
|
304, 310
|
9974, 9974
|
3959, 3959
|
10946, 12051
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2871, 2933
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|
9909, 9953
|
8117, 8416
|
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4550, 5465
|
2948, 3620
|
3636, 3940
|
7851, 8091
|
252, 266
|
338, 2230
|
3975, 4534
|
9989, 10101
|
5799, 7830
|
2252, 2623
|
2639, 2838
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,882
| 103,146
|
36556
|
Discharge summary
|
report
|
Admission Date: [**2114-4-23**] Discharge Date: [**2114-5-9**]
Date of Birth: [**2050-4-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
CHF & severe aortic stenosis
Major Surgical or Invasive Procedure:
aortic valvululoplasty
swan ganz catheter
History of Present Illness:
Mr. [**Known lastname 1511**] is a 64 yo man with dilated cardiomyopathy (presumed
non-ischemic) and severe aortic stenosis (valve are 0.8, peak
gradient 87) who was transferred from Holy [**Hospital 82745**] hospital for
further care of his aortic stenosis. According to his initial
H&P on [**4-15**] Mr. [**Known lastname 1511**] was admitted for dyspnea with minimal
activity, fatigue, orthopnea, and ankle edema. He is delerius
on transfer and is unable to provide any more information. Per
his wife he gets dyspneic usually upon ambulating from room to
room; this has worsened recently. At [**Hospital3 **] he was (hct
24.7 & BUN 100) he was found to have have GI bleed; upper GI
showed minimal erosions; c-scope showed residual blood & R-colon
AVM that was cuaterized; he was also placed on octreotide. For
an unclear reason he underwent cardiac cath today which showed
EF 25%, clean coronaries. AVG 58 peak with mean 40. PCW 16,
LVEDP 15, PA pressures of 85/29 & RVEDP 8. After the cardiac
cath he became agitated, agressive, and was dyspneic requiring
4L. bp 79/59, He was given 80mg IV lasix for presumed CHF. He
was in afib with RVR at the time in 110-130's and was given po
toprol (50mg) & IV metoprolol (10mg). no temp recorded. Na
136, K 3.6, BUN 45, Cr 1.1, chloritde 105, bicarb 24. WBC
increased to 15.8. VS prior to transfer: BP 160/56 HR 106 100%
on 4L. RR 26-32.
.
Mr. [**Known lastname 1511**] remembers nothing of the event. Upon speaking with is
wife, he was not delerious, febrile, or agitated prior to the
cath.
.
On transfer Mr. [**Known lastname 1511**] is delerius and febrile to 102.3, knows he
is in the hospital, unsure of which one. Thinks the year is
[**2049**]. He cannot recall any of the symptoms leading up to his
hospitalization. Currently he complains of fever and abdominal
pain. He denies orthopnea, pnd, cough. He is mildly dyspneic.
.
Past Medical History:
COPD; ?home oxygen
aortic stenosis
dilated CMP; last EF 25%. RV hypertrophy & hypokinesis
Lumbar disc disease
OSA
A fib
MRSA of R leg
atrial fibrillation
Social History:
former smoker. married with 3 chilldren. Denies EtoH
Family History:
n/c
Physical Exam:
On admission -
T 101.4 oral, 103.8 rectal, then T 105. RR 30-40 96% on 4L n/c.
BP 92/54 with HR 120 & irregular
Gen: ill-appearing, jaundiced
CV: tachycardic. Very difficult to appreciate heart sounds over
tachypnea
Pulm: Tachypneic but CTA B
Abdomen: obese, soft, non-distended diffusely TTP; maximally TTP
in RUQ. + [**Doctor Last Name **] sign.
Extremity: 1+ BLE edema
Neuro: oriented x 1. thinks it is [**2049**]. Knows hospital, but
not [**Location (un) 86**] or [**Hospital1 18**]. No meningismus.
Pertinent Results:
ADMISSION LABS:
[**2114-4-23**] 08:15PM BLOOD WBC-17.6* RBC-4.00* Hgb-10.9* Hct-34.4*
MCV-86 MCH-27.2 MCHC-31.7 RDW-19.2* Plt Ct-173
[**2114-4-23**] 08:15PM BLOOD Neuts-94.9* Lymphs-2.2* Monos-2.6 Eos-0.1
Baso-0.1
[**2114-4-23**] 08:15PM BLOOD PT-18.9* PTT-38.6* INR(PT)-1.7*
[**2114-4-25**] 01:34PM BLOOD FDP-40-80*
[**2114-4-23**] 08:15PM BLOOD Glucose-188* UreaN-45* Creat-2.0* Na-137
K-5.1 Cl-103 HCO3-21* AnGap-18
[**2114-4-23**] 08:15PM BLOOD ALT-321* AST-459* CK(CPK)-39 AlkPhos-75
Amylase-22 TotBili-2.7* DirBili-1.7* IndBili-1.0
[**2114-4-23**] 08:15PM BLOOD Albumin-3.7 Calcium-8.8 Phos-5.5* Mg-1.8
[**2114-4-23**] 08:15PM BLOOD Hapto-215*
[**2114-4-25**] 03:42AM BLOOD IgM HAV-NEGATIVE
[**2114-4-23**] 11:19PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2114-4-25**] 02:17PM BLOOD Smooth-NEGATIVE
[**2114-4-23**] 11:19PM BLOOD HCV Ab-NEGATIVE
.
cardiac cath:
hemodynamics:
peak gradient 59, mean gradient 40. [**Location (un) 109**] 0.8cm2. CO 4.73
LV pressure 135/14/17, AO 78/60/64
RA 23/26/23
RV [**2098-6-26**]
PA 85/29/55
PCW 21/23/16
RVEDP 8
.
original EKG on [**4-17**]: a fib with normal axis. IVCD & QRS of 91.
delayed RWP. lat ST depressions (V5-6)
.
EKG on arrival to CCU: irregular wide complex-tachycardia, axis
about 180. IVCD with QRS of 152. ?possible concordance of
precordial leads.
.
ECHO on [**2114-4-10**]. EF 20%, global LV hypok. dilated with
concentric hypertrophy. atrium dilated. 1+ MR. AS with [**Location (un) 109**]
0.88cm2. peak gradient 87, mean gradient 57. LVOT velocity
111cm/s, peak velocity 477 cm/s. 1+ TR. rheumatic aortic valve
with AS, 2+ AR, rheumatic MS, 1+ MR, 1+ TR. mild PA htn
CXR: no pulm edema
RUQ US: no gall stones, biliary ductal dilation or
cholecystitis. Neg [**Doctor Last Name **]
blood cultures: MSSA in [**3-24**] bottles on admission. negative
thereafter.
Brief Hospital Course:
Mr. [**Known lastname 1511**] is a 64 yo man with dilated cardiomyopathy and severe
aortic stenosis, OSA & pulmonary hypertension who was admitted
to the hospital for worsening dyspnea and is transferred to
[**Hospital1 18**] for further care. He expired after developing sepsis,
renal failure, acidosis and hypotension not responsive to
pressors.
# Sepsis/bacteremia: Mr. [**Known lastname 1511**] was febrile to 105 on admission.
He was empirically covered with vancomycin/cipro/flagyl on
admission. A central venous line was placed and he was
aggressively hydrated. He became hypotensive on the night of
admission and was started on dobutamine + levophed. Admission
blood cultures quickly turned positive for [**3-24**] MSSA. His
antibiotics were changed to nafcilling. TTE and TEE were
negative for endocarditis and repeat blood cultures remained
negative. He completed his course of nafcillin in-house. WBC
trended up and patient developed lactic acidosis in addition to
his leukocytosis. Culture data was negative at the time of
death. Patient was on broad spectrum antibiotics on [**2114-5-7**]
including vancomycin and zosyn. Patient was dependent on
pressors to keep MAPs greater than 55. As acidosis worsened,
patient became less pressor responsive and died in the presence
of his family.
# Cardiogenic shock: secondary to depressed EF and severe AS.
Maintained on dobutamine + levophed. Diuresed with guidance of
swan-ganz catheter. Mr. [**Known lastname 1511**] was evaluated by Dr. [**Last Name (STitle) 28946**] of CT
surgery for consideration of AVR, but was
# Dyspnea: likely multifactorial from fever, severe pulmonary
hypertension, COPD, and CHF. Swan Ganz Catheter was placed and
he was found to have severe pulmonary hypertension; some of
which was responsive to diuresis (at near-systemic pressures at
highest). He was aggressively diuresed.
# Transaminitis: From shock liver. Resolved with supportive
care
.
# Abdominal pain: due to hepatitis. RUQ US negative and pain
resolved.
.
# Aortic Stenosis: severe based on gradient and valve area.
Patient has had symptoms of refractory heart failure, but no
angina or syncope. Depressed EF alone is indication for valve
repair.
- consider dobutamine echo to r/o pseudo aortic stenosis
.
# Atrial fibrillation - given amiodarone for rate control. Had
rate-related BBB
.
# Lower GIB: stable
.
# Diabetes: decrease lantus to 26 while not eating much
.
# hyperlipidemia: continue statin
.
# Access: placed chordus with RIJ CVC [**2114-4-23**]. Will place swan
in AM
.
# FEN/GI: clears while unstable/poor mental status.
.
# Code: full
Medications on Admission:
torsemide 20mg po bid
metolazone 2.5mg po daily
lipitor 20mg po daily
lisinopril 20mg po daily
niaspan 500mg po daily
omeprazole 20mg po daily
prandin 2mg po tid
coumadin
metoclopramide
januvia 50mg o [**Hospital1 **]
carvedilol 6.25mg po bid
aspirin
lantus
advair
spiriva
.
meds on transfer
coreg 6.25mg po bid
valium prior to procedure
digoxin 0.25mg IV x 2
lovenox 40mg SQ daily
ferrous sulfate
advair daily
lasix 80mg IV x 1
lisinopril 20mg po daily
insulin levemir 34U QHS
Toprol 50mg po daily
niacin 500mg po daily
octerotide 0.05mg SQ tid
potassium 20mg po daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
primary: cardiogenic shock
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2114-5-15**]
|
[
"425.4",
"287.5",
"599.0",
"396.8",
"995.92",
"496",
"272.4",
"V70.7",
"785.51",
"038.11",
"428.0",
"428.23",
"276.2",
"327.23",
"584.5",
"416.8",
"570",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.96",
"88.72",
"38.93",
"37.28",
"88.55",
"99.62",
"89.64",
"37.23",
"37.21",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8276, 8285
|
5011, 7627
|
343, 387
|
8356, 8366
|
3133, 3133
|
8419, 8584
|
2581, 2586
|
8247, 8253
|
8306, 8335
|
7653, 8224
|
8390, 8396
|
2601, 3114
|
275, 305
|
415, 2314
|
3149, 4988
|
2336, 2492
|
2508, 2565
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,963
| 107,895
|
46319
|
Discharge summary
|
report
|
Admission Date: [**2121-1-19**] Discharge Date: [**2121-1-23**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
IV TPA
History of Present Illness:
HPI:Pt is a 89 yo with h/o AF, DMII, HTN, glaucoma, SBO in the
past, hypothyroidism who is here with bleeding hemorrhoids. She
was going to leave today, but couldn't get a ride. She was seen
normal at 8 pm by the nurse. She was then seen at 9 pm and was
found to be not moving her left side or speaking. The team
assessed her and then called me to assess her. Her BS was 124.
Her vitals were normal. On arrival, I found her saying only her
name and following only simple commands on the right. Her left
side was not moving. She had a left neglect and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 11849**]
toe. NIHSS was limited by severe aphasia and poor cooperation.
She was brought to the CT scanner and found to have no bleed,
but
she did have a hyperdense MCA sign on the right(corresponding
with symptoms). A subsequent CTA demonstrated a cut-off of the
right MCA. She was emergently brought to the SICU after
speaking
with her attending and her sister to clarify both her wishes and
also the nature of her apparent hemorrhoidal bleeding given that
we were considering tpa. The attending felt that her risk was
very low for having a source of her bleeding other than
hemorrhoids. She was brought to the unit and tpa given at ~10:30
pm. She had no immediate changes.
Past Medical History:
- Atrial fibrillation with RVR - has been rate controlled on
metoprolol
- Insulin resistance/diabetes - diet controlled
- Hypertension - on metoprolol, lisinopril and HCTZ
- glaucoma
- cataracts s/p right eye surgery
- SBO s/p LOA in [**2117**]
- stable RUL opacity
Social History:
Lives alone, sister in area. Denies tobacco, ETOH, IVDU.
Retired from sales.
Family History:
Non contributory
Physical Exam:
Exam:Vitals:
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear
Neck: No Carotid bruits
CV: Irreg, irreg., Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Ext:No cyanosis/edema
Neurologic examination:
Mental status: Awake and alert
Pt is able to repeat single words only. She follows simple
commands with her right hand only. Will not follow midline
commands consistently.
Cranial Nerves:
I: not tested
II: Pupils 4 to 3 on right. 5 mm and min reactive on left.
Apparent left hemianopsia vs neglect.
III, IV, VI: Extraocular movements intact grossly, but no formal
eval.
V, VII: Left facial droop with unclear sensory changes
[**Name (NI) 7060**]: Hearing intact grossly.
IX, X: Palatal elevation symmetrical
XII: Tongue midline without fasciculations
Motor:
Unable to assess formally, but not moving left side at all, even
to nox stim. Moves right arm and leg freely and normally. Tone
is normal on right, increased in LUE and LLE bilaterally.
Sensation: Responds in some way to nox stim in all exts.
Reflexes: B T Br Pa Ankle
Right 3 3 2 3 0
Left 3 3 2 3 0
Toes were downgoing on right, up on left
Coordination: No cooperation
Gait: Unable
Pertinent Results:
[**2121-1-19**] 05:20PM ALBUMIN-4.2
[**2121-1-19**] 05:20PM LIPASE-44
[**2121-1-19**] 05:20PM GLUCOSE-92 UREA N-28* CREAT-0.9 SODIUM-137
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-28 ANION GAP-14
[**2121-1-19**] 04:35PM PLT COUNT-271#
[**2121-1-19**] 05:20PM PT-11.0 PTT-23.5 INR(PT)-0.9
CT/CTA head [**2121-1-20**]:
IMPRESSION: Complete occlusion of the M1 segment of the right
MCA. CT perfusion conistent with right MCA stroke.
CT head [**2121-1-21**]: 1. Medullary hemorrhage, likely unchanged in
extent.
2. Progression of hypodensities corresponding to edema in areas
of restricted diffusion on MRI, consistent with evolving
ischemic infarct in these areas.3. Unchanged appearance of dense
right MCA, consistent with persistent clot despite thrombolysis
MRI head [**2121-1-21**]: Evolving right middle cerebral artery
infarction as well as hemorrhage within the medulla.
Ech [**2121-1-21**]: The left atrium is moderately dilated. The right
atrium is moderately dilated.
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler
or saline contrast with maneuvers. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is moderately depressed with anteroseptal and
apical
akinesis with mild to moderate hypokinesis elsewhere. Right
ventricular
chamber size is normal. The aortic valve leaflets (3) are mildly
thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
Brief Hospital Course:
Neurology: Patient was admitted to ICU after patient received IV
TPA for acute stroke within 3 hours from onset of stroke
symptoms ([**2121-1-20**] 10 pm). She initially had no improvement in
exam. At 24 hours, patient became more somulent and required
intubation. Head CT 24 hours after IV TPA given showed a
medullary hemorrhage. Though she had some minimal responsiveness
to voice (awoke to voice)and was able to move right arm/leg
spontaneiously her family decided to make her CMO as she had
made prior wishes not to be in nursing care and would not have
liked to tracheostomy or PEG dependent. The patient was
extubated and she passed away hours later.
Medications on Admission:
Metoprolol
Lisinopril
HCTZ
synthroid
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
hemorroid
stroke
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"455.2",
"250.00",
"244.9",
"434.11",
"401.9",
"427.31",
"365.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
5851, 5860
|
5075, 5734
|
283, 291
|
5921, 5932
|
3264, 5052
|
5985, 6103
|
2023, 2041
|
5822, 5828
|
5881, 5900
|
5760, 5799
|
5956, 5962
|
2056, 2256
|
224, 245
|
319, 1622
|
2469, 3245
|
2295, 2453
|
2280, 2280
|
1644, 1911
|
1927, 2007
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,608
| 156,088
|
7653+55858
|
Discharge summary
|
report+addendum
|
Admission Date: [**2187-11-11**] Discharge Date: [**2187-11-19**]
Date of Birth: [**2144-6-10**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 43-year-old male
with a past medical history of chronic hepatitis B and
metastatic hepatocellular carcinoma who presented to the
[**Location (un) 5871**] Emergency Room on [**11-11**] after four episodes of
hematemesis. He described the vomitus as bright red blood
with some clots, possibly also with some coffee ground. He
state through a translator that he had had one episode of
hematemesis one year ago, was admitted briefly to an outside
hospital, and then was discharged on some unknown medicines.
He has never had an upper endoscopy. He denied any chest
pain or pressure. He had some shortness of breath associated
with the vomiting. He also had some lightheadedness. He
denied bright red blood per rectum or melena.
PAST MEDICAL HISTORY: Chronic hepatitis B, poorly
differentiated hepatoma by liver biopsy with metastases to
the right adrenal gland, extensive metastases to the lung,
and direct invasion of the superior vena cava.
Thrombocytopenia.
MEDICATIONS: On admission, Vicodin 1-2 tablets q 4-6 hours
prn pain and Chinese herbal medicine.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Strong family history of hepatoma (both
parents and two brothers deceased of hepatoma).
SOCIAL HISTORY: The patient lives with his wife and
10-year-old son. [**Name (NI) **] is originally from [**Country 5142**].
PHYSICAL EXAMINATION: A fatigued appearing male. Vital
signs afebrile. Blood pressure 110/60, pulse 110 to 120, sat
97-99% on room air. HEENT: Pupils are equal, round, and
reactive to light, mild scleral icterus. Oropharynx with dry
blood in the oropharynx. Cardiac, sinus tachycardia, grade
2/6 systolic murmur at the left sternal border, no increase
in JVP. Lungs clear to auscultation with decreased breath
sounds at the bases bilaterally. Abdomen, distended with
bowel sounds present, nontender. Extremities, 2+ pulses,
dorsalis pedis bilaterally without edema. Neurologic, alert
and oriented times three, moving all extremities
spontaneously.
LABORATORY DATA: On admission, white blood cell count 6.8,
hematocrit 31.3, platelet count 92,000, PT 14.1, PTT 31.6,
INR 1.4, sodium 137, potassium 5.6 (hemolyzed), chloride 106,
CO2 26, BUN 12, creatinine 0.6, glucose 117. Labs from [**11-9**],
LDH 734, alkaline phosphatase 282, total bilirubin 1.7, alpha
fetoprotein 67.2 (29.3 on [**2187-9-28**]). MRI of the abdomen from
[**2187-9-10**], 11 by 9 by 8 cm lesion in the liver, non occlusive
thrombus in the right portal vein, tumor throughout right
adrenal gland with invasion to the inferior vena cava,
multiple pulmonary nodules. Pathology, biopsy [**2187-9-4**] of
liver mass showed poorly differentiated malignant tumor with
marked fibrosis and focal nodules suggesting likely
cirrhosis. EGD from [**2187-8-19**], grade 2 varices in the mid and
distal esophagus.
HOSPITAL COURSE:
1. GI: The patient was admitted to the Intensive Care Unit
at [**Hospital1 69**] on [**2187-11-11**] and
underwent urgent upper endoscopy which showed varices of the
upper, middle and lower thirds of the esophagus as well as
blood in the stomach. Six bands were successfully placed
during the procedure. The patient was then started on
Protonix 40 mg po bid and Octreotide drip over the next
several days per the GI service. He had no further episodes
of hematemesis and his hematocrit remained stable. On [**11-15**]
the patient underwent a repeat upper endoscopy which showed
no active bleeding from the esophageal varices. The patient
was transferred from the Intensive Care Unit to the floor on
[**2187-11-12**].
In terms of the patient's hepatocellular carcinoma, the
oncology staff unfortunately was not able to offer any
further chemotherapeutic options for Mr. [**Known lastname **] cancer as it
was widely metastatic. .........
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 737**]
MEDQUIST36
D: [**2187-11-17**] 13:21
T: [**2187-11-19**] 21:46
JOB#: [**Job Number 27851**]
Name: [**Known lastname **], [**Known firstname **] [**Doctor Last Name 909**] Unit No: [**Numeric Identifier 4828**]
Admission Date: [**2187-11-11**] Discharge Date: [**2187-11-19**]
Date of Birth: [**2144-6-10**] Sex: M
Service:
HOSPITAL COURSE:
Gastrointestinal: The patient was admitted to the Intensive
Care Unit to the [**Hospital1 536**] on
[**11-11**] with a diagnosis of upper gastrointestinal
bleeding. He underwent urgent upper endoscopy which showed
variceal varices were banded with six bands. He was
transfused with two units of packed red blood cells. He was
also started on Protonix IV and octreotide drip for 72 hours.
Following the procedure, his hematocrit remained stable
throughout the admission (range 29-30). A repeat upper
endoscopy on [**11-15**] showed no active bleeding. At the
banding in [**1-6**] weeks time with either Dr. [**Last Name (STitle) 3575**] or Dr.
[**Last Name (STitle) 4829**]. The patient is to call [**Telephone/Fax (1) 906**] to schedule the
procedure. Propanolol was added to the medical regimen to
decrease the risk of re-bleeding from the varices.
In terms of the patient's hepatocellular carcinoma which was
known to be metastatic, the patient was evaluated by his
oncologist, Dr. [**First Name (STitle) **], and unfortunately, no further
therapy was recommended. The patient's family inquired about
the use of thalidomide, however, according to Dr. [**First Name (STitle) **],
thalidomide was not considered appropriate in Mr. [**Known lastname 4830**]
situation.
As such, the hepatocellular carcinoma was managed
symptomatically with emphasis given to controlling Mr. [**Known lastname 4830**]
pain and lower extremity edema. This was accomplished with
pain medications including a Fentanyl patch 50 mcg/hour with
Dilaudid for breakthrough pain. The lower extremity edema
was modestly controlled with diuretics including Lasix and
aldactone as well as compression stockings and lower
extremity elevation. The medical team was concerned during
admission that attempts to reduce the lower extremity edema
might be limited if the edema resulted from a thrombus or
tumor thrombus of the portal vein or inferior vena cava. It
was also considered that the edema may have been due to
ascites and worsening hepatic failure. In terms of the
patient's hepatitis B, no therapy was initiated during this
admission.
Pulmonary: The patient remained stable from a pulmonary
standpoint. He had no subjective shortness of breath, had
good room air oxygen saturations and did not require oxygen.
Because of the patient's decreased breath sounds on
examination, he received a chest x-ray on [**11-13**],
which showed diffuse pulmonary metastases, bilateral pleural
effusions right greater than left, and right middle lobe, and
right lower lobe consolidation versus collapse.
Cardiovascular: The patient remained cardiovascularly stable
during the admission. Pulse ranged from the 80s to high 90s.
Blood pressure systolic ranged 90s-100s, and diastolic ranged
from 50-70s.
Nutrition: Patient was allowed to eat as tolerated and
mainly had a diet consisting of broth, noodles, and rice.
Nutrition service was also consulted to make recommendations
for nutritional supplements.
DISPOSITION:
A meeting with the patient, his family, and the medical team
was held on [**11-14**] to discuss a care plan. The
patient was informed of his poor prognosis and the available
medical interventions. After discussion with his family, he
decided to become comfort care/DNR/DNI, but indicated his
preference to return to the hospital should he experience
additional esophageal-variceal bleeding. Return to the
hospital for treatment of esophageal-variceal bleeding should
it recur. He indicated his preference to go home with home
services. Hospice was addressed with him but gien the potential
need for intervention for GI BLeed while he is still
fairly functional, this was deferred till later and he remains
DNR/DNI only. As his cancer progresses and his disease worsens
this will be broached with him again.
Arrangements at the time of this dictation have been made. Mr.
[**Known lastname 4830**] care at
home will be coordinated by Dr. [**First Name (STitle) 4831**] [**Name (STitle) **] at [**Telephone/Fax (1) 4832**].
CONDITION ON DISCHARGE:
Stable.
DISCHARGE DIAGNOSES:
1. Metastatic hepatocellular carcinoma.
2. Hepatitis B.
3. Grade III esophageal varices.
DISCHARGE STATUS:
To home with home hospice services.
DIET:
As tolerated with nutritional supplements.
ACTIVITY:
As tolerated; continue lower extremity elevation, compression
stockings, ambulation.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po bid.
2. Lasix 120 mg po q day.
3. Propanolol 20 mg po bid.
4. Aldactone 50 mg po q day.
5. Colace 100 mg po bid.
6. Lactulose 15-30 cc po q six hours as needed for
constipation.
7. Simethicone 80 mg po qid.
8. Fentanyl 50 mcg per hour topical patch, change q 72 hours,
hold for respiratory rate less than 10.
9. Dilaudid 2-4 mg po q six hours prn breakthrough pain.
10. Ativan 1-2 mg po q 6-8 hours prn anxiety, nausea.
11. Compazine 10 mg po q 4-6 hours prn nausea.
FOLLOWUP:
The patient is to followup with Dr. [**First Name (STitle) 4831**] [**Name (STitle) **] again at
[**Telephone/Fax (1) 4832**], and Dr. [**Last Name (STitle) **] will coordinate the [**Hospital 1325**]
hospice care and make changes to his medication regimen as
needed.
[**Name6 (MD) **] [**Last Name (NamePattern4) 424**], M.D. [**MD Number(1) 425**]
Dictated By:[**Last Name (NamePattern1) 30**]
MEDQUIST36
D: [**2187-11-20**] 11:12
T: [**2187-11-20**] 11:44
JOB#: [**Job Number 4833**]
|
[
"287.5",
"198.7",
"070.32",
"572.3",
"155.0",
"276.1",
"197.0",
"198.89",
"456.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"42.33",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
1319, 1408
|
8622, 8913
|
8936, 9963
|
4539, 8568
|
1559, 3023
|
168, 930
|
953, 1302
|
1425, 1536
|
8592, 8601
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,298
| 182,702
|
16449
|
Discharge summary
|
report
|
Admission Date: [**2104-10-23**] Discharge Date: [**2104-11-11**]
Date of Birth: [**2027-2-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Precedex
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
cardiac catheterization
dental extraction
CABGx1(LIMA->LAD)/AVR(25mm CE pericardial valve) [**2104-11-4**]
History of Present Illness:
Mr. [**Known lastname 46772**] is a 77M with DM, CAD s/p MI, and CHF EF40% who is
admitted for elective cardiac catheterization. He was seen for
follow up in cardiology clinic on [**10-22**] at which time he reported
a two week history of progressive exertional dyspnea. The past
weekend he was admitted for these symptoms to [**Location (un) **] where he
was apparently diagnosed with a COPD exacerbation (with no known
history of COPD). On his follow up cardiology visit he admits
that has been using nitroglycerin tablets frequently at home, up
to 6 per day.
On presentation to the floor pt appears comfortable he denies
any current chest pain, shortness of breath, palpitation, or
nausea. He admits to mild ankle edema and an occasional cough
which he attributes to his smoking history.
Past Medical History:
coronary artery disease, s/p stent and internal cardiac
defibrillator
Gastroesophageal reflux disease
Non-insulin dependent diabetes mellitus
Hypertension
Hyperlipidemia
Bladder CA-pt unaware of details
congestive heart failure (chronic systolic)
Seizure disorder
Social History:
Married. No smoking now. 50 pack year smoking history.
Family History:
Father had MI in 50s. No strokes/seizures.
Physical Exam:
VS - 97.2 102/56 76 22 96% 2L
Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. Very hard of hearing. R
hearing aid in place.
Neck: Supple, No LAD, no JVP appreciated
CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: Pt on supplemental oxygen via nasal cannula. Resp were
unlabored, no accessory muscle use. CTAB, no crackles, wheezes
or rhonchi, sternum stable, wounds healing well.
Abd: Soft, NTND. No abdominial bruits appreciated.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers. Two large scars on
abdominal wall in which pt can not recall their origin.
Pertinent Results:
[**2104-11-10**] 05:35AM BLOOD WBC-7.5 RBC-3.18* Hgb-9.7* Hct-28.0*
MCV-88 MCH-30.6 MCHC-34.8 RDW-14.4 Plt Ct-212
[**2104-11-9**] 04:29AM BLOOD PT-13.3 PTT-28.8 INR(PT)-1.1
[**2104-11-10**] 05:35AM BLOOD Glucose-74 UreaN-24* Creat-1.1 Na-138
K-4.0 Cl-101 HCO3-28 AnGap-13
[**Known lastname **],[**Known firstname 1775**] C [**Medical Record Number 46773**] M 77 [**2027-2-14**]
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2104-11-6**] 4:42 PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2104-11-6**] SCHED
CHEST PORT. LINE PLACEMENT Clip # [**Clip Number (Radiology) 46774**]
Reason: line placement
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with
Final Report
CHEST AP SINGLE VIEW.
INDICATION: Line placement.
FINDINGS: AP single view of the chest obtained with patient in
sitting
semi-upright position is analyzed in direct comparison with a
preceding
similar study obtained 10 hours earlier during the same date.
The previously
identified left-sided permanent pacer with ICD device and right
atrial
electrode is in unchanged position. Previously present pulmonary
artery
catheter has been removed. The patient is extubated. It is
assumed that a
smaller caliber line advanced through the right internal jugular
vein approach
appears to be new and it is seen to terminate overlying the SVC
at the level
of the carina. No pneumothorax has developed and the pulmonary
vasculature
appears unchanged. No new parenchymal infiltrates are seen, and
only mild
blunting of the lateral pleural sinuses is identified on the
single view
portable chest examination.
IMPRESSION: No evidence of pneumothorax after line exchange.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2104-11-6**] 8:16 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 1775**] [**Hospital1 18**] [**Numeric Identifier 46775**] (Complete)
Done [**2104-11-4**] at 8:47:24 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2027-2-14**]
Age (years): 77 M Hgt (in): 69
BP (mm Hg): 110/64 Wgt (lb): 250
HR (bpm): 64 BSA (m2): 2.27 m2
Indication: Intraoperative TEE for CABG AVR. Aortic valve
disease. Left ventricular function. Mitral valve disease.
Preoperative assessment. Right ventricular function. Shortness
of breath.
ICD-9 Codes: 440.0, 424.1, 424.0
Test Information
Date/Time: [**2104-11-4**] at 08:47 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3319**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: [**Doctor Last Name 11422**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 5.0 cm
Left Ventricle - Fractional Shortening: *0.17 >= 0.29
Left Ventricle - Ejection Fraction: 25% >= 55%
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Ascending: 2.5 cm <= 3.4 cm
Aorta - Arch: 2.0 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *3.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *37 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 21 mm Hg
Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Lipomatous hypertrophy
of the interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity. Severe regional LV systolic dysfunction. Severely
depressed LVEF.
LV WALL MOTION: Regional left ventricular wall motion findings
as shown below; remaining LV segments contract normally.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Mildly dilated RV cavity.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Normal aortic arch diameter. Normal descending aorta diameter.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Moderately thickened aortic valve leaflets. Severe
AS (AoVA <0.8cm2). Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. No
MVP. Moderate mitral annular calcification. Moderate to severe
(3+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
1. The left atrium is moderately dilated. No atrial septal
defect or PFO is seen by 2D or color Doppler. The left atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe
regional left ventricular systolic dysfunction with hypokinesis
of the inferior, inferioseptal, anterior, anteroseptal walls .
Overall left ventricular systolic function is severely depressed
(LVEF=25 %).
3. The right ventricular cavity is mildly dilated.
4. There are simple atheroma in the ascending aorta. There are
complex (>4mm) atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) are mildly thickened. There is
severe aortic valve stenosis (area <0.8cm2). Trace aortic
regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. There is
no mitral valve prolapse. Moderate (2+ to 3+) mitral
regurgitation is seen.
7. There is no pericardial effusion.
8. Dr. [**Last Name (STitle) **] was notified in person of the results on
[**2104-8-4**] at 830.
POSTBYPASS
1. The patient is on milrinone, epinephrine and phenylephrine
infusions.
2. A well seated, well functioning bioprosthetic valve is seen
in the aortic position. Two small jets of aortic regurgitation
are seen between the right and non coronary cusps and left and
non coronary cusps. All leaflets are moving well. Trace central
aortic insufficiency is also present.
3. LV function looks improved (on inotrope) with an EF of 40%.
The inferior and inferoseptal walls show continued hypokinesis
while improvement is seen in the anterior and anteroseptal
walls.
4. Aortic contour is smooth after decannulation.
5. MR is mild post bypass, all other findings remain similar.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2104-11-4**] 13:56
Brief Hospital Course:
The patient was admitted to the cardiology service on [**2104-10-23**]
and cardiac cath was attempted on [**2104-10-24**]. Access was not
obtained and the patient then developed a severe headache. He
had a stat head CT which was negative. He then went into atrial
fibrillation that night and spontaneously converted back to
sinus rhythm. Cath on [**2104-10-25**] was successful and revealed:
severe pulmonary hypertension, [**Location (un) 109**] of 1.0 cm2, gradient of 26.
The LAD was moderately calcified with a 95% stenosis in the
mid-distal region. There was also an 80% instent restenosis in
the LAD [**Last Name (un) 2435**]. The LCX tapered to 40% after the atrial branch,
ramus was occluded, and the RCA had mild diffuse plaquing
throughout. He had a moderately decreased LVEF.
Dr. [**First Name (STitle) **] was consulted and the patient underwent dental
extractions on [**2104-10-31**].
On [**2104-11-4**] he underwent AVR(25mm CE Pericardial
valve)/CABGx1(LIMA->LAD). The cross clamp time was 87 mins.,
total bypass time was 101 min. He tolerated the procedure well
and was tranferred to the CVICU on Epinephrine, Milrinone,
Propofol, and Neosynephrine. He remained intubated overnight
because of hypontension and agitation. He had hperglycemia and
[**Last Name (un) **] was consulted. He was extubated on POD#2 and required
aggressive respiratory therapy. The patient remained confused
and his mental status cleared and he was transferred to the
floor on POD#5. His chest tubes and pacing wires were
discontinued on POD#2. He continued to progress and he was
discharged to rehab in stable condition on POD# 7.
Medications on Admission:
Protonix 40-mg/day
metformin 750-mg [**Hospital1 **]
iron325-mg/day
Toprol 50-mg/day
Lotensin 20-mg/day
Imdur 30-mg/day
Lasix 80-mg q AM
Lipitor 20-mg/day
Plavix 75-mg/day
Lantus 80 units qhs.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day.
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed.
7. Metformin 500 mg Tablet Sig: 1.5 Tablets PO twice a day.
8. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 3 days: Decrease dose to 400 mg PO daily when [**Hospital1 **]
complete. After 7 days decrease dose to 200 mg PO daily.
10. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous once a day.
11. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: Insulin sliding scale:
BS 110-140 ins 2U
BS 141-160 ins 4U
BS 161-200 ins 6U
BS 201-240 ins 8U.
12. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**3-23**]
hours as needed.
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
15. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
IDDM
CAD, s/p MI, s/p coronary artery stenting
CHF
Hyperlipidemia
GERD
Bladder CA
Seizure disorder
V tach, s/p PPM/ICD
Discharge Condition:
Good.
Discharge Instructions:
Take medications as directed on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Call our office for sternal drainage, temperature>101.5.
Followup Instructions:
with Dr. [**Last Name (STitle) 6955**] for 1-2 weeks.
with Dr. [**Last Name (STitle) 1911**] for 2-3 weeks.
with Dr. [**Last Name (STitle) **] for 4 weeks.
Patient to call for all appointments
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2104-11-11**]
|
[
"997.1",
"396.2",
"522.4",
"428.0",
"784.0",
"250.00",
"272.4",
"511.9",
"414.01",
"345.90",
"496",
"V45.02",
"996.72",
"530.81",
"403.90",
"428.22",
"427.31",
"E879.0",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"35.21",
"23.19",
"39.61",
"37.23",
"38.91",
"88.72",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
13312, 13398
|
9854, 11493
|
296, 404
|
13561, 13569
|
2389, 3028
|
13863, 14179
|
1602, 1646
|
11736, 13289
|
3068, 9831
|
13419, 13540
|
11519, 11713
|
13593, 13840
|
1661, 2370
|
237, 258
|
432, 1226
|
1248, 1513
|
1529, 1586
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,132
| 129,355
|
21001
|
Discharge summary
|
report
|
Admission Date: [**2133-8-24**] Discharge Date: [**2133-9-18**]
Date of Birth: [**2070-12-12**] Sex: M
Service: OMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Pain, change in mental status
Major Surgical or Invasive Procedure:
Radiation Therapy to T5 and L3 lesions(10 and 14 treatments,
respectively)
History of Present Illness:
62 y/o man with unusually agressive metastatic cutaneous
squamous cell carcinoma presented to the ED [**8-24**] with 2 week
history of increasing back pain. In the ED, patient became
tachycardic, hypertensive and his oxygen satuartions hovered in
the low to mid 90% range despite oxygen therapy via nasal
cannula. The patient grew lethargic and was alert and oriented
x 1 only. His abdomen was distended, but not terribly tender;
he had a history of constipation as well. The ED staff grew
concerned about abdominal perforation as the above events
unfolded and his abdomen grew rigid. CT abdomen was negative
for perforation, but the patient was admitted to the surgical
ICU for further work-up and treatment.
Given his mental status changes, a head CT was performed which
was negative for acute pathology. CTA showed pneumonia but no
PE. The specific results are as follows:
CT chest/abd/pelvis
1. Metastatic disease, most marked in the retroperitoneum and
along the left
iliac lymph node chain. Not significantly changed in size or
distribution
since the PET examination of [**2133-8-20**].
2. Bibasilar consolidation consistent with pneumonia and mild
pulmonary
edema.
3. No perforation.
4. Suboptimal examination of the abdomen due to suboptimal
patient positioning
An MRI of the spine was then performed as the patient had
considerable lower extremity weakness. The results of that
study are as follows: Further compression of the T5 vertebral
body results in canal compromise and cord compression. In the
lumbosacral region there is further compression deformity of L3
but no neural compression. There is extensive prevertebral
tumor. Given this result, the patient was loaded with decadron
and a neurosurgery consult was obtained. Per neurosurgery, no
acute surgical management was warranted. Radiology consult was
therefore obtained and the arrangements were made to transfer
the patient to the Oncology Medicine service radiation therapy,
pain control and further management. Last, pt's PNA was treated
as aspiration PNA with levo/flagyl.
SUMMARY OF ONCOLOGIC HISTORY:
(1) SCC resected from left foot dorsum in [**2131**]. Recurrence in
left groin detected in [**2133-4-28**]. He had left radical groin
lymph node dissection by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**] on [**2133-5-26**], with 6 of
9 lymph nodes showing poorly differentiated SCC with focal
extracapsular extension. In advance of inguinal radiation
therapy for his resected SCC, repeat PET scanning on [**2133-7-8**]
compared to
a [**5-1**] PET scan showed new uptake of FDG in left iliac,
bilateral para-aortic lymph nodes, and T5 and L3 vertebral
bodies. An area of fainter uptake in the left supraclavicular
area was attributed to "brown fat." Findings were felt c/w
metastatic SCC, supported by FNA cytology of the left iliac
mass.
(2) Additionally, he has had evaluation of high PSAs, with deep
core biopsies on [**2133-7-8**] by Dr. [**First Name4 (NamePattern1) 892**] [**Last Name (NamePattern1) 55794**], with pathology
showing adenocarcinoma of the prostate gland, [**Doctor Last Name **] 7 (3+4),
currently undergoing lupron therapy.
Since [**Month (only) 216**], the patient has been on combinational interferon
alfa and Accutane. This is now the beginning of his 3rd week of
therapy, at 1.5 million units daily of IFA and 20 mg [**Hospital1 **] of
Accutane. The latter he increased several days ago to 40 mg [**Hospital1 **].
This week he plans to increase his IFA dose to 3 MMU daily.
He has also received Lupron per Dr. [**Last Name (STitle) **].
ROS: Currently, pt is in pain with slightest movement. Baseline
[**7-7**] pain improved with Dilaudid PCA. Movement increases pain
to [**9-6**], worse lower back > upper back. Intermittent SOB,
currently on nasal cannula. +20lb weight loss over the past 3
months. Denies fevers, chills. +abdominal distension, no BM in
last 2 weeks. Denies nausea, vomiting, bowel/bladder
incontinence.
Past Medical History:
Oncologic history as above
Hypertension
s/p Excision of colonic polyps
h/o basal cell ca
h/o chronic prostatitis
Social History:
Denies any history of smoking since college. He drinks
approximately [**1-29**] glasses of wine, 3-4 times per week. He
currently owns and runs a packing company. He lives in
Northwest CT with his wife.
Family History:
Paternal GF with gastric CA, paternal GM with Esophageal CA,
maternal GF
with Colon CA, maternal GM with Pancreatic CA.
Physical Exam:
T 97.3 BP 130-150/70-100 HR 88-92 RR 16 O2: 96%@4L NC
Gen- Elderly male, now less somnolent, responsive to questions
and anwering appropriately, lying still in bed.
HEENT- PERRL, EOMI. MMM, OP clear.
Neck supple, no LAD.
Lungs- Decreased breath sounds at bases anteriorly, no
crackles/wheeze
CV- rrr, nml, audible S1S2, II/VI SM, no r/g
Abd- soft but moderately distended - non-tender, no peritoneal
signs, no masses appreciated, tympanic to percussion, no
rebound/guarding.
Rectal- deferred secondary to pain
Back- deferred secondary to pain
Ext- spontaneous movt of all four extremities; LE: warm, trace
edema bilaterally. 2+ PT pulses b/l.
Neuro- A&OX3. Responding appropriately and following simple
commands. LE: Proprioception/sensation to light touch intact
b/l. Strength upper extremities [**4-1**]
bilaterally(biceps/triceps/deltoids), lower extremities [**4-1**]
plantar/dorsiflexion(no pain elicited), [**3-2**] hip flexors
bilaterally - limited [**12-29**] pain.
Pertinent Results:
[**2133-8-25**] 03:05AM BLOOD WBC-7.1 RBC-3.20* Hgb-10.2* Hct-28.6*
MCV-90 MCH-32.0 MCHC-35.8* RDW-13.8 Plt Ct-137*
[**2133-8-25**] 03:05AM BLOOD Glucose-148* UreaN-13 Creat-0.8 Na-140
K-3.6 Cl-107 HCO3-23 AnGap-14
[**2133-8-25**] 03:05AM BLOOD ALT-40 AST-52* AlkPhos-92 Amylase-54
TotBili-1.0
[**2133-8-25**] 03:05AM BLOOD Lipase-26
[**2133-8-25**] 03:05AM BLOOD Albumin-3.3* Calcium-7.9* Phos-2.1*
Mg-1.5*
Brief Hospital Course:
62 y/o man with metastatic SCC of the skin left pelvic and
para-aortic lymph nodes and skeleton, including vertebral
bodies. Pt tranferred to OMED service for radiologic and
medical management of vertebral mets causing neurologic
impingement. Other sentinel issues on transfer include pain
control, pneumonia and constipation.
1) SCC: Mr [**Known lastname **] has known aggressive SCC with metastasis to
retroperitoneum and spine (T5 now with retropulsion of bone and
cord compression and L3 with [**Last Name (un) 2043**] involvement). Other than b/l
hip weakness R>L likely secondary to pain, Mr [**Known lastname **] had no
neurologic deficits on exam on admission to OMED - no sensory
loss, numbness/tingling/bladderincontinence. Neurosurgery
recommended radiation to affected areas without preceeding
surgery. Radiation oncology did mapping on [**8-26**] which Mr. [**Known lastname **] [**Last Name (Titles) 42469**]d well. He received 10 treatments to T5 (starting [**8-26**]
and completed [**9-9**]) and 14 treatments to L3 lesion(completed
[**9-18**]). After [**4-2**] radiation treatments, his back pain had
minimal improvement, but unfortunately around that time he began
c/o pain at R knee when weight bearing. PET scan from [**2133-8-20**] he
had increase uptake in proximal femur. X-ray of R femur/ knee
were done to r/o pathologic/impending pathologic fracture which
were both which were negative for signs of fx. The right knee
pain continued to increase over the next few days, to the point
where Mr. [**Known lastname **] could not participate in PT or even get out of
bed. The knee/hip films were reviewed with the radiologists who
did not feel that the vague sclerotic lesion seen in R tibia and
R femur could be causing pt's symptoms. At this point, it was
thought that the R knee pain was likely referred pain from tumor
infiltrating lumar/sacral plexus. Repeat MRI of L spine was
ordered on [**9-10**] which showed evidence of L3 compression fx and
more retropulsion of fragments and reduction in the
anterior/posterior dimension of the thecal sac by approximately
50% but CSF is still visible around the cauda equina.
Neurosurgery was reconsulted at this time to reassess if Mr. [**Known lastname **]
was surgical candidate. Dr. [**Last Name (STitle) **] spoke with Dr. [**Name (STitle) 3548**]
[**Doctor Last Name 776**] (radiation oncology) and Drs. [**First Name8 (NamePattern2) **] [**Name (STitle) 1327**]
and [**First Name8 (NamePattern2) **] [**Doctor Last Name 1132**] (both in neurosurgery) and it was decided that
neurosurgery is not indicated, in large part because pain was
improving at this point from XRT and he had good results
symptomatically at the irradiated T5 site. Furthermore, surgery
would include risks of general anaesthesia, incisional wound
healing, and potential complications from the procedures. Also
surgery would delay systemic chemotherapy which primary oncology
team wanted to initiate as soon as possible since his disease
has been so aggressive. In addition to XRT, Mr. [**Known lastname **] was treated
early on during admission with ciplatin (50mg/m2) on [**8-27**] and
[**9-3**], which he tolerated well with exception of total body
aches/pains after administration. He recieved aggressive
pre/post chemo hydration, and chemo had no effect on creatinine
during admission. He also received bolus of 5-FU on [**2139-9-10**]
to help sensitize tumor to effects of radiation. No further
chemo was given during admission as plt were dropping (57,000 on
[**9-17**]) and ANC of 1120 on [**9-17**]. Please continue to trend daily
ANC. Please get daily CBC with absolute neutrophil count(ANC)
and chem-10 and fax results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 638**], daily.
Because ANC is below 1000, please put Mr. [**Known lastname **] on neutropenic
preacuations and private room.
Please call Dr. [**Last Name (STitle) **], oncologist, at [**Telephone/Fax (1) 9645**] if Mr. [**Known lastname **]
develops a fever and get CBC with differential.
Please call Dr. [**Last Name (STitle) 28988**] office with any questions that you have
regarding Mr. [**Known lastname 55795**] care or if he develops new onset of weakness,
numbness/tingling, fevers or other worrisome symptoms.Please
call Dr. [**Last Name (STitle) **], oncologist, at [**Telephone/Fax (1) 9645**] if Mr. [**Known lastname **] develops
a fever and get CBC with differential.
A portacath was placed on [**9-8**] and the plan is to start
systemic chemotherapy when counts recover. Decadron was
continued during hospitalization for vertebral mets and pain
control. He is being discharged on 4 mg every six hours but
will begin taper at rehab. Steroid taper as follows: 4mg TID
from [**Date range (1) 4359**]; 4mg [**Hospital1 **] from [**Date range (1) 12903**]; 2mg [**Hospital1 **] from
[**Date range (1) 55796**]; 2mg each day from [**Date range (1) 55797**] and then stop the
medication. He is to follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 55798**]
on [**9-29**], as scheduled.
2)Pain Control - On admission to OMED, Mr. [**Known lastname **] was on a dilaudid
PCA which was eventually weaned off on [**9-2**] as he was converted
to fentanly patch (100micrograms)with dilaudid/percocet for
breakthrough pain. He continued to have uncontrolled pain on
this regimen and his fentanyl patch was progressively increased
to 250 micrograms. Acute pain service evaluated patient.
Neurontin(300mg in am and noon, 600mg QHS) and motrin (as
needed) were added with some additional relief. By time of
discharge, Mr. [**Known lastname 55795**] pain was well controlled on Fentanyl patch
(250mcg) and neurontin. He was not requiring any dilaudid prn.
3) PNA: PNA on admission both clinically and per CT chest. He
was started on levo/flagyl which was switched to PO on [**8-29**].
He completed the 10 day course while in hospital and pna
resolved with abx. He had been on ampicillin prior to admisstion
per his surgeon following LN dissection which was continued
throughout admission and on discharge. Mr. [**Known lastname **] was noted to
have pulmonary edema on CXR on [**8-27**], likely secondary to
aggressive IVF hydration for chemotherapy. He responded well to
PO diuresis with no further episodes. He pneumonia resolved
prior to discharge.
4)ID: Blood cultures from [**8-24**] - 2/4 bottles with GNR -
Salmonella species sensitive to both levofloxacin and ampicillin
- both of which he was already taking for PNA. All further
survellience cultures were negative.
5)HEME: HCT: Fluctuated between 27-32 during beginning of
admission, baseline ~38. Patient has had extensive imaging of
head/abd/pelvis/chest since admission with no sign of active
internal bleeding and stool guiaic negative. Possibly secondary
to chemotherapy vs dilutional effect from aggresive hydration.
Hct improved throughout admission with no need for transfusion
and was 26.4 on day prior to discharge.
Thrombocytopenia: Mr [**Known lastname 55795**] [**Last Name (Titles) **] dropped during admission after
receiving chemotherapy. HIT Ab test was negative and TCP was
attributed to chemo regimen. His platelets were stil trending
down on discharge, with plt count of 57,000 on day prior to
discharge. Please continue to trend CBC.
6) Constipation: Pateint experienced constipation throughout
admission and was treated successfully with aggressive bowel
regimen - including colace, senna, dulcolax, lacutulose, and
enema as needed.
7) Prostate Cancer - Patient had received 2 lupron injections
prior to admission(8/25,[**8-20**]). Will hold off on further
injections for now and readdress as outpt.
8) HTN: Mr. [**Known lastname **] takes HCTZ and actopril at home which were
initally d/c'ed on admission. SBP's on transfer to OMED were
consistently between 170-200 likely secondary to pain and fluid
overload, and his outpatient HCTZ and actopril were restarted.
Lopressor was eventually added to further control BP with good
results.
Blood pressure was very well controlled on HCTZ(50mg each day),
Quinapril(10mg each day) and metoprolol(25mg TID).
9) PT: Physical therapy worked with Mr. [**Known lastname **] throughout his
admission on strength training of b/l lower ext, gait stability,
transfers from sit ->stand, stair training. There was a few days
around [**9-10**] during which he was unable to participate in PT [**12-29**]
R knee pain. However, with chemo/radiation pain improved and he
restarted training. He is to be discharged to rehabilitation
center to continue gait training, endurance training, and
transfer training and home safety evaluation.
10) PPX: Bowel regimen; prophylactic SQ heparin; PPI, Blood
sugar levels well controlled but will cont regular insulin
sliding scale for coverage given high dose steroids. [**Month (only) 116**] stop
sliding scale at end of steroid taper.
11) FEN: Tolerated PO diet without n/v. Hyponatremia - Mr. [**Known lastname **]
had a few episodes of hyponatremia during admission -
hypovolumic hyponatremia per exam and labs. Resolved with NS
IVFs; Potassium and phos were repleted as necessary. Continue to
monitor chemistries and electrolytes and replete as necessary.
12)Psychosocial - Mr. [**Known lastname **] was followed by social worker
throughout admission. He was started on celexa as his
progressive disease, pain, and prognosis had impacted his mental
state. His spirits had improved some by time of discharge.
Medications on Admission:
MEDS: HCTZ; Accupril; Ampicillin (for 1 year, per Dr. [**Last Name (STitle) 957**];
herbal tea Essiac; fish oil. On the advice of nurse [**Last Name (un) 55799**]
who is monitoring his IFA-Accutane therapy, he stopped taking
vitamin A. He is considering the merits of "coffee enemas" and
acknowledges an interest in allopathic medicine alongside
traditional medicine.
OxyContin
Vicodin
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: see scale
Injection ASDIR (AS DIRECTED).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day).
5. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
6. Quinapril HCl 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Ampicillin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
13. Lactulose 10 g/15 mL Syrup Sig: 45-60 MLs PO QID (4 times a
day) as needed for constipation.
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
15. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
16. Hydromorphone HCl 4 mg Tablet Sig: 1-2 Tablets PO Q3-4H ()
as needed.
17. Fentanyl 100 mcg/hr Patch 72HR Sig: Two (2) Patch 72HR
Transdermal Q72H (every 72 hours).
18. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
QD (once a day).
19. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
20. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
21. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): please give with am medications and at noon.
22. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours): Steroid taper as follows: 4mg TID from [**Date range (1) 4359**];
4mg [**Hospital1 **] from [**Date range (1) 12903**]; 2mg [**Hospital1 **] from [**Date range (1) 55796**]; 2mg each day
from [**Date range (1) 55797**] and then stop the medication. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital 55800**] Rehab Center
Discharge Diagnosis:
1. Metastatic Squamous Cell Carcinoma: newly diagnosed spinal
lesions (at T5 and L3).
2. Pneumonia - resolved on discharge
3. Hypertenstion
4. Hyponatremia - resolved
5. Thrombocytopenia - after chemotherapy
6. Right Knee Pain
Discharge Condition:
stable, but weak
Discharge Instructions:
Discharge to rehabilitation facility
Please continue all medications.
Please get daily CBC with absolute neutrophil count(ANC) and
chem-10. If ANC falls below 1000, please put Mr. [**Known lastname **] on
neutropenic preacuations and call Dr. [**Last Name (STitle) **] for further
instructions and treatment.
Please call Dr. [**Last Name (STitle) **], oncologist, at [**Telephone/Fax (1) 9645**] if Mr. [**Known lastname **]
develops a fever and get CBC with differential.
Please call Dr. [**Last Name (STitle) **] office with any questions that you have
regarding Mr. [**Known lastname 55795**] care or if he develops new onset of weakness,
numbness/tingling, fevers or other worrisome symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 2502**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 4054**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2133-9-29**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2133-9-29**] 11:00
|
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"197.6",
"336.3",
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icd9cm
|
[
[
[]
]
] |
[
"99.25",
"86.07",
"92.24"
] |
icd9pcs
|
[
[
[]
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|
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340, 417
|
18804, 18822
|
5947, 6357
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|
4815, 4936
|
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|
271, 302
|
445, 4440
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|
4592, 4799
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,789
| 125,699
|
49210
|
Discharge summary
|
report
|
Admission Date: [**2179-2-14**] Discharge Date: [**2179-2-16**]
Date of Birth: [**2106-8-17**] Sex: F
Service: MEDICINE
Allergies:
A.C.E Inhibitors
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 72F with Afib, asthma, CHF, pacer, diverticulitis, BIBA
after falling on her R leg in the bathroom. No LOC. Did not hit
head. Also, c/o 6 days epigastric abd discomfort, 1 day SOB, and
6cm R leg laceration.
.
In the ED: Initial vitals: 96.5, 80, 126/94, 21, 98% on 2L. Had
Lac repair. CT abdomen concerning for ischemic colitis but
surgery opting for medical management. They asked for ICU
admission to optimize her hemodynamics for a concern for
alow-flow state. Cardiology did not think she has a low-flow
state given normal renal function. Given Cipro/flagyl for
empiric coverage. Nebs, morphine. HD stable the entire ED stay.
Admitted to the ICU for close monitoring of hemodynamics as
recommended by surgical consult.
.
On arrival to the ICU, it was difficult to obtain a history
through a phone translator. The patient was tearful,
increasingly anxious and confused. Did not complain of any
abdominal pain, CP, SOB. On further questioning she admitted
that she had abdominal pain previously, but not during time of
interview. Did complain of pain at laceration site.
Her son phoned the ICU and was able to provide more information.
Stated his mother usually received her care at [**Hospital1 2177**], that she was
hospitalized there recently and had been quite ill, requiring
intubation for "water in her lungs...a problem with her
pacemaker." She was there for ~2.5 weeks, discharge about 2
weeks ago. He thought that since then she had been complaining
of abd pain, no associated n/v/d, no fevers. She had presented
to [**Hospital1 2177**] ED several days ago with same and was discharged from the
ER. DPTA she had gotten OOB to BR during the night and had
falled and cut her leg which precipitated this presentation.
.
ADDENDUM: per conversation w/ [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP on [**2-15**]: Pt had ICD
placed at end of [**Month (only) 359**], presented mid/end of [**Month (only) 1096**] w/
SOB/CP - found to have pericarditis [**2-6**] to procedure, put into
right heart failure (most recent ECHO EF 30%) intubated for
several weeks. Had enlarging pericardial effusion which resolved
w/out window. She was d/c-ed to [**Name (NI) **] [**Last Name (NamePattern1) **] (son works
there), there for 11 days, went home this past Weds; at home
visit Thurs/Fri was fluid overload, got 40 lasix those two days.
Saturday was seen at [**Hospital1 2177**] ED for abd pain (has been c/o abdominal
pain for years), neg ABD CT, had O2 sats in 93-95%.
.
Of note, pt very anxious at baseline. Doesn't use O2 at home but
is on CPAP set @17-18. Med list and recent D/C summary will be
faxed to SICU (CC6C) but [**First Name8 (NamePattern2) **] [**Name (NI) **] [**Name (NI) **] pt is on Cozar 50,
Lopressor XR 100, Synthroid, Clonopin 0.5mg [**Hospital1 **], ASA, Zoloft 50.
Past Medical History:
1. Hypertension.
2. Paroxysmal atrial fibrillation s/p TEE and cardioversion in
[**7-8**].
3. Dilated cardiomyopathy
4. CHF with EF 40% on [**4-/2169**]; 30% on [**1-11**].
5. Diverticulitis status post low anterior resection.
6. Osteoarthritis status post bilateral total knee replacement.
7. Recent RLQ cellulitis tx with two courses of keflex
Social History:
The patient denies tobacco, alcohol or intravenous drug use.
The patient lives in [**Location 669**] alone and is Spanish speaking.
Family History:
Mother died of colon CA at age 71.
Physical Exam:
Physical Exam:
VS: T: 98.0 HR: 82 BP: 100/90 RR: 20 Sat: 97%on2L NC
GEN: anxious, plethoric, appears confused
HEENT: PERRL, EOMI, anicteric, dry MM, + OP [**Female First Name (un) **]
NECK: no supraclavicular or cervical lymphadenopathy, + JVD to
angle of her jaw
RESP: poor air movement, bibasilar crackles. Diffuse wheezes
CV: irreg, irreg, tachy, no m/r/g
ABD: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: 6 cm lac across R shin, w/ sutures, no drainage, trace-+1
bilateral tender LE edema to knees
SKIN: no rashes, erythema around pacer pocket
.
Pertinent Results:
Chest U/S [**2-15**]: Small fluid collection in the region of left
chest wall
pacemaker.
CXR [**2-15**]: Slight increase in right hazy lower lung zone opacity
representing pleural effusion. Similar appearance of remainder
of chest since yesterday.
R LE tib/fib [**2-15**]: Very limited assessment of the right ankle
joint is grossly unremarkable. No subcutaneous emphysema is
seen. No soft tissue loss is identified. No abnormal
periosteal reaction is evident.
Echo [**2-15**]: Suboptimal image quality. Dilated right ventricular
cavity with free wall hypokinesis. Moderate pulmonary artery
systolic hypertension. Severe tricuspid regurgitation. Compared
with the prior study (images reviewed) of [**2176-2-12**], the left
ventricular systolic function is slightly improved. Right
ventricular cavity size, systolic function and estimated PA
systolic pressure are similar.
CT head [**2-14**]: There is no acute intracranial hemorrhage, shift
of
normally midline structures, or major vascular territorial
infarct. Prominence of the ventricles and sulci is consistent
with age-related involutional changes. There is no calvarial
fracture or soft tissue abnormality. The visualized paranasal
sinuses and mastoid air cells are well aerated.
CT abd/pelvis [**2-14**]: CT OF THE PELVIS: Sigmoid colon and rectum
are decompressed, with sigmoid diverticulosis. The distal
ureters, bladder, and adnexae are normal. Patient appears to be
post hysterectomy. An unusual clustering of left inguinal lymph
nodes (2:93) is unchanged from comparison of [**2176-4-10**]. There are
no suspicious lytic or sclerotic lesions. Multilevel
degenerative changes involving the lower thoracic and lumbar
spine are noted. CT ABD: Nonspecific colonic wall thickening
involving the splenic flexure, raising the possibility of
ischemic colitis from a low-flow state in this watershed region.
Infectious etiologies are possible, though less likely given the
focality of this finding. Marked cardiomegaly with distention of
IVC and reflux of contrast into the IVC and hepatic veins
suggesting elevated right heart pressure. Increasing small
bilateral pleural effusions, with partial loculation of the
right-sided effusion. Bibasilar atelectasis. Diverticulosis of
the right, left, and sigmoid colon. No diverticulitis.
CXR [**2-14**]: No definite areas of consolidation, although if
indicated right
lower lobe opacity may be followed with repeat PA and lateral
chest x- ray.
[**2179-2-16**] WBC-8.8 RBC-4.08* Hgb-10.3* Hct-35.0* MCV-86 MCH-25.2*
MCHC-29.3* RDW-16.0* Plt Ct-270 Neuts-81* Bands-3 Lymphs-11*
Monos-3 Eos-0 Baso-1 Atyps-0 Metas-1* Myelos-0 Hypochr-1+
Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL
Polychr-1+ Plt Ct-270 BLOOD PT-13.9* PTT-31.8 INR(PT)-1.2
[**2179-2-16**] 07:30AM BLOOD Glucose-87 UreaN-7 Creat-0.6 Na-142 K-4.1
Cl-100 HCO3-35* AnGap-11 Lipase-47 Calcium-8.9 Phos-3.2 Mg-2.0
Lactate-1.2
[**2179-2-14**] 08:00AM BLOOD WBC-14.9*# RBC-4.50 Hgb-11.3* Hct-38.3
MCV-85 MCH-25.0*# MCHC-29.4*# RDW-16.0* Plt Ct-291
[**2179-2-14**] 08:00AM BLOOD Neuts-85.2* Lymphs-8.5* Monos-5.5 Eos-0.7
Baso-0.1
[**2179-2-14**] 08:00AM BLOOD Plt Ct-291
[**2179-2-14**] 08:00AM BLOOD PT-14.1* PTT-32.5 INR(PT)-1.2*
[**2179-2-14**] 08:00AM BLOOD Glucose-109* UreaN-21* Creat-1.0 Na-128*
K-7.3* Cl-89* HCO3-26 AnGap-20
[**2179-2-14**] 08:00AM BLOOD ALT-27 AST-92* CK(CPK)-144* AlkPhos-118*
TotBili-0.6
[**2179-2-14**] 03:10PM BLOOD CK(CPK)-55
[**2179-2-14**] 08:00AM BLOOD Lipase-56
[**2179-2-14**] 03:10PM BLOOD cTropnT-0.01
[**2179-2-14**] 08:00AM BLOOD cTropnT-0.01
[**2179-2-14**] 08:00AM BLOOD CK-MB-9 proBNP-[**Numeric Identifier 100480**]*
[**2179-2-14**] 08:00AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.9
[**2179-2-14**] 08:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-12.4
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2179-2-14**] 10:29AM BLOOD Type-ART pO2-48* pCO2-44 pH-7.40
calTCO2-28 Base XS-102/10/08 10:29AM BLOOD Lactate-1.6
[**2179-2-14**] 08:07AM BLOOD K-4.1
Brief Hospital Course:
# Abdominal pain, chronic: On presentation, she complained of a
diffuse abdominal pain without rebound/guarding. Much of this is
reportedly chronic and related to her anxiety. A CT was
performed and found circumferential thickening around the colon
at the splenic flexure, concerning for watershed ischemia of the
colon. Less likely was the possibility of infectious colitis,
given that the patient had some diarrhea and a WBC count with a
left shift, however, she was afebrile throughout the hospital
stay and the clinical presentation was more consistent with
chronic abdominal pain and the incidental finding of ischemic
colitis, likely an old event. She never had bloody stools.
Blood, stool cultures, O&P lab studies were pending at
discharge, and we will notify your institution if they are
positive. Urine tests to evaluate for the possibility of a UTI
causing abdominal pain were negative. Initially, the LFTs were
increased (AST:ALT) c/w possible alcoholic liver disease but no
ETOH was present in serum, the specimen was hemolyzed, and
repeat LFTs were normal. We monitored her abdominal exams
serially in conjunction with surgery, who felt that the patient
did not have acute ischemic colitis. For a conservative
approach, we did continue the cipro/flagyl for empiric coverage
but this can be stopped after 5 days if she remains stable. She
was given morphine for pain control.
# Systolic heart failure: Her exam was notable for some evidence
of acute on chronic systolic heart failure, including elevated
JVP, LE edema, crackles on exam, and an elevated BNP. An echo on
[**2-12**] showed an EF of 45%. Fluid status was monitored closely
throughout the admission with daily goals of 0.5-1L negative per
day. She was given 1 dose of lasix IV 20 mg. Low dose metoprolol
was initiated. She was subjectively less short of breath and
overloaded at the time of transfer.
.
# Chest wall fluid collection: Pt had an area of erythema and
warmth over the ICD site. A chest wall U/S showed a tiny fluid
collection in the region of the AICD. The patient did not
endorse tenderness and exam was not significant for fluctuance,
so we do not think this represents active infection, but this
should be monitored.
.
# Afib: On admission she was subtherapeutic on her INR despite
the son's report that she was supposed to be on coumadin. She
was rate controlled with beta blockers, which were newly added.
Because we were concerned for the possibility of additional
procedures, we held the coumadin but this should be restarted
when she is stable.
.
#Leg laceration: She sustained a laceration after a fall, which
was sutured in the emergency department. An xray of the leg was
grossly unremarkable without evidence of subcutaneous emphysema
or soft tissue loss. She was kept on fall precautions during her
hospitalization.
.
#DM. We note that the patient had a HbA1c of 6.9 in [**2176**],
although the son denies a history of diabetes. For this concern
of possible diabetes, she was kept an a regular insulin sliding
scale.
.
#Anxiety: She has chronic anxiety and was given ativan as
needed.
.
#Oral candidiasis. She was noted to have oral thrush and was
treated with Nystatin S&S.
.
# F/E/N: She has been kept NPO since admission
.
# PPx: Bowel regimen, PPI while NPO, sq Heparin
.
# Access: PIV
.
# Code Status: Full
.
# Communication: son = [**Name (NI) **] [**Name (NI) 3234**] [**Telephone/Fax (1) 103186**]
Medications on Admission:
UNK,
via interpreter pt states that she gets her medications from the
[**Company 4916**] on [**State **] St, presumably this is the [**Company 4916**] in
[**Location (un) 669**]. Left a message with them to call back with
meds/provider [**Name Initial (PRE) **]: Phone ([**Telephone/Fax (1) 85065**]
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day) for 7 days.
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Ciprofloxacin 400 mg/40 mL Solution Sig: One (1)
Intravenous Q12H (every 12 hours).
11. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours).
12. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed for anxiety.
13. Morphine 10 mg/mL Solution Sig: One (1) Intravenous every
six (6) hours as needed for pain.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnoses:
Chronic mesenteric ischemia
Acute on chronic systolic congestive heart failure
Secondary Dignoses:
Paroxysmal Atrial fibrillation
Leg laceration
Diabetes Mellitus
Anxiety
Oral Candidiasis
Discharge Condition:
Afebrile
Stable
Discharge Instructions:
You were treated at [**Hospital1 18**] for chronic mesenteric ischemia with
bowel rest and rehydration therapy and will be transferred to
[**Hospital6 **] for further treatment.
Followup Instructions:
Please f/u with your PCP [**Last Name (LF) **],[**Name9 (PRE) 177**]
Completed by:[**2179-2-17**]
|
[
"425.4",
"427.31",
"300.00",
"891.0",
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"E885.9",
"428.23",
"493.20",
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"401.9",
"112.0",
"428.0",
"276.1",
"557.1"
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icd9cm
|
[
[
[]
]
] |
[
"86.59"
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icd9pcs
|
[
[
[]
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13239, 13254
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292, 299
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13506, 13524
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4322, 8271
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3746, 4303
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238, 254
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327, 3144
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3530, 3664
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,574
| 178,260
|
40071
|
Discharge summary
|
report
|
Admission Date: [**2150-11-2**] Discharge Date: [**2150-11-10**]
Date of Birth: [**2070-4-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 y/o M with questionable seizure disorder, Parkinson's on
sinemet, recently diagnosed UTI on ciprofloxacin transferred
from OSH following witnessed tonic clonic seizures x 2.
.
Per medical records, patient c/o progressive right lower
extremity weakness with painful leg spasms x 2- 3mths. Due to
impaired mobility, he was unable to take care of himself at home
and had several subsequent falls. Also according to notes, he
was displaying increasingly aggitated behavior/ unstable mood.
He initially presented to an OSH on [**10-21**] and was evaluated with
negative CT head and MRI spine. His symptoms were attributed to
parkinson's dx and his dose of sinemet was increased. He was
discharged to a nursing home.
.
At his nursing home, 2 days prior, he was noted to have cloudy/
foul smeeling urine and was dx with pansensitive citrobacter
UTI, and started on ciprofloxacin. This afternoon, he had
witnessed tonic clonic seizures x 2 lasting less than 2 min each
at NH. He was initially brought to an OSH and sent to [**Hospital1 **] for
neurologic evaluation.
.
VS at [**Hospital1 18**]: were T 97.4 HR 107 BP 118/73 RR 18 SpO2 100% 2L.
His exam was notable for poor attention and confusion with
initial labs revealing leukocytosis to 24.9 with grossly
positive U/A. Due to recent seizure activity, he was placed in a
c- collar and cleared with a CT c-spine with clinical exam.
Neurology evaluated patient in ED and felt that most of his
symptoms were due to his underlying infection.
Past Medical History:
Parkinsonism
Anxiety
HTN
Seizure Disorder
Social History:
Recently moved to nursing home. His [**Age over 90 **] y/o mother is his
healthcare proxy and former primary caregiver. [**First Name (Titles) **] [**Last Name (Titles) **], smoking
or IVDA.
Family History:
Non-contributory.
Physical Exam:
Admission Exam:
VS: Temp: 97.4 HR: 107 BP: 118/73 RR: 18 SaO2: 100% 2L
GEN: elderly, chronically ill appearing male
HEENT: Masked facies, b/l erythematous conjunctiva with purulent
discharge around R eye, PERRL, EOMI, anicteric. Dry oral mucosa
with dentures in place and moderate amt dried mucus secretions
plastered to upper palate
NECK: trachea midline, JVP at base of neck
RESP: CTA b/l with good air movement throughout
CV: tachycardic S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e +2 DP pulse
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx2 (not to place- thought [**Hospital3 **]). R sided
facial droop. Strength 4/5 right upper and lower extremity.
Grosly intact to light touch. +3 DTR throughout right with
upgoing toes. Dysmetria on FNF
.
Discharge Exam:
VS: Tm 97.8, Tc 97.0, BP 140-160/70-74, HR 81-82, RR 20, SO2 96%
GEN: elderly male in NAD
HEENT: conjunctivae clear with no erythema
NECK: trachea midline, JVP at base of neck
RESP: unlabored breathing, CTAB
CV: RRR, normal S1, S2
ABD: S/NT/ND, BS+
EXT: warm, 2+ peripheral pulses
NEURO: masked facies, AAOx3, CN II-XII intact, strength 5/5 on
the left and [**4-13**] on the right, cogwheel rigidity present,
sensation intact, with dysmetria on FNF
Pertinent Results:
Initial Results:
.
[**2150-11-2**] 06:20PM WBC-24.9* RBC-3.95* HGB-12.7* HCT-36.9*
MCV-93 MCH-32.2* MCHC-34.5 RDW-12.8
[**2150-11-2**] 06:20PM NEUTS-95.0* LYMPHS-2.6* MONOS-2.1 EOS-0.1
BASOS-0.2
[**2150-11-2**] 06:20PM PLT COUNT-187
[**2150-11-2**] 06:20PM PT-13.7* PTT-26.3 INR(PT)-1.2*
[**2150-11-2**] 06:20PM GLUCOSE-110* UREA N-30* CREAT-1.1 SODIUM-137
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-28 ANION GAP-14
[**2150-11-2**] 07:20PM URINE MUCOUS-MOD
[**2150-11-2**] 07:20PM URINE RBC-21-50* WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2150-11-2**] 07:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2150-11-2**] 07:20PM URINE COLOR-[**Location (un) **] APPEAR-Cloudy SP [**Last Name (un) 155**]-1.012
[**2150-11-2**] 08:52PM LACTATE-1.7
.
Microbiology:
.
Urine Culture ([**10-31**], OSH): Citrobacter UTI (pansensitive)
.
EKG ([**11-2**]): Sinus tachycardia. Left axis deviation. T wave
abnormalities. No previous tracing available for comparison.
.
Imaging:
.
CT C-Spine ([**11-2**]):
1. No acute fracture.
2. Minimal retrolisthesis of C3 on C4 may be degenerative but is
age-indeterminate and clinical correlation is advised.
3. Tracheal secretions may predispose to aspiration.
.
CT Head Without Contrast ([**11-2**]) (REPORT FROM OUTSIDE HOSPITAL):
Chronic-appearing bilateral lacunar infarcts with no
intraparrenchymal hemorrhage or extra-axial fluid collections.
No mass effect or midline shift.
.
Interval Results:
.
[**2150-11-4**] 05:40AM BLOOD calTIBC-142* Ferritn-894* TRF-109*
[**2150-11-4**] 05:40AM BLOOD %HbA1c-5.1 eAG-100
[**2150-11-4**] 05:40AM BLOOD Triglyc-89 HDL-37 CHOL/HD-2.4 LDLcalc-35
[**2150-11-5**] 06:22AM BLOOD CRP-39.0*
.
Lower Extremity U/S ([**11-3**]):
Acute DVT involving right posterior tibial veins.
.
EEG ([**11-4**]):
This is an abnormal routine EEG in the waking and drowsy
states due to the slow 8 Hz posterior predominant rhythm which
may be
seen in generalized encephalopathy such as due to medications,
ischemia,
or toxic/metabolic etiologies, as well as medication effect.
There were
no focal, lateralized, or epileptiform features noted.
.
MRA Brain Without Contrast/MR [**Name13 (STitle) 430**] With and Without
Contrast([**11-4**]):
1. Two heterogeneously enhancing lesions in the left parietal
lobe
subcortical white matter, the larger one measuring 3.2 x 2.8 x
3.9 cm with
mild-to-moderate surrounding edema without significant mass
effect.
Differential diagnosis includes primary glial neoplasm vs
metastasis/
lymphoma. Other etiologies such as inflammatory or subacute
infarction are
less likely given the thick rind of tissue in the periphery. To
correlate
clinically and consider neurosurgical consult.
2. Patent major intracranial arteries without focal
flow-limiting stenosis, occlusion, or aneurysm more than 2 mm
within the resolution of MR angiogram. Mild atherosclerotic
disease involving the Basilar, internal carotid, and the MCA
branches without flow-limiting stenosis.
.
CXR ([**11-8**]): Patchy opacity left base. This finding is similar,
but slighlty more prominent, than on an outside film dated
[**2150-11-2**] that has been scanned into PACS.
.
Lower Extremity U/S ([**11-9**]): Thrombus now visualized in the
right popliteal vein as well as the posterior tibial and
peroneal veins on the right.
.
Discharge Labs:
.
[**2150-11-10**] 06:19AM BLOOD WBC-8.8 RBC-3.27* Hgb-10.3* Hct-30.9*
MCV-94 MCH-31.5 MCHC-33.4 RDW-13.2 Plt Ct-373
[**2150-11-10**] 06:19AM BLOOD Glucose-94 UreaN-18 Creat-0.7 Na-139
K-4.2 Cl-104 HCO3-30 AnGap-9
[**2150-11-10**] 06:19AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.1
Brief Hospital Course:
80 year-old male with Parkinson's disease, a questionable
history of a seizure disorder and a recently diagnosed UTI being
treated with Ciprofloxacin who was transferred from an OSH
following two witnessed tonic clonic seizures.
.
1. Tonic-Clonic Seizures: On admission there was report of a
history of seizure disorder with recent witnessed epileptic
activity in setting of likely infection and medication known to
lower seizure threshold. The patient was confused on arrival to
the ED which was attributed to a post-ictal state with CT scan
at OSH showing no evidence of stroke and no significant
metabolic derangement on laboratory testing. The patient was
admitted to the ICU and started on Keppra for seizure
prophylaxis by neurology recommendations and his antibiotic was
changed to Ceftriaxone. His mental status was significantly
improved the morning after admission. The patient was
subsequently transferred from the ICU to the medicine service.
As part of the patient's seizure workup, an MRI was ordered
which revealed two heterogeneously enhancing lesions in the left
parietal lobe, with suspicion for a malignant glioma. An EEG
revealed diffuse slowing consistent with encephalopathy but no
epileptiform activity was noted. The information was presented
to the patient and given the progressive nature of his
Parkinson's disease and debilitated state he chose not to
undergo any further evaluation of the brain lesions. The patient
clearly expressed the risks of not pursuing any further
evaluation or treatment and was willing to accept the
consequences. The patient was discharged on Keppra 500 mg twice
a day for seizure prophylaxis which was the dose started on
admissionto [**Hospital1 18**].
.
2. Right Lower Extremity DVT: Several days into his admission,
the patient developed right lower extremity erythema and
swelling. A lower extremity ultrasound was performed and
revealed a right posterior tibial vein thrombosis. Vascular
surgery was consulted and recommended repeat ultrasound in 48
hours. Repeat ultrasound revealed presence of the thrombosis in
the right peroneal and right popliteal veins in addition to the
original location. Vascular surgery was again contact[**Name (NI) **] and an
IVC filter was placed without complication. Post-procedure
evaluation did not reveal any hematoma or venous hum at the
site. Vascular surgery reported that this patient would not be a
candidate for IVC filter removal and that no follow-up was
necessary.
.
3. Urinary Tract Infection: The patient was admitted two days
into a course of Ciprofloxacin for a urinary tract infection
that was culture positive for Citrobacter, which was
pan-sensitive. Given the neurological complications associated
with Ciprofloxacin in the elderly, the patient was switched to
Ceftriaxone. The patient completed a total of 10 days of
antibiotics (from the start of the Ciprofloxacin) as an
inpatient. Of note, the patient was transferred to the medicine
service with a foley in place but was discontinued. The patient
subsequently failed to void, was started on Tamsulosin for
presumed BPH and the foley was replaced. Two days later the
patient failed to void once again and was found to have 700 cc
of urine on bladder scan. The foley was again replaced and was
present at discharge. Given the patient's urinary retention
observed as an inpatient, it is likely that this contributed to
the development of his urinary tract infection. ** The foley may
be possible to discontinue as an outpatient and another trial is
likely warranted. **
.
4. Aspiration Risk: The patient was evaluated by speech and
swallow in the ICU and was started on a dysphagia diet and
nectar-thickened liquids due to high aspiration risk. The
patient repeatedly expressed interest in eating a regular diet.
The patient again failed a bedside evaluation. It was decided
that while inpatient that he should remain on the recommended
diet. The patient clearly understood the risks of eating a
regular diet and drinking normal liquids, particuarly that
aspiration was high likely. He stated that given his underlying
illness he would assume the risk. ** The patient again expressed
interest in eating a regular diet at discharge, understood the
risks and demonstrated clear capacity to make his own decisions.
This should be re-addressed as an outpatient but the patient
should likely be allowed to eat the diet he wishes. **
.
5. Right-sided Weakness: The patient reported chronic
right-sided weakness on presentation that most likely
represented an old neurologic deficit from his prior CVA that
was exacerbated by worsening malnutrition and acute illness. The
patient's listed PCP was called to discuss the patient's
baseline, however the PCP had only known the patient for the
several days that he was at the nursing home, and could not
provide much background information. The patient was continued
on Sinemet although it seemed unlikely that Parkinson's disease
was a major contributor to this particular problem.
.
6. Parkinson's Disease: The patient was admitted on Sinemet for
his Parkinson's disease of unknown duration. The patient had
masked-facies and bradykinesia with some cogwheel rigidity of
the upper extremities on examination. The patient was continued
on his Sinement during this hospitalization without problem.
.
7. Leukocytosis: The patient had a normal white count on
transfer to the. Several days into his stay on the medicine
floor, the patient's white count was elevated to 13. The patient
reported a new cough that was concerning for a possible
aspiration event. A chest x-ray revealed a patchy left lower
lobe opacity that was possibly increased over an outside film
scanned into the [**Hospital1 18**] system and likely represented atelectasis
vs possible early infectious infiltrate. The patient had a known
UTI as per above. Given the location of the infiltrate on chest
x-ray, there was low suspicion for an aspiration event but one
could not be ruled out definitely. Given that the patient was
already on a third generation cephalosporin and clinical
suspicion was low for another infectious process, no additional
antibiotic coverage was added. The following day the patient's
white count was down to 11.3 and was 8.8 the following day, the
morning of discharge.
.
8. Anemia: The patient's hematocrit was 37 on admission. The
patient received vigorous hydration in the ICU prior to transfer
to the medicine floor and his hematocrit declined to 32.8 at
time of transfer to the medicine service. Given his poor oral
intake, the patient was continued on intermittent fluids on the
floor. His hematocrit stabilized at approximately 30 and
remained so for the next eight days until the time of discharge.
The patient was guaiac negative. Iron studies were ordered and
were consistent with anemia of chronic disease (calTIBC 142,
Ferritin 894, TRF 109) which was consistent with the patient's
underlying disease process.
Medications on Admission:
1. Carbidopa-Levodopa - 25-100 1 Tablet(s) Four times daily
2. Cyanocobalamin (vitamin B-12) - 100 mcg 1 Syringe(s) monthly
3. Tylenol
4. Mylanta prn
5. Biscodyl
6. Ciprofloxacin: started yesterday 250 mg [**Hospital1 **] for a UTI
Discharge Medications:
1. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
2. cyanocobalamin (vitamin B-12) Injection
3. Tylenol Oral
4. bisacodyl 5 mg Tablet Oral
5. Mylanta Oral
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. Calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
9. Levetiracetam 500 mg tablet, Sig: One (1) tablet by mouth
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 6598**] Manor Extended Care Facility - [**Location (un) 6598**]
Discharge Diagnosis:
Primary Diagnosis:
Seizures
Brain tumor (likely malignant glioma but there is no tissue
diagnosis)
.
Secondary Diagnoses:
Parkinsonism
Hypertension
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname **]:
.
You were admitted to [**Hospital1 18**] after experiencing several seizures.
An imaging study of your brain was performed that revealed
several tumors. After lengthy discussions with you, it was
decided that you did not want to pursue further treatment.
Although you do not want to have treatment of your tumors, you
have been given medication to help prevent the seizures that the
tumors are likely causing. Also, on admission to the hospital
you were being treated for a urinary tract infection with an
antibiotic called Ciprofloxacin. As this medication can be
associated with neurological side-effects in elderly
individuals, you were changed to another antibiotic called
Ceftriaxone. You completed your course of this antibiotic in the
hospital and will not need any further antibiotics.
.
The following changes have been made to your medications:
.
1. Start Keppra 500 mg by mouth twice a day, in the morning and
in the evening. This medication will help prevent seizures.
2. Start Vitamin D 400 unit tablet. Take one tablet twice a day.
3. Start Calcium carbonate 500 mg tablet. Take one tablet by
mouth three times a day.
4. Start Tamsulosin 0.4 mg tablet by mouth. Take one tablet by
mouth at night. This medication will help prevent urinary
retention.
5. Stop Ciprofloxacin. You completed your course of antibiotics
in the hospital for your urinary tract infection.
.
No other changes were made to your medications. You should
continue taking all other medications as previously prescribed.
Followup Instructions:
Please follow-up with your outpatient physicians as you feel
appropriate.
Completed by:[**2150-11-11**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
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14926, 15033
|
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323, 330
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15233, 15233
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3459, 6808
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1869, 1912
|
1928, 2120
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,960
| 120,694
|
5820
|
Discharge summary
|
report
|
Admission Date: [**2150-5-26**] Discharge Date: [**2150-5-28**]
Date of Birth: [**2104-4-9**] Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 14385**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
45 yo woman with severe Asthma and COPD with FEV1 of 0.24 being
recently d/c from [**Hospital1 18**] last month after respiratory failure
requiring trach and PEG. Pt was d/c'd from [**Hospital3 **] on
[**5-22**] on course of Colistin abx neb [**Hospital1 **] for 16 days to treat a
multi-drug resistant acinetobacter. She was unable to get abx
started until today. Pt notes progressive worsening of SOB and
DOE in past few days with marked increase in work of breathing
today. She noted fever to 101. SHe has had marked back pain
since aggressive PT last week- worse with
breathing/cough/movement. + cough with scant sputum
In [**Name (NI) **] pt got solumderol 125mg IV X1, combivent nebs and was
started on BIPAP
Past Medical History:
1. COPD, PFTs in [**1-17**] with FEV1 0.24(10%), FVC 1.25(41%) and
FVC/FEV1 28%- on Home O2 at 2L NC, on chronic steroids, hx of
prolonged intubation requiring trach for resp failure in [**12-2**]
2. Hypertension
3. Anxiety
4. Leukocytosis of unknown etiology with negative BMBx.
5. Osteoporosis- on fosamax
6. Shoulder pain
7. History of positive PPD s/p 6mos of isoniazid
8. Mitral valve prolapse
Social History:
+smoker, has young son and involved mother
Family History:
NC
Physical Exam:
VS:afebile 129-156 215/126-172/113 43-28 96% NRB to BIPAP
14/5
GEN aao, tachypneic in mod resp distress, able to answer in
short word phrases with increased work of breathing
HEENT PERRL, dryMM, + trach scar
CHEST: poor air movement, no crackles
CV RRR, tachycardic
Abd soft, NT/ND, +BS
EXT no edema
Pertinent Results:
[**2150-5-26**] 11:08PM GLUCOSE-131* UREA N-9 CREAT-0.6 SODIUM-139
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-32* ANION GAP-13
[**2150-5-26**] 11:08PM CALCIUM-9.5 PHOSPHATE-4.5 MAGNESIUM-1.9
[**2150-5-26**] 11:08PM WBC-19.7* RBC-3.76* HGB-11.8* HCT-35.3*
MCV-94 MCH-31.4 MCHC-33.4 RDW-13.7
[**2150-5-26**] 11:08PM PLT COUNT-366
[**2150-5-26**] 08:06PM PO2-217* PCO2-84* PH-7.22* TOTAL CO2-36* BASE
XS-3
[**2150-5-26**] 08:06PM GLUCOSE-210* LACTATE-2.1* NA+-144 K+-4.4
CL--104
[**2150-5-26**] 08:06PM HGB-11.9* calcHCT-36 O2 SAT-98 CARBOXYHB-1
MET HGB-1
[**2150-5-26**] 08:06PM freeCa-1.28
[**2150-5-26**] 07:23PM PO2-180* PCO2-106* PH-7.16* TOTAL CO2-40*
BASE XS-5
*
Admision Chest X ray
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2150-5-26**] 7:09 PM
CHEST (PORTABLE AP)
Reason: SOB
INDICATION: Shortness of breath.
FINDINGS: Compared with [**2150-4-26**], the heart and lungs appear
normal.
No acute process is identified.
*
T-SPINE [**2150-5-27**] 4:00 PM
L-SPINE (AP & LAT); T-SPINE
Reason: r/o compression fracture
[**Hospital 93**] MEDICAL CONDITION:
46 year old woman with h/o osteoporosis with back pain
REASON FOR THIS EXAMINATION:
r/o compression fracture
INDICATIONS: History of osteoporosis. Back pain.
AP AND LATERAL VIEWS OF THE THORACIC SPINE: Comparison is made
to the lateral chest radiograph from [**2149-12-19**]. Again seen are
2 compression deformities in mid thoracic spine, which
demonstrates equivocal progression from [**12-19**]. (suboptimal
assessment due to positioning difficulty). There is diffuse
prominent demineralization.
AP AND LATERAL RADIOGRAPHS OF THE LUMBAR SPINE: Vertebral bodies
are normal in height and alignment. There is diffuse
demineralization. Hip and SI joints are unremarkable. No prior
study is available for comparison.
*
[**Hospital 93**] MEDICAL CONDITION:
46 year old woman with h/o osteoporosis with back pain
REASON FOR THIS EXAMINATION:
r/o compression fracture
INDICATIONS: History of osteoporosis. Back pain.
AP AND LATERAL VIEWS OF THE THORACIC SPINE: Comparison is made
to the lateral chest radiograph from [**2149-12-19**]. Again seen are
2 compression deformities in mid thoracic spine, which
demonstrates equivocal progression from [**12-19**]. (suboptimal
assessment due to positioning difficulty). There is diffuse
prominent demineralization.
AP AND LATERAL RADIOGRAPHS OF THE LUMBAR SPINE: Vertebral bodies
are normal in height and alignment. There is diffuse
demineralization. Hip and SI joints are unremarkable. No prior
study is available for comparison.
*
Brief Hospital Course:
46 y.o. female with h/o asthma/severe COPD with FEV1 = 0.24 who
p/w increasing shortness of breath in the setting of poor
compliance with her antibiotic colisitin.
A/p
1) Respiratory- COPD/Asthma flare
Concerning for a pneumonia especially in light of recent sputum
culture which grew multi-drug resistant actinobacter and pt's
non-compliance with this regimen. We were reassured by her clear
chest X ray on admission. Her ABG on admission in the ED was
7.16/106/18 which improved with CPAP 14/5 to 7.22/84/217. She
also received 125 mg IV solumedrol along with continuous
neubulizers with some effect. Upon arrival to the MICU she was
transitioned to 40 mg prednisone, her nebulizers were continued
and treatment with aerosolized colistin was initiated. The
patient improved on CPAP and was eventually weaned to 4L NC with
an ABG of 7.39/54/89. She is on 2L NC at home per the patient.
She was also continued on her inhalers per her home regimen. She
is also to continue a slow taper of her prednisone with 40 mg po
qd x1, 30 mg x 2 days, 20 mg x 2 days, 10 mg x 2 days and then
back to 7.5 mg qd which is her baseline.
*
2) ID/Pneumonia:
The infectious disease team was consulted with regards to her
multi-drug resistant positive sputum culture. They felt that
this sputum culture reflected colonization and not a true
pneumonia and adviced repeat sputum culture, d/c colistin and
and treat with a 10 day course of doxycycline c/w treatment of a
COPD exacerbation.
*
3) Back Pain/Osteopenia:
The patient underwent X rays of her spine which demonstrated 2
compression deformities in the mid thoracic spine, which
demonstrates ?equivocal progression from [**12-19**]. There was also
diffuse prominent demineralization. In light of this the patient
was started started on aledendronate and continued on vit D and
calcium.
*
4) HTN-
She was continued on verapamil per outpatient regimen. In the
ED she was markedly hypertensive but this resolved with an
improvement in her breathing. She was thus continued on her
single drug o/p regimen.
*
5) Psych/Anxiety
--She was continued on effexor, remeron, seroquel and ativan prn
. She is very anxious thus when she becomes short of breath she
gets very anxious which makes her breathing worse- a vicious
cycle. It is thus imperative that her anxioyltic regimen be
continued as this appears to ameliorate her pulmonary function.
*
Code: Full
*
Tobacco use: Pt was counselled on the importance of tobacco
cessation and demonstrates an understanding that her tobacco use
significantly contributes to her poor pulmonary funciton.
*
Eventual Disposition:
The patient has severe COPD and thus her pulmonary status is
tenous at best. We think that the patient should be considered
for long term placement in order to improve her pulmonary
toilette and overall medical compliance. Also when she is not at
home she is better able to abstain from nicotine.
Medications on Admission:
colistin 150mg IH [**Hospital1 **]
singulair 10mg daily
Effexor XR 150mg qam 75mg qpm
verapamil SR120mg po daily
Neurontin 300mg po HS
Protonix 40mg daily
Prednisone 7.5mg daily
Remeron 15mg hs
Percocet prm
albuterol MDI
Advair(500/50)IH [**Hospital1 **]
Tiotropium one capsule IH daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
COPD exacerbation
Past Medical History:
1. Severe end stage COPD
2. Hypertension
3. Anxiety
4. Leukocytosis of unknown etiology with negative BMBx.
5. Osteoporosis- on fosamax
6. Shoulder pain
7. History of positive PPD s/p 6mos of isoniazid
8. Mitral valve prolapse
Discharge Condition:
Good sating well on 4LNC, breathing much improved.
Discharge Instructions:
Please return to the ER or your PCP if you experience chest
pain, shortness of breath, weakness or light headedness.
*
Please take all of your medications as prescribed.
*
PLEASE STOP SMOKING!!
*
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2150-6-3**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD Where: [**Hospital6 29**]
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2150-6-23**] 2:10
|
[
"401.9",
"288.8",
"493.22",
"719.41",
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"733.00",
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] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
7707, 7786
|
4477, 7370
|
290, 297
|
8098, 8150
|
1887, 2941
|
8394, 8764
|
1543, 1547
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3734, 3789
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7807, 7826
|
7396, 7684
|
8174, 8371
|
1562, 1868
|
231, 252
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3818, 4454
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325, 1044
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7848, 8077
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1483, 1527
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,977
| 180,216
|
54626
|
Discharge summary
|
report
|
Admission Date: [**2146-2-25**] Discharge Date: [**2146-3-11**]
Date of Birth: [**2098-10-13**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Compazine / Reglan / Betadine Surgi-Prep / Tape /
Iodine; Iodine Containing / Vancomycin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Chills
Major Surgical or Invasive Procedure:
Transhepatic Line Placement
Groin Line Removal
History of Present Illness:
From ICU Admission Note:
The patient is a 47 year old female with PMHx sig. for [**Location (un) **]
syndrome s/p colecomty and multiple small bowel resections now
with short [**Location (un) **] syndrome on TPN and multiple episodes of
line-associated bacteremia. She presented to OSH with fevers and
hypotension. Pt reports that starting Monday, she has had sweats
and chills but no fevers. On Tuesday, VNA drew blood cultures
from her line. Pt was called to the ED for positive blood cxs.
In addition to sweats and chills, pt reports a headache for 4
days, no associated neck stiffness or photophobia. Pt has a
chronic nonproductive cough, denied SOB, CP, palpitations. She
has had n/v, nonbloody, for the past 2 days. She has chronic
lower abdominal pain. No change in stool output. No dysuria,
urinary frequency.
Currently she has a 2 week old L femoral tunnelled Hickman. She
was discharged on [**2-1**] with a planned 2 week course of linezolid
for coag-neg Staph line-associated blood streem infection. The
line was changed over a wire on [**1-28**]. She had returned on [**2-9**]
with sepsis and was found to have a Klebsiella pneumoniae
line-associated infection. The line was again exchanged over a
wire on [**2-11**], and the culture tip was negative. She was
discharged on [**2-16**] with 2 week planned course of ceftriaxone.
She is followed by ID.
At [**Location (un) 16843**], temperature was reportedly up to 102.5. She
received linezolid. In the ED, initial VS were: 101 93 101/66 28
96. Pt had CT abd/pelvis to eval LLQ pain. Neg. CXR. U/A sig.
for few WBCs. Prelim report was no sig. change. Pt was started
on levophed. BCxs pending, one off Hickman, one off peripherals.
Pt also received solumedrol 125 mg IV.
Past Medical History:
++ [**Location (un) **] syndrome
- diagnosed age 23
- total colectomy, end ileostomy [**2121**]
- small bowel resection (multiple) secondary to recurrent
polyposis
- subsequent short [**Year (4 digits) **] syndrome
- on TPN since [**2123**], [**9-/2131**]
++ Benign cystadenoma
- partial hepatectomy, [**2131**]
++ Line-associated blood stream infections
- Her CVL in her L leg has been in place for at least 5 years,
when she has had infections the line has been changed over a
wire
- MSSA, [**2127**]
- [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] [**12/2139**]
- C. parapsilosis + coag neg Staph, [**2-/2140**]
- [**Female First Name (un) 564**] non-albicans, [**3-/2141**]
- C.parapsilosis, [**9-/2142**]
- K. pneumoniae, [**9-/2145**]
--> Resistant to cipro, cefuroxime, TMP/SMX
--> Treated with meropenem [**Date range (1) 110935**]/08
- Line change due to positive blood cultures (?) [**10/2145**]
--> Had an echocardiogram that was abnormal as noted below
Coag neg Staph [**1-/2146**]
--> Line changed over wire
--> Linezolid [**Date range (1) 110936**]
++ Venous thrombosis/occlusion
- Failed access in R IJ, R brachiocephalic
- Reconstructed IVC w/ kissing stent extensions into high IVC
- Stenting to R femoral, external iliac
++ GI bleed
++ HSV-1
++ Fibromyalgia
++ Osteoporosis
++ Scoliosis; h/o surgical repair
++ Right hip fracture; ORIF [**2129**]
++ Meniscal tears of knee; 4 prior surgeries, [**2133**]
++ Total abdominal hysterectomy; bilateral salpingo-oophorectomy
++ Dermoid cyst removal (small bowel, ovaries)
++ Hepatic cyst adenoma; resected
++ Cholecystectomy, [**2131**]
Social History:
The patient lives with her mother who assists her with her
medical needs. No ETOh or Tob.
Family History:
Father with [**Name2 (NI) **] syndrome as do 6 of 8 siblings. Mother and
relatives with HTN and resulting CVA. Sister with breast ca.
Her father's parents died of cancer.
Physical Exam:
On Transfer to Floor:
T 100.3 (99.3-100.3) BP 98/62; HR 95; resp 21; 96% on 2L
General: pleasant thin woman in NAD, talking with eyes closed.
HEENT: refuses
Neck: refuses
Lungs: bilateral crackles [**11-27**]-/12 up lung fields, tachypnic to
21, no labored breathing
Heart: RRR, no m/r/g
Abdom: +BS, ND, soft, NT, ostomy bag with brown stool
Extrem: no edema, L fem hickman site c/d/i, no erythema
Neuro: alert, oriented x3
On Discharge:
VSS. BP 80-90's/50-60's which is patient's baseline
GEN: NAD, comfortable, thin
HEENT: mmm, EOMI, PERRL
Neck: Supple
CV: regular, no mrg
PULM: decrease breath sounds at the bases, otherwise clear
ABD: colostomy in place with no skin break down, no TTP over
abdomen. Transhepatic line in place, no erythma or exudate,
mild TTP over line site
EXT: no [**Location (un) **], warm, well perfused
NEURO: A/O to person, place, time and purpose
PSYCH: Appropriate
Pertinent Results:
Labs on admission:
- WBC-5.0 RBC-2.90* Hgb-9.3* Hct-26.0* MCV-90 MCH-32.1*
MCHC-35.8* RDW-14.3 Plt Ct-168
- Neuts-87.9* Lymphs-8.6* Monos-2.7 Eos-0.6 Baso-0.1
- PT-13.9* PTT-29.6 INR(PT)-1.2*
- Glucose-110* UreaN-21* Creat-0.9 Na-135 K-3.6 Cl-104 HCO3-21*
AnGap-14
- ALT-45* AST-20 AlkPhos-253* TotBili-0.9
- Lipase-26
- TotProt-6.0* Calcium-8.3* Phos-2.5* Mg-1.8
- Lactate-1.4
CT abdomen/pelvis, [**2146-2-24**]:
1. Unchanged appearance of discitis/osteomyelitis of L4-L5.
2. No evidence of intra-abdominal abscess or small bowel
obstruction.
Chest x-ray [**2146-2-24**]:
Relatively stable examination with improved aeration at the
right lung base with persistent elevation of the right
hemidiaphragm across multiple prior studies. Stable indwelling
stents and catheter. Question of vague ill-defined densities in
the lateral aspects of both mid lung zones may be
microatelectasis. If indicated, consider CT to assess for
underlying occult nodules.
Ultrasound [**2146-2-26**]:
Focal thrombus within the right common femoral vein. Normal
compressibility and flow noted inferiorly within the superficial
femoral vein on that side. No son[**Name (NI) 493**] evidence of deep vein
thrombosis of the left lower extremity. However, evaluation was
somewhat limited by presence of a tunneled catheter.
ECHO [**2146-2-28**]:
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The septal leaflet of the tricuspid
valve is mildly thickened but without discrete vegetation. There
is mild to moderate [[**11-26**]+] tricuspid regurgitation. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2146-2-11**],
the estimated pulmonary artery systolic pressure is higher (and
was normal on [**2145-9-23**]). The tricuspid valve morphology is
similar.
CHEST CT:
1. Segmental and subsegmental pulmonary emboli in the right
upper lobe, right middle lobe, and left lower lobe.
2. Multifocal peribronchial and mostly peripheral nodular
opacities, could be due to multifocal pneumonia or septic
emboli, should be followed.
3. Almost complete collapse and consolidation of the right lower
lobe, and
right middle lobe atelectasis, at least mostly in part due to
elevation of the right hemidiaphragm.
4. Small bilateral pleural effusions, more marked on the right.
5. Enlarged mediastinal lymph nodes, could be reactive.
6. SVC and IVC stents with multiple thoracic and epigastric
collaterals.
ABDOMINAL U/S:
Comparison is made with prior ultrasound from [**2145-9-23**].
There is no fluid collection, hematoma, or abscess. The
intrahepatic line is seen in the expected course of the right
hepatic vein with the tip in the IVC. The CBD is enlarged but
unchanged. The limited views of the right kidney are normal. The
spleen is enlarged at 13.5 cm, but unchanged.
IMPRESSION: No hematoma, fluid collection or abscess about the
transhepatic venous line. CBD dilatation and splenomegaly are
unchanged.
DISCHARGE LABS:
- CBC:5.3/9.2/28.0/453
- CHEM 7: 138/4.3/105/24/17/0.5/135
Brief Hospital Course:
This is a 47 year old female with a medical history significant
for [**Location (un) **] syndrome status-post colecomty and multiple small
bowel resections now with short [**Location (un) **] syndrome on TPN and multiple
episodes of line-associated bacteremia presents with fevers and
hypotension. Treated with iv antibiotics. Groin line removed
and transhepatic line placed. Survaillence cultures were
negative. Patient was discharged home in stable condition on a 2
week course of antimicrobials. Patient has PCP and infectious
[**Name9 (PRE) 111739**] follow up appointments.
# Line-Associated Sepsis: Admitted to the ICU in septic shock
presumably from groin line infection requiring levophed for
pressure support for 2 days which was successfully weaned off.
She has had multiple admission for sepsis secondary to line
infections, most recently coag negative Staph treated with
linezolid and Klebseilla pneumoniae with ceftriaxone. Each
time, her line has been exchanged over a wire due to lack of
access. The patient also has chronic LLQ pain. CT abdomen did
not reveal a source of infection. Infectious disease was
consulted and patient was ultimately treated with iv ampicillin
and fluconazole as outside hospital cultures grew out enteroccus
and [**Female First Name (un) **] albicans. Ophthalmologic evaluation was limited as
the patient refused dilation, however did not show evidence of
fungal sequalae. She was c.diff negative. Survaillence
cultures remained negative. The groin line was removed and
patient had a 2 day line holiday before a transhepatic line was
successfully placed by IR. Patient to complete a 2 week course
of IV ampicillin and fluconazole, last dose on [**2146-3-16**].
Visiting nurse to draw survaillence blood cultures on [**2146-3-21**]
and send them to infectious disease at [**Hospital1 18**]. Long term plan if
survaillence cultures negative is to resite line to femoral vein
with tunneling from above to avoid groin flora. This is to be
arranged as an out patient. Patient's blood pressures were at
baseline of mid 80's-90's after transfer to medical floor.
# Venous Thromboembolism: Patient developed hypoxia and was
found to have a DVT. CT showed multiple PE's. She was started
on a heparin gtt initially and then treated with lovenox. Given
that patient has had mulitple prior thrombotic events, will need
therapeutic anticoagulation indefinitely. Cannot be on oral
anticoagulation secondary to short [**Hospital1 **] syndrome.
# Chronic Hypotension: Baseline blood pressures in 80-90's
systolic. Patient remained stable with good urine output at
these pressures. Per prior admission records, this is patient's
baseline.
# Back Pain: Has known discitis at L4-5. Is s/p biopsy [**9-/2145**]
with no organisms. Fentanyl patch was increased to 75mcg as
patient's back pain was not adequately controlled. She was also
was started on oral morphine liquid 10-20mg q4h prn. If pain
persists, would recommend increasing fentanyl patch.
# Anemia: Iron deficency an anemia of chronic disease. Was
transfused a total of 3 units of blood. Hct was stable at
baseline of high 20-low 30's for 5 days prior to discharge.
Stool was guaiac negative.
# [**Location (un) **] syndrome status-post colectomy and multiple small
bowel resections, now with short [**Location (un) **] syndrome. She was continued
on home TPN. Pain managment as above.
# CODE: DNR but ok to intubate confirmed with patient.
# HCP: [**Name (NI) 714**] [**Name (NI) 1557**] (sister), [**Telephone/Fax (1) 111736**](h),
[**Numeric Identifier 110945**](c). Other contact: [**Doctor First Name 111740**] [**Telephone/Fax (1) 111741**],
mother: [**Telephone/Fax (1) 111742**]
---
TO DO FOR REHAB:
[ ] IV AMPICILLIN AND FLUCONAZOLE THROUGH [**2146-3-16**]
[ ] CONTINUE [**Hospital1 **] LOVENOX INDEFINITELY
[ ] PHYSICAL THERAPY
[ ] USE ETHANOL LOCKS FOR 2 HOURS/DAY FOR TRANSHEPATIC LINE
[ ] CHECK CBC, BUN, CREATININE, AST, ALT AND CK ON [**2146-3-18**] AND FAX TO [**Telephone/Fax (1) 432**] ATTN: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[ ] DRAW BCX X 2 ON [**2145-3-21**] AND FAX TO [**Telephone/Fax (1) 432**] ATTN: DR.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[ ] DAILY TPN
Medications on Admission:
1. Clopidogrel 75 mg PO DAILY
2. Fentanyl 50 mcg/hr Patch
3. Lorazepam 0.5 mg PO TID PRN
4. Ceftriaxone 1 gram daily x 14 days
Discharge Medications:
1. Fluconazole in Saline(Iso-osm) 400 mg/200 mL Piggyback Sig:
Four Hundred (400) mg Intravenous Q24H (every 24 hours) for 6
days: though [**2146-3-16**].
Disp:*2400 mg* Refills:*0*
2. Ampicillin Sodium 2 gram Recon Soln Sig: Two (2) grams
Injection Q4H (every 4 hours) for 6 days: last dose [**2146-3-16**].
Disp:*72 grams* Refills:*0*
3. Ethanol (Ethyl Alcohol) 70% Solution Sig: Two (2) MLs per
port Intravenous once a day: Not for IV use. To be instilled
into central catheter port for local dwell for 2 hours. 2ml per
each port.
Disp:*120 mL* Refills:*2*
4. Home Oxygen
Oxygen at 3 L, continuous with pulse dose for portability. Dx:
Pulmonary Embolus
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. Acetaminophen 160 mg/5 mL Solution Sig: [**11-26**] PO Q6H (every 6
hours) as needed for pain.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for apply to lower back: 12 hours on 12 hours off.
8. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours).
Disp:*60 injections* Refills:*11*
9. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. Ethanol (Ethyl Alcohol) 98 % Solution Sig: Two (2) ML
Intravenous DAILY (Daily): instill 2 ML into EACH port and lock
for 2 hours.
11. Morphine 10 mg/5 mL Solution Sig: 10-20 mg PO Q4H (every 4
hours) as needed for pain.
12. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO ONCE (Once) as needed for nausea.
13. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Outpatient Lab Work
Please check CBC, BUN, Creatinine, AST, ALT, and CK on [**2146-3-18**] and fax to [**Telephone/Fax (1) 432**] attn: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
16. Outpatient Lab Work
Please draw 2 sets of blood cultures on [**2146-3-21**], fax results to:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 111**] at [**Telephone/Fax (1) 432**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Line Related Sepsis [**12-27**] Enterococcus and [**Female First Name (un) 564**] Albicans
Pulmonary Embolus
Chronic Back Pain [**12-27**] Discitis
.
Secondary:
++ [**Location (un) **] syndrome
- diagnosed age 23
- total colectomy, end ileostomy [**2121**]
- small bowel resection (multiple) secondary to recurrent
polyposis
- subsequent short [**Year (4 digits) **] syndrome
- on TPN since [**2123**], [**9-/2131**]
++ Benign cystadenoma
- partial hepatectomy, [**2131**]
++ Line-associated blood stream infections
- Her CVL in her L leg has been in place for at least 5 years,
when she has had infections the line has been changed over a
wire
- MSSA, [**2127**]
- [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] [**12/2139**]
- C. parapsilosis + coag neg Staph, [**2-/2140**]
- [**Female First Name (un) 564**] non-albicans, [**3-/2141**]
- C.parapsilosis, [**9-/2142**]
- K. pneumoniae, [**9-/2145**]
--> Resistant to cipro, cefuroxime, TMP/SMX
--> Treated with meropenem [**Date range (1) 110935**]/08
- Line change due to positive blood cultures (?) [**10/2145**]
-Coag neg Staph [**1-/2146**]
--> Line changed over wire
--> Linezolid [**Date range (1) 110936**]
++ Venous thrombosis/occlusion
- Failed access in R IJ, R brachiocephalic
- Reconstructed IVC w/ kissing stent extensions into high IVC
- Stenting to R femoral, external iliac
++ GI bleed
++ HSV-1
++ Fibromyalgia
++ Osteoporosis
++ Scoliosis; h/o surgical repair
++ Right hip fracture; ORIF [**2129**]
++ Meniscal tears of knee; 4 prior surgeries, [**2133**]
++ Total abdominal hysterectomy; bilateral salpingo-oophorectomy
++ Dermoid cyst removal (small bowel, ovaries)
++ Hepatic cyst adenoma; resected
++ Cholecystectomy, [**2131**]
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted from an outside hospital to the ICU because of
sepsis from an infection from your groin line. You are being
discharged to a rehab facility as you will be receiving
antibiotics multiple times a day.
You were treated with iv antibiotics for this infection. Your
groin line was pulled and a transhepatic line was placed. You
are being discharged on ampicillin and fluconazole iv for a
total of a 2 week course - last dose will be on [**2146-3-16**].
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12081**] on [**2146-4-8**] at
9:30am. You will need blood cultures on [**2146-3-21**] drawn by
Visiting nurses or at the rehab facility. If those are negative
then the current plan is to re-site the line back to the femoral
vein. The infectious disease team will help to coordinate that.
You will also have blood work drawn on [**2146-3-18**].
Your line will be instilled with alcohol (ethanol lock) for 2
hours a day as you did previously.
You are being discharged on oral morphine liquid 10-20 mg every
4 hours. This controlled your pain well while you were in the
hospital.
Additionally, you were found to have a clot in your lung. You
were started on lovenox twice a day. Because you have had
multiple clots before, you will need to be on lovenox
indefinitely.
No other medication changes were made, you should continue all
your other home medication as directed.
If you have fever or chills, shortness of breath, severe
abdominal or back pain, chest pain, lightheadedness or dizziness
or any other concerning symptom, please seek medical care
immediately.
It was a pleasure meeting you and participating in your care.
Followup Instructions:
You have an appointment with Dr. [**First Name (STitle) 22917**] [**2146-3-23**] at 2:45pm. If
you need to change this, please call her office at [**Telephone/Fax (1) 75498**].
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12081**] in infectious
disease at [**Hospital1 18**] on [**2146-4-8**] at 9:30am
|
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icd9cm
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[
[
[]
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4576, 5035
|
319, 327
|
442, 2176
|
5073, 8397
|
2198, 3825
|
3841, 3933
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,533
| 196,621
|
26463
|
Discharge summary
|
report
|
Admission Date: [**2143-12-27**] Discharge Date: [**2144-1-3**]
Date of Birth: [**2107-5-23**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 65388**]
Chief Complaint:
fetal anomalies
Major Surgical or Invasive Procedure:
dilation and extraction
right salpingo-oophorectomy
exploratory laparotomy
ligation of uterine artery
repair of uterine laceration
History of Present Illness:
36yo G2P1 who presented at 18+2 wks for termination of severely
anomalous fetus. Had laminaria placed in triage on [**2143-12-26**], and
returned for D+E procedure on [**2143-12-27**].
Past Medical History:
MedHx:
none
SurgHx:
cervical lymph node resection ~20yrs ago -> benign
ObHx:
[**2142**] SVD @ 37 wks, IOL 2/HELLP, rec'd MgSO4
GynHx:
no abnl Paps
no cysts/fibroids
no STDs
LMP [**2143-8-21**]
Social History:
Lives with husband and son.
[**Name (NI) 1403**] as a director of a non-profit organization.
No T/E/D.
Family History:
Non-contributory
Physical Exam:
97.5 129/74 93 20
Gen: NAD
Pulm: CTAB
Cor: RRR
Abd: soft, gravid, NT, fundus 3cm below umbilicus
Extr: no edema, NT
Pelvic: nl external genitalia, nl cervix with parous os, no
adnexal masses
Pertinent Results:
[**2143-12-26**] 12:19PM BLOOD WBC-8.3 RBC-3.90* Hgb-12.2 Hct-34.7*
MCV-89 MCH-31.3 MCHC-35.3* RDW-12.8 Plt Ct-251
[**2143-12-28**] 03:00PM BLOOD WBC-10.3# RBC-2.80* Hgb-8.6* Hct-23.9*
MCV-85 MCH-30.7 MCHC-36.0* RDW-15.9* Plt Ct-105*
[**2144-1-2**] 08:50AM BLOOD WBC-6.9 RBC-4.31 Hgb-12.3 Hct-35.5*
MCV-82 MCH-28.6 MCHC-34.8 RDW-17.5* Plt Ct-230
[**2143-12-27**] 03:00PM BLOOD Neuts-90.9* Bands-0 Lymphs-7.5*
Monos-1.2* Eos-0.2 Baso-0.1
[**2143-12-26**] 12:19PM BLOOD PT-12.8 PTT-24.7 INR(PT)-1.1
[**2143-12-29**] 02:30AM BLOOD PT-14.9* PTT-26.9 INR(PT)-1.5
[**2144-1-2**] 08:50AM BLOOD PT-12.5 PTT-25.1 INR(PT)-1.0
[**2143-12-27**] 05:23PM BLOOD Fibrino-136*
[**2143-12-30**] 05:50AM BLOOD Fibrino-805*#
Brief Hospital Course:
The pt was taken to the operating room for a scheduled D+E on
[**2143-12-27**]. This procedure was complicated by uterine perforation
and iatrogenic right salpingo-oophorectomy. Intraoperative
gynecologic oncology consult was obtained, and an exploratory
laparotomy was performed. For details, please see the two
operative notes dated [**2143-12-27**].
Postoperatively, the pt was transferred intubated and sedated to
the ICU for close monitoring. She was called out of the ICU on
POD#2. Issues followed while hospitalized were as follows:
1. Heme: Combined EBL for her surgical procedures was estimated
at >2L. Intraoperatively, she was aggressively fluid
resuscitated and was transfused with 4u pRBCs. Intraoperative
labs revealed a coagulopathy, although she was not clinically
anticoagulated. Serial Hcts were followed and she was
transfused a total of two additional units to maintain a Hct of
30. Her coagulopathy resolved over the course of her hospital
stay. She showed no signs of excessive bleeding.
2. Pulm: The pt remained intubated until POD#2. Extubation was
uneventful. She remained stable on room air for the remainder
of her hospitalization.
3. CV: The pt was hypotensive and tachycardic after her surgery.
A neosynephrine drip was started on POD#0 and was quickly
weaned off as she responded to fluid resuscitation and blood
products. She remained stable after transfer to the floor.
4. ID: The pt was started on empiric ampicillin, levofloxacin,
and metronidazole postoperatively; these were D/C'd on POD#1.
She remained afebrile with no evidence of infection for the
remainder of her hospital stay.
5. Routine: After being called out to the floor, the pt's
postoperative course was unremarkable. She advanced her diet,
tolerated PO pain medications, voided without difficulty upon
D/C of her Foley catheter, and passed flatus. She met with
social work per protocol after a pregnancy loss/termination.
The pt was discharged home in good condition on POD#7.
Medications on Admission:
Pre-natal vitamins
Ibuprofen prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
fetal anomalies
uterine laceration
Discharge Condition:
good, stable
Discharge Instructions:
Take all medications as prescribed.
Do not drive for 2 weeks or while taking narcotics.
Call if you have fever of 100.4 or higher, heavy vaginal
bleeding (soaking 1 pad per hour for >2 hours), drainage from or
redness around your incision, or any other symptoms that worry
you.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 5777**] Call to schedule
appointment in 1 week to remove staples, and in 6 weeks for
routine postop follow-up.
Completed by:[**2144-1-15**]
|
[
"635.22",
"285.1",
"655.83",
"635.12",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"65.49",
"57.32",
"69.41",
"54.19",
"69.51",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4493, 4542
|
2027, 4027
|
345, 478
|
4621, 4636
|
1298, 2004
|
4962, 5183
|
1048, 1066
|
4110, 4470
|
4563, 4600
|
4053, 4087
|
4660, 4939
|
1081, 1279
|
290, 307
|
506, 693
|
715, 912
|
928, 1032
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,092
| 180,246
|
44485
|
Discharge summary
|
report
|
Admission Date: [**2157-9-7**] Discharge Date: [**2157-9-16**]
Date of Birth: [**2090-12-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18794**]
Chief Complaint:
weakness, decreased energy
Major Surgical or Invasive Procedure:
Thoracentesis on [**2157-9-12**]
History of Present Illness:
This is a 66 yo male with a history of PVD, CAD s/p MI and PCI
in [**2136**], IDDM, Afib, CHF, [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] AVR, PMR-predisone
dependent, s/p AK-[**Doctor Last Name **] bypass with PTFE [**2157-3-16**] who presents with
generalized weakness over the past 3-4 days. He reports vomiting
3-4x over this time period and having 2-3 episodes of diarrhea
daily which is loose and watery.
.
Notably, he has also had shortness of breath both at rest and
with exertion for months. He notes a 15lb weight gain over the
past 2-3 months with increased lower extremity swelling and
orthopnea. Denies any CP or palpitations.
.
In the ED, initial vs were: T: 101.8 HR: 80 BP:101/71 RR:18
O2Sat:94% on 4L. Patient was given a total of 6 L IVF. Also
received Vancomycin and Zosyn. He put out a total of 200cc. CXR
showed bilateral pleural effusions with pulmonary vascular
congestion. Pt had elev Trop of 0.1, cards consulted and did not
feel ECG suggestive of ischemia. He was seen by vascular surgery
who did not feel his left lower extremity graft side appeared
well healed. Patient admitted to MICU given concern for sepsis.
.
In the ICU, patient endorsed lethargy but no focal pain or
discomfort. Breathing felt comfortable.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied chest pain or
tightness, palpitations. Denied constipation or abdominal pain.
No recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
-insulin dependent diabetes mellitus
-coronary artery disease -s/p MI,s/p PCI [**2136**],s/p CABG'sx3 [**1-31**]
-history of aortic valve stenosis,s/p AVR(St. [**Male First Name (un) 923**] [**1-31**])
-chroinc systolic CHF
-atrial fibrillation,anticoagulated
-polyarthritis rheumatica,predisone dependent
-peripheral vascular disease
-s/p right BKA
-s/p AICD implant
Social History:
Lives at home in [**Location (un) 8117**], NH. Retired in [**11-28**] from his work as
a manager in auto sales. Denies ETOH. Former smoker.
Family History:
N/C
Physical Exam:
At Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP with minimal elevation, no LAD
Lungs: Crackles at bilateral bases, good air movement
CV: Irrgularly irregular, normal S1 + S2, +mechanical heart
sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: RLE: Stump warm, well perfused
Left lower extremity: medial thigh graft site well healed,
nontender, no erythema,no drainage. 1x1 cm ulcer with
surrounding erythema on dorsum of foot without any drainage.
Toes [**12-25**] with smal shallow ulcers.
Skin: large non-blanching red macular lesion with crisp medial
border on left medial thigh
Pertinent Results:
[**2157-9-7**] 04:20PM BLOOD WBC-14.2*# RBC-4.14*# Hgb-10.6*
Hct-36.5*# MCV-88 MCH-25.7*# MCHC-29.2* RDW-18.7* Plt Ct-335
[**2157-9-8**] 01:53AM BLOOD WBC-7.8 RBC-3.50* Hgb-9.2* Hct-31.2*
MCV-89 MCH-26.2* MCHC-29.4* RDW-17.7* Plt Ct-206
[**2157-9-9**] 06:00AM BLOOD WBC-7.9 RBC-3.56* Hgb-9.4* Hct-31.9*
MCV-90 MCH-26.4* MCHC-29.5* RDW-18.9* Plt Ct-248
[**2157-9-10**] 06:20AM BLOOD WBC-6.7 RBC-3.56* Hgb-9.2* Hct-31.5*
MCV-88 MCH-25.8* MCHC-29.1* RDW-17.8* Plt Ct-217
[**2157-9-11**] 06:55AM BLOOD WBC-5.8 RBC-3.56* Hgb-9.3* Hct-31.6*
MCV-89 MCH-26.2* MCHC-29.5* RDW-17.8* Plt Ct-216
[**2157-9-14**] 09:00AM BLOOD WBC-6.9 RBC-3.69* Hgb-9.8* Hct-33.0*
MCV-89 MCH-26.6* MCHC-29.8* RDW-18.3* Plt Ct-245
[**2157-9-15**] 05:45AM BLOOD WBC-6.5 RBC-3.85* Hgb-10.0* Hct-33.5*
MCV-87 MCH-26.1* MCHC-30.0* RDW-17.5* Plt Ct-253
[**2157-9-16**] 06:35AM BLOOD WBC-6.5 RBC-3.78* Hgb-9.6* Hct-32.7*
MCV-87 MCH-25.5* MCHC-29.4* RDW-17.5* Plt Ct-293
[**2157-9-7**] 04:20PM BLOOD Neuts-86.7* Lymphs-8.5* Monos-3.9 Eos-0.4
Baso-0.4
[**2157-9-8**] 01:53AM BLOOD Neuts-84.2* Lymphs-10.2* Monos-5.0
Eos-0.4 Baso-0.2
[**2157-9-7**] 04:20PM BLOOD PT-32.7* PTT-49.6* INR(PT)-3.3*
[**2157-9-9**] 06:00AM BLOOD PT-28.3* PTT-47.1* INR(PT)-2.8*
[**2157-9-11**] 06:55AM BLOOD PT-18.9* INR(PT)-1.7*
[**2157-9-12**] 06:05AM BLOOD PT-17.1* PTT-60.9* INR(PT)-1.5*
[**2157-9-14**] 12:45AM BLOOD PT-16.4* PTT-46.0* INR(PT)-1.5*
[**2157-9-14**] 09:00AM BLOOD PT-16.0* PTT-48.8* INR(PT)-1.4*
[**2157-9-14**] 05:00PM BLOOD PT-16.2* PTT-52.1* INR(PT)-1.4*
[**2157-9-15**] 05:45AM BLOOD PT-18.1* PTT-93.6* INR(PT)-1.6*
[**2157-9-15**] 03:35PM BLOOD PT-18.8* PTT-56.6* INR(PT)-1.7*
[**2157-9-16**] 06:35AM BLOOD PT-19.8* PTT-80.6* INR(PT)-1.8*
[**2157-9-7**] 04:20PM BLOOD Glucose-50* UreaN-32* Creat-1.4* Na-135
K-4.4 Cl-102 HCO3-24 AnGap-13
[**2157-9-8**] 01:53AM BLOOD Glucose-138* UreaN-31* Creat-1.3* Na-144
K-3.8 Cl-112* HCO3-22 AnGap-14
[**2157-9-8**] 03:00PM BLOOD Glucose-256* UreaN-30* Creat-1.3* Na-135
K-4.3 Cl-105 HCO3-22 AnGap-12
[**2157-9-9**] 06:00AM BLOOD Glucose-92 UreaN-27* Creat-1.2 Na-140
K-3.8 Cl-108 HCO3-24 AnGap-12
[**2157-9-9**] 07:03PM BLOOD UreaN-24* Creat-1.2 Na-138 K-4.0 Cl-106
HCO3-25 AnGap-11
[**2157-9-11**] 06:55AM BLOOD Glucose-166* UreaN-20 Creat-0.9 Na-135
K-3.9 Cl-102 HCO3-27 AnGap-10
[**2157-9-15**] 05:45AM BLOOD Glucose-126* UreaN-18 Creat-1.0 Na-137
K-3.9 Cl-100 HCO3-30 AnGap-11
[**2157-9-16**] 06:35AM BLOOD Glucose-88 UreaN-21* Creat-1.0 Na-138
K-4.4 Cl-99 HCO3-30 AnGap-13
[**2157-9-7**] 04:20PM BLOOD ALT-18 AST-33 CK(CPK)-46 AlkPhos-189*
TotBili-1.3
[**2157-9-8**] 01:53AM BLOOD CK(CPK)-55
[**2157-9-12**] 12:10PM BLOOD LD(LDH)-297*
[**2157-9-7**] 04:20PM BLOOD Lipase-20
[**2157-9-7**] 04:20PM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2157-9-8**] 01:53AM BLOOD CK-MB-NotDone cTropnT-0.07* proBNP-3145*
[**2157-9-7**] 04:20PM BLOOD Calcium-8.9 Phos-3.7 Mg-2.4
[**2157-9-8**] 01:53AM BLOOD Calcium-7.1* Phos-3.8 Mg-2.1
[**2157-9-9**] 06:00AM BLOOD Calcium-7.7* Phos-2.4* Mg-2.1
[**2157-9-10**] 06:20AM BLOOD Calcium-7.8* Phos-1.8* Mg-2.0
[**2157-9-14**] 05:00PM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9
[**2157-9-16**] 06:35AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1
[**2157-9-8**] 01:53AM BLOOD Digoxin-0.2*
[**2157-9-10**] 06:20AM BLOOD Digoxin-0.4*
[**2157-9-12**] 06:05AM BLOOD Digoxin-0.5*
[**2157-9-7**] 09:03PM BLOOD Type-[**Last Name (un) **] pO2-50* pCO2-44 pH-7.29*
calTCO2-22 Base XS--4 Comment-GREEN-TOP
[**2157-9-8**] 02:11AM BLOOD Type-MIX pH-7.32*
[**2157-9-7**] 04:29PM BLOOD Glucose-49* Lactate-1.3 Na-135 K-4.3
Cl-99* calHCO3-25
[**2157-9-7**] 09:03PM BLOOD Glucose-88 Lactate-1.1 Na-136 K-4.1
Cl-106
[**2157-9-7**] 04:29PM BLOOD Glucose-49* Lactate-1.3 Na-135 K-4.3
Cl-99* calHCO3-25
[**2157-9-7**] 09:03PM BLOOD Glucose-88 Lactate-1.1 Na-136 K-4.1
Cl-106
[**2157-9-7**] 09:27PM BLOOD Hgb-10.7* calcHCT-32 O2 Sat-70
[**2157-9-7**] 09:03PM BLOOD freeCa-0.96*
[**2157-9-8**] 02:11AM BLOOD freeCa-1.05*
[**2157-9-7**] 04:20PM URINE RBC-[**2-24**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2157-9-7**] 04:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG
[**2157-9-7**] 04:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2157-9-13**] 06:29PM OTHER BODY FLUID IPT-DONE
[**2157-9-13**] 06:29PM OTHER BODY FLUID CD3-DONE
[**2157-9-13**] 06:29PM OTHER BODY FLUID CD23-DONE CD45-DONE
HLA-DR[**Last Name (STitle) 7735**] [**Name (STitle) 7736**]7-DONE Kappa-DONE CD2-DONE CD7-DONE CD10-DONE
CD19-DONE CD20-DONE Lamba-DONE CD5-DONE
[**2157-9-12**] 04:39PM PLEURAL TotProt-1.3 Glucose-119 LD(LDH)-67
Albumin-0.6
[**2157-9-12**] 04:39PM PLEURAL WBC-130* RBC-940* Polys-1* Lymphs-99*
Monos-0
[**2157-9-12**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL;
ANAEROBIC CULTURE-PRELIMINARY INPATIENT
[**2157-9-8**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2157-9-8**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2157-9-8**] URINE Legionella Urinary Antigen -FINAL INPATIENT
[**2157-9-8**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2157-9-7**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2157-9-7**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
[**2157-9-7**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
Admit CXR
SINGLE AP VIEW OF THE CHEST: An AICD overlies the left chest
wall, with a
single lead terminating within the right ventricle. Median
sternotomy wires
are unchanged. Moderate cardiomegaly is stable, with
atherosclerotic
calcifications of the aortic arch. There are increased
interstitial markings
bilaterally, suggestive of mild fluid overload, with a slightly
more confluent
opacity within the right mid lung, also likely reflecting edema.
There are
small-to-moderate bilateral pleural effusions. No pneumothorax
is
appreciated.
IMPRESSION: Mild CHF with bilateral pleural effusions.
Stable cardiomegaly.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Severe regional left ventricular systolic dysfunction, c/w
multivessel CAD. Normally-functioning mechanical aortic valve
prosthesis. Moderate mitral regurgitation. Moderate to severe
tricuspid regurgitation. Moderate pulmonary hypertension. No
vegetations seen, but cannot be excluded due to suboptimal
acoustic windows. If clinically indicated, a transesophageal
study will better assess valvular morphology.
Compared with the prior study (images reviewed) of [**2157-1-12**],
stenotic aortic valve has been replaced with a mechanical
prosthesis. Tricuspid regurgitation is slightly more prominent.
The other findings are similar.
CXR 9.19
1. Worsening CHF with increasing edema and slight increase in
effusions.
2. Circumferential left pleural opacity, likely due to
loculated pleural
effusion, but malignant pleural disease could produce a similar
radiographic
appearance. Continued radiographic followup recommended to
document resolution following
treatment of the acute process. If this fails to resolve,
contrast-enhanced
CT may be helpful to look for areas of enhancement or
nodularity.
CT Chest [**9-11**]
IMPRESSION:
1. Bilateral, partly organized pleural effusions with bilateral
intrafissural
and left paramediastinal component. The effusions would be
consistent with
the clinical history of chronic cardiac insufficiency.
2. Moderate mediastinal lymphadenopathy, that would equally be
consistent
with a clinical history of chronic cardiac insufficiency.
3. Cardiomegaly with marked coronary calcifications, status post
aortic valve
repair.
4. Right apical emphysema, small subpleural areas of parenchymal
fibrosis, no
evidence of lung nodules or masses suspicious for malignancy.
5. Extensive calcifications of the upper abdominal arteries.
Pleural fluid:
ATYPICAL.
Many lymphocytes, some enlarged forms.
Brief Hospital Course:
# Hypotension: At initial presentation, there was concern for
infection given leukocytosis and fever with hypotension. He was
admitted to the MICU where his BP stablized with fluid
resucitation. Initial differential including pneumonia,
bacteremia related to LLE graft / ulcers / osteo and cardiac
decompensation in the setting of heart failure. Broad spectrum
antibiotics were started with Vancomycin and Zosyn and blood /
urine cultures were drawn. Pressures remained stable during the
initial part of hospitalization and the patient was restarted on
carvediolol for improved rate control in the setting of atrial
fibrillation. On [**9-10**], antibiotics were discontinued as patient
had been afebrile since admission with normalizing white counts
and clinical picture clear for exacerbation of CHF. He was
subsequently transfered to the medical floor where he remained
afebrile.
# acute on chronic systolic CHF exacerbation: At initial
presentation patient had substantial pulmary vascular
congestion, peripheral edema, mild elevation in JVP and pt's
history of progressive wt gain supported an acute on chronic
systolic heart failure exacerbation. His symptoms seemed
subacute and progressive over past few months and likely made
worse by volume resuscitation in the ED. Patient was
subsequently started on lasix with substantial diuresis and
substantial subjective improvement in symptoms throughout his
hospitalization. Echo was performed which showed severe
regional left ventricular systolic dysfunction, c/w multivessel
CAD, normal-functioning mechanical aortic valve prosthesis,
moderate mitral regurgitation, moderate to severe tricuspid
regurgitation, moderate pulmonary hypertension and no
vegetations seen. Digoxin was continued for improved ionotropy
in setting of systolic heart failure and lasix and carvedilol
re-started for diruesis and afterload reduction.
# AFib/Mechanical AV: Patient's carvedilol was stopped on
admission because on initial presentation he was thought to be
septic. Once sepsis was ruled out and antibiotics stopped he
was re-started on to improve rate control. On transfer to the
medicine floor the patient was found to be tachycardic up to
150s on several occasions. His carvedilol was increased to
12.5mg [**Hospital1 **] from his home dose of 6.25mg [**Hospital1 **], with this
intervention his heart rate was maintained below 100. Patient's
coumadin was stopped on admission given his presentation. He
remained therapeutic during his MICU course. Upon transfer to
the medical floor his INR became subtherapeutic and his coumadin
was increased. Upon further questioning the patient and his wife
stated that he was receiving a higher dose of coumadin at home
than what he was receiving presently. His coumadin was then
increased to his normal home dose and his INR began to increase.
On [**9-16**] his INR was 1.8, still in the subtherapeutic range, but
the patient decided that he could not wait for this to resolve.
The risks of having a stroke or of his mechanical AV
malfunctioning were explained to the patient on several
occasions but he remained adamant about leaving the hospital. On
[**9-16**] he decided to sign out AMA. He was discharged with a
prescription for lovenox as a bridge to therapeutic INR. He was
also instructed to get his INR checked on [**9-18**] and these results
made known to his cardiologist Dr. [**Last Name (STitle) 95337**] who was
informed about this.
# Loculated pleural effusion: Patient was found to have a
loculated effusion on CXR and the result confirmed by CT chest.
A thoracentesis was done to drain the fluid and send if for
analysis. Testing revealed that the fluid was consistent with a
transudative process. Cytology was done and it revealed atypical
cells, many lymphocytes and some enlarged forms. This could be
consistent with a reactive lymphocytosis or a lymphoma. These
cells were sent for further analysis by flow cytometry which was
pending upon discharge. His PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 95334**] was informed
about this. He will be contact[**Name (NI) **] if cytology/flow suggest
malignant process. He was given a prescription to repeat CT
chest in 5 weeks to evaluate for continued resolution or re
accumulation of the pleural effusion.
# DM II: He was continued on his outpatient regimen of lantus
and humalog.
# PMR: Patient was initially started on hydrocortisone. Later it
was found that he did not take hydrocortisone at home, but
prednisone. Hydrocort was stopped and prednisone started at his
home dose.
Medications on Admission:
Aspirin 325 mg Tablet DAILY
Carvedilol 6.25 mg Tablet [**Hospital1 **]
Citalopram 20 mg Tablet daily
Digoxin 125 mcg Tablet EVERY OTHER DAY
Furosemide 80 mg Tablet DAILY
Hydrocortisone 10 mg Tablet DAILY
Insulin Glargine [Lantus]Twenty (20) units qHS
Ipratropium Bromide 17 mcg/Actuation Aerosol every six (6) hours
as needed for wheezes.
Magnesium Oxide 400 mg Tablet DAILY (Daily).
Metoprolol Succinate 50 mg Tablet daily
Oxycodone-Acetaminophen 5-325 mg Tablet Q4 PRN
Pantoprazole 40 mg Tablet daily
Pregabalin 25 mg [**Hospital1 **]
Rosuvastatin 20 mg Tablet daily
Spironolactone 12.5 mg Tablet daily
Warfarin [Coumadin]3.5 mg daily
Discharge Medications:
1. CT Chest
Please obtain CT Chest to evaluate for resolution/reaccumulation
of loculated pleural effusion, any day on the week of
[**2157-10-31**]. Please fax these results to your PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 95334**] at [**Telephone/Fax (1) 95338**].
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath, wheezing.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
6. Gatifloxacin 0.3 % Drops Sig: One (1) Ophthalmic QID (4
times a day).
7. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
8. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Acular LS 0.4 % Drops Sig: One (1) Ophthalmic QID (4 times a
day).
10. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
12. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
15. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
16. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
19. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK
([**Doctor First Name **],WE,FR).
20. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
(MO,TU,TH,SA).
21. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day for 7 days.
Disp:*14 syringes* Refills:*0*
22. Outpatient Lab Work
Please check INR on [**2157-9-19**]. Please fax this result to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 14715**] at [**Telephone/Fax (1) **].
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary:
Acute on Chronic Systolic Congestive Heart Failure
Loculated Pleural Effusion
Atrial Fibrillation
Secondary Diagnosis:
Type 2 Diabetes
Discharge Condition:
Good. The patient's VS are stable, and his respiratory status
has improved to his baseline.
Discharge Instructions:
You were admitted to the hospital because you were having
nausea, vomiting, and weakness. You were found to have low
blood pressure. In the ER you received IV fluids and antibiotics
for a suspected infection. You initially were admitted to the
intensive care unit for closer monitoring of your respiratory
status. In the ICU, it appeared that you were having an
exacerbation of your congestive heart failure. You were started
on aggressive diuresis with IV Lasix, and your weight decreased
by 10 kg. Your respiratory status improved as well, and you are
currently back at your baseline.
While you were here, you were also found to have a small pocket
of fluid around your lungs. This was drained by a
thoracentesis, and the fluid was sent off for cytology. The
fluid did show an abnormal type of cell, which may be from your
congestive heart failure. However, we sent off these cells for
further analysis, as it is possible that they may be from a
cancer. We informed your PCP of this finding, and he will
follow up on these results as soon as they're available. Your
coumadin was stopped when we were preparing for this procedure.
Your INR is still currently sub-therapeutic at 1.8. We placed
you on a heparin drip and started you back on your home dose of
Coumadin. You have decided that you do not want to stay in the
hospital to wait for your INR to increase. We medically advised
you to stay in the hospital until your INR is 2.5, and we
explained to you that leaving the hospital with your current INR
is dangerous because you can develop blood clots that can cause
a stroke or your mechanical valve to malfunction, requiring
surgical repair. You understood these risks. We placed you on
Lovenox to prevent these complications until your INR is
therapeutic. You will need your INR checked on Sunday [**2157-9-19**]
to make sure it is increasing.
While you were in the hospital, we made the following changes to
your medications:
1. We increased your Carvedilol from 6.25 [**Hospital1 **] to 12.5 [**Hospital1 **].
2. We increased your Lasix to 60 mg twice daily. Please take
this increased dose until your appointment with your
cardiologist next week.
3. We started you on Lovenox to protect you from stroke until
your INR is 2.0-3.0. Please stop this medication when your INR
is 2.0-3.0, or when instructed by your cardiologist, Dr.
[**Last Name (STitle) 95337**]
Please return to the ED or your healthcare provider if you
experience chest pain, increased shortness of breath, weakness,
increasing fatigue, fevers, chills, or any other concerning
symptoms. Please weigh yourself every day and call your PCP if
your weight increases by more than 3 pounds. Please adhere to a
low Na diet (< 2 g/day).
Followup Instructions:
Please keep the following appointments:
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 95334**] (PCP). Date/Time: [**Last Name (LF) 766**], [**9-19**] at
4pm. Location: [**Location (un) 87037**] Ste. 202 , [**Location (un) 8117**] NH. Phone
number: [**Telephone/Fax (1) 88550**]
Dr. [**Last Name (STitle) 1391**] (Vascular surgery). Date/Time: [**2157-10-14**]. Someone
from his office will call you on [**2157-9-19**] to schedule you for a
non-invasive study of the blood vessels in you leg prior to you
appointment.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 95337**] (Cardiology). Date/Time: [**2157-9-22**] at
10 am.
|
[
"682.6",
"511.9",
"250.00",
"V49.75",
"428.0",
"V45.82",
"790.92",
"427.1",
"707.23",
"V58.66",
"427.31",
"443.9",
"707.07",
"707.22",
"V45.02",
"414.01",
"V58.67",
"428.23",
"707.09",
"725",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
18609, 18692
|
11108, 15702
|
342, 377
|
18881, 18976
|
3321, 11085
|
21750, 22423
|
2545, 2550
|
16390, 18586
|
18713, 18821
|
15728, 16367
|
19000, 21727
|
2565, 3302
|
1691, 1980
|
276, 304
|
405, 1672
|
18842, 18860
|
2002, 2371
|
2387, 2529
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,894
| 134,744
|
46283
|
Discharge summary
|
report
|
Admission Date: [**2187-10-21**] Discharge Date: [**2187-10-29**]
Date of Birth: [**2117-10-18**] Sex: M
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 70-year-old male with
a history of diabetes, hypercholesterolemia, coronary artery
disease, status post coronary artery bypass graft, severe
chronic obstructive pulmonary disease, who presented to
[**Hospital 1474**] Hospital initially with increased shortness of
breath/congestive heart failure and ischemic ST depressions
in leads V2 through V6 (1-2 mm). He was immediately
intubated for impending respiratory failure and transferred
to [**Hospital6 256**] for a cardiac
catheterization, where no acute lesions were found, but
pulmonary capillary wedge pressure of 45 was noted, prominent
V waves consistent with mitral regurgitation, a cardiac index
of 2.79, and a cardiac output of 6.09. He was admitted to
the Coronary Care Unit for [**Location (un) **] diuresis and ventilatory
support until volume overload improved. He was also noted to
be in atrial flutter upon admission to the catheterization
laboratory, but was in normal sinus rhythm upon arrival to
the Coronary Care Unit.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Coronary artery bypass graft times five ([**2176**]). All
native vessels are occluded. Had a left internal mammary
artery to the left anterior descending, had saphenous vein
graft to the OM3, posterior descending artery and an
saphenous vein graft to the ramus/OM (occluded).
3. Also history of chronic obstructive pulmonary
disease/asbestosis.
4. History of diabetes.
5. Hypercholesterolemia.
6. Obesity.
7. Gastroesophageal reflux disease.
8. Vitamin B12 deficiency.
9. Congestive heart failure.
MEDICATIONS AT HOME:
1. Aspirin 81 mg po q.d.
2. Lasix 80 mg po q.d.
3. Imdur 60 mg po q.d.
4. Metoprolol 150 mg po q.d.
5. Lisinopril 20 mg po q.d.
6. Lipitor 40 mg po q.d.
7. Calcium 250 mg po q.d.
8. Vitamin D 125 units q.d.
9. Multivitamin.
10. Rosiglitazone 2 mg b.i.d.
11. Aciphex 20 mg po b.i.d.
12. Salmeterol.
13. Albuterol.
14. Ipratropium.
15. Ferrous sulfate.
16. Flovent 220 mcg po q.d.
SOCIAL HISTORY: He lives with his girlfriend. [**Name (NI) **] not
smoked cigarettes in 22 years. No alcohol use since his
coronary artery bypass graft.
PHYSICAL EXAMINATION ON PRESENTATION: In general, he was
mildly agitated, intubated, obese. Vital signs: Temperature
98. Heart rate 70-80 in normal sinus rhythm. Blood pressure
124-162/62-80. Respiratory rate 12-13. He was saturating
100% on the ventilator. Head, eyes, ears, nose and throat:
Pupils equal, round and reactive to light. Conjunctivae
edema bilaterally. Moist mucous membranes, intubated. Neck:
Obese, jugular venous distention. Cardiovascular: Regular
rate and rhythm, distant S1, S2, unable to appreciate
murmurs. Pulmonary: Decreased breath sounds at the bases.
Abdomen: Obese, nontender, normal active bowel sounds.
Extremities: 1+ edema, dopplerable dorsalis pedis/ posterior
tibial pulses. Right groin without hematoma nor bruit.
Skin: Erythema on the lower abdomen. Right lower
extremities with no pustules or petechia. Neurological:
Sedated, intubated, withdrawals to pain.
LABORATORY DATA ON ADMISSION: White blood cell count 8.7,
hematocrit 29.0, platelet count 162,000, INR 1.2, sodium 139,
potassium 4.7, BUN 40, creatinine 1.7, platelet count
233,000. Troponin 9.3, CK 89, MB not done. Arterial blood
gas: 7.39/53/117. Venous gas 68%. Chest x-ray
demonstrating no pneumothorax, congestive heart failure, Swan
appropriately placed.
HOSPITAL COURSE: This is a 70-year-old male with history of
coronary artery disease, status post five vessel coronary
artery bypass graft in [**2176**] with three patent grafts, and an
ejection fraction of approximately 20-30%, history of chronic
obstructive pulmonary disease (FEV1 approximately 32% of
normal), presenting with decompensated heart failure,
intubated at outside hospital with ST depressions anteriorly,
transferred for catheterization and found to have high
filling pressures, however, no culprit lesions. Transfer to
the Coronary Care Unit for care of diuresis.
Patient was diuresed with Natrecor drips, Lasix drips, with
some improvement of volume overload state. His Coronary Care
Unit course, however, was complicated by ongoing respiratory
failure in the setting of severe chronic obstructive
pulmonary disease. Also complicated by recurrent
tachyarrhythmias and rate related ischemia in the setting of
atrial flutter. While the patient's rate was adequately
controlled and he was diuresed significantly, his respiratory
status remained tenuous given his significant underlying
disease. On [**10-28**], a family meeting was obtained and
the decision to withdrawal care was made at that time.
On [**2187-10-29**], at 10 o'clock in the morning, the
patient was found to be not breathing and unresponsive. His
pupils were fixed and dilated. He had no breath sounds and
no heart sounds.
CAUSE OF DEATH: Respiratory failure. The patient's family
was present at the bedside.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (un) 98421**]
MEDQUIST36
D: [**2188-1-3**] 17:24
T: [**2188-1-9**] 19:32
JOB#: [**Job Number 38920**]
|
[
"414.00",
"272.0",
"486",
"V45.81",
"427.1",
"496",
"332.0",
"428.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"96.04",
"37.23",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
3633, 5389
|
1783, 2172
|
148, 170
|
199, 1200
|
3277, 3615
|
1222, 1762
|
2189, 3262
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,860
| 157,657
|
44649
|
Discharge summary
|
report
|
Admission Date: [**2156-3-8**] Discharge Date: [**2156-3-11**]
Date of Birth: [**2095-10-21**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
elective surgical repair of b/l femoral artey anuerysms
Major Surgical or Invasive Procedure:
s/p repair b/l femoral a. pseudoaneurysm and b/l femoral
endarterectomy
Past Medical History:
PMH:
PVD,
tobacco use,
daily ETOH,
CAD s/p RCA
[**Last Name (LF) **], [**First Name3 (LF) **] 57%
PSH:
s/p CABG,
aortobifem,
R CFA-[**Doctor Last Name **] w/ PTFE,
L CFA-SFA w/ PTFE,
L profund-[**Doctor Last Name **] w/ R NRSVG,
R carpal tunnel release,
L subareolar excision'[**50**],
perc angioplasty dist. L fem-[**Doctor Last Name **] [**3-7**]
Social History:
pos smoker
pos drinker
Family History:
non contributary
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2156-3-11**] 05:15AM BLOOD
WBC-10.4 RBC-3.63* Hgb-10.5* Hct-29.4* MCV-81* MCH-28.9
MCHC-35.7* RDW-15.1 Plt Ct-196
[**2156-3-11**] 05:15AM
BLOOD PT-11.0 PTT-29.0 INR(PT)-0.9
[**2156-3-11**]
BLOOD Plt Ct-196
[**2156-3-11**]
BLOOD Glucose-106* UreaN-8 Creat-0.6 Na-126* K-3.7 Cl-90*
HCO3-25 AnGap-15
[**2156-3-11**]
Calcium-8.0* Phos-2.7 Mg-1.6
[**2156-3-8**]
freeCa-1.14
[**2156-3-9**]
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15
Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2156-3-9**] 9:57 AM
CHEST (PORTABLE AP)
Portable upright chest radiograph shows interim removal of the
patient's endotracheal tube compared to yesterday's exam.
Right-sided Cordis introducer with coaxial catheter is in
unchanged position. Minimal streaky density is seen in the left
retrocardiac region, and less so at the right lung base with an
appearance more suggestive of subsegmental atelectasis than
pneumonia, however, if symptoms continue, repeat PA and lateral
views may be revealing. Cardiac size and mediastinal contours
are stable. Callus at healed rib fractures bilaterally is again
noted. Calcification is seen in the arch of the aorta with
calcified plaque at both carotid arteries and both subclavian
and axillary arteries as well.
CONCLUSION:
1. Maintained inspiratory volumes status post extubation.
Minimal subsegmental atelectasis at the bases without evidence
of pneumonia. If symptoms continue, PA and lateral views may be
helpful.
2. Atherosclerosis.
Brief Hospital Course:
Pt admitted on [**2156-3-8**]
Pre-op'd in the usual fashion
Pt undergoes a Resection of bilateral femoral pseudoaneurysms;
right ilio to profunda bypass graft with Dacron and replacement
of fem-[**Doctor Last Name **] graft, proximal anastomosis onto ilioprofunda graft
and left ilioprofunda bypass graft with Dacron.
Pt tolerated the procedure well / extubated in the OR /
transfered to the PACU in stable condition.
Transfered to the VICU in stable condition
[**2156-3-9**]
Pt delined / foley removed / diuresed
[**2156-3-10**]
Pt stable / PT consult obtained / OOB / diet advanced
Wounds C/D/I
2/9.06
Pt stable
taking Po / ambulating / urinating / pos bm
Medications on Admission:
advair,
albuterol,
labetalol 400/600,
imdur 60",
lisinopril 40qhs,
plavix 75',
asa 81',
detrol 2tid,
lipitor 40',
neurontin 600qid,
klonipin 1prn,
verapamil 120',
zyrtec 10',
primidone 100tid,
NACL 1g qid,
nexium 40',
NTGprn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
4. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: 1.5 Tablet Sustained Release 24HRs PO BID (2 times a day).
6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Primidone 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
14. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Oxycodone-Acetaminophen 5-500 mg Capsule Sig: [**2-2**] Capsules
PO every 4-6 hours for 10 days.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
b/l femoral a. pseudoaneurysm and b/l femoral occlusion
Discharge Condition:
Stable
Her alcoholism and severe medical conditions have been discussed
with her and her primary care doctor. She refused to stay in the
hospital any longer and it was felt she would be safer at home
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING s/p repair b/l femoral a.
pseudoaneurysm and b/l femoral endarterectomy SURGERY
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
ACTIVITY:
There are no specific restrictions on activity. You should be as
active as is comfortable. Some fatigue is expected for the first
several weeks. Leg swelling is typical following this type of
surgery and can be controlled by elevating your leg above the
level of your heart when you are not walking.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 4 weeks.
No heavy lifting greater than 20 pounds for the next 7 days.
Do not drive untill cleared by surgeon
BATHING/SHOWERING:
You shower immediately upon coming home. No bathing. A clear
dressing may cover your leg incision and this should be left in
place for three (3) days. Remove it after this time and wash
your incision(s) gently with soap and water. Dissolving sutures,
which do not have to be removed, were probably used.
If you have staples these will be removed on your follow-up
appointment.
WOUND CARE:
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for
removal.).
When the sutures / staples are removed the doctor may or may not
place pieces of tape called steri-strips over the incision.
These will stay on about a week and you may shower with them on.
If these do not fall off after 10 days, you may peel them off
with warm water and soap in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
two weeks after surgery.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
Avoid bending for 4-6 weeks.
No strenuous activity for 4-6 weeks after surgery.
DIET :
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:00 Monday
through Friday.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
Call Dr [**Last Name (STitle) 8888**] office in two weeks and schedule an appoinment
for 2 weeks. He can be reached at [**Telephone/Fax (1) 1241**]
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] [**Location (un) 2788**] CARDIOLOGY-PRIVATE
Date/Time:[**2156-3-23**] 1:30
Provider: [**Name Initial (NameIs) **]. [**Last Name (un) **] 1 RADIOLOGY Phone:[**0-0-**]
Date/Time:[**2156-5-26**] 2:00
Provider: [**Name10 (NameIs) 11383**],[**First Name3 (LF) **] OB/GYN [**Location (un) 2788**] (SB) Date/Time:[**2156-5-26**]
2:30
Completed by:[**2156-3-11**]
|
[
"442.3",
"443.9",
"V45.81",
"996.74",
"780.39",
"491.20",
"413.9",
"E878.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"39.25",
"38.48",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5414, 5420
|
2960, 3632
|
370, 444
|
5520, 5722
|
1390, 2937
|
11027, 11593
|
876, 894
|
3907, 5391
|
5441, 5499
|
3658, 3884
|
5746, 7426
|
909, 1371
|
275, 332
|
7439, 10329
|
10353, 11004
|
466, 820
|
836, 860
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,032
| 124,627
|
33218
|
Discharge summary
|
report
|
Admission Date: [**2181-1-8**] Discharge Date: [**2181-1-12**]
Date of Birth: [**2103-7-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Left sided chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77 yo F with PMH of HTN who presented to her PCP's due to 6 days
of worsening L sided chest/back pain. She states that she first
noted the pain upon waking on thursday morning. The pain was
intermittent, initially not very severe, improved with
application of a hot pack. Over the next several days the pain
worsened and her daughter brought her to see her doctor today.
She denies any associated symptoms including dyspnea, cough,
light headedness, syncope, palpitations, n/v, abdominal pain,
calf pain/swelling, fever, recent injury or car/airplane travel.
She denies any h/o prior DVT or PE.
.
CTA ordered by PCP which showed multiple bilateral pulmonary
emboli, saddle PE, LUL lung mass and penetrating atherosclerotic
ulcer of the aortic arch. She was given lovenox 90mg SC x1.
Labs: WBC 13.1 HCT 42.4 PLT 171 PTT 22.7 INR 1 Na 137 K 3.6 Cl
100 CO2 30 BUN 6 Cr 0.9 Gluc 102 LDH 143 AST 18 ALT 13 CK 68
CKMB 0.7 Trop I <0.01. Guiac negative
.
In the ED T100.9 HR 89 105/70 RR 18 98% 4LNC. Given tylenol 1g
po for low grade fever and transferred to [**Hospital Unit Name 153**].
Past Medical History:
1. HTN
2. OA in her knees
Social History:
Born in [**Country 16573**], she has 8 children, lives with her daughter,
who is a nurse. non-smoker, rare alcohol, no drug use. Prior to
the winter she was walking 1.5 to 2 miles to church every day;
only stopped because of the cold weather.
Family History:
she denies any known family history of cancer, early heart
attack, stroke.
Physical Exam:
VS: Temp:99.6 BP:146/71 HR:85 RR:21 O2sat 98% 4L NC
GEN: pleasant, comfortable, NAD
HEENT: EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, DP's 2+ bilaterally
SKIN: no rashes/no jaundice
NEURO: AAOx3
RECTAL: deferred (Guiac negative at OSH)
Pertinent Results:
ECHO:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. 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. The left ventricular
inflow pattern suggests impaired relaxation. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Thrombus in the main and right pulmonary artery may be
identified (views suboptimal). Cannot exclude right atrial
thrombus (views suboptimal)
--------------
RADIOLOGY Final Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2181-1-9**] 7:54 AM
CTA CHEST W&W/O C&RECONS, NON-
Reason: evaluate aortic arch ulcer seen on CT at OSH
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with bilateral/saddle PE's, new LUL lung mass
and report of penetrating aortic arch atherosclerotic ulcer
REASON FOR THIS EXAMINATION:
evaluate aortic arch ulcer seen on CT at OSH
CONTRAINDICATIONS for IV CONTRAST: None.
CT OF THE CHEST:
CLINICAL HISTORY: 77-year-old woman with saddle pulmonary
embolism, new left upper lobe lung mass and reports of
penetrating aortic arch atherosclerotic ulcer.
TECHNIQUE: MDCT-acquired axial images were initially obtained
through the chest with a low-dose technique without contrast
followed by contrast-enhanced images through the chest utilizing
a pulmonary embolism protocol. Coronal, sagittal, and oblique
reformatted images were also obtained.
There are extensive pulmonary emboli involving the Upper and
lower lobes. Pulmonary emboli are seen in both main pulmonary
arteries, segmental and subsegmental branches. A linear thrombus
is seen extending between the main left and right pulmonary
arteries, compatible with saddle embolus.
The heart is mildly enlarged. Note is made of coronary artery
calcifications. There is no pericardial effusion. The thoracic
aorta is normal in caliber. The ascending thoracic aorta, for
example, measures 3.4 x 3.4 cm. Extensive atherosclerotic
calcifications are seen throughout the thoracic aorta. In
addition, the aortic arch contains a prominent peripheral
atherosclerotic plaque. However, there is no evidence of aortic
dissection or focal atherosclerotic ulcer.
Small subcentimeter mediastinal lymph nodes are seen that do not
meet CT criteria for malignancy. There is no hilar or axillary
lymphadenopathy.
There is a spiculated, poorly defined area in the left upper
lobe (series 3, image 16) that measures approximately 1.1 x 2.7
cm. Abdominal windows demonstrate large amount of thrombus
within the pulmonary artery branches in this region, and this
area therefore, may represent a focal pulmonary infarct.
However, other underlying pathology cannot be excluded.
Therefore, attention should be drawn to this region on
subsequent examination to assess for interval change.
There is a small left pleural effusion and bibasilar atelectasis
(left greater than right). Nonspecific pleural thickening is
evident along the medial aspects of both hemithoraces.
Limited images through the upper abdomen demonstrate several
small hepatic cysts. In addition, there are several cystic
lesions in the right kidney that are only partially included on
an unenhanced portion of examination,and probably represent
renal cysts.
BONE WINDOWS: There are multilevel degenerative changes in the
thoracic spine. No suspicious lytic or sclerotic lesions are
identified.
IMPRESSION:
1. Extensive bilateral pulmonary emboli with a saddle embolus
component.
2. Spiculated opacity in the left upper lobe, probably
reflecting a focal pulmonary infarction. However,an underlying
neoplasm cannot be excluded. Attention should be drawn to this
region on subsequent examinations to assess for interval change.
3. Small left pleural effusion. Bibasilar atelectasis.
4. Extensive peripheral plaque in the aortic arch. No evidence
of aortic dissection or focal atherosclerotic ulcer.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 74936**] [**Doctor Last Name **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: WED [**2181-1-10**] 2:27 PM
---------
RADIOLOGY Final Report
BILAT LOWER EXT VEINS PORT [**2181-1-9**] 10:06 AM
BILAT LOWER EXT VEINS PORT
Reason: SADDLE EMBOLI, BILAT DUPLEX TO ASSESS FOR DVT
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman saddle PE
REASON FOR THIS EXAMINATION:
bilat duplex to assess for dvt
INDICATION: 77-year-old female with PE, assess bilateral legs
for DVT.
COMPARISON: No previous exams for comparison.
FINDINGS: Grayscale, color and Doppler son[**Name (NI) 1417**] of bilateral
common femoral, superficial femoral, popliteal and tibial veins
were performed. Normal flow, compression and augmentation are
seen in all of the vessels of the right leg. In the left leg,
there is incomplete compression and slow flow seen in the common
femoral and the superficial femoral veins indicating
nonocclusive thrombus within those vessels. No DVT is seen in
the deep femoral vein or the popliteal vein of the left leg.
IMPRESSION: Nonocclusive thrombus identified in the left common
femoral and superficial femoral veins. No DVT seen in the right
leg.
These findings were communicated to N.P. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] at about
2:00pm on [**2181-1-9**].
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**First Name8 (NamePattern2) **] [**2181-1-9**] 3:13 PM
-------------------
Brief Hospital Course:
A/P: 77 yo previously healthy female admitted with extensive
bilateral pulmonary emboli, new LUL lung mass and
atherosclerotic ulcer of the aortic arch.
.
#Bilateral Pulmonary emboli/saddle embolus: Patient was
initially admitted to the ICU for close monitoring. She was
started on heparin drip and remained hemodynamically stable
without evidence of hypotension or R heart strain. Her most
significant risk factor for PE was the new spiculated LUL mass
which was concerning for malignancy. She denied other risk
factors including prior DVT, family history of hypercoagulable
state, injury, or stasis. After being stable in the ICU she was
then temporarily transferred to cardiothoracic surgery to
work-up a lesion concerning for aortic dissection (as below.)
Once the work-up was complete, she was called out to the general
medicine service. Patient was transitioned to Lovenox without
difficulty. She was observed for >48 on Lovenox and she
remained comfortable and symptom free. She was evaluated by PT
and discharged home in the company of her daughter, with a
planned home safety evaluation.
#atherosclerotic ulcer of aortic arch: Patient had a finding on
CT scan which was concerning for possibility of dissection vs
rupture. This was aggressively worked up in the setting of the
patient's need for anti-coagulation for her pulmonary embolisms.
Cardiothoracic surgery was consulted and a CTA with
reconstruction was performed, which ruled out dissection. The
finding was determined to be an atherosclerotic plaque. No
further work-up was required.
#LUL lung mass: This finding is very concerning for malignancy ,
especially in the setting of new extensive pulmonary emboli and
DVT without any other risk factors. There is a possibility that
the nodule may be infectious given her low grade fevers and
initially elevated white count, but these may have also been a
result of her multiple pulmonary embolisms. Patient will need a
biopsy to determine the exact nature of the nodule.
Interventional radiology was asked to evaluate the films, and
felt that the mass could likely be biopsied via CT-guided
transthoracic biopsy, but felt it would be best to wait [**2-4**]
weeks before proceeding. Patient was scheduled with a follow-up
appointment with the thoracic oncology clinic prior to
discharge.
# HTN: Patient's antihypertensives were initially held because
of her risk of hypotension in setting of bilateral/saddle
pulmonary emboli. When she remained hemodynamically stable, her
usual home medications restarted at her usual dose.
#leukocytosis, low grade temperature: Initially this was
concerning for infection but patient had no localizing symptoms
and no evidence on history to support an infectious etiology.
This was then attributed to her extensive pulmonary emboli and
overall inflammatory state. They resolved shortly after
starting on anti-coagulation. Her blood cultures showed no
growth to date x 5 days at the time of this summary and the
urine culture was negative.
# F/E/N: Her electrolytes were repleted PRN. She tolerated a
regular diet without difficulty.
# PPx: Patient was maintained on a bowel regimen. She was on a
heparin gtt to treat her known PE and DVT's.
# Code Status: Full
# Communication: Verania Onwaka (daughter) C: [**Telephone/Fax (1) 77173**] or
Daughter-in-law (physician) Ngozi Ogi [**Known lastname 77174**] [**Telephone/Fax (1) 77175**]
Medications on Admission:
1. Norvasc 10mg daily
2. Triamterene/HCTZ 37.5/25 daily
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
Q12H (every 12 hours).
Disp:*30 mg* Refills:*3*
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-3**] Sprays Nasal
QID (4 times a day) as needed.
Disp:*1 bottle* Refills:*0*
4. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
1. Acute pulmonary embolism
2. Lung mass NOS
3. Aortic atherosclerosis and ulceration.
Discharge Condition:
stable
Discharge Instructions:
Please take all of your medications as directed. Do not stop or
change your medications without first speaking to your
physician.
[**Name10 (NameIs) 2351**] this admission, the following medication was added:
-- LOVENOX 90 MG by injection twice daily
This medication was added to treat the blood clots in your lungs
and legs. Please do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] of this medication.
Follow up as outlined below.
Please call your doctor or return to the hospital if you
experience any shortness of breath, chest pain, coughing up
blood, or any other concerning symptoms.
Followup Instructions:
1. You have an appointment with your primary care doctor, Dr.
[**Last Name (STitle) **] at 6:00 PM on [**1-29**]. Please call [**Telephone/Fax (1) 30453**] if
you have any questions about this apppointment.
2. You have an appointment with Dr. [**Last Name (STitle) **] on Tuesday,
[**1-16**] at 1:30 PM at the the Thoracic [**Hospital **] clinic on
the [**Location (un) **] of the [**Hospital Ward Name 23**] building. If you have any
questions about this appointment, please call [**0-0-**].
|
[
"440.0",
"401.9",
"415.19",
"162.3",
"453.41"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12224, 12273
|
8281, 11697
|
334, 341
|
12412, 12421
|
2379, 3400
|
13086, 13586
|
1779, 1855
|
11804, 12201
|
7082, 7110
|
12294, 12391
|
11723, 11781
|
12445, 13063
|
1870, 2360
|
273, 296
|
7139, 8258
|
369, 1453
|
1475, 1503
|
1519, 1763
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,673
| 162,397
|
37840
|
Discharge summary
|
report
|
Admission Date: [**2132-12-3**] Discharge Date: [**2132-12-17**]
Date of Birth: [**2052-9-17**] Sex: M
Service: MEDICINE
Allergies:
Ambien / Codeine
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Abdominal distension
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
PC: Mark Denoyers, [**Location (un) 5503**]
This is an 80 yo man with recent discharge from [**Hospital1 18**] ([**11-19**])
after stay on surgery service for splenic abcess/splenectomy c/b
colonic enterocutaneous fistula with recent abdominal fluid
collection drained by IR who re-presents from rehab ([**Hospital1 **])
with worsening abdominal distension. During his last admit grew
bacteroides from abdomen and pseudomonas and stenotrophomonas
from sputum (treated with 2 weeks of [**Last Name (un) 2830**], tobra, bactrim, and
fluc). Currently he has no complaints. He feels well. He notes
foley has been indwelling for a long time. He notes no dizziness
or lightheadedness on standing and does not feel thirsty. He
denies abdominal pain, distension, nausea, vomitting, fevers,
chills, constipation (had 3 days, resolved 3 days ago with
diarrhea), last bm [**12-3**] normal without blood or melena. He has
stable/baseline (per him) cough productive of white sputum (no
blood) and intermittent sob not related to exertion (has not
been out of bed much at rehab). He denies pain at sacral decub,
ventral abdominal wound, or tube sites. He has not eaten by
mouth since discharge.
In the ED: VS: T 98.5 HR 110->107 112/78 18 97% on RA. He was
seen by surgery and felt to have stable abdominal CT, but there
was a read of ? enhancing fluid collection in thorax, IP
consulted and plan to place drain. Still with abdominal drain in
place until follow up with [**Doctor Last Name **] on [**12-8**]. He was given 1.5L
Ns.
ROS: 10 point review of systems negative except as noted above.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
--splenic trauma s/p coiling c/b abcess and splenectomy
--tracheostomy
--COPD
--CAD
--HTN
--hypercholesterolemia
--pneumonia
PSH:
--splenectomy
--Coronary stent
--embolization of splenic artery branches
Social History:
He is widowed and lives alone. He smoked 1.5 ppd x 30 years,
quit in [**2099**], no alcohol since [**2099**]. Denies drug use.
Family History:
Noncontributory
Physical Exam:
VS: T 97.4 HR 109 BP 109/69 RR 20 Sat 98% RA -> sitting: 89/64,
123 -> standing 94/62, 138
Gen: Chronically appearing elderly man who appears wasted but in
NAD
Eye: extra-occular movements intact, pupils equal round,
reactive to light, sclera anicteric, not injected, no exudates
ENT: mucus membranes moist, no ulcerations or exudates; white
plaque on tongue
Neck: no thyromegally, JVD: flat
Cardiovascular: tachy but regular rhythm, normal s1, s2, no
murmurs, rubs or gallops
Respiratory: trach in place, capped, decreased bs left base,
otherwise clear to auscultation bilaterally, no wheezes, rales
or rhonchi
Abd: Midline coloenteric fistual, approx 6cm by 1cm, draining
yellow fluid, splenic drain in place draining purulent material,
otherwise soft, non tender, non distended, no
heptosplenomegally, bowel sounds present
Back: stage III sacral decub
Extremities: No cyanosis, clubbing, edema, joint swelling
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, speech fluent
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Hematologic: no cervical or supraclavicular LAD
Pertinent Results:
Admit labs:
CBC: WBC-15.9* RBC-3.76*# HGB-10.2*# HCT-32.9*# MCV-87 MCH-27.1
MCHC-31.0 RDW-21.5* PLT COUNT-568*; diff: NEUTS-65.3 LYMPHS-24.9
MONOS-8.7 EOS-0.6 BASOS-0.4
BMP: GLUCOSE-112* UREA N-24* CREAT-1.0 SODIUM-134 POTASSIUM-4.6
CHLORIDE-101 TOTAL CO2-24
Urine: BLOOD-MOD NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-TR
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG RBC-[**2-21**]* WBC-[**2-21**]
BACTERIA-MOD YEAST-NONE EPI-0
(Select studies, as patient has numerous images from this
hospitalization)
CT [**2132-9-18**]:
1. Heterogeneous predominantly enhancing expansile lesion in the
posteromedial spleen consistent with either an intrasplenic
lesion, such as hemangioma, with extra- splenic hemorrhage or
intrasplenic contusion and extra-splenic hemorrhage.
CT [**2132-10-25**]
1. Patient is status post splenectomy. A small rim-enhancing
fluid
collection is noted in the post-splenectomy bed measuring 3.9 x
2.5 cm.
2. Small amount of free air noted along the left lateral
anterior aspect of the abdomen, likely due to recent JP drain
removal upon discussion with the surgical resident.
3. Focal area of small bowel wall thickening within the mid
lower abdomen,
which may represent a focal segment of enteritis.
4. Infrarenal abdominal aortic aneurysm measuring up to 4.7 cm.
5. Bilateral small pleural effusions.
6. Cholelithiasis.
CT [**2132-12-9**]:
IMPRESSION:
1. Unchanged left-sided pneumothorax and left thoracic wall
subcutaneous
emphysema.
2. Bilateral pneumonia and consolidations.
3. Pneumatosis within the descending colon without bowel
thickening or other features of ischemic colitis. Other
considerations include air tracking from adjacent drains or
subcutaneous emphysema.
4. Foley catheter ending within the prostate.
5. Resolution of anterior abdominal wall collection.
6. Slight increase in size of abdominal aortic aneurysm.
(Select Microbiology Data):
Blood Culture, Routine (Final [**2132-12-13**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2132-12-10**]):
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
GRAM STAIN (Final [**2132-12-8**]):
SPARSE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
AMIKACIN-------------- 16 S
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
Peritoneal Fluid:
GRAM STAIN (Final [**2132-12-8**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
FLUID CULTURE (Final [**2132-12-11**]):
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..
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND
MORPHOLOGY.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. THIRD
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| | PSEUDOMONAS
AERUGINOSA
| | |
CEFEPIME-------------- =>64 R =>64 R =>64 R
CEFTAZIDIME----------- =>64 R =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R =>4 R
GENTAMICIN------------ 2 S 2 S 2 S
MEROPENEM------------- =>16 R =>16 R =>16 R
PIPERACILLIN/TAZO----- =>128 R =>128 R =>128 R
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
ANAEROBIC CULTURE (Final [**2132-12-12**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
Brief Hospital Course:
80 man with splenic abscess who presented with leukocytosis and
enhancing left pleural effusion concerning for empyema.
#. Septic shock: Patient with septic shock, most likely from
overwhelming C.diff infection, though other contributing sources
include aspiration pneumonia and gram positive cocci in blood.
On [**2132-12-7**], Mr. [**Known lastname **] [**Last Name (Titles) 28316**] a fever, and his PICC line was
pulled because it had previously grown GPC. However, fevers
continued and patient was started on vancomycin. On [**2132-12-8**]
he developed intractable vomiting, and subsequently aspirated;
O2 sats decloined to 70% on trach mask. At that time his
antibiotic coverage was broadened to Vanc/Zosyn and he was
transferred to the MICU. A femoral line was placed and pressor
support was initiated. Moreover, a stool culture was positive
for c.diff, and PO/PR vanc and flagyl were added to antibiotic
regimen. A blood culture from [**12-8**] showed staph epi, and IV
vanc was continued. Eventually, the patient was changed from
vanc/zosyn to vanc/Tigecycline. ID recommended Tigecycline not
only for its broad coverage (covers gram negatives as well as
coag negative staph growing from blood Cx), but also for proven
effectiveness in C.Diff infections. The patient also had a
sputum culture growing pan-resistant pseudomonas. Per the
infectious disease team, the patient was felt to be colonized
with pseudomonas and a decision was made not to treat the
pseudomonas, as that would require using colistin, an antibiotic
known to cause renal failure. Pressors were weaned and stopped
the morning of [**12-11**]. Patient also continued to be afebrile,
and was clinically moving in the right direction. Antibiotics
were tailored to tigecycline, flagyl, and PO vanc on [**12-12**]. As
patient continued to improve clinically, his flagyl was
discontinued on [**12-13**]. His vancomycin was tapered to 125mg q6 on
[**12-14**] and tigecycline was d/cd on [**12-15**]. Infectious disase
recommends at total 14 day course of treatment, and then
vancomycin taper to 125mg [**Hospital1 **] for 7 days, then 125mg dailyx7
days, then 125mg qodx7days. He also displayed no change in his
respiratory status and thus was not treated for a pneumonia.
#. Colitis: During his [**Hospital Unit Name 153**] course, stool samples were sent,
which came back positive for c.diff. Patient had increased
stool output, marked leukocytosis, and septic picture. He was
treated with vancomycin PO/PR, flagyl and tigecycline to
minimize toxin production. PR vancomycin was eventually
discontinued, as patient had such large amounts of stool that
medication was not being absorbed. The patient intermittently
complained of LLL abdominal pain; surgery examined his abdomen
and felt that his tenderness was improving and likely related to
his c diff infection. A CT was obtained that showed interval
improvement in his prior abdominal fluid collection, as well as
pneumatosis within the descending colon; this was felt to be due
to his enterocutaneous fistula rather than ischemia. See
treatment course for antibiotics as above.
#. Tachycardia: He had sinus tachycardia on transfer to the MICU
that was felt to be compensatory due to sepsis. ECG showed
sinus tachycardia without ST changes. [**12-11**] he was increasingly
tachycardic in the setting of increasing cough. He was given
IVF and HR eventually trended down to 80s-90s on [**12-12**] and
[**12-13**].
#. Hypoxia and left pleural effusion: He had an abdominal CT on
admission that showed a pleural effusion suggestive of
infection. He underwent thoracentesis performed by IP on
[**2132-12-4**] which was complicated by pneumothorax requiring chest
tube placement. Results of pleural effusion ruled out empyema.
His chest tube was removed on [**2132-12-7**]. Cytology showed no
evidence for malignancy.
#. Orthostasis: He was hypovolemic on admission and was given
IVF to improve HR. Was tachycardic on [**2132-12-5**] after chest tube
placement, without hypoxia, SOB. IVF was re-initiated. This
resolved prior to transfer to floor. He was started on lasix for
anasarca....
#. Pericolic abscess with colocutaneous fistula: He was admitted
with a drain in place and was followed by the surgery team
during this admission. On [**2132-12-17**], patient had a fistulogram
and there was no evidence for ongoing fluid accumulation. The
drain was removed on [**2132-12-17**].
#. Dysphagia: Has enteric tube, getting tube feeds at [**Hospital1 **].
Clotrimzole for thrush, swish and spit was started. Refiber
Tube feeds were re-initiated goal 80cc/hr. However, a KUB in
the setting of increasing abdominal pain showed dilated loops of
bowel and tube feedings were stopped. TPN was also not an
option in the setting of sepsis. TFs were reinitiated. Speech
and swallow recommended a video swallow assessment on [**12-17**].
#. History of Respiratory failure: Has trach, breathing well on
room air with trach capped, received routine trach care. He was
given a trach valve on [**12-17**] and was able to speak.
#. COPD: Inhaled medications: tiotropium, symbicort, albuterol
prn were all continued.
#. CAD, native vessel: Continued on home regimen with aspirin.
BB and Isosorbide were held in the setting of hypotension and
have not been restarted.
#. Hypertension, benign: He was continued on metoprolol
initially but this was held in the setting of hypotension
#. Hyperlipidemia: statin on hold.
Full code.
Medications on Admission:
home meds:
Tylenol prn
Tiotropium bromide 18 mcg qday
Simvastatin 10 mg daily
Colace 100 mg [**Hospital1 **]
metoprolol 12.5 tid
Isosorbide dinitrite 10 mg daily
Aspirin 81 mg daily
REHAB MEDS:
symbicort 80/4.5 2 puffs [**Hospital1 **]
colace 100mg ng [**Hospital1 **]
fondaparinux 2.5 daily
ISS
ipratropium 4 puffs q6
lopressor 12.5 ng tid
Ranitidine 150mg ng [**Hospital1 **]
albuterol 90mcg 4 puffs q6prn
albuterol and iptratropium nebs prn
morphine 2mg ng q4prn pain
zofran 4q [**5-26**] iv hours prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing or dyspnea.
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q12 HOURS () as needed
for pain.
7. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days: then 125 mg po/per G tube [**Hospital1 **] x 7 days,
then 125 mg po/per G tube daily x 7 days, then 125 mg po/per G
tube every other day x 7 days.
8. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig: One
(1) Intravenous Q12H (every 12 hours).
9. Ondansetron 8 mg IV Q8H:PRN nausea
10. 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.
11. Furosemide 20 mg IV DAILY
12. Insulin sliding scale
Please see Insulin sliding scale and follow four times daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] [**Hospital1 **]
Discharge Diagnosis:
1) s/p splenic rupture secondary to abscess s/p splenectomy
laceration
2) splenic bed abscess s/p CT-guided drainage [**2132-11-18**] with
pigtail catheter placed, removed [**2132-12-17**] with no evidence for
ongoing fluid collection in this bed.
3) Severe C. diff associated diarrhea (CDAD) with septic shock
4) Atrial fibrillation with rapid ventricular response in the
setting of septic shock
5) copious pulmonary secretions with multi-drug resistant
PSEUDOMONAS AERUGINOSA and STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
6) PICC-associated coag-neg staph infection s/p treatment and
removal of line
7) malnutrition - severe
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:
Mr. [**Known lastname **] is a 80 year old man with a history of splenic
laceration, complicated by splenic abscess rupture with residual
abscess in the splenectomy bed who was treated for a pleural
effusion (s/p Chest Tube with iatrogenic pneumothorax) with
negative cytology, as well as severe C. diff associated diarrhea
(CDAD) with septic shock. There was concern from aspiration
pneumonia/pneumonitis as well. He required ICU level of care
and ultimately was transferred to the general medical floor with
treatment for CDAD with oral vancomycin. The CT-guided tube
placed [**2132-11-18**] for drainage of his splenectomy bed abscess was
removed on [**12-17**] after a fistulogram showed no evidence for
residual pocket and drainage was minimal.
Followup Instructions:
Please have Mr. [**Known lastname **] [**Last Name (Titles) **] a follow-up appointment with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Surgeon - who performed the emergency
splenectomy for the ruptured splenic abscess). Dr.[**Name (NI) 1863**]
phone # is ([**Telephone/Fax (1) 2300**].
|
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9,710
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47723
|
Discharge summary
|
report
|
Admission Date: [**2168-6-9**] Discharge Date: [**2168-6-20**]
Date of Birth: [**2105-10-26**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Reglan / Quinine Sulfate / Codeine / Augmentin /
Clindamycin / Dilaudid / Iodine
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62F with h/o MS, sarcoid, HTN, hyperlipidemia, DMII, CAD s/p
stents, PAD s/p L BKA, h/o CVA and recurrent DVTs who was
recently admitted at [**Hospital1 18**] from [**Date range (1) 100782**] for dyspnea and was
treated for exacerbation of reactive airway disease in setting
of recent URI, now presented back to ED for shortness of breath
and wheezing. During her last admission, she was treated with
nebulizers and flovent inhaler and improved. Her lung exam was
clear at the time of her discharge. During that admission, she
was also treated for pan-sensitive proteus UTI.
.
Patient reports that she was doing well, but yesterday
afternoon, she had sudden onset shortness of breath with diffuse
wheezing. Her symptoms persisted with inhaler treatment. So
she was told by her aid to come back to the hospital. She had no
fever or chills.
.
In the ED, initial VS: T 97.3 HR 114 BP 132/80 RR 20 100% RA.
BNP 41. UA showed trace leuks, [**7-21**] WBC and mod bacteria.
Portable CXR unremarkable. CTA chest was ordered to rule out PE,
but pt refused. She was given albuterol and ipratropium inhalers
as well as Bactrim. Transfer vitals: 97.9 142/96 116 24 98% 2L.
.
Last night on the floor, she complained to the night float
resident of intermittent wheezing/dyspnea without other acute
complaints. She also complained of chronic L shoulder and leg
pain that has not changed in character.
.
This morning, patient continued to complain of intermittent
shortness of breath. No wheezing. No fever, chills. No chest
pain.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. CARDIAC RISK FACTORS:
+ Diabetes, + Dyslipidemia, + Hypertension
-CARDIAC HISTORY: CAD [**12-18**] s/p 2 stents placed RCA, mild ICM
echo [**10-18**] with EF 45-50%
2. History of recurrent DVTs
--first DVT in [**2148**], given coumadin for 6 months, unknown why
she had DVT
--second DVT in [**2162**], given coumadin then plavix
--third DVT in [**2164-4-11**], now on coumadin and plavix
3. MS diagnosed in [**2150**], wheelchair bound since [**2151**]
4. s/p CVA in [**2152**], h/o TIAs on plavix [**Hospital1 **]
5. PAD on recent angiogram [**7-20**]-significant left SFA, [**Doctor Last Name **] and
anterior tibial disease, not amendable to stenting-->complicated
by LLE ulcer, nonhealing
6. Left BKA [**2167-9-28**] for non-healing ulcer
7. h/o spinal cord compression s/p C3-7 and T2-11 laminectomies
and fusion, with residual paraparesis and absent sensation in
bilateral LE. No sensation below T10
8. Seizure disorder, with staring spells due to MS, had status
recently [**7-20**]
9. T2DM on insulin, most recent HgA1c: 8.1% in [**2165**]
10. Hypertension
11. Hypercholesterolemia
12. Sarcoidosis
13. Anemia
14. Uterine/cervix cancer s/p radical hysterectomy
15. Asthma/COPD
16. Cardiac arrest after delivery (C-sect) of her 1st child at
36 yo
17. OSA no BiPAP/CPAP use
Social History:
Prior to hospitalization in [**7-20**], lived in [**Location 2312**] with 24 yo
dtr. She is Wheelchair bound but prior to [**7-20**] was able to cook
own meals and clean around the house; former alcoholic, sober
since [**94**] y/o when pregnant, 70 pack-year tobacco quit at 36yo;
no hx of drug use; retired RN at [**Hospital1 756**]. She is single.
Daughter [**Name (NI) 7905**] very involved in her care.
Family History:
Multiple relatives with DM, CAD, HTN, asthma, and cancers (at
least two with brain cancers). Mother died age 50 brain cancer
had DMII and "mild [**Name (NI) **]", father died age 48 MI and had DMII. No
FH of MS, or DVT/PE. Brother deceased 53yo had 3 bypass surgery.
Physical Exam:
Vitals - T: 98.1 BP: 128/56 HR: 66 RR: 20 02 sat: 94% on room
air
GENERAL: Obese female, appearing chronically ill but not
unstable. Lying in bed comfortably on her right side, which is
side she prefers.
HEENT: Neck supple, no JVD appreciated, no LAD
CARDIAC: RRR, normal S1, S2. No murmurs, rubs or gallops.
LUNG: Clear to auscultation, no wheezing, no crackles or rhonchi
ABDOMEN: Obese, nontender to palpation, BS present
EXT: L BKA stump intact, not edematous. RLE no edema, the clean
ulcer at right lateral foot has dressing in place, c/d/i.
NEURO: AAOx3, CN II-XII intact to confrontation, appropriate
Pertinent Results:
ADMISSION LABS:
[**2168-6-9**] 04:05PM BLOOD WBC-7.6 RBC-3.73* Hgb-10.2* Hct-31.7*
MCV-85 MCH-27.4 MCHC-32.3 RDW-15.8* Plt Ct-294
[**2168-6-9**] 04:05PM BLOOD Neuts-64.6 Lymphs-27.7 Monos-3.3 Eos-3.6
Baso-0.8
[**2168-6-9**] 04:05PM BLOOD PT-21.1* PTT-30.0 INR(PT)-2.0*
[**2168-6-9**] 04:05PM BLOOD Glucose-128* UreaN-47* Creat-1.2* Na-142
K-4.7 Cl-104 HCO3-26 AnGap-17
[**2168-6-9**] 04:05PM BLOOD proBNP-41
[**2168-6-8**] 06:25AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.4
===========================
DISCHARGE LABS:
===========================
EKG ([**6-8**]): Sinus rhythm with modest A-V conduction delay.
Leftward axis. Delayed R wave progression with late precordial
QRS transition. Findings are non-specific. Since the previous
tracing of [**2168-6-6**] the rate is slower. Otherwise, no significant
change.
.
CXR ([**6-9**]):
Brief Hospital Course:
62F with h/o MS, sarcoid, HTN, hyperlipidemia, DMII, CAD s/p
stents, PAD s/p L BKA, h/o CVA and recurrent DVTs who was
recently admitted at [**Hospital1 18**] from [**Date range (1) 100782**] for dyspnea and was
treated for exacerbation of reactive airway disease in setting
of recent URI, now presented back to ED for shortness of breath
and wheezing, likely from exactly the same etiology:
exacerbation of reactive airway disease/asthma/COPD.
.
# Dyspnea: The patient has known reactive airways
disease/Asthma/COPD and this appears to be an exacerbation of
the same process during her prior hospitalization. She does not
appear fluid overloaded, BNP 41, no evidence of PNA on CXR, and
she refused CTA to rule out PE but has been on warfarin.
Pulmonary was consulted. They recommended CT chest, which showed
evidence of bronchitis. PFTs were performed, but report not
available at time of discharge. ECHO showed normal EF with no
valvular abnormalities. Patient reports she has no nebulizers at
home, which is surprising since she has been discharged home
with nebulizers every time when she was discharged recently. We
set up a nebulizer for her this time. She was continued with
Albuterol & Ipratropium nebs. She was started on prednisone 60mg
PO x5 days, followed by prednisone taper. She was discharged
home with albuterol nebulizer and prednisone taper.
.
# Recent UTI: Patient had continued evidence of infection on UA
with chronic indwelling foley. She had known Pan-sensitive
Proteus. Of note, she did not fill her Bactrim for UTI
prescription on discharge. She was continued on Bactrim DS PO
BID x3 more days during this hospital stay.
.
# Diabetes Mellitus/Hypoglycemia/Altered mental status: On the
morning of [**6-14**] the pt was found to be altered on the floor.
Fingerstick was performed and in the 40s, the pt was given D50
and mental status improved significantly. Fingersticks were in
the low 80s-90s overnight in the ICU, morning NPH was held. The
afternoon upon callout, the pts glucose was up to 380s and SSI
was given. Patient's insulin dose was decreased afterwards, and
she had no more episodes of hypoglycemia.
.
# Chest pain/hypotension: After pts episode of hypoglycemia, she
began to complain of substernal chest pain, similar in character
to her ongoing angina. She was given SL NTG, after which she
became hypotensive and remained that way for 3-4 hours on the
floor. Refractory to 2-3L of IV NSS. The patient was
transferred to the MICU at that point for her ongoing
hemodynamic instability. With an additional 2L of IV NSS
overnight in the ICU pts SBPs improved back to baseline and
remained that way until she was called out to the floor the
following afternoon. She remained chest pain free. Plavix,
Statin, Imdur, and Metoprolol were continued. She is allergic to
aspirin.
.
# HTN: We decreased imdur to 60mg daily and metoprolol to 37.5
mg [**Hospital1 **]. Lisinopril was held.
.
# History of Recurrent DVTs: Coumadin was continued. Her
admission INR was 2.0. She was briefly on heparin gtt when her
INR was subtherapeutic. LENIS showed that while no DVT was
definitively seen, the right distal superficial femoral vein did
not fully compress, and a nonocclusive thrombus could not be
completely excluded. She was therapeutic on coumadin at time of
discharge.
.
# PAD s/p L BKA: Patient has a healing ulcer on RLE. She was
seen by [**Hospital1 1106**] while she was in the hospital, but arteriogram
was not done because she could not lie flat. Vicodin was
continued.
.
# Seizure Disorder: Carbamazepime was continued.
.
# CODE: The code status was changed from full to DNR/DNI during
this hospital stay per discussion with patient.
.
# CONTACT: Daughter [**First Name4 (NamePattern1) **] [**Known lastname 100774**] [**Telephone/Fax (1) 100775**].
Medications on Admission:
Acetaminophen 1000 mg po q8 hours
Baclofen 10 mg po BID
Acidophilus 2 capsules po TID
Carbamazepine 200 mg po QID
Famotidine 10 mg po q12 hours
Flovent HFA 2 puffs INH [**Hospital1 **]
Furosemide 40 mg po daily
Isosorbide Mononitrate 90 mg SR po daily
Atorvastatin 80 mg po daily
Metoprolol tartrate 75 mg po BID
Lisinopril 5 mg po daily
Clopidogrel 75 mg po BID
NTG 0.3 mg SL prn chest pain
Menthol-Cetylpyridinium 3 mg prn
Bactrim 800-160 mg po BID x 3 days (but did not fill)
NPH 80 units SQ with breakfast
NPH 15 units SQ at bedtime
Humalog SSI QIDACHS
Hydrocodone-Acetaminophen 5-500 mg 1-2 tablets po q6 hours prn
pain
Ipratropium neb q6 hours
Lidocaine 5% daily
Benzonatate 100 mg po TID prn cough
Warfarin 10 mg po qMonday and qFridays
Warfarin 12.5 mg every Tue, Wed, Thurs, Sat, and Sun
Discharge Medications:
1. NEBULIZER
home nebulizer, and all necessary accessories.
Dx: COPD and asthma
MH#: [**Telephone/Fax (5) 100783**]
x 1 year
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
Disp:*1 month supply* Refills:*0*
3. Baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
5. Acidophilus Capsule Sig: Two (2) Capsule PO three times a
day.
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours.
7. Famotidine 20 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12
hours).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for Chest pain.
14. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
15. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed for Pain.
16. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO DAYS (MO,FR):
DAYS (MO,FR) .
17. Warfarin 2.5 mg Tablet Sig: Five (5) Tablet PO DAYS
([**Doctor First Name **],TU,WE,TH,SA).
18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hour
on, 12 hour off.
19. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for Cough.
20. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Eighty
(80) unit Subcutaneous with breakfast.
21. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Fifteen
(15) unit Subcutaneous at bedtime.
22. Humalog 100 unit/mL Cartridge Sig: sliding scale
Subcutaneous QACHS.
23. Flovent HFA 220 mcg/Actuation Aerosol Sig: One (1) INH
Inhalation twice a day.
Disp:*1 diskus* Refills:*2*
24. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a
day.
Disp:*90 Tablet(s)* Refills:*2*
25. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB.
Disp:*1 inhaler* Refills:*3*
26. Prednisone 10 mg Tablet Sig: One (1) Tablet PO as directed
for 18 doses: Take 3 tabs for 3 days, then 2 tabs for 3 days,
then 1 tab for 3 days and stop. .
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
- Asthma/COPD
- Hypotension
- Hypoglycemia
- Dysphagia
Secondary Diagnosis:
- Diabetes Mellitus
- Sarcoidosis
- Hypertension
- Multiple Sclerosis
- Spinal Stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with shortness of breath due to exacerbation
of your reactive airway disease. You were treated with
nebulizers, antibiotics and prednisone. You were seen by
Pulmonology, who recommended CT scan of your chest which showed
bronchitis. You also underwent a pulmonary function test. The
report is still pending. You had a speech and swallow
evaluation, which showed that you were aspirating, so your diet
was changed to nectar-thickened liquids and soft solids.
.
CHANGES TO YOUR MEDICATIONS:
- prednisone taper
- flovent 220 inhaled twice a day
- DECREASED DOSE: Isosorbide mononitrate 60mg daily
- STOP lisinopril
- DECREASED DOSE: Metoprolol tartrate 37.5 mg PO bid
.
Followup Instructions:
You should follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within [**2-13**]
weeks of discharge. You can call Dr.[**Name (NI) 10373**] office at
[**Telephone/Fax (1) 250**] to arrange a follow-up appointment.
Since you have frequent chest pain, we have tried to make a
follow up appointment for you to see Dr. [**Last Name (STitle) **]. The earliest
appointment she has is on [**2168-9-7**] at 11:20am. The secretary
will email her and ask her whether she can see you earlier. As
you indicated to us, Dr. [**Last Name (STitle) **] would likely arrange another
cath when your chest pain episodes get more frequently. Please
talk to her regarding the need for cardiac catheterization.
Followup Instructions:
Please call ([**Telephone/Fax (1) 513**] to set a follow up appointment with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Department: [**Hospital3 249**]
When: THURSDAY [**2168-7-14**] at 9:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2168-9-7**] at 11:20 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2168-9-28**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2168-6-29**] 1:30
[**Last Name (NamePattern1) 439**], [**Hospital Unit Name **] [**Location (un) 442**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12999, 13056
|
5653, 7342
|
359, 366
|
13284, 13284
|
4802, 4802
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|
2163, 3447
|
3463, 3872
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,957
| 136,191
|
10126
|
Discharge summary
|
report
|
Admission Date: [**2101-3-14**] Discharge Date: [**2101-3-25**]
Date of Birth: [**2052-4-4**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 40-year-old
female with a complicated past medical history including
multiple abdominal surgeries who was transferred from the
[**Hospital 1558**] Hospital in [**Location (un) 16843**] to the
[**Hospital6 256**] Medical Intensive Care
The patient presented to [**Hospital 16843**] Hospital that morning
with fever, diarrhea and minimal emesis. She was found in
this hospital to have Klebsiella urinary tract infection and
was started on levofloxacin. days after transfer, blood
culture grew out yeast for which she was started on
intravenous fluconazole in our Intensive Care Unit. On the
day of transfer, the patient had subacute worsening of her
was transferred to the [**Hospital6 256**]
on 100% oxygen from a nonrebreather mask. She was able to
be weaned down to 5 liters of nasal cannula with minimal
diuresis of negative 1600 cc in the Intensive Care Unit.
PAST MEDICAL HISTORY:
1. The patient is status post Billroth 2 roux-en-y surgery
and distal gastrectomy for questionable septic ulcer disease.
2. Afferent limb anastomotic stricture.
3. Total parental nutrition since one year ago.
4. Questionable history of inflammatory bowel disease with a
negative work-up. The patient has been on chronic prednisone
in the past.
5. Status post appendectomy.
6. Patient has a history of [**Female First Name (un) **] fungemia.
7. The patient has osteoporosis with compression fractures
secondary to his steroid use. The patient requires chronic
pain medication for her compression fractures.
8. The patient had a line infection in [**2100-11-23**] with
enterococcus Vesalius which was sensitive to vancomycin.
9. The patient had a history of mild asthma. She was on
albuterol inhaler as needed.
10. The patient is status post percutaneous vertebroplasty
for her compression fracture in her vertebrae in [**2100-11-23**].
11. The patient had a history of staphylococcus epidermis
bacteremia presumed from her TPN line infection in [**2100-11-23**]. On echocardiogram, she has had no evidence of
vegetations.
12. The patient has interstitial lung disease status post
VATT biopsy. The etiology of this lung disease is unclear,
though, could be consistent with vasculitis on pathology. In
the patient's lung biopsy, both cement and bone marrow emboli
were also seen. The patient is followed by Dr. [**Last Name (STitle) **] in
Pulmonology and was placed on steroids for interstitial lung
disease.
13. The patient has a history of chronic diarrhea and
hypokalemia.
14. Per the patient's outpatient gastrointestinal specialist,
Dr. [**Last Name (STitle) 8571**], the patient has a post anastomotic stenosis
distal to her gastrectomy site, which has been causing her
nausea and vomiting requiring TPN.
MEDICATIONS ON ADMISSION TO THE [**Hospital6 **]: Protonix 40 mg po q.d., fluconazole 200 mg
intravenous po q.d., Solu-Medrol 80 mg intravenously t.i.d.,
Levaquin 500 mg po q.d., Fosamax 5 mg po q.d., Tums 500 mg po
t.i.d., Duragesic patch 200 mcg q. 72 hours and TPN.
ALLERGIES: The patient is allergic to sulfa drugs which
gives her a rash.
SOCIAL HISTORY: The patient lives with her husband and
children. She is a state representative of [**Location (un) 16843**]. Her
husband is a policeman. The patient has four children. The
patient has a 20 pack year smoking history and quit four
years ago. The patient denied any alcohol use.
When reviewing the patient's past medical records, it appears
that the patient is very actively involved in the political
world with her career. She has left the hospital several
times prior to complete treatment of her medical condition
due to her political obligations. The patient has also left
the hospital in the past on her prior admission to this
hospital in [**Month (only) 956**] claiming personal emergency, when she in
fact wanted to go to her outpatient [**Month (only) **] doctor
for a stenosis dilatation procedure. The patient did not
inform her in patient physicians that she was going to
undertake this procedure, neither did she inform her
outpatient gastroenterologist that at this time, she was in
fact bacteremic with Staph epidermis and was under treatment
with intravenous vancomycin and still febrile.
PHYSICAL EXAM ON ADMISSION TO THE MEDICAL INTENSIVE CARE
UNIT: Temperature was 96.7. Heart rate was 74. Blood
pressure 122/63. Patient was saturating 94% on five liters
by nasal cannula. General exam revealed a 40-year-old female
sitting up looking comfortable. Head, eyes, ears, nose and
throat exam revealed moist mucous membranes. Cardiovascular
exam revealed normal S1, S2, 2/6 systolic ejection murmur at
left upper sternal border. She had a regular rate and
rhythm. Her jugular venous pressure was about 8 cm. Lung
exam revealed bilateral crackles up to apex. Abdomen exam
revealed an abdomen soft, which was nontender, nondistended
with positive bowel sounds. Patient has multiple old
surgical scars in her abdomen. Extremity exam revealed lean
extremity with good pulses and warm. She had no lower
extremity edema. The patient had ecchymosis on lateral
aspects of her feet. She had a PIC line in her left arm.
Neurological exam revealed her pupils were equal and reactive
to light bilaterally. The patient had intact extraocular
movements.
LABORATORY STUDIES ON ADMISSION: Revealed a hematocrit of
28.2, white blood cell count of 6.7, platelet count of
218,000. Her INR was 1.0. PT of 12.1, PTT of 34.7.
Patient's sodium was 134, potassium of 4.5, chloride 92,
bicarbonate 32, BUN 14, creatinine 0.2. The patient's
calcium was 8.4, magnesium 1.5 and phosphate of 4.3.
COURSE IN HOSPITAL: The patient was transferred to [**Hospital6 1760**] with question of new onset
hypoxia. The patient was easily weaned from a nonrebreather
mask to five liters by nasal cannula saturating at 94% after
arrival with further diuresis of 1600 cc of fluid, the
patient was able to be weaned down to three liters by nasal
cannula. Upon transfer, the patient was known to have 1/4
bottles growing budding yeast. Because of this, the patient
was placed on 400 mg of intravenous fluconazole q.d. New
blood cultures, urine and sputum cultures were obtained. The
patient was continued on levofloxacin for a positive urine
culture from the outside hospital showing Klebsiella and
Citrobacter freundii. The patient was kept on her inhalers
for her pulmonary disease of unclear etiology. She was
maintained on her pain medication for her compression
fracture. Initially, on admission, the patient was given
standing doses of Solu-Medrol for stress dose steroids.
The patient was deemed stable enough to be transferred to the
floor soon after her arrival to the Medical Intensive Care
Unit. Due to the lack of beds, the patient remained in the
Medical Intensive Care Unit until [**2101-3-17**]. During
this time, her right arm PICC line was discontinued and the
patient was treated with only peripheral intravenous
catheters. The patient's TPN was stopped due to her active
high grade fungemia. At this time, the patient was noted to
be able to tolerate both pills and regular diet by mouth with
minimal emesis. The question arose then, why the patient had
required total parental nutrition for the past year. After
reviewing the patient's old records in this hospital, as well
as talking to [**Year (4 digits) **], Pulmonology, Endocrinology
and other physicians who knew the patient and had taken care
of her before, it appeared that the patient has an active
political career and had refused multiple times the placement
of a J tube due to cosmesis. She apparently also carries a
diagnosis of self tapering her prednisone, which was not
recommended by her physician for likely cosmesis causes as
well.
The [**Year (4 digits) **], Pulmonary, and Infectious Disease
Services were consulted after the patient's arrival to the
floor. The patient was switched to intravenous amphotericin
on [**2101-3-17**] when further species in her culture
revealed that the patient grew fluconazole resistant [**Female First Name (un) **].
The patient was started on a dose of 0.5 mg/kg/day of
amphotericin. The patient completed a total of a seven day
course of levofloxacin for her urinary tract infection. Her
Foley catheter was removed on [**2101-3-18**]. Patient
received further work-up to rule out systemic candidiasis
which included an abdominal high resolution CT scan to look
at her livers and spleens. There was no evidence on this CT
scan for hepatosplenic candidiasis, though the patient has
known liver abnormalities seen on this CT scan which was
thought to be unchanged from her prior CT scan.
Ophthalmology Consult was obtained to look at the patient's
retina and the exam was normal. During the patient's stay in
the Intensive Care Unit, she had received an transthoracic
echocardiogram which was negative for any vegetations on her
valve.
[**Year (4 digits) **] was consulted for help in work-up of the
patient's severe and longstanding gastroenterologic problem
with still unclear etiology. On reviewing the patient's
previous esophagogastroduodenoscopy results and her records,
the gastroenterologist recommended frequent small meals many
times a day. The patient was taken off her Fosamax and put
on high dose Protonix. On [**2101-3-18**], the patient's
outpatient physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8571**] [**Name (NI) 653**] patient's
clinical care team and clarified the patient's diagnosis of
post anastomotic stenosis as opposed to an esophageal
stricture which the patient has reported to medical team and
repeated on occasions. Dr. [**Last Name (STitle) 8571**] indicated that the
patient has had two positive serologies for Crohn's disease
for which she was supposed to be seen by Dr. [**Last Name (STitle) 9916**].
There apparently has been plans to revisit this post
anastomotic stricture with potential surgical corrections by
an outpatient meeting with Dr. [**Last Name (STitle) **], which the patient
was never able to make due to her active political career.
Dr. [**Last Name (STitle) 8571**] did indicate in this telephone call his severe
discontent with out clinical management of this patient on
her multiple previous admissions to the [**Hospital6 649**] and setting her up with outpatient
appointments that she is never able to attend because of her
political career.
On her first day of admission to the medical floor, the
patient was given 4 mg of po Dilaudid q. 6 hours as needed
for breakthrough pain. The patient was very unhappy with
this regimen and expressed worsening pain from her vertebral
compression fracture and indicated that she was used to
taking 6 mg of Dilaudid by mouth. The patient also reported
that she has high requirements of Valium because she is at
baseline very nervous. The patient's dosage of po Dilaudid
and Valium were both increased on this date to the dosage
that she requested. However, the patient was noted to have
asked the nursing staff to wake her up in her sleep to give
her her prn Dilaudid. Given the patient's extensive past
medical history and some possible past psychiatric history,
the Pain Service was called in to assist in management of the
patient's chronic pain. The Pain Service recommended using
pr Dilaudid for better absorption. The patient was kept on
the same regimen of Valium and Dilaudid as the new increased
dose on [**3-17**] without new complaints up until the date of
discharge. The patient's problems by systems are as follows:
1. Infectious Diseases: Fungemia: The patient has grown
high grade fungemia with fluconazole resistant [**Female First Name (un) **].
Although, there was no evidence on abdominal CT or
ophthalmologic exam of metastatic infections, the patient was
still felt to require a total of four weeks of amphotericin
treatment as we have no way to know how long she had been
fungemic prior to presentation to the hospital. The patient
was initially recommended to no longer undergo TPN and
explore other methods of nutritional supplementation given
her multiple histories of TPN line infection just within the
last year including two fungal infections and two high grade
bacterial infections.
2. Pulmonary: The patient has history of pulmonary
vasculitis/fibrosis on VATTS biopsy diagnosed in [**2101-2-21**]. The patient had required oxygen anywhere from 1-3
liters during her hospitalization. There had been one or two
days when the patient did not have any oxygen requirements
and was saturating at 91% on room air at rest. The Pulmonary
Service was consulted for treatment of the patient's
pulmonary vasculitis. Their impression is that the patient
will likely need cytotoxic therapy for better treatment of
her pulmonary vasculitis. This treatment, however, is not
possible at this time given the patient's sepsis. The
patient would need to clear her sepsis and follow-up with
Pulmonary Clinic for future initiation of cytotoxic or
re-initiation of steroid therapy. Given the likelihood of
long-term immunosuppression for her pulmonary disease, the
patient is again recommended not to receive TPN, but explore
other means of nutritional supplementation.
3. Gastrointestinal issues: The [**Year (4 digits) **] Service,
as well as the Surgery Service had been consulted on this
patient. Both services has known the patient very well with
her extensive history. From the [**Year (4 digits) **] point of
view, the patient has very complex anatomy and is status post
multiple failed efforts to dilate her post anastomotic
stricture. At this point in time, there is no interventional
procedures that [**Year (4 digits) **] could offer to this patient
at this time. They are not able to place a G tube for
feeding because of the patient's altered anatomy. A Surgery
Consult was obtained to evaluate the patient for potential
surgical correction for her post anastomotic stricture so
that she can take food by mouth again and/or placement of an
interim J tube for tube feeding so she can be off TPN. Due
to the patient's very extensive past surgical history, no
surgical team had to re-consult her original surgeon, Dr.
[**Last Name (STitle) 468**], who performed most of her surgeries. At the time of
this dictation, this final impression from the Surgery
Consultation are still pending.
3. Nutrition: The patient was observed to be able to
tolerate at least soft mechanical diet and a liquid diet and
has been tolerating whole pills including potassium chloride
pills without any problems on the [**Hospital1 **]. These clinical
observations raised the question, why the patient had ever
been started on TPN and whether she had continued indications
for TPN. Upon admission to the floor, the patient was put on
a po diet with mechanical soft diet and recommended multiple
small meals per day. The patient was also recommended to
take nutritional supplements such as boast and nutritional
shakes. A calorie count was initiated to determine the
adequacy of po intake for the patient's nutritional status.
In the first week of her admission to the floor, the patient
had had occasional episodes of nausea and vomiting causing
her not to tolerate any po intake. At other times, the
patient had been noted to tolerate her po food without any
problems. The patient has been encouraged aggressively to
take as much nutritional supplementation as she can tolerate.
Nutritional support had been working very closely with the
patient trying to pick out shakes that my be acceptable to
her.
Through multiple discussions with the patient, it appears
that she dislikes the taste of most of the nutritional
supplements and can only drink them when they are made into a
shake with ice cream and milk. Nutritional support was
requested to supply the patient with these shakes as
frequently as they could. Up to the date of this dictation,
which is [**2101-3-22**], the patient is noted to not have
very good po intake and not meeting her caloric needs. The
patient's weight at this time was 99.8 pounds. Even though
the patient had no nausea and vomiting, the patient was not
taking much nutritional supplementation. The patient was
again encouraged to take these nutritional supplementation
aggressively and the patient agreed to take them in between
meals. The patient was started on continuous magnesium and
potassium supplementation due to her severe hypomagnesemia
and hypokalemia on amphotericin. The patient is known to go
into a severe hypokalemia and hypomagnesemia on amphotericin
treatment from her past history. On this admission, the
patient again manifested magnesium and potassium wasting
after going on amphotericin.
4. Endocrinology: The patient is known to have severe
osteoporosis and was on calcium supplementation and Vitamin
D. The patient's outpatient endocrinologist passed by and
recommended changing calcium supplementation to with meals
rather than in between meals as well as increasing her
Vitamin D supplementation to 5000 units every week. The
patient was also put on calcitonin nasal spray during this
admission.
5. Access: The patient had a PICC line catheter placed on
[**2101-3-22**] after 72 hours of negative blood cultures.
The patient will require the PICC line for amphotericin
administration.
There will be an addendum to this dictation summary.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Name8 (MD) 9921**]
MEDQUIST36
D: [**2101-3-28**] 09:11
T: [**2101-3-28**] 09:11
JOB#: [**Job Number **]
|
[
"276.8",
"112.5",
"515",
"263.9",
"447.6",
"493.90",
"997.4",
"275.2",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
154, 1055
|
5479, 17746
|
1077, 3250
|
3267, 5464
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,927
| 143,664
|
6998
|
Discharge summary
|
report
|
Admission Date: [**2188-4-29**] Discharge Date: [**2188-5-2**]
Date of Birth: [**2133-8-12**] Sex: F
Service: MEDICINE
Allergies:
Motrin / Iodine; Iodine Containing / Percocet / Compazine /
Naprosyn / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
R LE cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 54 yo F with DMII, past cervical cancer surgically
resection with lymph node dissection complicated by chronic
right lower extremity lymphedema and numerous episodes of right
lower extremity cellulitis who presents with signs and symptoms
of recurrent right lower extremity cellulitis.
.
The patient notes that she was bit by a bug ("I think it was a
mesquito") while camping in [**State 350**] on Saturday. Three
days later, on the day of admission, she noted fevers at home to
100.9 and increased redness and swelling of the right lower
extremity. Of note the patient has baseline right lower
extremity swelling thought to be lymphedema after lymph node
dissection from past cervical cancer. She notes some nausea and
a single episode of non-bloody, non-bilious emesis. She also
notes 2-3 episodes of watery stools at home. She notes feeling
generally fatigued, achy and unwell. All of her symptoms were
consistent with her numerous prior episodes of right lower
extremity cellulitis.
.
In the ED 101.0 120 122/70 18 98% RA. She received Unasyn 3g IV
once, Vanc 1g, percocet and KCl 40mEq. After 2L NS her blood
pressure was in the high 80-90's/50-70's.
.
ROS: As described above. Denies headache, blurry vision, chest
pain, shortness of breath, cough, dysuria, joint swelling.
Past Medical History:
1. Cervical cancer ([**2170**])- s/p hysterectomy, L oophorectomy + LN
dissection at [**Hospital1 2025**].
2. Chronic lymphedema in R Leg
3. Right lower leg deep venous thrombosis in [**2176**] (no PE).
4. Recurrent R lower extremity infections (last time
hospitalized here in [**10-25**] - total of [**4-26**] hospitalizations)
5. DM2-
6. L thumb surgery for ganglion cyst
6. Hypokalemia
Social History:
The patient is from [**Location (un) 1411**], works as
supervisor in a day care [**Company 3596**]. No smoking history. She does
not drink. The patient has one child, daughter who is 32
years old, and she is married and lives with her husband.
Family History:
Mother died of lung cancer and brain tumor, Father died of lung
ca.
Physical Exam:
Gen: Well-appearing, NAD.
HEENT: No scleral icterus or jaundice.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: CTA bilaterally.
Abd: Soft, nontender, nondistended. No organomegaly.
Ext: Right lower extremity swollen without pitting edema,
erythematous from mid lower leg to hip. Minimal warmth. No
inguinal lymphadenopathy. No signs of crepitus.
Neuro: A&O x3, appropriate mood and affect.
Pertinent Results:
Labs: Na 135, K 2.4 -> 2.3, Cl Cl 87, Bicarb 28, BUN/Cr 34/1.3,
glucose 202, WBC 19.2 (N 93.5%, L 5%), Hct 35.5, platelets 345,
INR 1.0.
Lactate 3.1 -> 2.1
BLOOD CX ([**2188-4-29**]): NGTD
RLE U/S ([**2188-4-29**]): No DVT.
Brief Hospital Course:
A/P: 54 yo F with DMII, past cervical cancer surgically
resection with lymph node dissection complicated by chronic
right lower extremity lymphedema and numerous episodes of right
lower extremity cellulitis who presents with signs and symptoms
of recurrent right lower extremity cellulitis.
.
# Right Lower Extremity Cellulitis. Known chronic right lower
extremity lymphedema and prior DVT (though negative U/S in the
ED on admission). Site of bite is unremarkable though
potentially served as portal of entry. Likely caused by common
pathogens. No signs of lyme type rash. Started on broad spectrum
antibiotics with vancomycin and ampicillin-sulbactam. Blood
cultures NGTD. Patient's cellulitis rapidly improved and on day
of discharge was barely visible to both physicians and patient.
Patient discharged on 5 day course of keflex. Patient will
resume her prior keflex prophylaxis after completion of the
keflex.
# Hypotension. BP dipped into sys 80s. Much improved s/p several
liters of NS. Home lasix was held. Likely cause of hypotension
sepsis vs hypovolemia s/p vomiting. Started on broad spectrum
abx. Normotensive therafter.
.
# Hypokalemia. Chronic problem. [**Name (NI) 25122**] large doses of PO
potassium while on lasix at home. EKG with no changes. Repleted
as necessary. Lasix held initially and then restarted on [**5-1**].
Given risks of taking large dose of K+, patient's potassium
decreased to 40 meq [**Hospital1 **]. Patient to f/u with PCP.
.
# Acute on chronic renal failure. Likely hypovolemic in the
setting of recent febrile illness with poor PO intake and
vomiting. Creatinine peaked at 1.3. Improved with volume
resuscitation.
.
# Episodes of GI disturbance with N/V and diarrhea. Etiology
unclear. Possibly due to gastroenteritis or complications of
systemic infection. C Diff unlikely given no home antibiotics in
several weeks. Currently tolerating PO's. No further episodes
during her admission.
.
# DM2. Restarted on d/c.
.
.
# Contact: [**Name (NI) 4906**] [**Name (NI) **] [**Name (NI) 26211**] (c) [**Telephone/Fax (1) 26212**], (h) [**Telephone/Fax (1) **]
.
# Code: FULL.
Medications on Admission:
Omeprazole 40mg Daily
Furosemide 80mg Daily
KCl 40mEq Four times a day
Glipizide 5mg three times daily
Avandia 4mg Daily
Metformin 1000mg Daily
Albuterol
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO once a day.
2. Lasix 40 mg Tablet Sig: Two (2) Tablet PO once a day.
3. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day: Decreased
from qid.
4. Glipizide 5 mg Tablet Sig: One (1) Tablet PO three times a
day.
5. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day.
6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
four times a day as needed for shortness of breath or wheezing.
8. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 5 days: After finishing this, pt should restart her
normal penicillin prophylactis for cellulitis.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
RLE Lymphedema
Discharge Condition:
Vitals Sign Stable
Discharge Instructions:
Return if having fevers, chills, worsening rash.
Followup Instructions:
Call PCP for [**Name Initial (PRE) **]/u appt in [**11-21**] weeks.
|
[
"585.9",
"682.6",
"V10.41",
"250.00",
"457.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6299, 6305
|
3123, 5240
|
367, 373
|
6374, 6394
|
2872, 3100
|
6491, 6561
|
2379, 2449
|
5445, 6276
|
6326, 6353
|
5266, 5422
|
6418, 6468
|
2464, 2853
|
312, 329
|
401, 1688
|
1710, 2101
|
2117, 2363
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,481
| 117,708
|
3011+55432
|
Discharge summary
|
report+addendum
|
Admission Date: [**2155-12-25**] Discharge Date: [**2155-12-26**]
Date of Birth: [**2089-6-17**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Carotid stenosis
Major Surgical or Invasive Procedure:
Carotid catheterization with stent placement in lt internal
carotid artery.
History of Present Illness:
This 65 year old woman with a history of CAD, s/p two PCIs with
stenting of the RCA and LAD who was found to have a carotid
bruit on routine physical exam. She was referred for a duplex
ultrasound carotid scan which showed 40% rt ICA stenosis and
80-99% lt ICA stenosis. A MRA showed the same degree of ICA
stenosis. She was referred to Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] for carotid
artery stenting. She had her left carotid artery stented today
and is admitted to the CCU for observation overnight.
She reports that she is feeling well and has been free of any
neurological symptoms. No TIA, No CVA, No melena/GIB
Past Medical History:
1. Diabetes Melitis type 2, well controlled on Prandin
2. Hypertension
3. Hypercholesterolemia
4. Breast cancer s/p lumpectomy five years prior, s/p XRT,
previously on Tamoxifen
5. CAD s/p stenting of RCA and LAD in [**4-27**] and [**5-27**] respectively
Social History:
Married with three children, retired.
Family History:
No family history of CAD
Physical Exam:
BP 103/43
Pulse 49
Resp 97% on RA
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**3-6**] intact,
upper and lower extremity strength 5/5 bilaterally (left leg not
tested secondary to need to remain stationary), sensation
grossly intact
Skin - No rash
Brief Hospital Course:
1. Carotid stent - This 66 year old female s/p IMI with recent
catheterizations s/p RCA and LAD stents presenting with
asymptomatic left ICA stenosis. She had carotid angiography
with stenting of left internal carotid artery. She tolerated
the proceedure well. She was transfered to the CCU for care
after the proceedure where her SBP was maintained >100 and <140
with Neosynephrine drip. She had some symptomatic bradycardia
overnight which was treated with Atropine. All BP meds were
held and neuro checks were performed q1hour X 4, then q2hour X3,
then per routine. She was continued on ASA, Plavix, and
Lipitor. The following morning she was still requiring Neo drip
for hypotension. She was given multiple fluid boluses and the
Neo was weaned off. She was discharged when she was no longer
hyptensive.
2. CAD - She was continued on ASA, Plavix, Lipitor. All BP meds
were held, as mentioned above she had some bradycardia treated
with Atropine but was otherwise asymptomatic.
Medications on Admission:
Mavik 2mg daily
Toprol 100mg daily
ASA 325mg daily
Plavix 75 mg daily
lipitor 40 mg qhs
Prandin 1mg TID
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 300 days.
Disp:*30 Tablet(s)* Refills:*9*
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Prandin 1 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Carotid stenosis s/p stent placement
Secondary diagnosis:
Coronary artery disease
Hypertension
Hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
Continue to take all medications as prescribed. Plavix should
be taken daily.
Return to the hospital for any neurological symptoms including
but not limited to: changes in vision, changes in sensation,
changes in movement or strength.
Return to [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] on Monday [**12-29**] and have
Dr. [**First Name (STitle) **] check your blood pressure.
Return to the hospital for any shortness of breath or chest
pain.
Pt should not take any of blood prssure medication until she
sees Dr. [**First Name (STitle) **].
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **].
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2156-2-10**] 3:30
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2156-6-15**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2156-6-15**] 4:00
Return to [**Hospital3 **] [**Hospital3 **] [**Hospital3 **] on [**12-29**] to have Dr. [**First Name (STitle) **]
measure blood pressure
Name: [**Known lastname 2242**],[**Known firstname 2243**] Unit No: [**Numeric Identifier 2244**]
Admission Date: [**2155-12-25**] Discharge Date: [**2155-12-26**]
Date of Birth: [**2089-6-17**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2129**]
Addendum:
Secondary Diagnosis
Hypotension
Hypovolemia
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) 448**] [**Last Name (NamePattern4) 2130**] MD [**MD Number(1) 2131**]
Completed by:[**2156-3-1**]
|
[
"276.5",
"458.29",
"401.9",
"427.89",
"414.00",
"433.10",
"272.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"00.63",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
5572, 5737
|
2139, 3130
|
287, 365
|
3872, 3878
|
4495, 5549
|
1402, 1428
|
3284, 3684
|
3734, 3771
|
3156, 3261
|
3902, 4472
|
1443, 2116
|
231, 249
|
393, 1053
|
3792, 3851
|
1075, 1331
|
1347, 1386
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,463
| 176,700
|
45907
|
Discharge summary
|
report
|
Admission Date: [**2133-10-25**] Discharge Date: [**2133-10-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Rigors
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 3827**] is an 84 year old gentleman with history of CAD
s/p CABG ('[**20**]), CHF with biventricular systolic dysfunction (EF
35%), atrial fibrillation on coumadin, BPH s/p TURP, Parkinson's
disease, and recurrent UTIs due to intermittent catheterizations
who presents from home with 1 day of rigors and cough. He had
been in his usual state of health until two days prior to
admission he noted a sore throat and fatigue, but no associated
shortness of breath. On the day of admission his voice was
hoarse and he had a cough productive of yellow sputum. He has a
24/7 nursing assistant who lives in his home and was monitoring
q2H temperatures which had been normal until 8PM this evening
when she got a temp of 99 (high for him) and noted that his
whole body was shaking. He was brought to [**Hospital1 18**] by EMS.
Reportedly no recent nausea, vomiting, diarrhea or urinary
symptoms. Of note the patient reports frequent episodes of food
going "down the wrong tube" and resultant coughing fits. He has
been on a dysphagia and nectar thickened diet during past
admissions to [**Hospital1 18**].
.
In the ED, VS were T 105 (rectal), BP 108/76, HR 80, RR 22,
O2sat 94% on RA, 97% on 3L NC. With 1g PR tylenol temperature
improved to 103.6. Systolic BP remained stable in high 90s to
low 100s. Labs notable for elevated white count with bandemia.
Lactate 2.0. Blood and urine cultures sent. Chest xray was
consistent with a new multifocal pneumonia (LUL). Head CT
negative for bleed. He was given 1700cc NS boluses, one dose of
ceftazidime 2gm x1 and vancomycin 1gm x1 while in the ED. Per ED
discussion with daughter, DNR but intubation ok.
.
On arrival to the floor, he denies any shortness of breath,
chest pain, lightheadedness, dizziness. Denies any dysuria,
urinary frequency. No sick contacts.
.
At baseline, Mr [**Known lastname 3827**] is able to feed himself, and go on
short walks around his block - can walk 1 mile w/o shortness of
breath, oriented x 3. He and his wife have 24-7 nursing
assistance at their home in [**Location (un) 4628**] and have multiple family
members who live near by.
Past Medical History:
1. Coronary artery disease status post CABG in [**2120**], no cath
since then.
2. Atrial fibrillation on coumadin.
3. Biventricular heart failure with an EF of 35%.
4. Mild AS, MR [**First Name (Titles) **] [**Last Name (Titles) **]
5. Benign Prostatic hypertrophy status post TURP x 2, now 3x
daily catheterizations and keflex chronic suppression.
6. Anemia for which he receives darbepoetin every 2 weeks.
7. Macular degeneration in left eye.
8. Multiple UTIs last culture [**2132-6-26**] showed E.coli and
corynebacterium (diphtheroid) resistant to
cipro/levo/bactrim/amp, but sensitive to ceftriaxone; UTI in
[**2130**] grew bactrim, ticarcillin and fq resistant bacteria; UTI in
[**2129**] grew pan sensitive enterobacter cloacae
9. Parkinson's disease
Social History:
Former smoker - quit 50 years ago. He drank EtOH regularly until
25 years ago, and now only drinks rarely. Lives at home with
wife. Wife with dementia-has 24 hour caretaker. Active, walks
independently and independent of ADLs plays golf. Family very
involved with his care. HCP = [**Name (NI) **] [**Name (NI) 1182**] cell [**Telephone/Fax (1) 97770**], and
daughter [**Name (NI) **] [**Telephone/Fax (1) 97771**] is second HCP. [**Name (NI) **] used to be in the
navy, then worked in a creamery, and then owned two restaurants
and was in catering before he retired.
Family History:
Non-contributory
Physical Exam:
VS T100.6, BP 120/97, HR 90, RR 22, O2sat 97% on humidified O2
Gen: Thin, elderly appearing male in NAD
HEENT: dry MM, EOMI, PERRL
Neck: no LAD, no thyromegaly, no carotid bruits
Pulm: scattered rhonchi, , no wheezes or rhonchi
Cor: s1, irregularly, irregular, 2/6 systolic murmur at apex
radiating to axilla
Abdomen: scaphoid, nontender, nondistended, no organomegaly
Extremities: no cyanosis or edema. LE cool to touch.
Neuro: AOx2 (year [**2134**]). Resting tremor, bradykineasia. CN
II-XII intact.
Pertinent Results:
[**2133-10-24**] 09:15PM BLOOD WBC-12.3*# RBC-2.91* Hgb-10.4* Hct-30.9*#
MCV-106* MCH-35.8* MCHC-33.7 RDW-23.3* Plt Ct-181
[**2133-10-25**] 03:10AM BLOOD WBC-17.4* RBC-2.58* Hgb-9.3* Hct-27.4*
MCV-107* MCH-36.1* MCHC-33.9 RDW-23.1* Plt Ct-146*
[**2133-10-26**] 12:37PM BLOOD WBC-15.0* RBC-2.46* Hgb-9.0* Hct-26.4*
MCV-107* MCH-36.5* MCHC-34.1 RDW-22.9* Plt Ct-135*
[**2133-10-27**] 03:27AM BLOOD WBC-37.6*# RBC-3.09*# Hgb-11.1* Hct-32.7*
MCV-106* MCH-35.8* MCHC-33.8 RDW-23.5* Plt Ct-241#
[**2133-10-24**] 09:15PM BLOOD Neuts-80* Bands-12* Lymphs-6* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2133-10-24**] 09:15PM BLOOD PT-36.5* PTT-41.0* INR(PT)-4.0*
[**2133-10-26**] 12:37PM BLOOD PT-21.3* PTT-46.9* INR(PT)-2.1*
[**2133-10-27**] 03:27AM BLOOD PT-18.0* PTT-51.8* INR(PT)-1.7*
[**2133-10-24**] 09:15PM BLOOD Glucose-159* UreaN-27* Creat-1.0 Na-139
K-4.3 Cl-104 HCO3-25 AnGap-14
[**2133-10-26**] 03:51AM BLOOD Glucose-114* UreaN-34* Creat-1.1 Na-138
K-4.6 Cl-107 HCO3-20* AnGap-16
[**2133-10-27**] 03:27AM BLOOD Glucose-113* UreaN-51* Creat-2.1* Na-140
K-4.7 Cl-108 HCO3-20* AnGap-17
[**2133-10-26**] 03:51AM BLOOD ALT-72* AST-91* LD(LDH)-371* AlkPhos-76
Amylase-31 TotBili-2.1*
[**2133-10-26**] 12:37PM BLOOD ALT-26 AST-76* LD(LDH)-342* AlkPhos-69
Amylase-34 TotBili-2.7*
[**2133-10-27**] 10:33AM BLOOD CK-MB-12* MB Indx-2.0 cTropnT-1.83*
[**2133-10-24**] 09:15PM BLOOD Calcium-8.4 Phos-3.0 Mg-2.2
[**2133-10-26**] 03:51AM BLOOD calTIBC-126* VitB12-1497* Folate-12.1
Ferritn-1161* TRF-97*
[**2133-10-27**] 10:33AM BLOOD Cortsol-37.0*
[**2133-10-27**] 01:26PM BLOOD Cortsol-49.1*
[**2133-10-25**] 03:10AM BLOOD Digoxin-0.7*
[**2133-10-26**] 09:49AM BLOOD Type-ART FiO2-70 pO2-66* pCO2-42 pH-7.33*
calTCO2-23 Base XS--3
[**2133-10-26**] 02:02PM BLOOD Type-ART pO2-205* pCO2-42 pH-7.38
calTCO2-26 Base XS-0 Intubat-INTUBATED
[**2133-10-26**] 06:19PM BLOOD Type-ART Rates-14/ PEEP-5 FiO2-60 pO2-60*
pCO2-39 pH-7.39 calTCO2-24 Base XS-0 -ASSIST/CON
Intubat-INTUBATED
[**2133-10-26**] 10:48PM BLOOD Type-ART Temp-38.3 Rates-18/ Tidal V-500
FiO2-70 pO2-105 pCO2-58* pH-7.21* calTCO2-24 Base XS--5
-ASSIST/CON Intubat-INTUBATED
[**2133-10-27**] 12:18AM BLOOD Type-ART Temp-37.2 Rates-/16 Tidal V-600
FiO2-70 pO2-147* pCO2-48* pH-7.26* calTCO2-23 Base XS--5
-ASSIST/CON Intubat-INTUBATED
[**2133-10-27**] 10:43AM BLOOD Type-ART pO2-132* pCO2-45 pH-7.24*
calTCO2-20* Base XS--7
[**2133-10-24**] 09:27PM BLOOD Lactate-2.0
[**2133-10-27**] 10:49AM BLOOD Lactate-1.7
.
STUDIES:
[**10-24**] CXR: FRONTAL CHEST RADIOGRAPH: New multifocal, patchy
bilateral airspace opacities are seen, left greater than right.
Cardiac and mediastinal contours appear stable. Again seen is
evidence of prior CABG. Pulmonary vascularity remains within
normal limits. No definite pleural effusions identified.
IMPRESSION: Findings consistent with multifocal pneumonia.
.
[**10-24**] CT Head:
FINDINGS: There is no evidence of acute intracranial hemorrhage,
shift of normally midline structures or hydrocephalus. Again
seen are focal lacunes involving the right caudate head and
bilateral cerebral hemispheres. These do not appear
significantly changed compared to prior study. [**Doctor Last Name **]-white matter
differentiation appears grossly preserved. Again noted is a
hypoplastic right maxillary sinus. No mucosal thickening is seen
in the visualized paranasal
sinuses.
IMPRESSION: No evidence of acute intracranial hemorrhage. Old
lacunes in the right caudate head and bilateral cerebellar
hemispheres again seen, unchanged from prior.
.
[**10-26**] TTE:
No obvious vegetations seen on mitral, aortic, or tricuspid
valves although due to valvular thickening, the sensitivity of
TTE to detect endocarditis is decreased. Severe left ventricular
systolic dysfunction. Mild right ventricular systolic
dysfunction. Mild to moderate aortic stenosis. Moderate
pulmonary hypertension. Moderate mitral regurgitation. Biatrial
enlargement.
.
Compared with the prior study (images reviewed) of [**2133-7-1**],
left ventricular systolic function has declined. Estimated
pulmonary artery pressures are higher. Right ventricular
dysfunction is now present. The heart rate is markedly faster.
The severity of mitral regurgitation has increased.
Brief Hospital Course:
Assessment and Plan:
84 y/o M with history of CAD s/p CABG, CHF (EF35%), AF on
coumadin who presents to the ED with 1 day of rigors, found to
have new multifocal pneumonia, with progressively worsening
respiratory status, ultimately intubated, however continued to
do poorly, and decision made to change goals of care to comfort
measures only. pt expired [**2133-10-27**].
.
.
# respiratory distress - pt with gradually worsening respiratory
status, specifically increased RR, worsening ronchi on exam, and
CXR with worsening bilateral infiltrates, concerning for ARDS.
decision made to proceed with intubation on [**10-26**] [**3-13**] elevated
RR, hypoxia, however agreed to 7d trial, as pt would not want
tracheostomy per family. he was continued on abx empirically
for now awaiting sputum cx. respiratory status continued to
worsen despite intubation with rising pressures, and poor
oxygenation. decision made to change goals of care to comfort
measures only and pt expired on [**10-27**].
.
.
# Sepsis: Presented with rigors and cough, temperature to 105,
bandemia (12%), and tachycardia (HR 120s in ED) with evidence of
multifocal PNA on CXR. Also some confusion upon arrival to ED.
pt treated with broad spectrum antibiotics for empiric coverage.
blood and urine cultures sent in ED. attempted to get sputum
culture pt given aggressive fluid resuscitation to maintain MAP
>65. Received 1700cc in ED with minimal UOP and continued to
receive IVF in MICU, however ultimately started levophed, and
then added neo given episodes of tachycardia. culture data
remained unremakrable throughout hospital course (some yeast in
sputum sample), however pt treatd wtih ceftaz/vanco and flagyl
empirically. SBPs remained stable after fluid resuscitation,
and pt did tolerate gentle diuresis given pulmonary edema
contributing to hypoxia, however required pressors as above.
ultimately, given hypotension and worsening respiratory status,
decision made to change goals of care to comfort measures only
on [**10-27**] and pt expired that day.
.
# Cardiac
## Ischemia: +h/o CAD s/p CABG, no chest pain currently. pt
continued outpatient regimen of aspirin. digoxin initially held
amiodarone started. dig level not toxic. CE unremarkable.
- Check dig level with AM labs
.
## Rhythm: pt with Atrial fibrillation. INR supratherapeutic,
thus held warfarin for supratherapeutic INR. Not on beta
[**Last Name (LF) 7005**], [**First Name3 (LF) **] OMR due to severe bradycardia.
on [**10-26**] ?wide complex tachycardia, given amio 150mg iv load and
amiodarone gtt for ?SVT with aberrancy vs VT, with some
improvement in rate. Given likely is abberancy, d/c'd amdio in
favor of diltiazem 10mg iv bolus then dilt gtt for afib. also
restarted dig as above.
.
## Pump: Last echo done [**6-/2133**] which showed EF 35-40% with mild
AS, mild MR. [**First Name (Titles) **] [**Last Name (Titles) 21177**] and lasix for now given borderline
BPs.
.
# BPH: Requires TID catheterizations and prophylaxis, pt
continued on home regimen of daily keflex and foley placed.
.
# Anemia: Baseline of 28. On admission hematocrit 30.9, likely
hemoconcentrated from depleted intravascular volume, however
remained stable throughout admission.
.
# [**Name (NI) 5895**] Disease - pt continued on carbidopa-levodopa as
per home regimen
.
# FEN: NPO as diet given tenuous respiratory status.
.
# PPx: supratherapeutic coumadin, PPI, bowel regimen
.
# Code: initially DNR only per family and patient, ok to
intubate, discussed with daughter [**Doctor First Name **] and son [**Name (NI) **] again [**10-26**].
plan will be for 7d trial of intubation, with plan to reassess
goals of care at that time (specifically re trach). however pt
continued to do poorly with difficult to maintain oxygenation on
[**10-27**] and blood pressure (on neo and levo), and decision made to
change goals of care to comfort measures only. pt expired
[**10-27**].
Medications on Admission:
Medications: (from last d/c summary)
Carbidopa-Levodopa 25-100 mg PO TID
Digoxin 125 mcg Tablet daily
Aspirin 81 mg Tablet daily
Cephalexin 500 mg Capsule Q24H
[**Month/Year (2) **] 5 mg Tablet daily
Docusate Sodium 100 mg daily
Lasix 20 mg Tablet Every monday, thursday, saturday.
Coumadin 10 mg Tablet daily, on Monday takes 12.5mg
Omeprazole 20 mg Capsule daily
Discharge Medications:
pt expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
pt expired
Discharge Condition:
pt expired
Discharge Instructions:
pt expired
Followup Instructions:
pt expired
|
[
"786.3",
"486",
"428.20",
"428.0",
"396.0",
"799.02",
"V45.81",
"285.1",
"600.00",
"518.81",
"427.31",
"332.0",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.04",
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12985, 12994
|
8613, 12533
|
271, 277
|
13048, 13060
|
4370, 7235
|
13119, 13132
|
3814, 3832
|
12949, 12962
|
13015, 13027
|
12559, 12926
|
13084, 13096
|
3847, 4351
|
225, 233
|
305, 2432
|
7244, 8590
|
2454, 3214
|
3230, 3798
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,143
| 167,116
|
37281
|
Discharge summary
|
report
|
Admission Date: [**2102-11-28**] Discharge Date: [**2103-1-2**]
Date of Birth: [**2035-10-16**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
CVVH line placement
Central line placement
Tracheostomy placement
HD line placement
Lumbar puncture
History of Present Illness:
67 yo M with a history of aspiration PNA, COPD, CHF, A fib on
coumadin, CAD s/p CABG, who presented to OSH on [**11-27**]
complaining of shortness of breath.
.
Per OSH records, the patients wife had diagnosed [**Name (NI) 30475**] recently.
The patient completed a 10 day course of tamiflu. 48 hours after
stopping tamiflu, he developed shortness of breath, along with
fevers, rigors, and green colored sputum.
.
He presented to the ED on [**11-27**] at noon, at which time he was
hypertensive with SBP in 200s. EKG notable for 1mm ST
depressions in lateral leads. The patient was given nitro paste,
and started on a nitro gtt. He received 1 dose of Ceftriaxone,
Azithro, and Levofloxacin for community acquired pneumonia seen
on CXR. He was transferred to OSH ICU.
.
In the ICU the patient received 1L NS, 1u PRBCs, and Combivent.
Shortly after finishing the transfusion he got acutely short of
breath, requiring BiPap. The patient was hypertensive again,
requiring increased dose of nitro gtt. He got lasix 20mg IV x1,
40mg IV x1, but only put out 15cc of urine to this. He desatted
to the high 70s, and was intubated for hypoxemia.
.
After intubation he had transient desats to the 80s, likely
secondary to improper sedation. He was started on a propofol gtt
and a versed gtt. Thereafter he was hypotensive and tachycardic,
and started on a Dopamine gtt, and Levophed gtt. A R subclavian
was placed after a 2nd attempt. CVP was 15 at that time.
.
WBC 10.6, HCT was initially 27.3, Cr initially 1.1, went up to
1.7.
The patient received one dose of Vancomycin, Flagyl, and
Tamiflu. He also got 120mg IV solumedrol.
.
Most recent set of vitals at time of sign out was Afebrile, HR
99, Systolic BP 100, 95% on FiO2 80%, Tv 6cc/kg, RR 16.
Past Medical History:
h/o aspiration pneumonia
COPD
Afib on coumadin
CAD s/p CABG in [**2099-4-4**]
CHF with normal EF
HTN
HL
PUD
Anemia
Dysphagia
PVD
s/p R CEA
s/p CCY
Social History:
Unknown
Family History:
Unknown
Physical Exam:
Admission
Vitals - T: 97.5 BP: 108/69 HR: 90 RR: 22 02 sat: 98%
GENERAL: Intubated, sedated
HEENT: NCAT. PERRL. No LAD.
CARDIAC: Irregularly irregular. No murmurs.
LUNG: Diffuse rhonchi bilaterally L>R.
ABDOMEN: Soft, NT, ND. No masses. No rebound or guarding.
EXT: WWP. No LE edema.
NEURO: Sedated
DERM: Chronic venous stasis.
Pertinent Results:
=========
Labs
=========
Admission labs
135 101 34 AGap=21
=============< 160
4.3 17 2.1
estGFR: 32/38 (click for details)
CK: 672 MB: 33 MBI: 4.9 Trop-T: 0.55
91
8.7
15.3 > < 254
27.5
Source: [**Name (NI) 83907**]
PT: 15.7 PTT: 32.3 INR: 1.4
Discharge labs
WBC 10.4 RBC 2.58 Hgb 7.5 Hct 23.1 MCV 90 Plt 331
INR 1.2 PTT 76.9
Glucose 120 UreaN 40 Creat 3 Na 137 K 3.9 Cl 97 HCO3 30
=========
Radiology
=========
[**2102-11-28**] Echo
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is moderately dilated with severe global free
wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The aortic valve leaflets (3) are mildly thickened.
There is no valvular aortic stenosis. The increased transaortic
velocity is likely related to high cardiac output. 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.
IMPRESSION: Dilated right ventricle with severe RV systolic
dysfunction. Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. Mild
mitral regurgitation. Moderate pulmonary hypertension.
.
[**2102-12-19**] Echo
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60-70%). Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated at the
sinus level. 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. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
No definite vegetations seen.
.
[**2102-11-28**] EKG Atrial fibrillation with rapid ventricular
response. Incomplete right bundle-branch block. Inferior and
lateral ST segment depression. No previous tracing available for
comparison.
.
[**2102-12-15**] CT chest abdomen pelvis
. Abnormally located short segment of jejunum demonstrating a
prominent
bowel wall. This finding can be asociated with internal hernia.
However, no secondary signs of obstruction or adjacent
mesenteric stranding are
identified. Clinical correlation is recommended.
2. Multifocal airspace opacities, which are somewhat more
confluent in the
right upper lobe, in addition to small bilateral pleural
effusions, right
greater than left. These findings are most consistent with
pulmonary edema. However, superinfection, particularly in the
right upper lobe cannot entirely be excluded.
EEG [**12-20**]
This is an abnormal routine EEG secondary to persistent
generalized triphasic waves. During brief portions of the study
where
triphasics are not present, the background was diffusely slow
and
disorganized suggesting a moderate to severe encephalopathy.
There were
no epileptiform features on this study.
Renal U/s [**12-22**]
IMPRESSION: No hydronephrosis. Relatively echogenic renal
parenchyma, may be due to medical renal disease.
=============
Micro
=============
Blood 12/7
**FINAL REPORT [**2102-12-17**]**
Blood Culture, Routine (Final [**2102-12-17**]):
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
.
SENSITIVE TO Daptomycin AT 1.5 MCG/ML Sensitivity
testing
performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Sputum [**12-21**]
**FINAL REPORT [**2102-12-27**]**
GRAM STAIN (Final [**2102-12-21**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final [**2102-12-27**]):
Commensal Respiratory Flora Absent.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] PAGER [**Numeric Identifier 83908**] REQUESTED IDENTIFICATION AND
SENSITIVITIES ON GRAM NEGATIVE RODS..
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE
GROWTH.
SENSITIVITIES REQUESTED PER DR.[**First Name (STitle) 815**] #[**Numeric Identifier **] [**2102-12-25**].
ADDITIONAL sensitivity testing performed by Microscan.
SENSITIVE TO CHLORAMPHENICOL (<=8 MCG/ML).
SENSITIVE TO TIMENTIN (<=8 MCG/ML).
Intermediate Levofloxacin (<=2 MCG/ML).
YEAST. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- 8 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I 2 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- S
MEROPENEM------------- 4 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
Urine Culture [**12-23**]
[**2102-12-23**] 1:12 pm URINE Source: Catheter.
**FINAL REPORT [**2102-12-24**]**
URINE CULTURE (Final [**2102-12-24**]):
YEAST. >100,000 ORGANISMS/ML
Brief Hospital Course:
67 yo M with a history of aspiration PNA, COPD, CHF, A fib on
coumadin, CAD s/p CABG, who presented to OSH on [**11-27**]
complaining of shortness of breath. His wife had recently had
the flu and he was prophylaxed. His symptoms started 48 hours
after stopping prophylaxis. He was intubated in the ED for
hypoxia and admitted to the ICU. He was empirically treated with
oseltamivir for 10 days though his DFA and BAL respiratory viral
screen were negative. He was also noted to have some cardiac
ischemia thought secondary to demand, cardiology was consulted
and they felt that he would likely benefit from cardiac
catheterization after he is stabilized to define his anatomy. He
was treated medically for his cardiac ischemia. On admission he
was in shock which was initially thought to be cardiac secondary
to pulmonary hypertension and he was tried on inhaled nitric
oxide but did not improve his vigileo cardiac output. He was
started on amiodarone for AFib w/ RVR and hypotension, his blood
pressure improved with transition into regular atrial flutter
with a slower rate. He was maintained on a heparin drip and
started on coumadin on [**1-1**], and heparin was discontinued on
[**1-2**]. He was treated for septic shock from influenza with
pressors and then a ventilator associated pneumonia. He
developed acute on chronic renal failure and was initiated on
CVVH through a temporary line. He defervesced and slowly
improved from a ventilatory standpoint, and he was also weaned
from pressors after needing a small dose for >1 week. A
tracheostomy was performed as pt. did not appear to be able to
wean from the vent in the short term. He again began spiking
fevers and blood cultures grew out VRE 1/4 bottles so his
central lines were changed and his HD line was changed as well.
He was started on linezolid and continued to spike fevers. He
was also noted to be rigid on exam and so his buproprion and
prozac were discontinued for fear of serotonin syndrome. His
linezolid was changed to daptomycin out of concern for linezolid
contributing to serotonin syndrome. His rigidity and fevers
slowly improved. He was continued on dapto/meropenem for a total
of a 14/16 day course respectively, both finishing on [**12-26**].
.
However, his fevers continued after discontinuation of the above
antibiotics. Further sputum cultures revealed stenotrophomonas,
that was intermediately sensitive to ceftazidime but sensitive
to Bactrim. He was noted to have a sulfa drug allergy which his
wife thought was a rash but had never seen as it occured before
they were married. Per infectious disease, even the combination
of ceftazidime and levofloxacin would be inferior to Bactrim so
he was given one test dose of 1 DS tab of Bactrim. After 24
hours of observation, he exhibited no rash so he was started on
treatment dose for planned 14 day course, started on [**12-27**]. His
fevers began to completely resolve. Lines were removed during
fever workup.
.
After resolution of his fevers a tunnelled dialysis line was
placed as he showed no signs of renal recovery and would likely
be dialysis dependent. He was able to tolerate long periods of
trach mask at the time of discharge but was still not completely
independent from the vent.
Medications on Admission:
Protonix 40mg po daily
Reglan 10mg po qid
Albuterol PRN
Benicar with HCTZ 40-12.5mg daily
Wellbutrin SR 150mg [**Hospital1 **]
Digoxin 0.125mg po daily
Metoprolol 25mg po bid
Coumadin 5mg po daily
Prozac 40mg, 80mg po qod
Simvastatin 40mg po daily
ASA 81mg po daily
Discharge Medications:
1. Aspirin 325 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 for erythema.
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
4. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Bisacodyl 10 mg Suppository Sig: Ten (10) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) g PO DAILY (Daily) as needed for constipation.
11. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
Four (4) Puff Inhalation [**Hospital1 **] (2 times a day).
14. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing.
15. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig: One
(1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash.
16. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
17. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
18. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
19. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q6H (every
6 hours) as needed for back pain.
20. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain,
flash.
22. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: 2.5
Tablets PO DAILY (Daily) for 8 days.
23. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
24. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
25. Lorazepam 0.5-1 mg IV Q8H:PRN anxiety
26. Ondansetron 4 mg IV Q8H:PRN n/v
27. Epogen Injection
28. 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:
[**Hospital1 **]
Discharge Diagnosis:
Enterococcal Sepsis
End stage renal failure on dialysis
Ventilator associated pneumonia
Atrial fibrillation
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted to the hospital with low blood pressure from a
serious infection. You were treated for multiple infections in
the blood and lungs with various antibiotics. While in the
hospital you were started on dialysis because your kidneys were
severely damaged because of your infection. You were also
started on a blood thinning medication called coumadin because
of an irregular heart beat that you developed called atrial
fibrillation.
Followup Instructions:
Please follow up with your primary care physician after you
leave your long term acute care facility
|
[
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icd9cm
|
[
[
[]
]
] |
[
"00.14",
"99.04",
"38.93",
"31.1",
"44.13",
"03.31",
"38.95",
"39.95",
"33.23",
"38.91",
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] |
icd9pcs
|
[
[
[]
]
] |
15619, 15662
|
9474, 12705
|
300, 401
|
15814, 15833
|
2754, 9451
|
16327, 16431
|
2381, 2390
|
13022, 15596
|
15683, 15793
|
12731, 12999
|
15857, 16304
|
2405, 2735
|
253, 262
|
429, 2169
|
2191, 2340
|
2356, 2365
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,144
| 172,618
|
49695
|
Discharge summary
|
report
|
Admission Date: [**2202-6-4**] Discharge Date: [**2202-6-5**]
Date of Birth: [**2145-7-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
food stuck in throat
Major Surgical or Invasive Procedure:
Endoscopy
Intubation
History of Present Illness:
Mrs. [**Known lastname 9996**] is a very pleasant 56 yo woman with SLE c/b
nephritis, rheumatic heart disease s/p bioprosthetic AVR, HTN
and Raynaud's disease who presents with food impaction.
.
She has been in her USOH. At dinner, she was not able to swallow
a piece of lamb.
.
She has had multiple food impactions in the past.
.
She denies shortness of breath, inability to clear secretions or
pain. She has a sense of discomfort in her throat.
Past Medical History:
Systemic lupus erythematosis c/b lupus nephritis
Rheumatic heart disease s/p bioprosthetic AVR ([**2198**])
- now with moderate MS and MR, moderate AS and moderate to
severe TR
Mild pulmonary hypertension (42/16)
Hypertension
Raynaud??????s syndrome
s/p cholecystectomy
Social History:
Patient is married with one son, denies tobacco, minimal EtOH
Family History:
Grandmother died from a CVA at age 50. Father died at age 70
from complications of diabetes.
Physical Exam:
Vitals: T: 97.6 BP: 148/84 P: 64 R: 18 SaO2: 96%RA
General: Awake, alert, NAD, pleasant
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM dry, no food
noted in OP
Neck: supple, no significant JVD
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, II/VI systolic murmur heard throughout
the precordium
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Pertinent Results:
[**2202-6-4**] 11:20PM BLOOD WBC-7.9 RBC-3.45* Hgb-10.3* Hct-31.1*
MCV-90 MCH-30.0 MCHC-33.3 RDW-14.1 Plt Ct-225
[**2202-6-4**] 11:20PM BLOOD Neuts-74* Bands-0 Lymphs-13* Monos-7
Eos-2 Baso-3* Atyps-1* Metas-0 Myelos-0
[**2202-6-4**] 11:20PM BLOOD PT-14.1* PTT-39.7* INR(PT)-1.2*
[**2202-6-4**] 11:20PM BLOOD Glucose-95 UreaN-49* Creat-1.6* Na-138
K-4.4 Cl-107 HCO3-22 AnGap-13
[**2202-6-5**] 01:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2202-6-5**] 01:00AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2202-6-5**] 01:00AM URINE RBC-0 WBC-[**3-10**] Bacteri-RARE Yeast-RARE
Epi-0-2 TransE-0-2
Brief Hospital Course:
# Food impaction: Patient has had h/o multiple food impactions,
thought due to esophageal dysmotility associated with her SLE.
She did not have excessive secretions or evidence of respiratory
compromise. GI evaluated her the morning after admission and
performed an upper endoscopy. It was initially difficult so they
requested intubation for better airway protection. However, she
coughed up some material right before intubation. She was
intubated and the EGD was performed which did not demonstrate
any residual food and a normal esophagus and stomach.
.
# SLE: has history of nephritis, followed by nephrology. Her
home meds were held while she was NPO for the procedure and
restarted afterwards.
.
# Hypertension: Once she was able to take pos she was
re-started pm lisinopril, Valsartan, metoprolol once able to
take PO.
Medications on Admission:
Omeprazole 20 mg daily
Furosemide 20 mg daily
Hydroxychloroquine 200 mg [**Hospital1 **]
Lisinopril 40 mg daily
Ativan 0.5-1 mg prn
Metoprolol 25 mg [**Hospital1 **]
Valsartan 160 mg daily
Aspirin 81 mg daily
Centrum Silver 1 tablet daily
Iron [**Hospital1 **]
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO twice
a day.
4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for anxiety.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day.
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
9. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
10. Iron Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
food impaction
Secondary
Systemic lupus erythematosis complicated by lupus nephritis
Rheumatic heart disease with bioprosthetic AVR ([**2198**])
Mild pulmonary hypertension
Hypertension
Discharge Condition:
stable, obstruction removed
Discharge Instructions:
You were admitted to the hospital because of food impaction. You
had an upper endoscopy requiring general anesthesia and
intubation. Your endoscopy did not show any residual food after
what you had coughed.
.
Please make sure to chew your food well. Please take all your
medications as prescribed. Please go to all follow up
appointments.
.
If you develop difficulty swallowing, shortness of breath,
nausea, vomiting, fever, abdominal pain, or any other concerning
symptoms, please call your doctor or come to the hospital.
Followup Instructions:
Please make a follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**]
([**Telephone/Fax (1) 2306**] in [**1-6**] weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2202-6-5**]
|
[
"V42.2",
"E915",
"401.9",
"398.90",
"710.0",
"935.1",
"530.5",
"583.81",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
4353, 4359
|
2524, 3354
|
334, 357
|
4598, 4628
|
1816, 2501
|
5201, 5522
|
1223, 1317
|
3666, 4330
|
4380, 4577
|
3380, 3643
|
4652, 5178
|
1332, 1797
|
274, 296
|
385, 834
|
856, 1128
|
1144, 1207
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,129
| 100,282
|
33183
|
Discharge summary
|
report
|
Admission Date: [**2136-2-9**] Discharge Date: [**2136-3-6**]
Date of Birth: [**2061-6-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
CC: Fever, altered mental status, hypotension, sepsis
Major Surgical or Invasive Procedure:
[**2136-3-2**]-Open tracheostomy
[**2136-3-2**]-percutaneous endoscopic gastrostomy tube
History of Present Illness:
.
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 45938**] office [**Telephone/Fax (1) 45939**], [**Hospital **] Hospital ED
([**Telephone/Fax (1) 77108**].
.
HPI: 74yoF with PMH of tobacco use and glaucoma (no regular
medical care with last PCP [**Name Initial (PRE) **] 6 years ago) who developed
fever and body aches [**2136-2-1**] and progressively worsening
confusion since then presented to her PCP's office today with
complaints of generalized malaise and feeling unwell. She
specifically complained of inability to sleep and requested
sleep medication however also endorsed generalized weakness and
perhaps some dizziness. Her PCP referred her to [**Hospital **]
Hospital ED given her symptoms and she reportedly looked
"overall unwell". She (and family) report that her symptoms
began on [**2136-2-1**] at which time she developed "body aches" and
subjective fevers/chills. She also had a very mild dry cough.
Her daughter reports progressive confusion mainly over the past
few days. She has also had poor PO intake (food and fluid) [**3-10**]
poor appetite. She denies sore throat, runny nose,
N/V/diarrhea/abdominal pain, dysuria/hematuria. She further
denies night sweats, signifiant weight loss. She also denies
HA, changes in vision, neck stiffness.
.
At the OSH ED, noted peripheral blood WBC >60K with a reported
"left shift". RUL infiltrate was noted on CXR and she received
1 dose levofloxacin IV. ABG initially showed pCO2=59 however
she became increasingly lethargic and repeat ABG showed pCO2=78.
She was simultaneously noted to be hypoxemic (paO2 not clear),
but SaO2 70% on NRB prior to intubation. She was intubated and
was noted to be hypotensive with nadir 65/40 (? post sedation
vs. before) and was started on dopamine via peripheral IV
initially at 20mcg/kg/min. Dopamine was decreased to
5mcg/kg/min prior to transfer with maintenance of SBPs 90s. She
became tachycardic to the 140s on dopamine so was changed to
levophed without tachycardia and maintenance of MAPS
approximately 50-60.
.
Transferred to MICU for presumed sepsis.
.
ROS: As above, also denies rashes. + DOE when walking up
stairs, no PND, orthopnea (per family history). No
melena/hematochezia.
Medications:
Glaucoma eye gtts
.
Allergies: NKDA
Past Medical History:
Past Medical History:
Tobacco use, ? COPD
Glaucoma
Social History:
Social History: Quit tobacco 15years ago, previously has
approximately 20-30packyear history. No EtOH nor other
illicits. Formerly worked in parking permit department at the
police dept. Has 9 children (7 daughters, 2 sons).
Family History:
Family History: non-contributory
Physical Exam:
Physical Exam:
VS: Temp: 97.0 BP: 96/61 HR: 101 ST RR: 12 O2sat 95-96% AC
500/12 PEEP 10 FiO2 0.60
GEN: intubated
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions,
superior lip with mild blood oozing under ETT tape
NECK: no supraclavicular or cervical lymphadenopathy
appreciated, no jvd, no carotid bruits, no thyromegaly or
thyroid nodules
RESP: Rhonchorus anteriorly
CV: RRR, S1 and S2 wnl, systolic murmur heard greatest LUSB
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: trace to 1+ edema b/l feet, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: Somnolent on sedation, but arousable and able to answer
yes/no to questions, nods appropriately. Able to cooperate with
strength exam/follow commands. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
EKG: Sinus tachy rate 103, normal access, q II, III, aVF, 1mm ST
depression II and aVF, 1mm ST depression V5, 1mm ST elevation
V2. Isolated biphasic TW in aVL.
.
Imaging:
.
[**2136-2-9**] OSH CXR: Per verbal report showed opacity upper portion
of RLL. (Need to review CD)
.
[**2136-2-9**] CXR on presentation to ICU (WET): Opacity superior
portion of right lower lobe, left upper lobe opacity and hiatal
hernia vs. left hemidiaphragm elevation. Hilar fullness likely
representing LAD.
.
ADMISSION LABS: [**2136-2-9**]
.
[**2136-2-9**] 08:55PM BLOOD Neuts-91* Bands-3 Lymphs-2* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2136-2-9**] 08:55PM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
Schisto-OCCASIONAL
[**2136-2-9**] 08:55PM BLOOD Plt Smr-HIGH Plt Ct-538*
[**2136-2-9**] 10:55PM BLOOD PT-12.5 PTT-23.4 INR(PT)-1.1
[**2136-2-9**] 05:58PM BLOOD Glucose-188* UreaN-63* Creat-1.3* Na-136
K-3.5 Cl-98 HCO3-28 AnGap-14
[**2136-2-9**] 05:58PM BLOOD estGFR-Using this
[**2136-2-9**] 05:58PM BLOOD ALT-33 AST-37 LD(LDH)-311* AlkPhos-235*
TotBili-1.2
[**2136-2-9**] 05:58PM BLOOD Albumin-2.2* Calcium-7.4* Phos-4.5 Mg-2.5
[**2136-2-9**] 05:58PM BLOOD Cortsol-59.3*
[**2136-2-9**] 08:05PM BLOOD Type-ART pO2-62* pCO2-70* pH-7.26*
calTCO2-33* Base XS-1
[**2136-2-9**] 09:34PM BLOOD Type-MIX Temp-36.7
[**2136-2-9**] 08:05PM BLOOD Lactate-1.3 K-3.3*
[**2136-2-9**] 09:34PM BLOOD Hgb-10.9* calcHCT-33 O2 Sat-74
[**2136-2-9**] 08:05PM BLOOD freeCa-0.99*
.
.
MICRO DATA
[**2136-3-2**] 11:42 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
LEGIONELLA CULTURE (Preliminary):
NO LEGIONELLA ISOLATED.
ASPERGILLUS FUMIGATUS.
IDENTIFICATION PERFORMED ON CULTURE # 244-2449B
([**2136-2-26**]).
.
[**2136-2-9**] 9:31 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2136-2-12**]**
GRAM STAIN (Final [**2136-2-10**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS IN SHORT CHAINS.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2136-2-12**]):
OROPHARYNGEAL FLORA ABSENT.
STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH.
PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
PENICILLIN------------ S
.
[**2136-2-10**] 10:33 am URINE Site: CATHETER
**FINAL REPORT [**2136-2-11**]**
Legionella Urinary Antigen (Final [**2136-2-11**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
.
[**2136-2-14**] 2:24 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2136-2-20**]**
GRAM STAIN (Final [**2136-2-16**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2136-2-18**]): NO GROWTH, <1000
CFU/ml.
VIRAL CULTURE (Final [**2136-2-20**]):
HERPES SIMPLEX VIRUS TYPE 1.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
.
[**2136-2-17**] 3:05 pm SKIN SCRAPINGS
**FINAL REPORT [**2136-3-2**]**
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2136-3-2**]):
NO VIRUS ISOLATED.
.
[**2136-2-17**] 2:40 pm EAR LEFT EAR.
SITE CONFIRMED BY [**Numeric Identifier 77109**] DR [**Last Name (STitle) **] [**2136-2-21**].
**FINAL REPORT [**2136-2-21**]**
GRAM STAIN (Final [**2136-2-17**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2136-2-19**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
YEAST. MODERATE GROWTH.
.
[**2136-2-17**] 2:40 pm SWAB Site: EAR RIGHT EAR.
SITE CONFIRMED BY DR [**Last Name (STitle) **] [**Numeric Identifier 77109**] [**2136-2-21**].
**FINAL REPORT [**2136-2-21**]**
GRAM STAIN (Final [**2136-2-17**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2136-2-21**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. 2ND
TYPE.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH
.
[**2136-3-1**] 5:29 pm ASPIRATE Site: SINUS Source: Sinus.
GRAM STAIN (Final [**2136-3-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2136-3-3**]): NO GROWTH.
POTASSIUM HYDROXIDE PREPARATION (Final [**2136-3-1**]):
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen for Fungal Smear (KOH).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
RELEVANT IMAGING
Echo [**3-2**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No definite aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. There is
mild functional mitral stenosis (mean gradient 7 mmHg) due to
mitral annular calcification. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2136-2-10**], the
findings are similar.
.
[**3-1**] CT sinuses
IMPRESSION:
1. Improvement of the mucosal thickening in the paranasal
sinuses as described above. Resolution of the fluid within the
middle ear cavities bilaterally.
2. Persistent partial opacification of mastoid air cells
bilaterally.
.
[**2-29**]
chest CT
IMPRESSION:
1) Persisting multifocal consolidation, not significantly
changed.
2) Interval development of underlying pulmonary edema with
increasing, now moderate, bilateral pleural effusions.
3) Enlarged mediastinal lymph nodes likely reactive to the
underlying infectious process and/or CHF.
4) Lobulated, hypodense hepatic dome lesion, likely a cyst.
5) Left adrenal mass with Hounsfield Units between 5 and 15,
most likely an adenoma.
.
[**2-17**]-CT orbit, sella, IAC
IMPRESSION:
1. Paranasal sinus opacification as described above.
2. Soft/fluid density within the bilateral mastoid air cells and
right middle ear cavity without bony erosions or other
destructive changes. Findings may represent effusions of the
mastoid air cells and right middle ear cavity, versus
otomastoiditis.
3. 7-mm well-circumscribed lytic area within the left occipital
lobe, likely an arachnoid granulation. If there is clinical
concern or previous history of malignancy, a bone scan could be
considered for further characterization.
.
[**2136-2-11**]
CT Torso
1. Extensive bilateral pulmonary consolidations that are most
consistent with pneumonia.
2. Small bilateral pleural effusions.
3. Suboptimal position of the right internal jugular central
line with its tip in the inferior vena cava.
4. Ascites.
5. Cholelithiasis.
6. Left adrenal mass, which cannot be further characterized on
this study. Further evaluation with MRI may be obtained when
clinically feasible
.
echo [**2136-2-10**]
The left atrium is mildly dilated. The estimated right atrial
pressure is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
Left ventricular systolic function is hyperdynamic (EF 70-80%).
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is severe
mitral annular calcification. There is mild valvular mitral
stenosis (area 1.5-2.0cm2). Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to [**Hospital1 18**] MICU. 74F h/o tobacco use,
glaucoma (no past regular medical care) developed fever and body
aches [**2136-2-1**], with progressively worsening confusion since
then, presented to OSH ED and was found to have WBC 60+, RUL and
hypotension requiring pressors, intubated and was transferred
for further management of septic shock [**3-10**] pneumococcal RUL PNA.
Now with resolved WBC but continued respiratory failure and
ventilator dependancy; Now s/p Trach/PEG. Also now with new
growth of mold out of [**2-26**] sputum culture, and staph coag (-)
off the CVL tip on [**2-28**], completed treatment for pneumococcal
pneumonia, as well as herpes lung infection, still being treated
for mold in sputum-aspergillus infection.
.
Problems:
.
RESPIRATORY FAILURE:
She presented with a hypercarbic and hypoxic respiratory failure
with an acute on chronic respiratory acidosis secondary to
pneumonia which developed into ARDS. A chest CT showed
multifocal pneumonia, sputum culture showed penicillin resistant
strep pneumonia. Empirical Vancomycin and Flagyl were
discontinued, and levofloxacin and zosyn were continued for a
completed course.
There was also a component of underlying COPD exacerbation for
which she was on albuterol and atrovent. Diuresis was initiated
for a component of volume overload that was felt to be present.
However she was allowed to self diurese after she became
euvolemic. She was also found to have a herpetic pulmonary
infection (tracheobronchitis). BAL washings ([**2-14**])confirmed
HSV-positive herpetic lesions in trachea. Acyclovir was started
[**2-21**], ending [**3-6**] (2 week course); liver (AST 13. ALT 17), renal
function were monitored.
She had previously had aspergillus in her sputum but negative
beta-glucan and galactomannan. Whether this was a pathogen or a
contaminant was not clear. She was started voriconazole [**2-29**],
CT sinus and CT chest did not show invasive disease. She should
continue on this for two weeks and have LFTs monitored weekly.
She should also have a follow up sputum for KOH and fungal
culture in [**3-12**] weeks after stopping voriconazole.
.
Vent settings at d/c
ventilator settings:
CPAP 46% FiO2
PEEP 5
Pt averaging tidal volumes of 20
respiratory rate 30
.
She was in chronic respiratory failure and did not tolerate
weaning of vent given need for high PEEP & FIO2. Thus, she had
a tracheostomy placed and is now being slowly weaning from vent.
Trach: Dead space:tidal volume 78%. She needs PRN decreases in
FiO2, PEEP.
.
HYPOTENSION: On admission she had leukocytosis WBC 60, fever,
tachycardia c/w SIRS and since she had pneumonia and hypotension
she was in spetic shock. She was requiring Norepinephrine. In
the presence of a murmur on exam subacute bacterial endocarditis
was felt to be a possible etiology, thus an echo was done that
was negative for vegetations, Normal LVEF >55%, +1MR. Her
random cortisol was 59, with an appropriate decrease with
cortisol challenge. As there were no ischemic changes in
continguous leads cardiogenic etiology was not felt to be
likely. On [**2-12**] she was weaned successfully off pressor support.
She occasionally required small boluses for occasional
decreases in blood pressure and to aid urine output.
.
ACUTE RENAL FAILURE: She had no known CRI by history (although
no consistent medical care for several years). BUN/creatinine
ratio suggestive of prerenal etiology, improved to nml range
after IVFs. Admission BUN=63, Cr=1.3, Discharge BUN=23, Cr=0.5.
.
ILEUS: She had increasing abdominal distention with no BM. KUB
done on [**2-10**] c/w ileus. Abd CT demonstrated ascites but no SBO.
She was on a bowel regimen and TF with appropriate holding for
residuals were done. This resolved [**2-13**].
.
ALTERED MENTAL STATUS: She had ARDS, infection, but also heavy
sedation while intubated. On [**3-4**], decreased scheduled diazepam
with goal for autotaper, and decreased fentanyl patch to 12.5mg.
On [**3-5**] the patient was found to be awakening, able to
communicate somewhat with family and staff. Diazepam was
discontinued [**3-6**] and ativan 1mg Q6h:PRN was started.
.
ANEMIA: She had a slowly decreasing Hct. She was guiaic
negative and did not have any gross bleeding. Likely secondary
to blood draws, hemolysis labs were negative, should continue to
monitor. Admit HCT was 32. Discharge HCT was 26, this was stable
for 3 days prior to discharge. During admission patient was
transfused 1 unit of packed RBCs w/o complications.
.
RIGHT OTITIS MEDIA: ENT irrigated ear, no evidence of otitis
externa, likely otitis media s/p perforation or drained fluid
collection behind cerumen collection. Recieved
ciprofloxacin/dexamethasone drops 5 drops TID in ear for 10
days.
Started first full day [**2-18**], ended [**2-28**]. Now resolved.
.
NUTRITION: PEG was placed at the time of tracheostopy. Tube
feed recs. tube feeds-Nutren Pulmonary Full strength;
Additives:Beneprotein, 10 gm/day
Starting rate: 40 ml/hr; Do not advance rate Goal rate: 40 ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml
Other instructions: Please add 150 ml H20 TID to TF
.
GLAUCOMA: She remained on her home medications of timolol and
travatan
.
ACCESS: PICC line placed [**2-27**]: NO signs of infection at picc
site.
.
Follow up:
Pt will continue voriconazole until [**3-14**] for a total of 2weeks of
therapy
-Pt needs LFTs drawn on [**3-12**].
-sputum culture needed [**2136-3-28**] (for fungal culture and KOH)
-galactomannan and B-glucan [**2136-3-12**]
-Please contact your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 45938**] [**Telephone/Fax (1) 77110**] for a
follow up appointment within 2 weeks.
-Pt has an appointment with the infectious disease clinic; [**4-2**], 11:00am, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] on the [**Hospital Ward Name **] [**Hospital1 18**] [**Hospital Ward Name 23**]
building [**Location (un) **].
Medications on Admission:
`Glaucoma eye gtts
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Injection Q8H (every 8 hours).
2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 6-10 Puffs Inhalation
Q4H (every 4 hours).
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
6. Outpatient Lab Work
LFTs on Monday [**2136-3-12**]
7. Outpatient Lab Work
sputum culture [**2136-3-28**] (for fungal culture and KOH)
8. Outpatient Lab Work
galactomannan and B-glucan [**2136-3-12**]
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain or fever.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
15. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day).
16. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 8 days: last day [**2136-3-14**].
17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
18. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed: re-assess as necessary with intention to
taper.
19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
20. Insulin Lispro 100 unit/mL Cartridge Sig: as per scale
Subcutaneous every six (6) hours: as per scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 86**]
Discharge Diagnosis:
Pneumococcal Pneumonia
Herpetic pulmonary infection
Aspergillus
Acute Respiratory Distress Syndrome
history of tobacco use
glaucoma
Discharge Condition:
stable
--------
tube feeds-Nutren Pulmonary Full strength;
Additives:Beneprotein, 10 gm/day
Starting rate: 40 ml/hr; Do not advance rate Goal rate: 40 ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml
Other instructions: Please add 150 ml H20 TID to TF
-------------------
ventilator settings:
CPAP 46% FiO2
PEEP 5
Pt averaging tidal volumes of 20
respiratory rate 30
Discharge Instructions:
You were admitted with pneumonia and required intubation for
respiratory failure. You also had a herpetic pulmonary
infection and continued to require ventilation so a tracheostomy
was done. You also had a PEG tube placed for feeding. You were
treated for your pneumonia and herpetic lung infection with
antibiotics which you have completed. You also had mold in your
sputum requiring treatment with an antibiotic called
voriconazole. You will continue to take this and complete a two
week course, during which your liver function tests should be
checked weekly.
You are being discharged to a pulmonary rehab facility. You
should call your doctor for any fevers, chills, increased sputum
production, or any other concerning symptoms.
Please follow up as outlined below.
Followup Instructions:
Follow up:
Pt will continue voriconazole until [**3-14**] for a total of 2weeks of
therapy
-Pt needs LFTs drawn on [**3-12**].
-sputum culture needed [**2136-3-28**] (for fungal culture and KOH)
-galactomannan and B-glucan [**2136-3-12**]
-Please contact your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 45938**] [**Telephone/Fax (1) 77110**] for a
follow up appointment within 2 weeks.
-Pt has an appointment with the infectious disease clinic; [**4-2**], 11:00am, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] on the [**Hospital Ward Name **] [**Hospital1 18**] [**Hospital Ward Name 23**]
building [**Location (un) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2136-3-6**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
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|
2866, 3080
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,442
| 167,649
|
52791
|
Discharge summary
|
report
|
Admission Date: [**2159-11-7**] Discharge Date: [**2159-11-16**]
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Aggression/Manic Behavior/Abnormal labs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89M with PMHx of CAD s/p CABG, Aortic Stenosis s/p bovine AVR,
PVD, DM, Systolic CHF (LVEF of 35-40%) and hypothyroidism sent
in on section 12 by PCP after wife reported increasing
aggression and reported manic behavior over the past several
weeks. The patient has a history of CHF and has been undergoing
diuresis intermittently as an outpatient as well as an admission
2 months ago. Denies pain anywhere, fevers, cough, vomiting,
diarrhea, dysuria.
.
In the ED, initial vs were: 97.3 100 121/76 18 99%
ED Course (labs, imaging, interventions, consults):
- CXR: Stable cardiomegaly, mild fluid overload
- EKG: afib 98 LAD/LBBB incr ST depr V5-6 c/w prior no Sgarbossi
- urinalysis
- Right IJ placed as patient was difficult IV access
- insulin, D50, calcium and Kayexalate for hyperkalemia
- IV fluid resuscitation for elevated lactate - 2Liters
- Anion gap likely secondary to lactic acidosis
- differential diagnosis in ED included infection, overdiuresis,
ingestion. Likely a toxic metabolic encephalopathy rather than
psychiatric given lab abnormalities. Patient can have psych
consult as an inpatient
- Patient admitted to ICU, given above workup.
.
On the floor, patient is in no distress. [**First Name3 (LF) **] and oriented x3.
Very pleasant. Tells me that he had a disagreement with his
family members this morning, because he was trying to teach his
wife something. Denies any pain anywhere. No cough, no SOB, no
nausea/vomiting/diarrhea/fevers/new rashes. Tells me that he
indeed did not take his medicine for several days, because he
had not eaten in 5 days due to lack of appetite.
Past Medical History:
CAD s/p CABG
Systolic CHF with LVEF of 35-40%
Aortic stenosis s/p bovine AVR
Diabetes
Peripheral Vascular Disease s/p Left SFA to PT bypass with NRSVG
([**2148**]), redo left jump graft from SFA-PT to PT using left arm
cephalic vein ([**2150**])
s/p Bilateral BKA
Hypertension
hyperlipidemia
hypothyroidism
Social History:
Pt used to work as an appliance technician and is retired. He
lives at home with his wife who helps with his ADLs. He
ambulates with BKA prosthetics.He denies any hx of smoking, ETOH
and any illicit drug use.
Family History:
Noncontributory.
Physical Exam:
FEX ON ADMISSION
GEN:Pleasant, A&Ox3, NAD.
CV: RRR soft diast murmur over LSB, no rub/gallops, RIJ in
place, with clean dressing.
RESP: Overall minimal crackles at bases, good air movement.
ABD: NTTP, NABS, mildly distended,
GU: foley in place
EXTR: s/p bilateral BKA, minimal edema in his thighs, none in
arms.
DERM: scattered erythematous patches/plaques over bilateral
amputation sites, affected area in contact with devices
NEURO: [**Name (NI) **], oriented
FEX ON DISHCARGE:
97.6 102/52 80 18 97%RA Weight 161.8lb
GEN:Disheveled, A&Ox3, NAD.
CV: RRR. Soft diast murmur over LSB, no rub/gallops,
RESP:Diffuse crackles to mid zones, good air movement.
ABD: NTTP, NABS, mildly distended,
EXTR: s/p bilateral BKA, minimal edema in his thighs, none in
arms.
DERM: Multiple ecchymoses, prominenty over anterior arms.
Multiple scabs over same locations and lips. Pupuric rash under
arms bilaterally.
Pertinent Results:
MICROBIOLOGY: Negative except where otherwise noted
[**2159-11-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2159-11-8**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL
[**2159-11-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2159-11-7**] CULTURE Blood Culture, Routine-FINAL
[**2159-11-7**] URINE URINE CULTURE-FINAL
[**2159-11-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2159-11-8**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL
[**2159-11-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2159-11-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2159-11-7**] URINE URINE CULTURE-FINAL
.
.
STUDIES:
AP CXR: [**11-8**]: FINDINGS: As compared to the previous radiograph,
there is minimally improved ventilation at the right lung base.
Otherwise the radiograph is unchanged. Moderate cardiomegaly
with moderate pulmonary edema and right pleural effusion.
Bilateral basal areas of atelectasis. No evidence of newly
occurred focal parenchymal opacity suggesting pneumonia.
Unchanged position
of right central venous access line.
.
TTE [**2159-11-8**]:
Severely depressed left ventricular global systolic function.
Depressed right ventricular systolic function. Bioprosthetic
aortic valve with probable paravalvular leak and moderate aortic
regurgitation. At least moderate mitral regurgitation. At least
moderate to severe tricuspid regurgitation. Severe pulmonary
artery systolic pressure. Compared with the prior study (images
unavailable for review)) of [**2159-8-29**], an aortic bioprosthetic
paravalvular leak with moderate aortic regurgitation is now
present. The global left ventricular ejection fraction has
decreased from 30-35% to 15%. The severity of mitral and
tricuspid regurgitation has increased. The pulmonary artery
systolic pressure has decreased quanititatively (from 69 mmHg to
58 mmHg), but in the setting of moderate to severe tricuspid
regurgitation the severity of pulmonary artery systolic
hypertension may, in fact, be underestimated on the current
study
.
NCHCT [**2159-11-9**]:
1. No acute intracranial process.
2. Age-related diffuse cerebral atrophy.
3. Evidence of atheromatous disease demonstrated by
cerebrovascular
calcifications and white matter gliosis due to small vessel
ischemic disease.
.
MRI Head [**2159-11-11**]
There is no evidence of acute ischemic changes. Few foci of
magnetic susceptibility are noted on the mid brain, left
cerebellar hemisphere and right occipital lobe, likely
consistent with microbleeds.Prominent ventricles and sulci are
identified, likely age related and involutional in nature versus
cortical volume loss.
Scattered areas of high signal intensity are noted in the
subcortical and periventricular white matter, representing
chronic microvascular ischemic changes.
.
Abdominal US [**2159-11-13**]:
FINDINGS: Technically challenging study due to poor acoustic
window. The liver is normal in echogenicity and echotexture. No
focal liver lesion identified. There is no intra- or
extra-hepatic duct dilation. The common duct measures 5 mm.
There is normal flow within the portal vein in a hepatopetal
direction. The patient is status post cholecystectomy. The
spleen is normal in appearance measuring 7 cm. Both kidneys are
normal in size and echogenicity. The right kidney measures 11.2
cm. The left kidney is 10.5 cm. No evidence of hydronephrosis,
stone, or renal lesion. The pancreas is not visualized. There is
no ascites.
IMPRESSION: Technically challenging study due to limited
acoustic window. The pancreas is not visualized. The remainder
of the study is normal.
.
CHEMISTRY:
[**2159-11-7**] 04:20PM BLOOD WBC-9.5 RBC-4.15* Hgb-12.7* Hct-40.6
MCV-98 MCH-30.7 MCHC-31.4 RDW-17.1* Plt Ct-95*
[**2159-11-7**] 10:00PM BLOOD WBC-8.2 RBC-3.72* Hgb-11.6* Hct-36.0*
MCV-97 MCH-31.1 MCHC-32.1 RDW-17.2* Plt Ct-83*
[**2159-11-9**] 06:00AM BLOOD WBC-8.0 RBC-3.81* Hgb-11.6* Hct-36.6*
MCV-96 MCH-30.3 MCHC-31.6 RDW-17.3* Plt Ct-87*
[**2159-11-12**] 06:01AM BLOOD WBC-6.2 RBC-3.57* Hgb-10.6* Hct-33.1*
MCV-93 MCH-29.6 MCHC-32.0 RDW-17.5* Plt Ct-75*
[**2159-11-14**] 07:20PM BLOOD WBC-8.0 RBC-3.71* Hgb-11.0* Hct-35.2*
MCV-95 MCH-29.6 MCHC-31.1 RDW-17.5* Plt Ct-70*
[**2159-11-16**] 06:34AM BLOOD WBC-7.4 RBC-3.59* Hgb-10.7* Hct-33.4*
MCV-93 MCH-29.9 MCHC-32.2 RDW-17.0* Plt Ct-65*
[**2159-11-7**] 04:20PM BLOOD Neuts-88.1* Lymphs-8.0* Monos-3.2 Eos-0.4
Baso-0.2
[**2159-11-15**] 05:50AM BLOOD Neuts-84.5* Lymphs-11.2* Monos-2.8
Eos-1.4 Baso-0.2
[**2159-11-7**] 04:20PM BLOOD PT-14.8* PTT-32.9 INR(PT)-1.4*
[**2159-11-8**] 04:32AM BLOOD PT-15.3* PTT-33.2 INR(PT)-1.4*
[**2159-11-11**] 06:00AM BLOOD PT-14.3* PTT-33.4 INR(PT)-1.3*
[**2159-11-14**] 07:20PM BLOOD PT-12.7* PTT-32.0 INR(PT)-1.2*
[**2159-11-15**] 05:50AM BLOOD PT-12.8* PTT-34.2 INR(PT)-1.2*
[**2159-11-16**] 06:34AM BLOOD Fibrino-376#
[**2159-11-14**] 06:40AM BLOOD ESR-9
[**2159-11-15**] 05:50AM BLOOD Ret Aut-3.3*
[**2159-11-7**] 04:20PM BLOOD Glucose-216* UreaN-46* Creat-1.5* Na-129*
K-6.1* Cl-92* HCO3-21* AnGap-22*
[**2159-11-7**] 10:00PM BLOOD Glucose-86 UreaN-43* Creat-1.4* Na-134
K-4.6 Cl-99 HCO3-23 AnGap-17
[**2159-11-9**] 06:00AM BLOOD Glucose-135* UreaN-52* Creat-1.6* Na-131*
K-4.2 Cl-94* HCO3-25 AnGap-16
[**2159-11-10**] 02:09PM BLOOD Glucose-219* UreaN-55* Creat-1.5* Na-134
K-3.7 Cl-96 HCO3-27 AnGap-15
[**2159-11-12**] 06:01AM BLOOD Glucose-78 UreaN-44* Creat-1.2 Na-130*
K-3.9 Cl-96 HCO3-32 AnGap-6*
[**2159-11-14**] 07:20PM BLOOD Glucose-80 UreaN-34* Creat-1.3* Na-133
K-4.2 Cl-95* HCO3-31 AnGap-11
[**2159-11-16**] 06:34AM BLOOD Glucose-119* UreaN-41* Creat-1.4* Na-135
K-4.1 Cl-95* HCO3-31 AnGap-13
[**2159-11-9**] 06:00AM BLOOD ALT-268* AST-354* AlkPhos-133*
TotBili-1.5
[**2159-11-11**] 06:00AM BLOOD ALT-172* AST-90* AlkPhos-127 TotBili-1.1
[**2159-11-13**] 06:40AM BLOOD ALT-101* AST-55* AlkPhos-123 TotBili-1.2
[**2159-11-14**] 06:40AM BLOOD ALT-81* AST-39 LD(LDH)-251* AlkPhos-124
TotBili-1.5
[**2159-11-15**] 05:50AM BLOOD LD(LDH)-267* TotBili-1.6* DirBili-1.0*
IndBili-0.6
[**2159-11-7**] 04:20PM BLOOD CK-MB-6 cTropnT-0.12* proBNP-[**Numeric Identifier 108876**]*
[**2159-11-7**] 10:00PM BLOOD CK-MB-6 cTropnT-0.12*
[**2159-11-8**] 04:32AM BLOOD CK-MB-5 cTropnT-0.15*
[**2159-11-9**] 06:00AM BLOOD CK-MB-5 cTropnT-0.13*
[**2159-11-14**] 06:40AM BLOOD TotProt-4.9* Albumin-3.1* Globuln-1.8*
Calcium-8.9 Phos-2.9 Mg-2.2 Iron-36*
[**2159-11-16**] 06:34AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.3
[**2159-11-8**] 04:32AM BLOOD VitB12-1001*
[**2159-11-14**] 06:40AM BLOOD calTIBC-277 Hapto-19* Ferritn-162 TRF-213
[**2159-11-15**] 05:50AM BLOOD Hapto-23*
[**2159-11-8**] 04:32AM BLOOD TSH-5.4*
[**2159-11-8**] 04:32AM BLOOD T4-4.0* T3-56*
[**2159-11-9**] 05:12PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE IgM HAV-NEGATIVE
[**2159-11-14**] 06:40AM BLOOD CRP-24.1*
[**2159-11-14**] 06:40AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2159-11-8**] 04:32AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2159-11-9**] 05:12PM BLOOD HCV Ab-NEGATIVE
[**2159-11-9**] 09:06AM BLOOD Type-[**Last Name (un) **] pO2-218* pCO2-33* pH-7.44
calTCO2-23 Base XS-0
[**2159-11-7**] 04:41PM BLOOD Glucose-206* Lactate-5.0*
[**2159-11-7**] 08:30PM BLOOD Lactate-4.5*
[**2159-11-8**] 04:50AM BLOOD Lactate-1.7
URINE:
[**2159-11-7**] 05:39PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012
[**2159-11-9**] 02:57PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2159-11-7**] 05:39PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2159-11-9**] 02:57PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.0 Leuks-NEG
[**2159-11-7**] 05:39PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
[**2159-11-9**] 02:57PM URINE RBC-52* WBC-4 Bacteri-NONE Yeast-NONE
Epi-0
[**2159-11-7**] 05:39PM URINE CastHy-13*
[**2159-11-9**] 02:57PM URINE Eos-NEGATIVE
[**2159-11-9**] 02:57PM URINE Hours-RANDOM UreaN-831 Creat-91 Na-14
K-62 Cl-10
[**2159-11-7**] 10:34PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION:
89M with PMHx of CAD s/p CABG, Aortic Stenosis s/p bovine AVR,
PVD, DM, Systolic CHF (LVEF of 35-40%) and hypothyroidism sent
in on section 12 by PCP after wife reported increasing
aggression and reported manic behavior over the past several
weeks. He had multiple abnormal labs on admission, including K
of 6.1, elevated glucose, and creatinine of 1.5. Found to be in
CHF exacerbation and still with waxing and [**Doctor Last Name 688**] behavior.
.
ACTIVE ISSUES:
#Aggressive behavior: Continued throughout hospital, although
patient remained oriented during stay. Suspect progressive
dementia primarily affecting frontal lobes and/or previously
undiagnosed psychiatric condition. Head CT and MRI were
unrevealing except for chronic microvasculature changes. Given
abnormal labs on presentation, worsening behavior could have
represented a toxic-metabolic encephalopathy HW did not improve
with normalization of LFT's and sodium. Initiated seroquel and
depakote on [**11-14**].
.
# sCHF: Patient with hx of LVEF approximately 35-40%. TTE this
admission showed LVEF of 15% along with perivalvular leak from
bovine valve. Patient appeared volume overloaded on exam.
Patient was diuresed with IV lasix, 40-80mg IV daily early in
stay. Unfortunately, it was difficult to obtain objective
measurement of progress as patient was incontinent and generally
uncooperative with weights. His O2 saturation remained >95% on
RA during entirety of stay. Continued ASA, statin, BBlocker
during admission. Lisinopril was held during admission due to
ARF, but was restarted on discharge. Per outpatient
cardiologist, patient would not be a candidate for repeat
valvular surgery. Discharge weight as noted on discharge FEX.
# Elevated LFTs: LFT's noted to be elevated with ALT 268, AST
354, ALP 133, TBili 1.5 early in stay. Hepatitis serologies were
negative and RUQ US was unremarkable. Suspect congestive
hepatopathy due to sCHF as LFT's downtrended with diuresis. Of
note, TBili remained elevated with elevated direct bili as well.
.
# Thrombocytopenia - Baseline platelets low 100's since [**2157**].
Noted to be stable around 80K and but slowly decreasing. Unclear
etiology. Patient did have some evidence of hemolysis, HW TTP
appears unlikely given time course. Heparin induced etiology
also possible, but again time course unlikely. Liver disease was
considered, but did not improve with normalization of LFT's and
maintained moderate synthetic function. Spleen was not enlarged
on US. Heme was consulted who ultimately suspected MDS and would
recommend bone marrow bx as outpatient if consistent with
patient and family wishes, although given worsening mental
status and heart failure, little value would likely be gained.
.
#. CAD - Troponins on admission elevated, and trended:
0.12-->0.12-->0.15-->0.14. CK-MB noted to be flat. Suspect due
to sCHF although consdieration was given to inciting cardiac
event precipitating sCHF and worsening mental status. ASA,
statin and beta blocker were continued. Spoke with outpatient
cardiologist who noted patient would not be a good candidate for
revascularization.
.
#. Hyperkalemia: K elevated to 6.1 on admission. Patient
received kayexalate and calcium gluconate therapy in the ED with
good effect. Suspect was due to worsening renal function due to
sCHF exacerbation.
.
# Elevated Lactate - Resolved after 2L NS in ED/MICU. Unclear
etiology of tissue hypoperfusion, although IVF's may have
worsened volume overload on transfer to floor.
.
# CRF: Baseline Cr 1.3. Admitted with Cr of 1.5, and returned to
[**Location 4222**] with diuresis.
.
# Hypothyroidism - TSH mildly elevated at 5.4. T3 and T4 low at
4.0 and 56. Uptitrated synthroid to 50mcg twice weekly and 25
mcg 5x weekly. Would recheck as outpt in [**2-28**] weeks
.
# Diabetes - Patient admitted on insulin lantus 37u qPM at home.
Ultimately discontinued lantus due to persistently low blood
glucose despite decreasing dose, and frequent refusal of blood
sugar testing by patient.
TRANSITIONAL ISSUES
-Increased lasix to 60mg po daily. Would monitor K, BUN, Cr at
least weekly until stable.
-Would monitor weights daily if possible to determine need for
diuretic adjustment
-Would continue to monitor CBC weekly to monitor
thrombocytopenia
-Would monitor T Bili with platelets initiatlly to ensure no
progressive process.
-Would recheck TSH in [**2-28**] weeks as we increased synthroid to 50
twice weekly, 25 other days.
Medications on Admission:
- Lasix 20 [**Hospital1 **]
- insulin lantus 37u qPM
- levothyroxine 25mcg daily
- lisinopril 2.5mg daily
- metoprolol 25mg ER daily
- metoprolol tartarate 25 [**Hospital1 **]
- simvastatin 20mg daily
- aspirin 81mg daily
- cetirizine 10mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO 5X/WEEK
([**Doctor First Name **],MO,WE,TH,FR).
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO 2X/WEEK
(TU,SA).
6. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
7. insulin aspart 100 unit/mL Solution Sig: As directed by
sliding scale Subcutaneous qachs.
8. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day.
9. divalproex 125 mg Capsule, Sprinkle Sig: One (1) Capsule,
Sprinkle PO BID (2 times a day).
10. quetiapine 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. quetiapine 12.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for extreme agitation.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: Systolic heart failure
Vascular dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: [**Doctor First Name **] and interactive.
Activity Status: Ambulatory - requires assistance or aid
(prostheses).
Discharge Instructions:
Dear Mr. [**Known lastname 4640**],
You were admitted to the hospital because your family and
primary care physician were worried about your recent behavior.
We found that you had multiple medical problems on admission,
including worsening heart failure and dementia. The heart
failure was causing you to retain extra fluid. We used
medications to remove this extra fluid. Additionally, we started
you on medications to help improve the symptoms of your
dementia. Please note the following changes to your medications:
.
Increase lasix to three 20mg tabs (60mg) by mouth daily.
Increase levothyroxine (Synthroid) to 50 mg twice weekly (on
Tuesday and Saturday) and 25 mg daily for every other day
Start divalproex (Depakote) 125mg twice daily
Start Quitipine (Seroquel) 12.5mg twice daily and once at
bedtime as needed to help sleep
Decrease metoprolol tartrate to 12.5 mg twice daily
Stop lantus injections
.
No other changes were made to your medications. It was a
pleasure taking care of you at [**Hospital1 **]
weight goes up more than 3 lbs.
Followup Instructions:
Your long-term care facility will help schedule any necessary
follow up appointments.
|
[
"V49.86",
"V45.81",
"272.4",
"584.9",
"290.41",
"V42.2",
"790.4",
"437.0",
"250.00",
"276.2",
"287.5",
"585.9",
"440.20",
"244.9",
"403.90",
"428.23",
"276.7",
"V58.67",
"428.0",
"V49.75"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17159, 17174
|
11495, 11978
|
256, 263
|
17277, 17277
|
3419, 11472
|
18549, 18638
|
2466, 2485
|
16251, 17136
|
17195, 17256
|
15980, 16228
|
17477, 17968
|
2500, 3400
|
17997, 18526
|
177, 218
|
11993, 15954
|
291, 1890
|
17292, 17453
|
1912, 2221
|
2237, 2450
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,683
| 198,455
|
388
|
Discharge summary
|
report
|
Admission Date: [**2187-4-6**] Discharge Date: [**2187-4-10**]
Date of Birth: [**2129-9-11**] Sex: F
Service: Medicine, [**Hospital1 **] Firm
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
female with a history of obesity, severe obstructive sleep
apnea, pulmonary hypertension, and diastolic congestive heart
failure who was recently discharged from the hospital on
[**3-23**] who returned for evaluation of persistent nausea and
headache that has been progressive since discharge.
She was admitted on [**3-19**] with hypoxia and started on
[**Hospital1 **]-level positive airway pressure for obstructive sleep apnea
in the hospital and discharged on [**3-23**] with home [**Hospital1 **]-level
positive airway pressure at night. She reported mild nausea
before discharge but reports progressive symptoms over the
past two weeks not associated with eating. The patient
states her symptoms seem worse when she was off the [**Hospital1 **]-level
positive airway pressure machine. She was also complaining
of a headache that is sometimes associated with nausea but
not always. She denies any other urinary symptoms. She
denies gastrointestinal complaints such as diarrhea,
abdominal pain, or constipation. She denies any urinary
complaints such a dysuria, frequency, or hematuria. No chest
pain. No increase in her lower extremity edema. No increase
in her baseline shortness of breath. She states her [**Hospital1 **]-level
positive airway pressure has not been fitting well, and she
uses it less than three to four hours per night.
In the Emergency Room the patient was noted to be
hypertensive with a systolic blood pressure of 214. She was
given 12 mg of Zofran, 2 mg of Ativan, and 4 mg of morphine.
PAST MEDICAL HISTORY:
1. Hodgkin's disease; status post radiation therapy and
splenectomy.
2. Pulmonary hypertension.
3. Obesity.
4. Congestive heart failure with diastolic dysfunction with
an ejection fraction of 70%.
5. Hypertension.
6. Obstructive sleep apnea; on home [**Hospital1 **]-level positive
airway pressure.
7. Hiatal hernia.
8. Depression.
9. Anxiety.
10. Hypothyroidism.
11. Chronic facial pain with parotid enlargement.
12. Degenerative joint disease with severe pain and on
chronic home pain medications.
ALLERGIES: Her allergies include PENICILLIN and question to
INTRAVENOUS IODINE.
MEDICATIONS AT HOME:
1. Levoxyl 175 mcg by mouth once per day.
2. Valsartan 120 mg in the morning and 80 mg in the evening.
3. Hydrochlorothiazide 25 mg once per day.
4. Lopressor 12.5 mg twice per day.
5. Lasix 20 mg once per day.
6. Prilosec 20 mg once per day.
7. Ativan as needed (up to 8 mg once per day).
8. Percocet as needed.
9. Oxycodone (up to 50 mg once per day).
SOCIAL HISTORY: She lives with her husband. She quit
tobacco 25 years ago.
FAMILY HISTORY: Son with congestive heart failure. Father
and mother with hypertension.
PHYSICAL EXAMINATION ON PRESENTATION: Her vital signs on
admission revealed a temperature of 99.2 degrees Fahrenheit,
her blood pressure was 153/94 after getting multiple
medications and a systolic blood pressure of 214, her heart
rate was 80, her respiratory rate was 20, and her oxygen
saturation was 88% on 1.5 liters and 96% on 3 liters. In
general, pleasant and in no acute distress. Head, eyes,
ears, nose, and throat examination revealed the sclerae were
anicteric. The oropharynx was clear. The pupils were equal,
round, and reactive to light. Cardiovascular examination
revealed a regular rate and rhythm. No murmurs, rubs, or
gallops. A loud second heart sound. Lungs revealed
decreased breath sounds at the bases with crackles. No
egophony. The abdomen was obese, soft, ventral hernia, mild
epigastric pain, with some right upper quadrant tenderness.
No guarding. No rebound. There were positive bowel sounds.
Extremities revealed 1+ pitting edema to the low calf.
Distal pulses were 2+. Neurologic examination was grossly
intact. She was moving all four extremities with 4+/5
strength throughout.
PERTINENT LABORATORY VALUES ON PRESENTATION: Chemistry-7
revealed sodium was 142, potassium was 4, notable for a
chloride of 95, bicarbonate was 40, blood urea nitrogen was
10, and her creatinine was 0.5. Her INR was 1.2. Calcium
was 10.1. Her magnesium was 2.1. Liver function tests were
within normal limits. Complete blood count revealed her
white blood cell count was 10.7, her hematocrit was 43.3, and
her platelets were 376.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed moderate
bilateral pleural effusions (left greater than right) with
mild congestive heart failure.
An electrocardiogram showed sinus tachycardia with normal
axis. No significant changes compared to [**3-19**].
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was sent to the floor. On [**4-7**], the patient was
noted to have worsening hypoxia with increasing nausea and
nonbloody and nonbilious vomiting as well as a headache.
On the morning of [**4-7**], the patient became belligerent
with dropping oxygen saturations. Room air saturation was
87% which improved to 94% on 4 liters. A half hour later she
was noted to have a desaturation to 63% on 4 liters, and
[**Hospital1 **]-level positive airway pressure was initiated and improved
to 97% on 4 liters and [**Hospital1 **]-level positive airway pressure with
settings of 14 and 7. An arterial blood gas performed on
room air revealed a pH of 737, a PCO2 of 71, and a PAO2 of
34. Her [**Hospital1 **]-level positive airway pressure was increased to 7
liters at that point.
Her Medical Intensive Care Unit course was significant for
diuresis with intravenous Lasix. The patient received 20 mg
of intravenous Lasix times two over a 2-day period with a
good response. She diuresed a total of approximately 3
liters while in the Medical Intensive Care Unit for 48 hours.
The thought was the patient may have developed acute
pulmonary edema secondary to an elevated blood pressure plus
or minus tachycardia. Her quick resolution, however, would
most likely be consistent with a mucous plug. However, her
improvement with diuresis would lean more towards a pulmonary
edema picture with her chest x-ray confirming that diagnosis.
The patient was then transferred to the floor after diuresis
and initiation of [**Hospital1 **]-level positive airway pressure at night.
1. OBSTRUCTIVE SLEEP APNEA ISSUES: The patient was
maintained on overnight [**Hospital1 **]-level positive airway pressure
with settings of 14 and 7 with 3 liters nasal cannula. She
tolerated this well for six to eight hours per night and was
encouraged to continue this at home. The patient has a
follow-up pulmonary studies at the end of this month and will
follow up with Dr. [**Last Name (STitle) **] of Pulmonary at that point.
The patient will have mask refitting at home for a more
comfortable device.
2. CONGESTIVE HEART FAILURE ISSUES: The patient has a
history of diastolic congestive heart failure likely from
long-term hypertension. She was diuresed well while in the
Intensive Care Unit. She came to the floor and was switched
to a by mouth regimen of 20 once per day. The patient's goal
will likely to be to control blood pressure and heart rate
for avoidance of pulmonary edema. She will be maintained on
her doses of Valsartan 120 in the morning and 80 in the
evening, as well as Lopressor twice per day, and
hydrochlorothiazide.
She was to have a follow-up appointment to evaluate her blood
pressure and current medications. In addition, the patient
was told to maintain a low-sodium diet and to closely monitor
her weight.
3. CHRONIC PAIN ISSUES: Chronic pain issues secondary to
osteoarthritis. The Pain Service was consulted while the
patient was in house, and given their recommendations it was
difficult to implement secondary to her baseline hypercapnia.
Therefore, we maintained her current regimen of as needed
Percocet. She was to have a follow-up outpatient visit the
[**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Management Center. The patient was to be
maintained on her current dose Percocet and 5 mg to 10 mg of
oxycodone every six hours as needed for her pain. The
patient and her husband were warned of the signs of
hypercapnia and oversedation.
4. NEW SCLEROTIC LESION ISSUES: The patient has a history
of new osteoarthritic/sclerotic lesions consistent with
possible metastatic disease on a computed tomography of the
bad done during her last hospital stay as well as a note of
subcutaneous lesions; likely sebaceous cysts, but metastatic
melanoma could not be ruled out.
Because of these findings, the patient was to have a
follow-up Hematology/Oncology appointment within the next one
to three weeks.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable on 2 liters nasal cannula (her home dose) with
minimal complaints of pain.
DISCHARGE DIAGNOSES:
1. Severe obstructive sleep apnea.
2. Diastolic congestive heart failure.
3. Hypothyroidism.
4. Peripheral vascular disease.
5. Status post Hodgkin's disease with splenectomy and
radiation therapy in [**2175**].
6. New sclerotic lesions and subcutaneous nodules.
MEDICATIONS ON DISCHARGE:
1. Levoxyl 175 mcg by mouth once per day.
2. Valsartan 120 mg in the morning and 80 mg in the evening.
3. Percocet 5/325-mg tablets one to two tablets by mouth
q.6h. as needed.
4. Metoprolol 25 mg by mouth twice per day.
5. Hydrochlorothiazide 25 mg once per day.
6. Ativan 1 mg q.6h. as needed (for agitation and anxiety).
7. Lasix 20 mg once per day.
8. Prilosec 20 mg once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Dr. [**Last Name (STitle) 3478**]
and Dr. [**Last Name (STitle) 19**] on [**2187-4-27**] for evaluation of her new
lesions.
2. The patient was instructed to follow up with Dr. [**Last Name (STitle) **]
on [**2187-5-4**] at 10:15 a.m. for pulmonary function tests
as well as evaluation.
3. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
who will be seeing the patient in Dr.[**Name (NI) 3479**] place on [**4-12**]
at 3 p.m.
4. The patient was instructed to follow up with the Pain
Management Center on [**4-19**] at 3:40 p.m.
5. The patient was also instructed to continue with her
[**Hospital1 **]-level positive airway pressure at the current settings of
14 and 7 at 3 liters per minute nasal cannula.
6. The patient was also to have home physical therapy.
DR.[**First Name (STitle) 2416**],[**First Name3 (LF) 2415**] 12-929
Dictated By:[**Last Name (NamePattern1) 3480**]
MEDQUIST36
D: [**2187-4-10**] 18:24
T: [**2187-4-10**] 18:34
JOB#: [**Job Number 3481**]
|
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icd9cm
|
[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,893
| 156,487
|
53625
|
Discharge summary
|
report
|
Admission Date: [**2103-12-3**] Discharge Date: [**2103-12-11**]
Date of Birth: [**2028-9-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75 M presenting with atraumatic left hip and and low back pain
worse with standing, relieved with rest, no trauma, no
neurological symptoms, normal rectal tone, large left inguinal
hernia, unable to reduce. Unable to ambulate, so admitted. He
was evaluated by Gen Surgery in the ED, who felt the hernia was
stable, and not related to current complaints.
.
Pt states that the pain is severe, [**10-7**]. There is pain
localized L hip region, which starts L anterior pelvis at
midline, and wraps around pelvis to posterior L spine. Pain
worse with leg movement. Sharp. Relieved somewhat with rest.
Pt also notes history of bilateral leg pain, which starts at
hips and radiates downt to feet B; does not have currently, and
pt unable to describe if similar pain to hip pain, or if similar
onset. Pt does note that the leg pain improves when leaning
over a shopping cart. Pt is unclear if the hip pain improves
with this as well, as he has been unable to ambulate.
.
Of note, multiple phone calls logged in on Epic. [**12-2**], called
complaining of shortness of breath as well as ? rib vs chest
pain. Earlier, called about hip pain. [**11-29**], called about
chalky feeling in throat and difficulty walking as well as cold
extremities; was advised to suck on candy and push fluids. He
was seen by PCP [**Last Name (NamePattern4) **] [**11-27**] for hip pain. The PCP noted that the
pain might be due to decreased exercise and recommended that
patient start to exercise more. Hip film ordered but never
performed.
.
Pt also notes significant SOB, DOE, 3 pillow orthopnea (same as
prior), and increased weight gain recently. He states his dry
weight is 274-275, and states more recently has been 285-286.
He states he drinks "a lot of water", but has difficulty
quatifying. Estimated a little more than a liter, but this
estimate is suspect. States he reads labels, and eats low
sodium, but does not add numbers to ensure <2gm/day. He uses
CPAP, but is not religious about it, and states he tries to use
it for 6 hrs per night, but it is unclear if he is successful in
this goal.
.
ED Course:
Triage vitals: T 97.4 HR 78 BP 136/87 RR 17 SpO2 92% RA
- plain films L-spine hip and pelvis
- trial of ambulation, unable to stand [**1-30**] pain in hip
- CT pelvis negative for fracture and L-spine showed no fracture
but showed ? gas in back, thought to be incidental
- left inguinal hernia with bowel - failed attempt to reduce x 2
- attempt T-[**Doctor Last Name **] x 20 minutes and reduction, if failed call
surgery
Seen by surgery in ED and found to have b/l Hernias, not
believed to be source of pain.
- Given Percocet x 1, ativan 2 mg x1
.
Admission Vitals:
P 71 BP 127/71 RR 16 SpO2 92 2L NL
.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: [] All Normal
[ ] Fever [ ] Chills [ ] Sweats [ ] Fatigue [x ] Malaise
[ ]Anorexia [ ]Night sweats
[ ] _10____ lbs. weight gain
HEENT: [] All Normal
[ ] Blurred vision [ ] Blindness [ ] Photophobia
[ ] Decreased acuity [ ] Dry mouth [ ] Bleeding gums
[ ] Oral ulcers [ ] Sore throat [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ]Tinnitus [ x] Other: "chalk" in
throat
RESPIRATORY: [] All Normal
[x ] SOB [x ] DOE [ x] Can't walk 2 flights [ ] Cough
[ x] Wheeze [ ] Purulent sputum [ ] Hemoptysis [
]Pleuritic pain
[ ] Other:
CARDIAC: [] All Normal
[ ] Angina [ ] Palpitations [x ] Edema [x ] PND
[x ] Orthopnea (3 pillow) [x ] Chest Pain [ ] Other:
GI: [] All Normal
[ x] Blood in stool (on paper, not in stool) [ ] Hematemesis
[ ] Odynophagia
[ ] Dysphagia: [ ] Solids [ ] Liquids
[ ] Anorexia [] Nausea [] Vomiting [ ] Reflux
[ x] Diarrhea occas [ x] Constipation occas [] Abd pain [ ]
Other:
GU: [] All Normal
[ ] Dysuria [ ] Frequency [ ] Hematuria []Discharge
[]Menorrhagia
[x] incontinence
SKIN: [] All Normal
[x ] Rash [ ] Pruritus
MS: [] All Normal
[ ] Joint pain [ ] Jt swelling [ x] Back pain [ ] Bony
pain
NEURO: [] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [x ]Numbness/pain of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [] All Normal
[ ] Skin changes [ ] Hair changes [ ] Temp subjectivity
HEME/LYMPH: [] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
Past Medical History:
Pulmonary nodule
Squamous cell skin cancer
Basal cell carcinoma
Melanoma
OSA
Pulmonary hypertension
Systolic and diastolic heart failure
Osteoarthritis
Gout
Atrial Fibrillation
Morbid obesity
Peripheral Vascular disease
Venous insufficiency
Hypertension
Coronary artery disease
Anemia
BPH
Depression
Anxiety
Hypercholesterolemia
Social History:
Quit smoking in [**8-17**] 00. Drinks 6 ounces of alcohol per week.
Family History:
Brother had cancer and diabetes
Father had cancer
Sister had cancer and a heart disorder
Physical Exam:
PHYSICAL EXAM:
VITAL SIGNS: 96.7 132/80 65 18 94% 3L Weight: pending
PAIN SCORE [**10-7**]
VS T P BP RR O2Sat Wt, ht, BMI
GENERAL: appears comfortable. Non-toxic
Nourishment: obese
Mentation: Alert and oriented, but challenging historian, very
tangential, and unable to recall details or timelines.
Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: MM sl dry, no lesions noted in OP
Neck: supple, thick neck, difficult to appreciate JVP
Respiratory: wet rales to 2/3 up Bilaterally. Scattered wheezes.
Cardiovascular: RRR, nl.
Gastrointestinal: soft, NT/ND, normoactive bowel sounds.
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: Chronic skin changes LE B, c/w venous stasis. 2+
non-pitting edema LE B.
Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary or
inguinal lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Has difficulty relaying
history, timeline
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor, dysdiadochokinesia noted.
No foley catheter/tracheostomy/PEG/ventilator support/chest,
tube/colostomy
Pertinent Results:
CT L-spine ([**2103-12-3**]):
1. No acute fx or malalignment of the L spine.
2. A small pocket of air in the retroperitoneal space next to
the spine at
T11 (image 4:1), incompletely imaged and of uncertain etiology.
Could
represent vaccum gas phenomenon. Recommend clinical
correlations.
RADIOLOGY ATTENDING ADDENDUM
There is some degree of spinal stenosis at L4-5. The severity is
difficult to evaluate due to overlying artifacts, but it is
potentially severe. This appears to be due to a combination of
disk bulging, perhaps protrusion, and facet joint osteophytes.
MR may be helpful if further evaluation is indicated. There is a
small collection of gas in the spinal canal on the right, just
below the L4-5 interspace. This suggests a disk protrusion in
this location, atlhought there is not sufficient soft tissue
contrast to fully evaluate it. There is bulging of the disk at
L5-S1 without evidence of a protrusion. Again, image quality is
limited and MR may be helpful.
CT Pelvis ([**2103-12-3**]):
1. Large L inguinal hernia, with a loop of bowel in the sac. No
evidence of obstruction.
2. bony pelvis noted with DJD, but no acute fx.
Hip and L-spine X RAY [**2103-12-2**]:
No acute fracture or dislocation. Please refer to the concurrent
CT pelvis for additional findings of a large left inguinal
hernia.
Echo ([**2-6**]):
CONCLUSIONS
1. The left ventricle size is normal. There is mild concentric
left ventricular hypertrophy. Overall left ventricular systolic
function is low-normal, with an estimated LVEF of 50-55 %. There
is septal flattening in systole which is consistent with right
ventricular pressure overload.
2. The left atrium is moderately dilated.
3. The right ventricle is moderately enlarged. The right
ventricular systolic function is moderately impaired.
4. The right atrium is moderately dilated.
5. There is mild-to-moderate tricuspid regurgitation present.
Estimated PA systolic pressure, calculated from peak TR
velocity, is 53 mmHg above RA pressure.
6. Compared with the findings of the prior study (images
reviewed) of [**2-4**], right heart findings are worse. However, with
retrospective review of the prior study (which has even more
limited imaging of the rightheart than the present study), there
is probably some early and mild abnormalities of the right
heart.
[**2103-12-10**] ECHO
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. 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 dilated with depressed free wall
contractility. There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Atrial fibrillation making evaluation of ventricular
function challenging. Mild symmetric left ventricular
hypertrophy with preserved global and regional left ventricular
systolic function. Dilated and hypokinetic right ventricle with
evidence of volume overload.
CHEST X RAY PA/LAT [**2103-12-3**]:
Findings consistent with moderate pulmonary edema and small left
pleural effusion in the setting of cardiomegaly. Recommend
repeat radiograph after diuresis.
CHEST X RAY AP PORTABLE [**2103-12-10**]:
FINDINGS: In comparison with the study of [**12-7**], there is little
overall
change. Bibasilar atelectasis persists with enlargement of the
cardiac
silhouette in a patient with low lung volumes. Some left pleural
effusion may well be present. However, no definite pulmonary
edema is appreciated.
Of incidental note is an azygos fissure, of no clinical
significance.
[**2103-12-11**] 07:55AM BLOOD WBC-5.3 RBC-4.07* Hgb-13.5* Hct-42.1
MCV-103* MCH-33.2* MCHC-32.1 RDW-16.3* Plt Ct-86*
[**2103-12-3**] 02:45AM BLOOD WBC-4.7 RBC-3.44* Hgb-11.8* Hct-35.6*
MCV-103* MCH-34.2* MCHC-33.2 RDW-17.4* Plt Ct-74*
[**2103-12-3**] 02:45AM BLOOD Neuts-77.0* Lymphs-16.3* Monos-4.0
Eos-2.3 Baso-0.4
[**2103-12-11**] 07:55AM BLOOD PT-16.8* INR(PT)-1.5*
[**2103-12-3**] 02:45AM BLOOD PT-33.0* PTT-38.1* INR(PT)-3.3*
[**2103-12-11**] 07:55AM BLOOD Glucose-110* UreaN-47* Creat-1.4* Na-138
K-3.1* Cl-92* HCO3-39* AnGap-10
[**2103-12-3**] 02:45AM BLOOD Glucose-129* UreaN-26* Creat-1.3* Na-139
K-3.1* Cl-97 HCO3-33* AnGap-12
[**2103-12-8**] 04:21AM BLOOD CK(CPK)-24*
[**2103-12-7**] 07:30AM BLOOD CK(CPK)-23*
[**2103-12-6**] 05:28AM BLOOD CK(CPK)-33*
[**2103-12-5**] 07:15AM BLOOD CK(CPK)-40*
[**2103-12-8**] 04:21AM BLOOD CK-MB-3 cTropnT-0.05*
[**2103-12-7**] 07:48PM BLOOD CK-MB-3 cTropnT-0.05*
[**2103-12-7**] 07:30AM BLOOD CK-MB-3 cTropnT-0.05*
[**2103-12-6**] 05:28AM BLOOD CK-MB-3 cTropnT-0.04*
[**2103-12-5**] 07:15AM BLOOD CK-MB-3 cTropnT-0.04*
[**2103-12-3**] 02:45AM BLOOD proBNP-3632*
[**2103-12-10**] 07:18AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.4
[**2103-12-9**] 05:58AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.5
[**2103-12-6**] 01:55AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.8
[**2103-12-7**] 06:50PM BLOOD Type-ART pO2-86 pCO2-77* pH-7.41
calTCO2-51* Base XS-18 Intubat-NOT INTUBA Comment-O2 DELIVER
[**2103-12-6**] 12:52AM BLOOD Type-ART pO2-51* pCO2-55* pH-7.51*
calTCO2-45* Base XS-17
[**2103-12-6**] 02:28AM BLOOD Glucose-122* Lactate-0.9 Na-137 K-3.2*
Cl-83*
[**2103-12-6**] 12:52AM BLOOD Glucose-143* Lactate-0.9 Na-136 K-3.3*
Cl-85*
[**2103-12-6**] 02:28AM BLOOD freeCa-1.11*
[**2103-12-6**] 12:52AM BLOOD freeCa-1.09*
[**2103-12-6**] 2:00 am BLOOD CULTURE x2 Source: Venipuncture.
Blood Culture, Routine (Pending):
[**2103-12-3**] 12:28 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2103-12-4**]**
URINE CULTURE (Final [**2103-12-4**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
75 y/o male who presented with atraumatic left hip, left low
back, and occassional bilateral lower extremity pain worse with
standing and without neurological symptoms likely due to spinal
stenosis who was transferred to the ICU for hypoxia.
Hypoxia / acute on chronic diastolic CHF: Patient presented
with a new oxygen requirement, satting 94% on 3L NC with
bilateral rales on exam and a reported 10 lb weight gain over
his dry weight with concern for pulmonary edema. CXR revealed
moderate pulmonary edema and small left pleural effusion in the
setting of cardiomegaly, BNP was > 3000. He ruled out for an MI,
his repeat echocardiogram revealed a normal EF and mild LVH.
The patient was initially doing well on the floor early in his
admission. The patient was transferred to the ICU for hypoxia
related to worsening pulmonary edema. In addition the patient
was diuresed and developed a contraction alkylosis, and he was
treated with diamox to help correct this. He was given
agressive potassium repletion during diuresis and his potassium
remained at 3.1 upon discharge. He was discharged home at his
dry weight of 175 lbs, had a room air O2 sat of 97% and a
ambulatory O2 sat on room air of 91%. He was ambulating well
but will get home PT, and given his admission for heart failure
he was referred for tele health to help with diuretic management
should he gain greater than 3 pounds above his dry weight. He
was continued on his beta blocker and his home dose of lasix
120mg po bid. His obstructive sleep apnea is likely a dominant
cause in his R heart failure related to moderate pulmonary
hypertension and is treated with CPAP.
Back and Leg pain: CT demonstrated mild degenerative changes in
the pelvis but no fractures. He was noted to have spinal
stenosis. Patient received Tylenol standing and Oxycodone PRN
for breakthrough pain. PT consult was also provided. Pain and
mobility improved. Given the improvement in his symptoms he was
treated conservatively however an MRI of the spine is indicated
as an outpatient to further assess for severity of spinal
stenosis.
Obstructive sleep apnea: Patient was maintained on CPAP at
night.
Atrial Fibrillation: Patient was on Metoprolol for rate control
and Warfarin for anti-coagulation at home. INR was therapeutic
on admission, was down to 1.5 on discharge, he was given 7.5mg
po x 1 on [**12-11**] then continued on 6.25mg po daily until his
follow up on [**12-14**] with his PCP and warfarin dosing can be
adjusted.
Peripheral vascular disease: Patient was on Aspirin at home and
was continued throughout hospitalization.
Hypertension: Patient was continued on Metoprolol and Lasix.
Coronary Artery Disease: Continued on Aspirin and Metoprolol per
above.
History of Melanoma and Squamous Cell Cancer: No known current
recurrence.
Medications on Admission:
Lasix 120 mg Tab Oral Twice Daily
Coumadin 6.25mgx3days(m.th.sat) Tablet(s) Once Daily, 5mg x4days
or as directed
oxybutynin chloride 5 mg Tab Once Daily
finasteride 5 mg Tab Once Daily
Singulair 10 mg Tab Oral at bedtime
Lopressor 150 mg Tab Twice Daily
allopurinol 300 mg Tab Oral Once Daily
lansoprazole 30 mg Cap, Delayed Release 1 Capsule, Twice Daily
Athlete's Foot (clotrimazole) 1 % Topical Cream Topical 1
Cream(s) Twice Daily
potassium 75 mg Tab Oral unknown times daily
nystatin 100,000 unit/mL Oral Susp Oral 1 tablespoon
Suspension(s) Twice Daily
Levaquin 500 mg Tab Oral 1 Tablet(s) Once Daily
iodoquinol -- Unknown Strength 1 Tablet(s) Twice Daily
*clindamycin 1% 1 Twice Daily
Voltaren 1 % Topical Gel Topical 4 grams Gel(s) Four times daily
colchicine 0.6 mg Tab Oral 1 Tablet(s) Once Daily
metolazone 2.5 mg Tab Oral 1 Tablet(s) Once Daily, 30min prior
to a.m lasix
Ferrex 150 150 mg Cap Oral 1 Capsule(s) Once Daily
nitroglycerin 0.4 mg Sublingual Tab Sublingual 1 Tablet,
Sublingual(s) , as needed
aspirin 81 mg Tab Oral Daily
Multivitamin Tab Once Daily
albuterol sulfate 5 mg/mL (0.5 %) Neb Solution as needed
Flovent Diskus 100 mcg/Actuation for Inhalation 4 puffs q am
Discharge Medications:
1. Lasix 40 mg Tablet Sig: Three (3) Tablet PO twice a day.
2. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day:
take 2.5 tablets (6.25mg) daily until your follow up on [**12-14**],
your dose may be adjusted after this.
3. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO once a
day.
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lopressor 50 mg Tablet Sig: Three (3) Tablet PO twice a day.
7. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
9. Klor-Con M20 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Three
(3) Tab Sust.Rel. Particle/Crystal PO once a day.
10. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ferrex 150 150 mg Capsule Sig: One (1) Capsule PO once a
day.
12. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once a day as needed for chest pain.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. multivitamin Tablet Sig: One (1) Tablet PO once a day.
15. Flovent Diskus 100 mcg/Actuation Disk with Device Sig: Four
(4) puffs Inhalation once a day.
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for SOB.
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
# Acute on chronic systolic and diastolic heart failure
# Respiratory failure
# metabolic alkalosis
# Spinal stenosis
# Obstructive sleep apnea
# Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with back and leg pain due to spinal stenosis,
but were found to be in significant heart failure. You were
treated with medications to remove fluid from your body.
Please take your medications as prescribed and make your follow
up appointments.
Followup Instructions:
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6512**], MD
Specialty: Cardiology
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 6512**]
within 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.**
Name: [**Last Name (LF) 6512**], [**Name8 (MD) **] MD
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 6512**]
within 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: RADIOLOGY
When: THURSDAY [**2104-1-24**] at 11:15 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2104-1-24**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**First Name8 (NamePattern2) 26494**] [**Name8 (MD) 26493**], MD
Specialty: Internal Medicine
When: Friday [**12-14**] at 12pm
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
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|
12995, 15801
|
287, 293
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18756, 18756
|
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18567, 18735
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6363, 6678
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12707, 12972
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3051, 4825
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234, 249
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321, 3032
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18771, 18883
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4847, 5177
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5193, 5263
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,623
| 173,541
|
13577
|
Discharge summary
|
report
|
Admission Date: [**2111-7-7**] Discharge Date: [**2111-7-16**]
Date of Birth: [**2039-7-15**] Sex: M
Service: MEDICINE
Allergies:
Ambien
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 year old male with h/o CRI, HTN, hypercholesterolemia,
presents with 5 episodes of syncope without prodrome. 3 mos ago,
Maxzide was increased from 1-2 tabs daily, then 1.5 months ago,
his creatinine increased from 2.1-2.5. He then presented to his
PCPs office with 20 lb weight loss, fatigue, dry heaves, and
abdominal pain. Labs revealed Cr 7.2, K 4, HCO3 14, prompting
referral to the ED for further evaluation. In the ED, sbp 80s,
prompting volume resuscitation, bedside U/S was performed (no
evidence of pericardial effusion/tamponade), and he received
levofloxacin/flagyl and decadron prior to admission to the [**Hospital Unit Name 153**]
for further management.
Past Medical History:
Chronic renal insufficiency (baseline Cr 1.9-2.1)
Hypertension
History of VZV
Social History:
Lives by himself in [**Hospital3 4634**]. Smoked 2 ppd X 25 yrs, quit
25-30
Family History:
Noncontributory
Physical Exam:
Physical Exam on Admission
VS: Tc 97.3, bp 104/52, bp 87, resp 16, 95% 2L NC
Gen: NAD, pleasant
HEENT: PERRL, EOMI, anicteric, left conjunctival injection
Cardiac: distant heart sounds, RRR
Pulm: decreased lung sounds bilaterally, no wheezes, ronchi
Abd: NABS, soft, no flank TTP
Ext: No C/C/E
Neuro: A&OX3, moves all extremities equally, follows all
commands
Pertinent Results:
Laboratory studies on admission:
[**2111-7-6**]
LACTATE-2.2
LACTATE-1.8
ALT(SGPT)-24 AST(SGOT)-19 CK(CPK)-278 ALK PHOS-58 AMYLASE-269
TOT BILI-0.3
LIPASE-97
CK-MB-5 cTropnT-0.07
ALBUMIN-4.3 CALCIUM-9.2 PHOSPHATE-6.2 MAGNESIUM-1.6
NEUTS-87.3 LYMPHS-9.5 MONOS-3.0 EOS-0 BASOS-0.1
PLT COUNT-173
UREA N-68 CREAT-7.2 SODIUM-139 POTASSIUM-4.0 CHLORIDE-103 TOTAL
CO2-14
ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-5.9
CARBAMZPN-3.9*
WBC-7.5 RBC-3.48 HGB-11.7 HCT-36.5 MCV-105 MCH-33.6 MCHC-32.1
RDW-14.8
NEUTS-76 BANDS-1 LYMPHS-11 MONOS-10 EOS-1 BASOS-0 ATYPS-1*
METAS-0 MYELOS-0
[**7-6**] EKG: Technically difficult study; Sinus rhythm, Low limb
leads voltage
Radiology
[**7-6**] Abd CT1. Mild aneurysmatic dilatation of the infrarenal
aorta with a maximum diameter of 2.5 cm. 3-mm pulmonary nodule
in the right lower lobe.
Multiple bilateral renal cysts. Cholelithiasis. Diverticulosis
without diverticulitis.
[**7-7**] RUQ U/S: Cholelithiasis without evidence of cholecystitis.
Simple cyst in the upper pole of the right kidney
[**7-7**] Head CT (-)
[**7-7**] renal U/S: : Multiple renal cysts without hydronephrosis or
mass.
[**7-8**] TTE: 1. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). The aortic root is
mildly dilated.
Trace aortic regurgitation. 1+ MR. Mild pulmonary artery
systolic hypertension.
Brief Hospital Course:
71 yoM w/ h/o CRI (Cr 1.9-2.1), HTN, and hypercholesterolemia
initially admitted [**2111-7-7**] with syncope (5 episodes w/o
prodrome), N/V, abd pain. Given hypotension, he was admitted to
the ICU, where he received IVF and was transferred to the
general floor [**7-8**]. Over the evening of the [**7-8**], he developed
increased O2 requirement, requiring repeat ICU admission [**7-9**].
His hypoxia was attributed to CHF in the setting of volume
resuscitation. He was diuresed gently and transferred back to
the general floor [**7-11**].
Summary of hospital course by problem:
1) Abdominal pain: Most likely secondary to pancreatitis in the
setting of hypotension/dehydration, given elevated lipase on
admission. The patient was initially kept NPO with IVF.
Abdominal pain resolved. Abdomen CT (-), RUQ U/S with
choleltithiasis, no cholecystitis.
2) Acute renal failure: Cr 7.2 on admission from baseline
1.9-2.1. On time Most likely secondary to ATN, given muddy brown
casts on urine sediment. Cause of ATN was most likely profound
dehydration/hypotension in the setting of poor PO intake and
diuretic use. With supportive management of fluid status,
creatinine gradually returned to baseline (1.9 at time of
discharge). He should have outpatient renal follow-up following
discharge from rehabilitation facility
3) Syncopal episodes: Although these did not have a clear
prodrome, they were most likely secondary to orthostasis in the
setting of dehydration (diuretic use, poor PO intake)
exacerbated by uremia in the setting of acute renal failure.
Telemetry monitoring did not reveal any arrhythmias, only
notable for sinus tachycardia which improved with hydration.
Echocardiogram [**7-8**] with EF >55%, 1+ MR, trace AR, mild
pulmonary artery systolic hypertension. Given the patient's
reported weight loss, a malignancy work-up was initiated. PSA
was elevated at 4.5 (see below). UPEP/SPEP were negative. CXR
was without evidence of mass. The patient reports his last
colonoscopy was a year ago (polyps, unknown if adenomas); he
would benefit from an outpatient colonoscopy.
4) Diastolic congestive heart failure: The patient returned to
the ICU [**7-9**] for hypoxia; CXR was consistent with CHF, most
likely secondary to volume resucitation and demand ischemia. As
mentioned above, TTE showed EF >55%; he was gently diuresed and
oxygen was titrated to off. He was continued on low dose
metoprolol. He would benefit in the future from addition of
afterload reduction, either ACEI (currently limited by recent
ranal failure) or hydral/imdur (currently limited by sbp, which
is in the 110s).
5) Demand ischemia: The patient's troponin peaked on [**7-9**] at
2.31. He was transiently on heparin, which was discontinued in
the ICU, given this was felt to be secondary to demand ischemia
rather than ACS. He was continued on ASA, statin, lipitor.
6) Macrocytic anemia: HCT 25 from 36 on admit (likely
hemoconcentrated on admission). This was macrocytic, hawever
B12/folate were within normal limits. Given likely contributor
of chronic kidney disease, epogen was initiated. His HCT should
be checked on a weekly basis in the rehab to ensure stability
7) Elevated PSA: PSA, obtained as part of a malignancy work-up
was 4.5. This may, in part, be secondary to recent Foley
placement. This should be repeated as an outpatient and referral
for outpatient urology work-up considered
7) DNR/DNI
Medications on Admission:
Atenolol 25 mg PO daily
Maxzide 25/37.5 2 tabs daily, KCL 10 mg PO BID, Lipitor 10 mg PO
daily, Carbamazapine 200 mg PO BID, Niacin 1000 mg PO daily,
Folate 2 mg PO daily
Discharge Medications:
1. Aspirin 325 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. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
6. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**]) units
Injection QMOWEFR (Monday -Wednesday-Friday).
7. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary: acute renal failure
Secondary: congestive heart failure, demand myocardial ischemia,
Discharge Condition:
The patient is hemodynamically stable, with stable room air
oxygen saturation
Discharge Instructions:
Please follow-up with your PCP as directed. Please follow-up if
you develop chest pain, shortness of breath, lightheadedness, or
other symptoms that concern you.
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 333**]
[**Last Name (NamePattern1) 2472**] ([**Telephone/Fax (1) 41003**]) on Thursday [**2111-7-30**] 1:40 p.m.
- you will need a repeat chest CT in 1 year, given a lung nodule
that was seen on your CT scan here
- you would likely benefit from referral to an oupatient renal
doctor (at discretion of your PCP)
- you would benefit from a colonoscopy, given iron deficiency
anemia
- a PSA should be repeated, urology referral considered
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2111-7-17**]
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7368, 7438
|
2971, 3522
|
274, 280
|
7577, 7657
|
1604, 1623
|
7867, 8569
|
1191, 1208
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|
6398, 6570
|
7681, 7844
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1223, 1585
|
227, 236
|
3551, 6372
|
308, 981
|
1637, 2948
|
1003, 1082
|
1098, 1175
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,129
| 178,662
|
33184
|
Discharge summary
|
report
|
Admission Date: [**2138-10-7**] Discharge Date: [**2138-10-21**]
Date of Birth: [**2061-6-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Resp failure, intubated
Major Surgical or Invasive Procedure:
Intubation with mechanical ventilation (x2)
Tracheostomy placement
Right Internal Jugular vein line placement
Arterial line placement
PICC line placement [**10-11**]
History of Present Illness:
77F with COPD, significant smoking hx who was initially admitted
to [**Hospital6 18346**] last wednesday for RLE cellulits,
discharged home on Friday on a course of Augmentin. Per the
family and OSH notes, patient had a new O2 requirement on
discharge of 2L NC. Per her family, patient's cellulitis
improved but she began to act "wacky;" was saying strange
things, hallucinating, and was increasingly somnolent. She also
had decreased PO intake and activity, ? due to SOB. Presented to
her pcp's office today, and reportedly had an O2 sat in the 60s
(74-78 % on 2L), so was sent to the ED.
In the ED in [**Hospital1 6687**], initial VS were BP 167/110, HR 112, RR
28, SaO2 53% on RA, which increased to 94% on 4L. Initially, she
c/o nausea [**3-11**] Augmentin and was given zofran 4 mg IV. She
became obtunded and minimally responsive; CXR reportedly showed
Pulm edema and ABP showed 7.19/113/52/42 and the patient was
intubated. She was also given albuterol nebs and Lasix 60 IV,
Ativan 2 mg IV and Morphine 5 mg IV, and transferred to [**Hospital1 18**].
During [**Location (un) **], was started on peripheral Dopamine at 10
mcg/kg/min (no vitals recorded).
.
In the ED, T 100.8, BP initially 130/56, HR initially 60s but
increased to 140s transiently per nursing report (although HRs
recorded only to max of 120s). Consequently, patient was
changed from dopamine to levophed, and HR improved to 110s.
During this changed, BP reportedly dropped (again not recorded,
and patient bolused 2 liters). She was given vanco/levo to
cover leg and pulm sources, 10 mg IV dexamenthazone and admitted
to the MICU for further management.
Past Medical History:
COPD:
MICU admission [**2136**] for hypercarbic/hypoxic respiratory failure
[**3-11**] strep pneumo infectsion - underwent trach and peg and d/c'd
to [**Hospital **] [**Hospital **] hospital
MICU admission in [**Name (NI) 108**], pt intubated x 2 weeks
?CHF - last TTE [**2136**] showed normal EF
Glaucoma
Social History:
Quit tobacco 16years ago, previously has approximately 80 pack
year smoking history. No EtOH nor other illicits. Formerly
worked in parking permit department at the police dept. Has 9
children (7 daughters, 2 sons). Lives alone on [**Hospital1 6687**], part
of the year in Fla.
Family History:
Family History: non-contributory
Physical Exam:
Discharge Physical Exam
Vitals: T: 97.7 BP: 90/44 P: 85 R: 31 O2: 93%
General: trached, arousable, oriented x3
HEENT: Sclera anicteric, moist MM
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds anteriorly b/l
CV: Regular rate and rhythm, normal S1 + S2, [**3-15**] soft systolic
murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place draining yellow urine
Ext: warm, well perfused, [**2-8**]+ pitting edema b/l
Pertinent Results:
[**2138-10-7**] 10:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2138-10-7**] 09:59PM GLUCOSE-121* LACTATE-0.9 NA+-144 K+-4.4
CL--86* TCO2-41*
[**2138-10-7**] 09:50PM UREA N-17 CREAT-0.7
[**2138-10-7**] 09:50PM ALT(SGPT)-140* AST(SGOT)-95* LD(LDH)-246 ALK
PHOS-159* TOT BILI-0.4
[**2138-10-7**] 09:50PM LIPASE-18
[**2138-10-7**] 09:50PM proBNP-3654*
[**2138-10-7**] 09:50PM ALBUMIN-3.6
[**2138-10-7**] 09:50PM WBC-7.9 RBC-4.06* HGB-12.4 HCT-37.7 MCV-93
MCH-30.6 MCHC-32.9 RDW-14.0
[**2138-10-7**] 09:50PM NEUTS-82.9* LYMPHS-10.0* MONOS-4.5 EOS-1.6
BASOS-0.9
[**2138-10-7**] 09:50PM PT-11.6 PTT-21.0* INR(PT)-1.0
[**2138-10-7**] 09:50PM PLT COUNT-385
[**2138-10-7**] 09:49PM TYPE-ART PO2-75* PCO2-70* PH-7.36 TOTAL
CO2-41* BASE XS-10
___________________________________
IMAGING:
ECHO [**10-8**]
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). A mid-cavitary gradient is identified. 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 aortic valve leaflets
(3) are mildly thickened. There is no valvular aortic stenosis.
The increased transaortic velocity is likely related to high
cardiac output. Trace aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. There is no mitral
valve prolapse. There is severe mitral annular calcification.
There is moderate functional mitral stenosis (mean gradient 12
mmHg) due to mitral annular calcification. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. There is
moderate to severe pulmonary artery systolic hypertension. There
is no pericardial effusion.
[**10-8**]
CTA-
IMPRESSION:
1. Moderate pulmonary edema with bilateral pleural effusions and
bibasilar
consolidations which could be compressive atelectasis in the
setting of
effusions. Superimposed infection is not excluded.
2. Mediastinal adenopathy, unchanged since the prior study. This
could also be related to cardiac decompensation/heart failure.
Alternatively, this could be reactive to a generalized
infectious process.
3. Coronary artery disease, evidence of pulmonary hypertension,
significant mitral annular calcifications are all unchanged.
4. Unchanged left hepatic lobe lesion could represent a cyst or
a hemangioma.
5. Suboptimally visualized previously seen left adrenal mass.
This could
represent an adenoma, however is incompletely imaged, As
indicated previously,
this should be further evaluated with an adrenal protocol CT or
an MRI.
The study and the report were reviewed by the staff radiologist.
CXR [**10-20**]
IMPRESSION: Pulmonary anatomic detail in the lungs is obscured
by respiratory motion.
Chest configuration indicates substantial COPD. Moderate right
pleural
effusion unchanged since [**10-19**]. Left lower lobe opacification is probably atelectasis, but
pneumonia
cannot be excluded. Pulmonary vascular congestion is definitely
present, and
there may be mild pulmonary edema. Heart size top normal.
Tracheostomy tube
in standard placement. Feeding tube passes into the stomach and
out of view.
_______________________________________________
LABS DURING ADMISSION:
CBC [**10-7**]: 7.9 > 12.4/37.7 < 385
CHEM 7 [**10-7**]: 143/4.3 - 105/32 - 18/0.6 < 130
Ca: 7.3
Phos: 3.3
Mg: 1.7
ALT: 140
AST: 95
_______________________________________________
LABS AT DISCHARGE:
CBC [**10-21**]: 10.0 > 8.3/24.9 < 238
CHEM 7: 141/4.1 - 96/40 - 21/0.7 < 125
Ca: 8.3
Phos: 4.2
Mg: 2.4
ALT: 65 ([**10-10**])
AST: 27 ([**10-10**])
TSH: 5.3
Free T4: 0.92
Galactomannan - negative
beta-glucan - negative
Final cultures pending:
[**2138-10-18**] 4:39 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2138-10-18**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. HEAVY GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
Blood cultures from [**10-18**] and [**10-19**] pending - no growth to date
URINE CULTURE (Final [**2138-10-19**]):
YEAST. >100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
Brief Hospital Course:
77 yo F with Hx of COPD with multiple past intubations, now
presenting with hypercarbic respiratory failure and hypotension
concerning for sepsis in the setting of several possible sources
of infection.
.
# Respiratory failure - The patient presented to the [**Hospital1 18**] ED
intubated and sedated. CXR suggestive of pulmonary edema versus
interstitial infectious process. CTA of the chest showed no
pericardial effusion, unchanged mediastinal adenopathy, no PE,
dilated main PA, normal aorta, moderate bilateral pleural
effusions, and moderate pulmonary edema. Patient has been
exposed to hospital pathogens with recent hospital admission for
cellulitis. She was started on levophed, vancomycin, cefepime
and admitted to the MICU. She was able to extubated after being
intubated overnight and was transitioned to bilevel airway
ventilation. She was on this for 1.5 days, however when it was
attempted to wean her off, she became tachypneic, confused, and
hypercarbic and was re-intubated. On [**10-13**] pt was extubated again
, however she quickly became hypertensive and tachypneic and
required re-intubation. Trach and PEG option discussed with pt
and family. On [**10-16**] pt underwent trach (not PEG per patient
decision) with CT surgery and a dobhoff was placed. Pt tolerated
the procedure well with no complications other than residual
pain at the site. On [**10-17**], she had an episode of tachypnea and
fever and CXR showed possible infiltrate. Her Tv decreased and
peak pressures increased during this time. She also had
increased WBC and fever, she was started on empiric therapy for
Ventilator-associated on [**10-18**] with vanco/zosyn for a planned 8
day course to finish on [**2138-10-25**]. Additionally, during this
period she was requiring more pressure support, and was diuresed
with 20 mg IV lasix daily with good output. She can continue to
receive lasix prn if patient appears clinically volume
overloaded. At the time of discharge, the patient's ventilator
settings were: Pressure support at 20/5 with 50% FiO2, breathing
at a rate of 35, with tidal volumes 300-350cc.
.
# Hypotension/Shock: Unclear if septic etiology, or secondary to
combination of medication administration and positive pressure
ventilation. However, given RLE cellulitis as a known source of
infection and significant hypoxia pt was treated empirically for
sepsis. Central line placed (IJ). Cultures at OSH showed no
growth and cultures at [**Hospital1 18**] show NGTD. Vanco and cefepime
courses were completed. Hypotension resolved. However, on [**10-18**],
her worsening Tv, WBC and fevers led to empiric VAP coverage
with Vanc-Zosyn for an 8 day course, to end on [**2138-10-25**].
# Anxiety - The patient frequently became very anxious, becoming
hypertensive to the 200s/100s and tachcardic to the 120s. She
was able to be talked down/reoriented from her anxiety, but
frequently required an anxiolytic as well to calm her down. Pt
was initially treated with ativan and at times required versed.
On [**10-16**] pt was started on seroquel QHS. EKG was checked and
showed no QT prolongation. The patient did well with seroquel
at night, but continued to require small doses of prn ativan for
anxiety.
# SVT - The patient had episodes of tachycardia, her longest
being a run of approximately 30 seconds, which reached a peak of
200 beats per second before spontaneously breaking. She was
started on metoprolol tartrate that was titrated up to 37.5mg
TID before discharge. The SVT was thought to be multifocal
atrial tachycardia and her beta blocker can be titrated up to
suppress the ectopic atrial activity as tolerated.
# Adrenal Mass - Per final CTA read, patient needs follow up CT
or MR [**First Name (Titles) **] [**Last Name (Titles) **] known adrenal mass (not needed in ICU).
# Transaminitis - This was thought to be secondary to
hypotension and hypoperfusion of his liver. These values
improved with time and were not trended during the
hospitalization after normalization.
# Guaiac pos, slow Hct decline - The patient's Hct remained
stable throughout admission, but she needs a colonoscopy as an
outpatient.
Ms. [**Known lastname **] was full code throughout admission. Communication was
with her HCP [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 77111**] (cell), home [**Telephone/Fax (1) 77112**].
Medications on Admission:
Augmentin
Combivent
Symbicort
Vitamins D and C
Folic Acid
Flonase
ASA
.
Discharge Medications:
1. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
2. Colace 60 mg/15 mL Syrup Sig: Twenty Five (25) mL PO twice a
day.
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
4. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) puffs Inhalation four times a day.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO qHS:PRN as
needed for anxiety.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Vancomycin 750 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous every twelve (12) hours for 4 days.
9. Zosyn 4.5 gram Recon Soln Sig: 4.5 g Intravenous every eight
(8) hours for 4 days.
10. Chloraseptic Throat Spray 1.4 % Aerosol, Spray Sig: One (1)
sprays Mucous membrane every four (4) hours as needed for throat
pain.
11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO three
times a day.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection three times a day: Discontinue when patient
appropriately ambulatory.
13. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Primary: COPD exacerbation, pneumonia, anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during your
hospitalization. You were admitted with acute respiratory
failure, and needed to be intubated to help you breathe. Your
respiratory failure was thought to be caused by a flare of your
COPD as well as a possible infection. We treated you with
antibiotics that treated possible lung infections as well as the
cellulitis of your right leg. We tried to remove the breathing
tube twice, however each time you had progressive difficulty
breathing so we had to replace the breathing tubes. Because of
this, we decided to place a tracheostomy to give your lungs more
time to recover. After speaking with you and the surgical team,
it was decided not to place a PEG tube into your stomach.
Instead, a Dobhoff feeding tube was placed through which you are
getting your tube feeds. During your hospitalization, you had
several episodes where your heart began beating very fast. We
started a medication, metoprolol, that helps control this. You
also became anxious, especially at night. We gave you
anti-anxiety medication and started a medication called seroquel
that helped reduce your night time anxiety and let you sleep.
We started a new medication regimen for you. Please continue to
take these as prescribed unless instructed otherwise by one of
your physicians.
1. Bisacodyl 5 mg Two Tablet PO once a day as needed for
constipation.
2. Colace 60 mg/15 mL Syrup Twenty Five mL PO twice a day.
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Six
puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
4. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Six puffs Inhalation four times a day.
5. Metoprolol Tartrate 25 mg 1.5 Tablet PO three times a day.
6. Senna 8.6 mg One Tablet PO twice a day.
7. Quetiapine 25 mg One Tablet in the evening as needed for
anxiety.
8. Famotidine 20 mg One Tablet PO twice a day
9. Vancomycin 750mg IV q12 hours for 4 more days (8 day course)
10. Zosyn 4.5g IV q8 hours for 4 more days (8 day course)
11. Ativan 0.5-1mg po BID prn for anxiety
Followup Instructions:
Please have your tracheostomy stitches removed on [**10-23**]
([**10-23**]).
Follow-up with your PCP as needed after discharge from rehab.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"997.31",
"428.0",
"995.92",
"599.0",
"491.21",
"482.40",
"790.4",
"401.9",
"255.9",
"584.9",
"427.89",
"785.52",
"518.81",
"038.9",
"682.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"31.1",
"96.04",
"96.72",
"96.71",
"38.93",
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] |
icd9pcs
|
[
[
[]
]
] |
13978, 14021
|
8235, 12574
|
340, 508
|
14112, 14112
|
3404, 7243
|
16438, 16709
|
2836, 2854
|
12696, 13955
|
14042, 14091
|
12600, 12673
|
14288, 16415
|
2869, 3385
|
7877, 8212
|
277, 302
|
7262, 7836
|
536, 2175
|
14127, 14264
|
2197, 2506
|
2522, 2804
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,395
| 111,563
|
650
|
Discharge summary
|
report
|
Admission Date: [**2140-5-27**] Discharge Date: [**2140-6-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
[**2140-5-27**] [**Doctor Last Name 1352**] L3-5 PSIF Lami
History of Present Illness:
[**5-27**] [**Doctor Last Name 1352**]
[**5-27**] L3-5 PSIF Lami, 600 EBL
HPI: [**Age over 90 **] F L4-L5 spondylolisthesis with mild stenosis at
L3-4, L4-5, and L5-S1, R leg pain, amb with walker
PMH: Angina, HTN, Cholesterol, Skin Cancer, Insomnia, OA,
Restless leg syndrome, osteoperosis
MED: Fosamx 70, Atenlol 25, Aspirin 325, Nitro 0.6 mg SL,
lipitor 10, Gabapentin 100 [**Hospital1 **], Tramadol 50, Triamterene-HCTZ
37.5-25, Calcium 500-vitD, MVI
ALL: NKDA
Social History:
she lives alone in [**Location (un) 3320**]. No tobacco or alcohol use. Has four
sons, two of whom live close by.
Family History:
No premature CAD, SCD
Physical Exam:
RLE pain
BLE fires L2-S1 motor
Repsonds to senstion throughout BLE
Vitals: TEMP 97.1 HR 83 BP 124/68 RR 23 SAT 96% 3L NC
Gen: Pleasant, well appearing elderly woman lying in bed in NAD
Eyes: No conjunctival pallor. No icterus.
ENT: MMM. OP clear.
CV: JVP low. Normal carotid upstroke without bruits. PMI in 5th
intercostal space, mid clavicular line. RR. nl S1, S2. No
murmurs, rubs, clicks, or gallops. Full distal pulses
bilaterally. No femoral bruits.
LUNGS: L>R crackles. predominately basilar crackles on R, [**1-2**]
way up on the L. No wheezes or rales.
ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not
enlarged by palpation. No abdominal bruits.
Heme/Lymph/Immune: No CCE, no cervical lymphadenopathy.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Gait assessment deferred
PSYCH: Mood and affect were appropriate.
Pertinent Results:
[**2140-5-27**] 02:35PM BLOOD WBC-16.6*# RBC-2.98*# Hgb-9.5*#
Hct-29.1*# MCV-98 MCH-31.9 MCHC-32.7 RDW-14.5 Plt Ct-443*
[**2140-5-30**] 06:58AM BLOOD Neuts-85.1* Lymphs-7.6* Monos-6.6 Eos-0.5
Baso-0.2
[**2140-5-27**] 02:35PM BLOOD PT-13.4 PTT-27.6 INR(PT)-1.1
[**2140-5-27**] 02:35PM BLOOD Glucose-143* UreaN-11 Creat-0.7 Na-139
K-3.4 Cl-107 HCO3-25 AnGap-10
[**2140-5-29**] 09:20AM BLOOD CK(CPK)-508*
[**2140-5-30**] 06:58AM BLOOD CK-MB-23* MB Indx-10.7* cTropnT-1.17*
proBNP-[**Numeric Identifier 4978**]*
[**2140-5-30**] 09:02PM BLOOD CK-MB-13* MB Indx-9.6* cTropnT-1.30*
[**2140-5-31**] 03:23AM BLOOD CK-MB-10 MB Indx-9.8* cTropnT-1.26*
[**2140-6-1**] 05:30AM BLOOD Calcium-8.2* Phos-1.9* Mg-1.8
[**2140-5-30**] 06:58AM BLOOD TSH-2.4
[**2140-5-31**] 03:23AM BLOOD Cortsol-21.8*
[**2140-5-27**] 02:57PM BLOOD Type-ART Temp-36.3 Rates-/12 Tidal V-500
FiO2-50 pO2-84* pCO2-42 pH-7.36 calTCO2-25 Base XS--1
Intubat-INTUBATED
[**2140-5-29**] 05:18PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2140-5-29**] 05:18PM URINE Blood-MOD Nitrite-NEG Protein-75
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2140-5-29**] 05:18PM URINE RBC-[**6-9**]* WBC-[**3-4**] Bacteri-FEW Yeast-NONE
Epi-[**3-4**]
[**2140-5-29**] 05:18PM URINE CastGr-0-2 CastHy-[**3-4**]*
ECG [**2140-5-29**]: regular, narrow-complex tachycardia at 148 bpm,
left axis deviation, lateral ST-segment depression in V5-V6
compared with abseline ECG.
.
ECHO: The left atrium is mildly dilated. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is severely depressed with septal and apical akinesis
(LVEF= 25 %). Cannot exclude apical thrombus. There is distal
right ventricular free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is mild functional mitral
stenosis (mean gradient 4mmHg) due to mitral annular
calcification. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.There is moderate pulmonary artery systolic
hypertension.
.
OTHER TESTING:
CXR ([**2140-5-29**]): Single frontal view of the chest demonstrates
cardiomegaly. There is mild congestive failure with essential
prominence of the pulmonary vasculature. Aorta is somewhat
ectatic and the arch is calcified. There is left lower lobe
consolidation and a small left pleural effusion. The patient is
somewhat rotated.
.
CXR ([**2140-6-1**]): As compared to the previous radiograph, there is
unchanged moderate cardiomegaly and unchanged course and
position of the left-sided PICC line. Also unchanged is the
minimal left apical pneumothorax. The pre-existing opacity at
the left lung base is smaller and less dense than on the
previous examination. No newly occurred focal parenchymal
opacities.
Brief Hospital Course:
The patient underwent an uncomplicated procedure. She was
transfused 1 RBC. She was discharged to rehab about a routine
postop recovery. She was given written information and
precautionary guidance.
MICU Course- Patient admitted to the MICU after developing SVT,
delirium and leukocytosis on POD 3. Prior to transfer, EKG
obtained showed sinus rhythm with borderline left axis
deviation, borderline intraventricular conduction delay with TWF
in the inferolateral leads (all changes new since previous EKG
on record [**2123**]). CXR showed likely LLL infiltrate and increased
vascular markings suggestive of CHF. CE's trended with peak
troponin of 1.30, peak CK of 508 and peak MB of 37. Diagnosed
with NSTEMI vs demand ischemia. Cardiology consulted and
recommended medical management as patient could not be bolused
with heparin given recent spinal procedure. Therefore, she
could not undergo catheterization. She was started on aspirin
325mg, beta-blocker, high-dose statin. She underwent TTE on [**5-31**]
which showed EF of 25% with septal and apical akinesis.
After transferring to floor, she was taken off the heparin.
Questionable thrombus in left ventricle was evulated and thought
to be old with fibronsis over it, so patient was maintained on a
full dose of aspirin. She was not started on warfarin due to
her history of multiple falls. She remained afebrile
thoroughout her stay. Physical therapy evaluated her. It was
thought that her troponin leak is rate related and her poor EF
is due to an old MI. This post-op tachyarrhythmia revealed the
defect and cause her troponin to raise. She remained in sinus
on the floor and was discharged in stable condition. Her PICC
line was stopped and her foley was discharged. She does have a
residue small apical pneumothorax which we are following with
serial CXR. No intervention needed at this point but may need a
repeat CXR in about a week.
She has to follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Phone:[**Telephone/Fax (1) 3736**] Date/Time:[**2140-6-13**] 10:40. She also needs to
wear TLSO brace while she is up and out of bed for the next 4
weeks. She needs to follow up with her PCP for post
hospitalization followup. Please follow up with a cardiologist
at a location near your rehab regarding further titration of
your medications.
Medications on Admission:
MED: Fosamx 70, Atenlol 25, Aspirin 325, Nitro 0.6 mg SL,
lipitor 10, Gabapentin 100 [**Hospital1 **], Tramadol 50, Triamterene-HCTZ
37.5-25, Calcium 500-vitD, MVI
Discharge Medications:
1. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Calcium Carbonate 1,000 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for GI upset.
3. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Nitroglycerin 0.6 mg Tablet, Sublingual Sig: [**1-2**] Sublingual
PRN (as needed) as needed for chest pain.
10. Gabapentin 100 mg Capsule Sig: [**1-4**] Capsules PO BID (2 times
a day): 200 in am, 100 in pm, 400 in evening.
11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*2*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
Liberty Commons Nursing & Rehab Center - [**Location (un) 4979**]
Discharge Diagnosis:
L3-L5 Spinal Stenosis
SVT
h/o MI
CHF
low urine output
hypotension
AMS
anemia
pneumonia
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:
Mrs. [**Known lastname 4643**], you came to the hospital for back surgery. After
surgery, you developed a very fast heart rate and arrythmia
called atrial flutter. We were able to control your heart rate
and you converted back to the regular rhythm. However,
evaluation of your heart showed that you had a previous silent
heart attack that caused a reduction in how effective your heart
pumps. We believe this is the reason for all the lab
abnormalities when your heart was beating very fast. You were
discharged in stable condition and was started on the following
new medications (see below).
Please follow up the following doctors.
Please note we made the following changes to your medications.
STOPPED:
Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
INCREASED:
1. Aspirin 81mg by mouth daily to Aspirin 325 mg Tablet Sig:
One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet PO DAILY to Atorvastatin 80 mg
Tablet Sig: One (1) Tablet PO DAILY (Daily).
STARTED:
Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Lasix 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig:
0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
It was a pleasure taking care of you. We wish you the best on
your road to recovery.
You have activity limitations:
No Bending
No Twisting
No Lifting
Please call your PCP if your weight increases >2lb in one day.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2140-6-13**] 10:40
Please follow up with your PCP and cardiologist near your rehab.
You need to have your medications titrated to appropriate
level, specifically with regard to your diuretics.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
|
[
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"724.02",
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"427.32",
"780.52",
"272.0",
"285.9",
"E878.1",
"401.9",
"791.9",
"733.00",
"512.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.08",
"81.62"
] |
icd9pcs
|
[
[
[]
]
] |
8855, 8947
|
4824, 7220
|
277, 338
|
9078, 9078
|
1881, 4801
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|
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220, 239
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366, 834
|
9093, 9230
|
850, 965
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,593
| 199,515
|
40986
|
Discharge summary
|
report
|
Admission Date: [**2164-4-7**] Discharge Date: [**2164-4-13**]
Date of Birth: [**2142-1-26**] Sex: F
Service: MEDICINE
Allergies:
morphine / Codeine
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
c-scope and EGD [**2164-4-13**]
History of Present Illness:
Ms [**Known lastname 89417**] is a 22 year-old female with history of anxiety, s/p
recent rape (both vaginally and anally), which pt admitted to
multiple people was also with insertion of a baseball bat, with
subsequent pregnancy s/p abortion on [**4-7**] who presented to an OSH
with abdominal pain after the procedure. She went to went to
planned parenthood for the 2 day procedure; during second day
had desaturation to 78% and abdominal pain, and was sent to
[**Hospital1 **] for evaluation. There she was found to have a Hct of
24 and SBPs in the 70's. She was also noted to have ?SVT to the
150's and was given metoprolol and adenosine and was eventually
electrically cardioverted to sinus rhythm. She was given 2 unit
PRBCs and 7 L IVF, and also got FFP. She underwent a CTA which
showed no PE and an abdominal CT with no hemorrhage. Prior to
this presentation in the OSH ED, she had been experience milder
abdominal pain for the past two weeks and had an episode of
BRBPR the day prior to presentation.
.
In the [**Hospital1 18**] ED she had SBPs in the 90s. She was given an
additional unit of PRBC, 2 units FFP, and rhogham. Gynecology
evaluated her and recommended starting zosyn and doxycycline.
She had a left IJ placed and was briefly on neo for pressure
support. On vaginal exam she was noted to have small clots.
Rectal showed trace guaiac stool. Of note she has recently
beeing taking large amounts of ibuprofen for pain. She was
started on an IV PPI.
.
She was initially in respiratory distress on arrival to the MICU
(thought to be due to flash pulmonary edema from the IVF) and
was given lasix. In the MICU her Hcts remained stable with no
further need for transfusion. Her acute anemia was thought to be
a combination of blood loss from her recent abortion and a slow
GI bleed possibly from NSAID-induced gastritis. She has had
significant anxiety and ?PTSD and psychiatry has been following
and making recommendations. She continues to have abdominal pain
and is on a dilaudid PCA. Social work is also following. GI was
consulted and are planning possible EGD/colonoscopy for Tuesday
(will likely need MAC) versus watchful waiting.
.
Additionally she had been placed on prednisone by her
pulmonologist (to be tapered). She was on 60 mg prior to
admission and has been tapered to 40 mg.
.
MICU attempted to call her out [**4-8**] but when the team evaluated
her she was found to have HR in the 150's with significant
anxiety. ? SVT. Sinus massage was attempted, but she was so
shaky, it was difficult to do. When she slowed down (when her
anxiety started to be controled), the rhythm looked like sinus
tach, not SVT, and she was kept in the ICU for 1 more night.
.
Patient continues to have abdominal pain, worst on the L, most
TTP over the CVA on the L. The abdominal pain has been requiring
a dilaudid PCA; ICU team felt she may have nonobstructive
nephrolithiasis vs an ovarian cyst but all imaging is with
contrast, so unclear. GYN are following and does not think
there is any retained products but thinks may have had
endometritis so have continued course of abx, currently zosyn
and doxycycline.
.
Upon transfer to the floor, patient is tearful and anxious, c/o
abdominal pain.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- ADHD
- asthma
- anxiety
- eating disorder
- h/o nephrolithiasis, always on left, last one 1 month ago
- h/o left ovarian cyst
Social History:
just quit smoking, denies alcohol and illicit drugs
Family History:
Non-contributory
Physical Exam:
On Admission:
Vitals: 110, 117/74, 17, 97% 6L facemask
General: anxious, in pain
HEENT: PERRLA, EOMI, OP clear, no LAD, neck veins flat, L CVL in
place
CV: S1S2, tachycardic, no m/r/g
Chest: limited exam due to shallow breathing, +wheezes,
decreased BS in bilateral bases
Abd: soft, moderate TTP diffusely, pain worst in LLQ, mildly
distended, +BS, no rebound/guarding
GU: (per Ob/gyn) no CMT, minimal blood, diffuse TTP, no discrete
adnexal or fundal TTP
Rectal: (per ED) faintly guiac positive
Ext: no e/c/c, 2+ peripheral pulses
Neuro: CN II-XII grossly intact, moving all 4 extremities
Psych: anxious
On Discharge:
VS: Tm 98.1, Tc 98.0, BP 100/70 (100-110/68-82), HR 65 (65-93),
RR 15 (15-18), 96%RA (96-98%RA)
GENERAL - young female sitting in bed, alert, appropriate
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - hypoactive bowel sounds in all 4 quadrants. L CVA
tenderness, L abdominal tenderness with voluntary guarding, no
rebound
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
GU: Full speculum vaginal exam showed bright red blood in the
vaginal vault, but otherwise normal vaginal mucosa, no lesions,
no scars no areas of obvious trauma
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-5**] throughout, sensation grossly intact throughout
Pertinent Results:
Admission labs:
===============
[**2164-4-7**] 01:50AM BLOOD WBC-12.5* RBC-3.02* Hgb-9.2* Hct-27.2*
MCV-90 MCH-30.4 MCHC-33.7 RDW-14.4 Plt Ct-252
[**2164-4-7**] 01:50AM BLOOD Neuts-91.7* Lymphs-5.5* Monos-2.5 Eos-0.2
Baso-0.1
[**2164-4-7**] 01:50AM BLOOD PT-13.5* PTT-25.5 INR(PT)-1.1
[**2164-4-7**] 01:50AM BLOOD Glucose-155* UreaN-6 Creat-0.4 Na-144
K-2.7* Cl-117* HCO3-15* AnGap-15
[**2164-4-7**] 01:50AM BLOOD Calcium-7.2* Phos-2.9 Mg-1.5*
.
Discharge labs:
===============
[**2164-4-13**] 08:20AM BLOOD WBC-8.3 RBC-4.73 Hgb-14.3 Hct-42.2 MCV-89
MCH-30.3 MCHC-34.0 RDW-14.9 Plt Ct-222
[**2164-4-13**] 08:20AM BLOOD Glucose-92 UreaN-8 Creat-0.7 Na-142 K-3.6
Cl-109* HCO3-22 AnGap-15
[**2164-4-13**] 08:20AM BLOOD Calcium-9.3 Phos-4.4 Mg-1.8
[**2164-4-11**] 05:45AM BLOOD HIV Ab-NEGATIVE
.
Imaging:
========
CXR: There is a left-sided IJ central venous catheter with the
distal lead tip at the cavoatrial junction. There has been
worsening of the airspace opacities bilaterally which causes
more opacification of the left retrocardiac area. Findings are
concerning for worsening pneumonia and/or aspiration.
.
Renal U/S:
1. No renal calculus identified; however, please note that CT is
more sensitive. No hydronephrosis.
2. Mild splenomegaly, small amount of ascites, suggestion of
splenorenal shunt and prominent splenic hilar vessels. Correlate
with any history of known liver disease/portal hypertension.
Possible small bilateral pleural effusions.
.
Pelvic U/S:
1. Enlarged uterus, compatible with recent TAB. Heterogeneously
echogenic material without internal vascularity in the
endometrial canal, most compatible with blood products. No
internal vascularity to definitively suggest presence of
retained products of conception.
2. Small free fluid.
3. Normal right ovary. Nonvisualization of the left ovary.
.
Repeat pelvic U/S:
Again seen, thickened, heterogeneous endometrium, measuring 2.7
cm in diameter, without internal vascularity.
.
CTA CHEST W&W/O C&RECONS, NON-; OUTSIDE FILMS READ ONLY; CT ABD
& PELVIS WITH CONTRAST; OUTSIDE FILMS READ ONLY
1. Enlarged heterogeneous uterus, likely reflecting TAB one day
prior. However, there is a large amount of heterogeneous fluid
and debris within the endometrial canal. This may reflect
hematometra, though retained products of conception cannot be
excluded by CT and ultrasound is recommended for further
evaluation. Superinfection also cannot be excluded by CT
imaging, and clinical correlation is advised.
2. No free fluid or free air in the abdomen or pelvis to suggest
uterine perforation.
3. No evidence of pulmonary embolus within the limits of this
study, which is limited by suboptimal bolus timing.
4. Heterogeneous enhancement of the kidneys may reflect phase of
contrast
timing, though correlation with urinalysis is recommended to
exclude pyelonephritis.
REPEAT CXR [**2164-4-9**]: IMPRESSION:
1. Improving mild pulmonary edema.
2. Possible tiny right pleural effusion, unchanged.
HEAD CT:
IMPRESSION: No acute intracranial hemorrhage or amss effect. If
there is
continued clinical concern given the abnormal neuro examn as
mentioned on the requisition, MRI can be considered if not CI.
EGD [**2164-4-13**]: Normal GE junction (biopsy)
Antral gastritis (biopsy)
Erythema and petechiae in the stomach fundus and cardia (biopsy)
Erythema with prominent vasculature and pigmentation in the
duodenum (biopsy, biopsy)
Small hiatal hernia
Otherwise normal EGD to ligament of Treitz
Recommendations: Will follow up biopsy report and inform
patient
Continue PPI therapy
Treat for H.pylori if positive
Return to hospital floor
C-Scope [**2164-4-13**]:
Impression: Normal mucosa in the whole colon and terminal ileum
Non-bleeding grade 2 internal hemorrhoids
Otherwise normal colonoscopy to cecum and terminal ileum
Recommendations: The findings do not account for the symptoms
Return to hospital floor
If rebleeding, suggest flexible sigmoidoscopy
MICROBIOLOGY:
[**2164-4-8**] [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB- NEGATIVE; [**Doctor Last Name **]-[**Doctor Last Name **]
VIRUS EBNA IgG AB-NEGATIVE; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM
AB-NEGATIVE
[**2164-4-8**] CMV IgG ANTIBODY-FINAL; CMV IgM ANTIBODY- NEGATIVE
[**2164-4-8**] MONOSPOT-NEGATIVE
[**2164-4-7**] URINE CULTURE-NEGATIE
[**2164-4-7**] MRSA SCREEN-NEGATIVE
[**2164-4-7**] BLOOD CULTURE- NEGATIVE
[**2164-4-7**] BLOOD CULTURE- NEGATIVE
Per report from [**Hospital1 **]: Gonorrhea and Chlamydia screen -
NEGATIVE
Brief Hospital Course:
22 F G2P1 s/p TAB on [**4-6**] at 16 weeks, presented with
hypotension, vaginal bleeding, respiratory distress and
abdominal/pelvic pain.
.
#. Abdominal pain - patient admitted with abdominal pain after
TAB, she also had associated vaginal bleeding and pelvic pain
with no peritoneal signs on examination. Her abdominal pain has
been ongoing for several months with acute worsening of pain
over past several days prior to admission. No free
intra-abdominal air on CT. She received rhogam in the ED and
there was no abdominal free fluid visualized on ultrasound at
that time. She has a history of kidney stones though this is
unlikely at this time. PID, hemometria and splenomegaly also
consideration. Given splenomegaly and recent sexual assault HIV
testing was performed and returned negative. Patient was given
dilaudid PCA during MICU stay and continued on zosyn and
doxycycline per ObGyn recs for empiric coverage of endometritis.
Her cultures did not have any growth to date. GI was consulted
and felt that some of her pain may have been due to an ulcer or
gastritis in setting of heavy recent NSAID use. They recommended
an EGD/[**Last Name (un) **] once patient was stable. Of note, patient initially
reported that her pain has been ongoing for 2-4 weeks with
melena and occasional bloody stools prior to admission. On HD3
she reported prior assault with a small baseball bat in her
vagina and rectum and feels that the bleeding may be due to
this. We could not confirm whether this was the etiology. After
she was transferred out of the MICU she had frequent
"flashbacks" to the assualt, all of which brought on [**9-10**]
abdominal pain, for which she was given dilaudid and ativan. It
became clear that the pain was more somatic than anything as it
was relieved by just ativan at times, and the resolution of the
panic attacks. She received an EGD and c-scope on [**4-13**], which
showed likely healed gastritis and some hemorrhoids. She was
started on omeprazole at dispo (as an inpatient was on IV PPI)
and told to follow up with her new PCP to ensure resolution of
her sx. She also was encouraged to attend an outpatient psych
partial hospitalization program (as below). In addition she was
sent home with flagyl and doxycycline to complete a 14 day
course for PID per OB/GYN recs, although suspicion was low, and
gonorrhea and chlamydia were reported as negative at [**Hospital1 **].
She was sent home on a small amount of oral dilaudid for her
abdominal pain, although we felt that her pain would be more
likely improved with intensive psychotherapy to help decrease
the frequency of her flashbacks of the assault.
.
#. Acute respiratory distress - pulmonary edema likely from
large fluid bolus that patient received at OSH and ED. Improved
with IV lasix 10 mg x1. Patient with history of asthma, had been
on 60 mg of prednisone for the last 6 days prior to TAB. Also
with component of extreme anxiety. TRALI was also a
consideration given blood products given at OSH. Flash pulmonary
edema less likely given low BPs during episode. Aspiration and
ARDS [**1-4**] sepsis also on differential. We considered PE though
CTA was negative (poor study) and this is unlikely to cause
pulmonary edema. Repeat CXR prior to transfer to floor showed
improvement in pulmonary edema after receiving another dose of
lasix 10mg IV. She was continued on diuresis for 1-2L goal net
negative daily. Prednisone was tapered to 40mg for 2 days, and
20mg for 2 days then 10mg for 3 days, then stopped. She was
receviing ativan prn and standing to aid with anxiety. At time
of transfer out of the MICU, patient was on 4L NC, but quickly
it became apparent that she only needed the oxygen when she was
having a panic attack and was comfortable on RA otherwise. She
was sent home on no prednisone after having completed a taper.
.
#. Anxiety - patient has severe anxiety per family, had been on
ativan prior to pregnancy. She is s/p recent sexual assault with
severe episodes of anxiety. Psychiatry was following patient and
recommending ativan initially standing and prn, but then
downtitrating to PRN only. She was started on zoloft 25mg daily.
She was also started on trazodone 100mg QHS PRN insomnia. Social
work was also consulted and was helping patient obtain a
restraining order against perpetrator, but she refused despite
multiple providers attempting to convince her to do so. Patient
had frequent panic attacks during this hospitalization, with
tachycardia, hyperventilation and reported [**9-10**] abdominal pain.
We had to give IV ativan numerous times during these panic
attacks initially, but eventually we would just sit with the
patient while they resolved, and then give PO ativan once she
was able to safely swallow pills. Psychiatry started her on
zyprexa, initially at 1.25mg QD then at 2.5mg QD, which helped
decrease the frequency of pt's attacks. She was cleared by
psych to go home with intensive outpatient psychiatric
follow-up, as they felt she did not meet sectionable criteria.
Patient was given information about partial hospitalization
programs in her area, all of which require her to call for an
intake meeting 24hrs prior to the start date. She was
instructed of this, as were her parents, who would transport her
to the program, and reminded that this is an incredibly
important part of her healing process. She was also set up with
a f/u appt with her outpatient psychiatrist.
.
# Sinus Tachycardia ?????? Patient with sinus tachycardia in setting
of her panic attacks only. No evidence of acute blood loss or
fever. Tachycardia did not improve with fluid bolus, but did
improve with ativan, and resolution of panic attacks.
.
#. Hypotension - likely in setting of blood loss vs. sepsis
related to infection from TAB. Blood pressure improved with
fluid resuscitation, blood transfusion, and pressors which were
weaned quickly. There was also concern for infection given
abortion, with C. sordelli being the most concerning. She was
empirically started on zosyn and doxycycline for coverage of
endometirits. Her WBC trended down, and she was transitioned to
flagyl and doxy for a 14 day course for PID (although low
suspicion).
.
#. Anemia - in setting of acute GI bleed (likely has been having
chronic bleed in setting of NSAID use), only small amount of
blood loss during TAB. Also received 7 L of fluid resuscitation
at OSH so component of dilution. On pelvic exam, no active
bleeding. No evidence of bleeding on imaging. She is s/p a
total of 4 units pRBC given in the ICU. Faintly guaiac positive
in ED. Per family she has a history of polyps in rectum. As
above, a few days into her hospitalization patient reported
prior assault in her vagina and rectum with a small baseball bat
which she believes may be contributing to the bleeding. On
admission initially, she reported black stools at home, then
BRBPR. GI was consulted and recommended EGD/colonoscopy for
further evaluation. She was continued on pantoprazole IV q12h.
EGD showed likely healing gastritis, but this was done after pt
on PPI x1 week, and c-scope showed hemmorhoids. Patients HCT
stabilized to 42.2 at dispo.
.
#. Sexual assault - did not report this to authorities, does not
want her family to know. Family is aware that she's had the
abortion, but not the assualt. She was given rhogam on
admission. Psychiatry and social work are following patient. Her
HIV was negative here and G/C test at OSH negative. Patient's
assailant is the father of her other child. She reports that he
has been raping her many times over the last year. He was
previously in jail, but when he got out he raped her numerous
times. Per pt report this was both vaginally and anally, and
also with many painful objects including a broken off baseball
bat. She also reported that his friends had raped her 3 weeks
prior to her abortion, which was why she decided to have one.
"They told me I must have wanted it, if I'd had a kid with him
(the assailant), so I was a whore and they could do what they
wanted with me." She is very psychologically fragile and is
blaming herself for the assaults "if I'd just said yes, we could
have had normal sex". She will need longterm intensive
psychotherapy for these issues. One residual effect is that pt
has panic attacks around any male providers and should be
treated by female providers only if possible. We attempted
numerous times to convince her to file a restraining order, but
she felt this would just anger her assailant. Her mother
assures us that he was not allowed anywhere near the pt.
.
#. ADHD - held adderall per psychiatry both during the admission
and at dispo, as pt becomes tachycardic frequently with panic
attacks.
PENDING LABS:
None
TRANSITIONAL CARE ISSUES:
Pt set up with a new PCP, [**Name10 (NameIs) 1023**] has been contact[**Name (NI) **] to explain the
large amount of issues this pt will need followed up on.
Patient will need to start her partial hospitalization program
as soon as possible. She will need frequent follow-up visits in
the future to ensure improvement of her symptoms.
Medications on Admission:
home meds:
- Adderall
- Vistaril (hydroxyzine
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain: DO NOT EXCEED 4GRAMS IN 24
HOURS.
Disp:*30 Tablet(s)* Refills:*0*
4. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomina.
Disp:*14 Tablet(s)* Refills:*0*
6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): LAST DAY = [**2164-4-23**].
Disp:*30 Tablet(s)* Refills:*0*
7. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours): LAST DAY [**2164-4-20**].
Disp:*14 Capsule(s)* Refills:*0*
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*35 Tablet(s)* Refills:*0*
9. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
11. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Anxiety, Respiratory Distress, mild duodenitits
Secondary: Asthma
Discharge Condition:
.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 89417**],
You were seen in the hospital for low blood pressure,
respiratory distress and bleeding. This was improved after you
were in the ICU. You got a colonoscopy and EGD that showed the
possibility of a prior gastritis (irritation from likely
ibuprofen use). You had biopsies taken and your PCP will be
able to follow-up on these as an outpatient. We highly
recommend that you go to an outpatient psychiatric program, the
details of which were given to you at discharge. We also highly
recommend you file a restraining order as previously discussed
with you.
We made the following changes to your medications:
1) We STARTED you on SENNA 8.6mg twice a day as needed for
constipation.
2) We STARTED you on DOCUSATE 100mg twice a day for
constipation.
3) We STARTED you on TYLENOL 500mg to 1000mg every 6 hours as
needed for fever/pain.
4) We STARTED you on SERTRALINE 25mg once daily
5) We STARTED you on TRAZODONE 100mg at bedtime as needed for
insomnia.
6) We STARTED you on METRONIDAZOLE 500mg every 8 hours with last
dose on [**2164-4-23**].
7) We STARTED you on DOXYCYCLINE 100mg every 12hours, last day
[**2164-4-20**].
8) We STARTED you on DILAUDID 2-4mg every 4-6 hours as needed
for pain.
9) We STARTED you on OLANZAPINE 2.5mg once a day for anxiety.
10) We STARTED you on ATIVAN 1-2mg every 4 hours as needed for
anxiety.
11) We STARTED you on OMEPRAZOLE 40mg once a day for your
gastritis.
If you experience any of the below listed Danger Signs, please
call your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
Department: [**State **]When: FRIDAY [**2164-4-20**] at 9:20 AM
With: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2205**]
Building: [**State 7478**] ([**Location (un) 86**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
**Please contact your insurance company as soon as possible. You
will need to inform them of your new Primary Care Dr [**Last Name (STitle) 5001**] this
appointment. Your new Dr [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].**
You also have the following appt:
[**4-18**] Wednesday at 5:30 Dr. [**Last Name (STitle) 2645**]. Phone: [**Last Name (NamePattern1) 89418**]in [**Location (un) 47**] [**Numeric Identifier **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
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21,166
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Discharge summary
|
report
|
Admission Date: [**2195-1-25**] Discharge Date: [**2195-1-30**]
Date of Birth: [**2145-9-22**] Sex: M
Service: Thoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old man
with a history of esophageal cancer first diagnosed in [**2194-5-2**] status post chemotherapy and radiation, who underwent an
[**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy on [**2194-11-13**] by Dr. [**Last Name (STitle) 175**] at this
institution. Since that operation, the patient's
postoperative course has been complicated by a
methicillin-resistant Staphylococcus aureus wound infection,
wound dehiscence, and creation of a fistula and diversion
after breakdown of his anastomosis. The patient had a
prolonged hospital stay at that time, but recovered and was
discharged to rehabilitation. While at rehabilitation the
patient continued on his long-term vancomycin therapy, which
was completed on [**2195-1-21**]. On that date, the patient began
to experience fever and mental status changes, and was
transferred to [**Hospital3 417**] Hospital, where he was found to
be frankly septic. Once the patient's history was known, he
was transferred to the [**Hospital1 69**]
for further work-up.
HOSPITAL COURSE: Upon presentation at our facility the
patient was found to be frankly septic, in need of blood
products, which were given. The patient required near
immediate intubation, which was undertaken. Extensive
work-up of the patient included CT scan of his abdomen and
chest, magnetic resonance imaging scan of his abdomen,
bronchoscopy and multiple cultures, revealing that the
patient was floridly septic, although a discrete source was
not clearly identified.
The patient was started on broad-spectrum antibiotics,
vancomycin, levofloxacin, and Flagyl. The patient's fistula
was found to be draining frank pus, although no discrete
drainable fluid collection was found in his chest.
Over the next few days the patient remained in the intensive
care unit intubated, in extremely serious condition, not
improving on his antibiotics. Discussions were undertaken
with the family and he was made DNR, and the decision was
made to transfuse no new blood products and to start no
pressors. The patient's white count continued to rise. He
was found to be in disseminated intravascular coagulation and
appeared to be having liver failure. His blood gases
demonstrated that he was persistently severely acidotic.
The patient's course continued to deteriorate and on the
morning of [**2195-1-30**] the patient was found to still be
spiking fevers, was hemodynamically unstable, and to be in
severe disseminated intravascular coagulation. The patient
succumbed and was pronounced dead at 10:45 AM on [**2195-1-30**]. The family was notified of the death, as well as the
attending surgeon, and consent was obtained for a postmortem
examination.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 22409**]
MEDQUIST36
D: [**2195-1-30**] 11:24
T: [**2195-1-30**] 12:03
JOB#: [**Job Number 35106**]
|
[
"518.81",
"V10.03",
"038.9",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.23",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
1262, 3183
|
178, 1244
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,477
| 124,916
|
22730
|
Discharge summary
|
report
|
Admission Date: [**2180-3-30**] Discharge Date: [**2180-4-6**]
Date of Birth: [**2128-3-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
CC:[**CC Contact Info 58848**]
Major Surgical or Invasive Procedure:
Upper endoscopy twice. Thoracentesis
History of Present Illness:
HPI: 52 yo M c metastatic pancreatic CA treated with docetaxel
[**3-15**]. Presented to [**Hospital3 **] ED for malaise, fatigue [**3-20**]
c fever to 101 and WBC 0.4. At time of presentation also
complaining of intermittent reflux symptoms to liquids. Has
history of reflux to both solids intermittently but now
reporting occasional, unusual fullness especially with
carbonated beverages. No nausea, vomiting, however. In
addition, reported no localizing symptoms prior to admission at
[**Hospital1 **] --> no cough, congestion, pleuritic pain, headache,
abdominal pain, dysuria, diarrhea. At [**Hospital1 **], noted to have
febrile neutropenia. Sputum ctx positive for Klebsiella and
yeast. Blood ctx, urine ctx no growth to date. Treated with
various antibiotics. Initially piperacillin-tazobactam and
fluconazole, then transitioned to solely pip-taz. On transfer
appears as though pt was being treated with vancomycin (stopped
AM [**3-30**]), linezolid, metronidazole, and levofloxacin. Had CT
scan to evaluate symptoms of reflux and noted to have possible
gastric outlet obstruction. Transfered to [**Hospital1 **] for evaluation of
gastric outlet obstruction and possible stenting. Not
neutropenic on transfer.
Past Medical History:
ONC hx: Initially developed lower back pain fall [**2177**] and acute
onset of epigastric pain after PO intake in [**11-6**]. Had
ultrasound to look for biliary disease; unrevealing. Had EGD
which showed "inflamed duodenum". HIDA scan abnormal and CAT
scan done at [**Hospital3 4107**] showing pancreatic mass. Underwent
EUS c biopsy + malignant cells. Repeat CT scan [**Hospital1 18**] [**12-9**]
showed occlusion of SMV, splenic vein, involvement of arteries
of celiac axis. Underwent staging laparascopy [**12-9**], showing no
metastatic disease in liver or abdomen.
Treated first with XRT and gemcitabine; tolerated treatment well
except for some thrombocytopenia. Underwent repeat imaging
showing enlargement of pancreatic mass, new hepatic metastases,
omental metastatic disease. Was then placed on protocol for
pancreatic CA with capecitabine (Xeloda) and oxaliplatin. Had
some shrinkage of primary pancreatic mass on this protocol but
experienced paresthesias, development of intention tremor, and
peeling of skin over feet. Xeloda stopped intermittently and
then redosed. Also complicated by thrombocytopenia. He
experienced persistent neuropathy but continued on protocol at
adjusted doses given stability of disease. [**1-10**] pt. had
progression of liver lesions and was removed from protocol.
Started on docetaxel (taxotere) c neulasta injections [**2180-3-15**].
.
PMH:
Hypertension
Hyperlipidemia
Rhinoplasty
R knee arthroplasty
Social History:
SH: Smoked approx 30 pack years, quit 1.5 yrs ago. Social
alcohol use. Dentist. Trained at BU. Born in Poland.
Family History:
FH: Mother alive, father c CHF, brother c ? bipolar, maternal
uncle died of malignancy at 64 unknown type.
Physical Exam:
PE: on admission to oncology service.
VS - 100.2, 146/94, 93, 18, 100% RA
HEENT - ? mildly icteric sclerae, no mucositis, no thrush noted.
OP clear. Somewhat dry MM, diffuse erythematous rash over face.
LUNGS - CTA, no crackles, wheeze, rhonchi appreciated
HEART - RRR, S1, S2, ? [**1-10**] SM at RUSB
ABD - soft, NT, ND, no organomegaly noted. BS +, no dullness to
percussion
EXT - wwp, no cce. pain on palpation of plantar surface of
feet.
Pertinent Results:
DATA:
labs - see below
imaging -
CT ABD at [**Hospital3 **] - p
1. Mass in pancreatic head and body, hepatic masses c/w mets
2. Minimal ascites, ? splenic varices
3. Distended stomach, ? gastric outlet obstruction
4. lingular atelectasis or scarring/small L pleural effusion
micro -
sputum ctx + klebsiella at [**Hospital1 **]
blood ctx NGTD
urine ctx NGTD
.
pleural fluid studies:
[**2180-4-4**] 01:10PM PLEURAL WBC-190* RBC-4045* Polys-44* Lymphs-19*
Monos-11* Meso-9* Other-17*
[**2180-4-4**] 01:10PM PLEURAL TotProt-1.5 Glucose-88 LD(LDH)-92
[**2180-4-4**] 04:29AM BLOOD LD(LDH)-169
[**2180-4-4**] 04:29AM BLOOD TotProt-3.9*
.
Brief Hospital Course:
A/P: 52 yo M metastatic pancreatic CA admit c febrile
neutropenia.
.
Pancreatic Cancer - Admitted for concern for gastric outlet
obstruction. Underwent upper GI series demonstrating flow of
barium into duodenum. Tolerated imaging well but day following,
developed several episodes of hematemesis. Then had 1 grossly
melanotic bowel movement with a 7 point hematocrit drop (27-20).
Remained hemodynamically stable through this however.
Transfered to ICU for upper endoscopy. On first attempt, no
clear bleeding source was determined but copious coffee grounds
noted in stomach. Following day after requiring pRBCS without
appropriate rise in HCT, repeat endoscopy showed bleeding vessel
at GE junction. This was clipped endscopically. He remained HD
stable and his HCT bumped appropriately. He was transfered back
to the oncology service. His hematocrit remained stable at 27-28
at the time of discharge.
.
Pneumonia - Treated with 10 day course of oral levofloxacin
(transitioned to IV during UGIB). Was afebrile with minimal
cough throughout. Repeat micro data no growth to date (needs to
be followed up). CXR [**4-4**] shows LLL atelectasis and resolved LLL
effusion (compared to CXR [**4-1**] with LLL and LML opacities).
Pleural effusion was tapped [**4-4**] which is c/w transudative
uncomplicated parapneumonic effusion. However, there are
atypical cells with cytology pending.
.
Pleural Effusion - Noted to have new pleural effusion at time of
transfer to [**Hospital Unit Name 153**]. Unclear etiology; possibilities considered
included malignancy vs. parapneumonic vs. fluid resuscitation in
setting of low albumin. Tapped in [**Hospital Unit Name 153**] and shown to be
transudative. Cytology is pending.
.
Febrile neutropenia- resolved.
.
Peripheral Neuropathy - Related to hx of oxaliplatin treatment.
Continued hydromorphone for pain and discharged pt with prn
codeine.
.
Rash - Likely related to docetaxel; improved at time of
discharge
Medications on Admission:
Meds as outpt:
Amlodipine 5 qd
Percocet PRN
NKDA
.
Meds on transfer:
acetaminophen
dolasetron
milk of magnesia
nystatin swish and swallow
docusate
MVI
hydromorphone 2 PO q4-6 PRN
metronidazole 500 mg IV q6h
levofloxacin 500 mg IV qd
vancomycin 1 g q12 h (last dose 4/27 AM)
? linezolid ? - 400 mg PO bid
Discharge Medications:
1. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
2. 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*
3. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO
every 4-6 hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Metastatic pancreatic cancer
2. Erosive gastritis, esophageal ulcer s/p clipping, GI bleed
Discharge Condition:
stable, hematocrit stabilized, tolerating pos
Discharge Instructions:
You should take all your medications as directed. Keep all your
appointments. If you experience any worsening of nausea,
vomiting, diarrhea, abdominal pain, chest pain, or shortness of
breath, contact your PCP or Dr. [**Last Name (STitle) **] or come to the ED.
Followup Instructions:
1) Please call Dr.[**Name (NI) 8949**] office tomorrow to set up a
follow up appointment
|
[
"530.10",
"157.0",
"530.81",
"276.52",
"197.2",
"E933.1",
"482.0",
"530.21",
"197.6",
"197.7",
"276.2",
"693.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"99.04",
"45.13",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
7275, 7281
|
4519, 6487
|
343, 382
|
7419, 7467
|
3863, 4496
|
7778, 7870
|
3275, 3383
|
6841, 7252
|
7302, 7398
|
6513, 6564
|
7491, 7755
|
3398, 3844
|
274, 305
|
410, 1643
|
1665, 3125
|
3141, 3259
|
6582, 6818
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,885
| 197,937
|
52732
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 108779**]
Admission Date: [**2137-2-25**] Discharge Date: [**2137-3-1**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 68-year-old female
with severe coronary artery disease, status post CABG in [**2105**]
and redo in [**2123**], with angioplasty in [**4-24**] with patent
stents, SVG to LAD and patent LIMA to ramus, total occlusion
of SVG to RCA. Also, has history of anemia with negative
colonoscopy and EGD in the past. Patient presented on
[**2137-2-25**] to [**Hospital3 24768**] complaining of neck and jaw
pain, not resolved with nitroglycerin. EKG showed
intermittent AV pacing, inferior ST depressions. CK and
troponin were negative. Hematocrit was low at 21 percent.
She was given 3 units of packed red blood cells. INR was
found to be elevated at 5.9. She is taking Coumadin for
atrial fibrillation. She was given FFP, given nitroglycerin
this morning with hypotension. She is now off nitroglycerin
with elevated blood pressure. Currently pain free. Patient
denies abdominal pain, did not notice change in her bowel
movements but was found to be guaiac positive at the outside
hospital. No nausea or vomiting. She had a recent
catheterization in [**State 108**] for unclear indication. She was
started on Plavix, and her Coumadin dose was increased.
PHYSICAL EXAMINATION: Temperature 97.8 degrees, blood
pressure 106/55, respirations 11, saturating at 100 percent
on 2 liters. Generally, patient is in no acute distress.
HEENT: Left pupil round and reactive to light. Right pupil
non reactive, status post surgery. Mucous membranes moist.
Uvula midline. No JVP. PULMONARY: Bilateral basilar
crackles. CARDIOVASCULAR: Irregularly irregular with
midsystolic murmur radiating to the neck over the left upper
sternal border. Abdomen is soft, nontender, and
nondistended. Normoactive bowel sounds. EXTREMITIES: No
edema. Pulses, 1 plus dorsalis pedis bilaterally.
HOSPITAL COURSE: GI bleed. Patient presented to [**Location (un) 11790**]
with hematocrit of 21 percent, INR of 5.9, and guaiac-
positive stool. She was transfused 2 units of packed red
cells, given vitamin K, and 3 units of FFP, started on
pantoprazole. When she was transferred here, she had a
gastric lavage, which was guaiac negative. Her EGD was
negative except slight NG-tube trauma. She had a
colonoscopy, which showed non-bleeding diverticula and grade
1 internal hemorrhoids. She was felt to likely have a small
bowel AVM with bleeding secondary to elevated INR. She will
have an outpatient small bowel follow through or capsule
endoscopy, and her Coumadin was held until her small bowel
follow through.
Substernal chest pain. Patient was ruled out for myocardial
infarction by enzymes. This was felt to be likely demand
ischemia secondary to decreased hematocrit. Her
catheterization reports from [**State 108**] were obtained, and she
had a non-Q-wave MI in [**State 108**] on [**2137-1-13**]. Catheterization
showed essentially unchanged anatomy from prior
catheterization at [**Hospital3 **]. She had an attempted
rotablation of a proximal left circumflex lesion, which was
heavily calcified and rotablation was unsuccessful, and she
was sent home on antianginal therapy and optimal medical
treatment. She was also noted to have a systolic murmur.
Echocardiogram showed 3 plus TR and ejection fraction of 35
to 40 percent.
Atrial fibrillation. She was on amiodarone 200 mg orally
every day, which was discontinued on discharge. She was
continued on digoxin, but her dose was changed from 0.25 mg
every Sunday and Wednesday to 0.125 mg every other day. She
is status post DDD pacemaker from Mobitz type II.
Diabetes mellitus. Her metformin was held as an inpatient;
she was continued on Regular Insulin sliding scale.
Hypertension. Her antihypertensives including Isordil,
Aldactone, and beta-blocker were initially held secondary to
GI bleed.
Hypercholesterolemia. She was continued on atorvastatin.
Allergy. After being given ampicillin for GI prophylaxis
with TR, she complained of itchiness of her arms. She was
noted to have facial erythema and arm erythema. No tongue
edema. She was given Benadryl 25 mg intravenously x 1 with
resolution of her symptoms. [**Hospital **] medical record was
changed to add an allergy to ampicillin.
DISCHARGE DISPOSITION: Stable.
DISCHARGE STATUS: Patient was discharged to home. Patient
is to follow up with Dr. [**Last Name (STitle) 24717**] in 1 to 2 weeks. She is also
to follow up to have a small bowel follow through set up by
her primary care provider. [**Name10 (NameIs) **] the study is negative, she may
restart Coumadin per her PCP. [**Name10 (NameIs) **] is also to discuss
possible cardioversion in the future if she is unable to be
re-anticoagulated as an outpatient.
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg orally every day.
2. Glucophage XR 500 mg orally every day.
3. Atorvastatin 80 mg orally every day.
4. Digoxin 125 mcg orally every other day.
5. Isosorbide dinitrate 30 mg orally thrice daily.
6. Metoprolol 50 mg orally twice daily.
7. Norvasc 5 mg orally every day.
8. Plavix 75 mg orally every day.
9. Sublingual nitroglycerin 0.3 mg orally as needed.
10. Lisinopril 5 mg orally every day.
11. Lasix 40 mg orally every day.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 56294**]
Dictated By:[**Last Name (NamePattern1) 15388**]
MEDQUIST36
D: [**2137-4-23**] 14:53:11
T: [**2137-4-24**] 09:45:53
Job#: [**Job Number **]
|
[
"V58.61",
"411.1",
"569.85",
"401.9",
"428.0",
"V45.81",
"280.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13",
"99.07",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
4394, 4861
|
4884, 5627
|
2007, 4370
|
1387, 1989
|
193, 1364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,283
| 177,626
|
34376
|
Discharge summary
|
report
|
Admission Date: [**2184-10-6**] Discharge Date: [**2184-10-8**]
Date of Birth: [**2119-2-4**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Left leg and arm weakness
Major Surgical or Invasive Procedure:
Intubation/Extubation
History of Present Illness:
65yo M with HTN, hyperlipidemia, CAD s/p CABG, ? h/o PAF
oncoumadin presents with intracerebral hemorrhage. Pt was
welluntil this evening while taking a shower he called out to
hiswife. When wife entered the bathroom she noticed he was
sittingin the bathtub and stated, "My left leg and arm just went
out."EMS noted left facial droop and L hemiparesis. OSH CT
scanrevealed large left intraparenchymal hemorrhage with
extension tolateral ventricles 3rd and 4th ventricles. He was
given VitaminK, FFP at the OSH and transferred to [**Hospital1 18**].
His wife and daughter state that the patient lived an active
lifeand would not want to live his life with a hemiparesis or
worse.They have decided to defer offer by neurosurgery
forintraventricular drain. Repeat CT scan on arrival to
BIDMCreveals hydrocephalus and enlarged area of hemorrhage.
CTAreveals ruptured PCOM aneurysm.
Past Medical History:
Diabetes Mellitus
MI and CABG x3 ([**2169**])
Chest Melanoma
Social History:
Married, lives with his wife, daughter in the area, son in
[**Name (NI) 108**], works as a firefighter.
Family History:
not elicited
Physical Exam:
Vitals: T: 97 BP: 153/54 HR:81 R 14 O2Sats-100% intubated on
CMV
Gen- critically ill, intubated off sedation.
HEENT: NCAT, blood at ET tube tip, anicteric..
Neck- no carotid bruits
CV- RRR
Pulm- CTA B
Abd- obese, soft, ND, BS+
Extrem- 1+ pitting LE edema bilat
Neurologic Exam:
MS- no response to noxious stimulation.
CN- absent corneals, absent oculocephalic reflex, pupils 2mm and
unreactive to light. Unable to visualize optic discs. Intact gag
reflex.
Motor/Sensory- no response to nailbed pressure in all
extremities.
Reflexes: unable to elicit any DTR's.
Toes upgoing bilaterally.
Brief Hospital Course:
65yo M with HTN, Hyperlipid, CAD, Paroximal AF on coumadin
presents with large intracerebral hemorrhage with
intraventricular spread. His exam is limited due to likely
resdual effect of midazolam gtt (off x 1hr prior to exam).
However remarkable only for intact gag and otherwise absent
other brainstem reflexes. Family wishes to make pt [**Name (NI) 3225**] in
accordance with the patient's expressed wishes prior to the
event. The team informed the family about the prognosis.
The patient was transferred out the critical care unit to the
regular neurology floors. He was DNR/DNI and [**Name (NI) 3225**]. Hence, he was
kept on a Morphine gtt and a scopalamine patch for secretions
once extubated. He also received ativan PRN agitation.
He was pronounced on 09 12 08 at 15:35.
Medications on Admission:
Coumadin 5mg QDay
Amiodarone 200mg QOD
Lopressor 50mg Qday
Vasotec 20mg QDay
Zocor 80mg QDay
ASA 81mg QDay
Zetia 10mg QHS
Novalog (rapid acting) implanted insulin pump.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraventricular brain bleed
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"430",
"401.9",
"V45.81",
"331.4",
"427.31",
"250.00",
"V58.61",
"V10.82",
"414.00",
"272.4",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3172, 3181
|
2142, 2924
|
341, 364
|
3253, 3262
|
3318, 3443
|
1494, 1509
|
3144, 3149
|
3202, 3232
|
2950, 3121
|
3286, 3295
|
1524, 1788
|
276, 303
|
392, 1272
|
1805, 2119
|
1294, 1356
|
1372, 1478
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,199
| 184,444
|
9578+56043
|
Discharge summary
|
report+addendum
|
Admission Date: [**2158-9-26**] Discharge Date: [**2158-10-24**]
Date of Birth: [**2104-1-16**] Sex: F
Service: MICU
CHIEF COMPLAINT: Transfer from [**Hospital3 **]-[**Location (un) 32487**] in [**Location 32488**]for bronchial stenting
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 54-year-old woman
with a history of coronary artery disease, diabetes mellitus
Type 2, idiopathic cirrhosis, ulcerative colitis, chronic
pancreatitis, and tracheomalacia, who presents from an
outside hospital, [**Location (un) 32487**]-[**Hospital3 **] in [**State 531**] City, for
bronchial stenting. Ms. [**Known lastname **] has been hospitalized in
[**2158-8-6**] for pneumonia. She was hospitalized for a
week, continued to have progressive dyspnea after this
hospitalization. Three weeks prior to coming to [**Hospital1 346**], she developed increasing shortness
of breath, cough with productive sputum, low-grade
temperature, and was readmitted to [**Hospital3 **]-[**Location (un) 32487**] for
treatment of complicated bronchitis. This admission occurred
on [**2158-9-6**]. Her hospital course in [**State 531**] was
complicated by continued episodes of dyspnea, at first
attributed to mucous plugging, but later bronchoscopy
revealing granulation tissue overgrowth around her previous
stents, resulting in an obstruction. She was treated with
multiple antibiotics, including vancomycin and, at the time
of transfer to [**Hospital1 69**] on the
[**9-26**], she was on clindamycin. She was transferred
to [**Hospital1 69**] in hopes of clearing
granulation tissue and restenting.
Upon presentation, the patient denied any overt chest pain.
She does report some shortness of breath. She reports
three-pillow orthopnea and paroxysmal nocturnal dyspnea. She
currently denies any nausea, vomiting, diarrhea, or
constipation. Ms. [**Known lastname **] is oxygen-dependent at home. She
uses 2 liters approximately 90% of the time. She has
shortness of breath at rest, and dyspnea on exertion. She
can currently walk ten feet before needing to stop secondary
to dyspnea.
PHYSICAL EXAMINATION: On presentation, temperature 98.9,
heart rate 72, blood pressure 107/65, respiratory rate 18,
oxygen saturation 97% on 1 liter. In general, a pleasant,
middle-aged woman in no acute distress. Head, eyes, ears,
nose and throat: Sclerae without icterus, extraocular
movements intact, pupils equal, round and reactive to light.
Neck: Supple, no carotid bruits. Heart: Distant sounds,
obscured by harsh breath sounds. She does have a midline
surgical scar, which is well healed. Lungs with diffuse
bilateral rhonchi and upper airway breath sounds. Abdomen:
Obese, soft, nontender, nondistended, with active bowel
sounds. Extremities: Warm, 2+ dorsalis pedis pulses, no
edema in the extremities: Neurologic: She is alert and
oriented x 3.
HOSPITAL COURSE:
1. Respiratory: Ms. [**Known lastname **] was evaluated by the
Interventional Pulmonology team, including Dr. [**First Name (STitle) **] [**Name (STitle) **].
Ms. [**Known lastname **] is well known to Dr.[**Name (NI) 14680**] service, as she has
had previous tracheal stents placed by Dr. [**Last Name (STitle) **] several
years prior. Ms. [**Known lastname **] has multiple bronchoscopies. On
[**9-27**] she had a diagnostic bronchoscopy that showed a Y
stent in place. Polyps of tissue were seen just beyond the
distal ends of the stent in the main stem bronchus, leading
to 80 to 90% narrowing of the lumens of the bronchus. On
[**9-28**], she had another bronchoscopy. On this
bronchoscopy, a Y stent was again present. The granulation
tissue was again noted at the distal ends of the stent.
Multiple attempts were made to remove the Y stent, initially
unsuccessful due to adherence. Eventually [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**] bougie
was used to separate the stent from the tracheal wall, and
the stent was eventually removed. Mitomycin-C was applied to
the granulation tissue.
Following her bronchoscopy, on the 24th, she was transferred
to the Intensive Care Unit service secondary to intubation
following the bronchoscopy. The bronchoscopy led to a
significant amount of airway edema, necessitating intubation.
She was transferred to the Medical Intensive Care Unit
service for further management of her ventilatory status.
On further rigid bronchoscopy on [**9-29**], a YAG laser
was used to destruct the granulation tissue in the right main
stem bronchus. A Polyflex stent #10 x 20 mm was placed in
the right main stem bronchus, soon to be replaced by a larger
Polyflex stent, size 12 x 30 mm. A 12 x 30 mm Polyflex stent
was also placed in the left main stem bronchus, covering the
granulation tissue. A Dumon stent, size 14 x 20 mm, was
placed in the right main stem bronchus. Ms. [**Known lastname **] was noted
to have transient hypoxia, which was quickly relieved during
that bronchoscopy.
A subsequent bronchoscopy on [**9-30**] revealed thick
copious secretions. Stents were present in excellent
position. A bronchoscopy on the [**10-3**] again
revealed copious secretions, and stents in place. A
bronchoscopy on the [**10-4**] showed stents still in
place. A new Dumon stent, size 16 x 40 mm, was placed in the
trachea, terminating above the main carina. This
bronchoscopy was again a rigid bronchoscopy, done in the
operating room.
On [**10-5**], Ms. [**Known lastname **] was able to be weaned from the
ventilator, and was subsequently extubated. On [**10-7**],
her respiratory status was subsequently resolved, and she was
subsequently transferred to the Medical floor on supplemental
oxygen. On [**10-11**], Ms. [**Known lastname **] was noted to have some
shortness of breath and was unable to clear her own
secretions. At this point, she was transferred back to the
Medical Intensive Care Unit for management of her secretions.
Subsequently she required intubation for failure to clear the
secretions, and pending respiratory distress. This was
carried out with rapid-sequence intubation pre-oxygenation
with 100% oxygen, etomidate 20 mg intravenously,
succinylcholine 120 mg intravenously, and was carried out
without any complications.
On the [**10-11**], she had another bronchoscopy, noted
copious white viscous secretions, only partially cleared with
lavage. A 5 x 5 mm solid granular tissue was also suctioned
and sent to Pathology. On the [**10-12**], another
bronchoscopy revealed that the right main stem stent had
near-complete obstruction of her right upper lobe. The stent
was pulled back to 3 mm, and the orifice was only 20%
obstructed. Again noted copious secretions.
On [**10-13**], Ms. [**Known lastname **] was taken back to the operating room
for another bronchoscopy. This bronchoscopy again revealed
copious bilateral secretions, primarily emanating from the
right upper lobe. The right main stem stent was removed.
Subsequently a 14 x 20 mm Dumon stent was placed, with good
right upper lobe patency.
At the time of dictation, Ms. [**Known lastname **] remains intubated. She
is currently on ventilatory settings of pressure support with
oxygen saturation of 100% on an FIO2 of 40%, pressure support
set at 15, PEEP of 5. The Interventional Pulmonology team
notes that Ms. [**Known lastname **] likely needs CPAP following extubation.
2. Cardiovascular: Ms. [**Known lastname **] has remained cardiovascularly
stable. Throughout her hospital stay, she has had several
episodes of hypertension. Her atenolol dose of 50 mg per day
was changed to 75 mg twice a day during her hospitalization.
Heart rate and blood pressure have both remained stable. She
has had constant blood pressure monitoring with an arterial
line while in the Intensive Care Unit.
3. Infectious Disease: Ms. [**Known lastname **] has had multiple sputum
and bronchial cultures and Gram stains performed during the
course of her hospital stay. Her sputum has grown out
gram-positive cocci, consisting of a staphylococcus aureus
species, and a beta streptococcus. These species have not
been further delineated with specificities to date. She has
been placed on antibiotic therapy, including Levaquin and
Flagyl. She has also been on a short three day course of
vancomycin, and she was placed back on vancomycin on [**10-12**] for possible methicillin resistant staphylococcus aureus.
She has been placed on contact precautions. She has had a
number of temperature spikes during her hospital stay, and
with each spike she has been re-cultured. She still has
blood cultures pending. Currently blood cultures have not
had any growth. She currently has sputum cultures pending,
waiting for specific sensitivities and isolates. Her urine
cultures to date have been negative.
4. Endocrine: Ms. [**Known lastname **] has a history of diabetes mellitus.
She has been placed on a sliding scale insulin regimen to try
to maintain her glucose in the 150 mg/dl level. She has had
a somewhat difficult time controlling her glucose because she
has been on and off tube feeds given her repeated
bronchoscopies and necessity for nothing by mouth status.
When on tube feeds, she has also been on an NPH dose both in
the morning and the evening to try to maintain good control
of her glucose.
5. Renal: Ms. [**Known lastname 32489**] serum creatinine has remained low
throughout the course of her hospital stay, 0.5 to 0.6 for
the most part. Her urine output has been marginal for the
majority of her stay. We have followed her urine output
closely, as well as her serum creatinine. We feel
comfortable that, given that her serum creatinine has
remained stable, her kidneys are functioning well and her
urine output will pick up when she begins to mobilize her
fluids.
6. Fluids, electrolytes and nutrition: Ms. [**Known lastname **] has been
on tube feeds throughout the course of her hospitalization to
help with her nutrition. She has had to be nothing by mouth
for multiple bronchoscopies. Her electrolytes have generally
been stable. It has been necessary to replete her calcium,
magnesium, phosphorus and potassium at times.
7. Hematology: We have been following Ms. [**Known lastname 32489**]
hematocrit, platelets and white blood cell count regularly.
She was transfused two units of packed red blood cells on the
[**10-29**]. We have been attempting to keep her
hematocrit above 30, given her history of coronary artery
disease. Her platelets have generally been below 100, but
stable in the 70 to 86 range. They have been followed
closely.
8. Gastrointestinal: Given Ms. [**Known lastname 32489**] history of
ulcerative colitis, the Gastroenterology service was asked to
evaluate Ms. [**Known lastname **] during her hospital stay. She had a CT
scan of her abdomen on the [**10-11**] which demonstrated
some ascites, a liver that was consistent with cirrhosis,
some splenomegaly, vascular calcifications, and pancreatic
calcifications, consistent with chronic pancreatitis.
Gastroenterology thus evaluated her and suggested a
paracentesis to rule out spontaneous bacterial peritonitis.
Her ammonia level was checked and was 32. At this point, she
was not felt to have an ulcerative colitis flare. Her Asacol
was stopped. She was also being evaluated by the
Gastroenterology team to evaluate her hepatic encephalopathy,
given change in mental status on [**10-11**]. A paracentesis
was performed on the 6th, and had 154 white blood cells, 343
red blood cells, not consistent with SBP. Gastroenterology
did not feel Asacol or steroids were indicated at this time,
nor did they feel like this was an ulcerative colitis flare.
She has had intermittent abdominal pain. Her liver function
tests have remained within normal limits throughout her
hospitalization.
During the course of her hospital stay, her abdomen has
become increasingly distended. The CT scan did not
demonstrate enough fluid to warrant a therapeutic
paracentesis. Her C. difficile cultures were negative.
9. Neurology: During the course of her hospital stay, Ms.
[**Known lastname **] has been maintained on minimal sedation, even with
intubation. On [**10-11**], she had a change in her mental
status where she became increasingly obtunded and was part of
the reason for her transfer back to the Medical Intensive
Care Unit. A head CT was performed on [**10-11**], which did
not reveal any bleeding. There was also concern for
infection. She was re-cultured, with no growth to date.
There was also concern for spontaneous bacterial peritonitis
as a cause of her change in mental status. The paracentesis
did not indicate SBP. Since returning to the Medical
Intensive Care Unit, Ms. [**Known lastname 32489**] mental status has seemed to
have cleared somewhat. Will continue to follow.
10. Prophylaxis: Throughout her hospital stay, Ms. [**Known lastname **] has
been maintained on subcutaneous heparin and either
lansoprazole or Protonix.
11. Contact: Have maintained constant contact with Ms.
[**Known lastname 32489**] daughter, [**Name (NI) **], who lives in [**Name (NI) 531**]. She is very
involved with her mother's care, and makes daily phone calls
to check on her mother's progress.
12. Code status: Ms. [**Known lastname **] is full code.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: This is a discharge summary which is only
interim. Her discharge status will be determined at the end
of her hospitalization.
MEDICATIONS AT TIME OF DISCHARGE SUMMARY:
1. Vancomycin 1 gram intravenously every 12 hours
2. Levofloxacin 500 mg by mouth every 24 hours
3. Flagyl 500 mg by mouth three times a day
4. Metoprolol 75 mg by mouth twice a day
5. Heparin 5000 units subcutaneously every 12 hours
6. Calcium carbonate 500 mg by mouth four times a day
7. Lansoprazole 30 mg once daily
8. Colace 100 mg by mouth twice a day
9. Fluoxetine 60 mg by mouth once daily
10. Primidone 250 mg by mouth twice a day
11. Miconazole powder 2%
12. Neutra-Phos one packet by mouth four times a day
13. Magnesium oxide 400 mg by mouth once daily
14. Insulin sliding scale
15. Lactulose which has now been discontinued
16. Atrovent inhaler every six hours
17. Albuterol inhaler every six hours
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 9126**]
MEDQUIST36
D: [**2158-10-13**] 22:03
T: [**2158-10-14**] 00:10
JOB#: [**Job Number 32490**]
Name: [**Known lastname 5630**], [**Known firstname **] Unit No: [**Numeric Identifier 5631**]
Admission Date: Discharge Date: [**2158-10-24**]
Date of Birth: [**2104-1-16**] Sex: F
Service:
ADDENDUM: The following is an addenum covering hospital
course from [**2158-10-14**] through [**2158-10-24**].
1. PULMONARY: The patient failed extubation on [**2158-10-15**]
secondary to respiratory stress and work of breathing. Over
the next several days, the patient underwent several
bronchoscopies for copious secretions. Her stents were felt
to be in place and nonobstructive. The patient was weaned
off pressure support and she was successfully extubated on
[**2158-10-23**] with suctioning and nebulizer treatments. The
patient was able to maintain on a 50% face mask without need
for reintubation.
A family meeting was conducted and the decision was made for
no reintubation or pursuit of tracheostomy.
2. INFECTIOUS DISEASE: A. Sputum culture from [**2158-10-13**] and
[**2158-10-15**] were positive for MRSA. She was treated with
vancomycin and was discharged on day number 13 of a planned
14 day course. She also received empiric levofloxacin and
Flagyl but those were discontinued on [**2158-10-20**].
B. The patient received a three day course of ciprofloxacin
from [**2158-10-22**] through [**2158-10-24**] for a UTI.
C. The patient had undergone paracentesis with findings of
sterile ascites.
3. CARDIOVASCULAR: A. The patient's hypertension was well
controlled with Lopressor 75 mg p.o. b.i.d.
B. The patient had a baseline prolonged QT 0.474 seconds and
she thus remained monitored with telemetry and EKG while
receiving Haldol. However, she has not had further
prolongation while on Haldol.
4. RENAL: A. The patient had a low urine output, 20-30 cc
per hour, for much of her hospital course. This improved
over the last few days of her hospital course with the
addition of Lasix and spironolactone. Creatinine had
remained stable throughout (0.9 on [**2158-10-24**]).
5. ENDOCRINE: A. The patient's blood sugar has been
controlled with NPH and regular insulin sliding scale.
6. NEUROLOGIC/SEDATION/PAIN: A. The patient was weaned off
propofol and Ativan. She is currently on a Fentanyl patch
for chronic right upper quadrant pain.
B. The patient has had problems with night time agitation
which has been recently controlled with Haldol.
7. PROPHYLAXIS: A. The patient has been maintained on
subcutaneous heparin and Protonix for DVT and GI prophylaxis
respectively.
8. LINES: A. Foley. B. PICC line. Double-lumen placed
on [**2158-10-19**].
DISCHARGE STATUS: The patient was transferred to [**Initials (NamePattern4) 5632**]
[**Last Name (NamePattern4) **] Hospital in [**State 2625**] City. The patient was
discharged in fair condition.
DISCHARGE DIAGNOSIS:
1. Tracheomalacia.
2. Methicillin-resistant Staphylococcus aureus pneumonia
with respiratory failure requiring intubation.
3. Urinary tract infection.
4. Chronic pancreatitis.
5. Cryptogenic cirrhosis with ascites.
6. Diabetes mellitus.
CODE STATUS: DNR/DNI.
[**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**]
Dictated By:[**Name8 (MD) 5633**]
MEDQUIST36
D: [**2159-3-16**] 03:38
T: [**2159-3-16**] 22:23
JOB#: [**Job Number 5634**]
|
[
"571.5",
"996.69",
"997.3",
"482.32",
"482.41",
"491.20",
"789.5",
"519.1",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.01",
"96.04",
"96.6",
"96.72",
"00.10",
"98.15",
"33.24",
"33.23",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
13277, 17306
|
17327, 17826
|
2894, 13255
|
2129, 2877
|
156, 260
|
289, 2106
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,621
| 146,403
|
7883+55890
|
Discharge summary
|
report+addendum
|
Admission Date: [**2150-9-15**] Discharge Date: [**2150-10-24**]
Date of Birth: [**2082-2-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Ureteral stricture
Major Surgical or Invasive Procedure:
[**9-15**] Exploratory laparotomy with intraoperative ultrasound of
transplanted kidney and ureteropyelostomy of left ureter to
transplanted kidney
[**10-8**] Kidney Needle Bx
History of Present Illness:
The patient is a 68 year old Hispanic male with end-stage renal
disease who underwent a transplant several months ago that has
been complicated by a
persistent ureteral stricture. Despite multiple attempts at
dilation, this has been unsalvageable and recently access across
the stricture was lost during manipulation. He presents for
definitive repair.
Past Medical History:
PAST MEDICAL HISTORY:
1.Diabetes mellitus Type 2 times for 32
years associated with retinopathy, nephropathy and
neuropathy.
2.end-stage renal disease s/p CKT [**2150-1-15**] with LUE fistula
3. hypertension,
4. CAD s/p CABG '[**43**]
5. PVD s/p R femoral distal bypass and RBKA
hypercholesterolemia
6. R hip ORIF
.
PAST SURGICAL HISTORY:
1.Status post right open reduction,
internal fixation hip [**2150-2-13**].
2.CRT [**2150-1-15**], evacuation of the hematoma [**2150-1-16**], nephrostomy
tube [**2150-2-6**] for urinoma
3. status post coronary artery bypass graft in [**2143**].\
4. Right femoral-distal bypass
5. status post right below the knee
amputation.
6. Left upper extremity atrioventricular fistula.
Social History:
Significant for distant use of tobacco. The
patient quit in [**2143**]. There is no history of alcohol use or
drug use. His wife has [**Name2 (NI) 500**] cancer. He has six children, all
adults with the eldest son with a history of diabetes. He has
a supportive family in the area. Currently lives alone at home
with daughters visiting frequently.
Family History:
Noncontributory.
Physical Exam:
At time of discharge from hospital admission on [**2150-9-10**]
Physical Exam:
Tc=97.5 P=61 BP=106/58 RR=20 100% on RA 200 cc urine, 300 cc
soft stool
Gen - AOx3, easily arousable, answers questions appropriately
HEENT - PERLA, anicteric, atraumatic, normocephalic, dry MM
Heart - RRR, no M/R/G
Lungs - CTAB
Abdomen - NT, ND, + BS, nephrostomy tube in place that is
capped, no CVAT
Ext - R BKA, LLE with old heel ulcer, +1 d. pedis, skin tenting
Pertinent Results:
[**2150-9-15**] 09:14AM HGB-9.9* calcHCT-30
[**2150-9-15**] 09:14AM GLUCOSE-109* K+-4.9
[**2150-9-15**] 01:31PM freeCa-.94*
[**2150-9-15**] 01:31PM GLUCOSE-142* LACTATE-0.9 NA+-144 K+-5.0
CL--117*
[**2150-9-15**] 01:31PM TYPE-ART PO2-242* PCO2-40 PH-7.28* TOTAL
CO2-20* BASE XS--7
[**2150-9-15**] 03:24PM FIBRINOGE-373#
[**2150-9-15**] 03:24PM PT-14.0* PTT-24.5 INR(PT)-1.3
[**2150-9-15**] 03:24PM PLT COUNT-330
[**2150-9-15**] 05:25PM WBC-4.1 RBC-3.20* HGB-8.9* HCT-28.6* MCV-90
MCH-27.8 MCHC-31.0 RDW-16.0*
[**2150-9-15**] 05:25PM GLUCOSE-180* UREA N-32* CREAT-2.1* SODIUM-144
POTASSIUM-6.2* CHLORIDE-113* TOTAL CO2-19* ANION GAP-18
[**2150-10-24**] 06:00AM BLOOD WBC-6.5 RBC-3.86* Hgb-10.8* Hct-34.3*
MCV-89 MCH-28.1 MCHC-31.6 RDW-15.4 Plt Ct-313
[**2150-10-24**] 06:00AM BLOOD Plt Ct-313
[**2150-10-24**] 06:00AM BLOOD Glucose-116* UreaN-33* Creat-2.2* Na-134
K-5.8* Cl-104 HCO3-23 AnGap-13
[**2150-10-24**] 06:00AM BLOOD ALT-6 AST-24 AlkPhos-183* TotBili-0.4
[**2150-10-24**] 06:00AM BLOOD Albumin-2.0* Calcium-7.8* Phos-4.6*
Mg-1.6
[**2150-10-24**] 06:00AM BLOOD FK506-PND
[**2150-10-23**] 06:00AM BLOOD FK506-6.9
[**2150-10-24**] 05:30AM ASCITES Creat-52.2
[**2150-10-24**] 05:30AM OTHER BODY FLUID Creat-2.2
[**9-16**] Renal US - New blunting of the arterial waveforms without
diastolic flow demonstrated. Persistently elevated resistive
indices ranging from 0.87 to 0.91 (previously 0.86 to 1.0). 2.
Moderate hydronephrosis, probably mildly increased in the
interval, with questionable residual echogenic clot in the
collecting system.
[**9-17**] Nephrostomy Catheter Drainage exam - Patency of
ureteroureteral anastomotic site demonstrated, with free passage
of contrast and no leakage. 2. Exchange of existing nephrostomy
for a nephroureterostomy tube (40 cm 8-French biliary tube )
[**9-17**] ECHO - LVEF >55%
[**9-21**] Renal US - Persistent moderate hydronephrosis with some
debris in the collecting system. We question whether the
drainage catheter is functioning. 2. Minimal diastolic arterial
flow to the transplant, with resistive indices near 1.0
[**9-24**] MR [**Name13 (STitle) 430**] without Contrast - No recent infarct is identified.
[**10-3**] Renal US - Persistent moderate hydronephrosis with clot
again visualized within the collecting system. 2. Minimal
diastolic arterial flow to the transplant, unchanged from
[**2150-9-21**].
11/12,18,25 CT Head - No evidence of acute intracranial
hemorrhage. Please note that MRI with diffusion weighting is
more sensitive for the detection of acute ischemia.
[**10-6**] CT Abd - There is a transplanted kidney within the right
lower quadrant. This appears to be enlarged in size, and there
is marked hydronephrosis, with a small amount of high density
material within the lumen of the renal pelvis, consistent with
focal hemorrhage. This is likely not new in comparison to recent
renal ultrasounds. Additionally, there is adjacent inflammatory
stranding, with a focal confluence which contains several foci
of gas, consistent with early, nonorganized, inflammatory
change. There is associated compression of the distal right
native ureter, with right hydroureter and hydronephrosis of the
right native kidney. 2. Cholelithiasis. 3. There is mild
thickening of the descending colon and of the rectum. These
loops are not fluid filled, and these may represent early
colitis - clinical correlation is recommended.
[**10-8**] Kidney Needle Bx - There is no evidence of acute cellular
rejection in this sample. There is no evidence of fungal
involvement (neutrophilic infiltrate/granulomas). The findings
are consistent with chronic allograft nephropathy. No overt
diabetic changes are seen
[**10-4**] EEG - Abnormal EEG due to an overall generally low voltage
record
with marked slowing, somewhat accentuated over the right
hemisphere at
times. This would indicate a diffuse mild to moderate
encephalopathy
with the possibility of intermittent vascular insufficiency
involving
rightsided structures. No discharging features were seen
[**10-12**] Nephrostomy catheter drainage - No evidence of transplant
kidney hydronephrosis or ureteric stenosis. Free flow of
contrast was seen from the renal transplant collecting system to
the bladder. A collection of contrast is seen just inferior to
the renal transplant kidney.
Although this may be related to the right ureteric remnant, a
contrast leak cannot be entirely excluded. Note that a leakage
site was not definitely identified
[**10-21**] R Upper Ext US - No DVT
[**2150-9-23**] 1:22 pm URINE
**FINAL REPORT [**2150-9-25**]**
URINE CULTURE (Final [**2150-9-25**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
2ND ISOLATE. <10,000 organisms/ml.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
GRAM STAIN (Final [**2150-9-24**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2150-9-29**]):
OROPHARYNGEAL FLORA ABSENT.
KLEBSIELLA PNEUMONIAE. HEAVY GROWTH.
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 E. coli and Klebsiella species.
Trimethoprim/Sulfa sensitivity testing available on
request.
ACINETOBACTER BAUMANNII. SPARSE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ACINETOBACTER BAUMANNII
| |
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R =>64 R
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S =>16 R
IMIPENEM-------------- <=1 S =>16 R
LEVOFLOXACIN---------- =>8 R =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R 8 I
[**2150-9-28**] 3:36 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2150-9-30**]**
MRSA SCREEN (Final [**2150-9-30**]): NO STAPHYLOCOCCUS AUREUS
ISOLATED.
[**2150-9-28**] 3:36 pm SWAB Source: Rectal swab.
**FINAL REPORT [**2150-10-2**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2150-10-2**]):
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
CHLORAMPHENICOL------- <=4 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
PENICILLIN------------ =>64 R
VANCOMYCIN------------ =>32 R
[**2150-9-28**] 9:30 pm URINE ON NEPHROSTOMY OUTPUT.
**FINAL REPORT [**2150-9-30**]**
URINE CULTURE (Final [**2150-9-30**]):
YEAST. >100,000 ORGANISMS/ML..
GRAM STAIN (Final [**2150-9-29**]):
THIS IS A CORRECTED REPORT [**2150-9-30**].
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
.
PREVIOUSLY REPORTED AS [**2150-9-29**].
4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2150-9-30**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
OROPHARYNGEAL FLORA ABSENT.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
OF THREE COLONIAL MORPHOLOGIES.
GRAM STAIN (Final [**2150-9-29**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2150-10-1**]):
OROPHARYNGEAL FLORA ABSENT.
ACINETOBACTER BAUMANNII. >100,000 ORGANISMS/ML..
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVE TO AMIKACIN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
|
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 8 I
LEVOFLOXACIN---------- =>8 R
TOBRAMYCIN------------ 8 I
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2150-10-7**]):
REPORTED BY PHONE TO BRANDY CROSS ON [**2150-10-7**] AT 11:40A
FA10.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
[**2150-10-21**] 4:16 pm URINE
**FINAL REPORT [**2150-10-24**]**
URINE CULTURE (Final [**2150-10-24**]):
ACINETOBACTER BAUMANNII. >100,000 ORGANISMS/ML..
UNASYN (AMPICILLIN/SULBACTAM) SENSITIVITY CONFIRMED BY
[**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. AMIKACIN SENSITIVE BY [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 8 I
LEVOFLOXACIN---------- =>8 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
Patient admitted following ureteropyelostomy of patient's left
ureter to transplanted kidney for stricture. Patient tolerated
the procedure well, and was directly admitted intubated and
sedated to the surgical intensive care unit for stabilization
and postoperative care. Patient was resuscitated with pRBC for
postoperative anemia and low volume status as evaluated by poor
urinary output and CVP around [**3-27**]. Patient was given fluid
boluses and pRBC to maintain vascular volume, but poor urine
output continued, and ATN was considered, with renal consulted.
Renal felt that the oliguria of patient was likely secondary to
obstruction, as the operation did not have episodes of
hypotension, large blood loss, or asystole to justify ATN.
Patient did not have need for HD as patient was not fluid
overloaded and electrolytes were appropriate. A pulmonary
artery catheter was placed for accurate pressure and volume
recordings. On POD#2 the patient was started on TPN and had
sedation weaned to work towards extubation. Renal felt that the
problem was multifactorial ATN (based on urine sediment
analysis) +/- stent positioning in the newly constructed ureter.
Patient was taken to IR on POD#2 for nephroureteral stent
repositing, ECHO was also obtained for heart function with
results listed above. Renal US on [**9-17**] showed new blunting of
arterial waveform and increased RI. Patient continued on his
anti-rejection medications during this time, while on POD#4
patient began to mobilize fluid and lasix was started to improve
anuric condition of patient. Patient was attempted to be weaned
off of the vent, but despite good respiratory mechanisms and
oxygenation, patient was not ready to protect airway and
remained intubated. Patient was started on fluconazole at this
time for presence of yeast in the patient's urine, and HD to
remove extra fluid in addition to the lasix administration, and
for rising creatinine that may have contributed to the patient's
difficult extubation on [**9-21**], and altered mental status on
[**2150-9-22**] for which neurology was consulted in addition to
facial droop as reported by patient's daughter. CT of the noted
no acute bleed or process and patient was started on ASA 325mg.
Patient had EEG administered to r/o nonconvulsive status
epilepticus and consideration of toxic metabolic etiology, with
above noted results. Wound care was obtained on [**9-22**] for sacral
decubitus ulcer care, and left heel wound care. Patient was
intubated for altered mental status and maintained sedated. On
[**9-24**] patient spiked a fever to 101.3 and vanco/zosyn started
empirically. Tube feeds were started, and TPN stopped on [**9-25**],
while ID recommendations had patient switch abx coverage to
linezolid and meropenem, with continuance of Bactrim and
fluconazole. Patient had episodes of desaturation with
secretions, improving with suction and albuterol nebs. Urine
cultues showed infection with EColi covered by current
antibiotic regimen. For slowly falling Hct, patient was given
one unit on [**9-27**], along with discontinuing his CVL. Vent weans
were restarted on POD13, and patient was bronch'd showing GPC in
pairs and GNR. Speech and swallow at the bedside showed low
aspiration risk for food to patient, though basic aspiration
precautions were performed. Patient was extubated on [**9-28**] and
on [**9-29**] infectious disease was consulted for resistant sputum
microorganisms and vent-associated PNA, E.Coli/fungi urine
culture. Infectious disease recommended replacing the foley to
clear the fungemia, a CT abdomen to r/o urinoma and other pelvic
sources had above-noted results. Patient transferred from ICU
to regular surgical floor on [**2150-10-1**].
On [**10-1**] the hepatology service was consulted to r/o
hemochromatosis as patient felt to be "bronze" in appearance
with elevated ferritins, cirrhotic liver appearance in OR, and
patient having diabetes. Etiology of patient's cirrhosis
unclear, but thought secondary to NASH, viral hepatitis, or
atypical hemochromatosis. Once on floor, TF were held, and PO
intake encouraged. Physical therapy began working with the
patient on [**2150-10-3**], and HD sessions continued per renal's
recommendations. On [**10-3**] while moving patient to stretcher,
patient was noted to have discordant movement of eyes, though
medical doctor examination showed no focal neurological
deficits. Neurology was reconsulted with above noted EEG
findings from [**10-4**] Patient did not have recommended MRI
performed because of patient did not tolerate the procedure.
Patient had poor PO intake throughout surgical floor
hospitalization period, as monitored by serial calorie counts,
and episodes of hypoglycemia for which [**Last Name (un) **] was consulted and
monitored/administered needed insulin therapy for the patient.
Patient displayed continued rising creatine and repeat CT of
abdomen showed hydro of tx kidney and of right native kidney
with ? of early abscess at inferior pole of kidney, along with
question of colitis. ID was reconsulted for these new findings,
and flagyl was started for c.diff colitis, while fluc and
meropenem was continued for funguria, and drainage of inferior
kidney pole fluid collection recommended. To assess for the
salvagability of the tx kidney, a biopsy was performed on [**10-8**]
with above noted results. Patient had dobhoff tube placed for
feeding purposes, but patient removed dobhoff manually during
evening of [**10-8**]. On [**10-9**] patient was found on ground of
hospital room floor after falling out of bed, while later in
evening patient complained of chest pain and right shoulder
pain. This latest CT of Head was negative and EKG obtained
during chest pain episode was similar and consistent with prior
readings. Dobhoff tube was replaced on [**10-9**] but patient
removed it from his nose by the morning of [**10-10**]. Routine HD,
wound care, abx administration, and encouragement of PO intake
continued with no serious events, and on [**10-12**], nephrostomy tube
study showed small leak, whereby we maintained the nephrostomy
tube to drainage and JP drain to drainage. Food was
supplemented with Boost for nutritional support, but PO intake
remained poor.
On [**10-16**], patient began screening process for rehab placement,
and repeat JP drainage analysis did not show evidence of urinary
leakage, with creatinine near serum levels. Abx coverage, PT,
and OT were continued for patient rehabilitation. PICC venous
access catheter was placed on [**10-20**] for IV abx administration
and for access, but patient found rehab bed on [**9-24**] and had PICC
line removed. Repeat JP creatine emulated serum creatinine, and
therefore JP drain was removed on [**9-24**] prior to transfer to
extended care facility.
Medications on Admission:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain/fever.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
5. Epoetin Alfa 3,000 unit/mL Solution Sig: Two (2) Injection
QMOWEFR (Monday -Wednesday-Friday).
6. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO HS (at bedtime) as needed.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
9. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day) for 2 doses.
10. glargine Sig: Six (6) units at bedtime.
11. Insulin Lispro (Human) 100 unit/mL Solution Sig: follow
sliding scale Subcutaneous four times a day: see printed
sliding scale.
12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
13. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q12H (every 12 hours).
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): check level twice a week.
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: via picc after
flushing with 10ml of saline.
Discharge Medications:
1. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID
(Disp:*30 Capsule(s)* Refills:*2*
2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every [**2-25**]
hours as needed for fever or pain.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO QHS (once a day (at bedtime)).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
9. Papain-Urea [**Telephone/Fax (3) 3335**] unit-mg/g Ointment Sig: One (1) Appl
Topical DAILY (Daily).
10. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed.
12. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab
Discharge Diagnosis:
Ureteral Stricture
Discharge Condition:
Stable
Discharge Instructions:
Please return to hospital ER for fever greater than 101.4,
worsening abdominal pain, increasing nausea/vomiting, or signs
of a wound infection: increasing incisional redness, swelling,
tenderness, or drainage of purulent fluid.
Nylon suture in right lower quadrant of abdomen may be removed
after [**2150-10-31**]
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] of transplant surgery in 2
weeks; please call [**Telephone/Fax (1) 673**] to schedule an appointment
Completed by:[**2150-10-25**] Name: [**Known lastname 4971**],[**Known firstname **] Unit No: [**Numeric Identifier 4972**]
Admission Date: [**2150-9-15**] Discharge Date: [**2150-10-24**]
Date of Birth: [**2082-2-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2800**]
Addendum:
Discharge summary should read patient was discharged from [**Hospital1 8**]
on [**10-24**], not [**9-24**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2653**] Rehab
[**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**]
Completed by:[**2150-10-25**]
|
[
"008.45",
"707.14",
"518.5",
"707.03",
"250.40",
"781.94",
"593.3",
"996.81",
"585.9",
"V49.75",
"482.0",
"584.5",
"591",
"112.2",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"96.72",
"39.95",
"96.6",
"88.75",
"33.24",
"55.86",
"55.23",
"99.04",
"55.93",
"89.64",
"59.93",
"99.15",
"87.75"
] |
icd9pcs
|
[
[
[]
]
] |
24622, 24834
|
13908, 20711
|
333, 511
|
23547, 23556
|
2512, 13885
|
23919, 24599
|
2012, 2030
|
22244, 23409
|
23505, 23526
|
20737, 22221
|
23580, 23896
|
1254, 1630
|
2124, 2493
|
275, 295
|
539, 893
|
937, 1231
|
1646, 1996
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,435
| 122,287
|
21992
|
Discharge summary
|
report
|
Admission Date: [**2140-11-10**] Discharge Date: [**2140-11-13**]
Date of Birth: [**2103-4-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
37F with a history of DM1, gastroparesis, and bipolar disorder
presents with 3 days of fatigue and 2 days of nausea and
vomiting. She stopped taking insulin in [**January 2140**] with fear of
gaining weight although she continued taking her psychiatric
medications. She has chest and abdominal discomfort from nausea
and dry heaves. She denied any fevers, chest pain, hematemesis,
[**Last Name (un) 15557**]/hematoschezia, burning urination, cough or other
symptoms.
.
In the ED: Chem 7 revealed glucose of 349, HCO3 of 15 with anion
gap of 25. Started on insulin gtt at 7units/hr, given 3 L of NS
and IV potassium. CXR was unrmarkable. UA positive for Ketones,
rare bact, 0-2 WBC. She had a venous ABG with 7.25/34/42.
Past Medical History:
1. Type I DM (dx around [**2128**]), most recent HbA1C in [**September 2140**] of
17%
-complicated by gastroparesis (multiple hospitalizations)
-retinopathy
-orthostatic hypotension (fluronef discontinued in [**2138-4-6**]
secondary to hypertension to 140-150s systolic)
-autonomic neuropathy
2. bipolar disorder
3. attention deficit hyperactivity disorder
4. history of body dismorphic disorder
5. Depression
Social History:
Married, has 3, currently on disability. No smoking currently,
smoked intermittently previously. Occasional alcohol. Denies
drug use, IVDU.
Family History:
father died of melanoma
mother has HTN
.
Physical Exam:
afebrile, normotensive, on room air
GEN: full affect, pleasant
HEENT: PERRL, EOMI, anicteric
RESP: CTA b/l with good air movement throughout
CV: tachy, S1 and S2 wnl, no m/r/g
ABD: diffuse tenderness, no guarding/rigidity, no masses or
hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
Pertinent Results:
Admission Labs:
[**2140-11-10**] 05:00AM WBC-9.2# RBC-4.64# HGB-14.3# HCT-41.0# MCV-88
MCH-30.7 MCHC-34.8 RDW-13.2
[**2140-11-10**] 05:00AM PLT COUNT-448*
[**2140-11-10**] 05:00AM ALBUMIN-4.4 CALCIUM-9.5 PHOSPHATE-2.7
MAGNESIUM-2.0
[**2140-11-10**] 05:00AM LIPASE-14
[**2140-11-10**] 05:00AM LIPASE-14
[**2140-11-10**] 05:00AM GLUCOSE-343* UREA N-13 CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-15* ANION GAP-29*
[**2140-11-10**] 06:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2140-11-10**] 06:50AM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-[**2-8**]
[**2140-11-10**] 09:42AM CALCIUM-7.1* PHOSPHATE-1.4* MAGNESIUM-1.6
.
CXR - No evidence of acute cardiopulmonary process.
Discharge labs:
[**2140-11-13**] 06:05AM BLOOD WBC-5.8 RBC-4.12* Hgb-12.3 Hct-36.4
MCV-88 MCH-29.9 MCHC-33.8 RDW-12.9 Plt Ct-398
[**2140-11-13**] 06:05AM BLOOD Glucose-223* UreaN-4* Creat-0.6 Na-135
K-3.5 Cl-103 HCO3-25 AnGap-11
[**2140-11-10**] 05:00AM BLOOD ALT-21 AST-19 AlkPhos-87 TotBili-0.5
[**2140-11-13**] 06:05AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.2
Brief Hospital Course:
A/P: 37F with DM1, gastroparesis, BPD, body dysmorphic syndrome
presents with DKA after not taking insulin since [**January 2140**]
.
# DKA: Initially on insulin gtt,transitioned to sliding scale.
Aggresively hydrated in the ICU prior to transfer to floor.
[**Last Name (un) **] physicians consulted throughout her stay. Etiology of
DKA was clearly insulin noncompliance. She was stabilized,
tolerating full diet, and discharged on glargine 20 units sq qhs
and humalog sliding scale according to carb counting and 1
additional unit per 40 mg/dl above 200.
# Gastroparesis: Symptoms improved with antiemetics. Tolerating
full diet prior to d/c.
# Psych: h/o bipolar d.o, body dysmorphic d.o., eating disorder
with previous binge behavior -- This was felt to contribute to
her insulin noncompliance. Psychiatry consulted and felt she
was safe for discharge with close outpatient follow up (already
established for this Friday).
Medications on Admission:
Lantus 10ml Vial as directed up to 50 units a day (not taking
since [**January 2140**]) per pt, she was taking 30 units per day on and off
in [**9-11**]
Humulin N 300 U/3ml as directed once daily per sliding scale
(not taking)
Cymbalta 30mg
Adderall Xr 30mg QD
Lamictal 100mg 1 per day
Discharge Medications:
1. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Adderall XR 30 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO QD ().
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as
needed for nausea.
6. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20)
Subcutaneous at bedtime.
Disp:*QS QS 1 month* Refills:*0*
7. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
qAC and HS: carb counting, give 1 unit for every 40 mg/dL over
200, and 1 unit for every 15 gram carbohydrate eaten.
Disp:*QS QS 1 month* Refills:*0*
8. Compazine 25 mg Suppository Sig: One (1) Rectal every [**5-13**]
hours as needed for nausea.
Disp:*4 4* Refills:*0*
9. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours
as needed for nausea.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
diabetic ketoacidosis
Discharge Condition:
stable
Discharge Instructions:
You were hospitalized for diabetic ketoacidosis. Take your
insulin as recommended by the [**Last Name (un) **] physicians. Please call
your primary physician or return to the emergency department if
you have concerns or questions, particularly blood glucose level
>400, confusion, fever, inability to take food or drink.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2140-11-14**] 4:30
Call [**Last Name (un) **] at [**Telephone/Fax (1) 2384**] for follow up appointment within the
next week.
Please call your other physicians, Dr. [**Last Name (STitle) 32996**] and your
psychiatrist/psychologist to be seen in the next week.
|
[
"V17.49",
"250.53",
"296.89",
"314.01",
"V58.67",
"300.7",
"V15.82",
"362.01",
"337.1",
"250.63",
"V15.81",
"250.13",
"536.3",
"277.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5663, 5669
|
3252, 4187
|
332, 338
|
5735, 5744
|
2089, 2089
|
6115, 6513
|
1695, 1737
|
4524, 5640
|
5690, 5714
|
4213, 4501
|
5768, 6092
|
2887, 3229
|
1752, 2070
|
277, 294
|
366, 1088
|
2106, 2871
|
1110, 1522
|
1538, 1679
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,351
| 164,767
|
2320
|
Discharge summary
|
report
|
Admission Date: [**2142-10-26**] Discharge Date: [**2142-10-30**]
Date of Birth: [**2067-3-30**] Sex: M
Service: NEUROLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
right handed male with past medical history notable for
hypertension, hypercholesterolemia, history of colon cancer,
who presented to [**Hospital1 69**] on
[**2142-10-26**], after the onset of speech difficulties and right
arm weakness. He had been helping his wife with the laundry
and he suddenly developed slurred speech and difficulty
talking. He noticed his right arm was not moving well.
On arrival of Emergency Medical Services, he was noted to
have weakness of the right arm and leg. He was taken to the
Emergency Department. He was mildly hypertensive, normal
sinus rhythm. Within fifteen minutes, the leg weakness
resolved.
PHYSICAL EXAMINATION: On initial examination, he was alert
and oriented with sparse grammatical speech with paraphasic
errors and a mild anomia. He was unable to repeat. He had a
mild right facial droop and a right pronator drift with
distal greater than proximal weakness of the right arm. He
had sensory deficits of the right face, arm, trunk and leg.
HOSPITAL COURSE: He was given TPA at approximately two and
one half hours after the symptoms began and then transferred
to the Intensive Care Unit. Overnight, his symptoms
improved. By the morning of [**2142-10-27**], he had no complaints.
Of note, he was apparently seen by his primary care physician
in the Emergency Department on [**2142-10-20**], for complaints of
shaking in the right arm, slurred speech, had no significant
findings on physical examination and was sent home.
The patient had a magnetic resonance scan performed that
showed abnormal T2 signal hyperintensity within the left
frontoparietal junction which involves the [**Doctor Last Name 352**] and white
matter consistent with an acute infarct. There is also an
old infarct within the right parietal white matter. MRA
showed visualization of left middle cerebral artery and one
segment but no cortical branches.
Physical examination on [**2142-10-27**], was improved from that on
[**2142-10-26**]. His speech was fluent without paraphasic errors.
Repetition was intact. He has some mild anomia. His main
deficits at this time, he has graphesthesia and stereognosis
in the right hand. He does have a right pronator drift.
Finger extensors are 5-/5 on the right with full power in the
interossei. Deep tendon reflexes are 2+ bilaterally.
Plantar response is flexion bilaterally. Finger to nose
testing is accurate.
The patient then on [**2142-10-27**], underwent a carotid ultrasound
and a transthoracic echocardiogram. The patient was started
on Aspirin therapy 325 mg p.o. q.d. Noninvasive carotid study
showed narrowing of less than 40% bilaterally of the internal
carotid arteries and the patient's transthoracic
echocardiogram was within normal limits with no evidence of
thrombogenic area. The Transesophageal Echocardiography
service came by on [**2142-10-30**], and documented in the chart that
the patient's transthoracic echocardiogram was an adequate
study and that there was no indication to proceed to a
Transesophageal Echocardiogram as they say based on the
clinical scenario and evidence obtained on the transthoracic
echocardiogram.
The patient will be discharged on [**2142-10-30**], on all his
previous home medications which include:
1. Atenolol 50 mg p.o. q.d.
2. Prilosec 20 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
He will have follow-up with Dr. [**Last Name (STitle) **] on [**2143-1-1**], at 1:00
p.m. They will at that time decide whether the patient can
drive as he has been told he cannot drive until this visit.
They will also decide if the patient needs to undergo a
Transesophageal Echocardiogram.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 12114**]
Dictated By:[**Last Name (NamePattern1) 4039**]
MEDQUIST36
D: [**2142-10-30**] 15:55
T: [**2142-11-3**] 09:12
JOB#: [**Job Number 12115**]
|
[
"427.31",
"V10.05",
"434.91",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
1215, 4065
|
861, 1197
|
169, 838
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,081
| 175,774
|
49849
|
Discharge summary
|
report
|
Admission Date: [**2125-7-11**] Discharge Date: [**2125-7-17**]
Date of Birth: [**2052-9-15**] Sex: M
Service: MEDICINE
Allergies:
Sporanox / Ace Inhibitors / Penicillins
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
hematochezia
Major Surgical or Invasive Procedure:
EGD (upper GI endoscopy), colonoscopy
History of Present Illness:
Mr [**Known lastname 104150**] is a 72 gentleman with ESRD status post failing
transplant, now on hemodialysis (HD), and recent GI bleed with
colonic angiodysplasias and gastritis who is presenting in
transfer from [**Location (un) 620**] with anemia and hematochezia. The patient
had been having small amounts of diarrhea for the past 2 weeks
which he was managing with immodium. On the morning of admission
he awoke having near continuous liquid stool. He describes it as
dark, giving way to bright red blood. He had some cramping
abdominal discomfort, one episode of nausea with dry heaves, no
vomiting. He was dizzy and weak and required assistance with
standing and ambulation. Denies recent EtOH, new medications,
NSAID use, recent antibiotics, travel, new foods or sick
contacts. [**Name (NI) **] notes that he will usually have GI upset after HD,
and he did have HD yesterday, but he describes these symptoms as
much more severe. Denies chest pain and shortness of breath.
Upon further discussion with his wife who is [**Name8 (MD) **] RN, he has been
having intermittent guaiac positive stool since [**Hospital1 **] day. He
presented initially to [**Location (un) 620**] ED, and his initial vital signs
there were: 98.8 60 20 134/35 98%. On initial labs he was noted
to have a Hct of 21. His last hematocrit on [**6-20**] was 34. He was
given 40mg IV nexium, 500mg IV levaquin and 1 unit PRBCs. In ED
noted to be incontinent of bloody BM. He underwent abdominal CT
scan with oral contrast and was transfered to [**Hospital1 18**] per request
of transplant nephrologist Dr. [**Last Name (STitle) 17253**] for further
management.
Past Medical History:
ESRD [**2-12**] FSGS s/p CRT [**4-15**] c/b chronic rejection
CAD s/p 3V CABG [**5-13**] (SVG to OM, SVG to PDA, LIMA to LAD)
Chronic diastolic CHF
Mild MR
COPD
E. coli pelvic abscess
HTN
Hyperlipidemia
Angiodysplasias in stomach, duodenum and colon
VZV c/b PHN
Gout
BCC
Umbilical hernia repair
BPH
Social History:
Retired HMS physiologist. He has been living at rehab since
recent discharge. Quit smoking in [**1-19**]. Former heavy ETOH use,
now rare use.
Family History:
Father had CAD and died of a CVA. Mother died of an unknown
cancer that had metastasized to the liver. One brother has CAD.
Physical Exam:
Vitals: T:98 BP:135/46 P:64 R:15 O2:100% RA
General: Pleasant, fatigued, pale elderly gentleman, thin. Sad
affect. NAD.
HEENT: Sclera anicteric, conjunctiva pale, MMM
Neck: neck veins flat, neck supple.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, crescendo blowing
murmur in systole, radiates to LUE, likely represents fisutla
bruit.
Abdomen: Soft, diffusely tender, most in LLQ. Negative [**Doctor Last Name **]
sign. No rebound. Some voluntary guarding with deep palpation.
Hyperactive BS. No tympany. Aorta not enlarged by palpation.
Large central incision. Renal transplant on left, non-tender, no
bruit.
Ext: B/L LE without edema. Upper extremities: s/p distal right
thumb amputation. Right extremity pink, well perfused. LUE with
intact fistula with thrill. LUE hand with marked thenar and
interosseus wasting. Sensation intact. Grip strength 5/5,
intrinsic muscles [**4-15**].
Pertinent Results:
From [**Location (un) 620**]:
WBC 6.7 Hb 6.7 Hct 21.3 Plt 198
INR 1.1
142 106 32 107
4.5 24 4.3
Ca 7.7 alb 2.9 --> corrected 8.6
Trop T 0.026
AST 14 ALT 23 AP 55 TB 0.38 DB 0.11 Lip 85
Lactic Acid 2.5
CT Abdomen report from [**Location (un) 620**]:
FOCAL WALL THICKENING OF THE LARGE BOWEL AT THE RECTOSIGMOID
JUNCTION. NEOPLASTIC DISEASE CANNOT BE EXCLUDED AND ENDOSCOPIC
CORRELATION IS RECOMMENDED.
EGD ([**7-12**]): Normal esophagus, stomach and duodenum
Colonoscopy ([**7-16**]): A single medium angioectasia was seen in the
cecum which bled with provocation. A gold probe was applied for
tissue destruction successfully.
Brief Hospital Course:
1. Acute GI Bleed. EGD negative. Most likely lower GI source,
especially given history of AVM. Colonoscopy revealed AVM which
bled when provoked. This was cauterized. Hematocrit was
monitored over the 24 hours following the cauterization. The
patient was advised to follow up with a gastroenterologist.
2. Acute blood loss anemia.
Secondary to GI bleeding. The patient was transfused 1 unit
packed RBCs at the OSH and an additional unit in the MICU. He
did not require additional transfusion.
3. ESRD
Secondary to failing transplant for FSGS. On Prograf. Dialyzed
according to home Tuesday, Thursday, Saturday schedule.
4. CAD, CHF, chronic, compensated, systolic and diastolic
ECG without ischemic changes. Aspirin and beta blocker were held
given active bleeding and hypotension. Statin continued.
Discharged on home meds. * was not discharged on ACEI for EF of
40% given documented allergies. Will follow-up with primary care
physician.
5. HTN
Patient was hypotensive initially. His medications were held
initially. Home lasix was restarted on [**7-14**]. Beta blocker was
held and blood pressure regimen kept liberal given risk for
rebleed. He was discharged on home medications.
6. Gout
Home allopurinol continued. Colchicine was discontinued as
patient did not have acute gout and had recent diarrhea.
7. Neuralgia
Secondary to zoster. Pregabalin and fentanyl patch continued.
Medications on Admission:
# Mycophenolate Mofetil 500 mg Tablet [**Hospital1 **]
# Trimethoprim-Sulfamethoxazole 80-400 mg Tablet daily
# Simvastatin 40 mg Tablet Daily
# Fentanyl 75 mcg/hr Patch 72 hr
# Isosorbide Mononitrate 60mg SR daily
# Pregabalin 75 mg Capsule [**Hospital1 **]
# Pantoprazole 40 mg Tablet [**Hospital1 **]
# Metoprolol Tartrate 25 [**Hospital1 **]
# B Complex-Vitamin C-Folic Acid 1 mg Capsule daily
# Furosemide 80 mg Tablet daily
# Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) mL
Injection QMOWEFR
# Aspirin 81 mg Tablet daily
# Tacrolimus 0.5 mg Capsule [**Hospital1 **]
# Colchicine 0.6mg MWF
# Allopurinol 200mg daily (recently increased by Dr. [**Last Name (STitle) 17253**]
# Renagel 800mg TIDWM
Discharge Medications:
1. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Pregabalin 200 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for post-herpetic
neuralgia.
10. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
11. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Imdur 30 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO once a day.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Lower gastrointestinal bleed from colonic AVM,
hemodialysis-dependent renal disease from chronic rejection of
renal transplant for FSGS
Secondary: coronary artery diesease, hypertension, congestive
heart failure, gout, post-herpetic neuralgia
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital and at first to the ICU
because you had bleeding from your rectum. You received blood
products to replace lost blood. You also had an upper GI
endoscopy (esophagus, stomach and first part of small intestins)
and a colonoscopy. There was no source of bleeding revealed by
the upper GI endoscopy. Colonoscopy revealed an AVM
(arterio-venous malformation), which is an abnormal collection
of blood vessels that began to bleed when it was provoked. This
was cauterized during endoscopy.
The following changes were made to your medications:
STOP colchicine. This medication is for gout attack. It can
cause diarrhea. You take allopurinol to prevent gout attacks.
Please continue to take all of your other medications.
Please keep all your outpatient appointments.
Call a doctor or 911 if you have dark tarry stools, blood in
your stool, chest pain, shortness of breath, lightheadedness,
fever, or any other concerning symptom.
Because you have some heart failure, we recommend that you weigh
yourself every morning, and adhere to 2 gm sodium diet.
Followup Instructions:
Please see your primary care [**2125-8-3**] at 11am. If this conflicts, please call.
Name: [**Last Name (LF) 6162**],[**First Name3 (LF) **] M.
Address: [**Street Address(2) 21374**], [**Apartment Address(1) 36507**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 6163**]
Fax: [**Telephone/Fax (1) 36518**]
Please make an appointment to see our gastroenterologists here
by calling ([**Telephone/Fax (1) 2233**] or make an appointment with a
gastroenterologist in [**Location (un) 620**].
You also have an appointment with Dr. [**Last Name (STitle) **]:
Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2125-7-20**]
10:30
Please continue to receive hemodialysis according to your
regualr schedule.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"428.0",
"V58.61",
"996.81",
"496",
"747.61",
"V45.11",
"272.4",
"600.00",
"414.00",
"327.23",
"403.91",
"562.10",
"729.2",
"455.0",
"285.21",
"455.3",
"V45.81",
"V12.51",
"428.42",
"585.6",
"300.4",
"E878.0",
"569.85",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43",
"45.13",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7582, 7588
|
4283, 5673
|
312, 351
|
7884, 7890
|
3631, 4260
|
9020, 9940
|
2518, 2643
|
6430, 7559
|
7609, 7863
|
5699, 6407
|
7914, 8997
|
2658, 3612
|
260, 274
|
379, 2018
|
2040, 2341
|
2357, 2502
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,868
| 107,365
|
44092
|
Discharge summary
|
report
|
Admission Date: [**2125-6-14**] Discharge Date: [**2125-6-29**]
Date of Birth: [**2060-7-29**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Linezolid
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Fevers and increased WBC
Major Surgical or Invasive Procedure:
Interventional Radiology placed PICC line
History of Present Illness:
64 year old female with two-day vascular surgery ~ 5/808. Has
bovine aortic arch and innominate artery aneurysm. Had bypasses
to all of his great vessels and then covered stent to aorta (
anatomy unclear). Was dc'd to rehab and then represented [**6-14**] to
[**Hospital1 **] with resp distress and infection (multiple possible sources).
Past Medical History:
-- DM2
-- chronic foot ulcers/PVD
-- HTN
-- OA
-- obesity
-- asthma
-- leg pain/neuropathy
-- depression
-- anemia
-- h/o MRSA bacteremia [**11-18**], also septic arthritis treated at
[**Hospital3 **]
.
Right thalamic hemorrhage resulting in a gait disorder and
incontinence of urine, followed by Dr. [**Last Name (STitle) **].
Old CVAs.
Neuropathy, peripheral.
Anxiety and panic disorder.
Status post total abdominal hysterectomy.
Hypercholesterolemia.
Social History:
The patient lives with her daughter [**Name (NI) 2048**] and her three kids
since being d/c'ed from a nursing home last [**Month (only) 205**]. Has seven
children, many grandchildren. Smokes [**1-16**] to 1 pack per day.
Family History:
Brother died of an MI in his 30's, she denies diabetes mellitus
in the family. Cancer in parents (mother died in 40s, father in
80s), at least two siblings, but unsure what kind.
Physical Exam:
Obese AA woman laying in bed, appears to be acutely ill and
older
than staged age.
cta
rrr
abd benign
palp fems, dopp L DP only, dopp R DP/PT
Nuero
Comprehension seems intact.
Able to do months/days forwards but not backwards.
Registration intact but recall 0/3 in 3 min and [**2-17**] with prompt.
Speech is extremely slowed but coherent. Minimal output.
Mood is "OK".
Affect is flat
Pertinent Results:
ON ADMISSION:
[**2125-6-14**] 05:22PM BLOOD WBC-11.8* RBC-2.68* Hgb-7.5* Hct-23.4*
MCV-88 MCH-28.1 MCHC-32.2 RDW-17.3* Plt Ct-287
[**2125-6-14**] 05:22PM BLOOD PT-21.8* PTT-38.9* INR(PT)-2.1*
[**2125-6-14**] 05:22PM BLOOD Glucose-132* UreaN-25* Creat-1.6* Na-142
K-4.2 Cl-109* HCO3-22 AnGap-15
[**2125-6-14**] 05:22PM BLOOD CK(CPK)-348*
[**2125-6-14**] 05:22PM BLOOD CK-MB-2
[**2125-6-14**] 11:00PM BLOOD Mg-2.1
[**2125-6-14**] 08:57PM BLOOD Type-ART pO2-211* pCO2-25* pH-7.45
calTCO2-18* Base XS--4
[**2125-6-14**] 05:28PM BLOOD Lactate-1.7
[**2125-6-14**] 08:57PM BLOOD Glucose-103 Lactate-1.0
[**2125-6-14**] 08:57PM BLOOD O2 Sat-98
[**2125-6-14**] 10:22PM BLOOD freeCa-1.00*
.
ON DISCHARGE:
[**2125-6-28**] 05:26AM BLOOD WBC-10.1 RBC-3.23* Hgb-9.2* Hct-26.9*
MCV-83 MCH-28.5 MCHC-34.2 RDW-18.1* Plt Ct-256
[**2125-6-29**] 08:56AM BLOOD PT-15.9* PTT-33.4 INR(PT)-1.4*
[**2125-6-28**] 05:26AM BLOOD Glucose-79 UreaN-11 Creat-1.1 Na-141
K-4.0 Cl-107 HCO3-24 AnGap-14
[**2125-6-28**] 05:26AM BLOOD CK(CPK)-91
[**2125-6-28**] 05:26AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.2
[**2125-6-14**] 5:22 pm BLOOD CULTURE
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET
ONLY.
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
DAPTOMYCIN------------ S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- S
VANCOMYCIN------------ <=1 S
[**2125-6-20**] 6:44 pm BLOOD CULTURE Source: Line-picc.
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN------------ =>64 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R
[**2125-6-14**] 7:10 pm URINE Site: CATHETER
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Started on broad spectrum AB on admission
Pan CX'd
On first hospital night had resp distress followed PEA arrest
after meds given for intubation. transferd to the SICU. Got 1
min cpr, epi which led to af with rvr, and then dccv for AF.
Echo (reviewed with [**Doctor Last Name **]) showed large anterior mi with
aneurysmal apex. EKG also suggests anterior event in past month
(prwp). Suspect that she decompensated from cariopulmonary
perspective because of this infection and presented for care.
Cardiology consult / ID consult obtained
Pt delined / Cx's taken / Pt delined / blood, urine, surgical
site, cxr
Bronchoscopy performed [**6-15**]
Swnaz ganz placed [**6-16**]
orignal PICC pos for staph coag pos.
proteus UTI
[**6-19**] epi weaned / extubate / transfer to VICU
ID adjusts AB
PT consult / OT consult
heparin started per cardiology for ACAS / DVT upper extremity,
possible catherizationn discusse. Coumadin on hold.
Psych consult / depression.
[**6-21**] cipro dc for UTI
[**6-22**] vanco stopped / daptomycin started
pt with 2 days negative blood cx's / PICC replaced
[**6-26**] foley DC'd
Cardiolgy decides against catherization / to be arranged at
alter date
Id makes final recommendations
Pt stable for DC
Medications on Admission:
vicodin 500, lipitor 20, lopressor 25", aricept 10', celexa 10',
plavix 75'
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
INH Inhalation Q6H (every 6 hours).
5. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) INH Inhalation [**Hospital1 **] (2 times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP < 100 or HR < 60.
10. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 4 weeks: from [**6-15**] /
may DC [**7-29**] Follow labs as on Pg 1.
11. Insulin
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale
Regular
Glucose Insulin Dose
0-60 mg/dL 1 amp D50
61-120 mg/dL 0 Units
121-140 mg/dL 2 Units
141-160 mg/dL 4 Units
161-180 mg/dL 6 Units
181-200 mg/dL 8 Units
201-220 mg/dL 10 Units
221-240 mg/dL 12 Units
241-260 mg/dL 14 Units
261-280 mg/dL 16 Units
281-300 mg/dL 18 Units
> 300 mg/dL Notify M.D.
12. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 7 days: DC when INR is greater then 2/
Keep INR [**2-17**].
13. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: INR
goal is [**2-17**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Wound infection
PEA arrest after
MI
VRE, MRSA
Secondary:
HTN, PVD, depression, urinary incontinence, DM2, anemia(iron
def), CRI (1.1-1.4), vascular dementia,
Discharge Condition:
Stable
Discharge Instructions:
WOUND CARE:
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your wound(s).
New pain, numbness or discoloration of your lower or upper
extremities (notably on the side of the incision).
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Followup Instructions:
Scheduled Appointments :
Provider CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2125-7-12**] 8:45
Please follow with Dr [**Last Name (STitle) 3394**] her office number is [**Telephone/Fax (1) 79526**].
You have an appointment [**7-10**] at 1030 hrs.
Appointments to be made:
Please followup with Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) 2625**]. This
appointment should be in 4 weeks.
Call Dr [**Last Name (STitle) 30977**] office, you should see him in 4 weeks. he can be
reached at, Phone: [**Telephone/Fax (1) 5003**].
Completed by:[**2125-6-29**]
|
[
"707.09",
"410.71",
"401.9",
"250.60",
"518.81",
"996.62",
"995.92",
"599.0",
"493.90",
"427.31",
"V09.0",
"357.2",
"041.6",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"00.14",
"96.6",
"33.24",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7728, 7807
|
4686, 5929
|
308, 352
|
8021, 8030
|
2055, 2055
|
8547, 9127
|
1452, 1633
|
6055, 7705
|
7828, 8000
|
5955, 6032
|
8054, 8054
|
1648, 2036
|
2751, 4663
|
244, 270
|
8067, 8524
|
380, 720
|
2069, 2736
|
742, 1198
|
1214, 1436
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,713
| 197,252
|
41987+58493
|
Discharge summary
|
report+addendum
|
Admission Date: [**2139-9-17**] Discharge Date: [**2139-9-26**]
Date of Birth: [**2091-7-25**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache that started [**2139-9-13**]
Major Surgical or Invasive Procedure:
[**2139-9-17**] CEREBRAL ANGIOGRAM WITH COILING
History of Present Illness:
Pt is a 48 year old right handed female with HTN and
migraines who present to [**Hospital3 14325**] with acute onset headache
started on Sunday. She reported that the headaches persisted
even with OTC medications. She was seen at [**Hospital3 14325**] where a
head Ct demonstrated a SAH.
Past Medical History:
HTN
Social History:
no smoke, occ etoh
Family History:
NC
Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 1 GCS 15 E: 4 V: 5
Motor 6
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-9**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-11**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2+----------
Left 2+----------
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
[**2139-9-26**] On the day of discharge
The patient is alert and oriented to person, place, and time
Strength and sensation is full in all extremities, face is
symetric, there is no pronator drift, angio site at right groin
is clean, dry intact- there is no hematoma or drainage, pupils
are equal and reactive 3-2 mm bilaterally, EOM intact.
Pertinent Results:
CTA HEAD W&W/O C & RECONS [**2139-9-20**]
1. Slightly decreased attenuation of the previously noted
subarachnoid
hemorrhage. Prominent lateral ventricles, attention on followup.
2. Patent major intra- and extra-cranial arteries without focal
flow-limiting stenosis, occlusion, or obvious aneurysm.
3. The A1 and A2 segments of the anterior cerebral arteries on
both sides are slightly small in caliber; however, correlation
with conventional angiogram is recommended to assess the
interval change in size.
4. Small aneurysm, measuring 4.4x2.9 mm, at the origin of the
right posterior communicating artery. A smaller focus at the
location of the origin of the left posterior communicating
artery represents an additional small aneurysm. The left
posterior communicating artery itself is not seen on the present
study and hence, an aneurysm cannot be excluded though this was
felt to represent an infundibulum on the prior conventional
angiogram. Limited assessment of the coiled aneurysm at the
pericallosal artery due to artifacts
CHEST (PORTABLE AP) Study Date of [**2139-9-17**] 3:28 AM FINDINGS:
Normal lung volumes. No pneumothorax, no pleural effusion.
Normal transparency and architecture of the lung parenchyma. No
focal parenchymal opacity suggesting pneumonia. No pulmonary
edema. Normal size of the cardiac
silhouette.
Cardiology Report ECG Study Date of [**2139-9-17**] 8:49:54 AM
Normal sinus rhythm. Tracing is within normal limits and
unchanged from
tracing #1.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
64 122 84 [**Telephone/Fax (2) 91174**] 36
Procedure No: [**2139**]-84
Date Performed: [**2139-9-18**]
Attending Physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Referring Physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] Neurology Attending: Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Referring Transcranial Doppler Ultrasound Code: 430
Complete Transcranial Doppler Ultrasound Study
Indication: Subarachnoid Hemorrhage
Impression: Normal TCD evaluation. There was no evidence of
vasospasm.
Date Performed: [**2139-9-22**]
Attending Physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Referring Physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] Neurology Attending: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Referring Transcranial Doppler Ultrasound Code: 430
Complete Transcranial Doppler Ultrasound Study
Impression: Possible mild focal vasospasm in the left middle
cerebral artery. Slightly elevated peak flow velocity in the
right anterior cereberal artery comapred with prior study, but
still within the upper range for normal limits. These findings
were not observed on previous TCD study. I recommend repeating
TCD tomorrow and considering correlation with angiography if the
observed changes on today's study persist or worsen.
Date Performed: [**2139-9-23**]
Attending Physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Referring Physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] Neurology Attending: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Referring Transcranial Doppler Ultrasound Code: 430
Limited Transcranial Doppler Ultrasound Study
Impression: Abnormal TCD evaluation. While velocities in the
bilateral anterior cerebral arteries were above normal,
this did not meet criteria for mild vasospasm.
[**2139-9-17**] 02:22AM PT-12.6 PTT-25.1 INR(PT)-1.1
[**2139-9-17**] 02:22AM PLT COUNT-275
[**2139-9-17**] 02:22AM NEUTS-68.7 LYMPHS-25.2 MONOS-4.5 EOS-0.3
BASOS-1.2
[**2139-9-17**] 02:22AM WBC-10.0 RBC-3.86* HGB-12.5 HCT-35.1* MCV-91
MCH-32.4* MCHC-35.6* RDW-13.9
[**2139-9-17**] 02:22AM ALBUMIN-4.2 CALCIUM-9.2 PHOSPHATE-3.1
MAGNESIUM-2.1
[**2139-9-17**] 02:22AM ALT(SGPT)-24 AST(SGOT)-20 ALK PHOS-46 TOT
BILI-0.5
[**2139-9-17**] 02:22AM estGFR-Using this
[**2139-9-17**] 02:22AM GLUCOSE-127* UREA N-16 CREAT-0.6 SODIUM-138
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
[**2139-9-17**] 10:42AM URINE UCG-NEGATIVE
[**2139-9-17**] 10:42AM URINE HOURS-RANDOM
[**2139-9-17**] 09:03PM PTT-41.3*
[**2139-9-26**] 06:00AM BLOOD WBC-6.4 RBC-3.32* Hgb-10.6* Hct-30.1*
MCV-91 MCH-31.9 MCHC-35.2* RDW-14.7 Plt Ct-283
[**2139-9-26**] 06:00AM BLOOD Plt Ct-283
[**2139-9-26**] 06:00AM BLOOD Glucose-97 UreaN-7 Creat-0.6 Na-143 K-4.0
Cl-109* HCO3-28 AnGap-10
[**2139-9-26**] 06:00AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.1
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the Neurosurgery service and underwent
a cerebral angiogram with coiling of a L ACOM aneurysm. After
securing the aneurysm, the patient was transferred to the ICU
for monitoring and vasospam watch.
TCDs were perfromed on [**9-18**] which revealed normal vessel
velocities with no evidence of Vasospasm.
On [**9-20**] she underwent a CTA which revealed a small aneurysm in
the R PCA and a tiny infundibulum in the L PCA. In the settin of
a non focal and stable clinical exam, her blood pressure was
liberalized. On [**9-21**] the patient reported headache and
photophobia, but was otherwise intact. She will remain in the
ICU for vasospasm monitoring.
On [**9-22**] TCDs were performed which showed a question of mild
vasospasm but her clinical exam remained intact.
On [**9-23**] repeat TCDs showed Abnormal TCD evaluation. While
velocities in the bilateral anterior cerebral arteries were
above normal, this did not meet criteria for mild vasospasm.
On [**9-24**] the patient was transferred to floor.
On [**9-25**] the patient was seen by physical therapy and was
discontinued from acute physical and occupational therapy with
recommendations to go home without service.
On [**9-26**] the day of discharge the patient is alert and oriented
to person place and time. the patient exhibits full strength and
sensation. the angio site is clean dry and intact. The patient
vital signs are systolic blood pressure ranges 120-140/with
dyastolic pressures 80-90. The patient asked is she should go
home on antihypertensive therapy. Her blood pressure has been
normotensive while on the Nimodipine a calcium channel blocker
which she will continue for prevention of vasospasm until [**2139-10-8**]
for a total of 21 days. I let the patient know that she has not
required any additional blood pressure medications but that she
should follow up with her primary care physician this week or
next to consider blood pressure control medications in the
furture for her history of hypertension as she will be stopping
her nimodipine on [**10-8**]. The patient is tolerating a regular diet
and ambulating independently. She denies nausea or vomiting.
She has only intermittent headache that is well contolled with
fioricet pain medication.
Medications on Admission:
Unknown
Discharge Medications:
1. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 11 days: monday [**9-28**]-through [**2139-10-8**].
Disp:*132 Capsule(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
3. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**2-8**]
Tablets PO Q4H (every 4 hours) as needed for headache: do not
exceed 4 grams tylenol within 24 hours.
Disp:*60 Tablet(s)* Refills:*0*
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*40 Tablet(s)* Refills:*0*
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for headache.
Disp:*40 Tablet(s)* Refills:*0*
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
SAH
Multiple brain aneurysms
Rash
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
You will be on Nimodipine a calcium channel blocker for a total
of 21 days. This is a medication to prevent Vasospasm. This
also helps to decrease your blood pressure. This medication
will stop on [**2139-10-8**]. Please see your primary care physician
this week or next as you will need another blood pressure
medication to transition to as you discontinue your nimodipine.
While in the hospital your systolic blood presure was 120-150 on
nimodipine.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
PLEASE FOLLOW UP WITH DR [**First Name (STitle) **] IN 4 WEEKS. Please call to make
an appointment with Dr [**First Name (STitle) **] and to have your MRI/MRA scheduled
at 1-[**Telephone/Fax (1) 4296**]
YOU WILL NEED AT MRI MRA WITH Dr [**First Name (STitle) **] coiling PROTOCAL AT THAT
TIME
Please follow up with your primary care physician for your
history of hypertension and to begin a blood pressure medication
while you stop your Nimodipine on [**2139-10-8**]
Completed by:[**2139-9-26**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 14373**]
Admission Date: [**2139-9-17**] Discharge Date: [**2139-9-26**]
Date of Birth: [**2091-7-25**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 40**]
Addendum:
This patient was taking Lipitor while she was in patient here.
She will discuss the continuation of this medication with her
primary care provider when she follows up this week or next.
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2139-9-26**]
|
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8,946
| 103,015
|
17408
|
Discharge summary
|
report
|
Admission Date: [**2114-7-27**] Discharge Date: [**2114-8-1**]
Date of Birth: [**2086-8-27**] Sex: F
Service: NEUROLOGY
HISTORY OF PRESENT ILLNESS: This is a 27 year old
Spanish-speaking woman diagnosed with myasthenia [**Last Name (un) 2902**] in
[**2114-4-5**]. She is status post thymomectomy [**2114-6-11**]. She now
presents with increased weakness in her right arm, "eyelid
partly closing" on the right, and some increased shortness of
breath over the past two weeks. She says that she has
noticed the problems usually beginning three hours after
taking the Mestinon dose. She says she has felt well
throughout this time without fevers, chills, nausea,
vomiting, dysuria, headaches, cough, or chest pain.
Per patient as well as in the old notes, she has been having
some abdominal pain and diarrhea after Mestinon dose and so
the dose was decreased. Following this, she began to have
double vision so the dose was increased back to 60 mg q4
hours.
She says that she has not been short of breath while walking
so much as when lying in bed. She has not had any
difficulties with walking or swallowing. The left arm has
not been weak. She says that she currently feels well and
that after one course of plasmapheresis, she believes the
weakness in her right arm has improved. She also says that
she has no shortness of breath currently.
PAST MEDICAL HISTORY:
1. Myasthenia [**Last Name (un) 2902**].
2. Acetylcholine receptor antibody positive diagnosed [**4-7**].
3. Status post thymomectomy [**2114-6-11**].
4. PPD positive in the past status post BCG.
MEDICATIONS:
1. Mestinon 60 mg q4 hours.
2. Prednisone 120 mg by mouth daily.
3. Pepcid 20 mg twice a day.
4. CellCept [**Pager number **] mg twice a day.
5. Calcium carbonate.
6. Isoniazid.
7. B6.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Married with two children. No alcohol or
tobacco. Primarily Spanish speaking. This was immediate
family plus mother and brother.
PHYSICAL EXAMINATION: Temperature 99.3; pulse 75 to 103;
blood pressure 103-124/50-60; oxygen saturation rate 95-99%
on room air. In general, her physical examination is
unremarkable; vital capacity was 1.9 on admission, however,
increased to 3.2 by [**2114-7-29**] and was still 2.6 on [**2114-7-30**];
NIFS negative 80. Neurological examination: with last dose
of Mestinon almost three hours prior to examination, mental
status alert and oriented times three, says months of year
backwards accurately in Spanish, speech fluent, speaks
limited English but fairly good, tells a detailed history and
answers questions appropriately, no dysarthria, speech not
significantly nasal. Cranial nerves - Pupils equal, round,
reactive to light, EOMs full with some nystagmus on upgaze
and occasionally horizontal gaze, very minimal right ptosis
at rest, but significantly worsened with sustained upgaze,
however this improved by the date of discharge. Ptosis could
not be brought out after sustained upgaze. No diplopia,
fascial sensation intact, facial movement and strength
intact. Palate moves symmetrically, tongue protrudes
midline. Sternocleidomastoid and shoulders shrug 5 out of 5.
Motor - very mild pronator drift to the right that improved
by the date of discharge, by the date of discharge, the right
and left upper and lower extremities were 5 out of 5
bilaterally, sensation intact to light touch, pin prick and
temperature in all extremities bilaterally, reflexes 3+ in
upper extremities bilaterally and 2+ in lower extremities
bilaterally. Toes downgoing bilaterally. Coordination -
finger to nose and rapid alternating movements intact, gait
deferred.
LABS: Urine HCG negative; white count 19.3; hematocrit 42.5;
platelet count 233; INR 1.1; urinalysis negative; creatinine
138; potassium 3.5; ALT 21; AST 21; LDH 184; alk phos 71;
amylase 80; total bilirubin 0.4; calcium 9.8; phosphate 5.2;
magnesium 1.9. Blood cultures taken on [**2114-7-28**] were
negative; urine culture on [**2114-7-27**] showed no growth; chest
x-ray showed no evidence of acute cardiopulmonary disease.
HOSPITAL COURSE: This is a 27 year old woman with myasthenia
[**Last Name (un) 2902**] who presented with worsening right arm weakness and
increased shortness of breath, particularly as the Mestinon
dose is wearing off. She was found to have initially worse
PFTs than one month ago, however, this significantly
increased after her treatment with plasmapheresis during
admission. The patient was also started on CellCept for long
term immunosuppression in order to eventually taper off the
Prednisone. The patient did very well with the
plasmapheresis and significantly improved by the date of
discharge.
DISCHARGE DIAGNOSIS: Myasthenic crisis.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 48664**] [**Name (STitle) 2013**]
in Neurology on [**2114-8-14**] at 4:30 and [**2114-8-28**] at 4:00 p.m. The
patient has completed three courses of plasmapheresis during
her hospital course and will complete the second two courses
of plasmapheresis at [**Hospital **] Hospital in [**Location (un) 47**] under
the supervision of Dr. [**Last Name (STitle) **] upon discharge.
DISCHARGE MEDICATIONS:
1. Prednisone 120 mg by mouth once daily.
2. Isoniazid 300 mg by mouth once daily.
3. Vitamin B6 50 mg once daily.
4. Mestinon 90 mg q4 hours.
5. Protonix 40 mg once daily.
6. CellCept [**Pager number **] mg twice a day.
DISCHARGE CONDITION: Good.
[**First Name8 (NamePattern2) 4224**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 10034**]
MEDQUIST36
D: [**2114-7-30**] 15:44
T: [**2114-8-1**] 20:23
JOB#: [**Job Number 48665**]
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1853, 1986
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4,766
| 173,002
|
17378
|
Discharge summary
|
report
|
Admission Date: [**2108-6-6**] Discharge Date: [**2108-6-13**]
Date of Birth: [**2066-5-8**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Azithromycin / Augmentin / Klonopin
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
bradycardia, hypotension, suicide attempt
Major Surgical or Invasive Procedure:
-s/p temporary wire pacer, now removed
History of Present Illness:
41 y/o male PMH: CAD (multiple stents), HTN,
hypercholesterolemia, depression. CC: bradycardia and
hypotension secondary to overdose. HPI: On the morning of
admission [**2108-6-6**] the patient intentionally consumed amlodipine
(5 mg x about 20 tabs), Toprol XL (25 mg x about 20 tabs),
Lorazepam (dose unknown), and Lexapro (dose unknown). Soon
after the Pt told his partner that he consumed the medication
and his partner quickly took him to [**Name (NI) 4068**] ER where he received
the following: intubation w/ etomidate and succinylcholine, 4g
calcium gluconate, 2mg atropine, 2mg glucagon, phenylephrine
gtt, norepinephrine gtt, calcium gluconate 1g/h, insulin
70units/hr, 25g charcoal (vomited), and 1500cc NS, before being
transferred to [**Hospital1 18**] ED.
At [**Hospital1 18**] ED HR=40, BP=60s/40s. He further received 1amp D50,
D50 gtt, glucagon 3+5+5 mg, epinephrine gtt, dopamine gtt, with
minimal improvement in HR and BP. Pt was taken to EP lab where
a temporary pacer was placed in coronary sinus at 90 bpm. He was
then taken to CCU.
Past Medical History:
1. CAD- s/p multiple stents with stent to LAD, pRCA, RCA, D1,
mid LCX at various times. Cath [**2108-4-13**] showed no flow limiting
disease with EF=50%. 7 caths since [**11-20**].
2. Hypertension
3. Hyperlipidemia
4. Depression/anxiety
5. Tremor--essential
6. s/p hernia repair
Social History:
Smoker (0.5 ppd x 20+ years), former EtOH abuse x15 years, no
drugs. Lives with partnerworks at [**Hospital1 **] [**Name (NI) 620**] in kitchen
Family History:
Dad: cancer, DM2, mom: lung ca. ; sister= CAD
Physical Exam:
HEENT: edematous eyelids/face,
CV: RRR, soft S1/S2, no M/R/G
PULMO: coarse breath sounds b/l
ABD: BS+, soft, ND
EXT: warm, trace edema b/l, 2+ pulses DP/PT, no cyanosis
VITALS: HR 89 BP 119/79 RR 24 Sat 95% 4L NC
HEENT: mildly edematous face, PERRL, MM moist
CV: RRR, S1/S2, no m/r/g
PULMO: decr BS bilaterally, + bibasilar crackles to [**11-18**]
ABD: BS+, soft, ND, nontender
EXT: warm, trace edema b/l, 2+ pulses DP/PT, no cyanosis
Pertinent Results:
[**2108-6-6**] 05:15PM GLUCOSE-50* UREA N-20 CREAT-1.9*# SODIUM-141
POTASSIUM-3.6 CHLORIDE-114* TOTAL CO2-17* ANION GAP-14
[**2108-6-6**] 05:15PM ALT(SGPT)-47* AST(SGOT)-33 CK(CPK)-76 ALK
PHOS-80 TOT BILI-1.7*
[**2108-6-6**] 05:15PM ALBUMIN-3.6 CALCIUM-8.2* PHOSPHATE-1.3*#
MAGNESIUM-1.6
[**2108-6-6**] 05:15PM [**Month/Day/Year **]-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2108-6-6**] 05:15PM WBC-25.0*# RBC-4.64 HGB-14.5 HCT-41.4 MCV-89
MCH-31.2 MCHC-35.0 RDW-12.3
[**2108-6-6**] 05:15PM NEUTS-77.3* LYMPHS-16.9* MONOS-4.3 EOS-0.9
BASOS-0.5
[**2108-6-6**] 05:15PM PLT COUNT-360#
[**2108-6-6**] 05:15PM PT-13.0 PTT-23.7 INR(PT)-1.1
[**2108-6-6**] 05:25PM TYPE-ART PO2-142* PCO2-36 PH-7.28* TOTAL
CO2-18* BASE XS--8
[**2108-6-6**] 09:50PM CALCIUM-15.5* PHOSPHATE-0.9* MAGNESIUM-1.5*
CATH [**2107-11-23**]
1. Two vessel coronary artery disease.
2. Mild systolic and diastolic ventricular dysfunction.
3. Successful drug-eluting stenting of the proximal LAD
CATH [**2107-11-28**]
1. Two vessel coronary artery disease.
2. Normal ventricular function.
3. Successful stenting of the proximal and mid RCA.
CATH [**2107-12-20**]
1. Branch vessel coronary artery disease.
2. Stenting of LAD.
3. Enrollment in ACUITY trial.
CATH [**2108-1-3**]
1. Coronary arteries are without flow limiting stenoses.
2. Widely patent stents in the RCA, LAD, Diagonal branch.
CATH [**2108-4-9**]
1. One vessel native coronary artery disease.
2. Moderate focal restenosis of the mid RCA stent.
3. Successful stenting of the mid Cx.
CATH [**2108-4-13**]
1. No angiographic flow-limiting coronary artery disease.
CATH [**2108-5-16**]
1. No angiographically-apparent flow-limiting coronary artery
disease.
Brief Hospital Course:
In the CCU he received the following
Aspirin 325 mg PO QD
Atorvastatin 40 mg PO QD
Calcium Gluconate 35 Meq/HR IV Q1H equivlant to 7-8gm/hr
Clopidogrel Bisulfate 75 mg PO QD
Dextran 40 (10% Solution)-500 ml NS Continuous at 100 ml/hr
Dopamine 5-20 mcg/kg/min IV
Epinephrine HCl 0.01-0.14 mcg/kg/min IV
Golytely 2 L PO Q1H
Insulin 70 UNIT/HR IV
Norepinephrine 0.3-0.5 mcg/kg/min IV
Pantoprazole 40 mg IV Q24H
Phenylephrine HCl 0.5-5 mcg/kg/min IV
In the CCU he remained intubated, on multiple pressors, as well
as insulin drip (70units/hr) with D10W for CCB toxicity. His
pressures slowly improved and he was weaned off the pressors.
He was extubated on [**6-10**] without event. He was significantly
volume positive (+17 L) d/t D10W, and he required diuresis with
IV lasix, to which he responded well. His WBC was elevated and
CXR was suggestive of possible PNA, and he was started on
Levaquin x 7 days on [**6-11**].
Initial Labs:
BP94/55, T94.5, HR90, RR22
7.28/36/142
Na=141, K=3.6, Cl=114, CO2=17, BUN=12, Cr=1.9, Gluc=50
WBC=25, Hct 41.1, Plt=326,
PT=13, PTT=23.7, INR=1.1
lactate=1.4
CXR: Heart size and mediastinal contours are within normal
limits for technique. An ET tube is present at the thoracic
inlet, 2 to 3 cm above the carina. NG tube reaches the stomach.
Intersitital markings are prominent, but there is no pleural
effusion or pneumothorax. A right subclavian central venous line
is noted, the tip of which reaches a subclavian central venous
line is noted, the
tip of which reaches the brachiocephalus-SVC junction. The bones
are grossly unremarkable. IMPRESSION: Tube and lines in
satisfactory position.
KUB: Not suggestive of SBO.
O/N: we repleted his K and Mg. Weaned off norepinephrine,
phenylephrine, and dopamine. Difficulty with golytely through
NG tube may have aspirated. Magnesium citrate was also attempted
with similar difficulty. About 500 cc of stool was removed by
enema.
PUMP: EF 50%
RHTHYM: temporary pacer, monitor tele, daily EKG
CAD: continue [**Month/Year (2) **], atorvastatin, clopidogrel
CCB+BB DETOX:
--pacer--counter bradycardia
--bowel irrigation--Toprol XL could continue to adsorb for
24hrs.
--calcium tx--increase ionotropy
--hyperinsulinemic/euglycemic tx--increase glucose to myocytes,
and insulin may directly increase Ca release from SR
BENZO DETOX/WITHDRAWAL:
--no specific tx for o/d, monitor signs of withdrawal.
HYPOPHOSPHATEMIA:
--secondary to insulin, epinephrine and respiratory alkalosis,
continue KPO4 infusion with q2h checks
HYPOKALEMIA:
--secondary to insulin and calcium, continue KPO4 infusion with
q2h checks
Medications on Admission:
amlodipine 5 QD
isosorbide mononitrate 30 [**Hospital1 **]
atorvastatin 40 QD
clopidogrel 75 QD
[**Hospital1 **] 325 QD
metoprolol sr 50 QD
fluoxetine 20 QD
protonix 40 QD
escitalopram
Discharge Disposition:
Extended Care
Facility:
DECONNES 4
Discharge Diagnosis:
-Overdose on toprol, norvasc, ativan and lexapro
-Suicide attempt
-pneumonia
-CAD, s/p multiple stents
Discharge Condition:
good
Discharge Instructions:
Please let a doctor know if you're having worsened chest pain,
shortness of breath, fever, excessive sweating, palpitations.
Please check potassium level on Fri., [**6-15**], and 1 wk from then.
Adjust KCl repletion accordingly.
Please let a doctor know if you're having worsened chest pain,
shortness of breath, fever, excessive sweating, palpitations.
Please check potassium level on Fri., [**6-15**], and 1 wk from then.
Adjust KCl repletion accordingly.
Followup Instructions:
Please followup with your PCP and cardiologist in [**11-18**] (have not
been scheduled). At that time, he can adjust your lasix dose as
well as your potassium repletion.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"427.89",
"414.01",
"426.0",
"V45.82",
"428.0",
"518.82",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"37.78",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
7084, 7122
|
4255, 6849
|
355, 396
|
7269, 7275
|
2500, 4232
|
7783, 8051
|
1969, 2017
|
7143, 7248
|
6875, 7061
|
7299, 7760
|
2032, 2481
|
274, 317
|
424, 1490
|
1512, 1792
|
1808, 1953
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,133
| 117,979
|
43073
|
Discharge summary
|
report
|
Admission Date: [**2143-3-21**] Discharge Date: [**2143-4-1**]
Date of Birth: [**2081-12-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Talwin / Ambien
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
Percutaneous cholecystectostomy tube placement.
PICC placement on [**2143-4-1**]
History of Present Illness:
Mr. [**Known lastname 92900**] [**Last Name (Titles) **] 61 yo M with stage IIIa NSCLC, HCV cirrhosis,
CAD, HTN, depression who presents to the MICU after being found
somnolent at rad onc clinic today. Per report, the patient was
found to be unsteady on his feet and fell in front of the
nursing station. EMS arrived and he was found to be responsive
to painful stimuli, with pinpoint pupils. FSBS 319. He was given
1mg narcan with transient improvement in his somnolence. The
patient is now more awake and states that he felt otherwise well
over the last few days except for throat pain and mild HA. He
took is medications this AM but on the way to his appointment
began to feel cloudy and blurry and woozy. He got out of the car
and felt like he was going to fall. Onec he got to the clinic,
he felt much more sleepy and unsteady and fell. Per report, he
did not hit his head/neck of lose consiousness. Per his wife, he
reportedly took both his AM and PM medications which includes
his opiates and valium.
.
In the ED, T 97.1, BP 106/62, HR 84, RR 18, 100%2L. The patient
was given zofran 4mg, narcan 1mg x2 and then started on a narcan
drip at 0.4mg/hr. He underwent CXR, CT head, and C spine, tox
screen. EKG with inferior Q waves, unchanged from prior.
.
ROS: As per above, otherwise denies f/c, CP, SOB, vomitting, abd
pain. He endorses sore throat, and leg pain. He denies diploia,
numbness or weakness in his extremities.
Past Medical History:
<br><b>PAST MEDICAL HISTORY: </b>
Stage IIIa NSCLC (see below)
DM2
Hepatitis C cirrhosis
Coronary artery disease s/p stenting x2 to the RCA
HTN
Depression
<br><b>PAST ONCOLOGIC HISTORY: </b>
In [**11-26**] he was admitted for workup of dyspnea and this nodule
was noted on a CT angiogram. He was discharged to home and as an
outpatient, a PET CT scan as well as CT-guided needle biopsy
were obtained. PET scan disclosed this nodule to be FDG avid
with an SUV of 3.4. No mediastinal adenopathy or FDG uptake was
noted. A CT guided biopsy confirmed poorly differentiated large
cell type nonsmall cell lung cancer. Cervical mediastinoscopy
and flexible bronchoscopy on [**2143-1-4**] demonstrated metastatic
carcinoma in 4R lymph nodes. Considering his co-morbidities,
felt to be a poor surgical candidate and favored
chemoradiotherapy along without surgery. Currently undergoing
therapy with RT and navelbine.
Social History:
Mr. [**Known lastname 92900**] is a retired police officer and veteran of [**Country 3992**].
He is married with three children. He smoked for approximately
20 years (3 packs per day). He drinks only socially. He denies
IVDU.
Family History:
Father gastric ca, died age 64
Father EtOH, cirrhosis
Mother died of MI age 38
Brother died of suicide, age 38, shot himself
Uncle with psychologic issues "after returning from war"
Physical Exam:
VS: afebrile, BP 117/61, HR 80, RR 14, 100% 2L
Gen: initially sleepy but easy to arouse, now awake and oriented
HEENT: EOMI, PERRL 5mm->2cm and symmetric, anicteric sclera,
MMM, OP clear
Neck: supple, no LAD, no point tenderness down spine, full ROM
without tenderness
Heart: RRR no m/r/g
Lung: CTAB no wheezes or crackles
Abd: obese, sfot mild LUQ/flank tendereness, no rebound or
guarding + BS
Ext: warm well perfused no c/c/e
Skin: moist, no rash or bruising
Neuro: awake alert and oriented, talking clearly, CNII-XII
intact, full ROM extremities with 5/5 strenght in all muscle
groups. No dysmetria or asterixis. No clonus, sensation grossly
intact. Gait not assessed
Pertinent Results:
On Admission:
[**2143-3-20**] 10:40AM WBC-1.8*# RBC-3.92* HGB-8.9* HCT-30.4*
MCV-78* MCH-22.7* MCHC-29.3* RDW-19.7*
[**2143-3-20**] 10:40AM GLUCOSE-201* UREA N-10 CREAT-0.8 SODIUM-132*
POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-27 ANION GAP-13
[**2143-3-20**] 10:40AM PLT COUNT-170#
[**2143-3-21**] 11:50AM GLUCOSE-239* UREA N-11 CREAT-1.1 SODIUM-131*
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-25 ANION GAP-15
[**2143-3-21**] 11:50AM ALBUMIN-3.2* CALCIUM-8.2* PHOSPHATE-3.1
MAGNESIUM-1.8
[**2143-3-21**] 11:50AM VIT B12-939* FOLATE-14.2
[**2143-3-21**] 11:50AM PLT SMR-LOW PLT COUNT-129*
[**2143-3-20**] 10:40AM GRAN CT-1100*
.
CT C-spine:
1. No fracture or malalignment. MRI is more sensitive for
ligamentous injury
and cord contusion.
2. Extensive degenerative change with ankylosis of C5-C6 and
anterior
osteophyte fusion extending from C4 through C7. There is
moderate central
canal stenosis and severe neural foraminal narrowing, most
severe at C5-C7, as
described above.
3. Tracheal secretions place patient at increased risk for
aspiration.
4. Lipoma in the posterior neck soft tissues, unchanged.
5. Redemonstration of right apical spiculated lung nodule,
consistent with
known malignancy.
.
CT Head:
No acute intracranial process. No interval change compared to
prior study.
.
Abdominal CT [**2143-3-23**]:
1. Findings may suggest acute cholecystitis with worsening
inflammatory
change when compared to [**2143-2-19**]. Recommend surgical
consultation
since these features may simply reflect underlying liver disease
and third
spacing, especially since a prior HIDA scan was negative.
2. Cirrhosis and splenomegaly. Patent portal vein.
.
Abdominal CT [**2143-3-27**]:
1. No evidence of pulmonary embolism or aortic dissection.
2. Cholecystostomy tube in place, within a decompressed
gallbladder with
significant gallbladder wall edema and mild pericholecystic
stranding. No
abscess or fluid collection associated with the gallbladder.
3. Unchanged spiculated right upper lobe mass consistent with
adenocarcinoma.
4. Cirrhosis and findings of portal hypertension.
5. Patchy atelectasis at the lung bases. Superimposed pneumonia
is not
excluded.
.
Bile:
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
61 yo M with stage IIIa NSCLC, HCV cirrhosis, CAD, HTN,
depression, presents with altered mental status.
.
.
Altered Mental Status: Patient had double-dose of his sustained
released morphine accidentally prior to radiation therapy. In
the ER he was started in a Narcan drip improving rapidly. He was
monitored for 24 hours in the MICU Green, where the drip was
shut off immediately upon arrival. HE was stable and was sent to
the oncology floor. His morphine doses were held as well as
amitriptilin. He had normal LFTs.
.
Acute on Chronic Cholangitis: Patient developed in the hospital
RUQ pain and increase bilirubin and fever up to 103. He
underwent an abdominal CT scan that showed worsening of his
chronic cholecystitis with large amount of fluid surrounding the
gallbladder. Patient was hydrated and started on Vancomycin /
Ciprofloxacin / Flagyl. Surgery was consulted, who suggested
percutaneous-IR-guided drainage of the gallbladder. The
following day patient underwent IR-drainage. Surgery recommended
leaving the drain permanently. Patient kept having RUQ pain and
fever despite prior interventions. Antibiotics were switched to
Vancomycin / Cefepime / Flagyl. Blood cultures were drawn on
daily basis and were negative. Then, biliary tract cultures grew
ESCHERICHIA COLI that was ciprofloxacin resistant (Cefepime and
ceftriaxone sensitive). Infectious disease team was consulted.
Two days after switching the antibiotics patient became
afebrile. Vancomycin was stopped since the pt is MRSA negative
and the infection source is the biliary tract. The following day
he was switched to ceftriaxone and oral flagyl. He kept being
afebrile. He will have an indeterminate course of antibiotics at
this time. Therefore, he will be followed by infectious disease
team as outpatient who will determined when to stop antibiotics.
.
NCSLC: undergoing chemoradiation currently. He became
neutropenic while in the hospital and then counts recovered. He
will continue with radiotherapy as outpatient.
.
HCV cirrhosis: Currently appears compensated. Synthetic
function at baseline. Transaminases at baseline. No signs of
encephalopathy. Has grade II varices per EGD in [**2140**]. Lactulose
/ Rifaximin / Propranolol were continued.
.
Chronic Pain: Patient has back pain and chest pain due to his
malignancy and treatment. His pain medications were slowly
uptitrated until his home-dose morphine SR. He was discharged
with PO Dilaudid for breakthrough.
.
CAD: Stable. EKG with stable inferior Q waves. ASA,
beta-blocker and ACEI were continued.
.
Diabetes: Cont HISS with lantus.
.
Depression: Stable. Cont Paxil, amitryptiline
.
HTN: Stable. Cont ACE-I, propranolol
.
FEN: Low salt diet, monitor electrolytes
.
PPX: Pneumoboots, bowel regimen, PPI
.
ACCESS: PIV
.
Code: DNR/DNI. had extensive discussion with patient
.
Dispo: Home with VNA.
Home Infusion: Critical Care System [**Location (un) 8985**], MA [**Telephone/Fax (1) 92901**]
and [**Telephone/Fax (1) 86700**] Fax: [**Telephone/Fax (1) 86701**]
Medications on Admission:
Amitriptyline 50 mg PO HS
Diazepam 5 mg PO Q12H as needed.
Gabapentin 600 mg PO TID
Insulin Aspart 100 unit/mL Solution per outpatient sliding
scale.
Lantus 58 units Subcutaneous at bedtime.
Lisinopril 10 mg PO once a day.
Lorazepam 0.5-1 mg PO every eight hours as needed for nausea.
Morphine 15 mg PO Q8H
Morphine 15 mg PO every eight hours as needed for pain
Omeprazole 20 mg PO DAILY (Daily).
Zofran 4 mg PO every eight (8) hours as needed for nausea.
Paroxetine HCl 20 mg PO DAILY
Klor-Con 10 10 mEq PO twice a day.
Prochlorperazine Maleate 5 mg PO every six (6) hours as needed
Propranolol 40 mg PO BID
Aspirin 81 mg PO DAILY (Daily).
Lactulose Thirty (30) ML PO three times a day
Rifaximin 400 mg PO TID
Furosemide 20 mg PO BID
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
Disp:*270 Capsule(s)* Refills:*0*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Propranolol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q8H
(every 8 hours) as needed.
8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Insulin
Please resume your home insulin dosing
12. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO
four times a day as needed for nausea.
13. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
14. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours): Patient will
continue indefinetelly and follow with ID, who will decide when
to stop pending clinical improvement.
Disp:*21 gram* Refills:*0*
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours): Patient will continue indefinetelly and follow
with ID, who will decide when to stop pending clinical
improvement.
Disp:*63 Tablet(s)* Refills:*0*
16. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed for pain: Please be aware of sedative effect of
this medication. DO not take with alcohol and do not drive or do
high-risk activities.
Disp:*90 Tablet(s)* Refills:*0*
17. Saline Flush 0.9 % Syringe Sig: One (1) Syringe Injection
once a day.
Disp:*30 Syringe* Refills:*2*
18. Heparin Flush 10 unit/mL Kit Sig: One (1) Syringe
Intravenous once a day.
Disp:*30 Syringes* Refills:*2*
19. Line care
Please do line care per protocol.
20. Insulin
Please resume your home-dose insulin regimen.
21. Labs
Weekly cbc, chem7, lft's. Please fax the results to the
infectious disease nurses at ([**Telephone/Fax (1) 6313**]. If you have
questions regarding antibiotics please contact RNs in ID office
or covering physician [**Last Name (NamePattern4) **]: ([**Telephone/Fax (1) 14199**].
22. Percutaneous cholecystostomy tube.
Please do flushes three times a day with normal saline flushes.
23. Saline Flush 0.9 % Syringe Sig: One (1) Suringes Injection
three times a day: Please flush cholecystectomy tube three times
a day.
Disp:*90 Syringe* Refills:*2*
24. Dressing changes
Please do daily dressing changes in the cholecystostomy tube
placement.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis:
Opioid overdose
Acute on Chronic cholangitis
.
Secondary Diagnosis:
Stage IIIa NSCLC
DM2
Hepatitis C cirrhosis
Coronary artery disease s/p stenting x2 to the RCA
HTN
Depression
Discharge Condition:
Stable, pain controlled, breathing comfortably on room air,
tolerating PO.
Discharge Instructions:
You were seen at [**Hospital1 18**] for sleepiness and altered mental status.
The most likely etiology was your double-dose of morphine. You
required an antidote of morphine in the ICU and you improved.
You were watched for more than 24 hours. Then you were tranfered
to the floor and your pain regimen was re-established. You had
your raditaion therapy. Then later in the admission, most likely
in the setting of low white blood cells, you had an acute on
chronic cholecystitis (inflammation of gallbladder and bile
ducts) with a lot of fluid that was much worse than before. You
were seen by surgery who recommended percutaneous drainage.
Interventional radiology placed the drain. You kept having
fevers, so we consulted the infectious disease and changed the
antibiotics. You have been afebrile and are tolerating diet and
ambulating. You will need to follow with infectious disease
doctors and with your oncologist.
You will need to follow with Dr. [**Last Name (STitle) **] to assess fof further
therapy (i.e. chemotherapy) once your infection is better.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: None.
.
If you have fever, chills, rigors, changes in the abdominal
pain, nausea, vomit, unable to keep food or liquid down please
come to our ER.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3752**]
Date/Time:[**2143-5-23**] 10:45
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2143-7-23**] 11:20
.
You will require weekly cbc, chem7, lft's. Please fax the
results to the infectious disease nurses at ([**Telephone/Fax (1) 6313**]. If
you have questions regarding antibiotics please contact RNs in
ID office or covering physician [**Last Name (NamePattern4) **]: ([**Telephone/Fax (1) 14199**].
.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27106**] office will contact you with the following
appointment. They are making a special slot for you.
.
Please follow with your oncologist:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2143-4-19**]
10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23551**], MD Phone:[**Telephone/Fax (1) 447**]
Date/Time:[**2143-4-19**] 10:00
|
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icd9cm
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[
[]
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3953, 5142
|
6740, 9625
|
1905, 2786
|
2802, 3029
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,320
| 164,517
|
46897
|
Discharge summary
|
report
|
Admission Date: [**2111-11-29**] Discharge Date: [**2111-12-3**]
Date of Birth: [**2057-6-2**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Percocet / Tramadol
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
falls
Major Surgical or Invasive Procedure:
none
History of Present Illness:
54 yo W with chronic paranoia who per EMS, ED claims to be
thrown out of chair x 3 by unknown assalants. She claims this
has happened 3 times over the last week. She had called 911
multiple times and there was no sign of a struggle per EMT.
concerned that may be having psychotic issues vs syncope.
Evaluated by pysch in ED felt needed syncopy rule out. CT head
negative, CXR in ED limited by body habitis but negative.
.
On arrival to the floor. Pt claims she was not assalted, but
rather felt as though she was thrown to the floor on multiple
occasions. She denies LOC, shaking, toungue biting, loss of
bladder or bowel control. She can not further elaborate on
details of the falls. Upon arrival to the floor the pt is very
somulent. She complains of L sharp back pain [**8-4**] with walking
and right leg weakness. No numbness or tingling, no change in
bowel or bladder habits. She claims that her extreme fatigue is
new as of this am. No SOB, cough, chest pain.
.
Immediately upon arrival to floor pt triggered for tachycardia
to 180s. SaO2 to mid 80s, to 95% on 3L. Comparing radial pulse
to tele apprears tele was sensing P waves as seperate beats,
therefore the tachycardia was false. P 80-90s.
.
Soon after the pt appeared more solmulent and was noted to have
transient bradys to mid 20s with up to 3.5 sec asystolic pauses
on tele.
.
ROS: denies chest pain, cough, abd pain, diarrhea, constipation,
extremity edema.
Past Medical History:
Pt unable / unwilling to say. per d/c summary
spondilitis
numbness in fingers
HTN
Obesity
Pulm artery hytertension
Lower Ext edema
Social History:
40 year history of smoking, stopped a year ago. No drinking
reported. No other drug use.
Family History:
unknown - was raised at [**Doctor Last Name **] care
two daughters in good health
Physical Exam:
Afebrile, normotensive, satting in 90s on room air durring most
of day, occasionally requiring 1-2L O2 NC
Gen: at somulent but easily arousable.
HEENT: NCAT. OP clear. PERRLA, non icteric
neck: JVD unable to be acessed [**12-28**] body habitus
CV: RRR, no m/r/g
lungs: CTA BL
abd: ND/NT + BS
back: no spine tenderness or bruising. Neg straight leg raise
ext: BL LE edema, with chronic venous stasis ulcer L> R
neuro: somulent but arousable. CN grossly intact, 5/5 strength
Pertinent Results:
CBC
[**2111-11-29**] 02:00AM BLOOD WBC-10.8 RBC-4.32 Hgb-8.9* Hct-30.9*
MCV-72*# MCH-20.5*# MCHC-28.7* RDW-17.7* Plt Ct-547*
[**2111-12-2**] 06:30AM BLOOD WBC-8.6 RBC-4.22 Hgb-9.0* Hct-30.1*
MCV-71* MCH-21.3* MCHC-29.9* RDW-18.1* Plt Ct-556*
Chemistry:
[**2111-11-29**] 02:00AM BLOOD Glucose-91 UreaN-14 Creat-0.8 Na-137
K-4.2 Cl-99 HCO3-32 AnGap-10
[**2111-12-2**] 06:30AM BLOOD Glucose-100 UreaN-14 Creat-0.7 Na-140
K-4.8 Cl-99 HCO3-37* AnGap-9
[**2111-11-29**] 02:00AM BLOOD Calcium-9.7 Phos-3.4 Mg-1.8
[**2111-12-2**] 06:30AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.0
Cardiac Enzymes:
[**2111-11-29**] 02:00AM BLOOD CK(CPK)-263*
[**2111-11-29**] 04:39PM BLOOD CK(CPK)-519*
[**2111-11-30**] 01:58AM BLOOD CK(CPK)-359*
[**2111-11-29**] 02:00AM BLOOD CK-MB-8
[**2111-11-29**] 04:39PM BLOOD CK-MB-7 cTropnT-<0.01
[**2111-11-30**] 01:58AM BLOOD CK-MB-4 cTropnT-<0.01
Fe studdies:
[**2111-12-1**] 04:11AM BLOOD calTIBC-341 Ferritn-26 TRF-262
Vit b-12/Folate:
[**2111-11-29**] 02:00AM BLOOD VitB12-552 Folate-13.0
TSH:
[**2111-11-29**] 02:00AM BLOOD TSH-2.0
ABG:
[**2111-11-29**] 10:28PM BLOOD Type-ART pO2-63* pCO2-57* pH-7.38
calTCO2-35* Base XS-6
[**2111-12-1**] 09:19AM BLOOD Type-ART pO2-64* pCO2-60* pH-7.38
calTCO2-37* Base XS-7
CXR: Mild-to-moderate cardiomegaly, and vascular enlargement of
the hila are longstanding. There is no pulmonary edema. Pleural
effusion if any is small, on the left. Because of the technical
limitations of bedside radiography, conventional radiographs are
recommended for better evaluation of the left lower lobe. No
pneumothorax.
ECHO: The left atrium is mildly dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is no left ventricular outflow obstruction at
rest or with Valsalva. Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function.No structural cardiac cause of syncope
identified.
Compared with the prior study (images reviewed) of [**2110-6-16**], the
estimated pulmonary artery systolic pressure is lower.
CT HEAD: NON-CONTRAST HEAD CT: Images through the skull base are
limited due to patient motion despite rescanning. Allowing for
this, no evidence of hemorrhage, edema, mass effect,
hydrocephalus, or infarction is seen. The soft tissues and
orbits appear intact. No evidence of fracture or bony
destruction is noted along the visualized calvarium. Mild
mucosal thickening is noted along the left maxillary sinus and
some of the ethmoid air cells. The mastoid air cells remain well
aerated.
IMPRESSION: Minimal sinus mucosal disease. Otherwise normal
study.
Brief Hospital Course:
54 y/o with psych history reports repeated falls intermittently
attributed to being thrown out of her chair. Unclear daily of
falls but hypoxic, hypercarbic, with bradycardia and pauses on
tele suggestive of syncope.
.
# Paranoia: Chronic issue. Psych was consulted during
hospitalization. They recommended Haldol 2 mg [**Hospital1 **]. Also, the
patient will likely require inpatient admission in psych
facility given symptoms, complicated by patient refusal to take
meds. Sectioned 12 by psychiatry. Evaluated by BEST team for
placement and placed at [**Hospital1 3278**] inpatient psychiatric facility.
.
# Syncope/Pauses: No actual documented syncope during
hospitalization. Questionable given history of falls. Most
likely sinus pauses are in the setting of sleep or falling to
sleep. Given her sleep latency is likely shortened given her
significant OSA, she may have these pauses during the day. Full
work up revealed no contributing medical source including ECHO,
CE, labs. Cardiology consulted, and determined not to be pacer
candidate. Pauses on tele thought by cardiology to be related
to hypercapnia.
.
# Hypercarbia, hypoxia: Likely secondary to obesity
hypoventilation syndrome and OSA. Evidence of OSA by pulmonary
arterty hypertension. The patient refused to wear CPAP, became
acutely obtunded, ABG showed hypercapnia and acidosis. She was
able to have CPAP placed during this time, however removed it 3
hours after wearing. She then refused subsequent attempts.
Continued oxygen supplementation as this seems to help. Had
patient sleep upright in chair. [**Month (only) 116**] benefit from formal PFTs in
future. Patient was called out of the ICU as she was stable.
On the floor she required supplemental O2 overnight and
occasionally durring the day. She took frequent naps during the
day but was always easily arousable. She had no other signs or
indications of a primary pulmonary process. The patient is
closely followed by Dr. [**Last Name (STitle) **] who has previously arranged a sleep
study for the patient and will continue to follow and dictate
further possible treatment for her sleep apnea. It is hoped that
as her psychiatric illness is further controlled, she will be
able to tolerate CPAP.
.
#Anemia: Microcytic anemia. Iron panel sent and patient found
to be iron deficient. Patient was started on iron. Will
eventually need outpatient GI workup for age appropriate
screening.
.
# HTN: Unclear if a chronic issue. Started HCTZ during
hospitalization. Blood pressures within acceptable ranges.
.
# Back pain, leg pain: likely chronic, exacerbated by falls.
The patient was unwilling to take narcotic pain medication,
states Tylenol not effective but unwilling to try other meds.
.
# LE edema: chronic, [**12-28**] venous status. Wound care consulted
regarding dressing and ACE wraps
.
# FEN: reg diet, prn lytes
.
# PPx: SQ heparin
.
# Code: presumed full
Medications on Admission:
unknown
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3278**] Hospital
Discharge Diagnosis:
Paranoia
Syncope
Hypercarbia, hypoxia
Anemia
Hypertension
Back pain, leg pain
Lower extremity edema
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because of concern for passing out and your
safety while at home. You were found to be having spells of
falling asleep because of your sleep apnea. Our advice was to
wear the face mask which pushes oxygen into your lungs (CPAP
machine). You were not able to tolerate the mask. You will
follow up with your primary care physician to schedule an
appointment with a sleep doctor. For now, you will need oxygen
when you sleep.
Your psychiatric illness was felt to be contributing to your
inability to take care of yourself. Thus you will be transferred
to an inpatient psychiatric facility for further management.
Followup Instructions:
Please call PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 9251**] to arrange a
follow up visit in the next 2-4 weeks. Should also see her
social worker, [**Name (NI) **] [**Name (NI) 99485**], at the same time.
|
[
"295.32",
"327.23",
"459.81",
"729.5",
"780.2",
"416.8",
"493.20",
"278.00",
"401.9",
"280.9",
"724.5",
"707.12",
"427.89",
"518.84",
"338.29"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8756, 8811
|
5775, 8698
|
295, 301
|
8955, 8964
|
2626, 3192
|
9645, 9942
|
2034, 2118
|
8832, 8934
|
8724, 8733
|
8988, 9622
|
2133, 2607
|
3209, 5194
|
250, 257
|
329, 1757
|
5203, 5216
|
5225, 5752
|
1779, 1912
|
1928, 2018
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,516
| 170,010
|
54957
|
Discharge summary
|
report
|
Admission Date: [**2168-8-31**] Discharge Date: [**2168-9-8**]
Date of Birth: [**2107-1-6**] Sex: M
Service: SURGERY
Allergies:
Thiazides / ACE inhibitors / Terazosin
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Ampullary adenoma
Major Surgical or Invasive Procedure:
[**2168-8-31**]:
1. Transduodenal ampullary resection.
2. Reimplantation of common bile duct and pancreatic duct.
3. Open cholecystectomy with common bile duct exploration.
History of Present Illness:
Mr. [**Known lastname 112231**] is a 61M who was evaluated to have a pancreatic
ductal dilatation and a bulging ampullary mass that showed
low-grade dysplasia on biopsy. This was after he developed a
vague abdominal pain and a weight loss over the past several
months. He had no prior abdominal surgical history,
but he has relatively new diagnoses of coronary artery disease
that was being evaluated and chronic obstructive pulmonary
disease from 50 years of smoking cigarettes. He also drinks a
considerable amount.
He had mild jaundice, back pain, abdominal pain and weight loss,
but no steatorrhea. He is not diabetic. He does not have any
chest pains, palpitations. He is on aspirin and which was be
held preoperatively.
Past Medical History:
PAST MEDICAL HISTORY:
- [**7-/2168**] Cardiac cath - no CAD, mild LV dysfunction without MR
LVEF 45%, non-ischemic cardiomyopathy
- [**1-/2168**] Stress MIBI with abnormal gated scintigraphy. EKG 2mm
ST
depression. Occasional PVCs. Perfusion abnormaloty with mild
anterior wall LV and apex with reversibility. Mild global
hypokinesis.
- Hypertension
- Hyperlipidemia
- 50 pack year h/o tobacco abuse
- h/o impair fasting glucose
- COPD
- h/o ampullary adenoma with pancreatic ductation dilation
- recent 25lb unintentional weight loss since [**2168-2-24**]
PAST SURGICAL HISTORY:
- EGD/ERCP
- Right breast nodule excision
- [**8-/2168**] transduodenal ampullary resection
- [**8-/2168**] open cholecystectomy with common bile duct exploration
Social History:
ETOH: [**2-26**] rums/d for 30+ years. Pt does not endorse problem with
[**Name (NI) 31483**]
Tobacco: quit 12 days ago smoked 1.5 ppd for 40+ yrs
Illicits: prior marijuana, denies cocaine, no IVDU
Living: In townshend with wife
Working: [**Name (NI) **] worker driving the [**Name (NI) 68444**] bus
Family History:
Uncle premature CAD and death in 50s
Mother alive, no known heart disease
Father died from ETOHism and ?CAD
Brother died from AIDS
Sister unknown health status, estranged
Physical Exam:
Upon Discharge:
Vitals: 98.2, 56, 136/70, 12, 96% RA
Gen: AAo X 3, NAD
CV: Sinus bradycardia
Resp: CTAB, diminished bases b/l
Abd: Bilateral subcostal incision with staples and open to air,
moderate erythema around staples line with minimal swelling.
Right lateral portion open with moist-to-dry dressing and
moderate serosanguinous drainage. Old JP site with occlusive
dressing and c/d/i.
Ext: Warm, no c/c/e
Pertinent Results:
[**2168-9-6**] 03:13AM BLOOD WBC-4.2 RBC-4.19* Hgb-13.8* Hct-42.0
MCV-100* MCH-32.9* MCHC-32.8 RDW-14.0 Plt Ct-210
[**2168-9-1**] 05:40AM BLOOD WBC-9.0 RBC-4.54* Hgb-15.4 Hct-46.7
MCV-103* MCH-33.9* MCHC-32.9 RDW-13.7 Plt Ct-137*
[**2168-9-6**] 03:13AM BLOOD Glucose-124* UreaN-5* Creat-0.6 Na-142
K-3.8 Cl-102 HCO3-33* AnGap-11
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 112232**],[**Known firstname **] [**2107-1-6**] 61 Male [**-1/3519**]
[**Numeric Identifier 112233**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/mtd
SPECIMEN SUBMITTED: Gallbladder, ampulla Vater.
Procedure date Tissue received Report Date Diagnosed
by
[**2168-8-31**] [**2168-8-31**] [**2168-9-2**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 15706**]/dsj??????
DIAGNOSIS:
1. Gallbladder, cholecystectomy (A-B): Chronic cholecystitis
and cholelithiasis.
2. Ampulla of Vater, resection (C-F):
A. Adenoma (low-grade dysplasia) involving duodenum with
minimal involvement of the ampullary duct; no invasive carcinoma
seen.
B. Cauterized margins free of dysplasia.
Clinical: Ampullary adenoma.
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. On [**2168-8-31**], the patient underwent
transduodenal ampullary resection, 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, on IV fluids, with a foley
catheter, with CIWA protocol in place for alcohol withdrawal,
and an epidural for pain control. The patient was
hemodynamically stable.
On POD#1 ([**9-1**]): The epidural was continued for pain control, and
the foley catheter was maintained. IVF were continued, and the
patient remained NPO. Due to an episode of questionable chest
pain, an ECG, CXR, and cardiac enzymes were obtained, all of
which were negative. In the evening, his pain control was split
between an epidural and a PCA.
On POD#2 ([**9-2**]): He was continued on IVF, and due to an episode
of brief mom[**Name (NI) 12823**] unresponsiveness responding well to
supplementary oxygen, cardiac enzymes and CXR were repeated,
which were once again unremarkable. On this day his epidural was
discontinued, but foley catheter was maintained for strict input
and output monitoring.
On POD#3 ([**9-3**]): Due to some concern for erythema around his
incision, he was placed on IV antibiotics (cefazolin). IVF were
continued, and his PCA was maintained for pain control. Due to
severe agitation and signs of withdrawal in the evening, he was
transferred to the SICU for further care.
On POD#4 ([**9-4**]): He continued to display symptoms of withdrawal,
for which the CIWA protocol was employed. His foley catheter was
maintained, and IVF were continued.
On POD#5 ([**9-5**]): He had some continued, but improved symptoms of
withdrawal and agitation. His foley catheter was maintained, and
he was continued on IVF. He remained NPO for diet. His pain was
controlled with intermittent IV dilaudid.
On POD#6 ([**9-6**]): Patient was transferred on the floor from ICU
in stable condition. His diet was increased to clears and was
well tolerated. Small amount of erythema was noticed around
incision without any drainage.
On POD#7 ([**9-7**]): Diet increased to full liquids. Patient
ambulate independently. He was started on IV Cefazolin
empirically s/t redness around his wound was increased and small
fluid collection was palpable on right lateral site of incision.
JP drain was removed.
On POD#8 ([**9-8**]): Patient remained afebrile. Diet advanced to
regular and well tolerated. Right lateral aspect of incision was
open and moist-to-dry dressing was started, patient will
continue to have moist-to-dry dressing at home with VNA. The
patient was discharged home in stable condition.
The patient remained stable from a cardiovascular standpoint;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout hospitalization. Electrolytes were routinely
followed, and repleted when necessary. The patient's white blood
count and fever curves were closely watched for signs of
infection. Wound care was performed regularly and thoroughly.
The patient's blood sugar was monitored throughout his stay;
insulin dosing was adjusted accordingly. 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 regular
diet, ambulating, 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:
ASA 81 mg daily
Atenolol 50 mg daily
Nitrostat - PRN; has never used
Nicotine patch 21 mg daily
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL PRN chest pain
5. Nicotine Patch 14 mg TD DAILY
6. Cephalexin 500 mg PO Q6H
7. Famotidine 20 mg PO Q12H
8. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
9. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
1. Ampullary adenoma
2. Chronic cholecystitis and cholelithiasis
3. EtOH withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 return home 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 [**6-2**] 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.
*Right lateral part of you wound is open and will be packed with
gauze.
*Please call Dr. [**Last Name (STitle) 468**] office if you notice fever > 101, your
incision become more red or swollen, output will increase or
become odorous.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2168-9-19**] at 11:45 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Please follow up with Dr. [**Last Name (STitle) 71878**] (PCP) in [**2-26**] weeks after
discharge.
.
Please follow up with your Cardiologist in [**2-26**] weeks after
discharge.
Completed by:[**2168-9-8**]
|
[
"496",
"780.09",
"276.2",
"272.4",
"401.9",
"783.21",
"303.91",
"574.10",
"577.1",
"576.2",
"305.1",
"425.4",
"291.81",
"211.5",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.62",
"51.22",
"97.56",
"51.51"
] |
icd9pcs
|
[
[
[]
]
] |
8461, 8510
|
4272, 7990
|
314, 489
|
8638, 8638
|
2968, 4249
|
10263, 10758
|
2351, 2523
|
8136, 8438
|
8531, 8617
|
8016, 8113
|
8789, 9622
|
9637, 10240
|
1854, 2018
|
2538, 2538
|
256, 276
|
2554, 2949
|
517, 1251
|
8653, 8765
|
1295, 1831
|
2034, 2335
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,875
| 167,095
|
47214
|
Discharge summary
|
report
|
Admission Date: [**2160-8-6**] Discharge Date: [**2160-8-15**]
Date of Birth: [**2099-2-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Mediastinal Mass
Major Surgical or Invasive Procedure:
[**2160-8-7**] Ressection of mediastinal mass and repair of diaphramatic
hernia Medial sternotomy, radical thymectomy, and repair of
diaphragmatic hernia with 2-mm [**Doctor Last Name 4726**]-Tex mesh.
History of Present Illness:
61F with Crohns who presented with acute onset of chest pain and
shortness of breath. She states that she was up and walking
around a sales show and suddenly
noted severe substernal chest pain radiating to the back which
was accompanied by shortness of breath. She has not had symptoms
like this before. She was not dizzy or lightheaded. She denies
fever, chills or cough. She called her husband who picked her up
and transported her to the ED. The chest pain resolved after
roughly 15 minutes although the SOB persisted. ECG showed
non-specific ST deviations though cardiac enzymes were negative
x1. In the ED she underwent CTA to r/o aortic dissection and PE.
However the contrast bolus was suboptimal and while the
overnight prelim read by the radiologist was able to rule out
issection, PE could not be ruled out definitively.
Past Medical History:
Crohn's disease, on Remicade every other week, last dose [**2160-7-13**],
reports last flair several weeks ago.
OSA, not currently using Bipap but was prescribed
Osteopenia
Depression
HTN
Hyperlipidemia
Social History:
Smoking: 1ppd X 20 years, quit 30 years ago.
No EtOH or drug use.
Lives with husband, works in an pediatric orthodonic surgery
office.
Family History:
mother with breast cancer diagnosed at age 30, died at age 34;
sister deceased of breast cancer age 47; 2 maternal cousins with
breast cancer; 1 maternal aunt with ? ovarian or stomach cancer
per pt; father with leukemia, died at age 77; pt has 1 living
brother who is healthy; has 1 son and 1 daughter who are
healthy.
Physical Exam:
Vital Signs: T: 98.2 HR: 70-80's SR 20 BP: 130/76 O2 Sats: 97% 2
liters NC
General: A+ O NAD
Lungs: end expiratory wheeze otherwise clear
Cardiac: RRR
Abd: Lg Soft, NT ND + BS
Ext: neg edema
Incision: sternal site clean and dry w/o redness or swelling.
Pertinent Results:
[**2160-8-13**] WBC-6.3 RBC-3.72* Hgb-9.8* Hct-30.1* Plt Ct-301
[**2160-8-7**] WBC-12.0*# RBC-3.59* Hgb-8.9* Hct-28.6* Plt Ct-324
[**2160-8-13**] Glucose-113* UreaN-10 Creat-0.7 Na-139 K-4.4 Cl-101
HCO3-26
[**2160-8-7**] Glucose-115* UreaN-17 Creat-1.2* Na-141 K-5.0 Cl-106
HCO3-24
CXR: [**2160-8-13**] The left lung remains clear. The appearance of the
chest with elevation of the right hemidiaphragm is unchanged.
Cardiomediastinal contours are stable. The visualized right
upper lung is grossly clear. There is no pneumothorax, if any,
there is a small right pleural effusion. The sternal wires are
aligned
[**2160-8-12**] The patient was extubated in the meantime interval. The
NG tube has been removed. There is again a high position of the
right hemidiaphragm unchanged compared to the prior study or
even slightly higher. The right chest tube is unchanged in
location. The upper lungs and the left lung base are essentially
clear.
[**2160-8-7**] Right middle lobe is newly collapsed. Postoperative
elevation of the right hemidiaphragm is severe but unchanged.
Atelectasis at the medial aspect of the left lung base has not
improved. Upper lungs clear. Large postoperative
cardiomediastinal silhouette unchanged, right pleural tube still
in place.
Renal US [**2160-8-7**] Normal son[**Name (NI) 493**] assessment of the kidneys
on this technically limited assessment.
ECG: [**2160-8-7**] Sinus rhythm. Left axis deviation. Left anterior
fascicular block. Left ventricular hypertrophy. Possible
anterior myocardial infarction, age undetermined. However, the
late precordial QRS transition is non-specific.
Path Thyoma
Brief Hospital Course:
61F with Crohns who presented with acute onset of chest pain and
shortness of breath. She states that she was up and walking
around a sales show and suddenly
noted severe substernal chest pain radiating to the back which
was accompanied by shortness of breath. She has not had symptoms
like this before. She was not dizzy or lightheaded. She denies
fever, chills or cough. She called her husband who picked her up
and transported her to the ED. The chest pain resolved after
roughly 15 minutes although the SOB persisted. ECG showed
non-specific ST deviations though cardiac enzymes were negative
x1. In the ED she underwent CTA to r/o aortic dissection and PE.
However the contrast bolus was suboptimal and while the
overnight
prelim read by the radiologist was able to rule out dissection,
PE could not be ruled out definitively. Additionally CT of chest
showed anterior mediastinal mass on [**2160-8-6**] Anterior
mediastinal mass,anteromedial diaphragmatic hernia
(Morgagni)medial sternotomy, radical thymectomy, and repair of
diaphragmatic hernia with 2-mm [**Doctor Last Name 4726**]-Tex meshthymectomy with
diaphragmatic repair. Developed postop hypotension requiring 750
cc ns. Cr level climbing renal ultrasound done negative for
obstruction. [**2160-8-7**] patients UOP minimal and SOB. IV lasix
given with no response. Respiratory distress with no [**Hospital **]
transfered to ICU and ntubated. [**2160-8-8**] Transfused 1 u PRBcs,
hct 24.2>25.5. Switched to Levo, off during the day and then
back on overnight. [**8-9**]: switched to CPAP w/ PS, pt eventually
got tired and couldn't tolerate, switched back to CMV for rising
PCO2 [**2160-8-10**]: On CPAP/PS. Weaning PS. TF in AM. OGT 550 t/o
day. +UA w/ GNR. treated with Cipro last dose [**2160-8-14**]. [**2160-8-11**]:
extubated. on NC. [**2160-8-12**]: passed s/s. CPAP fitting. dc CT. CXR
showing elevated R hemidiaphram. [**2160-8-12**] transfered to the
floor on nasal cannual 7 liters, CXR continues with elevated
right hemidiaphram, diet adv, OOB, Nebs q 4 hours and PT consult
[**Hospital 99981**] Rehab.
Medications on Admission:
Dicyclomine 10mg before each meal and at bedtime
Humira Injection q 2 weeks stopped
Alendronate 70 mg qMonday
Zyrtec qd
Vit b12 IM q6 weeks
Cardizem CD 240 mg qd
Flonase 50MCG 2 sprays each nostril qd
Lamictal 200 mg qd
Levothyroxine 125 mcg qd
Lisinopril 20 mg qd
Mesalamine 1000 mg QID
Pantoprazole 40 mg qd
Zoloft 200 mg qd
Aspirin 81 mg qd
Vit D
Vit B6
Discharge Medications:
1. Mesalamine 250 mg Capsule, Sustained Release Sig: Four (4)
Capsule, Sustained Release PO QID (4 times a day).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
8. Aripiprazole 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: Three (3) mL
Inhalation Q4H (every 4 hours).
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q4H (every 4 hours).
13. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week:
Monday.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
anterior mediastinal mass
Discharge Condition:
Good
Discharge Instructions:
Please call Dr. [**Last Name (STitle) **] office [**Telephone/Fax (1) 2348**] with any
questions or concerns. Call with fevers greater than 101.5. Call
with increased shortness of breath, and or Chest Pain. Call
with drainage, redness or swelling from incisions.
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills.
-Increased shortness of breath or cough
-Sternal incision develop drainage or clicking
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] [**8-21**]
3:00pm on the [**Hospital Ward Name 516**] Shapairo Clinical Center [**Location (un) **].
Please arrive 45 minutes earlier for a Chest X-Ray on the [**Location (un) **] Radiology Department.
Completed by:[**2160-8-15**]
|
[
"327.23",
"553.3",
"555.9",
"401.9",
"786.6",
"458.29",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.3",
"07.82",
"96.72",
"53.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7839, 7911
|
4015, 6100
|
293, 497
|
7981, 7988
|
2362, 3992
|
8492, 8793
|
1753, 2074
|
6509, 7816
|
7932, 7960
|
6126, 6486
|
8012, 8469
|
2089, 2343
|
237, 255
|
525, 1357
|
1379, 1584
|
1600, 1737
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,731
| 125,193
|
12898
|
Discharge summary
|
report
|
Admission Date: [**2178-2-27**] Discharge Date: [**2178-3-2**]
Date of Birth: [**2113-10-29**] Sex: M
Service: UROLOGY
PREOPERATIVE DIAGNOSIS: Prostate cancer.
ADMITTING DIAGNOSIS: Status post radical retropubic
prostatectomy.
HISTORY OF PRESENT ILLNESS: The patient is a 64 year old
gentleman with a history of elevated PSA, prostate cancer.
He was diagnosed with needle biopsy on either side of the
prostate with 3+3 equals 6 on the right side and 3+4 equals 7
on the left side.
HOSPITAL COURSE: The patient underwent radical retropubic
prostatectomy on [**2178-2-27**]. Dr. [**Known firstname **] [**Last Name (NamePattern1) 365**] performed the
surgery. The patient tolerated the procedure well.
On postoperative day number one, he was administered 1 mg
Coumadin per protocol as well as on the operative day 1 mg of
Coumadin. The patient was advanced to regular diet on
postoperative day one. His laboratories were checked and his
hematocrit was noted to be stable. He was made to ambulate
on postoperative day one. His pain was well controlled with
oral medication at this time. On postoperative day two, he
continued to convalesce as planned. His intravenous fluids
were discontinued at this time. He was on a house diet and
tolerating it well at this time as well. His Penrose drain
was discontinued at this time.
He was ready for discharge home on postoperative day three.
He was discharged home with a Foley catheter and he will
follow-up with Dr. [**Last Name (STitle) 365**] in one to two weeks.
COMPLICATIONS DURING STAY: None.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
[**Known firstname 177**] [**Last Name (NamePattern4) 12485**], M.D. [**MD Number(1) 12486**]
Dictated By:[**Name8 (MD) 39655**]
MEDQUIST36
D: [**2178-6-6**] 17:18
T: [**2178-6-9**] 20:32
JOB#: [**Job Number 39656**]
|
[
"V45.81",
"185",
"410.91",
"272.0",
"997.1",
"401.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"60.5"
] |
icd9pcs
|
[
[
[]
]
] |
522, 1579
|
277, 504
|
201, 248
|
1604, 1898
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,638
| 185,349
|
20266
|
Discharge summary
|
report
|
Admission Date: [**2192-11-20**] Discharge Date: [**2192-11-26**]
Date of Birth: [**2120-6-19**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old
Chinese-only speaking male with a past medical history of
hypertension who had had chest pain/burning for one week. He
saw his primary care physician three days prior to admission
and was given a prescription for Cardura and Amoxicillin
(also had a cough at that time). The chest pain did not go
away, and early on the day of admission the patient was seen
in Dr.[**Name (NI) 21923**] office where EKG revealed ST segment
changes.
Patient was therefore transferred to [**Hospital6 649**], where his EKG showed anterior Q-waves with
residual ST elevations in V1 through V3. He was taken
directly to Cardiac Catheterization which revealed severe
three-vessel disease including total occlusion of the middle
left anterior descending. Cardiac Surgery was consulted, and
intra-aortic balloon pump was placed.
PAST MEDICAL HISTORY: Hypertension.
MEDICATIONS:
1. Cardura recently started by his primary care physician.
2. Zestril recently started by his primary care physician.
3. Procardia recently started by his primary care physician.
4. Protonix recently started by his primary care physician.
SOCIAL HISTORY: Distant tobacco use; quit four to five years
ago; was smoking one pack per day times 40 years. No
alcohol. No drug use.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: Afebrile, blood pressure
144/82, pulse 86, 100% on room air. General: Thin male; in
no acute distress. Heart is regular rate and rhythm.
Elevated JVP. Lungs are clear to auscultation anteriorly.
Abdomen is benign; no hepatosplenomegaly. Extremities: Good
dorsalis pedis pulses; no clubbing, cyanosis, or edema.
LABORATORY DATA ON ADMISSION: White count 9.8, hematocrit
28.7, platelets 349, BUN 23, creatinine 1.0, CK 201, ALT 18,
AST 53, total bilirubin 1.2, albumin 3.5.
Chest x-ray showed cardiomegaly; no acute cardiopulmonary
process.
Cardiac catheterization hemodynamics: Pulmonary artery of
33/10/17, wedge of [**9-13**]/8, SVR 1168, cardiac output 6.3/3.6,
ejection fraction 51%. There was 70% discrete stenosis of
the posterior descending artery, 60% stenosis of the left
main, 99% mid left anterior descending, 70% distal
circumflex.
EKG: ST elevations in V1 through V3, rate at 70.
HOSPITAL COURSE BY PROBLEM:
1. Cardiovascular: Patient with three-vessel disease seen
by catheterization was scheduled for a coronary artery bypass
graft however was delayed due to a fever. Patient's CKs
peaked at 497, but his MBs remained flat.
Patient had recurrent chest pain despite being on the
intra-aortic balloon pump. He was started on a nitro drip in
addition to beta blocker, angiotensin-converting enzyme
inhibitor, aspirin, Heparin drip, and statin. It was felt
patient needed to be revascularized and, due to his fever
Cardiothoracic Surgery was hesitant to take him for a CABG.
Patient was therefore taken back to the Catheterization Lab,
where he received a stent to the left anterior descending to
the left circumflex. Patient tolerated procedure well.
On hospital day four the intra-aortic balloon pump was
removed. Patient remained chest pain free. Patient was
maintained on a medical regimen of aspirin, Lipitor, Plavix,
Lopressor, and Lisinopril. He was to follow up with his
cardiologist, Dr. [**Last Name (STitle) 12167**]. Patient's ejection fraction was
preserved at around 50%.
2. Fever: Patient was febrile throughout his hospital stay.
There was no clear source for this fever. He was treated
with five-day course of Levaquin for a possible urinary tract
infection and was placed on droplet precautions for concern
over possible flu. By the time of discharge there was no
clear source for patient's fever, but all culture data was
negative and was felt to be either a urinary tract infection
or a viral syndrome. Patient was afebrile at time of
discharge.
3. Gastrointestinal bleed: On hospital day number three
patient had episode of melena. He received one unit of
packed red blood cells. This occurred in the setting or
Integrilin. Integrilin was stopped, and patient was
transfused with a goal greater than 30. Gastroenterology was
consulted. They recommended an outpatient endoscopy.
Patient was continued on Protonix and had no further episodes
of melena off the Integrilin, and his hematocrit remained
stable.
DISPOSITION: Discharged with plans for Gastroenterology
follow up.
DISCHARGE CONDITION: Stable.
FINAL DIAGNOSES:
1. Anterior acute myocardial infarction.
2. Fever of unknown source.
3. Anemia.
4. Gastrointestinal bleed.
DISCHARGE INSTRUCTIONS:
1. Follow up with his cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12167**].
2. Follow up with Dr. [**Last Name (STitle) **] of Gastroenterology for an
endoscopy within six weeks.
MAJOR SURGICAL OR INVASIVE PROCEDURES: Cardiac
catheterization.
DISCHARGE MEDICATIONS:
1. Aspirin 325 once a day.
2. Lipitor 10 mg once a day.
3. Plavix 75 mg once a day.
4. Lopressor 50 mg twice a day.
5. Lisinopril 10 mg once a day.
6. Levaquin 500 mg once a day times two days.
7. Protonix 40 mg once a day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 13747**]
MEDQUIST36
D: [**2193-3-8**] 11:59
T: [**2193-3-11**] 12:11
JOB#: [**Job Number 54407**]
|
[
"V64.1",
"414.01",
"401.9",
"428.20",
"599.7",
"780.6",
"410.01",
"578.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"88.56",
"99.04",
"37.22",
"37.23",
"97.44",
"36.07",
"99.20",
"36.05",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
4577, 4586
|
5046, 5541
|
4739, 5023
|
4603, 4715
|
2442, 4555
|
163, 998
|
1856, 2414
|
1021, 1293
|
1310, 1492
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,140
| 185,715
|
42761
|
Discharge summary
|
report
|
Admission Date: [**2188-1-8**] Discharge Date: [**2188-2-10**]
Date of Birth: [**2158-8-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
tricuspid valve endocarditis
Major Surgical or Invasive Procedure:
[**2188-1-25**] Tricuspid valve replacement (29mm [**Company 1543**]
Mosaic),mitral valve repair(P2 resection,26mm CG Future Ring)
[**2188-1-31**] PICC line placement
History of Present Illness:
Ms. [**Known lastname 50463**] is a 29 year-old woman with anxiety, asthma and
active IV drug abuse who presented to [**Hospital3 **] on [**1-6**]
complaining of nausea, vomiting and diarrhea of 3 days duration
and altered mental status for 1 day.
.
In the ED, initial vitals were 130 98/58 36 99% on 55%
facemask. Labs were notable for WBC 27.5, lactate of 4.4, Tbili
6.8, Dbili 4.1, AST 182, ALT 52 ABG 7.47/29.8/290.7 on FiO2
100%. She was admitted to the ICU and received aggressive fluid
resusciatition. A TTE on [**1-7**] identified a 1.4 cm vegetation
attached to the anterior leaflet of the tricuspid valve and
normal LVEF of 60%. The patient continued to require large
volume resusciation for hypotension subsequenly reqiring
Phenylephirine drip and intubation. The decision was then made
to transfer the patient to [**Hospital1 18**] for cardiac surgery evaluation.
Labs on the day of transfer were Cr 1.58, WBC 27.6 80% PMNs,
Triglycerides 534 and Vancomycin 15.7. Microbiology with 4/4
blood culture bottles growing MSSA.
Past Medical History:
IV drug abuse
asthma
anxiety
Social History:
Patient is actively abusing tobacco, cocaine and heroin. Denies
alcohol abuse.
Family History:
Unknown
Physical Exam:
Admission Physical
VS: T: 99.7, P: 102, BP: 117/55, RR: 24, 100% on vent
General: Intubated and sedated, arousable and follows commands
HEENT: NC/AT, Intubated, Pupils 2mm BL and reactive
CV: Tachycardic, no rubs or gallops
Lungs: Symmetric breath sounds, coarse anterior breath sounds
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly
Ext: warm, 2+ LE edema, splinter hemorrhage of left index
Neuro: Intubated and sedated
Pertinent Results:
TEE [**2188-1-25**]:
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is small
homogenous echodense mobile mass of 4 mm x 6mm on the posterior
mitral leaflet, atrial side near the P1 P2 junction of the
mitral valve accompanied by trivial MR and cannot rule
perforation near this mass suggestive of vegetation.
The tricuspid valve is abnormal. There is a large mass of 4 cm x
4 cm sitting on the tricuspid valve suggestive of vegetation on
the atrial aspect accompanied by. Moderate to severe [3+]
tricuspid regurgitation is seen. There is a large pericardial
effusion. Of 2 to 3cm that became apparent as the case
progressed with the supine position of the patient.
The pulmonary valve is not well visualized and there is trivial
pulmonary regurgitation.
Post bypass: Patient is on epi 0.03 mcg/kg/min, leveophed 0.1
mcg/kg/min and vasopressin 3.6 units/hour.
RV function normal and RV is mildly dilated.
There is a bioprosthesis in the tricuspid position with a mean
gradient of 2mm of HG. There are no regurgitant jets seen. NO
massess seen suggestive of [**Month/Day/Year **] vegetation.
The mitral ring appears stable with no periprosthetic
regurgitation. There is no MR. [**First Name (Titles) **] [**Last Name (Titles) **] masses seen.
Intact thoracic aorta.
LVEF 55%.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2188-1-29**] 07:31
.
CT OF THE ABDOMEN WITHOUT IV OR ORAL CONTRAST: [**2188-1-8**].
IMPRESSION:
1. Multiple cavitary lesions in the periphery of both lungs,
most consistent with septic emboli due to her MSSA endocarditis.
2. Moderate nonhemorrhagic right pleural effusion with
associated
atelectasis.
3. Small amount of fluid layering dependently within the
trachea.
4. 4-mm inferior pole right renal stone without evidence of
hydronephrosis.
5. Cholelithiasis with gallbladder wall edema which could be
related to fluid overload.
6. Right lower and left upper lobe pneumonia.
7. Hepatomegaly.
CTA CHEST [**2188-1-16**]
1. Whether solitary filling defect in lingular subsegmental
pulmonary artery is thrombus from a peripheral vein or embolized
cardiac vegetation is indeterminate.
2. Multiple abscesses from septic emboli have increased in
number and size
since the prior study.
3. New multifocal pneumonia.
4. Small bilateral pleural effusions, left new, right decreased.
5. Trace ascites, stable.
MRI Head [**2188-1-24**]
1. Focus of restricted diffusion in the left insular lobe
cortex, which in the setting of endocarditis appears highly
concerning for embolic stroke.
2. An additional focus in the right corona radiata with normal
ADC map and FLAIR hyperintensity may represent a further focus
of more subacute chronicity.
3. There is no evidence abscess, hemorrhage or space-occupying
lesion.
MICROBIOLOGY
Blood cultures
12/27, [**1-9**], [**1-12**], [**1-13**], [**1-14**], [**1-15**], [**1-16**], [**1-23**], [**1-24**]- NGTD
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2188-1-23**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 10:20PM ON
[**2188-1-23**].
.
URINE CULTURE (Final [**2188-1-22**]):
YEAST. ~1000/ML.
[**2188-2-3**] 1:47 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2188-2-5**]**
GRAM STAIN (Final [**2188-2-3**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2188-2-5**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2188-2-8**] 9:57 AM
CT CHEST W/O CONTRAST Clip # [**Clip Number (Radiology) 92397**]
Reason: increased SOB
[**Hospital 93**] MEDICAL CONDITION:
29 year old woman s/p MVr and TVR
REASON FOR THIS EXAMINATION:
increased SOB
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: Increased shortness of breath. The patient's history
is
significant for bacterial endocarditis, with extensive pulmonary
septic
emboli, more recently with mitral and tricuspid valve
replacements.
COMPARISON: Chest radiographs from [**0-0-0**] and [**0-0-0**], as
well as CT
from [**0-0-0**], [**0-0-0**] and [**0-0-0**]
TECHNIQUE: Axial CT images were acquired through the chest
without
intravenous contrast. Coronal and sagittal reformatted images
are also
reviewed.
FINDINGS: Central airways are patent, though lobar and segmental
bronchioles
are notable for diffuse wall thickening. There is small airway
plugging in
the lower lobes. A right chest tube has been removed, and there
is a small
amount of right pleural gas as well as a moderate amount of
right pleural
fluid. A moderate left pleural effusion also persists. As
before, there are
numerous, cavitary lesions throughout both lungs, the size and
extent of which
is unchanged. An area of consolidation and ground-glass opacity
at the right
apex seen on the most recent comparison examination has
resolved. However,
note is made of increasing consolidation, particularly involving
the right
middle, right lower, and left lower lobes.
The patient is status post mitral and tricuspid valve
replacement. The heart
size is enlarged and there is a moderate pericardial effusion,
which is
increased from the comparison examination. The degree of hilar
or mediastinal
lymphadenopathy is unchanged. A left peripherally inserted
central catheter
terminates in the superior portion of the superior vena cava.
Dense contrast
is present within the esophagus, as well as in the upper
stomach.
The study is not tailored for subdiaphragmatic assessment,
though note is made
of diffuse hepatic hypodensity, indicative of steatosis. There
is no
suspicious sclerotic or lytic lesions and multiple sternotomy
wires appear
intact and appropriately positioned.
IMPRESSION:
1. Interval worsening in the degree of lower lobe consolidation
and minimal
change in the burden of extensive cavitating lung lesions.
2. Moderate pericardial effusion, which is increased.
3. Unchanged left pleural effusion and right pleural effusion,
with a new
small amount of right pleural gas, status post chest tube
removal.
4. Dense contrast within the esophagus following swallowing
evaluation, a
finding which raises concern for future aspiration.
5. Hepatic steatosis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
Approved: [**First Name9 (NamePattern2) **] [**2188-2-8**] 4:32 PM
Radiology Report CHEST (PA & LAT) Study Date of [**2188-2-6**] 2:01 PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2188-2-6**] 2:01 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 92398**]
Reason: Please perform at 1:30pm and evaluate for interval
change
[**Hospital 93**] MEDICAL CONDITION:
29F w/ PMH significant for active IVDU, now POD 8 s/p TV
replacement & MV
repair, now w/ large right pleural effusion. Now s/p R CT
removal
REASON FOR THIS EXAMINATION:
Please perform at 1:30pm and evaluate for interval change
Final Report
HISTORY: IVDU postoperative with chest tube removal.
FINDINGS: In comparison with the study of [**2-5**], the right chest
tube has been
removed. The small predominantly lateral pneumothorax on the
right is
unchanged. Diffuse bilateral pulmonary opacifications persist,
though they
may be reducing slowly.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: WED [**2188-2-6**] 4:15 PM
[**2188-2-10**] HCT 23/ WBC 8.8
[**2188-1-31**] 05:22AM BLOOD WBC-13.4* RBC-3.03* Hgb-8.8* Hct-27.5*
MCV-91 MCH-29.1 MCHC-32.1 RDW-17.9* Plt Ct-256
[**2188-1-14**] 02:56AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-OCCASIONAL Polychr-1+ Acantho-1+
[**2188-1-30**] 02:00AM BLOOD PT-12.2 PTT-30.3 INR(PT)-1.1
[**2188-1-15**] 04:23PM BLOOD ESR-91*
[**2188-1-31**] 05:22AM BLOOD Glucose-101* UreaN-19 Creat-0.8 Na-138
K-3.6 Cl-105 HCO3-23 AnGap-14
[**2188-1-24**] 04:20PM BLOOD ALT-16 AST-24 LD(LDH)-659* AlkPhos-96
TotBili-1.4
[**2188-1-31**] 05:22AM BLOOD Mg-1.9
[**2188-1-25**] 12:15PM BLOOD %HbA1c-5.1 eAG-100
[**2188-1-14**] 09:48PM BLOOD TSH-2.4
[**2188-1-15**] 04:23PM BLOOD HBsAg-NEGATIVE
[**2188-1-13**] 04:59AM BLOOD HBsAb-POSITIVE HBcAb-NEGATIVE
[**2188-1-19**] 05:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2188-1-13**] 04:59AM BLOOD HCV Ab-NEGATIVE
Brief Hospital Course:
Following admission she underwent multiple imaging studies
including TEEs, MRI and CTs of the torso. Vancomycin was
continued after transfer. ID followed the patient closely.
Thoracentesis was performed and sterile. Nafcillin was
eventually started after MSSA sensitivities returned. There was
radiographic evidence for pulmonary abscesses and an MRI showed
cerebral emboli as well. She improved, weaned off pressors and
was able to be extubated.
Cardiac Surgery was consulted and after completing work up and
optimization, she went to the Operating Room on [**1-25**] where
tricuspid replacement and mitral repair were effected. There
was a large friable vegetation on the tricuspid valve, but no
annular abscess. The mitral was resected and an annuloplasty
performed. She weaned from bypass on Vasopressin and Neo
Synephrine. She gardually weaned from pressors and was
extubated. CTs were removed per protocol and temporary pacing
wires as well.
She was transferred to the floor on POD 5 and beta blockade and
diuresis begun. A calcoum channel blocker was added and titrated
to achieve better heart rate control. Cultures from the
Operating Room remained negative to date.
PICC line placed for longterm abx therapy due to pseudomonas
pneumonia. Infectious disease was consulted and followed the
patient throughut her admission. On POD #6 she was placed on an
IV zosyn course thru [**2188-2-27**].
She has loose stools for a prolonged period of time and was
traeted with po flagyl while awaiting her stool cultures. She
was negative for c-diff x 3 including a cdiff for PCR. The
flagyl was d/c'd and she was started on lomotil with
improvement.
She had a persistant complaint of breathlessness and a hoarse
voice. She has a speech and swallow evaluation which was normal.
ENT was consulted and found no evidence of vocal cord paralysis.
Pulmonary medicine was consulted for ongoing complaints of
shortness of breath. They felt that her shortness of breath was
multifactorial - deconditioning, her pneumonia and underlying
lung disease. A repeat CT scan was done (see results) and
thoracic surgery was consulted (Dr. [**Last Name (STitle) 7343**]. She may require a
VATS in the future for definitive decortication. She will see
Thoracic surgery in one week from this discharge with a CT scan
to evaluate her pulmonary status. Despite her pulmonary issues
she made slow but steady progess and was discharged to the
[**Hospital **] rehab on POD # 16/ HD# 34. Physical Therapy was
consulted for strength and mobility due to her profound
deconditioning after a prolonged period of illness. Social
Services met with her family as well for coping and issues
surrounding drug rehab.
All follow-up appointments were advised.
Medications on Admission:
Home Medications:
- Klonopin
.
Medications on Tranfer:
- Vancomycin 1000mg daily
- Ceftriaxone 2gm daily
- Phenylephrine drip
- Propofol drip
- Clonidine 0.1mg Q4H PRN
- Acetaminophen 650mg TID
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
8. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1) Mucous
membrane prn as needed for cough.
9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/temp.
11. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
12. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
13. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
14. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
15. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
16. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for loose stool.
17. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed for shortness of breath or
wheezing.
18. potassium chloride 10 mEq Tablet Extended Release Sig: Four
(4) Tablet Extended Release PO Q12H (every 12 hours).
19. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q6H (every 6 hours) for 2 weeks: end
date [**2188-2-27**].
20. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
21. furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
Q12H (every 12 hours).
22. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for picc line flush: PICC
line care.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
tricuspid endocarditis - MSSA
mitral regurgitation
IV drug abuse
septic emboli to brain and lungs
asthma
anxiety
Discharge Condition:
Alert and oriented x3 with generalized weakness
Taking small steps from bed to chair with max assist of two
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+ lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for 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 Name (STitle) **] ([**Telephone/Fax (1) 170**]) [**Hospital Ward Name **] 2A Tuesday [**2-26**] @ 1:30
pm
Cardiologist:Dr.[**Name (NI) 3733**] [**2-29**] @ 1:20 pm [**Hospital Ward Name 23**] 7
ID :[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2188-2-5**]
10:15 AM,[**Hospital Ward Name **] Ground Floor
Chest CT scan [**2188-2-14**] - please call [**Telephone/Fax (1) 92399**] for a time
Responsible MD: Dr. [**Last Name (STitle) 7343**], [**First Name3 (LF) 1092**] surgery
Please call to schedule appointments with:
Surgeon- Thoracic- Dr. [**Last Name (STitle) 7343**] [**Telephone/Fax (1) 92400**]- you need to be seen
on thursday [**2188-2-14**]. You will have a chest CT on that day.
Primary Care: Dr.[**Last Name (STitle) 92401**] [**Last Name (un) 92402**]([**Telephone/Fax (1) 72236**]in [**4-17**]
weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2188-2-10**]
|
[
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"518.81",
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"286.6",
"300.00",
"415.12",
"482.1",
"287.5",
"038.11",
"276.2",
"571.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
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"38.97",
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] |
icd9pcs
|
[
[
[]
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|
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|
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|
17764, 18009
|
2225, 5907
|
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|
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|
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|
1763, 2206
|
15104, 15281
|
5951, 7449
|
268, 298
|
10866, 12307
|
534, 1573
|
1595, 1625
|
1641, 1722
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,228
| 185,319
|
51786
|
Discharge summary
|
report
|
Admission Date: [**2128-8-13**] Discharge Date: [**2128-8-18**]
Date of Birth: [**2083-9-24**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Sulfonamides / Morphine / Shellfish
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
44-year-old female with collagenous colitis/Crohn's disease
presented to ER with fatigue and fever to 101.7 F at home after
having had her Hickman (X 18 hrs) repaired the previous day. In
the ED, temp 103 F, bp 142/69; bp dropped to 96/35. She received
vanco/Cefipime for presumed lung infection and 2L NS. She was
admitted to the [**Hospital Unit Name 153**], covered with vanco/cefapime until cx grew
coag negative staph, switched to vanco. Volume resuscitated with
stabilization of bp in 110s. ICU course also notable for d/c
coumadin (had completed 6 mos course for prior PE), hyponatremia
(resolving with fluid resuscitation), anemia (HCT dropped to
19.8) for which she received 1unit PRBC, and facial/neck
swelling (chronic in the setting of venous stenosis from
multiple prior line placements. IR and surgery consulted, goal
is to preserve Hickman. Currently, the patient reports
generalized myalgias, occasional lightheadedness. She denies
fevers/chills
.
ROS: No weight loss. (+) fatigue/malaise. No chills, night
sweats, loss of vision. (+) dry mouth. No sinus pain, sore
throat, chest pain, palpitations. (+) chronic LE edema and DOE.
No current shortness of breath or hemptoysis. (+) dry cough this
a.m. No nausea, vomiting. (+) chronic RUQ/RLQ abdominal pain,
unchanged from baseline. (+) diarrhea, [**6-2**] BM/day, at baseline,
no melena or hematochezia. No bleeding, lymphadenopathy,
dysuria, hematuria, increased urinary frequency/urgency, rash.
(+) loss of energy. (+0 myalgias/arthralgias. No
numbness/tingling, headache. (+) chronic LBP, no change from
baseline.
Past Medical History:
1) Crohn's disease (dx [**2122**], on MTX/Remicaide, baseline [**11-7**]
BM's per day), s/p colectomy [**1-25**], reanastamosis (ileo-rectal)
[**6-25**], h/o collagenous colitis
2) Crohn's arthropathy (seronegative)
3) GERD
4) Raynaud's
5) Depression/Anxiety
6) Migraine HA's
7) Iron Def Anemia
8) MSSA line infxn [**8-27**]
9) Burkholderia bacteremia [**9-27**] and [**10-27**]
10) Chronic Hickman Catheter for IVF
11) SVC syndrome, Left IJ and Left Subclavian stenosis s/p
angioplasty in
[**4-28**]
12) hx of left exudative pleural effusion of unclear etiology
h/o VATS~[**2123**] - for left exudative pleural effusion around time
of #7
13) hx of left pneumothorax due to porta-cath placement
14)left knee arthroscopy
15)Schatzki's ring-noted on EGD
16) h/o post menopausal vaginal bleeding
17) oral hsv
Social History:
The pt lives in [**Location 246**] with her husband and two children, She
does not work, She smokes 0.5-1ppd x 20 yrs, She drinks [**1-26**]
beers/day
Family History:
Father has polycythemia, mother has melanoma.
Physical Exam:
PE: Tc 98.5, pc 91, bpc 96/64, pc 91, resp 16, 96% RA
Gen: chronically-ill appearing elderly female, A&OX3, NAD
HEENT: anicteric, pale conjunctiva, OMM dry, OP clear, neck
supple, no LAD. (+) generalized neck swelling w/o cords palpated
Cardiac: RRR, II/VI SM at LSB
Pulm: CTA bilaterally
Chest: Hickman catheter with minimal erythema at opening,
non-tender
Abd: NABS, moderately distended, tympanitic, mod RLQ/LLQ
tenderness without rebound or guarding
Ext: trace LE edema at ankles bilaterally, warm, 2+ DP
bilaterally
Neuro: CN II-XII grossly intact and symmetric bilaterally, [**5-28**]
strength throughout with encouragement, sensation intact to
light touch proximally and distally in upper and lower
extremities bilaterally.
Pertinent Results:
EKG: Sinus tach, low voltage in limb leads
.
Radiology:
[**8-12**] CXR AP (-) PNA
.
Micro:
ucx: [**8-14**] >100k yeast, [**8-13**] >3 colony types
bcx [**8-14**] pending. [**8-12**] CNS [**3-27**] sensitive to oxacillin, gent,
levo (all drawn from line
.
Brief Hospital Course:
1) Coag neg staph line sepsis:
Patient presented with fatigue and fever of 101.7. In the ED
she was noted to have a temperature of 103, bp 142/69, hr 118,
and 95% on 2L NC. WBC was 12.9 with 93% neutrophils but no
bands. Initial lactate 3.1 but improved to 2.6 with IV fluids.
Patient was admitted to the ICU for monitoring and was treated
with vancomycin and ceftazidime. CXR and urinalysis were
unremarkable and her initial LFTs were normal. Her blood
cultures drawn off her line subsequently grew coag neg staph.
Her ceftazidime was discontinued. She was continued on vanc but
had persistent fever spikes. Her subsequent sensitivities
revealed oxacillin sensitivity. Thus, the patient was switched
to nafcillin and thereafter defervesced. IR was consulted but
all parties agreed it was in the best interest of the patient to
attempt to treat through this infection given she has very
difficult access. Other than her initial blood cultures, all of
her surveillance cultures have so far been no growth to date.
She did undergo an ECHO while in house to rule out a vegetation.
This revealed a normal EF with no evidence of vegetation. She
was discharged home on an additional 11 days of nafcillin for a
total of 14 days of this antibiotic, which seemed much more
effective in clearing her infection. She understands to monitor
the site for new erythema, pain, or temperature > 101. She will
be following up with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 3816**], [**8-24**] for interval assessment at which time her LFTs will need to be
rechecked given she is on nafcillin.
.
## Anemia:
Patient admitted with a hematocrit of 22.6 which dropped to 18.7
with IV hydration. She was thus transfused 3 units of PRBC.
Her hematocrit bumped appropriately to 30 and has since slowly
trended down to 26.7 on the day of discharge. She was continued
on her niferex-150 and will follow-up with her regular providers
to continue IV iron as needed. Her vitamin B12 and folate are
normal.
.
## Crohns and collagenous colitis:
Patient was continued on her home dose of mesalamine. She
continued to have her baseline chronic diarrhea. During her
stay she complained of diffuse arthralgias. She has taken
alleve for this in the past but did not receive NSAIDs while in
house. She moved comfortably with only her home pain
medications in addition to tylenol as needed. She did inquire
regarding her methotrexate infusion but was informed this cannot
be restarted until she has cleared her infection and only at the
discretion of her primary care doctor. I have arranged
follow-up for her with her gastroenterologist to consider
possibly increasing her mesalamine in hopes of improving her
joint complaints if they persist. There was no warmth or
erythema of her joints on exam to suggest infectious
involvement.
.
## GERD: Patient complained of significant GERD which she states
is long standing. An H2blocker was added to her home [**Hospital1 **] PPI.
In addition, her regular GI attending advised adding a
sucralfate slurry. In addition, at the request of her GI
physician, [**Name10 (NameIs) **] outpatient gastric emptying study has been ordered
to evaluate for delayed emptying as motility agents may also
help her symptoms if she does in fact have delayed emptying.
.
## Hyponatremia: Sodium 132 on admission. This was likely
resolved to her initial dehydration and revolved with IVF.
.
## Chronic abdominal pain: Patient was continue on her home
doses of dilaudid, methadone, and amitriptyline.
.
## h/o PE: Patient was taken off her coumadin given she is 6
months status post her PE and required PRBC transfusion for
ongoing iron deficiency anemia. She was scheduled to see Dr.
[**Last Name (STitle) 6160**] to address this further but wishes to follow-up with
her PCP first to determine if this is necessary. She has been
seen by Dr. [**Last Name (STitle) 6160**] previously who suggested a 6 month course.
He wishes to follow-up with her off of coumadin for a
hypercoagulable work-up to determine if her anticoagulation
should be continued further.
.
## Transaminitis:
Patient noted to have bump in LFTs on nafcillin. She will
follow-up with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] her labs
while on this antibiotic.
.
## Face/neck swelling: Patient had swelling with IV fluids which
improved with restriction of her IV fluid administration.
.
## Prophylaxis: PPI, anticoagulated, given she is on
methotrexate, it was thought patient would benefit from PCP
[**Name Initial (PRE) 1102**]. Given her bactrim allergy, she will need to
follow-up with her primary care doctor to consider inhaled
pentamadine for prophylaxis.
.
## Access: Hickman
.
## Code Status: Full
.
## Dispo: discharged home with services
Medications on Admission:
1. Advair one puff b.i.d.
2. Albuterol p.r.n.
3. Pentasa 1 gm t.i.d.
4. Klonopin 1 mg q.i.d.
5. Protonix 40 mg b.i.d.
6. Amitriptyline 50 mg q.h.s.
7. Methadone 10 mcg/mL, 3 mL or 30 mg q.i.d.
8. Dilaudid 8 mg one to two tablets every four hours p.r.n.
pain.
9. Weekly methotrexate (q [**Name Initial (PRE) 766**]).
10. Folate supplements.
11. Niferex 150 twice a day.
12. Coumadin 7.5 mg 4x/wk, 5 mg 3x/wk.
.
Discharge Medications:
1. Hickman Line Care
per CCS protocol
2. Nafcillin 2 g Recon Soln Sig: Two (2) grams Intravenous
every four (4) hours for 11 days: through [**2128-8-29**].
Disp:*132 grams* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for joint pain.
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Mesalamine 250 mg Capsule, Sustained Release Sig: Four (4)
Capsule, Sustained Release PO TID (3 times a day).
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Hydromorphone 4 mg Tablet Sig: 8-16 Tablets PO Q4H (every 4
hours) as needed for abdominal pain.
11. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
12. Methadone 10 mg Tablet Sig: Three (3) Tablet PO QID (4 times
a day).
13. Cimetidine 300 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*360 Tablet(s)* Refills:*2*
14. Sucralfate 1 g Tablet Sig: One (1) Tablet PO BID (2 times a
day): Please add tablet to 2 tablespoons of water to form a
slurry.
Disp:*180 Tablet(s)* Refills:*2*
15. Niferex-150 150-50 mg Capsule Sig: One (1) Capsule PO twice
a day.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
primary: coagulase negative staph line sepsis
secondary: arthralgias, crohns colitis, iron deficiency anemia,
gastroesophageal reflux
Discharge Condition:
good - afebrile
Discharge Instructions:
Please call your primary care doctor or go to the emergency room
if you experience temperature > 101, worsening redness around
your line, worsening or change in your chronic diarrhea, or
other concerning symptoms.
You can try your alleve for your joint pain but beware of
worsening reflux and irritation of your bowel disease on this
medication. Tylenol may also help with the discomfort and has
no GI side effects. I have contact[**Name (NI) **] Dr. [**Last Name (STitle) 79**] about possibly
increasing your mesalamine, which may also help your symptoms.
You will be following up with her on [**Last Name (STitle) 3816**].
Please note, you are no longer taking coumadin. I have started
you on cimetidine and sucralfate for your reflux. You also are
on IV antibiotics for the next 11 days to treat your line
infection.
You cannot restart your methotrexate until you have finished
your antibiotics and cleared your infection. Please see your
primary care doctor to determine when it is safe to restart this
medication.
Followup Instructions:
Please follow-up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 3816**],
[**2128-8-24**] at 2:50 PM at [**Hospital Ward Name 23**] Atrium Suite. Phone:
[**Telephone/Fax (1) 250**]
Please follow-up with Dr. [**First Name4 (NamePattern1) 450**] [**Last Name (NamePattern1) 79**] on [**8-24**] at 8:40 AM
on the [**Location (un) 436**] of [**Hospital Ward Name 23**]. Phone: [**Telephone/Fax (1) 1954**]
You are scheduled for a gastric emptying study on [**2128-8-25**]
at 8:00 AM. Do not eat breakfast on the day of your exam. The
exam will take up to 4 hours. Please go to the main entrance of
the [**Hospital Ward Name **] on the day of your exam. The scan will be done
on the [**Location (un) 448**] of the [**Hospital Ward Name 2104**] building in nuclear medicine.
Phone: [**Telephone/Fax (1) 2103**]
|
[
"555.9",
"794.8",
"300.4",
"995.91",
"996.62",
"443.0",
"276.1",
"558.9",
"285.9",
"038.19",
"713.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10794, 10846
|
4043, 8842
|
315, 322
|
11025, 11043
|
3763, 4020
|
12118, 12965
|
2949, 2996
|
9303, 10771
|
10867, 11004
|
8868, 9280
|
11067, 12095
|
3011, 3744
|
267, 277
|
350, 1935
|
1957, 2765
|
2781, 2933
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,083
| 188,353
|
10717
|
Discharge summary
|
report
|
Admission Date: [**2185-8-23**] Discharge Date: [**2185-8-25**]
Date of Birth: [**2147-9-19**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 37-year-old male who
presents to the CCU in arrhythmia, question SVT, question V
tach. The patient had no significant past medical history
until two months ago when he began experiencing palpitations
and was found to be in arrhythmia, probable SVT, question V
tach. The patient was converted with a calcium channel
block. He was discharged home. The patient had EP study at
[**Location (un) 47**] on [**6-17**] with no ablation. The patient had 6-7
episodes over the past two months, each time converted on
calcium channel blocker or beta blocker or with vagal
maneuvers. This a.m. on [**8-23**] the patient awoke tired at noon,
felt fatigued, mildly dyspneic, went to outside hospital,
found to be in cardiac arrhythmia. The patient received
Adenosine 6 mg IV times one, 12 mg IV times one, Lopressor 5
mg IV times one, Verapamil 5 mg IV times one, with no change.
The patient was then cardioverted 100 joules to normal sinus
rhythm. He then reverted back to his arrhythmia and was
loaded with Procainamide and converted to normal sinus rhythm
after 1 gm IV over one hour and then started on a drip at 2
mg per minute. The patient was transferred from outside
hospital and ?????? hour before he arrived he went back into his
arrhythmia.
At arrival the patient had no complaints, no chest pain,
shortness of breath, no nausea, vomiting, no palpitations, no
lightheadedness.
PAST MEDICAL HISTORY: 1) Cardiac arrhythmia times two
months, status post EP study [**6-17**]. 2) Increased cholesterol.
3) Status post vasectomy.
ALLERGIES: Penicillin. The patient gets edematous.
MEDICATIONS: As an outpatient, Lopressor 100 mg [**Hospital1 **],
Propafenone, Asafex 20 mg po q d, Niacin 500 mg po q d. On
presentation, Procainamide drip at 2.
SOCIAL HISTORY: The patient works at [**Company 35082**]. No
alcohol, no tobacco, no drug abuse. The patient lives at
home in [**Location (un) 17566**] with his parents.
FAMILY HISTORY: Father with CAD, with MI in his 60's.
PHYSICAL EXAMINATION: On admission, general, pleasant, no
apparent distress. Vitals, blood pressure 107/59, pulse 172,
pulse ox 97 on two liters, respiratory rate 22. HEENT:
Anicteric, mucus membranes moist. Neck, no JVP appreciated,
2+ carotids, no LAD. Heart, regular rhythm, tachycardic, S1
and S2, no murmurs, rubs or gallops. Lungs are clear
bilaterally. Abdomen obese, soft, nontender, non distended,
positive bowel sounds. Extremities, no edema bilaterally.
Neuro, alert and oriented times three, mentating well.
LABORATORY DATA: From [**Hospital3 1280**], white count 8,000,
hemoglobin 16.9, hematocrit 48, platelet count 196,000,
sodium 136, potassium 5.0, chloride 96, CO2 28, BUN 15,
creatinine 1.2, glucose 157, total protein 7, albumin 4.4,
calcium 9.3, AST 22, ALT 35, alkaline phosphatase 103, CK 46,
LDH 273, troponin I less than .3, PT 12, INR .98, PTT 36.1.
Chest x-ray, question enlarged cardiac silhouette, no acute
cardiopulmonary process. EKG, SVT at 174, right bundle
branch block, left axis. The right bundle branch block is
old.
HOSPITAL COURSE:
1. Cardiology: Patient had Procainamide drip stopped as he
was in his cardiac arrhythmia. He was started on Lidocaine
with 70 mg IV bolus and started at a drip of 1 mg per minute.
He converted to normal sinus rhythm at 90 at 11 p.m. on [**8-23**].
At midnight, however, he went back into his arrhythmia. He
was given Lido 35 mg IV push. He did not convert. He was
converted, however, after removal of his defibrillator pad.
The patient had episodes of cardiac arrhythmia throughout the
night of [**8-23**] into the morning of [**8-24**] and he was converted
these times with vagal maneuvers. The patient, on the
morning of [**8-24**] had his Lido drip stopped and promptly went
back into his cardiac arrhythmia. He was subsequently taken
to the EP lab where he had two ablations. First ablation was
right bundle branch re-entry vs nodofascicular BPT. Other
ablation was an AV NRT. The patient did not require pacer
after his AV NRT ablation. The patient was transferred to
the floor in stable condition after his EP study. The
patient had episodes of sinus tachycardia on the evening of
[**8-24**] and into the morning of [**8-25**] which was thought related to
his infectious disease issues. The patient was stopped from
Lopressor and Propafenone and patient was discharged on
Niacin 500 mg extended release q a.m. as his only cardiac
meds. The patient was to follow-up with Dr. [**First Name (STitle) 1075**], his
cardiologist at [**Location (un) 47**] [**8-26**] at 2:30 p.m.
2. Infectious Disease: The patient had a temperature spike
to 102.3 at 7:50 p.m. on [**8-24**]. The patient had urine
cultures, blood cultures, urinalysis and a chest x-ray done.
Chest x-ray showed no acute cardiopulmonary process. Blood
cultures showed no growth over 24 hours. Urine culture
showed no growth over 24 hours. Antibiotics were not
started. The patient had no focal signs or symptoms
suggestive of bacterial infection. The patient denied any
chest pain, shortness of breath or urinary symptoms, nausea,
vomiting, diarrhea, headache or stiff neck. The patient
states he had been around somebody with a viral bronchitis.
Etiology to his fever was thought to be secondary to a viral
process. The patient was instructed to follow-up with his
primary care physician if any focal symptoms occurred.
3. GI: The patient is on a proton pump inhibitor as an
outpatient. This is followed by his primary care physician
for question GERD. The patient denies any symptoms of GERD.
The patient was instructed to follow-up with primary care
physician as to whether he would need his proton pump
inhibitor. The patient was discharged on his outpatient dose
of Asafex 20 mg po q d.
4. Prophylaxis: The patient was maintained on Protonix
throughout his stay and discharged home on Asafex 20 mg po q
d. The patient was also started on subcu Heparin 5000 [**Hospital1 **]
subcu while he was at bedrest post EP study. This was
stopped upon discharge home.
5. Fluids, Electrolytes & Nutrition: The patient was npo
for his EP study. The patient had q d Lyte checks which
revealed no abnormalities. The patient was placed on a
regular diet.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSIS:
1. Cardiac arrhythmia with successful ablation of
nodofascicular BPT vs RBB reentrant. The patient also had AV
NRT ablated.
2. Hypercholesterolemia.
3. Viral syndrome.
4. Question GERD.
DISCHARGE MEDICATIONS: Asafex 20 mg po q d, Niacin extended
release 500 mg po q a.m.
DISCHARGE STATUS: No change in code status. The patient is
full code.
DISCHARGE APPOINTMENTS: The patient is to follow-up with
outpatient cardiologist, Dr. [**First Name (STitle) 1075**], [**8-26**] at 2:30 p.m.
[**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 12203**], MD [**MD Number(1) 12204**]
Dictated By:[**Last Name (NamePattern1) 1324**]
MEDQUIST36
D: [**2185-8-25**] 11:13
T: [**2185-8-30**] 08:55
JOB#: [**Job Number 35083**]
|
[
"780.6",
"427.89",
"998.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
2112, 2151
|
6653, 7213
|
6437, 6629
|
3236, 6416
|
2174, 3219
|
156, 1551
|
1574, 1921
|
1938, 2095
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,367
| 136,441
|
3812
|
Discharge summary
|
report
|
Admission Date: [**2202-2-2**] Discharge Date: [**2202-2-24**]
Date of Birth: [**2121-5-26**] Sex: F
Service: SURGERY
Allergies:
Codeine / Ace Inhibitors
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Admission to [**Hospital1 18**] for subtotal gastrectomy for known gastric ca
Major Surgical or Invasive Procedure:
[**2-2**] Subtotal Gastrectomy
[**2-2**] Cordis insertion
[**2-12**] R arm PICC placement
[**2-23**] R arm PICC removed
History of Present Illness:
80 yo F with gastric adenocarcinoma which was found after she
was hospitalized for a COPD flare and was found to have iron
deficiency anemia. She had an initial endoscopy which showed a
hiatal hernia and gastritis. Follow-up EGD on [**2202-11-20**] revealed
a 4cm malignant appearing mass on the ant antral wall. The mass
was biopsied and was poorly differentiated adenoscarcinoma.
It was decided that her gastric cancer was likely resectable and
she was seen in consultation by Dr. [**Last Name (STitle) **] as well as by her
cardiologist. The plan was for subtotal gastrectomy.
Past Medical History:
HTN, severe AS (valve area = 0.8 cm2), diastolic CHF, COPD
(FEV1=74%), prior R MCA stroke (resolved), hyperlipidemia, diet
controlled DM2, depression, Hyperlipidemia, Osteoporosis, hx of
Pyloric ulcer disease, Iron deficiency anemia
Social History:
Per chart review: Social History: Ms. [**Known lastname **] lives by herself.
She has 4 children who all live locally (1 in [**Location (un) 86**], 2 in
[**Location (un) 686**], 1 in [**Location (un) 47**]) and she has multiple grandchildren.
Occasionally plays Bingo with friends.
Tobacco: Continued use. >70 pack years
Alcohol: prior heavy use, sober for 5+ years
Family History:
Unknown
Physical Exam:
Upon discharge
98.6 92 114/65 16 97%RA
Alert, thin elderly female in NAD
EOMi, Anicteric, edentulous, no JVD
RRR + III/VI systolic harsh murmur that radiates to carotids and
abd heard throughout the precordium
CTAB
soft NT/ND midline incision, well-healed
no c/c/e
Pertinent Results:
[**2202-2-21**] 05:36AM WBC-12.1* RBC-3.19* Hgb-8.3* Hct-24.6* MCV-77*
Plt Ct-337
[**2202-2-17**] 05:09AM WBC-12.9* RBC-3.49* Hgb-8.6* Hct-27.2* MCV-78*
Plt Ct-375
[**2202-2-2**] 12:18PM WBC-23.1*# RBC-4.49 Hgb-11.2* Hct-34.8* MCV-78*
Plt Ct-329
[**2202-2-17**] 05:09AM Neuts-54 Bands-5 Lymphs-21 Monos-6 Eos-4 Baso-0
Atyps-0 Metas-4* Myelos-6*
[**2202-2-15**] 04:20AM Neuts-62 Bands-0 Lymphs-18 Monos-12* Eos-2
Baso-0 Atyps-0 Metas-3* Myelos-2* Promyel-1*
[**2202-2-23**] 05:30AM Gluc-110* UreaN-15 Creat-0.7 Na-133 K-4.6
Cl-101 HCO3-26
[**2202-2-18**] 06:00AM Gluc-102 UreaN-13 Creat-0.5 Na-132* K-4.1 Cl-98
HCO3-30 A
[**2202-2-2**] 12:18PM Gluc-178* UreaN-13 Creat-0.9 Na-139 K-4.1
Cl-103 HCO3-30
[**2202-2-18**] 06:00AM Calcium-8.5 Phos-4.0 Mg-1.9
[**2202-2-2**] 12:18PM Calcium-8.7 Phos-4.6*# Mg-1.8
Pathology:
-Distal stomach tissue: invasive adenocarcinoma, mixed
intestinal and diffuse types with focal signet ring cell
morphology.
-[**1-7**] lymph nodes positive for metastatic adenocarcinom
Brief Hospital Course:
OPERATIONS DURING ADMISSION
[**2-2**] Subtotal gastrectomy
CONSULTATIONS DURING ADMISSION
Infectious Disease
Gastroenterology
PERTINENT PATHOLOGY
I. Distal stomach, partial gastrectomy (A-Y): Invasive
adenocarcinoma, mixed intestinal and diffuse types with focal
signet ring cell morphology; Chronic inactive gastritis with
intestinal metaplasia and dysplasia; Margins of excision are
free of invasive carcinoma
II. Unremarkable duodenal segment.
III. Omentum with no carcinoma seen.
IV. Lymph node, left gastric (Z): Two of twelve lymph nodes
positive for metastatic adenocarcinoma
V. [**2-14**] Stool - Salmonella enteriditis
BRIEF HOSPITAL COURSE BY DATES/MAJOR EVENTS
[**2-2**] The patient was taken to the OR for a subtotal
gastrectomyl; she tolerated the procedure well. She was then
taken to the SICU, extubated postoperatively in SICU. She
developed slight post-op delerium that resolved upon her
transfer out of the SICU. She maintained her fluid status well
- no hypotension or signs of overload in spite of AS.
[**2-3**] On POD 1 her cordis was removed. In her post-op delerium
the pt removed both NGT and PIV; the PIV replaced but the NGT
kept out given the fresh anastomosis.
[**2-4**] Unfortunately, the patient developed emesis and was then
noted to desaturate to the 80s - likely aspiration - CXR was
unremarkable. Her O2 sats eventually recovered to RA without
antibiotic intervention.
[**2-6**] She was started on her home meds - nifedipine, valsartan,
hydrochlorthiazide, nebulizers for COPD. She was transferred to
the floor.
[**2-8**] She was started on clears and the foley discontinued.
[**2-9**] Her diet was advanced as tolerated; nutrition consulted for
post-gastrectomy diet. Unfortunately, that evening after eating
the patient developed nausea and emesis and profuse diarrhea;
she was made NPO with IVF; her symptoms thought to be secondary
to advancing her diet.
[**2-10**] A KUB was taken given her symptoms that was unremarkable.
Unfortunately, she developed profused diarrhea - up to 16
BM/day, without fevers, and intractable nausea/emesis requiring
anti-emetics throughout the day.
[**2-11**] The diarrhea continued; C diff stool samples sent during
the prior days were neagtive x3. Ova, parasites, and multiple
other
[**2114-2-11**] Given her symptoms and inability to tolerate PO intake,
a PICC was placed for TPN, and she was started on TPN. She
underwent an UGIS that revealed no leak. The diarrhea started
to slow up, but she was still having [**6-2**] loose green BM/day.
Gastroenterology was consulted for the diarrhea; they felt that
this was secondary to an infectious etiology or a
post-gastrectomy syndrome.
[**2-14**] The fecal stool sample grew out Salmonella species!
Infectious Disease was consulted; ID suspected that the patient
was likely a carrier prior to surgery and that the stress of
surgery/intraop abx had allowed for growth of the bacteria.
They recommended bld clx, TEE for concern with salmonella
bacteremia, and they recommended starting the patient on
ceftriaxone given her age.
[**2-15**] The TTE done for Salmonella bacteremia (without
vegetations). The diarrhea began slowing up though the patient
was without significant rx yet. The patient's diet was
advanced.
[**2-17**] ID recommended discontinuing the ceftriaxone and starting
cipro 500 [**Hospital1 **] x through [**2-21**] (7 days total); they signed off
given that her diarrhea was resolving. Unfortunately, the
patient once again developed recurrent emesis after eating
meatloaf, and so her diet was decreased to clears.
[**2-18**] The Salmonella speciated to S. enteriditis. The patient
was given [**Location (un) **] crackers, which she tolerated well. She
tolerated bland foods in the postgastrectomy diet; she was
started on calorie counts. She underwent a rehab screen given
PT recs, but case management discovered that her insurance did
not cover rehab. She developed soft stool again, and her stool
was sent for C dif.
[**2-19**] The patient began walking more. She tolerated her diet,
though was still eating little. She was diuresed x1 given the
volume of TPN. Her stool more solid; the C dif was negative.
The patient was also seen by OT, who actually recommended that
she go home with family helps w/ADLs.
[**2-20**] Her TPN was cycled. Once again the patient amulated well,
multiple times. Calorie counts still only 600/day. The patient
and her family once again counseled on PO intake,
post-gastrectomy diet.
[**2-21**] TPN cycled again and the volume halved. The patient
continued to ambulate well. Calorie counts improved. Meds all
changed to PO. The patient was noticed to become more anxious
and was treated with low dose ativan.
[**2-22**] Pt had nausea responsive to Zofran sublingual.
[**2-23**] PICC removed and pt was discharged home with services
The patient was kept on DVT prophylaxis (SQH) and PPI throughout
her stay.
Medications on Admission:
: Albuterol 90 mcg 2 puffs''', Alendronate 70 mg qweekly,
Lipitor 40 mg', Beconase AQ 1 spray'', Calcium 600/VitD'',
Fluoxetine 20 mg', Flovent 110mcg 2 puffs'', HCTZ 12.5',
Atrovent 17 mcg 2 puffs'''', Nifedipine SR 30 mg', Pantoprazole
40 mg DR'', Valsartan 80 mg'. OTC: APAP 325 prn, Docusate 100'',
Ferrous Sulfate 325'', MTV, Senna 8.6 mg qHS.
.
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
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*
9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0*
12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
inh Inhalation four times a day as needed for shortness of
breath or wheezing.
13. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
inh Inhalation three times a day as needed for shortness of
breath or wheezing.
14. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Gastric cancer s/p subtotal gastrectomy
Salmonella enteritis
Acute blood loss anemia
Aortic stenosis
PMH: severe AS (valve area = 0.8 cm2), diastolic CHF, HTN, COPD
(FEV1=74%), prior stroke (resolved), hyperlipidemia, diet
controlled DM2, gastric CA, depression
PSH: C-section ('[**57**])
Discharge Condition:
Stable
Discharge Instructions:
1. Take your medicines as prescribed.
2. Diet: Follow a post-gastrectomy diet: small meals
throughout the day, chewed well, with soft, easy to digest
foods: pureed carrots, squash, yams, applesauce, puddings,
yogurt, breads, rice, soup, fruit, ensure and protein
supplements, etc. It is important to supplement your diet with
Ensure or Boost to help maintain proper nutrition.
3. Activity: regular walking is encouraged
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) **] in [**11-27**] weeks. Call
[**Telephone/Fax (1) 2981**] to schedule an appointment.
2. Please call your primary care doctor for a follow-up visit.
Completed by:[**2202-2-23**]
|
[
"V02.3",
"401.1",
"536.2",
"934.9",
"428.32",
"496",
"424.1",
"276.2",
"250.00",
"151.2",
"285.1",
"196.2",
"E878.6",
"293.0",
"003.0",
"428.0",
"733.00",
"553.3",
"V12.54",
"E849.7",
"272.4",
"E915"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"43.7",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9984, 10041
|
3096, 8012
|
361, 483
|
10375, 10384
|
2067, 3073
|
10860, 11097
|
1753, 1762
|
8413, 9961
|
10062, 10354
|
8039, 8390
|
10408, 10837
|
1777, 2048
|
244, 323
|
511, 1095
|
1117, 1352
|
1402, 1737
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,708
| 129,900
|
15893
|
Discharge summary
|
report
|
Admission Date: [**2199-12-4**] Discharge Date: [**2199-12-9**]
Date of Birth: [**2124-8-6**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 75 year old man who
underwent an left anterior descending stent catheterization
and was found to have an occluded right, 80% circumflex
lesion with an ejection fraction in the 30% range. Plan at
that time was to bring him back for a bypass surgery after
four weeks or so after he recovered from an anterior infarct
and stent placement and was off Plavix. The patient is still
getting frequent angina probably around 3 to 5 times a day
which manifested itself as pain to his left elbow. He did
have some dyspnea on exertion but he denies paroxysmal
nocturnal dyspnea, orthopnea or peripheral edema.
HOSPITAL COURSE: The patient was brought to the Operating
Room [**2199-12-4**] at which time an off pump coronary
artery bypass graft times three was performed. The left
internal mammary artery was brought to the left anterior
descending, saphenous vein graft to the obtuse marginal, and
saphenous vein graft portion was brought to the posterior
descending artery. The patient was extubated and brought to
the Cardiothoracic Recovery Unit in good condition. He was
in normal sinus rhythm with first degree atrioventricular
block at the time of admission to the Recovery Unit. On
postoperative day #1 the patient remained in normal sinus
rhythm and was sating well at 97% on 10 liters/minute.
Creatinine was stable at 1.1 as well as hematocrit of 35. He
was subsequently transferred to the Cardiac Surgery Floor.
Late on postoperative day #2 the patient went into rapid
atrial fibrillation, rate at 140 at which time he was given 2
gm of magnesium and another 12.5 of p.o. Lopressor and he
went back into normal sinus rhythm promptly and remained
there until discharge.
Discharge plan was Amiodarone load 400 mg b.i.d. and then he
was switched to 200 mg of Amiodarone b.i.d. During his
hospital stay, the last two days he was on heparin drip and
planned to reach therapeutic levels on Coumadin. Discharge
medications were Lovenox b.i.d. as a bridge to get
therapeutic on the Coumadin. He was subsequently discharged
on [**2199-12-9**]. Rate at the time of discharge was
almost to 80s, normal sinus rhythm.
DISCHARGE MEDICATIONS:
1. Coumadin 5 mg q. day
2. Amiodarone 400 mg p.o. t.i.d. for seven days
3. Lopressor 25 mg p.o. b.i.d.
4. Plavix 75 mg p.o. q. day
5. Aspirin 325 mg p.o. q. day
6. Lasix 20 mg p.o. b.i.d. for only 14 days
7. K-Dur 20 mEq p.o. b.i.d. for only 14 days
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 14176**]
MEDQUIST36
D: [**2199-12-12**] 16:09
T: [**2199-12-12**] 14:20
JOB#: [**Job Number 4824**]
|
[
"272.0",
"414.01",
"427.31",
"V45.82",
"410.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.72",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
2335, 2878
|
813, 2312
|
183, 795
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,241
| 103,435
|
13846
|
Discharge summary
|
report
|
Admission Date: [**2155-4-27**] Discharge Date: [**2155-5-2**]
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
female, who presented with one-day history of severe
bilateral upper quadrant pain and epigastric pain with
radiation to the back and right shoulder. The patient
reports that she had an acute onset of pain with no known
precipitant. She was unable to tolerate PO the day before
presentation and reported nausea and vomiting times 3, the
day before. She was taken to an outside hospital and
reported significant pain during her travel with any sudden
movements. Her pain was controlled when lying still. She
received no relief with Maalox and Tums, but did improve when
admitted secondary to morphine at the outside hospital. She
denied pain with deep inspiration or pleuritic pain. No
dysuria or diarrhea. No melena, hematemesis, fever, chills,
or shortness of breath. No chest pain. No history of
gallstones or gallbladder disease. No history of
pancreatitis, dark urine, or weight loss.
PAST MEDICAL HISTORY: Significant for hypertension, coronary
artery disease, diabetes, and elevated cholesterol. She is
status post CABG.
MEDICATIONS: Medications on admission were:
1. Atenolol.
2. Glyburide.
3. Aspirin.
4. Lipitor.
5. Klonopin.
6. Meclozine.
7. Zetia.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives alone and no tobacco or
history of alcohol use.
PHYSICAL EXAMINATION: Vital Signs: Temperature 98.2, pulse
67, blood pressure 110/54, and saturations 95 percent on room
air. The patient was lying very still on bed, but was alert
and oriented. Cardiac exam: Regular rate and rhythm. No
murmurs, rubs, or gallops. Respiratory exam: Bibasilar
crackles. No pain or discomfort with deep inspiration.
Negative [**Doctor Last Name 515**] sign. Abdominal exam: She had positive
bowel sounds. No tenderness to percussion. Abdomen was soft
with mild epigastric tenderness. No rebound. No guarding.
She reported that her exam was different from when she
presented to outside hospital where she was much more
uncomfortable. Her rectal exam was negative for blood and
guaiac negative. Extremities: Warm and well perfused. No
peripheral edema.
LABORATORY DATA: At the outside hospital included, sodium of
145, potassium 3.8, chloride 106, bicarbonates 28, BUN 23,
creatinine 1.1, and glucose 139. Her white count was 20.7,
hematocrit 42.9, and platelets 291. Her magnesium was 1.8.
Albumin 3.5, alkaline phosphatase 205, ALT 134, AST 313,
lipase 22,460, and total bilirubin was 1.4. CT scan at the
outside hospital showed distention with edematous gallbladder
and common bile duct dilatation. No pseudocyst.
HOSPITAL COURSE: It was decided that the patient would be
admitted as her presentation was consistent with acute
cholecystitis and possible gallstone pancreatitis. She had
received levofloxacin and Flagyl at an outside hospital for
presumptive cholecystitis. She was admitted and aggressively
resuscitated with fluid. Ampicillin was given in the
emergency department. An ultrasound was obtained. She was
made nothing by mouth and ordered for IVP medication as
needed. She was monitored closely. She was initially
admitted to the Intensive Care Unit. The patient was started
on Lactated Ringers 200 cc per hour. Her ultrasound revealed
cholelithiasis with evidence of cholecystitis. Common bile
duct dilatation was present. It was thought that the patient
should receive an MRCP when she stabilized.
On hospital day number 1, her labs were checked, which
revealed an ALT of 214, AST of 494, amylase 1705, and lipase
of 4435, alkaline phosphatase is 178 and total bilirubin 2.1.
On hospital day number 2, her white count was down to 9.7,
her ALT was 113, AST 126, alkaline phosphatase 130, lipase
428, amylase 407, and total bilirubin 0.6. She was doing
well clinically on hospital day number 2 with her pain well
controlled. Her white blood count had normalized. She
continued to be monitored carefully. On hospital day number
2, she was transferred to the floor. On hospital day number
3, the patient reported some increase in pain that was
consistent with her presentation on admission. She continued
to be given IVP medication as needed, it consisted of a
hydromorphone 0.2-1 mg IV q.3-4h. p.r.n. Physical therapy
was ordered for her. Urine output remained good at this
time. A CT with IV contrast was obtained on hospital day
number 3. She was started on clears and was then advanced to
a low-fat diet on hospital day number 5. The CT scan, which
had been obtained showed significant improvement. Hence the
patient was improving clinically, it was decided on hospital
day number 6 that she would be ready for discharge.
On the day of discharge, her white count was 8.5. Her vital
signs were stable. She was afebrile. She was ambulating
regularly and tolerating a low-fat diet. Her amylase was
stable and it was decided that she would return to clinic
with Dr. [**Last Name (STitle) **] to schedule an appointment for surgery in
the future.
DISCHARGE DIAGNOSIS: Gallstones pancreatitis.
DISCHARGE INSTRUCTIONS: She was instructed to call the
clinic or come to the Emergency Department if she experienced
increased abdominal pain, nausea, vomiting, inability to take
p.o., fevers, chills, chest pain, or shortness of breath.
She was instructed to maintain a low-fat diet and to call Dr.[**Name (NI) 41561**] clinic to schedule a followup appointment and to
schedule a date for cholecystectomy.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Vicodin 5-500 mg 1 to 2 tablets p.o. q. 4-6h. She was
given 40.
2. Sucralfate 1 g 1 tablet p.o. q.i.d. She was given 120
tablets.
3. Pantoprazole 40 mg tablet delayed release one tablet p.o.
q. 24h. She was given 30 and she was instructed to
restart her home medications.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13037**]
Dictated By:[**Last Name (NamePattern1) 15009**]
MEDQUIST36
D: [**2155-6-21**] 17:36:14
T: [**2155-6-21**] 23:18:51
Job#: [**Job Number 41562**]
|
[
"574.20",
"250.00",
"414.00",
"401.9",
"577.0",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5588, 5597
|
5620, 6181
|
5132, 5158
|
2754, 5110
|
5183, 5566
|
1487, 2736
|
135, 1066
|
1089, 1380
|
1397, 1464
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,099
| 158,348
|
42769
|
Discharge summary
|
report
|
Admission Date: [**2175-3-3**] Discharge Date: [**2175-3-7**]
Date of Birth: [**2109-9-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Syncope and closed head injury
Major Surgical or Invasive Procedure:
Staple placement for scalp laceration
History of Present Illness:
65 yo M with T2DM not on insulin, CAD s/p stent x 2 years ago,
gout, HLD, HTN, and other medical issues presents to the
hospital after a syncopal/fall in the bank on [**2175-3-3**].
.
Patient reports having mild nausea and vomiting on [**2175-3-2**] and
threw up 1-2x, non-bloody, mostly food. He did not feel well on
[**2175-3-3**] and called in sick at work. He noticed that he lost 4
lbs. He had subjective fever and chill but did not measure
temperature. Then, he went to the bank to get some cash. At
the register, patient felt faint and fell backward. He denies
any palpitation, chest pain, dizziness, lightheadedness. He
does not recall the fall or the interval history going to [**Hospital **] and transfer here to [**Hospital1 18**]. He regained awareness until he
came to [**Hospital1 18**].
.
Per report, patient had left frontal SDH and right
occipital/parietal fracture. He is on baby aspirin for CAD but
not on warfarin. He had the posterior scalp laceration stapled
in the outside hospital. In the OSH, he denied photophobia,
emesis
.
He was transferred to TICU for reported left frontal SDH and
right occipital/parietal fracture. Serial CT scans here showed
bilat inferior frontal lobe intraparenchymal contusion and bilat
subarachnoid hemorrhage that is stable, without midline shift.
He also has right occipital fracture. Patient was started on
phenytoin for ppx of seizure. He was not orthostatic while on
the neurosurgery service. Patient is transferred for medicine
for further syncopal work-up.
.
Currently patient reports mild dizziness when he walks.
Dizziness is new after the fall, however, it has improved over
the last few days. Nausea is completely resolved. He reports
minimal vomiting after receiving morphine during the beginning
of hospital stay. No more vomiting. Denies diarrhea. Reports
that he had headache after the fall, but that is also resolved.
He denies sick contact at home or travel recently; however, he
does not know if there are people sick at work. He denies cough
or dysuria.
.
Review of systems:
(+) Per HPI
(-) Denies current fever, chills, night sweats, recent weight
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Type 2 DM
CAD s/p stent x2 yrs ago
Gout
Hyperlipidemia
Hypertension
GERD
Psoriasis
COPD
Social History:
- exercise director
- flies an airplane as a hobby from time to time
- smokes 5 cigars/day, smoking for about 55 years now. Had
about 35 pack-year with cigarettes which he quit 5 years ago.
- occasional EtOH
- denies illicit drugs
Family History:
- denies stroke, denies MI, denies bleeding disorder
- mother had multiple myeloma
Physical Exam:
ON ADMISSION:
O: T: 99.1 BP: 106/68 HR: 78 R 16 O2Sats 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: equal round reactive, EOMs intact b/l
Neck: Supple.
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, pt slow
to
respond to questions, appears groggy but clear, cooperative,
full
comprehension
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 6 to 3
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-17**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right 2+ 2 2+ 2+ 1+
Left 2+ 2 2+ 2+ 1+
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
ON DISCHARGE:
T: 97.5, BP 132/70, HR 57, RR 18, O2Sat 96% RA, I/O 240+/BR.
Gen: WD/WN, comfortable, NAD.
HEENT: PERRLA, EOMi, MMM, OP clear
Neck: supple, no JVD
CV: RRR, normal S1 and S2, no m/r/g
Resp: CTAB, no w/c/r
Abd: soft, NT, ND, BS+, no HSM
Ext: warm, dry, no c/c/e, 2+ DP pulses bilaterally
Neuro: alert, awake, oriented x 3, speech is fluent without
dysarthria, CN II-XII without focal finding, UE/LE strength 5/5,
normal cerebellar exams with finger-nose-finger/heel-shin
tests/rapid alternating movement, 2+ DTR at the biceps and
patellar tendons bilat, normal gait
Pertinent Results:
[**2175-3-3**] 04:20PM WBC-7.9 RBC-4.03* HGB-12.9* HCT-36.6* MCV-91
MCH-32.0 MCHC-35.2* RDW-13.1
[**2175-3-3**] 04:20PM PLT COUNT-179
[**2175-3-3**] 04:20PM PT-12.3 PTT-29.2 INR(PT)-1.1
[**2175-3-3**] 04:20PM cTropnT-<0.01
[**2175-3-3**] 04:20PM ALBUMIN-4.1 CALCIUM-8.8 PHOSPHATE-3.4
MAGNESIUM-1.4*
[**2175-3-3**] 04:20PM TSH-0.32
[**2175-3-3**] 04:20PM GLUCOSE-113* UREA N-25* CREAT-1.3* SODIUM-141
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-27 ANION GAP-12
[**2175-3-3**] 04:20PM LIPASE-14
[**2175-3-3**] 04:44PM GLUCOSE-104 K+-3.6
[**2175-3-4**] 01:46AM BLOOD CK(CPK)-42*
[**2175-3-4**] 01:46AM BLOOD CK-MB-1
[**2175-3-4**] 02:02AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2175-3-4**] 02:02AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2175-3-6**] 05:45AM BLOOD Phenyto-2.4*
[**2175-3-6**] 05:45AM BLOOD Albumin-3.8 Calcium-8.7 Phos-2.7 Mg-1.9
[**2175-3-7**] 06:00AM BLOOD WBC-5.7 RBC-4.15* Hgb-13.0* Hct-36.6*
MCV-88 MCH-31.3 MCHC-35.5* RDW-12.8 Plt Ct-208
[**2175-3-7**] 06:00AM BLOOD Glucose-109* UreaN-19 Creat-1.0 Na-138
K-3.7 Cl-101 HCO3-28 AnGap-13
EKG [**2175-3-3**]
Sinus rhythm. Possible inferior myocardial infarction, age
indeterminate.
Non-specific low amplitude T waves in leads II, V5 and V6. No
previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 182 96 [**Telephone/Fax (2) 92413**]
Head CT [**2175-3-3**]
There are increasingly apparent bilateral inferior frontal lobe
intraparenchymal contusion (3A:10, 3A:11), left greater than
right with
minimal leftsided edema, sulcal and left quadrigeminal cistern
effacement(3A:12). No appreciable shift of midline structures.
The previously noted left frontal and left parafalcine
extra-axial hemorrhage thought to be due to subdural hematoma is
less apparent on current study likely due to redistribution of
blood products from a subarachnoid hemorrhage. Tiny left
frontal subdural hematoma remains. Extraaxial hemorrhage now
noted layering along the left frontoparietal lobes, left sylvian
fissure and bilateral peri-anterior falcine sulci. There is
redemonstration of the known right nondisplaced occipital
fracture. Overlying skull fracture there is an incompletely
visualized subgaleal hematoma.
IMPRESSION:
1. Contrecoup injury with bilateral inferior frontal lobe
intraparenchymal
contusions as well as bilateral subarachnoid hemorrhage with
interval
redistribution of blood products to the bilateral parafalcine
region, left
sylvian fissure and left high frontoparietal lobe sulci.
2. Right occipital fracture with incompletely visualized right
parietooccipital subgaleal hematoma.
CXR [**2175-3-3**]
Frontal and lateral views of the chest were obtained. There is
subtle opacity in the right suprahilar region/medial right upper
lung. Anunderlying consolidation may be present. The remainder
of the lungs is clear. No pleural effusion or pneumothorax is
seen. Evidence of hiatal hernia is seen with retrocardiac
air-fluid level. The cardiac silhouette is top-normal to mildly
enlarged. The aorta is tortuous.
IMPRESSION:
1. Subtle medial right upper lung opacity, could be vascular in
nature,
underlying consolidation may be present.
2. Hiatal hernia.
Transthoracic echo [**2175-3-4**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF >55%).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
mild bileaflet mitral valve prolapse. Mild to moderate ([**2-13**]+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild bileaflet MVP with mild to moderate
regurgitation.
Head CT [**2175-3-4**]
Again seen are bilateral inferior frontal lobe contusions, left
greater than right, unchanged from the prior study. The amount
of surrounding edema has slightly increased with adjacent sulcal
effacement. Subarachnoid
hemorrhage in the left frontoparietal lobe and left sylvian
fissure is less apparent than on the prior study, likely due to
evolution of blood products. No new hemorrhage is identified.
There is no shift from normally midline structures. The basal
cisterns are patent. The ventricles are normal in size and
symmetric in configuration. The nondisplaced right occipital
fracture is re-demonstrated. Skin staples overlie the right
occiput with interval decrease in size of the subgaleal
hematoma.
IMPRESSION:
1. Stable bilateral inferior frontal lobe contusions with
slightly increased surrounding edema. No midline shift.
2. Subarachnoid hemorrhage is less apparent.
3. No new hemorrhage.
4. Right occipital fracture.
Head CT [**3-6**]:
Again noted are bilateral infra-frontal contusion with
intraparenchymal hemorrhage, peri-hemorrhagic edema and sulcal
effacement, left greater than right. There is no midline shift.
The largest hemorrhagic focus is along the paramedial left
inferior frontal lobe, measures 2.1 x 1.0 cm (image 2:8),
compared to 1.9 x 1.1 cm two days ago. A hemorrhagic focus is
again noted at the anterior left temporal lobe, now measures 7
mm, compared to 10 mm previously. A sliver curvilinear
hyperdensity along the left parietal convexity is unchanged and
represents a trace of subdural/subarachnoid hemorrhage. No new
focal intracranial hemorrhage is noted. There is no
intraventricular hemorrhagic extension. The ventricles and sulci
remain normal in size and symmetric in configuration. The
[**Doctor Last Name 352**]-white matter differentiation is preserved, apart from the
contusion sites. A moderate-sized subgaleal hematoma along the
right parieto-occipital region is similar in appearance. The
non-displaced hairline right occipital calvarial fracture is
also unchanged. The visualized paranasal sinuses and mastoid
air cells are clear. No new fracture is identified.
IMPRESSION:
1. Similar multifocal intraparenchymal hemorrhage, predominately
in the left infra-frontal lobe, with unchanged adjacent edema
and sulcal effacement. No gross midline shift, intraventricular
hemorrhagic extension, or developing hydrocephalus.
2. Similar right parieto-occipital subgaleal hematoma, with
non-displaced
hairline right occipital calvarial fracture.
3. No new intracranial hemorrhagic focus or fracture.
Carotid U/S [**2175-3-6**]
A very minute amount of plaque was visualized in the right
common
carotid artery, with [**Doctor Last Name 352**]-scale ultrasound. On the right side
peak systolic velocities were 61 cm/sec for the internal carotid
artery, 53 cm/sec for the common carotid artery and 74 cm/sec
for the external carotid artery. The right ICA/CCA ratio was
1.2. On the left side peak systolic velocities were 50 cm/sec
for the ICA, 36 cm/sec for the CCA and 71 cm/sec for the ECA.
The left ICA/CCA ratio was 1.4. Both vertebral arteries
presented antegrade flow.
COMPARISON: None available.
IMPRESSION: No evidence of internal carotid artery stenosis in
its extracranial portions.
Brief Hospital Course:
Mr. [**Known lastname 10446**] is a 65 yo M with h/o HTN, T2DM, CAD s/p stents
presented after an syncopal event.
Hospital Course under neurosurgery service.
Mr. [**Known lastname 10446**] was seen in the ED upon transfer for reported SDH
after syncopal fall. He appeared intact with the exception of
appearing slow/groggy in his speech but completely coherent. He
had a repeat head CT in the ED with some evolution of frontal
contusions from contracoup injury. He was admitted to the Neuro
ICU under the neurosurgery service for serial exams and
monitoring. Repeat Head CT in the morning of [**3-4**] revealed mild
further evolution of contusion, with stable neuro exam. He had
negative troponins, and a full syncope workup was initiated. He
underwent repeat cranial imaging once on the floor on [**3-6**] which
showed stable contusions and non displaced occipital fracture.
A medical consult was obtained for completion of syncope workup
and clearence for discharge.
Hospital Course under medicine service.
# Syncope/Fall. Based on history, patient may be slightly
volume down, as he self reported 4 lb weight loss from the
vomiting the day prior to the event. It is possible that he may
have suffered from mild gastritis/gastroenteritis. He did not
have prodromes of palpitation, diaphoresis, chest pain, focal
weakness, numbness, tingling, involuntary movements. While in
the hospital, his telemetry did not show signs of ventricular
arrhythmia. His troponin was negative and EKG and echo did now
show acute change to suggest acute MI. Echocardiogram did not
show evidence of hypokinesis or akinesis. Carotid ultrasound
was without stenosis. His neurological exams were normal. He
was not orthostatic after transfer from the neurosurgery
service. PT evaluated patient and thought that patient would
benefit from home PT given recent traumatic head injury. He did
not have further events. Patient was advised to avoid flying
until syncope work-up is completed in the outpatient setting.
He was recommended to have outpatient halter monitor or event
monitor to rule out arrhythmia.
# Traumatic head injury: bilateral inferior frontal lobe
intraparenchymal contusion, bilateral subarachnoid hemorrhage,
right occipital fracture. Patient had his posterior scalp
stapled at the ED. He was started on dilantin for seizure
prophylaxis by the neurosurgery team. His serial CT scan of the
head did not show any worsening of his bleeding. His headache,
nausea, and vomiting improved throughout the course of his
hospital stay. His neurological exam remained unchanged.
Patient required minimal narcotics and antiemetics on the day of
discharge. Neurosurgery recommended discontinuation of dilantin
after 5 days, removal of staples after 7-10 days by primary care
physician, [**Name10 (NameIs) **] [**Name11 (NameIs) 13124**] of baby aspirin (given stability of
the bleeding). Patient was advised to follow up with
neurosurgery within 4 weeks and repeat CT head without contrast.
Patient was discharged with limited number of Vicodin, Tylenol,
Zofran, and bowel regimen. Patient was given instruction on not
to exceed more than 4000 mg acetaminophen a day.
# Type 2 diabetes mellitus. Patient was well controlled on home
metformin and Januvia.
# Hypertension. He remained largely normotensive through most
of his stay on the medicine service. He was continued on
atenolol 100 mg, lisinopril 10 mg, and terazosin 5 mg daily. He
was advised to discuss with his primary care physician if his
blood pressure become elevated. His goal BP should be < 160
given recent SAH.
# CAD. Not an active issue during the hospital course. He was
continued on his atenolol, lisinopril, Crestor, Trilipix as at
home. He was restarted on baby aspirin at the time of
discharge.
# History of gout. He was continued on home allopurinol.
# COPD. He continued albuterol inhaler as needed.
# GERD. He continued home omeprazole.
# Psoriasis. Not an active issue. He was given clobetasol as
needed.
Transitional Issues:
[] suture removal on [**2175-3-10**] at PCP [**Name Initial (PRE) 648**]
[] halter monitor or event monitor for further syncope work-up
[] BP monitoring with goal SBP < 160 given recent SAH
[] discussion with patient about flying and safety given recent
syncope
[] follow up with neurosurgery, Dr. [**First Name (STitle) **], in 4 weeks with
follow up CT head scan
Medications on Admission:
Lisinopril 10mg
Atenolol 100mg
terazosin 5mg
aspirin 81mg
allopurinol 300mg
omeprazole 20mg
clobetasol cream
crestor 40mg
trilitix 135mg
Januvia 50mg
Metformin 500mg [**Hospital1 **]
Proair 90mcg
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for psoriatic rash.
8. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Trilipix 135 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO daily ().
10. Januvia 50 mg Tablet Sig: One (1) Tablet PO daily ().
11. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**2-13**] puff Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
14. 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*
15. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*15 Tablet, Rapid Dissolve(s)* Refills:*0*
16. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for headache.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnoses:
- Syncope, likely orthostatic hypotension vs. cardiogenic
- Bilateral subarachnoid hemorrhage, bifrontal contusion and
non-displaced right occipital skull fracture
- status post staple placement for occipital scalp laceration
Secondary diagnoese:
- Type 2 diabetes mellitus
- Hypertension
- Coronary artery disease
- Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 10446**],
You were admitted to [**Hospital1 69**] after
fainting and falling on the back of your head. Based on your CT
scan of the head, there is some bruising and bleeding in your
brain. You also have a skull fracture. However, these injuries
remain stable on repeat CT scans. Your initial symptoms of
nausea, vomiting, and headache improved over time. It is
unclear what the cause of the fainting spell is, but it may be
related to dehydration, although a heart condition cannot be
ruled out at this time. A halter monitor or event monitor for
the heart could be useful for the outpatient work-up.
After discussing with the neurosurgery team, it is felt that you
no longer need Dilantin, an anti-seizure medication. You were
only on it for a few days for prevention given the bleeding in
your brain. They also feel that it is safe for you to restart
aspirin 81 mg once a day.
Please note the following changes in your medication.
# Please START acetaminophen (Tylenol) 325 mg, 1-2 tabs, by
mouth, every 6 hours as needed for pain. You should not take
more than a total of 4000 mg acetaminophen (Tylenol) a day.
# Please START Vicodin, [**2-13**] tab, by mouth, every 6 hours as
needed for pain. You should not take more than 4000 mg of
acetaminophen (Tylenol) a day. Each Vicodin also has about 500
mg of acetaminophen (Tylenol).
# Please START ondansetron (zofran) 4 mg tab, 1 tab, by mouth
every 8 hours as needed for nausea.
# Please START Colace (docusate) 100 mg tab, 1 tab, by mouth
twice a day as needed for constipation while you are on Vicodin.
# Please START senna, 1 tab, by mouth, once a day as needed for
constipation while you are on Vicodin.
- Exercise should be limited to walking; no lifting, straining,
or excessive bending.
- Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
- You should NOT operate an airplane while you are still getting
followed by the neurosurgery team for the recent bleeding in
your head.
- Your staples should come out on [**2175-3-9**] or [**2175-3-10**] during
your appointment with your primary care physician.
Followup Instructions:
Please call the Cognitive [**Hospital 878**] Clinic for follow up within
1 week of your discharge from the hospital. The clinic number
is [**Telephone/Fax (1) 1690**]. This is the recommendation from occupational
therapy.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M
Location: INTERNAL MEDICINE & CARDIOLOGY ASSOCIATE
Address: [**Location (un) 92414**], [**Location (un) **],[**Numeric Identifier 17156**]
Phone: [**Telephone/Fax (1) 58549**]
Appointment: Friday [**2175-3-10**] 11:45am
You can have your primary care physician remove the staples for
you. You should discuss about further work-up of your fainting
spell. You should discuss possible need for event monitor for
your heart.
Department: RADIOLOGY
When: THURSDAY [**2175-4-13**] at 11:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
*Nothing to eat 3 hours prior to the CT Scan*
You need this CT scan of the brain without contrast before your
appointment with Dr. [**First Name (STitle) **].
Department: NEUROSURGERY
When: THURSDAY [**2175-4-13**] at 1 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2175-3-7**]
|
[
"272.4",
"V58.66",
"803.26",
"305.1",
"496",
"V45.82",
"458.0",
"401.9",
"530.81",
"414.01",
"250.00",
"274.9",
"E849.6",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
19098, 19147
|
12797, 16811
|
332, 372
|
19533, 19533
|
5215, 12774
|
21989, 23387
|
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|
17444, 19075
|
19168, 19512
|
17224, 17421
|
19684, 21966
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3322, 3322
|
4631, 5196
|
16832, 17198
|
2467, 2846
|
262, 294
|
400, 2448
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3859, 4617
|
3337, 3546
|
19548, 19660
|
2868, 2957
|
2973, 3207
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,034
| 101,708
|
13329+56444
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-4-12**] Discharge Date: [**2129-4-16**]
Date of Birth: [**2052-7-14**] Sex: M
Service: BLOOMGARD
HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old
gentleman with history of coronary artery disease, ischemic
cardiomyopathy, ejection 20 percent, atrial fibrillation,
diabetes mellitus with neuropathy, end stage renal disease on
hemodialysis. The patient was admitted on [**4-7**] to an
outside for failure to thrive and hypotensive. The patient
was found to have a large right pleural effusion at the
outside hospital. He was also hypoxic to the 70s on 6 liters
and thoracentesis revealed [**12-10**] liter of transudative fluid
removed. Patient's oxygenation reportedly improved after
that. At the outside hospital the patient's left upper
extremity antecubital AV fistula was noted to be
nonfunctional and a temporary femoral line was placed for
dialysis. The patient was transferred to the [**Hospital1 346**] for evaluation of fistula, repair
and further medical management. The patient was transferred
to the Intensive Care Unit on the [**Hospital Ward Name 516**] of [**Hospital1 346**] on [**2129-4-12**]. Upon transfer his
systolic blood pressures were marginal in the 70s. Otherwise
the patient was stable and afebrile. The patient was
aggressively dialyzed as well as ultrafiltration by
nephrology and was transferred to the regular internal
medicine floor on [**2129-4-13**].
PAST MEDICAL HISTORY: Coronary artery disease, status post
coronary artery bypass graft times three in [**2099**], [**2112**] and
[**2121**] at [**Hospital 4415**]. Patient underwent
catheterization with no intervention in [**2127-8-10**] at
the [**Hospital1 69**]. In [**2127-8-10**]
transesophageal echocardiogram showed ejection fraction of
about 20 percent, 1+ mitral regurgitation, 2+ tricuspid
regurgitation. Patient reportedly with a chronic right lung
pleural effusion, chronic atrial fibrillation, status post
multiple failed cardioversions. Intermittently
anticoagulated but this was limited by a GI bleed which the
patient has had in the past related to Barrett's esophagus.
Also history of stroke with short term memory loss. History
of falls and syncope. History of sick sinus syndrome with
pacemaker placed DDI. Also diabetes mellitus with neuropathy
and nephropathy. Patient with end stage renal disease on
hemodialysis in [**2126-11-9**] on Monday, Wednesday and
Friday. Also hypothyroidism. Also gout. Also depression.
Also prostatic hyperplasia. Also status post appendectomy.
Also reported restrictive and obstructive lung disease on
home oxygen. Also history of Legionnaire's disease.
SOCIAL HISTORY: Patient lives in [**Hospital3 **]. His wife
is alive but demented. [**Hospital **] health care proxy is one of
his daughters. Remote tobacco history with history of 100
pack years. Alcohol once to twice per week.
ALLERGIES: Cardizem "makes me turn into a puffer fish."
MEDICATIONS ON TRANSFER: Prevacid 30 once a day, Zoloft 20
once a day, Synthroid .75 once a day, Neurontin 300 once a
day, Renagel 800 t.i.d. on Monday, Wednesday and Friday,
Midodrine 10 pre-hemodialysis Monday, Wednesday and Friday.
Digoxin .125, Tums 1,000 mg t.i.d., amiodarone 200 t.i.d.,
Reglan 10 q.i.d., allopurinol 100 q.d., Zebeta 2.5 mg
Tuesday, Thursday, Saturday, Sunday, Coumadin 1 mg q.d. which
had been held at the outside hospital.
PHYSICAL EXAMINATION: On admission temperature 97.1, blood
pressure 89/50, heart rate 60, saturating 97 percent on 4
liters nasal cannula. Patient is an elderly gentleman in no
apparent distress. Lungs with coarse breath sounds
anteriorly. Heart with S1, 2, II/VI systolic murmur.
Patient's abdomen was benign. Skin with decubitus ulcer,
also skin breakdown on right and left upper extremities as
well as right lower extremity. Neuropsychiatric: Patient
responds appropriately and answers questions appropriately
but with poor recall. Alert and oriented times three.
Muscle strength 4 out 5 throughout, decreased sensation to
light touch in bilateral lower extremities.
LABORATORY DATA UPON TRANSFER: White count 6.6, hematocrit
39, platelets 171. Chemistries within normal limits except
for potassium of 5.2, BUN/creatinine 30/5.5, TSH 15, Digoxin
level 2.2.
SUMMARY OF HOSPITAL COURSE: This 76 year-old gentleman with
history of severe coronary artery disease, status post
coronary artery bypass graft, severe congestive heart failure
and cardiomyopathy, pacemaker, diabetes, end stage renal
disease on hemodialysis, transferred from an outside hospital
with a nonfunctioning AV fistula used for dialysis.
Transiently in the Intensive Care Unit for one day for close
monitoring and then transferred to Medicine on [**4-13**].
1. Congestive heart failure: Ejection fraction estimated at
20 percent per echocardiogram in [**2126**]. Patient's Digoxin was
held due to his low blood pressures as well as elevated serum
levels. Patient's serum levels should be monitored and
consider restarting as an outpatient. Renal followed the
patient closely and performed ultrafiltration daily as well
as dialysis three times per week for fluid removal for the
patient's congestive heart failure. The patient's oxygen
saturations remained stable throughout his hospital stay.
Clinically the patient initially with jugular venous
distention and lower extremity edema. However, this improved
with dialysis and ultrafiltration.
2. Blood pressure: Patient with marginal systolic blood
pressure in the 70s to 80s on admission. However, blood
pressure remained in the 90s to 100s throughout the remainder
of his hospital stay. Patient's cortisol was checked and was
within normal limits. Patient's blood pressure remained
stable and tolerated the hemodialysis and ultrafiltration
well. Given the patient's cardiac risk factors we discussed
starting low dose ACE inhibitors as well as beta blocker.
For this patient, however, given his marginal blood pressures
which were very hemodialysis dependent, the patient was not
started on one. Recommend outpatient consideration of
starting low dose ACE inhibitor on beta blocker.
3. Pulmonary: Patient with congestive heart failure as
mentioned above. Also with restrictive lung disease per
report. Patient also with stable transudative pleural fluid
per report. Patient on home oxygen as well. Patient's
oxygen saturation was stable in the mid 90s throughout his
hospital stay on low amounts of oxygen via nasal cannula.
4. End stage renal disease: Patient followed by renal
consult and team and underwent ultrafiltration q.d. as well
as dialysis three times per week which he tolerated well.
Patient's AV fistula was found to be clotted and
interventional radiology attempted to fix this, however, were
unable to. Therefore, patient had a tunneled right internal
jugular dialysis catheter placed for access. Patient was
evaluated by transplant surgery regarding possible fistula
repair or placing a new access site for hemodialysis.
Transplant surgery deferred doing this at this time given the
patient's skin breakdown over the sites that they would want
to do that. Recommend outpatient follow up for possible
access procedure in the future. Patient tolerated renal low
sodium diet well. Patient also with Nephrocaps and phosphate
binders.
5. Dermatology: Patient with skin breakdown on his back,
right shin and bilateral upper extremities. These were
changed with dressings and monitored closely.
6. Atrial fibrillation: Patient's Coumadin was held due to
interventional radiology procedure. Given the patient's
history of GI bleed, patient's Coumadin was continued to be
held at discharge. Defer to outpatient primary care
physician regarding pros and cons of restarting Coumadin with
patient likely to undergo re-access in the future. Patient's
Digoxin was held as mentioned above. Patient was continued
on amiodarone for his atrial fibrillation which he tolerated
well.
7. Coronary artery disease, status post coronary artery
bypass graft most recently in [**2121**]: Patient's cardiac
enzymes negative times three, however, with slightly elevated
troponins likely related to chronic end stage renal disease.
Patient continued on aspirin. Cardiology was consulted
regarding patient's heart issues and stated that the patient
could be a candidate for ICD placement due to his low
ejection fraction. Medical team discussion with patient and
patient decided against this given patient's likely prognosis
due to other comobidities.
8. Diabetes mellitus: Patient maintained on insulin sliding
scale throughout this hospital stay. This was stable.
Continue diabetic diet.
9. Infectious disease: Patient's skin swab from [**4-14**] grew
out methicillin resistant staph aureus and patient was placed
on precautions. No signs of active infection, however.
10. Fluid, electrolytes and nutrition: Patient maintained
on low sodium renal diet. Also proton pump inhibitor.
Patient's stools were guaiaced. Patient's hematocrit
remained stable.
CODE: Code status is full confirmed with the patient as well
as his health care proxy, his daughter. Communication daily
with the patient as well as his daughters.
ACCESS: Peripheral intravenous as well as femoral dialysis
catheter placed at the outside hospital on [**4-11**]. Plan to
discontinue the femoral dialysis catheter once the right
internal jugular tunnel catheter is confirmed to be working
properly.
CONDITION ON DISCHARGE: Fair, at baseline.
DISCHARGE STATUS: To skilled nursing facility.
DISCHARGE DIAGNOSES:
End stage renal disease on hemodialysis.
Coronary artery disease, status post coronary artery bypass
graft.
Congestive heart failure.
Diabetes mellitus.
Depression.
Hypotension.
Pleural effusions.
Hyperlipidemia.
Skin breakdown.
DISCHARGE MEDICATIONS: Pantoprazole 40 once a day,
gabapentin 300 mg once a day, allopurinol 100 q.o.d.,
cevalomir 800 t.i.d., vitamin B, vitamin C, folate,
ranitidine 10 mg 30 minutes prior to dialysis, amiodarone 200
t.i.d., Reglan 10 q.i.d. AC, h.s., aspirin 325 q.d., calcium
carbonate 1,000 t.i.d., senna b.i.d., colace b.i.d.,
bisacodyl p.r.n., insulin sliding scale, Synthroid 75 mcg
q.d., subcutaneous heparin 5,000 q 12 q.d., Lipitor 10 q.d.,
sertraline 50 q.d., polyvinylalcohol 1.4 percent ophthalmic
drops p.r.n., albuterol MDI p.r.n.
FOLLOW UP PLANS: Patient to follow with primary care
physician and hemodialysis as outpatient as scheduled.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 6906**]
MEDQUIST36
D: [**2129-4-15**] 19:05
T: [**2129-4-15**] 20:55
JOB#: [**Job Number 40565**]
Name: [**Known lastname 7288**], [**Known firstname **] T Unit No: [**Numeric Identifier 7289**]
Admission Date: [**2129-4-12**] Discharge Date: [**2129-4-17**]
Date of Birth: [**2052-7-14**] Sex: M
Service: MED
Patient is a 76-year-old gentleman with severe coronary
artery disease, ischemic cardiomyopathy, and end-stage renal
disease on hemodialysis. Patient was awaiting rehabilitation
placement.
On [**Last Name (LF) 7290**], [**4-17**] at approximately 3:15 p.m., the patient
became unresponsive and asystolic. The patient's family was
present as well as the covering attending, Dr. [**Last Name (STitle) **]. A
medical code was initially called and the Intensive Care Unit
teams were called to the bedside. The patient was
unresponsive, and without spontaneous breathing or heart
function. Per the family's request, patient was not coded.
The patient was pronounced dead at 3:30 p.m. [**2129-4-17**].
The family declined a postmortem. The attending was present
and aware.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 7291**]
Dictated By:[**Last Name (NamePattern1) 7292**]
MEDQUIST36
D: [**2129-4-20**] 14:57:18
T: [**2129-4-21**] 09:50:06
Job#: [**Job Number 7293**]
|
[
"585",
"427.31",
"250.40",
"285.9",
"428.0",
"414.00",
"496",
"414.8",
"996.73"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
9583, 9813
|
9837, 12015
|
4315, 9468
|
3437, 4286
|
171, 1450
|
2989, 3414
|
1473, 2670
|
2687, 2963
|
9493, 9562
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,230
| 185,855
|
34033
|
Discharge summary
|
report
|
Admission Date: [**2170-5-10**] [**Month/Day/Year **] Date: [**2170-5-14**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Apnea, Hypoxia
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
84 yo F with a history of parkinson's disease and aspiration
pneumonia transferred after intubation in the field for apnea
and cyanosis after a coughing episode.
.
Unable to obtain any history from the patient who arrives
intubated without family. Family is also unreachable at the only
available contact number. History is obtained from medical
records and verbal report.
.
By report the patient had several days of coughing. On the day
of admission she appeared to choke and cough. Her home health
assistant called paramedics. The patient became apneic and
cyanotic. Paramedics intubated in the field. Of note the patient
is DNR/DNI however she was intubated prior to code status
knowledge.
.
The patient was brought to the [**Hospital6 2561**] ED (VS: T
97.3 HR 97 158/73 RR 24 100% on vent- settings unk) where she
was found to have a WBC to 14, Cr 2.3 and a metabolic gap
acidosis of 15 with a lactate of 3.2. She received Vancomycin
and Clindamycin for presumed aspiration pneumonia. They
discussed management decisions with her guardian who wanted her
to stay intubated for the time being. [**Hospital3 **] had no beds
and the patient was therefore transferred to the [**Hospital1 18**] ED. In
the [**Hospital1 18**] ED, T 101.8 HR 77 BP 180/64 RR 14 100% on FiO2 60%
TV 500 RR 12 PEEP 5. She was also noted to be incontient of
Brown stool with bright red blood, she also was noted to have
"cloudy urine." She recieved 1 amp of D50 and 10 units of
regular insulin IV for hyperkalemia. The patient has 3 health
care decision makers and only 1 was available at the time of
admission. For now she will remain intubated until all 3
decision makers have a chance to discuss her situation.
Past Medical History:
- Parkinson's disease with dementia. Also with periods of
unresponsiveness thought to be related to parkinsonism. EEG in
[**2167**] per neurology consult with moderate slowing and
disorganization suggesting diffuse encephalopathic process,
nonspecific. No focal or paroxysmal features.
- Chronic renal insufficiency, last Cr 1.4 in [**2167**]
- A Fib, anticoagulated with aspirin only, reasoning not known
- Prior aspiration pneumonia
- Hypertension
- Postural hypotension
- Peptic ulcer disease
- Right hip fracture s/p right hip arthroplasty [**2165**]
Social History:
Lives at home with 24 hour care. Nonsmoker. Occassional EtOH
use.
Retired bank VIP. Divorced.
Family History:
Non-contributory.
.
Physical Exam:
Admission exam:
==============
Well-appearing. NAD. Intubated. Squeezes hand to command.
HEENT: Right pupil round and reactive to light. Left pupil
unable to assess due to inability to pull open eyelid.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: CTA bilaterally. Intubated.
Abd: Soft, nontender. No organomegaly.
Ext: No edema.
Neuro: Intubated and sedated. Squeezes hand to command.
.
[**Year (4 digits) **] Exam:
================
VITAL SIGNS: 96.3 ax 140/78 74 16 95% RA
GEN: Elderly female, lying on bed. NAD. Looking around room.
HEENT: Scab to upper right forehead. Left eye PERRLA, right eye
closing to light. EOMI. Mouth dry.
RESP: Coarse crackles at bases, no wheezes, fair good air
exchange throughout.
COR: Irregular, normal S1S2, II/VI SEM mumur, no gallops, no
rubs.
ABD: + BS, soft, non-distended, nontender, no masses, no
guarding.
PULSES: 2+ radial B, 2+ PT/DP bilaterally.
EXT: no edema, no cyanosis, no clubbing. Decreased ROM to
bilateral arms, hands/fingers, and legs.
SKIN: scattered actinic keratosis, left lateral shin with old
scab. Slightly errythematic area to lower spine at area of
protusion.
NEURO: Alert and oriented x 3. Able to say days of the week
forwards and backwards. Pleasant, conversant, attentive.
Answering questions appropriately.
Pertinent Results:
Admission labs:
==============
[**2170-5-10**] 08:10PM WBC-13.6* RBC-3.46* HGB-10.2* HCT-32.0*
MCV-92 MCH-29.6 MCHC-32.0 RDW-14.7
[**2170-5-10**] 08:10PM NEUTS-83.3* BANDS-0 LYMPHS-9.9* MONOS-2.5
EOS-4.0 BASOS-0.2
[**2170-5-10**] 08:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
TEARDROP-OCCASIONAL
[**2170-5-10**] 08:10PM PLT SMR-NORMAL PLT COUNT-337
[**2170-5-10**] 08:10PM PT-12.4 PTT-23.1 INR(PT)-1.0
[**2170-5-10**] 08:10PM GLUCOSE-108* UREA N-40* CREAT-2.3* SODIUM-137
POTASSIUM-6.2* CHLORIDE-104 TOTAL CO2-24 ANION GAP-15
Imaging:
=========
6.20 CXR HISTORY: Parkinsonism with intubation, to evaluate for
OG tube placement.
FINDINGS: In comparison with study of [**5-10**], there has been
placement of an
orogastric tube that extends at least to the body of the
stomach, where the
bottom of the film ends. The endotracheal tube remains in
position. The
cardiac silhouette is mildly enlarged and there is some
indistinctness of
pulmonary vessels consistent with elevated pulmonary venous
pressure. The
left hemidiaphragm is not sharply seen and there is probably
basilar
atelectasis on the left.
ECG [**5-10**] sinus rhythm
Rate PR QRS QT/QTc P QRS T
79 0 82 416/449 0 -51 20
[**Month/Year (2) **] Labs:
================
[**2170-5-14**] 08:55AM BLOOD WBC-7.1 RBC-3.23* Hgb-9.6* Hct-29.1*
MCV-90 MCH-29.7 MCHC-33.0 RDW-13.8 Plt Ct-320
[**2170-5-14**] 08:55AM BLOOD Glucose-97 UreaN-26* Creat-1.9* Na-146*
K-4.1 Cl-113* HCO3-22 AnGap-15
[**2170-5-14**] 08:55AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.0
Brief Hospital Course:
/P: 84 yo F with a history of parkinson's disease and aspiration
pneumonia transferred after intubation in the field for apnea
and cyanosis after a coughing episode.
.
1. Respiratory failure
The patient was transferred to [**Hospital1 18**] from Mt Aubrun following
intubation in the field for apnea and cyanosis after a coughing
episode. The clinical presentation was consistent with a primary
aspiration event given history of aspirations, parkinsonism and
report of coughing prior to event during feeding. Initially she
was given IV vancomycin and clindamycin at [**Hospital **] [**Hospital 78548**] hospital.
The patient was successfully extubated the morning after
admission. She was continued on levofloxacin for aspiration PNA
for two days, then this was discontinued as she remained
afebrile, without purulent sputum, and WBC decreased. Her
health care decision makers were contact[**Name (NI) **] about possbility of
continued aspiration with taking po nutrition. After speaking
with the patient, plan is continue oral feeds with modified diet
and not place a feeding tube now or in the future. She was
evaluated by Speech therapist [**5-14**] who recomended puree solid
diet with nectar thick liquids and aspiration precautions.
Event was likely related to acute weakness from urinary tract
infection, as she normally is able to tolerate oral feeds.
- Continue diet of puree solids with nectar thick liquids.
- Niece, PCP, [**Name10 (NameIs) **] home care agency should discuss how to deal
with future events in light of DNR/DNI wishes. Hospice was
discussed and she will speak with the patient's sister and
patient.
.
2. Leukocytosis
Likely related to acute aspiration pneumonitis, but could also
be related to urinary tract infection. This returned to [**Location 213**]
after extubation and treatment of e. coli UTI with cipro that
was sensitive.
- She is to finish a three day course with last dose this
evening.
.
3. Acute on chronic renal failure
Chronicity unknown, baseline 1.4-1.6 per [**Hospital3 **] labs, was up
to 2.3 on admission. Likely hypovolemic, improved with IVF
rescucitation.
.
4. Hyperkalemia
Potassium 5.9 on admission. Likely in part secondary to acute
renal failure +/- acidosis. This may also represent a medication
effect from paralytics potentially used in the field during
intubation. No signs of acute EKG changes on admission, resolved
with IVF and Kayexalate.
.
5. Parkinson's disease
6. Depression
Continued home sinemet, zoloft, and exelon. No active issues.
She was given oral exelon while hospitalized because transdermal
patch was not available. She will resume home route when
discharged.
.
7. Atrial fibrillation
She was continued home beta-blocker and aspirin. ECG was noted
for normal sinus rhythm this admission.
.
8. Hypertension
She was maintained on Metoprolol during hospitalization with
good control.
.
9. Peptic ulcer disease
She was maintained on PPI during hospitalization. She had blood
in stool in the emergency department on admission, this did not
reoccur.
Medications on Admission:
Unable to obtain. From [**Hospital3 **] ED report,
Sinemet 25/100 twice daily
Metoprolol XL 50mg Daily
Zoloft 25mg Daily
[**Hospital3 **] Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 doses.
Disp:*1 Tablet(s)* Refills:*0*
4. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Rivastigmine 9.5 mg/24 hour Patch 24 hr Sig: One (1)
Transdermal [**Hospital1 **] (2 times a day).
6. [**Doctor Last Name 2598**] Lift
[**Doctor Last Name 2598**] lift with commode sling
Length of need 6 months
Diagnosis: end stage parkinson's disease and [**Last Name (un) **] body dementia
7. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Last Name (un) **] Disposition:
Home With Service
Facility:
HHA best Home Care.
[**Last Name (un) **] Diagnosis:
Primary Diagnosis:
1. Aspiration pneumonitis
2. Urinary tract infection
Secondary Diagnosis:
3. Parkinson's Disease
4. Depression
5. Atrial fibrillation
6. Peptic culer disease
7. Hypertension
8. s/p hip fracture with arthroplasty
9. history of aspiration pneumonia
[**Last Name (un) **] Condition:
Stable, alert and oriented x 3. Tolerating puree diet without
aspiration. [**Doctor Last Name 2598**] out of bed to chair.
[**Doctor Last Name **] Instructions:
You were admitted after having an episode of choking at home
while eating. You had some irritation to your lungs from this
but no pneumonia. You will need to eat a modified diet at home
to prevent reoccurance.
You were also found to have a urinary tract infection on
admission. You were treated with antibiotics for three days and
will need to take one more antibiotic pill this evening.
Please see your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **].
Please call your primary care doctor with any fever, cough,
decreased mental status, or lethargy.
Followup Instructions:
Please contact your primary care physician or nurse [**Name9 (PRE) 78549**]
at home for an appointment 1-2 weeks after [**Name9 (PRE) **].
Name: [**Doctor Last Name 60585**], [**Last Name (NamePattern4) 78550**] MD
Location: GERIATRIC OUTREACH SERVICES
Address: [**Location (un) 78551**], [**Hospital1 **],[**Numeric Identifier 78552**]
Phone: [**Telephone/Fax (1) 60586**]
Completed by:[**2170-5-14**]
|
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"584.9",
"333.0",
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"276.7",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5657, 8690
|
246, 271
|
4052, 4052
|
10932, 11339
|
2710, 2732
|
8716, 9861
|
2747, 4033
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4068, 5634
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|
2024, 2581
|
2597, 2694
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,405
| 111,170
|
1507
|
Discharge summary
|
report
|
Admission Date: [**2103-8-10**] Discharge Date: [**2103-9-26**]
Date of Birth: [**2063-11-9**] Sex: F
Service: OMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8841**]
Chief Complaint:
Confusion, nausea, vomiting, headache
Major Surgical or Invasive Procedure:
Ventriculostomy
Ventriculoperitoneal shunt placement
Intrathecal Vancomycin
History of Present Illness:
39F transferred from [**Hospital **] Hospital for evaluation of multiple
brain lesions. Pt had been well until approx 1 month prior to
admission when she travelled to [**Country 651**] via [**Location (un) 6847**] and [**State 8842**].
Patient states that she first noticed problem when "it felt odd
when my children touched my left leg". Denied pain, pins and
needles, loss of bladder/bowel control. Following one week in
[**State 8842**], the pt began to have LBP (no prior hx). Pain was over
the spine at L3-4 level w/o radiation. Several days later the pt
developed severe headache w/ nausea and vomiting. On return to
the U.S., she noted confusion mostly in regards to getting lost
and forgetting what she was doing. Presented to [**Hospital **]
hospital where she was noted to have multiple brain lesions on
CT, lung mass, liver mass, bony lesions, transferred for further
eval. Denies F/C/visual changes/or weakness.
Past Medical History:
[**Last Name (un) **] diabetes
Social History:
Denies smoke/drink/drugs
Married, two children
Trained as M.D., microbiologist at [**Hospital1 2025**].
Family History:
Non-contributory
Physical Exam:
97.1 99/60 71 18 98% RA
General: No acute distress
HEENT: PERRLA. EOMI. no nystagmus. anicteric oropharynx clear.
Neck: no cervical/sm/sc la noted
Cardiovascular: Regular S1, S2. no m/r/g
Lungs: Clear to auscultation bilaterally
Breast: Negative for masses/nodules
Abdomen: Bowel sounds present, soft, nontender nondistended,
hepatomegaly (~9cm) No splenomegaly.
Extremities: No c/c/e. No palmar erythema noted.
Neuro: CN III-XII intact
2+DTR's b/l
[**5-30**] ue, [**4-30**] le b/l
Mild past pointing on finger
Mentating clearly, able to do days of the week backwards
Pertinent Results:
At [**Hospital **] Hospital:
WBCC 10..1, hct 37.0, plt 186, mcv88
diff n76, l15,
inr 1.1, ptt 26.3
alb 3.5 tbili 0.8, ld 584, ap 219, ast 36, alt 52, cea 17.8
CXr: rounded density in LUL and L hilar enlargement
CT chest: soft tissue mass in L apex extending to hilum abutting
L main PA and L main bronchus. L hilar adenopathy. three mm r
lung nodule.
CT abd/pelvis: Lobulated mass in L hepatic lobe 7.5x3.2cm,
suspicious for mets, no splenomegaly, no adrenal mets.
CT head: numerous cerebral and cerebellar mass lesions c/w mets.
MRI head: innumerable ring enhancing lesions, largest on R
2.8x2.2 cm, largest on L is 2.5x1.8. In cerebellum, 2.8x2.4cm.
Midline shift to L. Some lesions demonstate surrounding
vasogenic edema.
----
[**Hospital1 18**]
ECG: Sinus at 84 w/ L axis deviation. Nl intervals. No st-tw
abnormalities.
[**2103-8-10**] 09:30AM GLUCOSE-334* UREA N-15 CREAT-0.6 SODIUM-135
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-22 ANION GAP-18
[**2103-8-10**] 09:30AM ALT(SGPT)-68* AST(SGOT)-38 LD(LDH)-762* ALK
PHOS-286* TOT BILI-0.3
[**2103-8-10**] 09:30AM ALBUMIN-4.1 CALCIUM-8.5 PHOSPHATE-2.8
MAGNESIUM-2.1
[**2103-8-10**] 09:30AM WBC-16.6* RBC-4.25 HGB-12.8 HCT-37.4 MCV-88
MCH-30.0 MCHC-34.2 RDW-12.5
[**2103-8-10**] 09:30AM PLT COUNT-253
[**2103-8-10**] 09:30AM PT-13.4* PTT-26.6 INR(PT)-1.2
---
RADIOLOGY Final Report
MR HEAD W & W/O CONTRAST [**2103-8-13**] 3:27 PM
MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN
Reason: Evaluate lesions
[**Hospital 93**] MEDICAL CONDITION:
39 year old woman with no PMH found to have multiple enhancing
lesions on MR at outside hospital.
REASON FOR THIS EXAMINATION:
Evaluate lesions
INDICATIONS: Enhancing lesions on outside MRI. Left upper lobe
mass, liver mass and lytic lesions of the spine.
MRI OF THE BRAIN WITHOUT CONTRAST:
TECHNIQUE: Multiplanar pre and post contrast T1W images, axial
T2W, susceptibility, and FLAIR images were obtained.
FINDINGS: There are innumerable areas of susceptibility effect
in the cerebellum and cerebrum, many associated with T1
hyperintensity. The lesions enhance peripherally. Many are
located at the [**Doctor Last Name 352**]/white matter junction. Others lie in the
right lentiform nucleus on thalamus. There is a lesion in the
dorsal left mid brain on the lateral claviculi. Given the
history, they are most likely hemorrhagic metastases.
Largest lesion is in the left cerebellar hemisphere measuring
approximately 2.6 cm in maximum dimension. There are 2.3 cm
lesions in the lateral left frontal lobe, the medial right
parietal lobe and the right lentiform nucleus. There is
vasogenic edema, particularly prominent in the parietal white
matter, the right posterior temporal region and the right
cerebellar hemisphere. There is some shift of septum pellucidum
towards the right left. There is minimal right sided mass effect
in the fourth ventricle. There is no hydrocephalus. Some of the
sulci are effaced. The right cerebellar tonsils displace
slightly inferiorly into the foramen magnum.
There is also a 16 mm peripherally enhancing pineal mass,
probably also a metastases in an unusual location.
IMPRESSION: There are innumerable lesions in the brain
parenchyma with associated blood break down products and
enhancement most consistent with multiple metastases. The
largest are on the order of 2.5 cm in size. There is some shift
of the septum pellucidum towards the left but no dilatation of
the ventricular system. There is a large right cerebellar lesion
with some edema but only minimal mass effect on the fourth
ventricle. An unusual peripherally enhancing pineal mass is
noted, probably also a metastases. The outside study is not
available for comparison.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2103-8-21**] 9:44 PM
---
CT ABD W&W/O C [**2103-8-11**] 5:08 PM
CT ABD W&W/O C; CT PELVIS W/CONTRAST
Reason: Possibility for tissue sample, either via bronchoscopy
or li
Field of view: 30 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
39 year old woman with multiple cerebral lesions, l lung lesion,
and large liver mass.
REASON FOR THIS EXAMINATION:
Possibility for tissue sample, either via bronchoscopy or liver
biopsy.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Multiple cerebral lesions, left lung lesion, large
liver mass.
COMPARISON: Outside CT from [**2103-8-9**].
TECHNIQUE: Helically aquired contiguous axial images were
obtained from the lung apices through pubic symphysis following
the administration of 150 cc of IV Optiray. Nonionic contrast
was used secondary to patient debilitation. Multiphasic images
of the liver were also obtained.
CT CHEST WITH IV CONTRAST: Within the apex of the left upper
lobe, there is an ill defined mass present, measuring 2.4 x 3.2
cm. Contiguous with this mass and just inferior to it are
several, smaller, ill defined nodules within the left upper lobe
and left hilar region, the largest of which measures 1.5 x 1.2
cm. Additionally within the right middle and right lower lobes,
there are at least four, 1-2 mm, noncalcified pulmonary nodules
identified. There is narrowing of the left upper lobe bronchus
by the left hilar mass. Otherwise, the airways are patent to the
level of the segmental bronchi bilaterally. An enlarged
prevascular lymph node is identified adjacent to the aorta
measuring approximately 11 mm. An ill defined left hilar mass is
identified which appears to consist of a conglomeration of
smaller pulmonary parenchymal nodules and left hilar lymph
nodes, which narrows the left upper lobe bronchus. No other
pathologically enlarged axillary lymphadenopathy is seen. The
heart, pericardium and great vessels are unremarkable. No
pleural or pericardial effusion is present.
CT ABDOMEN W/O&W IV CONTRAST: Within the left lateral segment of
the liver, there is a large, heterogeneously enhancing mass
present which measures approximately 4.0 x 7.7 cm. Within the
dome of the right lobe of the liver, there is a second,
enhancing, low attenuation lesion present measuring 2.1 x 1.3
cm. Multiple, smaller, heterogeneously enhancing, low
attenuation lesions appear to be present throughout the liver,
findings suggestive of innumerable metastatic lesions. There is
no intrahepatic biliary duct dilatation. The portal vein is
patent. The gallbladder, pancreas, spleen, adrenal glands,
kidneys, ureters, stomach, and loops of large and small bowel
are all within normal limits. There is no free air or free
fluid. There is no significant mesenteric or retroperitoneal
lymphadenopathy.
CT PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, uterus,
adnexa, distal ureters, and bladder are all within normal
limits. There is no free fluid. There is no pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: Multiple lytic lesions are noted within the T6,
T12, L2, and L4 vertebral bodies with the most destructive
changes noted within the L4 vertebral body. No definite
extension into the spinal canal is present. Additionally a lytic
lucency is identified within the posterior right iliac [**Doctor First Name 362**].
IMPRESSION:
Large ill defined mass within the left upper lobe of the lung
concerning for a primary neoplastic process. Heterogeneously
enhancing low attenuation lesions within the liver as well as
lytic lesions within the bones are concerning for hepatic and
osseous metastases. The large mass within the left lateral
segment of the liver would be amenable to ultrasound guided
biopsy.
The findings have been discussed with Dr. [**Last Name (STitle) **] on [**2103-8-11**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**First Name8 (NamePattern2) 8843**] [**Location (un) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: MON [**2103-8-13**] 2:17 PM
---
SPECIMEN RECEIVED: [**2103-9-21**] [**-4/3309**] SPINAL FLUID
SPECIMEN DESCRIPTION: Received 1ml cloudy fluid.
Prepared 1 ThinPrep slide.
CLINICAL DATA: None provided.
PREVIOUS BIOPSIES:
[**2103-8-13**] [**-4/2774**] LIVER MASS
REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DIAGNOSIS: POSITIVE FOR MALIGNANT CELLS.
Rare atypical cells present, consistent with metastatic
carcinoma.
Note:
Previous cytology slides of liver FNA (C04-[**Numeric Identifier 8844**]) were
reviewed. Cytologic features of rare malignant cells seen
in CSF specimen are similar to that of liver FNA specimen.
Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] notified of the diagnosis by Dr. [**Last Name (STitle) **]. [**Doctor Last Name 8845**] via
e-mail on [**2103-9-24**].
DIAGNOSED BY:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8846**], CT(ASCP)
[**Name6 (MD) 8847**] [**Name8 (MD) **], M.D.
[**First Name11 (Name Pattern1) 2127**] [**Last Name (NamePattern1) **], M.D.
---
[**Last Name (NamePattern1) **]
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2103-9-26**] 09:35AM 3.4* 3.07* 9.9* 29.8* 97 32.4* 33.4 17.9*
98*
[**2103-9-25**] 08:00AM 3.1* 3.15* 10.1* 30.1* 95 31.9 33.4 17.6*
102*
BASIC COAGULATION PT PTT Plt Ct INR(PT)
[**2103-9-26**] 09:35AM 98*
[**2103-9-25**] 08:00AM 102*
[**2103-9-25**] 08:00AM 12.01 25.8 0.9
1 NOTE NEW NORMAL RANGE AS OF 12AM OF [**2103-9-4**]
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2103-9-26**] 09:35AM 111* 13 0.4 140 3.8 103 26 15
[**2103-9-25**] 08:00AM 109* 16 0.4 140 3.2* 103 26 14
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2103-9-26**] 09:35AM 8.3* 3.6 1.8
[**2103-9-25**] 08:00AM 8.3* 5.1* 1.9
---
CT HEAD W/O CONTRAST [**2103-9-22**] 10:31 PM
Reason: Any hydrocephalus or indication of shunt malfunction?
[**Hospital 93**] MEDICAL CONDITION:
39 year old woman with nsclc mets to brain, s/p VP shunt 2 days
ago now with fairly severe HA for several hours.
REASON FOR THIS EXAMINATION:
Any hydrocephalus or indication of shunt malfunction?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Severe headache for several hours, status-post VP
shunt two days ago, metastatic non-small cell lung cancer to
brain.
Comparison is made to the prior CT scan dated [**2103-9-17**].
TECHNIQUE: Noncontrast head CT.
FINDINGS: There is again demonstrated a small amount of residual
intraventricular hemorrhage in the left occipital [**Doctor Last Name 534**] of the
lateral ventricle. There has been interval removal of the
right-sided intraventricular drain with a small amount of
hemorrhagic products along the course of the prior drain. There
has been interval placement of a left-sided intraventricular
drain with the tip in the frontal [**Doctor Last Name 534**] of the left lateral
ventricle. There are again demonstrated innumerable metastatic
brain lesions. The ventricles, sulci and cisterns are unchanged
in configuration. There is no shift of normally midline
structures or hydrocephalus. The visualized paranasal sinuses
and osseous structures are unremarkable. Skin staples are seen
overlying the course of the VP shunt.
IMPRESSION:
1. Interval placement of VP shunt with removal of prior right
intraventricular drainage. A small amount of hemorrhage products
are noted along the course of the prior drainage catheter.
2. Otherwise stable appearance of the brain with innumerable
brain metastases.
Brief Hospital Course:
39F recent onset of paresthesias, low back pain, headache
accompanied by nausea and vomiting, and confusion, transferred
from outside hospital, with multiple intracranial, pulmonary,
bony, and hepatic masses.
1) Altered mental status associated with multiple intracranial
masses:
Patient was transferred to [**Hospital1 18**] on [**8-10**]. Diagnosis of
metastatic large cell lung cancer was made by ultrasound guided
liver biopsy, and multiple metases noted throughout spine and
brain by MRI (L spine metases, loss of L4 disc space, foraminal
narrowing; multiple enhancing lesions in brain, largest of 2.5
cm with hemorrhage).
Carboplatin/Taxol chemotherapy was administered, however, over
several days, patient began to have decreased level of
consciousness, increased headache, nausea, and vomiting with no
relief from narcotics or acetaminophen. On day 4 following
chemotherapy, patient became unresponsive to verbal stimuli and
somnolent with decreased tone; this was thought to be possibly a
non-convulsive status event. CT head at the time indicated new
metastases, effacement of sulci and herniation into the foramen
magnum.
Patient was given a bolus of 10mg decadron q6hours, and
transferred to the ICU for q1hour neuro checks. Patient was
administered whole brain radiation therapy (total dose 2,000
cGy). A right frontal EVD was placed, and mannitol and decadron
were administered to reduce edema and increased intracranial
pressure. Mental status/neurolic function slowly improved with
increased response to commands and increased amount of
communication. However, over the next several days, it was
determined that the EVD was infected with coagulase negative
staphylococcus, which was treated with both intravenous and
intraventricular Vancomycin until cultures from CSF were
negative for seven consecutive days. The EVD was then removed
and a ventriculoperitoneal shunt was placed without
complication.
The patient's mental status continued to improve and at the time
of discharge, decadron had been weaned to 4mg QD. The patient
was placed on a regiment of Keppra 750 [**Hospital1 **] to maintain seizure
prophylaxis.
2) Metastatic lung cancer: Although it was felt that the patient
had an overall poor prognosis, it was felt that she may still
benefit from a palliative standpoint from aggressive treatment.
Completed one cycle of [**Doctor Last Name **]/Taxol (as above). Was scheduled
for repeated chemotherapy but delayed due to EVD infection. The
patient was started on Iressa (EGFR inhibitor) 250mg qd, since
shown to have some benefit in metastatic lung Ca to brain as 2nd
line [**Doctor Last Name 360**] to chemo/XRT.
3) Non-sustained ventricular tachycardia: Had multiple runs of
NSVT and was started on amiodarone infusion. Evaluated by
Cardiology who felt that the rhythm was polymorphic, and likely
catecholamine mediated VT which would be best treated with a
beta-blocker. Amiodarone was discontinued. Felt to be NOT a
candidate for ICD given her metastatic disease. Also felt to
have some component of Brugada syndrome (but does not strictly
meet criteria for this). At the time of discharge, patient's
blood pressure and heart rate were stable without ectopy, and
patient was discharged on 25mg Metoprolol [**Hospital1 **].
4) Hyperglycemia: Likely steroid-induced. Diabetic diet
initiated with good glucose control. Sliding scale insulin
administered while on daily decadron to good effect.
5) Pain control: Patient was continuing to have headaches
despite recovery of her mental status. Repeat head CT showed
residual blood in the ventricles, likely from removal of the
EVD. It was felt that her headaches were likely due to this
residual blood, and that the VP shunt was still patent and
functioning. Patient's pain was fairly well controlled with
morphine PCA, then converted to Oxycontin with oxycodone for
breakthrough pain.
6) Patient will follow up with Neurosurgery the day after
discharge.
Medications on Admission:
Meds at Home:
OCP
Meds on Transfer:
Decadron 4mg po q6
Protonix 40mg po qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
3. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. IRESSA 250 mg Tablet Sig: One (1) Tablet PO once a day ().
5. Kaolin-Pectin 5.85-0.13 g/30 mL Suspension Sig: 30-60 MLs PO
PRN (as needed) as needed for give with stools.
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Psyllium 58.6 % Packet Sig: One (1) Packet PO TID (3 times a
day) as needed.
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q12H (every 12 hours).
11. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
12. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
13. Ondansetron HCl 2 mg/mL Solution Sig: [**1-26**] Intravenous Q6H
(every 6 hours) as needed for nausea.
14. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
15. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Units Injection ASDIR (AS DIRECTED).
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day: Hold for RR<10, SBP<110.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Metastatic non Small Cell Lung Cancer
(Liver, Brain, and Bone metastases)
Central Nervous System Infection
Discharge Condition:
Good
Discharge Instructions:
1) Follow up with your neurosurgeon tomorrow as directed.
2) Continue taking your medications as directed.
3) If you have fever, chills, extreme headache, weakness,
seizures, or confusion, call your doctor who will decide if you
should come to the emergency room. Some headache is to be
expected, and you should take your pain medication. However, if
it associated with mental status changes or weakness, you should
call your doctor immediately ([**Telephone/Fax (1) 1669**]).
4) Continue to follow up with your primary care physician,
[**Name10 (NameIs) 5564**], and neurosurgeon as directed.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] (Neurosurgery) [**Last Name (NamePattern1) **].
Date/Time:[**2103-9-27**] 11:00 AM. [**Telephone/Fax (1) 1669**]
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTI-SPECIALTY MULTI-SPECIALTY
THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI
Date/Time:[**2103-10-4**] 8:30
Provider: [**Name10 (NameIs) 8848**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9 Where: [**Hospital 4054**] [**Hospital **]/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2103-10-4**] 8:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 8849**]
|
[
"198.5",
"427.1",
"331.4",
"198.3",
"197.7",
"162.3",
"431",
"996.63"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"99.25",
"02.2",
"50.11",
"02.34"
] |
icd9pcs
|
[
[
[]
]
] |
19326, 19398
|
13713, 17671
|
349, 427
|
19549, 19555
|
2203, 2672
|
20199, 20916
|
1577, 1595
|
17798, 19303
|
12128, 12241
|
19419, 19528
|
17697, 17716
|
19579, 20176
|
1610, 2184
|
272, 311
|
12270, 13690
|
455, 1386
|
2681, 3678
|
1408, 1440
|
1456, 1561
|
17734, 17775
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,339
| 167,250
|
15013
|
Discharge summary
|
report
|
Admission Date: [**2117-3-11**] Discharge Date: [**2117-3-16**]
Date of Birth: [**2043-5-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
cludication
Major Surgical or Invasive Procedure:
B/L fem endarterectomy
History of Present Illness:
PREOPERATIVE DIAGNOSIS: Bilateral common femoral and
profunda femoris artery stenosis.
POSTOPERATIVE DIAGNOSIS: Bilateral common femoral and
profunda femoris artery stenosis.
PROCEDURE: On the right side, right common femoral and
profunda femoris artery endarterectomy.
Bypass graft from right common femoral artery to distal
profunda femoris artery with 8 mm Dacron graft.
On the left side, left common femoral and profunda femoris
endarterectomy.
Dacron patch angioplasty and angioplasty and stenting of left
external iliac artery with a 10 x 40 self-expanding stent and
completion arteriography.
Past Medical History:
-CAD, s/p cath in [**1-21**] with EF 35%, 3vd, s/p 3 v. CABG, c/b
sternal drainage and rewiring in [**2116-2-23**]
-atrial fibrillation, s/p MAZE procedure, on coumadin
-hypertension
-hypercholesterolemia
-diabetes
-AAA, s/p repair in '[**11**]
-h/o colon CA s/p resection
-DJD s/p b/l total knee replacement
-h/o e. coli urosepsis in [**8-20**]
Social History:
Patient lives alone. He has a remote tobacco history, quit over
18 years ago alcohol use limited to one drink per day.
Family History:
Father died of prostate carcinoma.
Physical Exam:
Physical Exam:
96.2, 158/88, 78, 24, 96% on RA, FS161, I/O 1630/1300
gen - NAD, no dyspnea
HEENT - MMM, OPC, subconj pallor improved
neck - supple, no LAD, no JVD
chest - well healed sternal incision with some scarring. No
erythema/tend or drainage
lungs - CTAB
c/v - RRR, no m/g/r
abd - s/nt/nd
extr - no c/c/e, 2+ b/l radial, fem, & pedal pulses, no bleeding
neuro - A+Ox3, ambulating well, no focal weakness or loss
sensation
Pertinent Results:
[**2117-3-15**] 03:20AM BLOOD WBC-8.2 RBC-3.50* Hgb-10.0* Hct-28.9*
MCV-82 MCH-28.5 MCHC-34.6 RDW-18.0* Plt Ct-180
[**2117-3-15**] 03:20AM BLOOD PT-14.1* PTT-29.9 INR(PT)-1.3*
[**2117-3-15**] 03:20AM BLOOD Plt Ct-180
Brief Hospital Course:
Patient was admitted and procedure described in brief was
performed
PREOPERATIVE DIAGNOSIS: Bilateral common femoral and
profunda femoris artery stenosis.
POSTOPERATIVE DIAGNOSIS: Bilateral common femoral and
profunda femoris artery stenosis.
PROCEDURE: On the right side, right common femoral and
profunda femoris artery endarterectomy.
Bypass graft from right common femoral artery to distal
profunda femoris artery with 8 mm Dacron graft.
On the left side, left common femoral and profunda femoris
endarterectomy.
Dacron patch angioplasty and angioplasty and stenting of left
external iliac artery with a 10 x 40 self-expanding stent and
completion arteriography.
Patient did well post operatively and and was able to void after
removal of foley catheter and was abulating and working with
physical therapy. Physical therapy deemed the patient
appropriate candidate for D/C to rehab facility. Patient was
restarted on his coumadin for his parosysmal A-fib and his
levels will be evaluated at the rehab facility and his coumadin
dosing will likely need adjusting
Medications on Admission:
[**Last Name (un) 1724**]: metoprolol 50 mg [**Hospital1 **], aspirin 81 mg qd, Coumadin 6',
Lisinopril 20 mg qd, glipizide 2.5", Lipitor 40 mg qd, Protonix
40', amiodarone 200 mg qd, Magnesium, lasix 40'
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
5. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Tablet(s)
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] house
Discharge Diagnosis:
B/L fem endarterectomy
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:1500 cc
Do not remove staples until discussion with Dr. [**Last Name (STitle) **] and
have appointment in 2 weeks, return
Followup Instructions:
F/U in 2 weeks
Completed by:[**2117-3-15**]
|
[
"447.1",
"V43.65",
"414.00",
"401.9",
"440.21",
"272.0",
"V10.05",
"427.31",
"250.00",
"496",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.40",
"39.29",
"38.18"
] |
icd9pcs
|
[
[
[]
]
] |
4736, 4792
|
2248, 3318
|
326, 351
|
4859, 4868
|
2007, 2225
|
5157, 5203
|
1505, 1541
|
3573, 4713
|
4813, 4838
|
3344, 3550
|
4892, 5134
|
1571, 1988
|
275, 288
|
379, 981
|
1003, 1351
|
1367, 1489
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,071
| 107,344
|
50906
|
Discharge summary
|
report
|
Admission Date: [**2131-12-11**] Discharge Date: [**2131-12-20**]
Service: General Surgery, Gold Team
HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old
male with a history of coronary artery disease, status post
CABG, diabetes mellitus, who presents with sudden onset of
epigastric pain, sharp, constant, which now resolved. The
patient complained of chills, no fevers at home, 102.4
degrees in the Emergency Room. The patient had two episodes
of non bilious emesis, no hematemesis, no bright red blood
per rectum, no urinary symptoms. Pain now resolved but still
has shaking chills.
PAST MEDICAL HISTORY: Diabetes mellitus, coronary artery
disease, status post CABG 6 years ago and atrial
fibrillation.
PAST SURGICAL HISTORY: CABG and appendectomy as a child. He
takes Aspirin, Glucovance and Amiodarone. Amiodarone was
stopped on [**2131-12-10**].
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Temperature in the Emergency [**Apartment Address(1) 105819**].4, pulse 104, blood pressure 162/64, respiratory rate 22,
sats 96% on room air. The patient was awake, alert, oriented
times three with shaking chills, clear to auscultation
bilaterally, regular rate and rhythm. Abdomen was distended,
nontender, no peritoneal signs. Guaiac negative.
Extremities were warm, white blood cells 3.7, hematocrit
43.6, platelet count 108, sodium 145, potassium 4.4, BUN 27,
creatinine 1.3, ALT 284, AST 568, total bilirubin 1.3,
amylase 773, lipase more than 6000. CT scan was done which
showed pancreatitis and a dilated thickened gallbladder.
Right upper quadrant ultrasound showed an inflamed pancreas
and no gallstones.
HOSPITAL COURSE: The patient was admitted. There was a
question on CT scan whether there was gallstones and it was
presumed by the radiologist that the patient did have chest
x-ray which was normal. The patient was admitted for IV
fluids and kept npo. The patient was given the right
subclavian line and admitted to MICU for resuscitation and
monitoring of PT and platelet count also, to rule out MI.
The patient did rule out for MI on admission. Blood cultures
were sent which grew E. coli. The patient was treated with
Ceftriaxone and Flagyl which later were converted to Keflex
when patient took po. The patient had two issues during his
hospital stay, one was platelet count which dropped to 91,
Heparin and Zantac were discontinued. Hematology consult was
called. The patient's platelets rose up to greater than 100.
On [**12-14**] the patient went into rapid atrial fibrillation,
Lopressor was used unsuccessfully, the patient was put on
Amiodarone 600 mg and converted back to sinus rhythm.
However, throughout hospital stay the patient converted from
atrial fibrillation to atrial flutter, to normal sinus
rhythm. A repeat CT on the 29th showed no change and no
portal vein thrombosis. On the 30th the patient began to
take clears. On the 30th the patient had an echocardiogram
done which showed an ejection fraction from 40-50%,
anteroseptal to mid ventricular hypokinesis. The
cardiologist believed that the patient has more minor
subendocardial MI, however, there was no change in the risk
for surgery. On the 31st the patient was advanced to regular
diet, platelets 109,000. On [**12-19**] the patient was cardioverted
without Heparin. On the 3rd the patient was stable and
normal sinus rhythm and discharged to home on Keflex 500 mg
po qid for two more weeks, Amiodarone 200 mg po tid, Percocet
and Colace. Patient was scheduled to return on [**12-28**] for a
laparoscopic cholecystectomy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D. [**MD Number(1) 1307**]
Dictated By:[**Name8 (MD) 6908**]
MEDQUIST36
D: [**2131-12-28**] 11:44
T: [**2131-12-31**] 13:17
JOB#: [**Job Number 105820**]
|
[
"414.01",
"287.4",
"038.42",
"427.32",
"286.6",
"577.0",
"574.00",
"250.00",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.23",
"99.61",
"88.72",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
1677, 3847
|
752, 916
|
939, 1659
|
141, 606
|
629, 728
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,212
| 163,189
|
35802
|
Discharge summary
|
report
|
Admission Date: [**2123-11-24**] Discharge Date: [**2123-12-30**]
Date of Birth: [**2078-6-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Transferred from OSH for septic shock, ARDS, ARF and possible
need for CVVH
Major Surgical or Invasive Procedure:
Cordis central line placement
Temporary dialysis line placement
Tunnelled dialysis line placement
Endotracheal intubation
Paracentesis
History of Present Illness:
Ms. [**Known lastname 81431**] is a 45 year old female with a history of EtOH
hepatitis/cirrhosis with septic shock on pressors,
aspiration/ARDS, [**Hospital **] transfer from [**Hospital 8**] hospital for CVVH
for volume overload.
She was initially admitted to [**Hospital 8**] hospital on [**2123-11-17**]
after her nurse practitioner [**First Name (Titles) 767**] [**Last Name (Titles) **] for the Homeless
found her with multiple empty vodka bottles scattered around her
apartment. [**Name8 (MD) **] NP had seen her intoxicated in the past and did
not feel like her behavior at that time could be explained by
intoxication alone and brought her to the [**Hospital1 8**] ED. On
admission to OSH, her EtOH level was <10. She had elevation in
her liver function tests with AST/ALT 279/66, INR 1.6, Tbili
17.4. Ammonia was 168 on presentation. Cr 0.5 on presentation.
K 1.9, Phos 1.2 on presentation. Tylenol level was negative.
She was intially treated for acute hepatic failure and hepatic
encephalopathy. She did not receive steriods. She was started
on lactulose and her mental status improved. She began to spike
fevers on [**2123-11-20**] to 101-102. Blood cultures from [**11-19**]
eventually grew MSSA in [**1-3**] bottles and she was started on
vancomycin/cefepime. Blood cultures repeated on [**2123-11-22**] and
were negative. A U/A from [**11-22**] grew E. coli, not yet
speciated. With MSSA and E. coli results, vanco/cefepime
changed to zosyn. An abdominal CT scan also obtained which
showed evidence of pancolitis and patient was started on empiric
oral vancomycin despite C diff toxin stool assays being negative
x 4.
On [**11-20**], urine output began to decline and Cr increased from
0.6 -> 1.3. Around the same time her blood pressures began to
decrease. She was initially fluid responsive but then became
refractory. on [**11-21**], a cordis was placed. She received several
units of FFP prior to line placement due to worsening
coagulopathy and following the line placement she became hypoxic
and acutely SOB. She was placed on BiPAP without improvement in
ABG and she was eventually intubated. CXR at that time showed
diffuse bilateral infiltrates. An ECHO was obtained and prelim
read showed preserved systolic function. PA catheter placement
was attempted unsuccessfully(CVP ~20, RV 60s/20, PA 40s??/20 at
80cm, unable to wedge). Concern for aspiration and pulmonary
edema and vent requirements rapidly increased. Most recently on
AC with TVs of 350 cc, PEEP of 18, FiO2 of 100%. She has a
persistent vasopressor requirement, currently on levophed 4
micrograms/min, and remains anuric with most recent Cr of 3.1.
Tbili has continued to rise to 18 and she has become
increasingly coagulopathic.
Past Medical History:
# alcoholic hepatitis/cirrhosis
# h/o aspiration pneumonia
# HTN
Social History:
Intermittently estranged from her family. Homeless until 3
months ago. Now lives alone. History of heavy EtOH use. +
current tobacco, unknown amount. H/o crack cocaine use, but no
known IVDU.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
T: 100.3 BP: 93/54 HR: 100 RR: 40 O2 100% AC 350x28 FiO2 60%
PEEP 12
bladder pressure: 11
Gen: intubated, sedated
HEENT: PERRL, + scleral icterus and orbital edema, could not
assess O/P
NECK: Right IJ in place, difficult to assess JVP, No
masses/thyromegaly/bruits noted.
CV: tachycardic, RRR. + systolic and diastolic murmurs, no rubs
or gallops
LUNGS: coarse BS bilaterally, but No W/R/C
ABD: Large scar noted; No BS, distended; Difficult to assess HSM
due to thick scar, but liver felt to be 4cm below ribs; No
masses noted
EXT: NO CCE. dimished DP pulses BL; bounding radial pulses BL
SKIN: No rashes/lesions, + ecchymoses on medial aspect of LLE
NEURO: Intubated, sedated. Moves all 4 extremities. Responds to
verbal stimuli, does not withdraw to pain
Pertinent Results:
STUDIES FROM [**Hospital **] HOSPITAL ON TRANSFER:
[**11-23**]: 7.34/31/64 on AC 400x32 FiO2 55% PEEP 15
145 119 9
----------< 183
3.5 17 3.7
AST 109 ALT 34, INR 2.0, Tbili 19.7 Ammonia 86
[**2123-11-23**]:
CK 44
6.1>--<53
24.6
Culture data: UCx from [**2123-11-20**] >100K E. Coli
Viral data: HIV non-reactive
Micro: Stool cx (-), C.diff (-),
Urine Cx from [**11-22**] pansensitive E.coli >100,000 organisms/ML
Blood cx from [**11-21**] [**1-3**] GPCs, ID and sensitivity pending
ADMISSION LABS:
[**2123-11-24**] 02:40PM BLOOD WBC-8.8 RBC-2.68* Hgb-8.5* Hct-25.9*
MCV-97 MCH-31.9 MCHC-33.0 RDW-21.2* Plt Ct-71*
[**2123-11-24**] 02:40PM BLOOD Neuts-84.0* Lymphs-13.3* Monos-1.7*
Eos-0.7 Baso-0.3
[**2123-11-24**] 02:40PM BLOOD Fibrino-499*
[**2123-11-24**] 02:40PM BLOOD Glucose-115* UreaN-55* Creat-3.8* Na-146*
K-3.0* Cl-113* HCO3-18* AnGap-18
[**2123-11-24**] 02:40PM BLOOD Glucose-115* UreaN-55* Creat-3.8* Na-146*
K-3.0* Cl-113* HCO3-18* AnGap-18
[**2123-11-24**] 02:40PM BLOOD ALT-31 AST-127* LD(LDH)-420* CK(CPK)-28
AlkPhos-42 TotBili-19.8*
[**2123-11-24**] 02:40PM BLOOD Albumin-2.9* Calcium-7.6* Phos-4.1 Mg-2.3
[**2123-11-24**] 02:47PM BLOOD Lactate-2.5*
[**2123-11-24**] 02:47PM BLOOD Type-ART Temp-37.9 pO2-165* pCO2-40
pH-7.28* calTCO2-20* Base XS--7 Intubat-INTUBATED
[**2123-11-24**] 04:37PM BLOOD Cortsol-34.9*
[**2123-11-24**] 04:37PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2123-11-24**] 04:37PM BLOOD HCV Ab-NEGATIVE
MICROBIOLOGY DATA:
Blood Cultures from [**2123-11-24**], [**11-24**] x 2, [**11-25**] x 2, [**2123-12-2**] x 2,
[**12-6**] x 2, [**12-10**] x 2, [**12-21**]: negative
Urine cultures from [**2123-11-24**]: negative
Urine Legionella from [**2123-11-14**]: negative
Sputum cultures from [**2123-11-24**], [**11-30**], [**12-3**]: negative
Sputum cultures from [**2123-12-7**]: yeast (contaminant)
Stool C. diff toxin A&B from [**2123-11-28**], [**11-30**], [**2123-12-2**], [**12-8**] x 2:
negative
Stool O&P from [**2123-12-9**], [**12-10**]: negative
KEY IMAGING:
ADMISSION CXR from [**2123-11-24**]:
There is diffuse opacification of the lungs bilaterally which is
consistent with multifocal pneumonia versus ARDS. The heart size
is mildly enlarged. The mediastinal silhouette is within normal
limits.
[**2124-11-23**] ABD US:
1. Cirrhotic liver, ascites, and splenomegaly, reflecting
chronic liver disease.
2. Non-occlusive thrombus within the main portal vein, with
extremely slow flow throughout the portal venous system. Patent
hepatic veins and hepatic artery.
3. Possible subhepatic fluid collection.
[**2124-11-25**] TTE:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. No aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
[**2123-12-7**] CT TORSO w/ CONTRAST:
1. Pancolitis, likely due to C. difficile.
2. Ascites.
3. Hypodense kidneys that do not excrete contrast. According to
Dr. [**First Name (STitle) **],
the patient is on continuous dialysis.
4. Pulmonary edema. No pleural effusion.
5. Questionable fullness of the left adrenal gland, with no
definite
nodularity. Attention should be made on the next follow-up.
[**2123-12-7**] CT SINUSES:
1. No evidence of acute sinusitis.
2. Periapical lucencies associated with the maxillary incisors
as described above, concerning for abscesses.
.
[**12-30**] labs: Na 144, K 3.1, Cr 3.9, BUN 60
WBC 9.5, HCT 27.2, plt 96, INR 2.3, Tbili 28.9
Brief Hospital Course:
ALCOHOLIC HEPATITIS, CIRRHOSIS:
Ms. [**Known lastname 81431**] was admitted with profound alcoholic hepatitis
complicated by shock, ARDS and ARF requiring hemodialysis. Her
liver injury was likely in large part due to shock liver in the
setting of baseline cirrhosis. (Of note, other liver studies
performed at the OSH were negative including Tylenol levels,
[**Doctor First Name **], anti-mitochondrial antibodies, Sm ab, RNP ab and hepatitis
serologies.) Imaging at [**Hospital1 18**] showed evidence of cirrhosis,
ascites and splenomegaly, as well as a non-occlusive thrombus
within the main portal vein. Total bilirubin maxed at 41 and
trended downwards though was still persistently in the range of
29 at the time of discharge. The liver service followed her
while in house; she is considered ineligible for a liver
transplant given her substance abuse history. Treatment with
steroids and pentoxifylline was not pursued. She was started on
ciprofloxacin for SBP prophylaxis.
Her hepatic encephalopathy was treated with lactulose and
rifaximin. The results of CMV serologies were not obtained from
the OSH and may require followup
SHOCK: The origin of the patient's shock is presumed sepsis in
the setting of fevers and findings of MSSA bacteremia and E Coli
UTI. She was also noted to have a pancolitis of unclear etiology
(initially thought to be C Diff though multiple stool studies
were negative for C Diff toxin). She had a negative TTE to rule
out endocarditis. She was treated with Vancomycin and Zosyn for
the bacteremia and urinary tract infection. She also received
empiric therapy with oral vancomycin and then oral flagyl for
possible C Diff. She did require vasopressors while in the ICU.
RESPIRATORY FAILURE: The patient became hypoxic and required
intubation in the setting of oliguric renal failure, volume
challenge with FFP, and trendelenberg positioning for line
placement while in the ICU. Her respiratory compromise may have
been due to aspiration and/or flash pulmonary edema. She did
develop bilateral pulmonary infiltrates concerning for ARDS. She
received low-volume ARDSNet ventilation. With treatment of the
source of sepsis and dialysis the patient was successfully
extubated.
ACUTE RENAL FAILURE, REQUIRING RENAL REPLACEMENT THERAPY:
Ms. [**Known lastname 81431**] was thought to be in ARF from profound ATN in the
setting of shock. Urine output was minimal on admission with
normal bladder pressure, and she eventually became fully anuric.
The renal service followed her while in the hospital, and she
was started on CVVH. Blood pressures remained quite low weeks
into admission, requiring CVVH dependence. In the final [**12-3**]
weeks of her hospitalization the patient was able to tolerate 3
times weekly scheduled HD. A tunneled dialysis line was placed
by IR into the left IJ. She remains dependent on midodrine for
blood pressure elevation to allow significant filtration during
HD.
Hypernatremia: on [**12-29**] NA had risen to 152. This was felt to be
hypovolemic given inconsistant PO intake secondary to altered
mental status, ongoing diarrhea from lactulose, increasingly
aggressive diaylsis. A free water deficit was calculated to be
4L. With HD and 1 L D5W her NA improved to 144 on [**12-30**]. The
Sodium should be trended at rehabilitation.
THROMBOCYTOPENIA, ANEMIA:
Halfway through the admission, Ms. [**Known lastname 81431**] had progressive
thrombocytopenia with gradual decline in platelet counts from
143 ([**2123-12-7**]) to less than 5 ([**2123-12-17**]). She also had
persistently low Hct in the low 20's, refractory to transfusions
and without signs of overt bleeding. This was thought to be
multifactorial related to liver disease, acute illness causing
BM suppression, drugs (specifically zosyn & famotidine), and
auto-immune mediated destruction (Coombs positive, low
haptoglobin). The heme-onc service was following the patient.
A trial of IV solumedrol was begun on [**2123-12-17**] with gradual
improvement in platelet counts and stabilization of Hct. She
was eventually transitioned to a prolonged prednisone taper. Her
platelets were stable around 100 prior to discharge. She is to
follow up with hematology.
MENTAL STATUS: The patient had persistent altered mental status
during her hospitalization. This was felt potentially due to
multiple etiologies including hepatic encephalopathy,
toxic-metabolic encephalopathy (including potentially due to
markedly elevated T Bili), uremia (with BUN peak at >100),
sepsis and hypoxic brain injury. For a long period after
extubation, the patient was A&Ox1 to person only and was noted
to perseverate on the word 'forty-four thousand.' In the days
prior to discharge, the patient was at times more verbal,
speaking in full sentences. At best she is oriented to person
and place and still was waxing and [**Doctor Last Name 688**] levels of arousal and
orientation.
.
SACRAL DECUB: The patient has stage 3 sacral decubitus ulcers.
She was treated throughout her hospitalization by the wound care
nursing team. She requires ongoing care of these sites.
.
The [**Hospital 228**] health care proxy, [**Name (NI) **] [**Name (NI) 81432**] (h)
[**Telephone/Fax (1) 81433**], (w) [**2123**], (c) [**Telephone/Fax (1) 81434**] confirmed that
the patient is full code.
Medications on Admission:
Medications at home:
atenolol
Medications on transfer from OSH:
vancomycin po 250 mg Q6H started [**11-20**]
zosyn 2.25 grams Q6H started [**11-21**]
propofol gtt
levophed gtt
nadolol 40 mg daily
insulin sliding scale
lactulose [**Hospital1 **]
pantoprazole 40 mg [**Hospital1 **]
heparin sc 5000 units TID
TPN
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed: not to exceed 2 gm daily.
2. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day) as needed.
3. Nystatin 100,000 unit/g Cream [**Hospital1 **]: One (1) Appl Topical
5X/DAY (5 Times a Day) as needed.
4. Midodrine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day).
5. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID (3
times a day): titrate to 1 liter of stool daily .
6. Ciprofloxacin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H
(every 24 hours): for SBP ppx.
7. Rifaximin 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day).
8. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
11. Epoetin Alfa 4,000 unit/mL Solution [**Last Name (STitle) **]: Two (2) ml (8000
Units) Injection QMOWEFR (Monday -Wednesday-Friday).
12. Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
13. Ascorbic Acid 250 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO DAILY (Daily).
14. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO TID (3 times a day).
15. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) ml
(5000 Units) Injection TID (3 times a day).
16. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Ten (10) ML PO QID
(4 times a day) as needed for thrush.
17. Sevelamer HCl 400 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
18. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
20. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: 2-12 units
Injection ASDIR (AS DIRECTED): while on steroid taper.
21. Prednisone 10 mg Tablet [**Last Name (STitle) **]: 1-6 Tablets PO as directed: 6
pills on [**12-30**], then 5 pills qd for 5 days, then 4 pills daily
for 5 days, then 3 pills daily for 5 days, then 2 pills daily
for 5 days, then 1 pill daily for 5 days, then 0.5 pills daily
for 5 days.
Discharge Disposition:
Extended Care
Facility:
Radius [**Hospital 4094**] Rehab
Discharge Diagnosis:
Septic shock
Hepatic encephalopathy
shock liver
Thrombocytopenia, likely secondary to ITP
Subacute Renal faliure
Anemia
Alcoholic hepatitis
cirrohsis
Decubitis ulcers
Discharge Condition:
Stable, tolerating HD well.
Discharge Instructions:
You were admitted with multiple complex medical problems. [**Name (NI) **]
likely you had overwhelming infection. This led to significant
injury to your liver, kidneys, lungs and possibly brain. You
completed a course of antibiotics for the infection. You are
doing much better however you require ongoing care of multiple
issues.
.
You must follow-up with a liver specialist for ongoing care of
alcohol induced cirrhosis complicated by shock liver.
.
You must continue to receive hemodialysis 3 times weekly on
Monday, Wednesday and Friday.
.
Complete a taper of the steroid prednisone for treatment of low
platelets likely due to antibodies against your platelets,
called ITP. Follow-up with a hematologist to further discuss
this issue as well as your anemia or low numbers of red blood
cells.
.
You must receive wound care at the site of your sacral decubitus
ulcers or pressure sores on your back.
.
You will receive physical rehabilitation at a nursing facility.
.
Take all medications as prescribed.
.
Attend all follow-up appointments.
.
Call your doctor or return to the hospital for any new or
worsening fevers, chills, vomiting, diarrhea or any other
concerning symptoms.
Followup Instructions:
You will continue to receive dialysis, wound care and
rehabilitation through your nursing facility.
.
Hematology (low platelets and low red blood cells): Provider:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2124-1-28**] 10:30
.
Hepatology (liver): [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2124-3-15**] 11:00
.
Establish new primary care after you leave the nursing facility.
If you would like to be seen at [**Hospital1 1170**] please call [**Telephone/Fax (1) **] to schedule an appointment.
Completed by:[**2123-12-30**]
|
[
"041.4",
"585.5",
"570",
"789.59",
"599.0",
"707.23",
"283.9",
"038.11",
"276.0",
"571.1",
"482.41",
"571.2",
"348.1",
"287.31",
"995.92",
"518.81",
"572.2",
"584.5",
"452",
"785.52",
"556.6",
"560.1",
"403.91",
"707.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"96.72",
"39.95",
"38.95",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
16853, 16912
|
8489, 12684
|
393, 530
|
17123, 17153
|
4448, 4937
|
18384, 19072
|
3612, 3630
|
14141, 16830
|
16933, 17102
|
13804, 13804
|
17177, 18361
|
13825, 14118
|
3670, 4429
|
278, 355
|
558, 3298
|
4953, 8466
|
12699, 13778
|
3320, 3386
|
3402, 3596
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,275
| 176,548
|
43677
|
Discharge summary
|
report
|
Admission Date: [**2137-8-12**] Discharge Date: [**2137-8-14**]
Date of Birth: [**2078-11-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Carbamazepine
Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
SOB, HTN
Major Surgical or Invasive Procedure:
none
History of Present Illness:
58M with ESRD on HD, PVD, HCV c/b cirrhosis and ascites,
seizures with SOB worsening over past 24 hours. Yesterday the
patient noted increased fatigue. At around midnight, he was
lying down to go to bed and noted acute onset SOB that improved
with sitting up. Denies associated CP, N/V, diaphoresis, or
other symptoms. Was last dialyzed 3 days ago (scheduled again
for today) terminated early at 2kg over dry weight due to low
BPs. Has has noted increased LE edema recently primarily in his
right leg; also with worsening ascites s/p therapeutic
paracentesis 2 weeks prior. While in the ambulance, the patient
desated to 70% thought to be [**3-15**] flash pulm edema and improved
to 100% on NRB. Noted to be hypertensive with SBP 240s, HR 110s.
He was given nitro sl, and then started on BiPAP and nitro gtt.
Also hyperkalemic to 6.4 with ECG changes - given 5U IV insulin,
[**2-12**] amp D50, 1 amp Ca gluconate. Admitted to MICU for
hypertensive urgency and acute dialysis.
.
Currently feels much better, SOB resolved. Does complain of
bilateral finger numbness x 1 week. Otherwise [**Month/Day (2) **] negative for
fever, chills, headache, visual changes, weakness.
Past Medical History:
-Seizure disorder
-ESRD on HD (M,W,F) due to idiopathic glomerulonephritis, s/p 2
failed renal transplants
-labile hypertension
-hypothyroidism
-peripheral [**Month/Day (2) 1106**] disease
-hypoparathyroidism
-hepatitis C
-CHF-systolic w/ EF 45% and diastolic dysfunction (echo
[**12/2135**])
-SVT/AVNRT s/p ablation
-multiple fistulas
-H/O MRSA line infection
-Recent admission [**2136-2-29**] for infected L upper arm AV fistula.
-h/o mechanical falls admitted [**1-16**]
-h/o VRE, MRSA
Social History:
Lives at [**Hospital3 **] facility on Mission [**Doctor Last Name **] called
[**Hospital1 **] at
[**Hospital1 1426**], on disability, has two sons. smokes 1ppd x 40 yrs, no
etoh, drugs.
Family History:
Mother with breast CA; father alive with CAD & CHF; sons
healthy.
Physical Exam:
T 96.6 BP 194/110 HR 84 RR 20 SpO2 100% on BiPAP Wt 63.2kg
Gen: Chronically ill-appearing thin male
Skin: Warm, no rashes. Right chest wall HD line without
erythema.
HEENT: PERRL, anicteric, MM dry, +JVD
Lungs: Bilateral crackles lower [**2-12**] lung fields
Heart: RRR, s1s2 normal, no m/r/g
Abd: Soft, distended, NABS, +ascites
Extr: no cyanosis, RLE pitting edema without calf tenderness
Neuro: A&Ox3, speech clear, strength 5/5 bilat, sensation intact
to light touch, moves all extremities
.
Pertinent Results:
Admission labs:
[**2137-8-12**] 04:41PM GLUCOSE-98 UREA N-31* CREAT-3.2*# SODIUM-141
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-24 ANION GAP-16
[**2137-8-12**] 04:41PM CK(CPK)-42
[**2137-8-12**] 04:41PM CK-MB-NotDone cTropnT-0.10*
[**2137-8-12**] 04:41PM CALCIUM-7.3* PHOSPHATE-4.8* MAGNESIUM-1.7
[**2137-8-12**] 09:16AM TYPE-ART PEEP-4 PO2-454* PCO2-41 PH-7.45
TOTAL CO2-29 BASE XS-4 INTUBATED-NOT INTUBA
[**2137-8-12**] 08:51AM TYPE-[**Last Name (un) **] COMMENTS-SPEC NOT H
[**2137-8-12**] 08:51AM LACTATE-1.6 K+-6.2*
[**2137-8-12**] 08:45AM GLUCOSE-91 UREA N-77* CREAT-6.1*# SODIUM-136
POTASSIUM-6.4* CHLORIDE-92* TOTAL CO2-25 ANION GAP-25*
[**2137-8-12**] 08:45AM CK(CPK)-91
[**2137-8-12**] 08:45AM CK-MB-NotDone cTropnT-0.11*
[**2137-8-12**] 08:45AM WBC-7.9 RBC-3.86* HGB-10.9* HCT-31.0* MCV-80*
MCH-28.2 MCHC-35.1* RDW-19.6*
[**2137-8-12**] 08:45AM NEUTS-67.2 LYMPHS-20.9 MONOS-10.5 EOS-0.3
BASOS-1.2
[**2137-8-12**] 08:45AM PLT COUNT-344
[**2137-8-12**] 08:45AM PT-12.5 PTT-28.4 INR(PT)-1.1
UNILAT LOWER EXT VEINS RIGHT [**2137-8-12**] 12:52 PM
UNILAT LOWER EXT VEINS RIGHT
Reason: eval for DVT
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with Hcv cirrhosis and ESRD with asymetric LE
edema and SOB
REASON FOR THIS EXAMINATION:
eval for DVT
INDICATION: Right lower extremity edema.
RIGHT LOWER EXTREMITY ULTRASOUND: Normal compressibility, color
flow, and Doppler waveforms are seen in the deep venous system
from the common femoral vein to the popliteal.
IMPRESSION: No evidence of DVT in the right lower extremity.
CHEST (PORTABLE AP) [**2137-8-12**] 8:59 AM
Reason: eval for chf
[**Hospital 93**] MEDICAL CONDITION:
58 year old man with SOB
REASON FOR THIS EXAMINATION:
eval for chf
INDICATIONS: 58-year-old man with shortness of breath. Question
congestive heart failure.
CHEST, UPRIGHT AP PORTABLE: Comparison is made to [**2137-4-16**]. A
right internal jugular dialysis catheter terminates in the right
atrium, as before. There are perihilar alveolar opacities and
[**Year (4 digits) 1106**] engorgement with upper zone redistribution of pulmonary
vessels, consistent with moderate fluid overload or congestive
heart failure. Linear opacity in the right lower lobe is most
compatible with atelectasis. There are no definite effusions or
pneumothorax.
IMPRESSION: Moderate pulmonary edema which may be due to
congestive heart failure or fluid overload.
PARACENTESIS DIAG. OR THERAPEU; GUIDANCE FOR [**Female First Name (un) **]/ABD/PARA CE
Reason: therapeutic paracentesis x 6L. no albumin necessary
afterwar
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with Hcv cirrhosis and ESRD and cirrhosis,
ascites. loculated, scarred peritoneum with 2 xplanted kidneys
in situ. h/o of US guided [**Doctor First Name 4397**] in the past. difficult bedside
tap.
REASON FOR THIS EXAMINATION:
therapeutic paracentesis x 6L. no albumin necessary afterwards
INDICATION: Cirrhosis, ascites.
ULTRASOUND-GUIDED PARACENTESIS: Written and informed consent
were obtained. A preprocedure timeout was performed to confirm
patient, site, and procedure. Doctors [**Name5 (PTitle) 1022**] and [**Name5 (PTitle) 4401**] performed
this procedure, with Dr. [**Last Name (STitle) 4401**], the attending radiologist,
present and supervising throughout.
A suitable pocket of fluid was located in the left lower
quadrant. The area was prepped and draped in the usual sterile
fashion. Approximately 10 mL of 1% lidocaine were administered
for subcutaneous lidocaine. A 19 gauge [**Last Name (un) 11097**] catheter was
advanced into the abdomen, and 4 liters of fluid drained. The
patient tolerated the procedure well. There were no immediate
complications.
IMPRESSION: Successful ultrasound-guided paracentesis.
Brief Hospital Course:
A/P: 58M with ESRD on HD, PVD, HCV c/b cirrhosis and ascites,
seizure d/o presents with hypertensive urgency and acute onset
SOB likely from flash pulmonary edema.
.
# SOB: Flash pulm edema [**3-15**] hypertensive urgency in setting of
recent incomplete HD. Admitted to MICU after urgent dialysis
with 3.6L removed with continuing o2 requirement, and started
home anti-hypertensives and transiently on labetalol/nitro gtts
overnight. Had some BIPAP o/n as well and was quickly weaned to
NC. Cardiac enzymes x 2 flat and RLE ultrasound negative for
DVT. Weaned to RA and transferred to floor with stable blood
pressures. On floor pt's BP were stable and good. Recieved HD
on Wed morning, slightly high BP afterwards, but this quickly
resolved with restart of home meds. Pt. sent home on new,
higher nifedipine dose. Cont' HD TIW.
- Otherwise, volume management at HD per renal
.
# ESRD: MWF HD schedule. HD removed 7.5kg prior to call out to
floor. Renal following. Continue nephrocaps, sevelamer,
sensipar.
.
# Anemia: Chronic due to renal disease. Hct decreased on
admission without known active bleeding. Recheck showed no
further decrease in levels.
.
# Hyperkalemia: Noted to have ECG changes and given insulin,
D50, calcium; ECG changes resolved s/p HD and K+ normal.
Continued monitoring of electrolytes showed no further
alterations in levels.
.
# CHF: EF 45%. Systolic and diastolic dysfunction. Volume
overloaded, manage with HD per renal. Continued BB, ACEi.
.
# HTN: Restarted home anti-hypertensives (changed toprol XL to
metoprolol, nifedipine CR to nifedipine while inpatient). Weaned
nitro gtt especially in setting of HD to avoid hypotension.
Uptitrate nifedipine to 60mg q8h.
.
# HCV: Cirrhosis and ascites. Followed by Dr. [**Last Name (STitle) 497**] from Liver
as outpatient, liver team following this admission. Therapeutic
paracentesis x 4L by IR performed [**8-13**].
.
# PVD: s/p bilat common iliac stents. Continued plavix, aspirin.
.
# Epilepsy: Continued lamictal, keppra.
.
# PPx: PPI, bowel reg, heparin sc tid
# FEN: Renal diet, [**Hospital1 **] lytes for now
# Access: right HD catheter, PIV
# Code: DNR/DNI confirmed with patient
# Communication: [**Name (NI) 3640**] (son) [**Numeric Identifier 93894**]; [**Name (NI) **] (father)
[**Numeric Identifier 93895**]; [**Name (NI) **] (son) [**Numeric Identifier 93896**]
Medications on Admission:
Nephrocaps 1 daily
Lamictal 250 mg b.i.d.
Keppra 375 mg b.i.d. and 250 mg after each HD session (MWF)
Toprol-XL 200 mg once daily
Nifedipine 120 mg once daily
Lisinopril 20 mg once HS
Plavix 75 mg once daily
ASA 81 mg once daily
Clonidine 0.1 mg b.i.d.
Prevacid 30 mg once daily
Nortriptyline 10 mg q.h.s.
Sevelamer 800 mg tid
Cinacalcet 30 mg daily
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Numeric Identifier **]: One (1) Cap
PO DAILY (Daily).
2. Lamotrigine 100 mg Tablet [**Numeric Identifier **]: 2.5 Tablets PO BID (2 times a
day).
3. Nifedipine 10 mg Capsule [**Numeric Identifier **]: Six (6) Capsule PO Q8H (every 8
hours).
Disp:*540 Capsule(s)* Refills:*2*
4. Levetiracetam 250 mg Tablet [**Numeric Identifier **]: 1.5 Tablets PO BID (2 times
a day).
5. Metoprolol Tartrate 50 mg Tablet [**Numeric Identifier **]: Two (2) Tablet PO BID
(2 times a day).
6. Lisinopril 20 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO HS (at
bedtime).
7. Clopidogrel 75 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Chewable [**Numeric Identifier **]: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Clonidine 0.1 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO BID (2 times a
day). Tablet(s)
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Nortriptyline 10 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO HS (at
bedtime).
12. Cinacalcet 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
15. Levetiracetam 500 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO QHD (each
hemodialysis).
16. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
17. Ibuprofen 400 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8
hours) as needed.
18. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: Eight (8)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
19. Oxazepam 10 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO HS (at
bedtime) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Urgency
Flash Pulmonary Edema
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:
Followup Instructions:
Please go to Dialysis on [**Name8 (MD) 2974**]
Please see your PCP [**Name Initial (PRE) 176**] 3 days of discharge
|
[
"428.0",
"403.91",
"070.70",
"345.90",
"571.5",
"285.21",
"276.8",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"54.91",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11418, 11424
|
6640, 9001
|
327, 333
|
11511, 11518
|
2866, 2866
|
11685, 11804
|
2266, 2334
|
9402, 11395
|
5472, 5685
|
11445, 11490
|
9027, 9379
|
11542, 11662
|
2349, 2847
|
279, 289
|
5714, 6617
|
361, 1532
|
2882, 3996
|
1554, 2046
|
2062, 2250
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,443
| 199,628
|
19789
|
Discharge summary
|
report
|
Admission Date: [**2156-11-29**] Discharge Date: [**2156-12-16**]
Date of Birth: [**2128-3-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Haldol / Compazine / Desipramine / Chlorpromazine
/ Imipramine / Zoloft / Shellfish Derived
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
PICC line placement under IR guidance
Transesophageal echocardiography
Intubation x 2
History of Present Illness:
HPI: 28F morbidly obese female with h/o of DVT/PE on coumadin
presenting with chest pain. Pt states that the pain began day
before yesterday. She describes it as the same pain as his PE
but worse. States that the pain came on suddenly has been
constant and severe, a [**10-20**]. She states that the pain radiates
to both arms, her neck and her lungs. She describes it as a
sharp pain. Pt also notes that she feels wheezy. She last took
her advair yesterday morning and she said that it did not help.
Prior to admission she has been in radius Rehab for 3 days and
before that at [**Hospital1 2177**] for 5 days for MRSA bacteremia.
In the ED, 99.9 123 145/88 22 93% RA. Pt received SL NTG x3 and
4mg IV morphine x2 and IV dilaudid x1, and was started on
heparin gtt. D-Dimer negative, first set of cardiac enzymes
negative, and CTA negative for PE but suboptimal study. EKG
showed sinus tach with subtle changes in V3 and V4.
Review of outside hospital records revealed:
Ms. [**Known lastname **] has experienced multiple admissions to Caritas [**Hospital 28941**], [**Hospital6 **], [**University/College 53476**] Hospital and
[**Hospital6 2752**]. What follows below is my best attempt
at a summary of the data from discharge summaries and cultures
received from the various institutions. Segments of this
information will be repeated in her discharge summary.
[**8-20**]- [**8-23**] Admitted to Caritas [**Hospital3 **] for Dyspnea no
Abx/BCx reported
[**Date range (1) 53477**] Admitted to Caritas [**Hospital3 **] for PICC related
bacteremia. No indication of when PICC was placed initially.
"Power PICC" placed on discharge for Vanc therapy 1g Q12 to end
[**2156-10-23**]
[**10-3**] Wound Cx: Light skin flora
[**10-4**] Wound Cx: Skin flora
[**10-4**] MRSA screen "present"
[**10-7**] UCx: >100,000 CFU/mL mixed perineal flora
[**10-8**] BCx: NGTD
[**10-9**] BCx: Staph Epidermidis: [**Last Name (un) **]: Levoflox, Tetra, Vanc, Dapto,
Rif
[**10-10**] UCx: [**Female First Name (un) 564**] & mixed perineal flora
[**10-10**] BCx: NGTD
[**10-10**] BCx: Staph Hominis: [**Last Name (un) **]: Levoflox, Tetra, Vanc, Dapto, Rif
[**10-12**] BCx: NGTD
[**10-14**] BCx: NGTD
[**Date range (1) 41321**]: Admitted to Caritas [**Hospital3 **] for Chest pain ruled
to be DVT of R subclavian, brachial veins & PE. No mention of
Vanc or PICC line.
[**Date range (1) 53478**]: Admitted for Chest Pain, PE "improved" on CTA from
prior admission. RUE PICC line mentioned in PCP [**Name Initial (PRE) **]
[**11-6**]: MRSA Screen neg
[**11-7**]: VRE Present
[**11-10**]: BCx: NGTD
[**Date range (1) 3927**]: Admitted to Caritas for RUE with MRSA PICC
Bacteremia.
[**11-16**]: Staph Hemo: [**Last Name (un) **]: Clinda, Linezolid, Tet, vanc, Dap, Rif
MRSA: [**Last Name (un) **]: Linezolid, Tet, vanc, Dap, Rif
[**11-16**]: BCx: Staph H & MRSA [**Last Name (un) **]: Levoflox, Tetra, Vanc, Dapto,
Rif
[**11-17**]: BCx: Staph H & MRSA [**Last Name (un) **]: Levoflox, Tetra, Vanc, Dapto,
Rif
[**11-23**]: PICC Cx: MRSA & Staph Hemo
[**Date range (1) 53479**]: Admitted to [**Hospital3 **] for Chest Pain ruled
to be Costochondritis after no EKG changes or Enzymes changes
from [**Hospital3 **] (reports not available)
No Culture Data
Transferred to [**Hospital1 2177**]
[**Date range (1) 40096**]: Transferred to [**Hospital1 2177**] at patients request for
chestpain & port placement?
PICC removed and replaced for Vancomycin 1g IV BID to end on
[**9-14**], [**1-7**] at various points in the chart.
All records available on chart in "OSH records"
[**11-25**]: BCx: Coag Negative Staph: [**Last Name (un) **]: Levoflox, Tetra, Vanc,
Dapto, Rif
Past Medical History:
Bipolar disorder
COPD - Asthma
Obesity
Depression
Suicidal ideation and multiple attempts in the past on [**2156-12-10**]
MRSA cellulitis
PNA
Bacteremia
Urinary Incontinence
PE/DVTs
Self-mutilation
Social History:
Only child, raised by IV drug addict, physically abusive parents
until age 8 when taken into DSS custody. States she was "mad at
the world" and set fires. Was psychiatrically hospitalized and
grew up between [**Doctor Last Name **] homes, residential
facilities, and inpatient psychiatric hospitals. Remained
institutionalized in various settings including years in
intermediate care at [**Hospital6 4331**]. One year ago,
tried it on her own and describes struggling since being outside
of a group home or other institutionalized setting.
Of note, anniversary of mother's death is [**12-10**] and
anniversary of father's death is [**8-13**]. She generally
psychiatrically decompensates and becomes suicidal on these
dates.
Family History:
Parents deceased; otherwise noncontributory
Physical Exam:
Vitals 99.0 124/69 88 22 95%RA
GEN: Morbidly Obese, Hirsutism, NAD
HEENT: NC, AT, MMM, EOMI
NECK: Obese, unable to assess JVP
RESP: Difficult to assess breath sounds [**3-13**] body habitus, +
wheezes, otherwise clear
CV: Difficult to assess [**3-13**] body habitus, RRR.
ABD: soft, diffusely mildly tender, obese, BS+
EXT: no edema, WWP
SKIN: candidal rash in right groin
Pertinent Results:
Admission Labs:
[**2156-11-28**] 09:55PM BLOOD WBC-15.3*# RBC-4.18* Hgb-11.9* Hct-37.5
MCV-90# MCH-28.4 MCHC-31.7 RDW-16.0* Plt Ct-439
[**2156-11-28**] 09:55PM BLOOD Neuts-90.8* Lymphs-7.6* Monos-1.2*
Eos-0.3 Baso-0.1
[**2156-11-28**] 09:55PM BLOOD PT-18.9* PTT-18.6* INR(PT)-1.7*
[**2156-11-28**] 09:55PM BLOOD D-Dimer-237
[**2156-11-28**] 09:55PM BLOOD Glucose-217* UreaN-15 Creat-0.8 Na-140
K-4.9 Cl-97 HCO3-35*
[**2156-11-28**] 09:55PM BLOOD CK(CPK)-29
[**2156-11-29**] 06:50AM BLOOD ALT-7 AST-8 LD(LDH)-173 CK(CPK)-16*
AlkPhos-59 Amylase-33 TotBili-0.1
[**2156-11-29**] 06:50AM BLOOD Lipase-19
[**2156-11-28**] 09:55PM BLOOD cTropnT-<0.01
[**2156-11-29**] 06:50AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2156-11-30**] 06:52PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2156-11-29**] 06:50AM BLOOD Albumin-3.3* Calcium-9.2 Phos-4.5 Mg-2.3
Cholest-213*
[**2156-11-29**] 06:50AM BLOOD %HbA1c-6.5*
[**2156-11-29**] 06:50AM BLOOD Triglyc-202* HDL-84 CHOL/HD-2.5
LDLcalc-89
[**2156-12-2**] 08:59AM BLOOD Prolact-78*
[**2156-11-29**] 06:50AM BLOOD CRP-25.8*
[**2156-12-2**] 08:59AM BLOOD Lithium-0.5 Valproa-34*
[**2156-12-9**] 03:27PM BLOOD Lithium-0.3* Valproa-94
GRAM STAIN (Final [**2156-11-30**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
FLUID CULTURE (Final [**2156-12-6**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**8-/2454**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.
SECOND STRAIN.
Please contact the Microbiology Laboratory ([**8-/2454**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
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
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 4 R =>8 R
OXACILLIN------------- =>4 R =>4 R
PENICILLIN G---------- 0.25 R =>0.5 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
VANCOMYCIN------------ 2 S <=1 S
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2156-12-8**]):
Feces negative for C.difficile toxin A & B by EIA.
Discharge Labs:
[**2156-12-16**] 03:44AM BLOOD WBC-5.5 RBC-3.01* Hgb-8.4* Hct-26.4*
MCV-88 MCH-28.0 MCHC-31.9 RDW-16.6* Plt Ct-363
[**2156-12-16**] 03:44AM BLOOD PT-32.3* PTT-31.4 INR(PT)-3.4*
[**2156-12-16**] 03:44AM BLOOD Glucose-112* UreaN-7 Creat-0.5 Na-145
K-3.5 Cl-101 HCO3-36* AnGap-12
[**2156-12-16**] 03:44AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.8
[**2156-12-14**] 09:50PM BLOOD Type-ART FiO2-40 pO2-84* pCO2-62* pH-7.40
calTCO2-40* Base XS-10 Intubat-INTUBATED
[**2156-12-14**] 11:19AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2156-12-14**] 11:19AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5
Leuks-NEGTEE [**12-3**]: No valvular disease
Studies:
EKG: Sinus rhythm. Normal tracing. Compared to the previous
tracing the rate is slower.
[**2156-11-28**] CTA chest - IMPRESSION:
1. No central or segmental pulmonary embolism.
2. No aortic dissection.
[**2156-11-30**] TTE - The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is dilated but function appears preserved. The aortic
valve leaflets appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is moderate pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Technically suboptimal to exclude focal wall
motion abnormality. Moderate pulmonary hypertension. No obvious
valvular vegetations seen but technically suboptimal to exclude
endocarditis. If clinically indicated, a TEE would better assess
for vegetations.
[**2156-11-30**] Abdominal Ultrasound - IMPRESSION:
1. Markedly limited study due to patient body habitus.
2. Fatty infiltration of the liver, fibrosis, and/or cirrhosis,
with no focal liver lesions.
3. No explanation for abdominal pain.
4. Ill-defined density in the upper third of the right kidney,
for which
further imaging is recommended.
[**2156-12-1**] CT abdomen & pelvis with contrast - IMPRESSION:
No acute intra-abdominal pathology to explain patient's chest
pain.
[**2156-12-3**] TEE - The left atrium is normal in size. No spontaneous
echo contrast or thrombus is seen in the body of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. A small color Doppler signal
(#50) is seen c/w a small secundum type atrial septal defect
with left-to-right shunt flow. Overall left ventricular systolic
function is normal. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 45 cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.
IMPRESSION: No valvular pathology identified. Small secundum
type atrial septal defect.
[**2156-12-3**] Right hand x-rays:
IMPRESSION: No acute fracture or dislocation. Slight osseous
prominence at
fourth digit proximal phalanx may be the sequelae of old trauma.
[**2156-12-6**] CT abdomen & pelvis without contrast - IMPRESSION:
1. No evidence of retroperitoneal hemorrhage.
2. Mild, focal, ascending colon bowel wall thickening and
peri-colonic fat
stranding consistent with colitis. Differential includes
infectious or
inflammatory causes; correlation with antibiotic history would
also be
helpful.
[**2156-12-6**] Right hand x-ray - There are no signs for acute
fractures or dislocation. Some slight flexion deformity of the
right fourth DIP joint, however no acute fractures identified.
There is a prominence of soft tissues due to the patient's body
habitus.
[**2156-12-14**] CT head without contrast - IMPRESSION: No acute
intracranial pathology including no hemorrhage.
[**2156-12-15**] EEG - FINDINGS:
ABNORMALITY #1: Throughout the recording the background rhythm
was a
[**1-24**] Hz rapid pattern with an anterior predominance but
generalized
distribution.
ABNORMALITY #2: There were frequent bursts of generalized delta
slowing.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Abnormal portable EEG due to the widespread,
relatively
uniform alpha-beta frequencies in the background and due to the
bursts
of generalized slowing. These findings suggest a widespread
encephalopathy. The faster frequencies seen without the usual
posterior
predominance are very suggestive of medication effect. There
were no
areas of prominent focal slowing, and there were no epileptiform
features.
Brief Hospital Course:
28 year old morbidly obese lady with psychiatric & medical
problems presenting with chest pain of indeterminate etiology
and recent bacteremia. PE and ischemia were ruled out as causes
of her chest pain, however, her hospital course was complicated
by an episode of hypercarbic respiratory failure and an episode
of respiratory alkalemia, both requiring intubation.
Chest Pain: The patient complained of [**2158-7-18**] chest pain
throughout her hospital stay. A thorough history and physical
exam, EKG, Cardiac Enzymes, Echocardiogaphy (TTE & TEE), breast
discharge cultures, blood cultures, chest x-rays, CT scan,
Abdominal ultrasound and CT failed to discover an organic
etiology of her pain. Her pain was relieved temporarily on
Morphine & acetaminophen, but the patient declined these
medications. A comprehensive review of outside hospital records
from [**Hospital3 **], Caritas [**Hospital3 **], Caritas [**Hospital 28941**], and [**Hospital6 **] indicated that the patient has
chronically complained of unexplained chest pain in the past 6
months. Given her history of upper extremity DVTs we maintained
her on a heparin drip until her INR returned to the therapeutic
range. No evidence of DVT was found via D-dimer or on CT scan.
We were unable to conclusively diagnose or medically treat her
pain on this admission.
Bacteremia: The patient was admitted with a L PICC line in
place for Vancomycin therapy for MRSA bacteremia from [**Hospital **] per her report. Her PICC line could not verified
on CXR, so it was removed, tip cultured and replaced under IR
guidance. Outside records from several hospitals were obtained
indicating a recent history of PICC line infections resulting in
bacteremia. Her blood cultures remained negative while
admitted. Infectious disease was consulted and recommended TEE
to exclude endocarditis. Upon exclusion of endocarditis, the
patient was continued on Vancomycin until [**2156-12-6**] and the
patient's PICC line was removed.
History of PE: The patient has a history of upper extremity DVTs
leading to PE. She was continued on heparin while her INR
became therapeutic between [**3-14**]. Negative D-Dimer and CTA
excluded PE at this time.
Bipolar Disorder/Borderline Personality Disorder: Psychiatry
was consulted to assist in the managment of the patient's
psychiatric medication. Through communications with her outside
psychiatrist, it was determined that the patient would be
tapered off of Lithium given her polyuria/incontinence. In
addition, while evaluating a scant breast discharge, it was
discovered that the patient was hyperprolactinemic. Her
risperdal was stopped and she was converted to Abilify.
Asthma: The patient had a history of Asthma. She had received
one dose of prednisone taper from [**Hospital1 2177**] before admission to [**Hospital1 18**].
This was not continued given her recent bacteremia. She was
maintained on Advair & Atrovent as needed. Her respiratory
status remained stable.
R 4th digit dislocation: Patient dislocated 4th digit when
trying to sit up in bed. A hand x-ray confirmed dislocation.
Patient was seen by plastic surgery who reduced and splinted her
with an ulnar gutter splint. The cast should stay on until the
patient sees them for follow-up in hand clinic two weeks after
the splint was placed. She has an appointment scheduled with
them.
MICU Course:
The patient was transfered to the MICU on [**2156-12-9**] after
becoming hypoxic, acidotic, and hypercarbic in the setting of
being more somnolent after refusing CPAP at night. A
respiratory code was called and she was intubated on the floor
and brought to the ICU. She was extubated on [**2156-12-10**]. She
maintained good O2 sats throughout the night of [**12-10**] while
wearing CPAP, but desatted the following morning to the mid 70s
when refusing to wear her CPAP. She was called out the floor
the evening of [**12-11**], but returned to the ICU after becoming
agitated and refusing to use CPAP at night. The patient was
placed on 2L NC with pulse oximetry monitoring. She maintained
O2 sats in the mid to upper 80s for most of the night, but
desatted to the low 70s again and CPAP was placed on her face
while she continued sleeping. She maintained O2 sats in the low
to mid 90s while on CPAP.
On the evening of [**2156-12-14**] the patient was nonresponsive to
sternal rub despite O2 sats >98% and being on CPAP. Her eyes
were deviated downward and an ABG revealed a respiratory
alkalosis. The patient was reintubated and her blood gases
normalized. She had a head CT that showed no intranial bleeding
or acute abnormality. The following day she was extubated and
had an EEG, given concern for seizure activity. No epileptiform
activity was noted on EEG. Neurology was consulted and felt
that the patient had not had a seizure, though she did have some
clonus on exam. Ultimately, it was felt that this episode of
unresponsiveness may have been medication related, though
seizure could not be definitively excluded.
To maintain her oxygen saturation and prevent hypercarbia, the
patient must wear BiPAP or CPAP mask while sleeping. She
intermittantly refused this and had to be continually encouraged
to wear it. Her settings on discharge with a nasal BiPAP mask
were inspiratory pressure 16, expiratory pressure 6 with 12 L O2
to keep O2 sats >88%.
Throughout her MICU stay, psychiatry continued to follow the
patient in consultation to assist with adjusting her psychiatric
medications and guiding the psychosocial aspects of her care.
Given her two incidents of unresponsiveness (one hypercarbic and
the other respiratory alkalosis) they recommended decreasing her
abilify from 20 mg to 15 mg on discharge. They also recommended
crushing her medications and doing mouth checks given the
patient's history of stockpiling medications and a lingering
question of whether taking extra medications may have
contributed to one or more of her epidoes of unresponsiveness.
The patient has had a number of different outpatient
psychiatrists involved in her care and it has been awhile since
she has seen Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**] ([**Telephone/Fax (1) 53480**]). She would
benefit from having a single provider following her care.
Medications on Admission:
Albuterol q4h prn
Colace
Senokot
MVI
Oscal [**Telephone/Fax (1) 53481**] mg daily
Nexium 40mg daily
Ditropan 5mg tid
Atrovent Neb q4h prn
Advair 500/50 [**Hospital1 **]
Depakote 2000mg qhs
Risperdal 3mg qhs
Celexa 60mg daily per rehab (80mg per pt)
Lithium 450mg tid
Coumadin
Prednisone - one time dose 50mg at 9am [**11-28**]
Vancomycin 1gm at 1400
Coumadin 5mg daily
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Ropinirole 1 mg Tablet Sig: 1.5 Tablets PO QPM (once a day
(in the evening)).
10. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
13. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
14. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for agitation.
15. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO once a day.
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
17. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
18. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS
(at bedtime) for 5 days.
19. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
20. Valproic Acid 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours).
21. Albuterol 90 mcg/Actuation Aerosol Sig: [**2-11**] Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
22. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Please hold on [**2156-12-16**] and monitor INR before resuming this
medication.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnoses:
1) Bipolar disorder
2) Borderline personality disorder
3) MRSA Bacteremia
4) Hypercarbic respiratory failure
5) Respiratory alkalosis
6) Right phalangeal dislocation, s/p reduction & splinting
Secondary Diagnoses:
1) Hyperprolactinemia
2) Hypertension
3) History of DVTs
Discharge Condition:
Stable, maintains O2 sats >88% on room air while awake, requires
supplemental O2 by BiPAP or CPAP while sleeping. Intermittantly
refuses medication, labs, and O2 therapy.
Discharge Instructions:
You have been admitted to the hospital with chest pain and for a
blood infection. We performed extensive testing but were unable
to determine a cause for your chest pain. While you were here,
we continued your treatment for a blood bacterial infection and
determined that it did not enter your heart. Your infection
cleared and antibiotics were stopped.
You were transfered to the ICU for an episode of
unresponsiveness due to too much CO2 in your blood. You need to
wear a CPAP or BiPAP mask while you sleep to prevent this from
occuring again.
Please take your medications as prescribed.
Please call your doctor for any concerning medical symptoms.
Followup Instructions:
Please attend the following appointments regarding your right
hand splint and plan to arrive at the [**Hospital Ward Name 23**] building, [**Location (un) 17879**] at 8:10 am on [**2156-12-21**].
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2156-12-21**] 8:10
Provider: [**Name10 (NameIs) **] CLINIC Phone:[**Telephone/Fax (1) 3009**] Date/Time:[**2156-12-21**] 8:30
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5138, 5183
|
20849, 22999
|
23058, 23271
|
20456, 20826
|
23570, 24229
|
8941, 14126
|
5198, 5573
|
23292, 23351
|
329, 341
|
495, 4146
|
5608, 8925
|
4168, 4368
|
4384, 5122
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,219
| 185,090
|
33453
|
Discharge summary
|
report
|
Admission Date: [**2168-5-23**] Discharge Date: [**2168-6-3**]
Date of Birth: [**2101-1-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Left Upper Lobe Mass
Major Surgical or Invasive Procedure:
[**2168-5-23**] Flexible Bronchoscopy, left thoracotomy, mediastinal
lymph node dissection, left pneumonectomy, chest wall
reconstruction with [**Doctor Last Name **]-tex dual mesh
[**2168-5-24**] Oropharyngeal Videofluoroscopic Evaluation
[**2168-5-25**] Laryngoscopy with vocal cord injection with gelfoam
[**2168-5-31**] Oropharyngeal Videfluoroscopy
History of Present Illness:
Mr. [**Known lastname **] is a 67 year-old male with a history of a left lung
lesion. After
discussion with the patient and review of his preoperative
imaging, the patient had undergone mediastinoscopy at an outside
center. The mediastinoscopy had been negative, and as such, the
patient was deemed to be a surgical candidate.
Past Medical History:
DM (diet controlled)
CAD (EF 56%, norm perfusion), s/p MI, HTN,
PSH: appy, tonsils
Social History:
Non-contributory
Family History:
Non-contributory
Physical Exam:
General: no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck; supple, no lymphadenopathy
Card: RRR, normal S1S2 no murmur/gallop or rub
Resp: decreased breath sounds
GI: positive bowel sounds, abdomen soft non-tender/non-distended
Extr: warm no edema
Incision: L thoracotomy site clean/dry/intact, with steri-strips
Neuro: non-focal
Pertinent Results:
[**2168-6-1**] WBC-4.7 RBC-3.56* Hgb-10.2* Hct-30.6 Plt Ct-487*
[**2168-5-23**] WBC-9.0 RBC-4.60 Hgb-12.8* Hct-37.5 Plt Ct-624*
[**2168-6-1**] Glucose-88 UreaN-20 Creat-0.8 Na-141 K-3.8 Cl-108
HCO3-25
04/14/0 Glucose-158* UreaN-19 Creat-0.9 Na-134 K-6.1* Cl-102
HCO3-22
CHEST (PA & LAT) [**2168-5-31**]
FRONTAL AND LATERAL CHEST RADIOGRAPHS: No significant change is
seen compared to prior study. Left-sided subclavian central
venous line again seen with tip at the cavoatrial junction.
Surgical clips again seen at the mediastinum. There are
persistent postoperative changes consistent with left
pneumonectomy, with persistent left hydropneumothorax, similar
in appearance compared to prior study. Mild blunting of the
right costophrenic angle consistent with small pleural effusion
is also unchanged.
VIDEO OROPHARYNGEAL SWALLOW [**2168-5-31**]
ORAL PHASE: There is moderate reduction in bolus formation,
bolus control, and anterior-to-posterior tongue movement. There
was moderate impairment in the base of the tongue retraction.
Moderate oral residue was noted after the swallow. No premature
spillover was seen in the pharynx.
PHARYNGEAL PHASE: The pharyngeal swallow was timely. There is
moderate reduction in laryngeal elevation and valve closure.
Epiglottic deflection was severely reduced. A moderate-to-severe
amount of residue remained in the vallecula, and a mild amount
of residue remained in the piriform sinuses after the swallow.
ASPIRATION/PENETRATION: There was penetration during the swallow
with thin liquids via straw sips. Aspiration occurred after the
swallow with thin- and thick-nectar liquids due to residue
falling from the laryngeal vestibule into the airway. Aspiration
was silent (without coughing). A cued cough was not effective in
clearing the aspirated material.
IMPRESSION:
1. Aspiration of thin liquids after the swallow with straw sips.
2. Cued cough was ineffective in clearing the aspirated
material.
3. No aspiration with nectar-thick liquid when
swallow-cough-swallow technique was performed.
Brief Hospital Course:
Mr. [**Known lastname **] is who was admitted on [**2168-5-23**] and underwent
successful Left thoracotomy, left pneumonectomy with en bloc
chest wall resection (third rib); mediastinal lymph node
dissection, flexible bronchoscopy. He was extubated in the
operating room and transferred to the SICU for close monitoring.
His pain was managed with a Dilaudid Epidural managed by the
acute pain service. He had a pen-rose drain , foley and NG tube
in place. On POD #1 he was seen by ENT for his vagal resection
and found to have a left vocal fold paresis. He was seen by
Speech and Swallow and found to have moderate to severe
oropharyngeal dysphagia with aspiration of small amounts of all
consistencies. On POD #2 underwent Left true vocal fold Gelfoam
therapeutic injection. On POD #3 he was transfused with 1 unit
PRBC to a Hct of 30, a Dobbhoff feeding tube was placed and tube
feeds were started per Nutrition recommendations. On POD #5 he
developed atrial fibrillation with a RVR and was started on IV
amiodarone converted to sinus rhythm within 24 hours. On POD #6
he continued to remain hemodynamically stable and transferred to
the floor. His epidural was converted to Dilaudid PCA with good
pain control. The foley was removed and he voided without
difficulty. On POD #8 a repeat video-swallow was performed and
he aspirated with thin liquids. Speech recommended ground with
nectar thick and supervision feeds which was started and he
tolerated. Follow-up Video-swallow in [**8-18**] days. He was seen by
physical therapy. He was seen by ENT who recommended follow-up
in weeks. On POD #10 he was restarted on his home medication
and PO pain meds. He continued to make steady progress his
oxygen saturation remained 93% on room air while ambulating and
was discharged to rehab. He will follow-up with Dr. [**Last Name (STitle) **], Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) 77594**] as an outpatient.
Medications on Admission:
Allopurinol 300 daily, Atenolol 100 daily, Lasix 40 daily,
Lisinopril 40 daily, Nifedipine 60 daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ML PO BID (2
times a day).
Disp:*60 * Refills:*0*
3. Insulin Sliding Scale
Regular insulin sliding scale
4. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
5. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily):
Crush give with puree food.
6. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily): crush give with puree.
7. Hydromorphone 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q3H (every 3
hours) as needed: crush give with puree.
8. Allopurinol 300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day:
crush give with puree.
9. Atrovent HFA 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 puffs
Inhalation every 6-8 hours as needed for shortness of breath or
wheezing.
10. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 puffs Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO BID (2
times a day): hold HR < 60 SBP < 100
Crush & give in puree.
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
Left Upper Lobe Squamous Cell Carcinoma
Hypertension
Coronary Artery Disease s/p MI
Diabetes Mellitus Type II
Smoker
Tonsillectomy, appy
Discharge Condition:
Stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experince:
-Temp greater than 101
-Increased shortness of breath, cough
-Chest pain
-Incision develops drainage or increased redness
Steri-strips remove in 10 days or sooner if start to peel off
-Keep Head of Bed elevated > 30 degress at all times
You may shower: no bathing or swimming for 6 weeks
Follow-up with cardiology for amiodarone dosing.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] on [**2169-6-16**] at 9:30am on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
Report to the [**Location (un) **] Radiology Department for a Chest X-Ray
45 minutes before your appointment.
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 41**] on [**2168-6-16**] 11:45am at
[**Last Name (NamePattern1) **], [**Hospital 2577**] Medical Building [**Location (un) **].
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 24862**] [**Telephone/Fax (1) 64296**]
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] cardiology in 2 months call
for an appointment [**Telephone/Fax (1) 902**] on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**]
Clinical Center
Completed by:[**2168-6-3**]
|
[
"414.01",
"285.9",
"305.1",
"162.8",
"427.1",
"401.9",
"787.22",
"250.00",
"427.31",
"478.32",
"198.89",
"490",
"196.1",
"197.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.08",
"34.4",
"99.04",
"33.22",
"99.15",
"34.79",
"31.42",
"38.93",
"31.0",
"40.3",
"32.49",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
7399, 7458
|
3679, 5623
|
341, 697
|
7639, 7648
|
1616, 3656
|
8119, 8990
|
1212, 1230
|
5773, 7376
|
7479, 7618
|
5649, 5750
|
7672, 8096
|
1245, 1597
|
281, 303
|
725, 1055
|
1077, 1162
|
1178, 1196
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,425
| 172,779
|
41066
|
Discharge summary
|
report
|
Admission Date: [**2112-2-5**] Discharge Date: [**2112-2-15**]
Date of Birth: [**2043-8-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2-5**] Cardiac cath
[**2-8**] Urgent coronary artery bypass grafting x3 -- left internal
mammary artery to left anterior descending artery and saphenous
vein graft to obtuse marginal and posterior descending arteries
[**2-9**] Re-exploration for bleeding following coronary artery bypass
grafting
History of Present Illness:
68 male with history of myocardial infarction in [**2084**] with
progressive chest pain and abnormal stress test, which was
limited due to pain. He underwent cath today which revealed 90%
left main disease and 2 vessel CAD. IABP was placed and cardiac
surgery consultation was requested.
Past Medical History:
Hypertension
Diabetes
Fatty Liver
Myocardial Infarction
Loss vision in left eye in [**2062**] (while in service)
s/p cholecystectomy
Social History:
Race: Caucasian
Last Dental Exam: years
Lives with: son and daughter, active -bowls 3x/week, avid
walker
Occupation: retired machinest
Tobacco: current
ETOH: quit yrs. ago
Family History:
Mother had DM and hypertension.
Physical Exam:
Pulse: 81SR Resp: 16 O2 sat: 93% nc
B/P Right: Left: 105/47
Height: 5'9" Weight: 101.6kg
General: NAD, lethargic, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [] left pupil fixed/dilated, right
round/reactive
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema none
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: IABP Left: 2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2112-2-5**] CATH: 1. Selective coronary angiography of this right
dominant system revealed 3-vessel coronary artery disease. The
RCA was occluded proximally and filled via left to right
collaterals. The LMCA had a 90% distal vessel stenois given rise
to an LAD with poststenotic aneurysmal dilatation. The mid and
distal LAD were free of angiographically significant disease and
were good targets for surgical bypass. The LCx was free of
angiographically significant disease and also was a good target
for surgical bypass. 2. Limited resting hemodynamics
demonstrated elevated left ventricular filling pressures with an
LVEDP of 19mmHg. Systemic arterial systolic pressure was
borderline at 91mmHg.
[**2112-2-8**] Carotid U/S: Plaque at the carotid bifurcations on both
sides, predominantly involving the proximal internal carotid
arteries, slightly worse on the left. No hemodynamically
significant stenoses on the right with a mild 40-59% stenosis in
the proximal left internal carotid artery. Flow in the
vertebrals is prograde.
[**2112-2-8**] Echo: Pre-CPB: No spontaneous echo contrast is seen in
the left atrial appendage. Overall left ventricular systolic
function is normal (LVEF>55%). with mild global free wall
hypokinesis. There are simple atheroma in the descending
thoracic aorta. There is an IABP in the proximal descending
aorta 3 cm beyond the left subclavian artery. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
Post-CPB: The patient is A-Paced on no inotropes. Normal
biventricular systolic fxn. No MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact.
[**2112-2-15**] 06:05AM BLOOD WBC-15.1* RBC-3.64* Hgb-10.7* Hct-31.8*
MCV-87 MCH-29.4 MCHC-33.6 RDW-15.8* Plt Ct-332
[**2112-2-5**] 10:25AM BLOOD WBC-14.1* RBC-5.22 Hgb-16.7 Hct-45.6
MCV-87 MCH-32.0 MCHC-36.6* RDW-12.7 Plt Ct-240
[**2112-2-15**] 06:05AM BLOOD UreaN-20 Creat-1.0 Na-136 K-4.0 Cl-102
[**2112-2-5**] 01:09PM BLOOD Glucose-135* UreaN-14 Creat-0.8 Na-136
K-3.7 Cl-105 HCO3-22 AnGap-13
[**2112-2-9**] 06:01AM BLOOD ALT-28 AST-44* LD(LDH)-245 AlkPhos-23*
TotBili-0.7
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 16844**] is a 68 year old gentleman
with remote history of CAD (s/p MI in [**2084**]), hypertension,
dyslipidemia and diabetes, on Plavix, who presented for elective
cath after positive ETT and was found to have significant three
vessel coronary disease (left main and an occluded RCA). A
balloon pump was placed and the patient was admitted to the CCU
awaiting CABG by Cardiac Surgery. He underwent usual
pre-operative work-up, including Carotid U/S. Plavix was allowed
to wash out several days while receiving medical management
(including Heparin) and on [**2-8**] 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. Post-op he had progressively worsening
bleeding from his chest tubes. Despite receiving multiple blood
products his bleeding didn't slow down. His HCT dropped and
chest x-ray showed a significant hemothorax. He therefore was
brought back to the operating room on post-op day one for
mediastinal exploration. No specific bleeding was found. His
chest was washed out and he was transferred back to the CVICU.
His IABP was removed on post-op day one. On post-op day two he
was weaned from sedation, awoke neurologically intact and
extubated. Beta-blockers and diuretics were started and he was
gently diuresed towards his pre-op weight. Chest tubes and
epicardial pacing wires were removed per protocol.
Beta-blockade/Statin/and diuresis was initiated. On post-op day
four he was transferred to the telemetry floor for further care.
On post-op day six he required re-insertion of Foley catheter
due to urinary retention. Flomax was started. Physical Therapy
was consulted for evaluation of strength and mobility. The
remainder of his postoperative course was essentially
uneventful. He continued to progress and on POD# 7 he was
cleared by Dr.[**First Name (STitle) **] for discharge to TCU at [**Hospital 1474**] Hospital
for further recovery of strength and mobility. All follow up
appointments were advised.
Medications on Admission:
1. Metformin 850 mg
2. Plavix 75 mg daily
3. Aspirin 81 mg qdaily
4. Simvastatin 80mg qHS
5. Atenolol 100 mg qdaily
6. Vitamin E 800 IU qdaily
7. Vitamin D 3 300 units qdaily
8. Lisinopril 5mg daily
9. Glipizide 5mg [**Hospital1 **] before meals
Discharge Medications:
1. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
6. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. metformin 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
15. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1474**] Hospital TCU - [**Hospital1 1474**]
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft x 3
Past medical history:
Hypertension
Diabetes
Fatty Liver
Myocardial Infarction
Loss vision in left eye in [**2062**] (while in service)
s/p cholecystectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Surgeon: Dr. [**First Name (STitle) **] on [**2112-3-7**] on 1:45pm
Cardiologist: Need referral from PCP
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 17918**] in [**4-5**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2112-2-15**]
|
[
"998.11",
"788.20",
"272.4",
"511.89",
"790.4",
"285.9",
"571.8",
"305.1",
"412",
"401.9",
"518.81",
"E879.6",
"600.01",
"288.60",
"411.1",
"250.00",
"E878.2",
"427.89",
"E849.7",
"414.01",
"369.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.44",
"39.61",
"34.04",
"36.12",
"36.15",
"37.61",
"34.03",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8098, 8180
|
4317, 6478
|
319, 621
|
8439, 8666
|
2081, 4294
|
9589, 10095
|
1300, 1333
|
6774, 8075
|
8201, 8262
|
6504, 6751
|
8690, 9566
|
1348, 2062
|
269, 281
|
649, 938
|
8284, 8418
|
1110, 1284
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,359
| 108,532
|
47225
|
Discharge summary
|
report
|
Admission Date: [**2195-3-19**] Discharge Date: [**2195-3-23**]
Date of Birth: [**2131-8-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
[**3-20**] EGD & Colonoscopy
History of Present Illness:
63 y.o man with history of type II [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **]'s disease and
history of GI bleeds presents with 2 week history of dark
stools. The patient reports that 2 weeks ago he had a nosebleed
that lasted longer than his usual ones. He then noticed that
his stools became progressively darker, becoming black as of
today. He also noticed that he had increasing frequency of
stools, from 2x a day to 4x a day. He began to feel more and
more fatigued and had shortness of breath on exertion. Several
days ago, he also noticed some blood tinged sputum. He also
reports that yesterday he had some chest discomfort that he
describes as a stinging sensation.
.
Per OMR and the patient he was diagnosed with type 2 [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 23872**] disease in [**2192**] after bleeding post-operatively. He
had no real complications aside from epistaxis until [**1-2**] when
he developed dyspnea, presented to the ED, and was found to have
UGIB with hct 15. He underwent EGD with clipping of the duodenal
blub and then required angiography with gastroduodenal artery
coiling, Humate 6, IVIG, and 16units pRBCs before his hct
stabilized at 22. After discharge he was seen in heme/onc clinic
and received IV iron for continued anemia. His hcts trended from
22-33 over the last two months.
.
In the ED, he was found to be hypotensive with pressures in the
80s. He was given 2L of NS and 2 units of blood, and GI was
consulted. His vitals prior to transfer were 73 131/78 20 98%
on RA. NG lavage negative for blood, although rectal exam was
positive for melena. On arrival to the ICU, the patient
reported that he felt much better. He was chest pain free and
denied any shortness of breath. He denies any recent NSAID use.
.
.
Review of systems:
(+) Per HPI; also positive for pica which has been chronic.
(-) Denies fever, chills, nausea, vomiting, current chest pain
or shortness of breath, abdominal pain, leg swelling.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Rt heart failure with diastolic dysfunction
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
MGUS
Acquired [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Disease
H/O RESPIRATORY FAILURE
H/O RT HEART FAILURE
Diastolic dysfunction.
H/O MORBID OBESITY
RENAL INSUFFICIENCY
FACTOR VIII DEFICIENCY
ERECTILE DIFFICULTY
MONOCLONAL GAMMOPATHY
HYPERTENSION
IRON DEFICIENCY ANEMIA
h/o ugi bleed from AV malformation seen on endoscopy 08.
PROBLEMS WITH BALANCE
SECONDARY HYPERPARATHYROIDISM
+Lupus anticoagulant
Social History:
Lives with son in [**Name2 (NI) **]. Retired. No ETOH, smoking [**6-30**] cigs
a day x 30 years from 20 to 50, hx of marijuana. Sister
currently in MICU at [**Hospital1 2177**].
Family History:
Sister with [**Name2 (NI) 14165**] cell trait, kidney transplant and sarcoid.
Father died of colon CA
Physical Exam:
97.6 145/90 83 20 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. Mild
conjunctival pallor
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
at RUSB.
Abdomen: soft, non-tender, protuberant, 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:
EKG: NSR, no ST changes. Normal axis. Intervals OK. isolated
Q wave in III of no clinical significance. Unchanged from
prior.
.
Studies:.
EGD [**2195-3-19**]-
.
Polyps in the duodenal bulb
Normal mucosa in the whole examined duodenum
Mild thickening and erythema in the antrum
Small hiatal hernia
Erythema in the gastroesophageal junction compatible with mild
esophagitis
Otherwise normal EGD to second part of the duodenum
.
CLS [**2195-3-19**]-
.
Diverticulosis of the sigmoid colon and descending colon
Grade 2 internal hemorrhoids
Pigmented raised area noted at 40 cm in sigmoid colon. No clear
hx of tatoo from previous polypectomy site. Given bleeding
disorder and melena this site was not biopsied. No bleeding
noted from site.
Otherwise normal colonoscopy to terminal ileum
.
MRE:
IMPRESSION: The small bowel appears normal. No bowel
obstruction.
Admission:
[**2195-3-19**] 09:00AM BLOOD WBC-4.7 RBC-2.59*# Hgb-6.1*# Hct-19.6*#
MCV-76* MCH-23.4* MCHC-31.0 RDW-17.6* Plt Ct-196
[**2195-3-19**] 09:00AM BLOOD PT-13.3 PTT-39.2* INR(PT)-1.1
[**2195-3-21**] 08:40PM BLOOD Ret Aut-3.0
[**2195-3-19**] 09:00AM BLOOD Glucose-112* UreaN-34* Creat-1.6* Na-139
K-3.9 Cl-101 HCO3-34* AnGap-8
[**2195-3-20**] 03:02AM BLOOD Calcium-8.2* Phos-4.2 Mg-1.7 Iron-26*
[**2195-3-19**] 09:00AM BLOOD calTIBC-400 Ferritn-9.0* TRF-308
[**2195-3-21**] 08:40PM BLOOD Hapto-59
[**2195-3-19**] 09:00AM BLOOD VWF AG-26* VWF CoF-LESS THAN
[**2195-3-20**] 03:02AM BLOOD VWF AG-41* VWF CoF-33*
[**2195-3-21**] 04:41AM BLOOD VWF AG-68 VWF CoF-45*
[**2195-3-22**] 09:30AM BLOOD VWF AG-155 VWF CoF-136
[**2195-3-23**] 05:55AM BLOOD VWF AG-126 VWF CoF-105
[**2195-3-19**] 09:00AM BLOOD FacVIII-37*
[**2195-3-20**] 03:02AM BLOOD FacVIII-53
[**2195-3-21**] 04:41AM BLOOD FacVIII-81
[**2195-3-22**] 09:30AM BLOOD FacVIII-146
[**2195-3-23**] 05:55AM BLOOD FacVIII-123
Discharge:
[**2195-3-23**] 05:55AM BLOOD WBC-4.9 RBC-3.33* Hgb-8.8* Hct-26.8*
MCV-80* MCH-26.5* MCHC-33.0 RDW-17.3* Plt Ct-132*
[**2195-3-23**] 05:55AM BLOOD Glucose-115* UreaN-13 Creat-1.3* Na-136
K-3.9 Cl-100 HCO3-34* AnGap-6*
[**2195-3-21**] 08:40PM BLOOD LD(LDH)-158 TotBili-0.7 DirBili-0.2
IndBili-0.5
[**2195-3-23**] 05:55AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
Brief Hospital Course:
1. GI bleed: The patient does not have a clear inciting event
although clearly his vWD causes him to be at high risk for
bleeding. Upon admission to the ICU, hematocrits were closely
monitored every 6 hours with a transfusion goal of HCT >25. He
was placed on a protonix drip, GI was consulted who recommended
upper and lower endoscopy, so the patient and was prepped with
Moviprep. On [**3-20**], he underwent upper endoscopy which revealed
erythema in the gastroesophageal junction compatible with mild
esophagitis but otherwise normal EGD to second part of the
duodenum. Colonoscopy showed diverticulosis of the sigmoid colon
and descending colon, grade 2 internal hemorrhoids and a
pigmented raised area noted at 40 cm in sigmoid colon. No clear
hx of tattoo from previous polypectomy site. Given bleeding
disorder and melena this site was not biopsied. Otherwise normal
colonoscopy to terminal ileum. He underwent MRE that showed
normal small bowel. The patient received a total of 6U pRBC and
his Hct stablized at 26. He was hemodynamically stable and
transferred to the floor. On the floor the patient Hct remained
stable and stools were guaiac negative. The patient was followed
by GI with plans for outpatient capsule endoscopy and GI
follow-up
-- patient needs an outpatient capsule endoscopy
-- repeat CBC in Hem/[**Hospital **] clinic on [**3-26**]
*** patient needs evaluation of the pigmented raised area in the
sigmoid colon. No history of tattoo and possible melenoma.
2. [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) **] disease: Heme/Onc team was consulted as the
patient previously had received Humate-P and IVIG during his
last admission. He was treated with IVIG x2 days and had factor
VIII, vWF antigen and cofactor levels checked. He was closely
followed by Hem/Onc. His bleeding stopped and remained stable.
He will have repeat labs checked on [**2195-3-26**] and follow-up in
Hem/[**Hospital **] Clinic.
3. Nosebleeds: ENT evaluated and did not see evidence of active
bleeding. He was continued on nasal saline.
4. History of right heart failure with diastolic CHF: Patient
has been euvolemic thoughout his admission. His carvedilol,
lisinopril and lasix were initially held, but restarted on the
floor.
5. Hypertension - His anti-hypertensives were initially held in
the setting of his GI bleed, but restarted on the floor.
Medications on Admission:
Carvedilol 25mg [**Hospital1 **]
Furosemide 40mg daily
Lisinopril 10mg daily
Omeprazole 40mg daily
B complex vitamin daily
Calcium & Vit D
Discharge Medications:
1. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. B Complex Capsule Sig: One (1) Capsule PO once a day.
6. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One
(1) Tablet PO twice a day.
7. Outpatient Lab Work
Please have your CBC check on [**2195-3-26**] and have the results sent
to Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 22**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
GI bleed
Secondary:
Type 2 [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) **] disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted because of a bleed in your GI tract. You underwent a
EGD and colonoscopy that did not show any evidence of active
bleeding. You also had an MRI of you small bowel that was also
unremarkable. It is recommended that you have a capsule
endoscopy as an outpatient
The following changes were made to your medications:
1) You omeprazole was increased to 40mg twice a day.
You have several follow-up that are important to maintain.
1) You should have your lab drawn on Thursday, [**2195-3-26**], to check
your blood level. The results should be sent to Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 22**].
2) You should have an outpatient Capsule Endoscopy that should
be scheduled through the GI department within the next week. If
you do not hear from them within the next day or two please
call: [**Telephone/Fax (1) 463**]
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: [**Hospital1 **] [**2195-3-27**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
*It is recommended that you have a capsule endoscopy within the
next week.
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2195-3-31**] at 3:00 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], 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
Department: HEMATOLOGY/ONCOLOGY
When: [**Location (un) **] [**2195-4-10**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2195-3-24**]
|
[
"272.4",
"578.9",
"286.4",
"585.3",
"455.0",
"273.1",
"428.0",
"458.9",
"562.10",
"285.1",
"428.32",
"278.01",
"403.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"22.19",
"45.13",
"99.14",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
9438, 9444
|
6142, 8516
|
313, 344
|
9595, 9595
|
3910, 6119
|
10765, 11951
|
3255, 3358
|
8706, 9415
|
9465, 9574
|
8542, 8683
|
9746, 10742
|
3373, 3891
|
2466, 2584
|
2191, 2372
|
264, 275
|
372, 2172
|
9610, 9722
|
2615, 3042
|
2394, 2446
|
3058, 3239
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,308
| 117,318
|
35680
|
Discharge summary
|
report
|
Admission Date: [**2189-2-8**] Discharge Date: [**2189-2-10**]
Date of Birth: [**2149-11-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
EtOH withdrawal
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
39F with history of EtOH abuse and withdrawals, depression,
presenting to ED with suicidal ideation after alcohol
intoxication. Drinks [**12-13**] gallon vodka daily for the past 3 weeks
(since leaving her halfway house); last drink early AM on [**2-8**].
Worsening depression during these weeks as well. Seen at [**Hospital1 2177**]
earlier last week where she stayed for one night. Today she felt
as if she had "given up" and had thoughts of self harm without
definitive plan. Has had SI in past but no attempts or self
harm. No HI. Endorses VH with seeing "flies" or things moving on
the floor. Presented to ED for assistance with EtOH addiction
and depression.
.
In the ED, initial vs were: T97.6 95 137/80 18 100%RA. EtOH
level 276. Became increasingly tremulous with headache as well.
CIWAs consistently >10. Patient was given thiamine/MVI/folate,
zofran, tylenol, and total of 3 mg PO/IV ativan (refused
diazepam). Psych was consulted given SI but full assessment
could not be completed given active withdrawals.
.
On the floor, patient endorses tremors, posterior headache (x
many weeks), night sweats, nausea and dry heaves and diarrhea x
1 week. Endorses R knee pain with swelling (off and on for a
year), no erythema, + warmth at times. Also describes recent
course of azithromycin for bronchitis a few weeks ago with
improvement in cough and breathing.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, current cough, shortness of breath.
Denied chest pain or tightness, palpitations. Denied vomiting,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria.
Past Medical History:
Alcohol abuse: with multiple admissions for withdrawal (at least
5 admissions in last 6 months). Reports history of withdrawal
seizures and multiple ICU stays for severe withdrawals.
R fibular fx (no surgery, was put in a cast)
Dysfunctional uterine bleeding
Depression
GERD
Social History:
Recently living in halfway house, [**Hospital3 81174**]. Now renting a
room with friends. Widowed, has 14yo daughter who does not live
with her. EtOH abuse of estimated [**12-13**] gallon vodka daily. Heavy
drinking for the last 3 years (since husband's death) and also
worsened by father's death 1 year ago. Denies illicit drug abuse
and tobacco abuse.
Family History:
Alcohol abuse in both parents and multiple other family members.
Physical Exam:
Vitals: 96.6 85 122/72 RR 18 97%RA
General: Alert, oriented, slightly tremulous, no distress.
HEENT: Sclera anicteric, EOMIs with some horizontal nystagmus,
MMM, oropharynx clear.
Neck: supple, JVP not elevated, no LAD. No posterior neck pain.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Borderline tachy, regular, soft SM at RUSB.
Abdomen: soft, non-distended, bowel sounds present, mild TTP
diffusely in RUQ and epigastric area, no rebound tenderness or
guarding, no organomegaly appreciated.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. R knee slightly warm, nonerythematous, likely small
effusion. Tenderness to palpation over lateral joint line as
well as area slightly proximal to this.
Neuro: CN II-XII intact. Nystagmus as above. Strength 5/5 in UEs
and LEs. Denies sensory deficits. No asterixis but somewhat
tremulous.
Pertinent Results:
[**2189-2-9**] 08:31PM BLOOD WBC-5.8 RBC-3.74* Hgb-10.5* Hct-30.2*
MCV-81* MCH-28.2 MCHC-34.9 RDW-13.5 Plt Ct-393
[**2189-2-8**] 12:10PM BLOOD WBC-5.4 RBC-4.14* Hgb-11.3* Hct-33.6*
MCV-81* MCH-27.2 MCHC-33.5 RDW-14.5 Plt Ct-392#
[**2189-2-8**] 12:10PM BLOOD Neuts-53.8 Lymphs-39.8 Monos-2.9 Eos-3.1
Baso-0.4
[**2189-2-8**] 12:10PM BLOOD Glucose-85 UreaN-7 Creat-0.7 Na-147*
K-4.0 Cl-109* HCO3-27 AnGap-15
[**2189-2-9**] 08:31PM BLOOD Glucose-110* UreaN-8 Creat-0.9 Na-138
K-3.8 Cl-102 HCO3-28 AnGap-12
[**2189-2-8**] 12:10PM BLOOD ALT-26 AST-23 LD(LDH)-224 AlkPhos-84
TotBili-0.2
[**2189-2-9**] 08:31PM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0
[**2189-2-8**] 12:10PM BLOOD Albumin-4.4 Iron-98
[**2189-2-8**] 12:10PM BLOOD calTIBC-398 Ferritn-42 TRF-306
[**2189-2-8**] 12:10PM BLOOD ASA-NEG Ethanol-276* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
39F with history of EtOH abuse, depression, presenting with SI
after EtOH intoxication.
# EtOH abuse/withdrawal: Patient was admitted with an EtOH level
of 270 on presentation and was initially [**Doctor Last Name **] >10 on CIWA
scale. She also had with positive benzos on serum tox though
patient denies taking any benzodiazepines. Initially, the
patient was requiring Ativan for CIWA score >10, but this
resolved within the first 24 hours of her stay and her CIWA
scale was ultimately discontinued due to low [**Doctor Last Name **]. Psychiatry
recommended standing Librium as an inpatient for anxiety and the
patient's vitals signs remained stable. She was able to tolerate
a regular diet and was continued on thiamine, folate, and a
multivitamin. Social work was consulted and saw pt on [**2-10**]. Pt
had inpatient psych bed at [**Hospital1 **] in JP as per BEST team and was
discharged in stable condition on [**2-10**].
# Depression and suicidal ideation: Patient endorsed SI in the
setting of alcohol intoxication without an active plan.
Psychiatry was consulted and did not think that the patient was
suicidal (no section 12), but recommended an inpatient
psychiatric stay as well as standing Librium 25 mg TID for
anxiety.
# Microcytic Anemia: Patient with a mild microcytic anemia
despite normal iron/b12/folate studies. She was continued on
folate as an inpatient and her hematocrit remained stable
throughout her ICU course.
# Urinary retention: Patient with retention on admission,
putting out 1.7L of urine after Foley placement, though with
minimal symptoms. A U/A was negative and her retention was
thought to be a medication effect of benzodiazepines. She had a
successful voiding trial on HD2 before being transferred out of
the ICU.
# GERD: Patient continued on home Omeprazole 20mg daily.
# Access: Patient has required PICC lines in the past due to
inability to gain peripheral access and again had a PICC line
placed to ensure IV access.
Medications on Admission:
thiamine
folate
MVI
omeprazole 20 mg daily
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) 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. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache.
6. Chlordiazepoxide HCl 25 mg Capsule Sig: One (1) Capsule PO
TID (3 times a day).
7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for headache.
8. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1680**] Hospital - [**Location (un) 538**]
Discharge Diagnosis:
ETOH WITHDRAWAL
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital for alcohol withdrawal and
detox. Please do not drink any more alcohol.
Your medications have changed as follows:
-we added librium 25mg three times per day
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2189-3-24**]
1:45
Completed by:[**2189-2-10**]
|
[
"296.90",
"291.81",
"303.01",
"285.9",
"788.20",
"V62.84",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
7213, 7294
|
4489, 6460
|
288, 309
|
7354, 7354
|
3621, 4466
|
7719, 7897
|
2636, 2703
|
6554, 7190
|
7315, 7333
|
6486, 6531
|
7504, 7696
|
2718, 3602
|
233, 250
|
1722, 1950
|
337, 1704
|
7369, 7480
|
1972, 2249
|
2265, 2620
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,921
| 160,185
|
49686
|
Discharge summary
|
report
|
Admission Date: [**2104-6-24**] Discharge Date: [**2104-7-1**]
Date of Birth: [**2035-3-30**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Lipitor / Demerol
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Hypertensive urgency
Major Surgical or Invasive Procedure:
Cardiac catheterization and placement of drug eluting stent
History of Present Illness:
Pt is a 69 yo female with PMH of NIDDM, HTN, hyperlipidemia, 2
prior strokes (L PCA, L lacunar)with last P-MIBI [**10-28**]
demonstrating mod partially reversible apical defect, moderate
fixed distal anterior/anteroseptal defect w/ normal wall motion,
and EF 70%. Per patient, she had episode of nausea and vomiting
and "passing out" with difficulty recalling event. According to
prior notes, Pt had episode of CP at 11pm 1day PTA associated
with diaphoresis, vomiting and SOB. Pain recurred the following
morning at 6am associated with change in mental status and was
brought into the ED.
In the ED, the patient was hypertensive at 181/83, then with a
systolic BP up to 250s. The patient was confused and
uncooperative with episode of emesis. Pt was intubated for
airway protection and a CT Head was negative for stroke/bleed.
Her second set of CE's had Tn-T 0.51, CK 87. Her EKG showed TWI
in V1-V3, flattened T in V4. Follow up EKG showed flattened V2
and normalization of TWI in V3. Card consult saw patient and
recommended tx for NSTEMI with hep gtt. She was also noted to
have a + UA and was started on cipro 500 mg iv, and 2 L NS.
The patient was transferred to MICU for further management where
she was successfully extubated. She had an episode of relative
hypotension with systolic to 92. She was given 2 500cc NS
boluses and transferred to our service for further management of
? NSTEMI and hypertensive urgency.
Past Medical History:
L PCA stroke with R hemianopia
HTN
ADD
AODM (medicated in past, now diet controlled)
hypercholesterolemia
s/p ectopic pregnancy [**2072**]
possible seizure disorder
h/o breast cancer
migraine
Social History:
Lives at home with her husband and daughter. In process of
separating from husband. [**Name (NI) **] smoking, etoh or drug use
Family History:
Negative for cancer, no strokes
Physical Exam:
Gen: awake, alert, NAD
HEENT: EOMI, PERRL, no sclericterus, MMM
Neck: No JVP, No cervical lymphadenopathy
CV: Irregular rhythm, no m/g/r
Pulm: CTA b/l no wheezes, no crackles.
ABD: soft, NT/ND, +BS
EXT: No pitting edema.
Pertinent Results:
[**2104-6-24**] 12:20PM BLOOD WBC-8.1 RBC-4.27 Hgb-13.8 Hct-39.0 MCV-91
MCH-32.3* MCHC-35.3* RDW-13.6 Plt Ct-249
[**2104-6-26**] 05:35AM BLOOD WBC-7.0 RBC-3.66* Hgb-11.7* Hct-33.7*
MCV-92 MCH-31.9 MCHC-34.6 RDW-13.5 Plt Ct-189
[**2104-7-1**] 05:55AM BLOOD WBC-6.5 RBC-3.56* Hgb-11.4* Hct-32.0*
MCV-90 MCH-32.1* MCHC-35.7* RDW-13.6 Plt Ct-262
[**2104-6-26**] 05:35AM BLOOD PT-12.0 PTT-94.8* INR(PT)-1.0
[**2104-6-24**] 12:43PM BLOOD Glucose-248* UreaN-14 Creat-0.9 Na-141
K-4.1 Cl-104 HCO3-22 AnGap-19
[**2104-7-1**] 05:55AM BLOOD Glucose-148* UreaN-13 Creat-0.7 Na-141
K-3.7 Cl-106 HCO3-28 AnGap-11
[**2104-6-24**] 12:43PM BLOOD ALT-18 AST-15 CK(CPK)-22* AlkPhos-84
Amylase-60 TotBili-0.7
[**2104-6-24**] 12:43PM BLOOD cTropnT-<0.01
[**2104-6-24**] 08:33PM BLOOD CK-MB-NotDone cTropnT-0.51*
[**2104-6-25**] 01:51AM BLOOD CK-MB-NotDone cTropnT-0.45*
[**2104-6-26**] 05:35AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2104-6-24**] 12:43PM BLOOD TotProt-6.9 Albumin-4.3 Globuln-2.6
Calcium-10.1 Phos-3.2 Mg-1.8
[**2104-7-1**] 05:55AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2
[**6-24**] Head CT: [**Hospital 93**] MEDICAL CONDITION:
69 year old woman with ams since [**07**]
REASON FOR THIS EXAMINATION:
eval for acute change
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 69-year-old woman with altered mental status.
COMPARISON: [**2104-1-9**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no evidence of acute intracranial hemorrhage,
mass effect, hydrocephalus, shift of normally midline
structures, or new vascular territorial infarction. The
encephalomalacic changes in the left occipital lobe are stable.
Lacunar infarct in the left thalamus is again noted. Surrounding
osseous and soft tissue structures are unremarkable.
IMPRESSION: No acute intracranial pathology including no
evidence of intracranial hemorrhage.
[**6-24**] ECG Irregular sinus bradycardia. Prolonged Q-T interval.
Anterolateral ST-T wave
changes. Consider ischemia. Compared to tracing of [**2104-1-10**] the
ST-T wave
changes are new.
[**7-1**] ECG Sinus rhythm. Premature atrial beats. Long QTc
interval. Anterolateral
T wave changes suggest myocardial ischemia. Compared to tracing
#2
on [**2104-6-30**] the inferior ST-T wave changes are improved.
[**6-27**] Cardiac Cath COMMENTS:
1. Selective coronary angiography demonstrated significant two
vessel
coronary artery disease. The mid LAD had 80% stenosis within a
diffuse
lesion. The OM2, a small to moderate sized vessel, had 70%
stenosis. The
RCA and LMCA demonstrated no angiographically apparent disease.
2. Limited hemodynamic assessment was performed. The systemic
arterial
pressures were elevated at 186/77 mm Hg.
3. Successful stenting of the mid LAD 80% lesion with 3.0 X 23
mm Cypher
DES with no residual stenosis or dissection (see PTCA comments
for
detail).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful stenting of the LAD with Cypher DES.
[**6-28**] Head MRI 69 year old woman s/p 2 prior CVAs ( L PCA, L
lacunar)s/p cardiac catheterization and stent placement now with
new onset b/l vision loss
REASON FOR THIS EXAMINATION:
Please evaluate for new CVA.
INDICATION: History of stroke with new onset bilateral vision
loss.
COMPARISON: Multiple priors, the most recent CT head dated [**6-24**], [**2103**].
TECHNIQUE: Multiplanar T1- and T2-weighted imaging.
FINDINGS: Overall, examination is moderately limited secondary
to patient motion artifact. A large focus of abnormal T2 signal
involving the left posterior cerebral artery territory is
consistent with chronic infarct with associated atrophy,
hemorrhagic products and ex vacuo dilatation of the occipital
[**Known lastname 534**] of the left lateral ventricle. While involvement of the
posterior corpus callosum appears new compared to [**2103-10-4**], there is evidence of its involvement on the CT head from
[**2104-1-9**]. [**Year (4 digits) **] weighted images are not provided,
though there is no evidence of recent infarct on other
sequences. There is no hydrocephalus or shift of normally
midline structures.
IMPRESSION: Chronic left PCA territory infarct. While there is
no evidence of recent infarct, repeat study with [**Year (4 digits) 3631**]
weighted imaging is recommended if there is continued clinical
concern.
[**6-30**] Head CT INDICATION: 69-year-old woman with bilateral vision
loss after catheterization. Please assess for infarction.
Comparison is made to the prior MR of the head done on [**2104-6-28**], and CT of the head done on [**2104-6-24**].
NON-CONTRAST HEAD CT: The large encephalomalacic change within
the left occipital lobe is stable. No acute intracranial
hemorrhage, mass effect, hydrocephalus or shift of normal
midline structure is noted. Small hypodensity noted within the
left thalamus appears unchanged. Calcification within the left
globus pallidus is unchanged.
BONE WINDOWS: No fracture is identified. The density values of
brain parenchyma are within normal limits.
IMPRESSION: No acute intracranial pathology including no
evidence of intracranial hemorrhage is identified. The large
chronic infarct of the left occipital lobe and old lacunar
infarct of the left thalamus appear unchanged.
NOTE AT ATTENDING REVIEW: As was indicated in prior MR report,
MR [**First Name (Titles) 151**] [**Last Name (Titles) 3631**] imaging is more sensitive than CT in detecting
areas of acute brain ischemia.
[**6-24**] Ucx: [**2104-6-24**] 1:45 pm URINE Site: CATHETER
**FINAL REPORT [**2104-6-27**]**
URINE CULTURE (Final [**2104-6-27**]):
ESCHERICHIA COLI.
>100,000 ORGANISMS/ML. PRESUMPTIVE IDENTIFICATION.
OF TWO COLONIAL MORPHOLOGIES.
[**6-24**] Bcx: negative
Brief Hospital Course:
Upon presentation to the floor, her CAD risk factors were
optimized with administration of aspirin, simvastatin, and
metoprolol. The patient underwent cardiac catheterization on
[**6-27**], which revealed 80% stenosis of the LAD. this stenosis was
stented with a cypher drug eluting stent. After this procedure,
the patient was complaining of bilateral blindness. Neuro was
consulted and they believed the symptoms were a result of TIA.
Head MRI did not reveal any new areas of infarct, however this
study was limited secondary to the patient's inability to
tolerate the procedure. Her vision gradually improved over the
next three days. Ophthalmology was consulted and believe she
has a refractive error, and she can follow up with them in
clinic as an outpatient. Neurology recommended that though the
patient could not tolerate MRI, a head CT without contrast would
be suitable to definitively rule out stroke, considering the
suspected event occurred over 48 hours earlier. This head CT
was performed and did not show any new areas of infarct. The
patient was seen by OT and worked with PT daily. Concern was
raised that the patient's subjective blindness may be a
manifestation of conversion disorder, and that this could be
followed up as an outpatient. Concern was also raised for a
prolonged QT interval on serial EKGs. No cause of the
prolongation was found, her electrolytes were normal, and she
was not on any medicines that could have caused this ekg
finding.
The patient also had a UTI during admission. She was begun on
Cipro, and changed to Augmentin to complete a 7 day course while
admitted.
The patient was discharged on [**7-1**], afebrile and with stable
vital signs.
Medications on Admission:
Metformin
Lisinopril
atenolol
ASA 325
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Hypertensive urgency
Coronary Artery Disease
Urinary tract infection
Prolonged QT interval
Discharge Condition:
good
Discharge Instructions:
We have started you on a medication named Metoprolol. Continue
to take 12.5mg by mouth twice a day. We have started you on a
medication called Plavix. Continue to take 75mg by mouth every
day.
Take all of your medications as directed.
Keep all of your follow-up appointments.
If you have any of the following symptoms please return to the
emergency department:
Chest Pain
Shortness of breath
Passing out
Persistent vomiting
Followup Instructions:
Please call your primary care doctor, Dr. [**Last Name (STitle) 7790**] and schedule
an appointment within one week to follow-up after this
hospitalization.
Please follow up with your previously scheduled appointments
below:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2104-9-15**] 10:15
|
[
"435.9",
"250.00",
"272.4",
"410.71",
"426.82",
"V12.59",
"414.01",
"401.9",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"88.52",
"00.40",
"37.22",
"96.04",
"00.45",
"36.07",
"88.55",
"96.71",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
10612, 10683
|
8213, 9917
|
307, 368
|
10818, 10825
|
2488, 3559
|
11303, 11691
|
2199, 2232
|
10005, 10589
|
3605, 3647
|
10704, 10797
|
9943, 9982
|
5311, 5559
|
10849, 11280
|
2247, 2469
|
247, 269
|
5588, 7011
|
396, 1822
|
7020, 8190
|
1844, 2038
|
2054, 2183
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,329
| 131,317
|
49963
|
Discharge summary
|
report
|
Admission Date: [**2124-8-31**] Discharge Date: [**2124-9-9**]
Date of Birth: [**2079-7-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
RIJ
History of Present Illness:
Mr. [**Known lastname 104318**] is a 45 year old male with a PMH significant for DM
2, ESRD on HD with a history of multiple admissions for left
flank and left chest pain and hypertension admitted from
outpatient HD with chest pain. Patient is somnolent likely due
to large doses of narcotics in ED, but he states that he was 4
hours into his hemodialysis session when he had abrupt onset of
sharp CP rated [**9-25**] without radiation to back, arm, or jaw. He
endorses SOB during this episode, and says this is a pain he has
never had before. He also was having nausea and vomiting during
[**Month/Year (2) 2286**] that has continued since presentation to [**Hospital1 18**]. He
states that, per usual routine, he did not take his
anti-hypertensive meds prior to HD.
.
In the [**Hospital1 18**] ED, VS 97.2 91 [**Telephone/Fax (2) 104341**]0%4L nc. During his ED
course, he had a max SBP of 240. Cardiac biomarkers and an ECG
were unchanged from baseline. He received [**Telephone/Fax (2) **] 325 mg, nitro SL
x3, morphine 4 mg IV x2, dilaudid 1 mg x1, labetalol 10 mg x1.
He was started on nitro gtt without improvement in his BP, so he
was started on a nicardipine gtt. Given inadequate PIV access,
a RIJ was placed. Cardiology was consulted in the ED, and his
chest pain and elevated TnI was felt to be at most demand
ischemia and not ACS. He was then transferred to the [**Hospital Unit Name 153**] for
further management.
.
On arrival, he denies any CP/SOB, but endorses nausea, vomiting,
and left-sided flank pain.
Past Medical History:
- DM1 x over 20 years
- ESRD, on HD T,Th,Sa at [**Location (un) **] [**Location (un) **]
- HTN, poorly controlled
- h/o chroninc L flank pain since [**2119**] with multiple admissions
and extensive work-up, possibly due to diabetic thoracic
polyneuropathy
- Diastolic CHF: LVEF >=60% by echo
- Esophagitis on EGD [**10-21**] with negative H. Pylori
- Gastroparesis
- Depression
- Fibromyaglia
- Adhesive capsulitis of left shoulder
- Mod-severe cognitive deficits per neuropsych testing in [**2121**]
- h/o R foot ulcer s/p R foot operation - bone excision
- h/o Cellulitis in right antecubital
Social History:
Originally from [**Male First Name (un) 1056**]. Lives alone with cat. Has several
siblings who are local, 4 children as well who don't live with
him. Denies alcohol, tobacco, or other drug use. Past work as
floor tech but not currently working. His mother passed away 1
year ago. Earlier this year in PR to attempt to get a renal
[**Male First Name (un) **], was unable to do so. History of suicide attempt
using "lots of pills." Financial issues making it difficult to
afford medications (SOCIAL WORK SHOULD SEE PATIENT ANYTIME IN
HOSPITAL AND HELP WITH GETTING NEW MEDICATIONS AT DISCHARGE).
Family History:
Diabetes in multiple relatives on both sides.
Physical Exam:
VS: 97.2 77 153/70 16 100%RA
GENERAL: somnolent, slow to respond to questions, A&O x2,
initially vomiting
HEENT: Normocephalic, atraumatic. No scleral icterus. Pupils 2
mm, perrl, eomi. MMM. OP clear. Neck Supple, No LAD, No
thyromegaly. Limited eye exam due to pupillary constriction and
lack of cooperation.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. +S4,
systolic murmur c/w AV fistula
PULM: CTAB, good air movement
ABDOMEN: Soft, TTP diffusely on left flank
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: LE changes consistent with stasis dermatitis.
NEURO: Oriented to person, place, and year. lethargic, slow to
respond to questions, falling alseep in mid-sentence. CN 2-12
[**Male First Name (un) 5235**]. Now gross motor or sensory deficits
Pertinent Results:
LABORATORIES:
[**2124-8-31**] 11:24AM BLOOD WBC-4.1 RBC-3.90* Hgb-10.5* Hct-32.7*
MCV-84 MCH-26.8* MCHC-32.0 RDW-19.1* Plt Ct-168
[**2124-8-31**] 11:24AM BLOOD Neuts-63.7 Lymphs-26.1 Monos-4.6 Eos-5.3*
Baso-0.4
.
[**2124-8-31**] 11:24AM BLOOD PT-15.5* PTT-30.6 INR(PT)-1.4*
.
[**2124-8-31**] 11:24AM BLOOD Glucose-277* UreaN-14 Creat-2.9*# Na-135
K-3.7 Cl-92* HCO3-28 AnGap-19
.
[**2124-8-31**] 11:24AM BLOOD CK(CPK)-211*
[**2124-8-31**] 06:58PM BLOOD CK(CPK)-157
[**2124-9-1**] 05:12AM BLOOD CK(CPK)-91
[**2124-8-31**] 11:24AM BLOOD cTropnT-0.21*
[**2124-8-31**] 06:58PM BLOOD CK-MB-6 cTropnT-0.20*
[**2124-9-1**] 05:12AM BLOOD cTropnT-0.18*
.
[**2124-9-2**] 05:35AM BLOOD Calcium-9.3 Phos-5.3* Mg-2.2
[**2124-8-31**] 08:36PM BLOOD Lactate-1.5
===================
IMAGINGS:
CXR ([**8-31**]) final: Two portable AP chest radiographs demonstrate
unchanged cardiomediastinal contours compared to [**2124-7-11**].
Multiple surgical clips project over the axilla. The lungs are
clear. There is no pneumothorax or pleural effusion.
IMPRESSION: No acute cardiopulmonary process.
CT head ([**8-31**]) final: FINDINGS: No evidence of hemorrhage,
edema, mass effect, or infarction. There is a septum cavum
pellucidum et vergae, unchanged which is a normal variant.
[**Doctor Last Name **]-white matter differentiation remains well preserved, and
there is no shift of normally midline structures. The ventricles
and sulci are unchanged in size or configuration. There are
vascular calcifications of bilateral carotid siphons and
bilateral vertebral arteries as well as bilateral temporal
arterial vessels. The osseous structures appear [**Doctor Last Name 5235**].
Paranasal sinuses, ethmoid, and mastoid air cells are well
aerated.
IMPRESSION: No acute intracranial pathology. No hemorrhage.
===================
ECG ([**8-31**]): Sinus with 1:1 conduction. Leftward axis. NI. LAA,
LVH. <1mm STD in V4-V6 unchanged from prior.
Brief Hospital Course:
Mr. [**Known lastname 104318**] is a 45 year old male with ESRD on HD admitted with CP
and hypertensive urgency.
# Hypertensive urgency: In the [**Name (NI) 153**], pt was taken off
nicardipine gtt (he was on nicardipine gtt for at least 5
hours). He then received lisinopril, nifedipine, labetalol for
blood pressure control. Also received nitro SL, morphine, and
dilaudid. We were unable to assess end organ damage to kidneys
given ESRD. Cardiac biomarkers and ECG unchanged from baseline
per cardiology evaluation in ED. Chest pain may have contributed
to hypertensive episode. Unclear precipitating even, but
medication non-compliance is a possibility and patient has
frequent admissions for hypertension. Volume overload is
unlikely given recent HD session and physical exam. Patient was
transferred to the floor on HD2, lisinopril was converted to
captopril, home metoprolol, valsartan and nifedipine were
continued. Slowly SBP returned down to normal range on the above
regimen. It appeared that patient's blood pressure tends to run
high after [**Name (NI) 2286**], so the post-[**Name (NI) 2286**] period is the time of
maximal vigilance for blood pressure monitoring. On [**Name (NI) 2286**]
days, Patient should be given nifedipine prior to [**Name (NI) 2286**] as
nifedipine is not dialyzed, and resume other blood pressure meds
after [**Name (NI) 2286**].
.
# Chest pain: ACS was ruled out with serial cardiac biomarkers
and repeat ECGs. Pain was initially controlled with IV morphine
and dilaudid which were discontinued due to patient somnolence.
A similar episode of chest pain associated with hypertension
occurred on [**9-7**] after [**Month/Year (2) 2286**], and patient was ruled out with
EKG and negative cardiac enzymes.
.
# Left flank pain: This is chronic issue. He's had this pain
since [**2119**] with multiple admissions and extensive work-up and it
is thought possibly due to diabetic thoracic polyneuropathy.
After IV pain medications were discontinued, patient was put
back on his home percocet with better pain control. We also
restarted gabapentin which patient thinks helped him in the
past. It fell off the discharge medications in [**6-24**]. We talked
to PCP's office and it continues to be on his med list. Pt was
on 300mg Q [**Date Range 2286**] which was increased to 600mg daily in [**5-25**]
before it was off the med list in [**6-24**]. After talking to pt's
nephrologist Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**], it was restarted on [**9-4**] at
300mg QHS. Pt tolerates it well and pain improved on this
regimen of standing gabapentin and percocet PRN. Pt also
received lidocaine patch for pain control.
.
# Depression: Psychiatry was consulted during this hospital
stay. Per psych, 1:1 sitter was not indicated. citalopam was
increased to 30mg daily. Methylphenidate 5 mg PO QAM AND Q12P
Trazadone 25mg QHS prn insomnia were continued. Unfortunately,
per Social Work, patient is using the hospital as a way of
coping with his depression, and once he leaves the hospital, as
much as his family and the social workers have tried, it has
been very difficult to manage to get him consistently to the
services available to him. Social Work here at [**Hospital1 18**] knows him
very well, and has been closely involved in trying to connect
him with help outside the hospital. Because of worsening
depression and patient's concern of "thinkging about killing
myself when I go home", patient will be transferred to the psych
floor on [**Hospital1 **] 4 for more focused psychiatric treatment.
.
# DM1: Patient was put on basal 70/30 and sliding scale insulin.
Because of poor eating, his blood glucose level fluctuated
widely. Patient's blood sugar was eventually stable on a new
regimen of 5unit of 70/30 before breakfast, 4unit of 70/30
before dinner, and ISS QACHS.
.
# Gastroparesis: Patient was found to have markedly delayed
gastric emptying in [**7-25**] during the last admission. He was
continued on standing dose of reglan and PRN zofran.
Erythromycin was added to the regimen as well.
.
# Somnolence: On arrival to [**Hospital Unit Name 153**] patient was somnolent and
lethargic and slow to respond to questions, likely due to opiods
received in ED including 8mg morphine total and 1mg dilaudid.
Non-contrast CTH ruled out hypertensive bleed. IV pain
medications were discontinued, and patient was put back on his
home percocet.
.
# Medication non-compliance: Because of patient's depression and
social and financial situations, it is very difficult for
patient to cope with getting his medications. SOCIAL WORK SHOULD
ALWAYS BE CONTACT[**Name (NI) **] WHEN THIS PATIENT IS ADMITTED so that he can
have his medications in hand at discharge.
.
# ESRD on HD: Renal was following the patient during the
hospital stay. Patient was on T,R,Sa HD. We continued home
sevalamer and calcium acetate. Pt receives epo and zemplar at
HD.
.
# Chronic diastolic CHF: LVEF >60% by echo (5/[**2123**]). Home
metoprolol, [**Year (4 digits) **], and valsartan were continued.
.
# Esophagitis: Home PPI was continued.
.
# Anemia: Multifactorial given ESRD and other chronic diseases.
Hct was at baseline during this hospital stay. Pt receives epo
at HD.
.
Patient was on renal and diabetic diet, he tolerated POs well
with the help of anti-emetics. He received subcutaneous heparin
for DVT prophylaxis, and had RIJ for access. He was full code,
and his contact was his sister [**Name (NI) **],[**Name (NI) **] at [**Telephone/Fax (1) 104334**].
Medications on Admission:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): qam and qnoon.
6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Metoprolol Tartrate 25 mg Tablet Sig: Five (5) Tablet PO
twice a day.
9. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
10. Glycopyrrolate 1 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
12. Insulin 70/30, 4U qam, 6U qhs
13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO qidachs.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
4. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM AND
Q12P ().
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
12. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO Q
[**Telephone/Fax (1) **] (PRE-[**Telephone/Fax (1) **]) ().
14. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO DAILY (Daily): Hold if SBP<90. On
[**Telephone/Fax (1) 2286**] days, give before [**Telephone/Fax (1) 2286**]. On non-[**Telephone/Fax (1) 2286**] days, give
it at 12pm. .
15. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day): Hold if SBP<90 or HR<55. Please give at 8am and
8pm. .
16. Hydralazine 50 mg Tablet Sig: 0.5 Tablet PO PRN (as needed)
as needed for SBP>180.
17. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day).
20. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold if SBP<90, give at 10am.
21. Erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
22. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Five (5) Unit Subcutaneous q before breakfast.
23. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Five (5) Unit Subcutaneous q before dinner.
24. Humalog 100 unit/mL Solution Sig: please refer to the
included sliding scale unit Subcutaneous QACHS.
25. Glycopyrrolate 1 mg Tablet Sig: One (1) Tablet PO twice a
day as needed: for excessive salivation.
26. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day:
Hold if SBP<90. Give at 8am. .
27. Blood pressure med regimen
On the days of NO [**Telephone/Fax (1) 2286**], lisinopril (20mg daily) at 8am, home
metoprolol (125mg [**Hospital1 **]) at 8am and 8pm, nifedipine (120mg daily)
at 12am and valsartan (160mg daily) at 10am. On the days of
[**Hospital1 2286**] (T, Th, Sat), give nefedipine prior to [**Hospital1 2286**], and
give the rest of the medications after [**Hospital1 2286**] according to the
above schedule.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnoses:
- Hypertension
- ESRD on HD
- type II DM
- Depression
- Chronic left flank pain
Secondary Diagnoses:
- Esophagitis
- Gastroparesis
- Diastolic CHF
- Mild-to-moderate cognitive deficits
Discharge Condition:
Stable, ambulating, afebrile.
Discharge Instructions:
It was a pleasure to be involved in your care, Mr. [**Known lastname 104318**]. You
were admitted to [**Hospital1 69**] because of
hypertension and chest pain. Your systolic blood pressure was up
to 240 when you were in the emergency department. On discharge,
you were back to your home blood pressure medications which
include metoprolol, nifedipine, lisinopril and valsartan, and
your blood pressure is better controlled. You should continue to
take your medications. Your chest pain was also worked up, and
you did not have a heart attack. Your left flank pain has stayed
the same during this admission. We put you back on your
neurontin which you think help with the chronic pain. Psychiatry
saw you, and recommended that we increase your citalopram dose
from 20mg daily to 30mg daily. Because of your worsening
depression, you will be discharged to the Psychiatry floor at
[**Hospital1 18**] for more focused psychiatric treatment.
Your medications have changed.
The following medications have been added:
Gabapentin (to help with your pain)
Citalopram (for depression, increased from 20mg daily to 30mg
daily)
Erythromycin (to help with your nausea)
Basal Insulin 70/30 and Insulin sliding scale were changed
Lidocaine patch for pain control
If you develop chest pain, shortness of [**Hospital1 1440**], confusion,
worsening depression, suicidal ideation, or any other symptoms
that concern you, please call your doctor or come to the
emergency department immediately.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]:
[**Hospital1 **] Health Center
[**Location (un) 104342**], [**Numeric Identifier 8542**]
Phone: ([**Telephone/Fax (1) 104343**]
Appointment: Monday, [**2124-9-11**] @ 1:45 pm
|
[
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"V15.81",
"V58.67",
"729.1",
"285.21",
"428.0",
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"786.59",
"331.83",
"536.3",
"311",
"276.7",
"428.32",
"250.61",
"530.10",
"357.2",
"789.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15896, 15966
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5963, 11461
|
325, 330
|
16215, 16247
|
4017, 5940
|
17774, 18023
|
3134, 3181
|
12725, 15873
|
15987, 16087
|
11487, 12702
|
16271, 17751
|
3196, 3998
|
16108, 16194
|
275, 287
|
358, 1887
|
1909, 2505
|
2521, 3118
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,736
| 173,931
|
50740+59285
|
Discharge summary
|
report+addendum
|
Admission Date: [**2180-1-12**] Discharge Date: [**2180-1-15**]
Date of Birth: [**2121-6-11**] Sex: M
Service: MEDICINE
Allergies:
Reglan / heparin (porcine) / Vancomycin
Attending:[**First Name3 (LF) 20146**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
This is a 58 year old gentleman with a complicated past medical
history notable for diverticulosis s/p perforated diverticulum
in [**2175**] necessitating anterior resection with descending
colostomy with hospital course complicated by multiorgan
failure, ongoing colitis attributed to ulcerative vs.
diverticular associated colitis of both proximal and distal
areas to the stoma, ongoing colostomy bleeding, peristomal
varices, who presents today with bright red blood per stoma bag.
Patient reports large volume bright red blood from his stoma
starting at 11PM last evening. Overnight and over the course of
the day, he has filled his bag completely six times with bright
red blood. He reported dizziness, shortness of breath, and
shoulder discomfort/heaviness, for 20 minutes which resolved
with fluids. Denies any abdominal pain, nausea, vomiting,
fevers, chills. No NSAIDs or alcohol consumption for several
months.
Of note, patient sees Dr. [**Last Name (STitle) 3708**] and Dr. [**Last Name (STitle) 10446**] of GI, and is
noted to be of poor medication compliance. He has been tried on
oral asacol with canasa supposotories.
In the ED, initial vital signs were: 98.4, HR: 103, BP: 70/30,
RR: 16, 99%RA. 2 large bore IVs were placed and patient was
volume resuscitated with 4L NS and transfused with 2 unit prbcs.
Patient was started on protonix gtt. Blood pressure improved
to 94/72 with improvement in tachycardia. ECG with no signs of
ischemia. Labs notable for a hematocrit of 31.9 (baseline),
creatinine of 1.8 (1.9 in [**11/2179**]), and a lactate of 2.7.
Initial cardiac enzymes negative times one. CXR without acute
process. GI was consulted who recommended IV PPI, trending hct,
possible colonoscopy. Surgery was consulted who believed
bleeding to be IBD or diverticular. Vitals at the time of
transfer: HR: 70, BP: 94/72, RR: 13, 100%RA.
Past Medical History:
1. Diverticulosis with diverticular perforation in [**2175**]
2. Descending colostomy.
3. Bleeding from site of stoma.
4. Persistent rectal bleeding and ongoing colitis attributed to
ulcerative vs. diverticular associated colitis
5. Diabetes Mellitus II
6. ?para stomal varices related to PVT
7. Stricture at stomal insertion site
8. Chronic kidney disease subsequent to multiorgan failure at
the time of his [**2175**] admission, with baseline creatinine 1.6
9. Attention deficit hyperactivity disorder
Social History:
Chronic kidney disease subsequent to multiorgan failure at the
time of his [**2175**] admission, with baseline creatinine 1.6 in
06/[**2177**]. Patient is not married, not sexually active for the
past five years. Cigarettes - denies. Alcohol - denies, illicit
drugs - denies.
Family History:
Throat cancer in his father. DM in his family.
Physical Exam:
VS: Temp: 96.6, BP: 114/69, HR: 79, RR: 9, O2sat: 100% RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, dry mucous membranes, op without
lesions, no supraclavicular or cervical lymphadenopathy, no jvd,
no carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: left sided ostomy /s, soft, nt, no masses or
hepatosplenomegaly
EXT: no pedal edema
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Pertinent Results:
Admission labs:
[**2180-1-12**] 04:15PM GLUCOSE-214* UREA N-37* CREAT-1.8* SODIUM-136
POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-17* ANION GAP-16
[**2180-1-12**] 04:15PM ALT(SGPT)-32 AST(SGOT)-27 ALK PHOS-84 TOT
BILI-0.5
[**2180-1-12**] 04:15PM LIPASE-36
[**2180-1-12**] 04:15PM cTropnT-<0.01
[**2180-1-12**] 04:15PM PHOSPHATE-3.5 MAGNESIUM-1.8
[**2180-1-12**] 04:15PM WBC-11.0# RBC-3.87* HGB-11.0* HCT-31.9*
MCV-83 MCH-28.5 MCHC-34.5 RDW-15.2
[**2180-1-12**] 04:15PM NEUTS-81.1* LYMPHS-13.0* MONOS-4.2 EOS-1.5
BASOS-0.3
[**2180-1-12**] 04:15PM PLT COUNT-118*
[**2180-1-12**] 04:15PM PT-15.2* PTT-31.5 INR(PT)-1.3*
[**2180-1-12**] 11:44PM CK(CPK)-46*
[**2180-1-12**] 11:44PM CK-MB-2 cTropnT-<0.01
[**2180-1-12**] 04:44PM LACTATE-2.7* K+-5.0
EKG: Normal sinus rhythm with rate of 76, left axis deviation,
no ST or T wave changes concerning for ischemia. Unchanged from
prior ECG in [**2179-11-8**].
Imaging:
.
# Endoscopy:
[**6-14**] colonoscopy: Petechiae and congestion in the whole colon
compatible with ischemia (biopsy). Polyp in the transverse
colon (polypectomy).
.
[**1-18**] colonoscopy: Erythema, nodularity in the colon compatible
with mild colitis (biopsy). Erythema, congestion, friability
nodularity with polyps suggestive of inflammatory polyps seen in
the distal 20 cm to stoma. Friability limited ability to take
biopsies at this site given thrombocytopenia and risk of
bleeding in the colon. Otherwise normal colonoscopy to terminal
ileum
Chest Radiograph [**2179-1-12**]: No acute process.
Brief Hospital Course:
This is a 58 year old gentleman with a complicated past medical
history notable for diverticulosis c/b perforated diverticulum
in [**2175**] s/p anterior resection with descending colostomy,
ongoing colitis (ulcerative vs. diverticular), ongoing colostomy
bleeding, peristomal varices, who presented with bright red
blood per stoma bag, evidence of ulcerative colitis on
colonoscopy.
# GI Bleed: Based on history of prior parastomal varices,
diverticulosis, bleeding from significant colitis in combination
with appearance of bright red blood per stoma, most likely
source of bleeding was lower GI source. Patient refused NG
lavage in the ED. He was transfused 4 units total PRBC and
received IVF, was then HDS and with brown stools. Surgery and IR
were consulted, no need for intervention, GI recommended
colonoscopy and IV PPI [**Hospital1 **]. Colonoscopy without complications,
patient found to have inflammatory changes and polyps around
stoma site. Biopsies taken, patient to follow with PCP and
gastroenterologist Dr. [**Last Name (STitle) 3708**]. Patient has been informed of
preliminary colonsocopy findings, has been advised to continue
mesalamine PO and suppositories, and home iron supplements. He
has a history of nonadherence to medications and importance of
medication compliance was discussed at length with patient.
# Hypotension: Likely was hypovolemic in ICU in the setting of
ongoing gastrointestinal bleeding. Status post 3L NS with
appropriate response in blood pressure. However, patient with
elevated lactate and relative leukocytosis and must therefore
rule out any potential causes of sepsis. Blood cultures were
sent and are pending. CXR was clear. UA was ordered, found to
have large amounts WBCs, few bacteria. UA discussed below.
Lactate trended down to normal with IVF and PRBC. Home
lisinopril and tamsulosin were held during admission and
restarted in discharge, as BPs were stable.
# Acute on chronic Anemia: Hematocrit currently at baseline on
admission, but dropped with IVF/volume resusication versus
ongoing bleeding (although no further blood in his bag). Has
known iron deficiency anemia. He was given 2 units PRBC in the
ED and another unit the am of [**1-13**]. Serial hematocrits were
checked, hct stable. Patient advised to continue home iron
supplements at discharge.
# CP: Had one episode of CP in ICU, may have been secondary
demand ischemia in setting of anemia and acute blood loss.
Patient's description of pain as bilateral shoulder cramping
suggests tissue ischemia, lactate build-up. ECG without
ischemic signs and cardiac enzymes negative time three. No
further episodes of CP during admission
# Thrombocytopenia and leukopenia: Patinet with baseline Plts of
about 80, WBC 4.9. Was higher on admission (likely
hemoconcentrated). Dropped overnight with resuscitation to 40
and 2.7, respectively, unusual lows for pt. Chronic
thrombocytopenia thought to be secondary to splenic
sequestration, enlarged spleen on prior CT. Peripheral smear
sent, no schistocytes, platelet clumping, or evidence of
peripheral blood heme malignancy. Given pt's leukopenia, was
tested for HIV, which was negative. Would consider rechecking
CBC at f/u visit, and if not improving, would consider bone
marrow biopsy in future if counts do not increase.
#Dysuria: UA with elevated WBC, few bacteria, rechecked and
showed >800 WBC also with few bacteria. Pt complained of
dysuria now much like in the recent past, he was recently
treated with 2 week course of cipro with no improvement. UA was
rechecked, initial urine cx grew mixed colonies (likely
contaminated), second ucx was negative. Initially was treated
with cipro, was dc'ed when second cx negative. Rectal exam was
done to eval for prostatitis, no prostate tenderness. He did
complain of penile discharge in the last few days, however no
recent sexual contacts, but a GC/chlamydia urine PCR was sent,
results pending on discharge. Would consider repeat UA after
discharge to ensure pyuria resolved.
# Chronic kidney disease: Secondary to multiorgan failure at the
time of prior [**2175**] admission. Creatinine at baseline on
admission.
# Diabetes: Home glipizide was held while not on a regular diet.
He was covered with a sliding scale, will continue home
medications on discharge.
Code: Full
Issues on discharge:
-Would recheck CBC at f/u appointment to trend WBC, was
leukopenic during admission, HIV negative
-Would recheck UA to ensure resolution of pyuria
-GC/chlamydia urine PCR pending (sent to evaluate penile
discharge)
Medications on Admission:
- gabapentin 600mg PO TID
- glipizide 5mg PO daily
- lisinopril 10mg PO daily
- tamsulosin 0.4mg PO daily
- ferrous gluconate 324mg PO daily
- patient is written for mesalamine 1200mg PO BID but does NOT
take this medication
- patient is written for mesalamine 1000mg suppository rectally
once a day but does NOT take this medication
Discharge Medications:
1. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime) for 1 doses.
3. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*180 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. gabapentin 600 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
6. mesalamine 1,000 mg Suppository Sig: One (1) Rectal QPM
(once a day (in the evening)).
Disp:*30 suppository* Refills:*2*
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleed
Colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for blood coming out of your
stoma, which resolved on its own. This was most likely due to
polyps found in your colon near your stoma site during
colonoscopy. The colonoscopy showed that these polyps might be
signs of inflammation. Some of these polyps were sampled during
the colonoscopy to better understand the type of inflammation.
To counter the inflammation, you should start taking mesalamine
twice a day and also canasa suppositories in your rectum every
evening. If you feel the medications don't work well for you,
you should inform your gastroenterologist Dr. [**Last Name (STitle) 3708**].
You were also found to have a urinary tract infection. Please
continue taking ciprofloxacin for the next 2 weeks (last day
[**1-27**])
Changes to your medications:
-START taking ciprofloxacin twice a day for the next 12 days
(last day [**1-27**])
-CONTINUE taking mesalamine 1200 mg [**Hospital1 **] and canasa suppository
every night
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) **] in [**1-9**] weeks, at
([**Telephone/Fax (1) 1300**] in order to follow up and discuss your
medications
Please also make an appointment with your gastroenterologist,
Dr. [**Last Name (STitle) 3708**]. At this appointment you will discuss the results of
your biopsy, and further diagnosis and treatment options. The
phone number is [**Telephone/Fax (1) 65629**]. Please make an appointment in
about 2 weeks.
Completed by:[**2180-1-16**] Name: [**Known lastname 17191**],[**Known firstname 63**] Unit No: [**Numeric Identifier 17192**]
Admission Date: [**2180-1-12**] Discharge Date: [**2180-1-15**]
Date of Birth: [**2121-6-11**] Sex: M
Service: MEDICINE
Allergies:
Reglan / heparin (porcine) / Vancomycin
Attending:[**First Name3 (LF) 13666**]
Addendum:
Correction: GC/chlamydia PCR were sent, however were unable to
be processed. Would consider sending as an outpatient
considering h/o penile discharge
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 13671**] MD [**MD Number(2) 13672**]
Completed by:[**2180-1-17**]
|
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icd9cm
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44,383
| 146,025
|
39324
|
Discharge summary
|
report
|
Admission Date: [**2126-7-5**] Discharge Date: [**2126-7-22**]
Date of Birth: [**2066-5-29**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
[**7-18**] PEG placement
[**7-19**] PEG Placement
History of Present Illness:
Patient is a gentleman presumed to be in mid to late 60's who
fell 6 feet over a railing yesterday and refused medical
treatment and then today developed altered mental status and
subsequently seized. His friends witnessed the seizure and
called EMS who administered benzos with good effect. He was
taken to [**Hospital 86953**] [**Hospital **] hospital where he was intubated for
"low GCS" and was noted to have SBP's in the 220's. He recieved
fentanyl for pain and his blood pressure normalized. A head CT
was performed which showed a large left frontal IPH as well as
Right temporal IPH and contusion. He was loaded with
fosphenytoin and transferred to [**Hospital1 18**] for further care. Upon
arrival he was intubated and not sedated. He was bucking the
ventilator and spontaneous movements were noted.
Past Medical History:
only known is ETOH abuse
Social History:
unknown
Family History:
nc
Physical Exam:
Gen: intubated gentleman overbreathing ventilator and agitated
when not sedated
HEENT: Pupils: PERRL EOMs intact
Neck: Hard cervical collar, Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: sedated, no commands
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2mm to
1.5mm bilaterally. Visual fields are full to confrontation.
III-XII: unable to assess
Motor: moves BUE and LLE spontaneously, briskly w/d's RLE
Sensation: unable to assess
Toes upgoing bilaterally
Coordination: unable to assess
Pertinent Results:
CT [**2126-7-5**]:Overall stable multicompartmental ICH including L
frontal intraaxial hematoma, Bifrontal and R temporal SDH, R
temporal contusions, and supratentorial SDH. No increased mass
effect,midline shift, or herniation since preceding exam.
Effacement L frontal [**Doctor Last Name 534**] same. Small SAH not excluded.
Head CT [**2126-7-11**]:
1. Decreased density of parenchymal and subarachnoid hemorrhage
with no new site seen.
2. Decrease in density but continued presence of
intraventricular hemorrhage, most prominent in the right lateral
ventricle.
3. Slight decrease in multifocal paranasal sinus disease.
B/L lower ext dopplers [**7-21**]
No evidence of DVT in bilateral lower extremities
Cervical spine x rays [**7-17**]
1. Probable scoliosis. Mild multilevel degenerative changes.
2. Minimal listhesis at C4/5 which changes between flexion and
extension.
3. Dental caries.
4. Salt-and-pepper-type appearance to the skull, of uncertain
significance.
Brief Hospital Course:
Pt was admitted to ICU and monitored closely. He had repeat CT
[**2126-7-5**] which was stable and he was weaned to extubation. He was
maintained on dilantin for seizure prophylaxis. On [**7-6**], an NGT
was place in routine fashion ands started on TFs. He was noted
to be hyponatremic with a NA of 129. As a result, he was
started on Salt Tabs TID. On [**7-8**] he continued to be confused
and pulled his NG Tube. He was hypertensive and started on
lopressor for hypertension. His dilantin was 58.8. His
phenytoin was held and was transitioned to keppra. A dobhoff
was placed in routine fashion and CXR confirmed placement in
abdominen. However, after multiple attempts to access dobhoff
it did not work. Thus, on [**7-9**] an NGT was placed in routine
fashion. Also overngiht on [**7-9**] his amlodopine and labetolol
were increased. On [**7-10**] nutrition was consulted regarding tube
feeds. Clonidine and SQH were also started. On [**7-11**] he was noted
to have a probable enterococcus UTI and cipro was started. His
PICC line was not working properly so tPA was instilled with
good effect. He was also febrile to 101.2 and ID was consulted.
They recommended resending cultures, changing foley catheter,
and recontactign them if he continued to eb febrile. On [**7-12**] he
was again febrile so ID was recontacted and they recommended
that the patient may require an LP.
Over the weekend, ID recommended that stool be sent for c.diff,
check LFTs, and discontinue all non-essential medications. They
also felt that there was no need to start patient on antibiotics
until cultures were complete. Patient was also seen to be
hyponatremic, his NaCl was increased with free water boluses
Q6H. Swelling in the RUE was noticed near his PICC line and
doppler studies were done.
On [**7-15**], patient much more alert. Speech and swallow was called
to re-evaluate. RUE doppler was negative for DVT and patient
remained afebrile throughout the weekend. ID did not feel
necessary to treat patient and will follow up the blood
cultures. Speech and swallow recommended that we keep him NPO
and they will re-evaluate on Wednesday. On [**7-16**], pt pull out
his NGT. Speech and Swallow evaluated the patient and
recommended to keep NPO and consider G-tube placement.
Subsequently, ACS was consulted for PEG tube. In addition, NGT
was replaced in routine fashion and XR confirmed placement.
Additionally, patient was more awake and cervical collar was
cleared clinically. To ensure no instability a cervical
flexion/extension was obtained to rule out instability and this
demonstrated no movement and his cervical collar was removed.
On [**7-18**], pt underwent a PEG placement with General Surgery. He
tolerated the procedure and was extubated without incident and
transferred to floor in stable condition. His tube feeds were
initiated. The patient pulled his tube back approximately 3
inches, the general surgery team evaluated him and brought him
back to the OR for replacement.
Over the weekend, tubefeeds were restarted. Patient have low
urine output and recieved a 250cc bolus. Patient was febrile
with a temperature of 101.5 and cultures were sent.
On [**7-22**], patient is stable and rehab screen was started. CXR
showed atelectasis and no growth was seen on UA. He was
afebrile. Dopplers were also negative for DVT. He will be
discharged to rehab in stable condition.
Medications on Admission:
unknown
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q6H (every 6
hours) as needed for pain.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
7. labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
8. amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
10. sodium chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3
times a day).
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
16. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Intracerebral hemorrhage
Intraventricular hemorrhage
hyponatremia
malnutrition
Pyrexia
dysphagia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been prescribed Keppra for seizure prevention, take
it as directed.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**] to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
You need to see an opthomologist for ptygerium. This has been
made for you on [**8-19**] at 2:45. They are located on the [**Hospital Ward Name 5074**], fifth floor [**Hospital Ward Name 23**] building. Please call [**Telephone/Fax (1) 253**]
You need to see a podiatrist for your toenail care. Please call
[**Telephone/Fax (1) 543**] if you have any concerns. Your appointment is on
[**7-30**] at 4pm at [**Street Address(2) **].
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2126-7-22**]
|
[
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"599.0",
"787.20",
"305.00",
"780.33",
"851.81",
"263.9",
"401.9",
"536.49",
"041.04",
"567.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
"43.19",
"44.62",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
7780, 7852
|
2961, 6353
|
329, 381
|
7993, 7993
|
1960, 2938
|
8783, 9638
|
1307, 1311
|
6411, 7757
|
7873, 7972
|
6379, 6388
|
8175, 8760
|
1326, 1586
|
268, 291
|
409, 1218
|
1639, 1941
|
8008, 8151
|
1240, 1266
|
1282, 1291
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,961
| 157,937
|
29626
|
Discharge summary
|
report
|
Admission Date: [**2146-12-26**] Discharge Date: [**2147-1-24**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
Bronchoscopy
Tracheostomy
Percutaneous gastrostomy tube placement
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **]F with DM, HTN, s/p pacer placement for
complete heart block transferred to [**Hospital1 18**] on the date of
admission, s/p a fall 2 days prior to her arrival. In the
incident, Ms. [**Known lastname **] was vacuuming at home and fell backwards,
striking her head against toilet. She denies loss of
consciousness. A CT head was without acute changes, and the pt
was noted to be dehydrated and had LLL PNA. A CT C spine showed
C2 and C5 laminar fractures, and the pt was transferred to [**Hospital1 18**]
for neurosurgical evaluation. At time of transfer, pt
reportedly had no neuro deficits, was able to move all
extremities, and c/o neck pain at times. She was initially
admitted to the wards for ongoing treatment. Shortly after her
admission, she was noted to have increasing O2 requirements.
She was tachypneic to the 30s-40s, worse with being woken up.
Her O2 requirement - initially 94% 4L NC - increased to 93% on
6L NC, then up to 97-98% on 100% NRB. At the time of eval, she
was 95% on 12L and she was transferred to the MICU for closer
monitoring with hypercarbic and hypoxemic respiratory failure.
Past Medical History:
DM2
HTN
complete heart block s/p pacer placement ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] trilogy DR[**Last Name (STitle) 71016**],
[**2138**])
cerebellar degeneration
s/p partial thyroidectomy
Social History:
Lives independently, no tobacco or EtOH.
Family History:
Non-contributory.
Physical Exam:
VS: 96.6 136/74 83 28 95% 12L Venti
Gen: appears somewhat tachypneic, more with being awakened; is
sleeping on initial evaluation
HEENT: neck in C collar
CV: RRR, nl S1/S2, no murmurs
Pulm: clear anteriorly, no wheezes or crackles
Abd: soft, NT/ND, +BS, no masses
Ext: no c/c/e
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2147-1-24**] 03:13AM 11.2* 3.23* 9.3* 28.7* 89 28.9 32.4 15.4
354
Source: Line-rt PICC
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2147-1-19**] 03:07AM 71.5* 18.0 5.1 4.5* 0.9
Source: Line-PICC
RED CELL MORPHOLOGY Hypochr
[**2147-1-19**] 03:07AM 1+
Source: Line-PICC
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2147-1-24**] 03:13AM 354
Source: Line-rt PICC
[**2147-1-24**] 03:13AM 12.1 33.0 1.0
Source: Line-rt PICC
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2147-1-24**] 03:13AM 80 30* 0.9 142 3.8 99 37* 10
Source: Line-rt PICC
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2147-1-19**] 03:07AM Using this1
Source: Line-PICC
1 Using this patient's age, gender, and serum creatinine value
of 1.2,
Estimated GFR = 42 if non African-American (mL/min/1.73 m2)
Estimated GFR = 51 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2146-12-28**] 05:16AM 9 10 207 49 51 0.6
LFT ADDED [**12-28**] @ 09:12
OTHER ENZYMES & BILIRUBINS Lipase
[**2146-12-28**] 05:16AM 36
LFT ADDED [**12-28**] @ 09:12
CPK ISOENZYMES CK-MB MB Indx cTropnT
[**2146-12-27**] 04:15AM 21* 2.7 <0.011
1 <0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2147-1-24**] 03:13AM 10.8* 2.9 2.4
Source: Line-rt PICC
HEMATOLOGIC calTIBC Ferritn TRF
[**2147-1-22**] 02:22AM 247* 201* 190*
Source: [**Name (NI) 71017**]
THYROID PTH
[**2147-1-19**] 03:07AM 97*
Source: Line-PICC
ANTIBIOTICS Vanco
[**2147-1-22**] 07:27AM 15.21
Source: Line-Right PICC; Vancomycin @ Trough
1 UPDATED REFERENCE RANGE AS OF [**2146-7-27**] == REPRESENTS
THERAPEUTIC TROUGH
LAB USE ONLY GreenHd HoldBLu RedHold
[**2147-1-20**] 04:50PM HOLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS Intubat Vent Comment
[**2147-1-18**] 01:00PM [**Last Name (un) **] 37.5 7.46*
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate
[**2146-12-30**] 02:26PM 0.9
[**2146-12-30**] 08:08AM 0.6
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) O2 Sat
[**2147-1-2**] 03:03PM 94
CALCIUM freeCa
[**2147-1-18**] 01:00PM 1.29
CERVICAL SPINE CT WITHOUT INTRAVENOUS CONTRAST:
The bones are severely demineralized. There is a comminuted
fracture of the vertebral body of C2, which extends through the
base of the odontoid (odontoid fracture type III, which is
unstable). The odontoid fragment is displaced anteriorly by 4
mm. A small posterior fragment of C2 vertebral body is displaced
into the spinal canal (series 2, images 20-21) without any
significant narrowing of the spinal canal. The fracture extends
into the left vertebral foramen.
There are minimally displaced fractures of the right and left
lamina and the spinous process of C7. There is a nondisplaced
fracture of the left lamina of T3. No definite fractures are
identified at C5, although severe demineralization limits
evaluation.
Mild loss of vertebral body height, disc space narrowing,
degenerative endplate changes and facet arthrosis is present at
multiple levels. Disc/osteophyte complexes at C3/4, C4/5, and
C5/6 result in mild narrowing of the spinal canal.
The left mastoid is underpneumatized compared to the right and
partially opacified. There is a retention cyst in the right
maxillary sinus. The patient is intubated. The thyroid gland is
diffusely enlarged and heterogeneous with multiple nodules.
Findings and recommendations were discussed with Dr. [**First Name8 (NamePattern2) 698**]
[**Last Name (NamePattern1) **] at 4:00 p.m. on [**2146-12-27**].
IMPRESSION:
1. Comminuted C2 fracture involving the odontoid (type III
odontoid fracture), which is unstable. The fracture extends
through the left vertebral foramen. If there is a clinical
concern for vertebral dissection, MRA may be performed for
further evaluation.
2. Fracture of bilateral posterior elements of C7.
3. Fracture of left T3 lamina.
4. Partially opacified left mastoid air cells.
5. Diffusely enlarged and nodular thyroid. Further evaluation by
ultrasound is recommended, if not performed previously.
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **]
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on MON [**2147-1-9**]
9:11 AM
Name: [**Known lastname **], [**Known firstname **] [**Last Name (NamePattern1) **]
Unit No: [**Numeric Identifier 71018**]
Service: MED
Date: [**2147-1-5**]
Sex: F
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 19187**]
ASSISTANT: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
PREOPERATIVE DIAGNOSIS: Respiratory failure.
POSTOPERATIVE DIAGNOSIS: Bronchoscopic-guided tracheostomy
tube placement.
PROCEDURE: Flexible bronchoscopy with therapeutic aspiration of
secretions.
INDICATION FOR PROCEDURE: Tracheostomy tube placement and
therapeutic aspiration of secretions.
DESCRIPTION OF PROCEDURE: After informed consent was
obtained, Ms. [**Known lastname **] was prepped with lidocaine applied to the
endotracheal tube. A flexible bronchoscope was introduced
through the ET tube and into the airway. There were a
moderate amount of secretions throughout the airways which were
therapeutically aspirated. There were no endobronchial lesions
up
to the subsegmental levels. Bronchoscopic imaging was then
performed in order to guide a percutaneous tracheostomy tube
insertion. After the trachesotomy, a minimal amount of bloody
secretions were removed with the bronchoscope.
COMPLICATIONS: None.
OPERATIVE REPORT
Name: [**Known lastname **], [**Known firstname **] [**Last Name (NamePattern1) **]
Unit No: [**Numeric Identifier 71018**]
Service: MED
Date: [**2147-1-5**]
Sex: F
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 19187**]
ASSISTANT: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
PREOPERATIVE DIAGNOSIS: Respiratory failure.
POSTOPERATIVE DIAGNOSIS: Respiratory failure.
PROCEDURE: Percutaneous gastrostomy tube placement.
INDICATIONS FOR PROCEDURE: Need for long-term nutrition.
DESCRIPTION OF PROCEDURE: After informed consent was
obtained, the patient was given a single dose of vancomycin 1
gram IV, and was placed on a 45-degree angle. The patient was
already sedated with propofol and mechanical ventilation. The
gastroscope was inserted through the oral cavity and passed
through the esophagus into the stomach. The mucosa was
entirely normal with no obvious lesions.
The skin over the left upper quadrant was palpated, and a
sharp indentation with 1 finger was seen, as well as
excellent transillumination. The skin was prepped with
chlorhexidine and draped in the usual sterile fashion. Local
anesthesia was employed with 1% lidocaine at the left upper
quadrant site. An Angiocatheter was inserted under direct
vision, and a snare was lassoed and pulled back through the
esophagus and into the oral cavity. A 20 French PEG tube was
loaded and pulled back through the oral cavity in the
esophagus and through the abdominal wall. The gastroscope was
reinserted to confirm excellent placement with a mushroom cap
against the abdominal wall cavity. Bolsters were placed at 3
cm to secure the PEG tube.
COMPLICATIONS: None.
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **]F with DM, HTN, s/p pacer placement for
complete heart block transferred to [**Hospital1 18**] on the date of
admission, s/p a fall 2 days prior to her arrival. In the
incident, Ms. [**Known lastname **] was vacuuming at home and fell backwards,
striking her head against toilet. She denies loss of
consciousness. A CT head was without acute changes, and the pt
was noted to be dehydrated and had LLL PNA. A CT C spine showed
C2 and C5 laminar fractures, and the pt was transferred to [**Hospital1 18**]
for neurosurgical evaluation. At time of transfer, pt
reportedly had no neuro deficits, was able to move all
extremities, and c/o neck pain at times. She was initially
admitted to the wards for ongoing treatment. Shortly after her
admission, she was noted to have increasing O2 requirements.
She was tachypneic to the 30s-40s, worse with being woken up.
Her O2 requirement - initially 94% 4L NC - increased to 93% on
6L NC, then up to 97-98% on 100% NRB. At the time of eval, she
was 95% on 12L and she was transferred to the MICU for closer
monitoring with hypercarbic and hypoxemic respiratory failure.
.
Her MICU course, by problem:
[**Age over 90 **]F with DM, HTN, s/p pacer, with hypoxemic and hypercarbic
respiratory failure.
.
# Respiratory Failure - Ms. [**Known lastname **] had a persistent ventilator
requirement throughout her MICU stay, eventually requiring
placement of a tracheostomy tube and percuteaneous gastrostomy
tube. CT scans of the chest showed pleural effusions and she
completed two separate courses of antibiotics
(vancomycin/cefepime) for evolving pneumonias. She remained
intermittently dependent upon ventilator support and now
tolerates trach collar for longer periods of time, particularly
in the daytime hours. Bronchoscopy did not show cause for her
persistent requirement. She will need to continue antibiotics
for a total 14 day course (started [**2147-1-11**]).
.
# Low grade fever and leukocytosis- Felt to be related to her
bacteremia, likely stemming from pneumonia. She grew coag
negative staph from her blood cultures on [**2147-1-11**]. She was
treated with vancomycin and cefepime. A BAL grew only
oropharyngeal organisms. Urine cx on [**1-12**] +yeast
.
# C-Spine fractures - Ms. [**Known lastname **] [**Last Name (Titles) 18095**] a C2 fracture,
extending up to the odontoid, and a C7 fracture in her initial
fall. She was evaluated by neurosurgery and felt not to be a
candidate for halo placement given her age and comorbidities.
She was placed in a hard cervical collar, which will remain for
3 months from the date of injury. She will need to follow up
with Dr. [**Last Name (STitle) **] as an outpatient, approximately 4 weeks from
discharge. A Head CT was negative for intracranial injury.
.
# chronic kidney disease - Baseline Cr not known- stable.
.
# DM2 - Pt is on oral hypoglycemics at home (metformin), which
were held during her hospitalization to allow for better control
of her glucose levels. She may be restarted on her meds as an
outpatient.
.
# HTN - Her home regimen antihypertensives were held and IV
medications were used as needed for BP control.
.
# Code - Ms. [**Known lastname **] is full code, this was confirmed with son
[**Name (NI) **].
.
# Communication - son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 71019**]
Medications on Admission:
accupril 40mg daily
atenolol 50mg daily
diazide 1 tab po daily
aspirin 325mg daily
metformin 1g [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
2. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H (every
8 hours) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
injection Injection TID (3 times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
5. Fentanyl 50 mcg/hr Patch 72HR [**Hospital1 **]: One (1) Patch 72HR
Transdermal Q72H (every 72 hours): hold for sedation.
6. Haloperidol 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
7. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: One (1) dose PO Q4-6H
(every 4 to 6 hours) as needed.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
10. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
11. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed.
12. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Last Name (STitle) **]: [**11-29**]
Puffs Inhalation Q6H (every 6 hours) as needed.
13. Camphor-Menthol 0.5-0.5 % Lotion [**Month/Day (2) **]: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
14. Metformin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
15. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
16. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1)
injection Injection ASDIR (AS DIRECTED).
17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Hospital1 **]: One
(1) flush Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Cervical spine fracture
S/P tracheostomy tube placement
S/P percutaneous gastrostomy tube placement
Pneumonia
Respiratory Failure
Discharge Condition:
Stable
Discharge Instructions:
You have had a cervical spine fracture resulting in your need
for the hard collar. You will need to stay in the collar for 3
months from when it was placed. Then, you will need further
follow-up with the neurosurgeons.
.
You also have had multiple pneumonias and needed intubation and
tracheotomy placement.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] from neurosurgery in
approximately 4 weeks: ([**Telephone/Fax (1) 88**]. You should have a follow
up C-spine CT before your appointment. Please arrange for this
CT at [**Hospital1 18**] by calling ([**Telephone/Fax (1) 6713**].
Please follow up with your PCP 1-2 weeks after discharge from
rehab.
|
[
"E888.1",
"276.51",
"482.41",
"707.03",
"518.5",
"252.01",
"241.0",
"V45.01",
"250.00",
"790.7",
"805.2",
"585.9",
"401.9",
"721.90",
"276.0",
"805.07",
"805.02",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.05",
"96.04",
"99.04",
"33.24",
"43.11",
"38.93",
"96.6",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
15238, 15318
|
9739, 13109
|
272, 339
|
15491, 15499
|
2185, 9716
|
15855, 16208
|
1848, 1867
|
13273, 15215
|
15339, 15470
|
13135, 13250
|
15523, 15832
|
1882, 2166
|
224, 234
|
367, 1531
|
1553, 1774
|
1790, 1832
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,847
| 138,564
|
39973
|
Discharge summary
|
report
|
Admission Date: [**2191-3-7**] Discharge Date: [**2191-3-9**]
Date of Birth: [**2127-3-17**] Sex: F
Service: NEUROSURGERY
Allergies:
Prochlorperazine / Aspirin / Nsaids
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
L MCA aneurysm
Major Surgical or Invasive Procedure:
[**2191-3-8**]: Cerebral Angiogram with Coiling of the L MCA aneurysm
History of Present Illness:
63F elective admission for L MCA aneurysm coiling
Past Medical History:
Fibromyalgia, anxiety, depression
PSH for colon cancer surgery, tubal ligation, laminectomy and
spinal fusion, hemorrhoidectomy, exploratory exposure surgery
for ovarian cysts appendectomy.
Social History:
Smoker 1ppd for 30 years
Family History:
Noncontributory
Physical Exam:
Pre-procedure:
Exam nonfocal
Post-procedure:
Exam nonfocal
Brief Hospital Course:
63F who was admitted for an elective admission. She was
originally scheduled for coiling on the 14th but emergent cases
delayed and she was admitted overnight so she may go Tuesday
15th AM. Post-coiling she was admitted to the ICU for
observation. She did well and remained stable, but overnight her
SBP was 70-80 and was placed on Neo for some time. [**3-9**] AM the
neo was discontinued and her pressures maintained. Her foley was
removed and she voided. She ambulated independently. She was
discharged on [**2191-3-9**] to home.
Medications on Admission:
aspirin 325 mg
butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-23**]
Tablets PO Q4H (every 4 hours) as needed for headache
escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
pregabalin 75 mg Capsule Sig: Two (2) Capsule PO BID (2 times a
day).
diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours)
as needed for anxiety.
ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as
needed for Insomnia.
Vicodin PRN
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-23**]
Tablets PO Q4H (every 4 hours) as needed for headache: Do not
exceed 8 tablets in one day. Do not take with Vicodin.
Disp:*90 Tablet(s)* Refills:*1*
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain: Please see PCP for refill.
Disp:*20 Tablet(s)* Refills:*0*
4. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. pregabalin 75 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
9. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
10. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
11. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for Insomnia.
Discharge Disposition:
Home
Discharge Diagnosis:
L MCA aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with coiling
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
** Please follow-up with your PCP regarding pain management. You
were taking Fioricet and Vicodin and this exceeded a safe amount
of Tylenol in one day which can be harmful to your liver. We
have provided you a prescription for oxycodone which does not
have tylenol to have until you speak with your PCP regarding
your pain management. ***
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Known lastname **] in 4 weeks, no imaging is
needed at that time. You will also need to see him 6 months from
coiling with a MRI/MRA Brain +/-. Please call [**Telephone/Fax (1) 4296**] to
make this appointment.
Completed by:[**2191-3-9**]
|
[
"437.3",
"300.4",
"305.1",
"V10.05",
"V45.4",
"729.1",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"88.48",
"39.76"
] |
icd9pcs
|
[
[
[]
]
] |
3291, 3297
|
851, 1384
|
311, 383
|
3356, 3356
|
5782, 6086
|
735, 752
|
2168, 3268
|
3318, 3335
|
1410, 2145
|
3507, 4499
|
4525, 5759
|
767, 828
|
257, 273
|
411, 462
|
3371, 3483
|
484, 676
|
692, 719
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,166
| 115,359
|
38198
|
Discharge summary
|
report
|
Admission Date: [**2201-7-22**] Discharge Date: [**2201-7-26**]
Date of Birth: [**2169-5-2**] Sex: M
Service: SURGERY
Allergies:
Egg
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
31 year old male s/p fall of [**2106**] feet.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
31 year old male with a mechanical fall of [**2106**] while on
construction site performing a roof repair. Patient was brought
to the ED in obtunded state. There was a failed intubation at
the scene of the accident. Patient was intubated in the ED and
evaluated for injuries.
Past Medical History:
Substance Abuse
Social History:
Married and lives with wife.
[**Name (NI) 85176**] abuse.
Family History:
NC
Physical Exam:
Gen: Well-appearing, NAD
HEENT: neck is sore, but with normal ROM
Chest: CTAB
CV: RRR
Abd: Soft, non-tender, non-distended.
Msk: Neurovasculary intact in extremities.
Pertinent Results:
[**7-21**] - CT scans of Head, C-Spine, Abdomen, Pelvis all show no
acute injury.
Lab results below show stable Hematocrit.
[**2201-7-23**] 03:41AM BLOOD WBC-9.6 RBC-4.53* Hgb-13.4* Hct-39.4*
MCV-87 MCH-29.5 MCHC-33.9 RDW-13.8 Plt Ct-243
[**2201-7-22**] 09:05PM BLOOD WBC-7.4 RBC-4.31* Hgb-12.8* Hct-37.1*
MCV-86 MCH-29.7 MCHC-34.5 RDW-14.1 Plt Ct-278
Brief Hospital Course:
32M s/p fall from 15 ft onto soft ground, intubated in ED for
airway protection, reported GCS 3. In TSICU able to MAE and
follow commands, exam w/o e/o trauma. Patient was extubated,
found to be stable and transferred to the floor. Patient was
found to have no acute injuries on clinical exam or on CT scans.
Patient will be discharged to home.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3)
Tablet Sustained Release 12 hr PO every eight (8) hours as
needed for pain for 1 weeks.
Disp:*40 Tablet Sustained Release 12 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
status post fall.
possible nasal septal fracture, no acute intracranial process.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call if fever >101 F. Call if dizziness, weakness of
extremities, fainting spells or other symptoms of concern. Call
with any questions or concerns. Call if increasing pain.
Ambulate daily.
Call in any symptoms are concerning.
Followup Instructions:
Follow up Primary Care Physcian in one week/
Patient will f/u with Orthopaedics, Dr. [**Last Name (STitle) 85177**].
Completed by:[**2201-7-27**]
|
[
"780.09",
"304.00",
"719.46",
"E882"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2099, 2105
|
1337, 1684
|
308, 314
|
2230, 2230
|
959, 1313
|
2634, 2782
|
750, 754
|
1739, 2076
|
2126, 2209
|
1710, 1716
|
2381, 2611
|
769, 940
|
223, 270
|
342, 620
|
2245, 2357
|
642, 659
|
675, 734
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,468
| 199,762
|
1571
|
Discharge summary
|
report
|
Admission Date: [**2111-8-24**] Discharge Date: [**2111-10-12**]
Date of Birth: [**2049-8-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Found unresponsive in driveway
Major Surgical or Invasive Procedure:
- Right craniotomy with evacuation of subdural
hematoma/intracerebral
hemorrage and right temporal lobectomy.
- PEG placement
- Tracheostomy
- Reduction nasal fracture
History of Present Illness:
This patient is currently unidentified female in her 60's who
was found down in her driveway and unresponsive. Paramedics were
called and pt reported to be GCS at the scene. She was taken to
OSH where she was intubated and CT head was obtained. Initial
reports from OSH were of a 11mm acute SDH with 9mm of midline
shift. She was transferred to [**Hospital1 18**] for emergent neurosurgery
evaluation.
Past Medical History:
EtOH abuse
HTN
Social History:
Chronic ETOH abuse, patient is adopted, has one daughter,
husband passed away
Family History:
unknown secondary to adoption
Physical Exam:
On admission:
BP: 155/77 HR: 83 R 14 O2Sats 100
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: L 4mm-3mm R 3mm-2mm ck: Supple.
Neuro:
Mental status: Pt is intubated. She is not following commands
and
she does not open her eyes. She does have spontaneous movement
in
her RUE and withdraws BLE. She has no movement to noxious in her
LUE. Her face appears symmetric.
On discharge:
Pertinent Results:
Admission Labs:
[**2111-8-24**] 09:32PM BLOOD WBC-8.3 RBC-2.01* Hgb-7.4* Hct-21.9*
MCV-109* MCH-36.7* MCHC-33.7 RDW-14.4 Plt Ct-192
[**2111-8-24**] 09:32PM BLOOD PT-18.9* PTT-56.5* INR(PT)-1.7*
[**2111-8-24**] 09:32PM BLOOD Fibrino-73*
[**2111-8-25**] 12:40AM BLOOD Glucose-178* UreaN-9 Creat-0.8 Na-136
K-4.2 Cl-104 HCO3-13* AnGap-23*
[**2111-8-26**] 02:12AM BLOOD ALT-13 AST-26 LD(LDH)-220 AlkPhos-60
Amylase-241* TotBili-0.4
[**2111-8-24**] 08:45PM BLOOD Lipase-40
[**2111-8-25**] 12:40AM BLOOD Calcium-7.6* Phos-5.6* Mg-2.0
[**2111-8-26**] 02:12AM BLOOD Phenyto-26.2*
[**2111-8-24**] 08:45PM BLOOD ASA-NEG Ethanol-229* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2111-8-24**] 09:53PM BLOOD pO2-447* pCO2-32* pH-7.27* calTCO2-15*
Base XS--10 Intubat-INTUBATED
[**2111-8-24**] 08:55PM BLOOD Lactate-3.6*
[**2111-8-24**] 09:53PM BLOOD Glucose-135* Lactate-3.3* Na-134* K-3.5
Cl-108
[**2111-8-24**] 11:05PM BLOOD Glucose-145* Lactate-2.7* Na-132* K-4.0
Cl-102
[**2111-8-24**] 09:53PM BLOOD freeCa-0.97*
.
Labs during hospitalzation:
[**2111-9-5**] 12:11PM BLOOD Ret Aut-1.7
[**2111-9-5**] 12:11PM BLOOD TotBili-0.2
[**2111-9-4**] 03:12PM BLOOD Iron-31
[**2111-9-5**] 12:11PM BLOOD Hapto-307*
[**2111-9-4**] 03:12PM BLOOD calTIBC-218* VitB12-323 Folate-15.1
Ferritn-1065* TRF-168*
[**2111-9-10**] 12:50PM BLOOD Osmolal-268*
[**2111-9-9**] 05:41AM BLOOD TSH-7.1*
[**2111-9-10**] 05:30AM BLOOD T4-6.1
.
Discharge Labs:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2111-10-12**] 07:30 9.1 3.01 9.7 28.6 95 32.1 33.8 15.3 326
PT PTT INR(PT)
[**2111-10-12**] 07:30 12.5 23.7 1.1
Glucose UreaN Creat Na K Cl HCO3
[**2111-10-12**] 07:30 128 11 0.5 139 4.3 104 26
.
Urine:
[**2111-8-24**] 08:45PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.032
[**2111-8-24**] 08:45PM URINE Blood-LG Nitrite-NEG Protein-25
Glucose-100 Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2111-8-24**] 08:45PM URINE RBC->1000 WBC-[**6-4**]* Bacteri-MANY
Yeast-NONE Epi-0
[**2111-8-24**] 08:45PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2111-8-29**] 07:22PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.015
[**2111-8-29**] 07:22PM URINE Blood-LG Nitrite-POS Protein->300
Glucose-NEG Ketone-40 Bilirub-LG Urobiln-2* pH-5.5 Leuks-LG
[**2111-8-29**] 07:22PM URINE RBC->50 WBC-[**6-4**]* Bacteri-MOD Yeast-NONE
Epi-0-2
[**2111-8-29**] 07:22PM URINE Hours-RANDOM UreaN-512 Creat-111 Na-72
K-55 Cl-66
[**2111-8-28**] 09:00PM URINE Osmolal-394
[**2111-10-5**] 05:58AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2111-10-5**] 05:58AM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
ENTEROCOCCUS SP >100,000 ORGANISMS/ML
.
Pleural Fluid:
[**2111-9-4**] 05:01PM PLEURAL WBC-190* RBC-325* Polys-29* Lymphs-40*
Monos-2* Meso-5* Macro-24*
[**2111-9-4**] 05:01PM PLEURAL TotProt-1.9 LD(LDH)-123 Albumin-1.5
Cholest-40
.
.
Imaging:
CTA HEAD [**2111-8-24**]
A 2.9 x 2.5 cm R temporal lobe hgic contusion. Multiple regions
of
hyperdense, extra-axial blood (Subdural with possible
epidural)799 along the right cerebral convexity. 9 mm leftward
shift of midline structures. Sub- falcine herniation. These
findings have progressed since the earloer study. Basal cisterns
patent. Multiple fractures involving anterior wall of Rmaxillary
sinus, nasal process of R maxillary bone, left zygomatic arch
extending to the left sphenoid [**Doctor First Name 362**] and left squamous temporal
and parietal bones. left lateral orbital wall .
CTA: No vascular injury or occlusion identified in source
images. 3 D recons pending.
CT HEAD [**8-25**] POST-OP
Expected postoperative changes status post evacuation of
right-sided subdural hematoma and right temporal
intraparenchymal hemorrhage.
There is continued leftward shift of midline structures of 9 mm,
unchanged.Small residual hematoma in the right temporal lobe.
CT Head [**8-26**]:
Status post right craniotomy for subdural hemorrhage evacuation,
decreasing size of post-surgical bed with decreased mass effect,
evolving
intraparenchymal hemorrhage
CT Head [**8-27**]:
Little change since the previous study with stable leftward
shift of midline structures of approximately 6 mm.
CT head [**8-28**]:
Improving leftward shift of midline structures, now measuring 4
mm, previously 6 mm, with resolving pneumocephalus. Stable fluid
collection overlying the right frontoparietal lobes. Areas of
previously noted hemorrhage are stable.
MRI brain [**8-28**] +/- gad
1. No evidence of acute infarct or hydrocephalus.
2. Post-operative changes of subdural hematoma evacuation with
blood products and air within the subdural space measuring up to
1.4 mm as on the CT obtained earlier on the same day, [**2111-8-28**].
3. Small amount of subarachnoid and intraventricular blood as
well as right temporal hematoma again identified.
4. No enhancing brain lesions seen on the post-gadolinium
images.
CT head [**8-30**]:
Stable appearance of the brain, status post right craniotomy
with
a stable 3.5 mm leftward shift. Otherwise normal appearance of
evolving right temporal hematoma. No new site of hemorrhage.
Stable opacification of the ethmoidal air cells and layering
fluid within bilateral maxillary sinuses.
CTA chest +/- [**9-3**]: No evidence of pulmonary embolism in the
first to fifth order pulmonary arteries, although evaluation
distal to this level particularly in the lower lobes is limited
by atelectasis.
Patulous esophagus with mild gastric distention and pooled
airway secretions.
place the patient at risk of aspiration.
Probable tendency to tracheal collapse.
Severe coronary artery disease.
Probable anemia.
[**9-4**] PCXR: Increasing left and new large right pleural
effusions with
associated lower lobe atelectasis. Persistent gastric
distention.
[**9-4**] PCXR: There has been interval decrease in the right-sided
pleural effusion. There remains some minimal blunting of both CP
angles consistent with small pleural effusions. Unchanged left
retrocardiac opacity. The tracheostomy tube and left-sided
central venous catheter are unchanged in position. There are no
signs for overt pulmonary edema.
[**9-5**] CT A/P w/o con: No evidence of retroperitoneal hemorrhage.
No CT findings to explain declining hematocrit.
2. Small bilateral pleural effusions and dependent bibasilar
atelectasis.
3. Atherosclerosis.
[**9-7**] TTE: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (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. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
[**9-10**] EEG: This telemetry captured no pushbutton activations.
Recording over the 24-hour period showed no epileptiform
features or
electrographic seizures. Background voltages were decreased over
the
left side. This could be related to the skull defect on the
right.
Cardiogram showed a regular tachycardia. There were no
electrographic
seizures.
[**9-11**] EEG: This extended monitoring on [**2111-9-11**] showed
a
mildly slow background throughout, with more disorganization and
posterior delta slowing on the right side. This was unchanged
from
earlier recordings. There were no epileptiform features or
electrographic seizures.
.
[**2111-9-30**] CT Head
IMPRESSION:
.
1. Interval increase in size of ventricular system predominantly
involving
the temporal and the occipital horns. Findings may represent
underlying
atrophy, but continued followup in 24-48 hours is recommended to
document
stability as hydrocephalus is not excluded. There is no evidence
of
transependymal migration of CSF, however.
.
2. Stable right frontal subdural collection consistent with
patient's known
subdural hematoma. Interval resolution of right temporal
intraparenchymal
hematoma with residual right middle cranial fossa subdural
collection. Stable 2.4 mm leftward midline shift.
.
[**2111-10-8**] CT Head:
FINDINGS: There is no evidence of acute hemorrhage, large acute
territorial infarction, or large masses. The patient is status
post right frontoparietal craniotomy. There is a stable right
frontal hypodense extra-axial fluid collection consistent with
evolution of right subdural hematoma, measuring 12mm in largest
diameter. There is mass effect on adjacent sulci of the right
hemisphere. There is stable 2-mm leftward shift of midline
structures, 2:10. There is an area of hypodensity at the right
temporal lobe at site of prior hemorrhage, with a stable
residual right middle cranial fossa small extra-axial fluid
collection, 2:7. There is a focal hypodensity in the left basal
ganglia, in keeping with old lacunar ischemic event. The
ventricles are prominent, however, stable compared to CT from
[**2111-9-30**]. There is no subfalcine or uncal herniation.
There is opacification in several mastoid cells bilaterally.
There is mucosal thickening in the sphenoid sinus.
.
IMPRESSION:
1. Stable prominence of ventricles compared to [**2111-9-30**].
Findings may represent underlying atrophy.
2. Stable right frontal extra-axial fluid collection in keeping
with
evolution of subdural hematoma.
3. Hypodensity in the right temporal lobe at the site of prior
hematoma with stable residual small right middle cranial fossa
subdural collection.
Brief Hospital Course:
Patient was transferred to [**Hospital1 18**] from an outside hospital after
being found down at home in her driveway with a GCS of 3. At
the OSH she had a Noncontrast CT scan of the head which showed a
Right sided acute on Chronic SDH as well as a Right temporal ICH
measuring 2.9cm x 2.5cm. She was also noted to have 9mm of
midline shift to the left and subalfcine herniation as well as
multiple facial fractures. Upon arrival at [**Hospital1 18**] her exam was
poor as she was following no commands, and her pupils were
asymmetric the decision was made to take her emergently to the
OR for evacuation of the SDH. Intraoperatively she was noted to
have an INR of 1.7 and a PTT of 56.5. For this she received 2
units of PRBC's as well as FFP and cryoprecipitate. Following
the procedure she was transferred to the ICU where she remained
intubated overnight, and was started on decadron and dilantin.
On morning rounds on [**8-25**] she was found to be more interactive
off sedation and intermittently following commands. Plastics was
consulted to evaluate her facial fractures and recommended a
dedicated Maxillofacial CT to better evaluate the extent of the
fractures. Plastics decided to repair her nasal fracature at
the bedside on [**8-26**]. This was done successfully, and she was
placed on antibiotics.
On [**8-26**], a CT of the cervical spine was obtained to rule out neck
injury. This did not demonstrate any acute cervical fracture.
Her C-Spine was cleared by the TSICU staff. Her neurological
exam reamined unchanged.
On [**8-27**] - a repeat CT dmonstrated little to no change in the size
of her SDH and MLS. She remained intubated, as she had a weak
gag.
On [**8-28**], on examination, patient was less interactive following
no commands, she was brisk with localization in the RUE and
brisk w/d in the RLE, but no movement in the LUE to noxious
stimuli and spontaneous movement in the LLE toes, but no w/d. An
MRI was ordered to rule out stroke, and this was negative.
Neurology was consulted on [**8-29**], and they recommended continuous
EEG monitoring to rule out seizure. Keppra was added to her
Dilantin, and her neurological exam continued to be closely
monitored. She received a trach and a PEG tube as well.
On [**9-1**], patient's exam much improved. She was able to follow
simple commands on RUE, shows two fingers and squeeze hands, w/d
RLE to noxious stimuli. L side is plegic, but patient stable
overall. She was also given a bolus of dilantin for a dilantin
level of 6.1.
Her staples were removed on [**9-2**]. Overnight she was tachycardic
and tachypenic. A CT Chest was obtained and was negative for PE.
It did show bilateral effusions with lower lobe collapse. EKG
showed tachycardia and enzymes were orderd and the first CK was
48. Her clindamycin was dicontinued as she completed a 7 days
course for her nasal fracture. Neurology was closely followng
her dilantin levels and bolusing when appropriate.
[**9-4**] Pt tachypneic into the 40's on this day as well as
tachycardic. CT chest revealed bilateral pleural effusions on
[**9-3**]. The patient underwent thoracentesis and her respiratory
status returned to [**Location 213**]. She later underwent a TTE which
showed normal LVEF.
She also developed a UTI with e. coli resistant to bactrim. She
was started on ciprofloxacin and completed a 7 day course for
complicated UTI related to Foley. Foley was d/c'ed week of [**9-11**]
but did not spontaneously void and Foley was replaced.
She also became quite anemic with a HCT of 18. An anemia workup
revealed decreased reticulocytes as well as iron deficiency. She
underwent CT Abdomen/Pelvis which revealed no evidence of
retroperitoneal hemorrhage. The patient was transfused 2u pRBCs
and her HCT remained stable at around 30 for the remainder of
her hospitalization.
The patient developed hyponatremia to 126. Urine lytes were
consistent with SIADH. Tube feeds were concentrated and protein
was added. Hyponatremia stabilized, normalized.
Over the course of her hospitalization, her mental status
improved dramatically and she was able to work with PT such that
she was standing with a 1 person assist. She was out of bed to
the chair. She passed speech and swallow and was able to eat a
pureed diet with thin liquids. She had the tracheostomy
removed, and she improved such that she was conversant and
mostly appropriate, though word finding difficulty was an issue.
She underwent calorie count, and she was able to have the PEG
removed.
She was followed by neurology given concern for seizure activity
(see above). She was started on keppra, dilantin, and lorazepam
with tapering lorazepam (stopped prior to discharge)and dilantin
based on level (150mg TID). She was also seen by psychiatry for
delirium in the setting of multiple [**Date Range 4982**]. We tapered her
lorazepam off and we started valproic acid with taper of keppra
starting on [**10-11**] once valproic acid was therapeutic. SHe was
started on Thorazine for restlessness and agitation, and her
delirium improved.
On [**10-25**] her delirium and agitation began to slowly
worsen, and a urine was checked. She had a positive culture
which grew enterococcus. She was started on cefpodoxime and
switched to nitrofurantoin when sensitivities returned.
The patient remained full code throughout her hospitalization.
[**Date range (1) **] on Admission:
none known
Discharge [**Date range (1) **]:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain or fever.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day): please stop once patient
mobilizes.
3. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for irritation.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day): hold for loose stool, patient may refuse.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
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. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
10. 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.
11. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) g PO DAILY (Daily) as needed for constipation.
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash around anus.
13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
15. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO Q 12H
(Every 12 Hours).
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. Phenytoin 100 mg/4 mL Suspension Sig: Eight (8) mL PO Q2PM
().
18. Phenytoin 100 mg/4 mL Suspension Sig: Six (6) mL PO BID (2
times a day).
19. Outpatient Lab Work
Please check Dilantin (phenytoin) level every other day
Discharge Disposition:
Extended Care
Facility:
Neuro-Rehabilitation Center - [**Location (un) 7740**]
Discharge Diagnosis:
Primary:
- Traumatic right temporal ICH s/p lobectomy
- Acute on chronic right subdural hematoma
- Basilar skull fracture
- Multiple facial fractures
- Alcohol intoxication
- Catheter associated UTI
- Generalized seizure
- Blood loss anemia
- SIADH
Secondary:
- Alcohol abuse
- Hypertension
- Radial nerve compression
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:
WOUND CARE
?????? You or a family member should inspect your wound every day and
report any problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
[**Name Initial (NameIs) **]:
?????? Take all of your [**Name Initial (NameIs) 4982**] as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? [**Name Initial (NameIs) **] that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing. This can be drawn at your PCP??????s office, but
please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been
discharged on Keppra (Levetiracetam), you will not require blood
work monitoring.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
You underwent craniotomy and craniectomy with right temporal
lobectomy. You were also found to have difficulty breathing so
we removed fluid from around your lungs. Your breathing
improved. You had a urinary tract infection which we treated
with antibiotics. There was concern you had a seizure and you
were started on anti-seizure [**Telephone/Fax (1) 4982**]. Your blood pressure
was high so we started [**Telephone/Fax (1) 4982**] to lower it. You had low
blood counts and no evidence of internal bleeding. It was
probably related to your recent surgery. We transfused you with
blood and your counts improved. Your sodium was low and we
restricted your fluids.
.
You were admitted to the hospital with bleeding in your brain.
You underwent emergent neurosurgery and a portion of your skull
and brain was removed. You tolerated the procedure well. You had
a feeding tube placed. Later in the hospitalization, there was a
concern that you were having a seizure and the neurologists
started seizure [**Telephone/Fax (1) 4982**]. You later had EEGs of your brain
which showed no evidence of seizures. You had low blood counts
but no evidence of bleeding. This is probably related to your
alcohol intake in the past and your recent surgery. We
transfused your blood products. You were also found to have a
urinary tract infection. We treated it with antibiotics. You
worked with physical therapy and occupational therapy.
.
You were not known to be taking any [**Telephone/Fax (1) 4982**] prior to
admission. You should continue to take the following
[**Telephone/Fax (1) 4982**]:
.
1. Heparin (Porcine) 5,000 unit/mL Solution Injection 3 times a
day: please stop once patient mobilizes.
2. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment: One (1)
Appl Ophthalmic as needed as needed for irritation.
3. Docusate Sodium 50 mg/5 mL Liquid: Ten (10) ml by mouth 2
times a day. Hold for loose stool, patient may refuse.
4. Senna 8.6 mg by mouth 2 times a day as needed for
constipation.
5. Bisacodyl 10 mg by mouth daily as needed for constipation.
6. Polyethylene Glycol 3350 17 gram/dose 17g by mouth daily as
needed for constipation.
7. Miconazole Nitrate 2 % Powder Appl Topical 4 times a day as
needed for rash around anus
8. Amlodipine 10 mg by mouth daily
9. Levetiracetam 1000 mg by mouth every 12 hours
10. Metoprolol Tartrate 50 mg Tablet by mouth 2 times a day
11. Outpatient Lab Work Please check Dilantin (phenytoin) level
every week
12. Phenytoin 100 mg/4 mL Suspension: six (6) mL (150mg) by
mouth three times a day.
13. chlorpromazine 25 mg by mouth every 6 hours as needed for
severe agitation.
14. acetaminophen 325 mg 1-2 tabs by mouth every 6 hours as
needed for Pain
15. simethicone 80 mg Tablet, Chewable by mouth 3 times a day as
needed for bloating
16. chlorpromazine 37.5 mg by mouth once a day at bedtime
17. chlorpromazine 25 mg by mouth 3 times a day
18. thiamine HCl 100 mg by mouth daily
19. folic acid 1 mg by mouth daily
20. multivitamin one (1) tablet by mouth daily
21. cyanocobalamin (vitamin B-12) 250 mcg by mouth daily
22. nitrofurantoin (macrocryst25%) 100 mg by mouth 2 times a day
for 7 days: Last day of therapy is [**2111-10-13**]
23. valproic acid (as sodium salt) 250 mg/5 mL Syrup Fifteen
(15) ml by mouth every night
24. valproic acid 250 mg/5 mL Syrup Ten (10) ml by mouth every
morning
.
You should have your phenytoin level checked every week and your
dose should be adjusted accordingly. The goal level is between
15-20.
.
Your goal valproic acid level is 50-100. Once it is at a
therapeutic level, your Keppra should be tapered as follows.
750mg by mouth twice a day for 4 days, then 500mg by mouth twice
a day for 3 days. Then this medication can be stopped.
.
You should stop drinking alcohol.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], upon discharge from rehab. You will need a CT scan of
the brain without contrast.
You can follow up with Dr. [**First Name (STitle) **] of Plastic surgery if you have
any concerns about your nasal fracture ([**Telephone/Fax (1) 9144**]
.
You should make an appointment to follow up with your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 9145**], at [**Telephone/Fax (1) 9146**] upon discharge from rehab.
You should have your dilantin level checked every other day.
Department: NEUROLOGY
When: FRIDAY [**2111-10-23**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD [**Telephone/Fax (1) 3294**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2111-10-12**]
|
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icd9cm
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[
[
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[
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icd9pcs
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304, 474
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19162, 19162
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1513, 1513
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27378, 28318
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1054, 1085
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18820, 19141
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19342, 21773
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2956, 10077
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1100, 1100
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1494, 1494
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21800, 27355
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234, 266
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502, 905
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10086, 11431
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1529, 2920
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16833, 18695
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19177, 19318
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927, 943
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959, 1038
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