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28,641
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5758
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Discharge summary
|
report
|
Admission Date: [**2196-9-18**] Discharge Date: [**2196-9-30**]
Date of Birth: [**2116-7-16**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / Keppra
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Attempted PEG tube placement
History of Present Illness:
This is a 80 y/o male with metastatic melanoma to the brain and
Parkinson's disease who was brought to the ED by his family by
ambulance on [**2196-9-19**] because several days of altered mental
status.
.
The pt has been c/o gradually worsening confusion, increased
movements, difficulty with speech and decreased fluid intake
(recent swallow eval recommending no thin liquids). His wife
noticed increased fatigue over the past couple days. One day PTA
he was not able to sit still in the church and was listing to
the right. His wife stated that he had a right facial droop
concerning for a stroke and he was transported to the ED at
[**Hospital1 18**].
.
In the ED, HR 68 BP 99/68 RR 20 SAT 97%, FS140. Seen by
neurology, who felt he was not having a stroke. Labs significant
for elebated troponin, CK, and CK-MB. UA negative. Head CT
negative for hemorrhage. Exam was negative for right facial
droop and listing to his right side. He had dyskinesia of
UE/LE/mouth but without focal weakness. There was right
flattening of nasolabial fold (but wife says this is his
longstanding baseline). He was given 0.5 mg Ativan and IV fluids
and admitted to the medicine service for further evaluation.
Past Medical History:
1. Hypertension
2. Metastatic Melanoma with mets to the brain (bilateral
cerebral hemishpheres), liver, lungs, and spine. Had whole brain
radiation on [**2196-8-26**] for ten sessions. Finished on [**2196-9-16**].
3. Parkinson's Disease
4. Anemia (baseline 30-32)
Social History:
Lives with his wife in [**Name (NI) **]. Has several children. Former
smoker, occassional alcohol.
Family History:
Non contributory
Physical Exam:
VITALS: T 97.9 HR 55 BP 130/68 RR 20 Sat 97%RA Pain 0/10
GENERAL: Ill appearing elderly male, poorly responsive at first
but able to open eyes and follow commands. Eyes dry and crusted
shut. Mucous membranes severely dry and tongue stuck within
[**Last Name (un) 22923**].
SKIN: Dry with multiple skin tears with bandages over them.
HEENT: NC/AT. Sclera Anicteric, EOMI w/ limited right movement,
PERRL.
NECK: Supple, no LAD, noraml carotid pulses, transmitted AS
murrmur. No JVD.
CHEST: CTA bilatearlly. No Wheezes/Rhonchi/Crackles. No
supraclavicular LAD. Bilateral axillary LAD.
HEART: RRR. Normal S1 and S2. [**12-29**] early peaking Systolic
creshendo / descreshendo murmur with audible S2.
ABDOMEN: Soft, non-tender, non-distended. +BS. No organomegaly,
No guarding, No rebound.
EXT: No edema. 2+ DP, PT Pulses.
NEURO:
Mental Status: Oriented to person, unable to orient to time and
location.
Cranial Nerves: II-XII intact
Muscle Strength: Increased tone. [**2-25**] UE and LE
Reflexes: +1 bic, pat
Pertinent Results:
[**2196-9-18**] 08:31PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2196-9-18**] 08:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2196-9-18**] 04:30PM GLUCOSE-113* UREA N-23* CREAT-1.1 SODIUM-141
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-30 ANION GAP-14
[**2196-9-18**] 04:30PM CK(CPK)-417*
[**2196-9-18**] 04:30PM cTropnT-0.02*
[**2196-9-18**] 04:30PM CK-MB-15* MB INDX-3.6
[**2196-9-18**] 04:30PM CALCIUM-9.9 PHOSPHATE-3.5 MAGNESIUM-2.4
[**2196-9-18**] 04:30PM WBC-8.1 RBC-3.06* HGB-10.4* HCT-31.9*
MCV-104* MCH-34.0* MCHC-32.6 RDW-16.4*
[**2196-9-18**] 04:30PM NEUTS-81.2* LYMPHS-11.5* MONOS-5.0 EOS-1.8
BASOS-0.5
[**2196-9-18**] 04:30PM PLT COUNT-351
[**2196-9-19**] - CXR - No definitive evidence for pneumonia. Interval
increase in size of pulmonary metastases.
MRI/MRA Head - [**2196-9-19**] - In spite of the recent CT scan
report, the lesions suspected of being metastatic in etiology do
not exhibit overt enhancement, arguing against this diagnosis.
They do reveal susceptibility effects, which are consistent with
blood products or calcification. However, the CT scans do not
reveal calcification. In view of the patient's age, perhaps
these lesions represent ischemic/hemorrhagic events, rather than
metastatic lesions. Certainly, the present study, and even the
prior MR scan of [**2188-8-14**] exhibited areas of high T2
signal within the periventricular white matter of both cerebral
hemispheres, consistent with chronic small vessel infarction.
Diffusion-weighted images are normal. There is no mass effect or
shift of normally midline structures. Considering the eight
years between scans, there has been negligible change in
ventricular size.
There does appear to be a posterior angulation of the odontoid
process relative to the body, a finding which was not observed
on the prior MR study. There does not appear to be any
prevertebral soft tissue swelling in this locale. Has there been
prior trauma? Certainly, no cervical spine imaging studies are
present on the PACS system to address this issue in greater
detail. It should also be mentioned that there is some loss of
definition of the atlanto-dental articulation. To clarify this
finding further, a CT scan is advised.
FINDINGS: The major vascular tributaries of the circle of [**Location (un) 431**]
are patent. There is limited imaging of the distal vasculature,
likely due to reduced cardiac stroke volume. There are no overt
areas of hemodynamically significant stenosis or aneurysm
identified.
[**2196-9-19**] CT Head -
1. No evidence of acute intracranial hemorrhage.
2. Two hyperdense lesions identified, stable since [**2196-8-23**],
and consistent with known metastatic disease. Evaluation for
additional metastatic lesions is limited on non-contrast head
CT. For restaging, CT with contrast or MRI of the brain can be
obtained on a nonemergent basis.
[**2196-9-19**] EEG - This is a normal routine EEG in the waking and
drowsy
states. No focal, lateralized, or epileptiform discharges were
noted.
[**2196-9-23**] Cspine XR - There is again seen a un-united fracture
involving the dens with the base of C2. The fracture gap
measures 5 mm, and this does not change with flexion or
extension. There is anterolisthesis of the superior fracture
fragment in relation to the base and angulation posteriorly;
also unchanged with flexion or extension views. Degenerative
changes of the remainder of the cervical spine is again seen and
unchanged, and the findings are most prominent at C4-5 and C5-6.
Brief Hospital Course:
This is a 80 y/o male with metastatic melanoma to the brain and
Parkinson's disease who was brought to the ED by his family on
[**2196-9-19**] because of several days of altered mental status. He
was transferred to the MICU on [**2196-9-19**] for hypoxia secondary to
aspiration and transferred back to the medicine floor on
[**2196-9-23**]. After his episode of aspiration pneumonia, his clinical
status worsened significantly with increased difficulty clearing
his secretions and declining mental status. Given patient's
clinical worsening and multiple meetings with the Primary Team
and Palliative care team, comfort measures only were initiated
per the family's request. On Friday, [**9-30**], Mr. [**Known lastname 4223**]
died from likely cardiopulmonary arrest secondary to metastatic
melanoma and end stage Parkinson's Disease complicated by
aspiration pneumonia. For further details, please see below.
.
1. Metastatic Melanoma:
Likely progressive given woresening poor functional status. Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was contact[**Name (NI) **] and the team spoke to radiation
oncology. Given progressive clinical worsening, patient was
changed to comfort measures with no further plans for
chemotherapy or radiation.
.
2. Altered Mental Status:
The etiology of his initial altered mental status may have been
exacerbated by the whole brain radiation which he received prior
to admission, in addition to dehydration, acute renal failure,
metastatic brain lesions, worsening Parkinson's Disease, and
malnutrition.
.
3. Dysphagia
Patient had progressively worsening dysphagia over his
admission. An NG tube was placed by IR on [**2196-9-23**]. PEG tube
placement was attempted by IR on [**2196-9-26**] but could not be
completed secondary to overlying stool. Surgery was consulted to
evaluate for PEG placement, and they recommended an open
procedure. Given patient's worsening clinical status, surgery
was declined and patient was made comfort measures only very
shortly after.
.
4. Posterior displacemnt of odontoid process
During work-up of patient's altered mental status, head MRI
noted posterior displacement of odontoid process. Cervical CT
spine was obtained [**2196-9-23**] which showed non-united fracture
involving the dens, with the base of C2. Cervical x-ray series
showed no change of fracture with flexion or extension and
anterolisthesis of the superior fracture fragment in relation to
the base and angulation posteriorly which does not changed with
flexion or extension views. His C-spine was cleared per
orthopedic spine consult service.
.
5. ARF:
Patient was admitted with acute renal failure with an elevated
creatinine to 1.1, thought likely secondary to hypovolemia.
Creatinine improved to .7 after hydration.
.
6. Parkinson's Disease:
Patient continued his parkinson's medications, initially by PEG
tube and then by transdermal patch when PEG tube could not be
placed.
.
Medications on Admission:
- Amantadine 200 mg twice a day.
- Norvasc 5 mg DAILY
- Vitamin C
- Calcium/calciferol 600+D
- Sinemet-CR 50/200 five times a day
- Stalevo 150 37.5 mg-15 five times a day
- Imipramine 10 mg [**Hospital1 **]
- Mirapex 1 mg TID
- Multivitamin DAILY
- Niacin 500 mg [**Hospital1 **]
- Ocuvite [**Hospital1 **]
- Bactrim DS [**Hospital1 **]
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
1. Metastatic Melanoma.
2. Brain Metastasis.
3. Aspiration Pneumonia.
4. Delirium.
5. Malnutrition.
6. Parkinson's Disease.
7. Hypertension.
8. Old C2 fracture with retrolisthesis of C1 on C2.
Discharge Condition:
Died
Discharge Instructions:
none
Followup Instructions:
None
|
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"427.5",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.08"
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icd9pcs
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[
[
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6654, 7939
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303, 334
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2011, 2841
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241, 264
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362, 1558
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1580, 1846
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1862, 1962
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,376
| 130,010
|
30579
|
Discharge summary
|
report
|
Admission Date: [**2170-8-2**] Discharge Date: [**2170-8-10**]
Date of Birth: [**2138-12-19**] Sex: F
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient transferred from outside facility with abdominal pain
and CT scan showing perforated cholecystitis with large impacted
stones at the gallbladder and common bile duct.
Major Surgical or Invasive Procedure:
Open cholecystectomy, CBD exploration, T-tube placement, Small
bowel resection, revision of ileostomy; Reoperation for bleeding
from mesenteric vessel.
History of Present Illness:
Patient was in her usual state of health when she developed
abdominal pain, nausea and vomiting. She went to her local
hospital where a CT scan was done.
Past Medical History:
[**First Name3 (LF) 72564**]-Danlos syndrome (type 4), bipolar disorder, anxiety
disorder, h/o migraines
PSH: ileostomy secondary to obstetric trauma x10 years, hand
surgery x3, bilateral knee surgeries, R shoulder surgery
Social History:
Lives in [**Hospital1 **] with her 10-year old son. Smoked 1pack a day
from age 15 to recently (15 pack year history). Does not drink
EtOH or use illicit drugs.
Family History:
Mother also had [**Name (NI) 72564**] Danlos but was murdered in [**2154**].
Several other family members died of "alcoholism, drugs, stroke,
heart attacks" but no specifics known
Physical Exam:
Please see chart.
Pertinent Results:
[**2170-8-2**] 05:29PM BLOOD WBC-19.9*# RBC-3.55* Hgb-11.0* Hct-31.3*
MCV-88 MCH-31.0 MCHC-35.1* RDW-13.2 Plt Ct-514*#
[**2170-8-6**] 08:45AM BLOOD WBC-16.3* RBC-3.69* Hgb-11.1* Hct-31.2*
MCV-84 MCH-30.1 MCHC-35.7* RDW-13.7 Plt Ct-358#
[**2170-8-8**] 05:10AM BLOOD WBC-11.3* RBC-3.65* Hgb-10.9* Hct-31.3*
MCV-86 MCH-30.0 MCHC-35.0 RDW-13.4 Plt Ct-413
[**2170-8-2**] 06:00AM BLOOD PT-13.5* PTT-25.8 INR(PT)-1.2*
[**2170-8-2**] 11:00PM BLOOD PT-16.5* PTT-36.2* INR(PT)-1.5*
[**2170-8-4**] 03:41AM BLOOD PT-14.4* PTT-28.7 INR(PT)-1.3*
[**2170-8-2**] 06:00AM BLOOD Glucose-129* UreaN-4* Creat-0.4 Na-139
K-3.1* Cl-103 HCO3-26 AnGap-13
[**2170-8-4**] 03:41AM BLOOD Glucose-101 UreaN-4* Creat-0.4 Na-135
K-3.2* Cl-95* HCO3-36* AnGap-7*
[**2170-8-9**] 06:05AM BLOOD Glucose-115* UreaN-3* Creat-0.6 Na-133
K-3.9 Cl-99 HCO3-26 AnGap-12
[**2170-8-4**] 03:41AM BLOOD ALT-26 AST-49* CK(CPK)-1014* AlkPhos-49
TotBili-0.6
[**2170-8-2**] 06:00AM BLOOD Albumin-3.6 Calcium-7.5* Phos-2.7 Mg-1.4*
[**2170-8-3**] 02:34AM BLOOD Albumin-3.3* Calcium-9.5 Phos-2.2* Mg-1.7
[**2170-8-9**] 06:05AM BLOOD Calcium-7.9* Phos-4.2 Mg-2.1
[**2170-8-2**] 02:02PM BLOOD Type-ART Rates-/8 Tidal V-400 FiO2-60
pO2-280* pCO2-44 pH-7.42 calTCO2-30 Base XS-4 -ASSIST/CON
Intubat-INTUBATED
[**2170-8-3**] 02:48AM BLOOD Type-[**Last Name (un) **] pO2-85 pCO2-55* pH-7.42
calTCO2-37* Base XS-8
[**2170-8-2**] 02:02PM BLOOD Glucose-135* Lactate-0.9 Na-135 K-2.7*
Cl-98*
[**2170-8-2**] 09:34PM BLOOD Glucose-280* Lactate-7.7* Na-137 K-3.0*
Cl-101
Brief Hospital Course:
Patient's CT scan was reviewed and she was taken to the
operating room. She underwent an open cholecystectomy,
intraoperative choledochoscopy, Common bile duct exploration,
removal of common bile duct stone and T-tube placement and
resection of ileum and revision of ileostomy. Shortly after in
post anesthesia recovery unit patient JP drain was filled with
blood and patient became tachycardic. She was urgently returned
to the operating room for re-exploration.
A mesenteric artery was found to be bleeding. This was repaired
and patient stabilized.
Postoperative course was relatively uneventful with difficulty
with nausea. Patient eventually was able to eat without nausea
and she was sent home.
Medications on Admission:
lamictal 100mg', klonopin 1mg qid prn, seroquel 100mg' prn
insomnia, topamax 25mg''
Discharge Medications:
1. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO QID (4 times
a day) as needed.
4. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Carisoprodol 350 mg Tablet Sig: One (1) Tablet PO Q4HR () as
needed.
6. Dilaudid 2 mg Tablet Sig: 1-3 Tablets PO q3-4 hrs (ever three
to four hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Perforated cholecystitis with large impacted
stones at the gallbladder and common bile duct
Secondary Diagnosis: [**Month/Day/Year 72564**]-Danlos syndrome, Bipolar disorder,
Anxiety disorder, Migraines
Discharge Condition:
Stable.
Discharge Instructions:
Incision Care: Keep clean and dry.
-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.
-If you have staples, they will be removed during at your follow
up appointment.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**10-3**] lbs) until your follow up appointment.
You have refused to accept VNA services to help with your T-tube
at home, so please make certain to record the amount of output
from your T-tube each day. Please care for tube and bag as you
have been taught to by our nursing staff.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2170-8-17**] 1:30
Completed by:[**2170-8-17**]
|
[
"998.12",
"574.71",
"V55.2",
"998.2",
"568.81",
"296.80",
"998.11",
"557.9",
"575.4",
"756.83",
"E870.0",
"E878.8",
"346.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"51.41",
"45.62",
"51.22",
"38.86",
"99.04",
"38.93",
"99.15",
"54.75",
"86.59",
"46.41",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
4338, 4344
|
2984, 3688
|
441, 595
|
4610, 4620
|
1455, 2961
|
6664, 6845
|
1220, 1402
|
3823, 4315
|
4365, 4365
|
3715, 3800
|
4644, 4644
|
4660, 6641
|
1417, 1436
|
227, 403
|
623, 778
|
4497, 4589
|
4384, 4476
|
801, 1026
|
1042, 1204
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,354
| 147,171
|
31995
|
Discharge summary
|
report
|
Admission Date: [**2102-9-26**] Discharge Date: [**2102-10-2**]
Date of Birth: [**2042-5-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Substernal Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization.
History of Present Illness:
60 year old male with no PMH, non smoker, who presented to
[**Hospital6 8283**] [**9-26**] after experiencing SSCP while
working excavating and shoveling dirt. States that the pain was
sharp and crescendoed to a [**10-11**]. It was initially located on
the right side of his chest but then progressed to involve his
entire chest, without radiation to his neck, arm, or jaw. It did
not subside despite resting. It was associated with diaphoresis,
and later on with some nausea. Taken by ambulance to MVH, found
to have STs elevation in inferior and precordial leads. Given 4
ASAs, 3 sl nitro sprays, and Medivac'ed to [**Hospital1 18**] for emergent
cath.
.
AT [**Hospital1 18**] ED, given 600 plavix at 1215, heparin bolus of 4000 at
1215, heparin gtt at 800u/hr. At cath, found to have TO of LAD
and diag, and 2 BMSs were deployed.
.
After his first cath he was noted to have AIVR as well as runs
of NSVT (8-12 beats), with occasional symptoms such as
lightheadedness and diaphoresis. He was started on a lidocaine
drip but continued to have NSVT. His BP began to drop and he was
started on wide open IVF for a total of approximately 1.5
liters. After this volume resuscitation he desatted to low 90's.
He was also started on a dopamine drip but was still
hypotensive. Given his symptoms he was taken back to the cath
lab when a repeat procedure showed patent stents. A spot film of
the groin showed no bleeding. His lidocaine was changed to
amiodarone. A right heart cath was performed and he was given
20mg IV lasix for what was felt to be volume overload.
.
Currently he states his CP remains much improved, approx [**1-11**].
Denies N/V/palpitation/diaphoresis. States that although he has
never had CP like this before in his life, he did note a brief
episode of self limiting CP last week while at rest.
Past Medical History:
None
Social History:
Social history is significant for the absence of current or
former tobacco use. There is no history of alcohol abuse.
Family History:
There is a family history of CAd, as his brother had an MI at 52
and his father had an MI in his 50s-60s. No sudden premature
death.
Physical Exam:
VSL T: 96.9 BP 107/72 P: 97 RR: 21 Sat: 98% 2LNC
Gen: WDWN, lying flat in bed, A+Ox3
HEENT: NC/AT, MMM. Slightly flushed. Sclerae anicteric, PERRLA.
Orophyarynx with poor dentition and extensive dental work with a
broken L lower molar with mild bleeding
Neck: supple, no elevation of JVP. No carotid bruits
Resp: CTA anteriorly, no accessory muscle use
Cor: non-displaced PMI. RR, borderline tachycardia. s1 s2, no
m/r/g
Abd: S/ND, tender to deep palpation suprapubically. + BS. No
palpable masses
Ext: WWP, no C/C/E. R Groin site without hematoma.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
EKG demonstrated NSR with extensive Q waves in II, III, aVF, and
midline precordial leads, with significant change compared with
prior dated [**9-26**], notable resolution of diffuse precordial ST
elevations.
.
TELEMETRY demonstrated:
Accelerated Idioventricular Rhythm
Occasional runs of VT, Non-sustained, 8-12 beats
.
CARDIAC CATH performed on [**2102-9-26**] demonstrated:
1. One vessel coronary artery disease.
2. Normal ventricular function.
3. Acute anterior myocardial infarction, managed by acute ptca.
4. Successful PTCA and stenting of the mid LAD with a bare metal
stent.
5. Successful PTCA and stenting of the jailed first diagonal
with a bare metal stent.
.
Repeat cardiac cath demonstrated no in-stent thrombosis or
change from above.
.
HEMODYNAMICS FROM 2ND CATH (on dopamine 5-10 mcg/kg):
CVP/RA mean: 9
RV 58/5
PA pressure 54/21 mean 37
PCWP: 13
CO: 5.0
CI 2.8
.
[**2102-9-26**] CK 3712 -> [**2102-9-27**] 3274 -> 1107*
[**2102-9-26**] 09:53PM BLOOD CK-MB-469* MB Indx-12.6*
[**2102-9-27**] 05:33AM BLOOD CK-MB-324* MB Indx-9.9* cTropnT-10.7*
[**2102-9-28**] 05:45AM BLOOD CK-MB-46* MB Indx-4.2 cTropnT-5.48*
[**2102-9-30**] 04:17AM BLOOD CK-MB-7 cTropnT-4.52*
Brief Hospital Course:
60M with no cardiac risk factors except +FH who presented with
acute STEMI, got PCI with with 2 BMS to LAD and diag, post-cath
with resolution of STE's but symptomatic NSVT and hypotension
leading to re-cath (no re-thrombosis). Currently stable with 2
runs of asymptomatic VT on tele.
.
1) STEMI: patient found to have large anterior MI, cathed with
stents to LAD. PAtient was hypotensive immediately after cath
with IAVR and many runs of Vtach. He was also very hypotensive.
He was recathed and found to have a caged diagnonal, but no
stent rethrombosus. He was in integrillin immediately after
cath, and heparin, which was bridged to coumadin. He was started
on ASA, plavix, metoprolol 12.5 [**Hospital1 **] (unable to tolerate higher
doses seconary to hypotension), lisinopril, and a statin. His
LDL is 98, his goal is below 70. An ECHO was done and showed EF
of 35-40% and apical and anterior wall hypokinesis. Patient
showing some sighns of acute systolic heart failure. He is to
f/u with his PCP later this week, and with Dr. [**Last Name (STitle) **] within 2
weeks.
.
2) Runs of NSVT: Patient had many runs of NSVT immediately after
MI, he was started on Lidocaine gtt for the arrythmia, with no
change, got 2 grams Mg iv, and was switched to amiodarone gtt.
he remained on this for a total of 24 hours. After this he
reverted to NSR, bradycardic with 2 runs of NSVT 5 days post MI.
He was on amiodoarine PO for several days, but this was dc/ed
because his blood pressure did not tolerated it.
.
3) Hypotension - Per hemodynamicss in cath lab, patient with
signs of mild pulmonary hypertension. Patient put out 2 L in
response to 20IV lasix in cathlab, found to be hypotensive post
cath. got fluid bolus, and was briefly on dopamine. He has
maintained pressure with systolics in high 80s-90s during
hospitalization.
.
4)abdominal pain. patient described this as gas pains. resolved
with simethicone.
Medications on Admission:
none
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute MI
.
Secondary
Systolic heart failure acute
CAD
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with a heart attack. you were
started on several medications, which are listed below. You had
a cardiac catherization and a stent placed in one of your
coronary arteries. You heart has also had an abnormal rhythm
both immediately after the heart attack and also few time
afterward. You were not sypmtomatic, but it is somethign to be
aware of.
.
Please return to the hospital or your doctor if you have any
more chest pain, lightheadedness or shortness of breath.
Followup Instructions:
You have an appt with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] scheduled for [**2102-10-5**] at 9:30am.
.
You are to follow up with your cardiologist, Dr. [**Last Name (STitle) **], in 2 weeks
in his [**Location (un) **] [**Last Name (un) **] office. They will call you with an
appointment. if you do not hear from them by the end of the
week, Please call and make an appointment, the office number is
[**Telephone/Fax (1) 74956**].
Completed by:[**2102-10-2**]
|
[
"428.21",
"458.29",
"414.01",
"427.31",
"427.1",
"997.1",
"428.0",
"410.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.41",
"36.06",
"99.20",
"00.46",
"37.23",
"37.22",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
7040, 7046
|
4379, 6288
|
337, 364
|
7144, 7153
|
3175, 4356
|
7699, 8192
|
2383, 2517
|
6343, 7017
|
7067, 7123
|
6314, 6320
|
7177, 7676
|
2532, 3156
|
276, 299
|
392, 2204
|
2226, 2232
|
2248, 2367
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,132
| 197,639
|
53581
|
Discharge summary
|
report
|
Admission Date: [**2198-6-4**] Discharge Date: [**2198-6-12**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
angina with exertion; positive ETT
Major Surgical or Invasive Procedure:
CABG X 4(LIMA->LAD, SVG->OM1 and OM2, SVG to PDA) [**2198-6-7**]
History of Present Illness:
82 yo male with exertional angina and + ETT. Referred for cath
which revealed 30% LM, LAD 90%, CX 90%, RCA 70%. EF 56% on prior
nuclear stress test. Referred for CABG with Dr. [**Last Name (STitle) **].
Past Medical History:
HTN
asbestosis
chronic back pain
arthritis
Social History:
retired dock worker
widowed, lives alone
no tobacco use
no ETOH
Family History:
non-contributory
Physical Exam:
Hr 63 RR 16 right 162/83 left 155/85
68" 180#
NAD
skin unremarkable
EOMI, PERRLA
neck supple with full ROM, no lymphadenopathy, no carotid bruits
CTAB anteriorly
RRR no m/r/g
+ BS, soft, NT, ND
warm, well-perfused, no edema
minimal left LLE varocosities
neuro grossly intact
right fem post-cath
left fem/ bil radials 2+
Bil DP/PTs 1+
Pertinent Results:
[**2198-6-11**] 07:00AM BLOOD WBC-9.1 RBC-3.01* Hgb-10.2* Hct-29.1*
MCV-97 MCH-34.0* MCHC-35.2* RDW-13.5 Plt Ct-301
[**2198-6-11**] 07:00AM BLOOD PT-12.8 PTT-25.6 INR(PT)-1.1
[**2198-6-11**] 07:00AM BLOOD Plt Ct-301
[**2198-6-11**] 07:00AM BLOOD Glucose-98 UreaN-24* Creat-1.2 Na-137
K-3.6 Cl-95* HCO3-33* AnGap-13
[**2198-6-4**] 11:00AM BLOOD ALT-20 AST-42* CK(CPK)-69 AlkPhos-83
Amylase-66 TotBili-0.8
[**2198-6-11**] 07:00AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.3
[**2198-6-4**] 11:00AM BLOOD %HbA1c-5.5
[**2198-6-4**] 11:00AM BLOOD Triglyc-95 HDL-31 CHOL/HD-5.4 LDLcalc-116
Cardiology Report ECHO Study Date of [**2198-6-7**]
PATIENT/TEST INFORMATION:
Indication: Coronary artery disease. Left ventricular function.
Preoperative assessment. Right ventricular function.
Status: Inpatient
Date/Time: [**2198-6-7**] at 13:43
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW4-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
Aorta - Ascending: 3.3 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: 2.3 cm (nl <= 2.5 cm)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild
regional LV
systolic dysfunction.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal
anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal
- hypo; mid
inferoseptal - hypo; septal apex - hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
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 patient was under general anesthesia
throughout the
procedure.
Conclusions:
PRE BYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with
septal hypokinesis.. Right ventricular chamber size and free
wall motion are
normal. There are simple atheroma in the descending thoracic
aorta. The aortic
valve leaflets (3) are mildly thickened. The mitral valve
leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen.
POST BYPASS
Preserved biventricular systolic function. LVEF >55%. Remaining
study6 is
unchanged from prebypass.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD on [**2198-6-7**] 14:12.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 110100**])
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2198-6-10**] 7:46 AM
CHEST (PORTABLE AP)
Reason: f/u possible pneumothorax
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with
REASON FOR THIS EXAMINATION:
f/u possible pneumothorax
HISTORY: Pneumothorax.
Single portable radiograph of the chest demonstrates no change
in the cardiomediastinal contour when compared with [**2198-6-9**].
The previously seen, equivocal, small, left-sided pneumothorax
is not evident on the current study. There is a small left-sided
pleural effusion. The right lung is clear. No right-sided
pleural effusion. The patient is status post median sternotomy.
Surgical staples project over the right upper quadrant. The
aorta is tortuous. No consolidation is identified.
IMPRESSION:
The previously seen, equivocal, small, left-sided pneumothorax
is not evident on the current exam.
Small left-sided pleural effusion.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Approved: SUN [**2198-6-10**] 10:58 PM
Brief Hospital Course:
Admitted [**6-4**] and completed pre-op evaluation with PFTs, echo .
Carotid US showed no signif. [**Last Name (un) 2435**]. Surgery delayed for several
days awaiting plavix washout . Underwent cabg x4 on [**6-7**].
Transferred to the CSRU in stable condition on a propofol
drip.Extubated that evening and gentle diuresis started.
Transferred to the floor to begin increasing his activity level.
Went into A fib on POD #2 and converted to SR with
amiodarone.Chest tubes removed on POD #3.Pacing wires removed
without incident. Cleared for discharge to home with VNA on POD
#5. Pt is to make all follow-up appts. as per discharge
instructions.
Medications on Admission:
triamterene/HCTZ 37.5mg/25 mg daily
atenolol 50 mg daily
ASA 81 mg daily
isosorbide MN 30 mg daily
herbal supplement
SL NTG 0.4 mg prn
Plavix 600 mg (dosed [**6-4**])
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 4 days: Decrease dose to 400 mg PO daily for 7 days
when this dose is done, then decrease dose to 200 mg daily.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of greater [**Location (un) **]
Discharge Diagnosis:
CAD s/p cabg x4
HTN
asbestosis
chr. back pain
OA
Discharge Condition:
good
Discharge Instructions:
Shower daily, no bathing or swimming for 1 month
no lifting > 10# for 10 weeks
no creams, lotions or powders to any incisions
follow medications on discharge instructions
call our office for temps>101.5, sternal drainage
do not drive for 4 weeks
Followup Instructions:
with Dr. [**Last Name (STitle) 32668**] in [**3-3**] weeks
with Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Hospital Ward Name 121**] 2 wound clinic in 2 weeks
Completed by:[**2198-6-14**]
|
[
"724.5",
"715.90",
"414.01",
"401.9",
"501",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"88.56",
"39.61",
"37.22",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
7530, 7596
|
5421, 6065
|
302, 369
|
7689, 7696
|
1157, 1787
|
7990, 8209
|
764, 782
|
6282, 7507
|
4503, 4524
|
7617, 7668
|
6091, 6259
|
7720, 7967
|
1813, 4269
|
797, 1138
|
228, 264
|
4553, 5398
|
397, 601
|
4304, 4466
|
623, 667
|
683, 748
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,187
| 103,402
|
22175
|
Discharge summary
|
report
|
Admission Date: [**2145-9-13**] Discharge Date: [**2145-9-29**]
Date of Birth: [**2075-8-10**] Sex: M
Service: MED
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
wheezing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
70 year old man with severe COPD, CHF, and dementia secondary to
chronic alcohol use was admitted [**2145-9-13**] for acute respiratory
distress and hypoxia requiring intubation in teh ED and transfer
to the MICU.
At his extended care facility in [**Hospital1 789**], NH, the patient was
noted to be agitated and wheezing. At baseline he is prescribed
continuous 02 but is reportedly noncompliant as per his
neuropsychiatric baseline of agitation and behavioral outbursts.
On the day of admission, he was increasingly agitated and his
nurse noted that his RA sats dropped to 73% from low 90s. Also,
he had a temperature of 99.0, drop in blood pressure 120/78 ->
100/60, tachycardia 132-150, wheezing, and respiratory distress
without improvement after nebulizer therapy and oxygen
supplementation by face mask.
In ED patient was found to be agitated with saturation of 87% on
non-rebreather mask in respiratory distress and ABG 7.39/37/57.
He was intubated with etomidate and succinate. Copious, thick
yellow secretions were found post-intubation. His temperature
spiked to 101.8 and he was started on vancomycin and
levofloxacin, given 40mg IV lasix with 1L IV normal saline with
resulting urine output of 540ml. Also, he received nebs,
solumedrol 125 x1, haldol, and ativan.
In the MICU, the patient was was extubated on [**9-14**] and tolerated
a switch to CPAP well with preserved oxygenation, maintaining 02
sats 90-94%. Chest x ray post extubation showed worsening
bilateral lower lobe infiltrates which improved over time. By
[**9-16**], the patient was oxygenating well at 95-100% on a
non-rebreather mask. However, it was difficult to assess the
patient's true oxygen requirement since he frequently exhibits
agitated behavior and would remove the mask. In the MICU, the
patient became severely agitated and delirious. Psychiatry
consult was obtained while the patient was in the MICU and all
psych meds except haldol were discontinued per psych
recommendations. Ativan was discontinued because it worsened the
delirium. The patient's mental status and behavior became less
acutely agitated over time.
The patient transferred to the medicine floor today in
restraints with a security guard sitter in stable condition
breathing spontaneously on ventimask oxygen supplementation.
Past Medical History:
Pneumonia
Chronic Obstructive Pulmonary Disease: on chronic predisone 5mg
tid, s/p previous intubation in the setting of percocet OD.
Congestive Heart Failure: with preseved EF 70% and chronic
bilateral lower extremity edema
Hyptertension
H/O alcohol abuse
Organic personality disorder with negative head CT in [**4-25**].
Dementia attributed to alcohol abuse w/agitation,
hallucinations.
Chronic low back pain, treated with percocet.
Gastroesophageal Reflux Disease
h/o c. diff, VRE
Urinary Incontinence
Social History:
Transferred to [**Location (un) 3844**] resident facility in [**2145-5-22**], for
verbally abusive behavior at previous facility. History of
percocet overdose and severe alcohol abuse. Further history
unknown. PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5762**] of [**Hospital3 4262**] Group, gets other care
at [**Hospital3 1443**]. Previous psychiatric admissions at
[**Hospital3 1443**].
Family History:
Unknown.
Physical Exam:
EXAMINATION: Temperature 97.9, heart rate 100, blood pressure
144/68, respiratory rate 19, oxygen saturation 90% ventimask
FiO2 0.5, 12L
air. In general, the patient is alert and oriented to self and
hospital, in four point soft restraints with a security guard
sitter, speaking loudly with verbal repetition and using
profanity
HEENT: PERRL, EOMI, anicteric, moist mucous membranes,
oropharynx crowded.
NECK: Supple, thick, no LAD
CARDIOVASCULAR: RRR, normal S1 and S2, no murmurs, rubs or
gallops.
LUNGS: +wheezing
ABDOMEN: obese, soft, nontender, nondistended, NABS
EXTREMITIES: no edema, erythema or warmth, +toenail
onychomycosis
NEURO: A&O x 2. Sensation intact. Moves all extemities well.
MSEx: speech sparse, mood labile with anger, thoughts
perseverative, uncooperative with exam
Skin: no rash
Pertinent Results:
[**2145-9-17**] 03:21AM BLOOD WBC-14.4* RBC-4.80 Hgb-12.7*# Hct-38.6*
MCV-80* MCH-26.4* MCHC-32.9 RDW-18.5* Plt Ct-323
[**2145-9-14**] 04:50AM BLOOD Neuts-90.0* Lymphs-6.9* Monos-2.5 Eos-0.5
Baso-0.1
[**2145-9-17**] 03:21AM BLOOD Glucose-66* UreaN-24* Creat-0.7 Na-142
K-4.1 Cl-100 HCO3-30* AnGap-16
[**2145-9-14**] 04:50AM BLOOD ALT-8 AST-10
[**2145-9-17**] 03:21AM BLOOD Calcium-9.8 Phos-5.2* Mg-2.1
[**2145-9-13**] 09:47PM BLOOD Valproa-58
[**2145-9-15**] 04:00AM BLOOD Glucose-127* Na-134* K-3.0* Cl-97*
[**2145-9-13**] 05:40AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2145-9-13**] 05:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2145-9-13**] 05:40AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2145-9-14**] 6:20 pm **FINAL REPORT [**2145-9-15**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2145-9-15**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2145-9-14**] 11:50 am SPUTUM Site: ENDOTRACHEAL **FINAL REPORT
[**2145-9-16**]**
GRAM STAIN >25 PMNs and >10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS c/w
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2145-9-16**]):
No predominance of these respiratory pathogens: S.
pneumoniae, H.
influenzae, and M. catarrhalis.
GRAM STAIN (Final [**2145-9-13**]):
>25 PMNs and <10 epithelial cells/100X field. NO
MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2145-9-15**]): SPARSE GROWTH
OROPHARYNGEAL FLORA.
BETA STREPTOCOCCI, NOT GROUP A.
[**2145-9-14**] 9:52 am urine/serology**FINAL REPORT [**2145-9-15**]**
Legionella Urinary Antigen (Final [**2145-9-15**]): NEGATIVE
[**2145-9-13**] 5:40 am URINE CULTURE (Final [**2145-9-14**]): NO GROWTH.
Blood Cx x4 pending
ECG Study Date of [**2145-9-17**] 12:49:06 PM Sinus tachycardia.
Probable left atrial abnormality. Compared to the previous
tracing of [**2145-9-15**] the rate is slightly faster. Otherwise, no
significant diagnostic change.
CHEST (PORTABLE AP) [**2145-9-15**] 12:24 AM IMPRESSION:
1. Triangular opacity adjacent to right heart border, concerning
for a collapsed right middle lobe. In a patient recently
intubated, this could be due to mucus plugging. However, follow
up films are suggested to document resolution. If this fails to
resolve, CT or bronchoscopy would be recommended.
2. Improving aeration at the lung bases, likely due to a
resolving aspiration pneumonia.
Brief Hospital Course:
Brief Hospital Course by System
70 year old man with history of severe COPD, CHF, and dementia
due to prior alcohol abuse presented with respiratory distress,
was intubated and treated for pneumonia in the MICU, and
transferred to the medicine floor in stable condition.
1) PNEUMONIA: Admitted from Provident NH, where he was found to
have desaturated to 73%, wheezing and in resp distress.
Susequently intubated and sedated on propofol. Initially started
on Vancomycin, levofloxacin, nebs and solumedrol. LLL infiltrate
on CXR. HD #2, Pt placed on PSV, did well and susequently
extubated. Pt placed on shovel mask post extubation but agitated
and wouldn't cooperate. He received IV vancomycin and
levofloxacin for his first 2 days of admission and the
vancomycin was discontinued on [**9-15**] since cultures were negative
for s. aureus. Sputum was legionella negative and consistent
with normal flora. For several days Pt remained dependednt on
NRB for sat's >95%. [**2145-9-13**], Pt transfered to general medical
service. Pt slowly improved saturation wise so that eventually
weaned off O2 and with refusal of NC was saturating consistently
inthe low 90's. Pt finished 10 day total course of
levofloxacin. Pt afebrile and respiratory wise stable on medical
service.
2) COPD: Pt with lonstanding COPD and chronic oxygen dependance.
On admission started on Prednisone 60, Salmeterol, Fluticasone,
Montelukast, albuterol and atrovent with impression of COPD
exacerbation in light of likely bacteria PNA. Prednisone tapered
from 60mg qd, to 40mg qd, to 20mg qd and finally to home dose of
15mg qd; however might be adequate to taper even further to 10qd
given psychiatric comobidities. Pt tolerating current COPD
regimen and would continue so as an outpatient. As PNA and COPD
exacerbation resolved so did Pt's respiratory status.
3) CHF: Cardiac enzymes negative for MI on presentation with an
unremarkable ECG. Pt has history of diastolic dysfuntcion with
preerved EF; LVEF 70% per echo. Pt started on metoprolol 12.5 mg
[**Hospital1 **] as well as 325 mg ASA without difficulty. Not started on
ACEi, but would consider it in the outpatient setting.
Continued on lasix PRN for gradual diuresis during hospital
stay.
4) PSYCH/personality disorder: Pt with a complex and significant
psychiatric history including personality disorder, EtOH induced
dementia . It is not uncommon for Pt to uncooperative and
noncomplinat with treatment as resident of nursing home. Patient
had been extraordinarily agitated and delirious at times in the
MICU, considered worse than his baseline of dementia and
irritability from organic personality disorder due to prior
severe alcohol abuse. Pt seen and followed by psychiatry who
recommendations initially recommended d/c home seroquell. He was
started on an alternating Haldol/Ativan regimen, witrh combined
ativan/haldol PRN. Placed in restraints and with 1:1 sitter.
The following day, Ativan was d/c'd as well and was placed on
Haldol only. Haldol increased as tolerated and as necessary. He
was recieveing 15-20 mg q2-4 hrs prn. Per report seemed to have
improved somewhat on these high doses of haldol. Pt transferred
to medical service recieving 60mg PO TID with 15-20 mg IV q2-4hr
prn. ECGs were frequently checked given risk for QTc elongation;
and it was found that the high doses of Haldol were elongating
the QTc (480 on [**9-20**]). Because of this Haldol was decreased
almost daily and seroquell added and slowly titrated up from 50
mg qhs. Pt's agitation still consistent, but slowly improved as
seroquell increased. Pt over the last few days of
hospitalization were able to be off restraints for several hours
at a time. Pt eventually titrated up to home regimen of 100 mg
qAM, 100 mg qNoon, 150 mg qPM.
5) PPX: Pneumoboots, SC heparin, PPI while hospitalized.
Medications on Admission:
prednisone 15mg
lasix 40 mg [**Hospital1 **]
protonix 40 qd
percocet [**1-22**] q4 prn
combivent
atrovent
albuterol
Buspar 20 tid
seroquell 100/100/250 am/noon/pm
neurontin 400 qid
trileptal 300 tid
seroquel 50 prn
KCL 40 qd
depakote 1000/2250/2250
thiamine
folate
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
3. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
6. Salmeterol Xinafoate 50 mcg/DOSE Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-22**]
Drops Ophthalmic PRN (as needed).
11. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID
(4 times a day).
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
14. Quetiapine Fumarate 25 mg Tablet Sig: Three (3) Tablet PO
QAM (once a day (in the morning)).
15. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed.
16. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
[**Hospital1 **] (2 times a day) as needed.
17. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day.
18. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
19. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
20. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
21. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
22. Quetiapine Fumarate 100 mg Tablet Sig: 1.5 Tablets PO QHS
(once a day (at bedtime)).
23. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO
qNoon.
24. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
Discharge Disposition:
Extended Care
Facility:
Provident Skilled Nursing Center - [**Location (un) 583**]
Discharge Diagnosis:
pneumonia
COPD exacerbation
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please call PCP or return to ED if fever >101, severe chest
pain, acute shortness of breath, persitsent nause or vomitting,
inability to tolerate food or liquid.
Followup Instructions:
follow up with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5762**] at [**Telephone/Fax (1) 608**], in one to two
weeks
|
[
"428.0",
"788.30",
"491.21",
"486",
"518.81",
"263.9",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"93.90",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13394, 13479
|
7016, 10845
|
287, 293
|
13551, 13557
|
4459, 6993
|
13868, 14006
|
3601, 3611
|
11161, 13371
|
13500, 13530
|
10871, 11138
|
13581, 13845
|
3626, 4440
|
239, 249
|
321, 2625
|
2647, 3153
|
3169, 3585
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,206
| 125,687
|
41883
|
Discharge summary
|
report
|
Admission Date: [**2132-2-26**] Discharge Date: [**2132-2-29**]
Date of Birth: [**2074-11-25**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
EGD
Flex Sig
Capsule study
History of Present Illness:
57 yo F with chronic anemia of unkown etiology, RA and MGUS,
referred to the ED for a Hct of 16. She has had a workup of her
anemia, including normal endoscopy and colonoscopy. A capsule
study was unsuccsesful when the capsule did not pass through her
stomach. She denies any bleeding source, although states that
during the bowel prep, she irritated her external hemorrhoids
with diarrhea (approx 3 episodes/ day for 5 days) and did notice
blood in the bowel, on the toilet paper during the prep. This is
currently resolving. On Friday [**2-22**], she noticed some
lightheadiness and dyspnea. On Sunday, [**2-24**], she developed some
chest burning while walking that lasted [**11-10**]' and went away
with sitting down. She has never had any episodes like this in
the past.
In the ED inital vitals were, 99.5 128 98/55 16 100%, tachy up
to 130s. 2 large bore IVs. Gave her 1 UPRBC and 2 L IVF. CXR
with Right base opacity, given levofloxacin. GI was consulted.
Vitals prior to transfer: HR 100, BP 101/55, RR 16, 99%2L, 98.1
T.
On arrival to the ICU, patient is getting 3rd Unit of PRBCs and
a liter of normal saline. She is not actively bleeding and is
in no acute distress. She is speaking in full sentences.
Denies any cough or dyspnea, but does endorse a history of
"pleurisy" in her right lower lobe followd by an outside
pulmonolgist.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain (+ initially with prednisone). Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies palpitations, or weakness. Denies
nausea, vomiting, constipation, abdominal pain. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
rheumatoid arthritis for many years, recently complicated by
episcleritis
monoclonal gammopathy
pleural fibrosis: [**7-7**] PFT: Data revealed a moderate - combined
obstructive and restrictive ventilatory defect with a reduced
DLCO.
COPD
obliterative bronchiolitis
anemia
acne
GERD
obesity
Social History:
Married, works as a IT consultant for helath care system team.
- Tobacco: None
- Alcohol: None
- Illicits: None
Family History:
Mother: CAD, [**Name (NI) **]: unknown cardiomyopathy, died at 54, Sister:
breast cancer, Brother: healthy
Physical Exam:
Admission:
Vitals: 97.1, 103, 98/67, 100% 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, trace crackles at bases, R>L
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, Obese, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema (trace puffiness on hands)
Rectal: external hemorrhoids, no active bleeding, negative
Guiac.
Brief Hospital Course:
57 F with RA, chronic anemia (baseline Hct 27-30) presented to
the ED with a Hct of 17 found on routine labs. She was initially
admitted to the ICU where she underwent a GI workup. She had an
NSTEMI. She was transferred to the floor on [**2132-2-28**].
.
ICU Course:
# Anemia - Microcytic with normal iron studies. Patient had had
a thorough GI workup including endoscopy and colonoscopy [**12-7**]
for evaluation of anemia. Capsule study performed but capsule
did not pass the stomach (not visualized on surveliance x-ray
here). She was guaiac negative on admission (2 times), but had
red blood w/ BM morning following admission. GI was consulted
and patient underwent bowel prep and upper and lower endoscopy
which demonstrated gastritis but no significant bleeding source.
Additional concerns of poor production given high WBC count and
may suggest heme malignancy (reticulocyte count of 7.9, RI of
1.3). On admission, patient was transfused 3 units PRBCs with
appropriate response of Hct from 17.7 to 28.1. Patient was
continued on home omprazole 20mg daily as well as Iron 325mg
daily and Folate 1mg daily (400mcg at home).
# NSTEMI: >1mm ST depression in lateral leads. She had positive
Troponin with chest pain on [**2132-2-24**]. It was thought to be likely
[**2-28**] demand ischemia due to combination of tachycardia and
anemia. The ICU team documented that there was no concern for
active ischemia as EKG ST depression resolved with 3 units of
blood however, her cardiologist called it an NSTEMI. Tropoinins
went from 0.11 to 0.18 and peaking at 0.27. On the night of
admission, she was given 325mg ASA. An echo done [**2132-2-27**]
demonstrated an EF of 25-30% with regional left ventricular
systolic dysfunction consistent with coronary artery disease.
She was transitioned to 81mg ASA daily as well as Atorvastatin
80mg qd and Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]. Outside
lipids from [**2-7**] demonstrated an LDL of 132 and HDL 63. Patient
was evaluated by Atrius cardiology and recommended follow up
with Dr. [**Last Name (STitle) 6512**] and he will decide whether to pursue a nuclear
stress test. Given that her BP was 100s, lisinopril was not
started prior to discharge but the patient was advised to follow
up with her cardiologist as scheduled on [**3-12**] and discuss
restarting it. She will also discuss getting a stress test as
her ECHO showed a LV systolic dysfunction concerning for an
ischemic etiology. Her tachycardia resolved after transfusions
and at discharge was in the 90s.
.
# Infiltrate on CXR with increased WBC. Patient got
levofloxacin in the ED but was not continued on it. She is on
doxycycline for episcleritis. She did not have a cough or sputum
production. She has a history of "pleurisy" in right lower
lobe.
.
# RA: has been active: complicated by pleurisy/ pulmonary
fibrosis, episcleritis. She receives outpatient infusions of
methotrexate and actemra. Her diclofenac was held due to
bleeding. Her prednisone was increased to 30 mg po daily in the
ICU. Upon discharge, she will complete a short taper back to 10
mg po daily.
.
# Episcleritis - the patient continued on her regiment of eye
dropps.
.
# COPD - Pt was on symbicort as outpatient. While in house, she
was given Advair but will resume symbicort at home.
.
# Tachycardia: The patient has a history of tachycardia and was
on metoprolol. IN the acute setting, her tachycardia was
thought to be secondary to anemia, hypovolemia. It improved
with fluids and PRBCS. She was restarted on her BB.
.
# Hypertension: Not active - Lisinopril was held due to concern
for bleeding and SBPs in the 100s.
.
# Question Sleep apnea: Patient was noted to be snoring with
desaturations to the mid 80s while on continuous O2 monitoring.
She would recover her saturations promptly without any
intervention but likely needs to follow up with an outpatient
sleep study with consideration of CPAP.
Medications on Admission:
prednisone 10mg daily - tapering (was on 15 [**2-26**])
Moxifloxicin 0.05% eye drops 1 drop in eye QID
lisinopril 10mg daily
doxycycline 100mg [**Hospital1 **] (taking for episcleritis)
Bacitracin-Polymyxin B 500-[**Numeric Identifier 961**] ointment to eye qHS
methotrexate 25 mg/ml inj weekly on Mondays
vitamin D
metoprolol 25 mg daily
tramadol as needed (not taking)
omeprazole 20 mg daily
Symbicort 2 inhalations twice daily
diclofenac 50 mg daily
folic acid 400 mcg daily
iron daily
vitamin C daily
calcium 600 mg
Actemra (one infusion every 4 weeks, next due [**2132-3-11**])
Discharge Medications:
1. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
7. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Systane 0.4-0.3 % Drops Sig: One (1) Ophthalmic QID (4 times
a day).
9. moxifloxacin 0.5 % Drops Sig: One (1) Ophthalmic QID (4
times a day).
10. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
13. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Patient should take 30 mg po on [**2132-3-1**], then 20 mg po
daily x 2 days, then back to baseline 10 mg po daily.
Disp:*33 Tablet(s)* Refills:*2*
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Anemia
GI bleed
NSTEMI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You should follow up with your PCP and discuss referral for a
hemorroidectomy.
You should follow up with your cardiologist to discuss getting a
stress test. You were started on aspirin and atorvastatin.
You should follow up with your PCP and discuss referral for a
hemorroidectomy.
You should follow up with your cardiologist to discuss getting a
stress test. You were started on aspirin and atorvastatin.
Followup Instructions:
Follow up with your PCP [**Last Name (NamePattern4) **] [**2-29**] weeks.
Follow up with your cardiologist as scheduled for [**3-12**].
|
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"401.9",
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"273.1",
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"276.52",
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icd9cm
|
[
[
[]
]
] |
[
"45.16",
"45.24"
] |
icd9pcs
|
[
[
[]
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9385, 9391
|
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|
276, 305
|
9458, 9458
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9473, 9585
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2136, 2427
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2443, 2557
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,269
| 171,293
|
44850+58709
|
Discharge summary
|
report+addendum
|
Admission Date: [**2124-9-11**] Discharge Date: [**2124-9-19**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
Dark stools x3 days, lethargy
Major Surgical or Invasive Procedure:
endotracheal intubation
arterial line placement
femoral line placement
History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **] yoM with PMH significant for CHF, CAD, HTN, DM,
mild dementia, CVA, PE on coumadin, and s/p L hip repair on
[**2124-8-13**], who was was found to be semi-repsonsive at home on
[**2124-9-11**]. Patient has been weak and lethargic for a few days
since returning home from [**Hospital3 2558**] on [**2124-9-9**], and wife
mentioned that he has been having dark stool for three days.
While patient was walking to the bathroom, pt felt weak and
became acutely less responsive. Mrs. [**Known lastname **] called 911 and he was
brought to the ED for further evaluation.
.
In the ED, initial vitals were: afebrile 139/63 56 19 94% on 2L.
He was lethargic but reponded appropriately to questions,
denying CP/SOB. His rectal exam showed red blood, but no frank
hemorrhage. Labs revealed HCT 20 from baseline 29. His EKG was
significant for new ST depressions in V2-V6. An NG lavage was
performed which was negative. GI was consulted, recommended IV
PPI bolus and gtt. Given his ST depressions in V2-V6, cards was
called, and recommended continuing plavix and coumadin
(therapeutic), but no asa due to allergy (anaphylaxis). Received
2 units of FFP and 2 large bore IVs and was admitted.
.
Upon immediate arrival to MICU, while being turned by nursing,
the patient was noted to be agonally breathing and became
asystolic on the monitor. A code blue was called. Pt was
intubated. A sinus ryhthm of 20 was noted, and the patient
received 1 round of epinephrine and atropine and regained both
pulse and blood pressure. Rhythm was noted to be SVT with
abberency. No antiarryhthmics were administered. Central and
arterial access was obtained, and he received 1 unit of PRBCs
and 1L NS wide open. Then he was intubated.
.
His cardiac arrest was thought to be likly due to demand
ischemia from GI bleed which triggered myocardial infarction and
potentially cardiac arrest. Coumadin was held and Plavix was
given instead. His GI bleed ceased and Hct stabilized at 31.4
post total 5 units of tranfusion and fluid resuscitation. Echo
was done to evaluate LVEF and showed EF of 35%-->20%. He had
acute on chronic renal failture at Cr of 3.2 from 2.7, now at
3.4. GI was consulted and considered EGD but decided to do as an
elective EGD prior to D/C if pt re-bleeds since no further
episodes of GI bleed occured and Hct stabilized. Patient was
extubated on [**2124-9-13**] and pt tolerated well at O2 sat greater
than 95%. Oxygen was weaned as tolerated. Given patient's
moderatly stable conditon, it was decided to transfer pt to
regular floor for further management.
Past Medical History:
1. DM2 -latest A1C 6.1%
2. CAD s/p CABG x4 in [**2111**], SVG to post and lat circ, svg to OM,
LIMA to LAD
3. s/p MI (15 years ago)
4. CHF: [**2124-4-13**] echo -EF 30-35% -moderate MR, moderate to
severe TR
5. h/o afib -per chart. Patient denies this.
6. CKD -baseline Cr 2.3
7. Peripheral neuropathy
8. Hypertension - not currently being treated
9. PVD s/p fem-[**Doctor Last Name **] bypass in [**2115**]
10. Hypercholesteremia
11. Depression
12. Memory loss
13. CVA [**2109**]
14. Left intertrochanteric fracture s/p ORIF [**2124-8-10**]
15. Recent PE in early [**7-21**], on coumadin
16. Histoy of R CEA
Social History:
Lives at home with wife of 60 years. Just d/c'ed form [**Hospital **]. Ambulates without assistance of walker or cane. Denies
tobacco, illicit drugs. Occasional EtOH use.
Family History:
non-contributory
Physical Exam:
VS: 96.8 64 122/54 19 94%
GENERAL: elderly causasian male, pale, lying on bed, NAD
HEENT: NC/AT. PERRLA. Sclera anicteric. Conjunctiva pale. Dry
MM, partially edentoulus.
NECK: Supple with no visible JVD
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts.
LUNGS: equal BS bilaterally, mild bilateral rales.
ABDOMEN: Soft, mildy distended, non-tender. + bowel sounds
EXTREMITIES: No c/c/e. Pneumoboots in place distal pulses
present.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
HEME:
[**2124-9-11**] 10:45AM BLOOD WBC-6.9 RBC-2.11*# Hgb-6.6*# Hct-20.1*#
MCV-95# MCH-31.2 MCHC-32.7 RDW-18.4* Plt Ct-321
[**2124-9-19**] 01:20PM BLOOD WBC-10.2 RBC-4.13* Hgb-12.7* Hct-37.3*
MCV-90 MCH-30.8 MCHC-34.1 RDW-16.1* Plt Ct-416
.
COAGS:
[**2124-9-11**] 10:45AM BLOOD PT-26.3* PTT-30.7 INR(PT)-2.6*
[**2124-9-19**] 01:20PM BLOOD PT-14.6* PTT-74.1* INR(PT)-1.3*
.
CHEM:
[**2124-9-11**] 10:45AM BLOOD Glucose-269* UreaN-85* Creat-3.2* Na-138
[**2124-9-19**] 01:20PM BLOOD Glucose-226* UreaN-66* Creat-2.6* Na-137
K-4.4 Cl-100 HCO3-27 AnGap-14
.
LFTs:
[**2124-9-11**] 04:08PM BLOOD ALT-59* AST-59* CK(CPK)-106 AlkPhos-147*
TotBili-0.8
[**2124-9-14**] 06:03AM BLOOD ALT-43* AST-31 LD(LDH)-295* CK(CPK)-75
AlkPhos-144* TotBili-0.9
.
CE's:
[**2124-9-11**] 10:45AM BLOOD CK-MB-12* MB Indx-11.3*
[**2124-9-11**] 10:45AM BLOOD cTropnT-0.42*
[**2124-9-14**] 06:03AM BLOOD CK-MB-NotDone cTropnT-1.22*
.
Lactate:
[**2124-9-11**] 01:52PM BLOOD Lactate-6.7*
[**2124-9-13**] 04:40PM BLOOD Lactate-1.2
.
BILAT LOWER EXT VEINS [**2124-9-16**]
Cresentic thrombus within the left popliteal vein which is only
partially occlusive and is most consistent with chronic DVT with
recanalization. No evidence of acute DVT within the lower
extremities.
.
Echo [**2124-9-11**]
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 20 %) with global hypokinesis and inferior, septal and
apical akinesis. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. The right ventricular cavity is
moderately dilated with severe global free wall hypokinesis. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
ECG [**2124-9-14**]
Sinus bradycardia. Ventricular ectopy. Left axis deviation.
Right
bundle-branch block with left anterior fascicular block. There
are Q waves
in the inferior leads consistent with prior myocardial
infarction. There are tiny R waves in the anterior leads
consistent with probable prior anterior myocardial infarction.
Compared to the previous tracing there is no significant change
Brief Hospital Course:
This is a [**Age over 90 **] yo male with extensive cardiac disease including
CAD s/p MI and CABG, PE on coumadin, who presents with lethargy
and black stools, found to have a GI bleed, who is s/p cardiac
arrest and resuscitation. Patient was intubated and sedated in
MICU, successfully extubated on [**2124-9-13**], and transferred to
regular floor([**2124-9-14**]) for further care.
.
# CAD s/p Cardiac Arrest: Extensive previous cardiac history s/p
CABG. His EKG on this admission demonstrated changes c/w
ischemia, most likely due to demand from GI bleeding. Trop-T was
elevated in the setting of acute on chronic renal failure, but
MB-index was positive, again likely due to demand ischemia. This
could have triggered myocardial infarction and potentially his
cardiac arrest. Less likely to be ACS/unstable plaque rupture.
Patient was transferred to regular floor after extubation in
MICU. Pt was monitored on tele with no acute episode of cardiac
symptoms or any signs of cardiogenic shock. The benefit of ICD
was discussed since LVEF at 20%, but Cardiologist thought that
he would not benefit much from ICD placement given his
comorbidities and he and his wifes wishes to avoid invasive
procedures. It was recommended to have repeated Echo to re-eval
LVEF as out patient per his Cardiologist. Plavix was
discontinued and Heparin drip was started for his atrial
fibrillation. Pt was resummend on his regular BP meds at
adjusted doses and he tolerated this well. We started on
Coumadin in addition to heparin and closly monitored Hct. His
Hct was stable at 37.3 on discharge. no ASA given- allergy. It
is important to closly monitor his Hct given h/o acute blood
loss and resulted in cardiac arrest. Pt need to be transitioned
off Heparin once INR is therapeutic with coumadin.
.
# GI bleed: Gi followed patient and decided not to perform
endoscopy/colonoscopy due to recent cardiac arrest and per
patient/family request. Pt was on PPI gtt then switched to PO
PPI. No further signs of bleeding noted. Coumadin started on
[**2124-9-18**] and HCT was checked Q4D while on IV heparin. Hct was
stable on d/c at 37.3. It is important that his HCT closly
monitored for potential recurrent blood loss. and IV Heparin
need to be transitioned off once INR is therapeutic. Plavix was
held for risk of bleeding and pt need to discuss with his
cardiologist for when to restart Plavix.
.
# Respiratory Failure is setting of cardiac arrest. Pt. weaned
off respirator and did well on 98% at RA.
.
# Chronic systolic heart failure: Recent EF of 35%-->20% post
Cardiac arrest. Does not appear decompensated currently given
CXR. initially held lasix and aldactone but restarted on
[**2124-9-15**]. Pt needs to obtain repeated Echo to re-eval LVEF as out
patient.
.
# Acute on chronic RF - Baseline Cr has been 2.2-2.5 in early
[**Month (only) 216**]. Likely prerenal in etiology given GIB. Concern for
ischemic ATN in setting of cardiac arrest. His Cr stablized to
his baseline 3.2->3.7->2.6 with volume resuscitation.
.
# DM - last A1c was 6.1%. He was on home regimen of NPH 20 units
am 12 units pm with SSI with FSG qid. BS well countrolled aroung
130.
.
# h/o PE: INR was therapeutic in the ED, but pt was reversed
with FFP in setting of GI bleed. LENI showed left chronic
popliteal vein DVT. Decision was made to re-anticoagulate him
and IV heparin was started with Hct check every 6 hours. Pt was
stable on Heparin then Coumadin 2.5mg daily was added on [**9-18**]
with close Hct monitoring. His Hct was 37.3 on discharge. Pt
will need to be transitioned off Heparin once INR is therapeutic
(goal 2.0-2.5). please monitor Hct closly.
.
# Delirium: we held his venlafaxine and Donepezil due to acute
delirium but not resolved. Pt need to discuss with primary care
physician when to resume these medications.
.
# s/p Hip fracture: previous hardware survey appears intact.
pain controlled and no acute issue noted
.
# HTN: continue home meds
.
# FEN-cariac and diabetic healthy diet
.
# PPx- on PO PPI, BR standing, hep IV, pboots
.
# Code - Full code confirmed with family, but if pt deteriorates
would not want life to be prolonged by life support
.
# Dispo: To Medical facility
Medications on Admission:
1. Carvedilol 6.25 mg Tablet Sig:One(1)Tablet PO BID(2 times a
day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO q other day.
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO bid PRN
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig:
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr PO HS
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
10. Isosorbide Mononitrate 30 mg One Tablet Sust Release 24hr PO
DAILY
11. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: Twenty Seven (27) units Subcutaneous qam.
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: Twelve (12) units Subcutaneous q pm.
13. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H prn for 2
weeks.
14. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO QID
17. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**12-15**] Tablet, PRN
Discharge Medications:
1. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Other
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. insulin regimen at your home dose
NPH: 20 units at breakfast and 12 units with dinner
15. heparin gtt (goal ptt 60-100)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Gastrointestinal bleed
2. Cardiac arrest
3. Congestive heart failure
4. Diabetes Mellitus 2
5. Coronary artery disease
6. history of myocardial infarction status post Coronary artery
bypass graft
7. Atrial fibrillation
8. Hypertension
9. Hypercholesteremia
.
Secondary:
1. Peripheral neuropathy
2. depression
3. dementia
Discharge Condition:
stable, no evidence of blood loss
Discharge Instructions:
You were admitted with weakness and dark stool x 3 days which
suggested gastrointestinal bleed. Your Hematocrit was at 20.1 on
admission and red blood was noted in your rectum and you were
transfused with blood. You experienced cardiac arrest in Medical
intensive care unit and you were resuscitated with CPR and
medications. In total, you were transfused 5 units of blood with
2 units of plasma.
.
Once your condition was stable (no evidence of bleeding) you
were again restarted on heparin and coumadin, your blood levels
remained stable and there was no evidence of bleeding. It was
necessary to restart these medications as you are at risk for a
stroke due to atrial fibrillation and you have a chronic lower
leg vein blood clot. [**Hospital1 4692**], in accordance with you and
your wife's wishes, we did not do an endoscopy or colonoscopy to
investigate the initial source of your bleeding. You will need
to carefully monitor your INR and your blood level (hematocrit)
with your primary care doctor for signs of bleeding.
we strongly recommend your Hematocrit to be closely monitored
since you experienced cardiac arrest secondary to acute blood
loss.
.
If you feel weakness or further dark stool, it is important that
you call your primary care or come to Emergency room.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet and fluid Restriction.
.
Medication changes: your donepezil and venlafaxine, these
medications should be restarted in consultation with your
physician. [**Name10 (NameIs) 4692**], we stopped your plavix in consultation
with your cardiologist. Do not restart without speaking with Dr.
[**Last Name (STitle) **] first.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD Phone:[**Telephone/Fax (1) 5068**]
Date/Time:[**2124-10-3**] 9:45
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2124-10-31**] 8:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2124-10-31**] 9:00
.
please call Dr.[**Name (NI) 1602**] office ([**Telephone/Fax (1) 719**] to make a follow
up appointment in approximately 2 weeks after leaving [**Hospital1 **].
Completed by:[**2124-9-19**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 15053**]
Admission Date: [**2124-9-11**] Discharge Date: [**2124-9-19**]
Date of Birth: [**2033-9-24**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 548**]
Addendum:
He was likely having an NSTEMI that had started at home due to
blood loss, which was noted in the ED by ECG (ST depressions)
and labs (+MB index).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 550**] MD [**MD Number(2) 551**]
Completed by:[**2124-10-30**]
|
[
"285.9",
"416.8",
"250.00",
"427.89",
"584.9",
"428.0",
"403.90",
"427.5",
"518.81",
"426.52",
"443.9",
"V58.61",
"585.9",
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"V12.54",
"583.9",
"276.2",
"356.9",
"578.1",
"362.10",
"427.31",
"311",
"397.0",
"V12.51",
"410.71",
"424.0",
"414.01",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.04",
"38.91",
"96.04",
"96.71",
"38.93",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
16964, 17183
|
7097, 11271
|
245, 317
|
14062, 14098
|
4330, 7074
|
15844, 16941
|
3781, 3799
|
12459, 13583
|
13706, 14041
|
11297, 12436
|
14122, 15528
|
3814, 4311
|
15548, 15821
|
176, 207
|
345, 2944
|
2966, 3577
|
3593, 3765
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,680
| 136,301
|
47365
|
Discharge summary
|
report
|
Admission Date: [**2178-8-17**] Discharge Date: [**2178-9-17**]
Date of Birth: [**2111-4-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
SIRS, acute on chronic systolic heart failure
Major Surgical or Invasive Procedure:
intubation x 3
right heart catherization x 2
left heart catherization
surgical debridement of right foot ulcer
central line placement (and subsequent removal)
PICC placement
History of Present Illness:
67 yo M with a PMH of DM type 2, [**Hospital3 9642**] mechanical AVR
([**2168**]), Ascending aorta repair with graft ([**2168**]), hx of VF
arrest s/p AICD [**2175**], recurrent high grade CoNS and VRE BSI s/p
removal of leads now presenting with suprapubic pain and fever.
.
The patient has a history of s/p CAD s/p three-vessel bypass
surgery and mechanical AVR in [**4-/2169**], with multiple subsequent
coronary interventions underwent a biventricular ICD
implantation [**2176-7-19**] after a VF arrest for which he underwent
evaluation at [**Hospital6 1129**]. He then sustained
an MRSA AICD pocket infection and it was explanted on [**2176-8-22**].
After one month treatment with IV vancomycin, he underwent a
second ICD implantation on [**2176-10-25**].
.
He was then admitted [**2-2**] with high grade CoNS BSI of unclear
source. At that time had a negative TTE/TEE. He was dishcarged
on vancomycin for a planned 4 week course given a hematoma was
found around ICD. He was then readmitted [**Date range (1) 100253**] with
recurrent high grade CoNS and VRE bacteremia while on 5th week
of Vancomycin with adequate troughs. TEE and CT chest were
unremarkable. ICD leads X 3 were removed on [**2178-3-26**].
.
He was then admitted [**6-5**] with a pseudomonas UTI and was treated
with cefepime for 14 day course ended on [**6-22**]. He was also found
to have ascending colitis on CT scan of unclear etiology,
thought secondary to ileus and was improved with conservative
management.
.
The patient was again admitted [**Date range (1) 100254**] for an elective surgical
debridement of R lateral foot chronic ulcer by vascular service.
He was not evaluated by ID at this time. Gangrene ulcer was
debrided on
[**6-29**] with a fifth metatarsal head resection. Wound vac was
placed. No bone specimen were sent to path or micro. Tissue
revealed 3+PMNs and culture grew out proteus and MRSA. Pt was
discharged to
complete 14 days of Zosyn.
.
He was seen in follow up in [**Hospital **] clinic on [**7-29**]. Further
antibiotics were held given it was felt good tissue margins were
obtained intraoperatively.
.
The patient presents now with complaints of 1 day of suprapubic
pain and fever. The patient reports a 4 day history of
constipation. He then passed a large BM and subsequently
developed suprapubic pain. Denies diarrhea. Denies
melena/hematochezia. Denies dysuria. No chronic foley. Denies
CP/SOB. Reports chronic cough, minimally productive. His
suprapubic pain persisted and he presented to the ED.
.
In the ED, intial vitals: T 100.2, HR 99, BP 102/59, RR 16, O2
99% on RA. He had emesis X3 without evidence of blood. UA with
WBC >50, Leuks Mod, Nit Pos, Bact few. WBC 19 and lactate 2.1.
He was given vancomycin 1gm IV and Zosyn 4.5g IV. SBP dropped to
80s systolic and he was given 1L NS with improvement in BP to
97/52. Blood cultures sent. CXR demonstrated no acute process.
.
On arrival to the MICU, the patient is resting comfortably.
Denies current pain. Denies CP/SOB.
Past Medical History:
-High grade CoNS bacteremia ([**2-2**])--> high grade CoNS/VRE
bacteremia while on Vancomycin for CoNS bacteremia ([**3-2**]) s/p 4
weeks daptomycin and explantation of ICD leads.
-Pseudomonas UTI [**6-2**] s/p 14 days cefepime
-R lateral foot ulcer s/p debridement s/p 14 days zosyn
-Diabetes, c/b neuropathy
-Coronary artery disease s/p 3V CABG [**2168**]
-History of VF cardiac arrest [**6-30**] s/p ICD placement - generator
explantation for MRSA pocket infection with reimplantation [**10-31**]
s/p lead removal [**2178-3-26**].
-Mechanical AVR St. Jude's Valve '[**68**]
-AAA repair ([**4-/2169**])
-Congestive heart failure EF 25-30%
-Hep C (dx [**4-2**] 2,380,000 IU/mL. Seen by Hepatology; last note
by [**First Name8 (NamePattern2) 2943**] [**Doctor Last Name 696**] [**2178-7-30**] emphasizes deferring IFN/ribavirin tx
in face of multiple infections, etc.)
-Hypertension
-Dyslipidemia
-Peripheral vascular disease s/p L BKA [**7-/2172**]
-Hypothyroidism
-Short-term memory deficit
-History of opiate dependence
-Acute on chronic SDH ([**8-/2175**])
-History of right right scapula fracture
-History of MRSA elbow bursitis ([**5-1**])
-History of closed bimalleolar fracture with repair and
subsequent removal of hardware ([**6-26**])
Social History:
Social history is significant for the current tobacco use of 40
pack years. There is no history of alcohol abuse or recreational
drug use. Lives with common-law wife of 35 years who is a home
health aide.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
On admission:
Vitals: T 100.4, HR 75, BP 103/57, RR 17, O2 100% RA
Gen: alert and oriented X4, NAD
HEENT: MMM, OP clear
Chest: midline sternotomy scar well-healed, L chest pacer scar
well healed
CV: RRR, nl S1/S2, mechanical valve, soft systolic murmur at
apex
Resp: CTAB, no WRR
Abd: soft, NT/ND, NABS
Ext: L BKA, R lateral ulcer with wound vac in place, + warmth,
no surrounding erythema
On discharge:
O: Tm/c 98.3/97.7 HR 64-85 BP 87-104/42-52 RR 16-20 Sats 96-100%
RA
Weight: 105 kg
GEN: NAD, AAOx3
CV: RRR, normal S1, mechanical S2 c [**2-27**] SM heard best @ LUSB.
Cannot appreciable JVD, likely [**1-26**] body habitus.
Resp: CTAB s rwr
Abd: +BS, S, NT/ND
Ext: WWP, 2+ pulses, L BKA, trace edema on dependent regions of
leg. Well healed R lateral ulcer with wound vac in place.
Pertinent Results:
Previous Lab Data:
MICROBIOLOGY:
URINE:
Urine Culture [**2178-7-1**] Pseudomonas aeruginosa 10K-100K
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM------------- 1 S
PIPERACILLIN---------- R
PIPERACILLIN/TAZO----- 32 S
TOBRAMYCIN------------ <=1 S
.
Urine Culture [**2178-6-6**]: Pseudomonas aeruginosa >100K
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM------------- 1 S
PIPERACILLIN---------- R
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
.
BLOOD:
Blood Culture [**2178-6-5**]: 1 bottle CoNS
Blood Culture [**Date range (1) 100255**]: Enterococcus faecalis ([**3-30**]) and CoNS
([**5-30**])
E. faecalis: BETA LACTAMASE NEGATIVE, High level gentamicin and
streptomycin resistant. Daptomycin MIC 2 mcg/ml
CoNS
.
Blood Culture [**2178-2-3**]: CoNS (6/8 bottles) Vanc MIC 2mcg/ml
.
MISC:
R foot [**2178-6-29**] - 3+ MRSA and 1+ Proteus mirabilis
PROTEUS MIRABILIS
| STAPH AUREUS COAG +
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- 4 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I <=0.5 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
OXACILLIN------------- =>4 R
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R <=0.5 S
VANCOMYCIN------------ <=1 S
.
[**2177-5-22**] L Elbow Aspirate: 2+ MRSA
.
RADIOLOGY:
CXR [**2178-8-17**]:
.
TEE [**2178-3-26**] - The left ventricular cavity is severely dilated.
There is severe left ventricular systolic dysfunction with
severe hypokinesis of the inferior, lateral, and septal walls
with somewhat better function of the anterior and anteroseptal
walls. Overall left ventricular systolic function is about 25 to
30%. Right ventricular chamber size and free wall motion are
normal. The ascending aortic graft is poorly seen. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. A bileaflet aortic valve
prosthesis is present. Mild (1+) aortic regurgitation is seen.
[The amount of regurgitation present is normal for this
prosthetic aortic valve.] The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
a trivial/physiologic pericardial effusion.
.
TTE [**2178-3-19**] - No spontaneous echo contrast or thrombus/mass is
seen in the body of the left atrium or right atrium. A patent
foramen ovale is seen by 2D and color Doppler. There are
catheters in the right atrium, right ventricle and coronary
sinus which are all free of masses or vegetations. Overall left
ventricular systolic function is moderately depressed (LVEF= 35
%). A bileaflet aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. Trace aortic regurgitation
is seen, which is normal for this prosthetic valve. The
appearance of the ascending aorta is consistent with a normal
tube graft. There are simple atheroma in the aortic arch. The
descending aorta could not be fully visualized. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**12-26**]+) mitral
regurgitation is seen. No mass or vegetation is seen on the
mitral, aortic, or tricuspid valve. There is no pericardial
effusion.
IMPRESSION: No valvular or catheter-related
vegetations/abscesses. Mild-moderate mitral regurgitation with
mildly thickened mitral leaflets. Moderately depressed left
ventricular systolic function. Compared to prior study dated
[**2178-2-13**], the amount of mitral regurgitation is slightly worse.
.
.
Laboratory data on this admission:
.
[**2178-8-17**] 04:00AM WBC-19.0*# RBC-4.35* HGB-12.4* HCT-37.5*
MCV-86 MCH-28.5 MCHC-33.0 RDW-16.5*
[**2178-8-17**] 04:00AM NEUTS-86.4* BANDS-0 LYMPHS-8.4* MONOS-4.5
EOS-0.4 BASOS-0.3
[**2178-8-17**] 04:00AM PLT COUNT-259
[**2178-8-17**] 04:00AM GLUCOSE-126* UREA N-58* CREAT-1.5*
SODIUM-129* POTASSIUM-7.6* CHLORIDE-94* TOTAL CO2-24 ANION
GAP-19
[**2178-8-17**] 04:00AM CALCIUM-9.6 PHOSPHATE-3.3 MAGNESIUM-2.6
[**2178-8-17**] 04:00AM ALT(SGPT)-39 AST(SGOT)-127* CK(CPK)-124 ALK
PHOS-73 AMYLASE-37 TOT BILI-0.9
[**2178-8-17**] 04:00AM LIPASE-33
[**2178-8-17**] 04:08AM LACTATE-2.1* K+-5.8*
[**2178-8-17**] 05:40AM URINE RBC-0-2 WBC->50 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2178-8-17**] 04:00AM CK-MB-2 cTropnT-0.03*
[**2178-8-17**] 01:06PM CK-MB-NotDone cTropnT-0.04*
[**2178-8-17**] 08:29PM CK(CPK)-46
.
Microbiology
[**2178-8-25**] STOOL FECAL CULTURE-PENDING; CAMPYLOBACTER
CULTURE-PENDING; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-negative
INPATIENT
[**2178-8-25**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2178-8-23**] URINE Legionella Urinary Antigen -negative INPATIENT
[**2178-8-23**] URINE URINE CULTURE-negative INPATIENT
[**2178-8-23**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2178-8-23**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2178-8-23**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-negative
INPATIENT
[**2178-8-22**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2178-8-22**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2178-8-22**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2178-8-21**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2178-8-21**] URINE URINE CULTURE-negative INPATIENT
[**2178-8-21**] BLOOD CULTURE Blood Culture, Routine-negative
INPATIENT
[**2178-8-19**] BLOOD CULTURE Blood Culture, Routine-negative
INPATIENT
[**2178-8-19**] BLOOD CULTURE Blood Culture, Routine-negative
INPATIENT
[**2178-8-17**] BLOOD CULTURE Blood Culture, Routine-negative
INPATIENT
[**2178-8-17**] BLOOD CULTURE Blood Culture, Routine-negative
INPATIENT
[**2178-8-17**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA}
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
.
SENSITIVITIES: MIC expressed in
MCG/ML
.
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 2 S
MEROPENEM------------- 0.5 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
.
[**2178-8-17**] BLOOD CULTURE Blood Culture, Routine-negative
EMERGENCY [**Hospital1 **]
[**2178-8-17**] BLOOD CULTURE Blood Culture, Routine-negative
EMERGENCY [**Hospital1 **]
.
Imaging:
CT abd/pelvis ([**2178-8-17**]):
1. No acute findings in the abdomen/pelvis. Specifically, no
evidence of
retroperitoneal hemorrhage.
2. Cholelithiasis, without evidence of cholecystitis.
3. Bibasilar atelectasis, with subtle new areas of tree-in-[**Male First Name (un) 239**]
opacity at the lung bases bilaterally, which could represent
aspiration, or superinfection.
4. Stable lower lumbar spine degenerative changes, and T11
vertebral body
compression deformity.
.
Echo ([**2178-8-19**]):
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is severely dilated.
There is severe global left ventricular hypokinesis (LVEF =
20%). Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. A bileaflet
aortic valve prosthesis is present. The aortic valve prosthesis
leaflets appear to move normally. The transaortic gradient is
higher than expected for this type of prosthesis. Trace aortic
regurgitation is seen. [The amount of regurgitation present is
normal for this prosthetic aortic valve.] There is a small
abnormal diastolic flow in the ascending aorta involving the
anterior portion of the ?ascending aorta graft (clips 17, 41).
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The left ventricular inflow pattern suggests a
restrictive filling abnormality, with elevated left atrial
pressure. There is an anterior space which most likely
represents a fat pad.
.
Compared with the prior study (images reviewed) of [**2178-2-10**],
the left ventricular systolic function has further deteriorated.
The severity of mitral regurgitation has increased. The gradient
across the aortic prosthesis has increased. There is an abnormal
flow in the ascending aorta. If clinically indicated, a
transesophageal echocardiographic examination is recommended to
evaluate the valves and the ascending aorta .
.
CT torso ([**2178-8-22**]):
1. New diffuse opacities seen in both lungs, particularly in the
upper lobes, but also to a lesser degree in the lower lobes,
although some small areas are entirely spared. These opacities
have a mixed ground-glass and consolidative appearance, also
areas without consolidation. Major differential considerations
include widespread bronchopneumonia, ARDS, and pulmonary edema,
a potentially a combination of etiologies.
2. Stable appearance of the abdomen and pelvis.
.
Right foot Xray ([**2178-8-22**]):
FINDINGS: In comparison with the study of [**6-11**], there has
apparently been
resection of the distal half of the fifth metatarsal.
Generalized osteopenia persists with vascular calcification
consistent with diabetes. Some apparent resorption is seen about
the head of the third metatarsal. The degree of soft tissue
swelling about the dorsum of the foot is substantially less than
on the prior study.
.
RHC ([**9-4**]):
COMMENTS:
1. Limited resting hemodynamics revealed elevated right and left
sided
filling pressures. The RVEDP was moderately elevated at 14 mmHg,
and
the PCWP was moderately elevated with a mean of 24 mmHg. The
pulmonary
pressures were moderately elevated with essentially normal with
a PASP
of 41 mmHg. The cardiac index was preserved at 3.2 l/min/m2.
.
FINAL DIAGNOSIS:
1. Moderate left and right ventricular diastolic dysfunction.
2. Moderate pulmonary artery hypertension.
.
LHC/RHC/renal angiogram ([**9-14**]):
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
two vessel coronary artery disease. The LMCA came off the [**Doctor Last Name **]
pouch
and had a 40% stenosis at the origin. The LAD had a 40%
stenosis. The
Lcx had a 40% stenosis at the origin. The RCA had no
angiographically
apparent disease.
2. Resting hemodynamics revealed elevated left and right sided
filling
pressures with an RVEDP of 20 mmHg and mean PCWP of 26 mmHg.
There was
moderate pulmonary hypertension with a pasp of 53/26 mmHg. There
was a
normal cardiac index of 2.8 L/min/m2. The was normal central
aortic
blood pressure.
3. The saphenous vein grafts were known to be occluded and were
not
engaged.
4. Arterial conduit angiography revealed a patent LIMA to LAD.
5. Selective engagement of both renal arteries revealed no
significant
stenoses bilaterally.
.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Patent LIMA to LAD.
3. Moderate right and left ventricular diastolic dysfunction.
4. Patent bilateral renal arteries.
5. Moderate pulmonary hypertension.
6. Known occluded saphenous vein grafts.
7. Normal systemic blood pressure.
Brief Hospital Course:
The patient is a 67y/o M with a complex PMH including DM type 2,
[**Hospital3 9642**] mechanical AVR ([**2168**]), Ascending aorta repair with
graft ([**2168**]), hx of VF arrest s/p AICD [**2175**] with subsequent
explantation in setting of recurrent high grade CoNS and VRE BSI
[**4-2**], with recent broad spectrum antibiotic courses Pseudomonal
UTI [**6-2**] and R foot infection [**7-2**] now presenting with
suprapubic pain, low grade fever, leukocytosis and hypotension.
.
# SIRS - WBC elevated to 19 on admission. He had multiple
potential sources of infection including UTI, R foot ulcer s/p
debridement and BSI. No evidence of PNA on CXR and cough at
patient's baseline on admission. Also considered C. diff given
multiple recent broad spectrum courses of antimicrobials, but
negative x 2. The patient is at high risk for resistant GP and
GN organsisms given history. He did grow out Pseudomonas from
urine, for which he was treated with meropenem x 14 day course
given resistance in the past. He does not have chronic
indwelling foley. No evidence of cardiac event or additional
source of leukocytosis. With previous history of VRE and MRSA
did initially receive daptomycin/vancomycin pending further
culture data, as GNR more likely source, but d/c'ed on [**8-22**] and
[**8-23**] respectively after blood cultures negative.
.
Pt completed 14d course of meropenem for pseudomonas UTI. No
evidence of abdominal/pelvic source of infection. No evidence of
osteo on Xray and vascular commented that wound does not look
acutely infected. He is s/p debridement on [**2178-6-29**] with
additional debridement on [**2178-8-25**]. ESR found to be 122. There was
also concern over possible graft or AV valve infection. Line
does not look infected. Patient has been afebrile since [**2178-8-24**].
.
Pt became hypotensive and bradycardic while on the commode on
[**2178-8-30**] requiring atropine, pressors (dopamine) and pt was also
intubated. His WBC count was found to be elevated at 26 but pt
was afebrile. Initially there was concern that pt had SIRS or
sepsis, however, WBC count resolved w/in 12 hours. Pt was
pan-cultured, no cultures positive to date since the urine
culture gotten on admission. It was felt that the hypotension
was likely vasovagal.
.
# Hypotension - BP dropped to systolic 80s in ED, was responsive
to IVF boluses and also was on levophed in MICU. Argument
against dobutamine: arythmogenic in tachycardic person, also
vasodilator so would need dobutamine +levo. Levophed d/c'ed on
[**2178-8-23**]. Also considered source of bleeding given elevated INR,
but guaiac negative in ED and Hct's stable. CT abdomen, pelvis
showed No RP bleed, no acute process. On [**2178-8-18**] had flash
pulmonary edema with acute drop in sats, tachycardia, HTN,
diaphoresis, new crackles on exam with new bilateral pleural
effusions on CXR. Responded to nebs, nitro, lasix, morphine and
bipap. Soon after, dc/d nitro drip, poor UO thus started on
lasix drip. Lasix was titrated and diuril added as needed to
maintain 1-2L negative daily. On [**2178-8-27**], patient was +600mL, so
additional 60mg IV lasix administed prior to transfer to the
floors. SBP's ranging in 100's to 110's.
.
Pt became hypotensive and bradycardic while on the commode on
[**2178-8-30**] requiring atropine, transfer to MICU, pressors (dopamine)
and intubation [**1-26**] ventilatory failure. His WBC count was found
to be elevated at 26 but pt was afebrile. Initially there was
concern that pt had SIRS or sepsis, however, WBC count resolved
w/in 12 hours. Pt was pan-cultured, no cultures positive to date
since the urine culture gotten on admission. It was felt that
the hypotension was likely vasovagal and c/b fluid resuscitation
which then caused pulmonary edema. Pt's dopamine was slowly
weaned. He was able to be extubated 24 hours after intubation.
Because he had flash pulmonary edema on multiple occasions and
was occasionally bradycardic in the setting of hypotension,
cardiology was consulted for further advice on managing his
tenous volume status and for ? of sick sinus syndrome, they
recommended that he not get an ICD at this time but he may
require one in the future. Because of his difficult volume
status he was transferred from the ICU to the cardiology service
rather than to the regular floor team for further management.
After about 24 hours on the cardiology service, the patient
developed hypertension and SOB, found to be tachypneic and
tachycardic c ventilatory failure on ABG and was intubated. He
was transferred to the CCU, where he was successfully diuresed
and extubated. He was hemodynamically stable throughout this
time and was started on lasix gtt and metolazone. He diuresed
well on this regimen and was extubated within 24 hours. He
received RHC on [**9-4**] which revealed PCWP = 24, RVEDP = 14, PASP
= 41, CI = 3.2. He was converted to PO lasix and called back out
to the floor, under the management of the cardiology service.
.
Patient continued to diurese well on the floor. After Cr bumped
after several days of aggressive diuresis, patient was switched
to torsemide as monotherapy for diuresis. This was ultimately
downtitrated as Cr allowed with good diuresis of about negative
15L during his last week on the floor. It was felt that the
patient's recurrent flash sx might have been [**1-26**] ischemia from
known CAD (s/p CABG with intact LIMA, occluded vein grafts per
last cath). Felt that patient could benefit from LHC to attempt
to restore blood flow to regions noted on echo to be
hypokinetic. LHC/RHC/renal angiogram was performed on [**9-14**].
LHC showed known blockages with no targets for intervention.
RHC showed improved PCWP but still elevated. Renal angiogram
showed no evidence of stenosis.
.
After procedure, patient was restarted on heparin bridge to
coumadin and was felt to be clinically stable for discharge.
.
# Hypoxic respiratory failure - During flash edema episdodes, pt
w/ pulmonary edema, poor oxygen sats. Was on BiPAP, but with
persistent hypoxia despite diuresis. Etiology intially thought
to be cardiogenic from decompensated heart failure. CT torso on
[**8-22**] showed ground glass opacity with consolidation, suggestive
of infection, edema, or ARDS. CXR's improved with diuresis, so
most likely source was pulmonary edema. Over the course of his
admission, the patient had three episodes of hypoxic respiratory
failure requiring intubation; all resolved with aggressive
diuresis and the patient was able to be extubated.
.
# Chronic Systolic CHF - EF 25-30% s/p VF arrest [**2175**] and ICD
explantation. Repeat echo showed EF of 20%. Held
antihypertensives including metoprolol, lisinopril and
spironolactone as above given hypotension. Diuresis as above.
Restarted lisinopril on discharge but continued to hold
metoprolol and spironolactone as it was felt patient could not
tolerate at this time due to HR 60s and SBP 90s-100s on
discharge. Will have to continue discussion as outpatient and
restart if possible.
.
# s/p Mechanical AVR - on coumadin, INR supratherapeutic on
admission, and patient with high sensitivity to coumadin doses
(? if secondary to antibiotics). He is s/p Vitamin K
administration and reversal. Has be subtherapeutic since [**2178-8-24**]
(goal is 2.5-3.5). Now currently on coumadin 5 mg QHS and
heparin gtt for bridging (requires bridge [**1-26**] severe CHF).
.
# Acute Renal Failure - Likely secondary to diuresis vs. poor
perfusion vs. hypotension vs. UTI. Creatinine had been ranging
1.4-1.6 during MICU stay. On discharge, improved to 1.0-1.1.
.
# ?C diff - multiple loose bowel movements on [**2178-9-1**]. cdiff
toxin was sent and pt was started on PO flagyl. C. diff EIA was
negative and patient's diarrhea resolved, at which point PO
flagyl was discontinued.
.
# DM type 2 - continue home lantus and insulin SS. Patient had
elevated CBGs during hospitalization initially that were
controlled after uptitrating sliding scale to provide aggressive
mealtime coverage. The following sliding scale was achieving
good glucose control at the time of discharge: At all mealtimes,
give 4 units of insulin if glucose 50-150, 12 units if 151-200,
16 units if 201-250, and so on with extra 4 units for every CBG
range in increments of 50. The bedtime sliding scale was
identical to mealtime except -4 units at all ranges.
.
# Dyslipidemia - continue statin.
Medications on Admission:
AMIODARONE - 200 mg daily
ATORVASTATIN [LIPITOR] - 40 mg daily
FUROSEMIDE - 80 mg [**Hospital1 **]
GABAPENTIN - 400 mg TID
INSULIN GLARGINE [LANTUS] - 120 units at bedtime
INSULIN LISPRO [HUMALOG] - scale, before meals
LEVETIRACETAM [KEPPRA] - 500 mg PO qHS "for seizures"
LISINOPRIL - 2.5 mg daily
METOLAZONE - 2.5 mg daily
METOPROLOL TARTRATE - 12.5 mg daily
NITROGLYCERIN - 0.4 mg SL prn chest pain, up to 3, etc.
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg, 1 tab q4 to 6
hrs max of 3 a day
POTASSIUM CHLORIDE - 40 mEq daily
RANITIDINE HCL - 150 mg [**Hospital1 **]
SPIRONOLACTONE - 12.5 mg daily
WARFARIN - 4-6 mg qHS as directed by coumadin clinic to maintain
INR
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety.
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Titrate to INR between 2.5 and 3.5, as directed by
[**Hospital3 **].
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Heparin (Porcine) in D5W 10,000 unit/100 mL Parenteral
Solution Sig: AS DIRECTED Intravenous CONTINUOUS INFUSION:
Titrate to PTT between 60-100. Stop when INR is therapeutic
(greater than 2.5) for 48 hours.
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
16. Insulin Glargine 100 unit/mL Solution Sig: One Hundred
Twenty (120) units Subcutaneous at bedtime.
17. Insulin Lispro 100 unit/mL Solution Sig: PER SLIDING SCALE
Subcutaneous BEFORE MEALS AND AT BEDTIME.
18. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): GIVE AT 8AM, 2PM daily to avoid excessive diuresis at
nighttime.
19. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day.
20. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
21. Miralax 17 gram/dose Powder Sig: One (1) dose PO once a day
as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis: urosepsis, acute on chronic systolic heart
failure, right-sided foot ulcer status post multiple surgical
debridements
Secondary Diagnoses:
1. coronary artery disease status post bypass
2. history of ventricular fibrillation
3. history of pacemaker placement with subsequent infection and
lead removal
4. aortic valve replacement
5. history of ascending aorta repair
6. hypertension
7. hyperlipidemia
8. diabetes mellitus, type 2, complicated by neuropathy
9. peripheral vascular disease, complicated by left sided below
knee amputation
10. hepatitis C
11. hypothyroidism
12. history of opiate and benzodiazepine dependence
13. chronic subdural hematoma
Discharge Condition:
Fair, with no shortness of breath or chest pain. Lungs are
clear to auscultation with trace dependent edema. Patient
cannot walk (despite prosthesis) at baseline.
Discharge Instructions:
You were originally seen at [**Hospital1 18**] for suprapubic pain and fever.
You were found to have a severe urinary tract infection and
were treated with IV antibiotics. Your hospital course was
complicated by numerous occurrences of rapid fluid collection in
the lungs causing difficulty breathing and requiring intubation
three separate times. We felt that this was likely due to your
severe congestive heart failure. We aggressively treated you
with diuretics to take off this excess fluid and improve your
breathing.
We felt that you would benefit from cardiac catherization to see
if there were any blockages that could be precipitating your
episodes of pulmonary edema. You received cardiac catherization
which showed no new blockages that could be intervened on;
therefore, the plan was to continue you on medical management.
The following medications were changed during your
hospitalization:
DISCONTINUED furosemide
DISCONTINUED metolazone
ADDED torsemide (instead of the two above medications) for
removal of excess fluid
DISCONTINUED metoprolol for now as your blood pressure and heart
rate may not tolerate it
DISCONTINUED spironolactone for now as your blood pressure may
not tolerate it
INCREASED gabapentin to 600 three times a day for better control
of your neuropathic pain
ADDED docusate for constipation
ADDED senna for constipation
ADDED bisacodyl for constipation
ADDED miralax as needed for constipation
ADDED lorazepam as needed for anxiety. Please do NOT use
outside benzodiazepines with this medication, including Valium,
Ativan, Xanax, etc.
Please keep all follow up appointments. During your next
appointment with Dr. [**Last Name (STitle) **], your cardiologist, you will need to
discuss restarting metoprolol, and/or spironolactone, as those
medications are good for people with heart failure. You were
not restarted on this medication in the hospital because we were
not sure your blood pressure could tolerate them at this time.
You are scheduled to see Dr. [**Last Name (STitle) **] in two weeks. At that time,
your wound will be re-examined and a decision will be made
regarding whether your wound VAC needs to be continued.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 L / day
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2178-9-23**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2178-9-29**] 2:45
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2178-10-15**] 3:00
Completed by:[**2178-9-19**]
|
[
"787.91",
"E934.2",
"428.0",
"276.1",
"244.9",
"584.9",
"414.02",
"458.8",
"707.15",
"285.9",
"V49.75",
"305.1",
"518.81",
"414.01",
"V45.02",
"070.70",
"272.4",
"304.03",
"V58.67",
"250.60",
"599.0",
"428.43",
"440.20",
"V43.3",
"424.0",
"276.4",
"995.90",
"401.9",
"041.7",
"414.8",
"780.09",
"427.89",
"276.52",
"780.93",
"790.92",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"38.91",
"96.6",
"86.22",
"38.93",
"88.45",
"37.21",
"96.04",
"96.72",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
28745, 28824
|
17589, 25956
|
360, 535
|
29540, 29707
|
5965, 16253
|
32060, 32576
|
5061, 5143
|
26682, 28722
|
28845, 28845
|
25982, 26659
|
17293, 17566
|
29731, 32037
|
5158, 5158
|
29003, 29519
|
5562, 5946
|
275, 322
|
563, 3553
|
28864, 28982
|
5172, 5548
|
3575, 4822
|
4838, 5045
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,975
| 191,098
|
25595
|
Discharge summary
|
report
|
Admission Date: [**2189-6-4**] Discharge Date: [**2189-7-9**]
Date of Birth: [**2138-5-2**] Sex: M
Service: SURGERY
Allergies:
Kefzol
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p plane crash
Major Surgical or Invasive Procedure:
[**6-4**] irrigation, debridement & ex fix of open left tibial
fracture;
compartment release of left lower extremity; irrigation,
debridement & ex fix of open right femur fracture; closed
reduction of right ankle
[**6-5**] placement of swan ganz catheter & esophageal balloon for
hemodynamic monitoring
[**6-7**] T12 vertebrectomy; T11-L1 fusion & anterior cage placement;
CPR following severe blood loss
[**6-11**] placement of IVC filter
[**6-12**] open tracheostomy; right ankle ORIF; nailing of R femur
fracture
[**6-17**] left tibia ORIF with plate
[**6-22**] closure of LLE fasciotomies
[**6-4**] irrigation, debridement & ex fix of open left tibial
fracture;
compartment release of left lower extremity; irrigation,
debridement & ex fix of open right femur fracture; closed
reduction of right ankle
[**6-5**] placement of swan ganz catheter & esophageal balloon for
hemodynamic monitoring
[**6-7**] T12 vertebrectomy; T11-L1 fusion & anterior cage placement;
CPR following severe blood loss; post-repair [**6-25**]
[**6-11**] placement of IVC filter
[**6-12**] open tracheostomy; right ankle ORIF; nailing of R femur
fracture
[**6-17**] left tibia ORIF with plate
[**6-22**] closure of LLE fasciotomies
History of Present Illness:
51M deaf pilot s/p plane crash over [**Hospital3 4298**] [**6-4**], who
was first seen at [**Hospital **] Hospital, where he was intubated & received
1 unit RBC on top of his trauma resuscitation. He was
transferred to [**Hospital1 18**] for further management of his multiple
traumatic injuries.
Past Medical History:
Deaf
Social History:
Supportive family. Resides in [**State 531**]
Family History:
noncontributory
Physical Exam:
On admission to trauma bay:
T 98.6 P 112 BP 180/palp 97%
Intubated, sedated. GCS 3T
Foreign body embedded in L scalp
PERRLA
+C collar
RRR
CTA B
Soft, NT, ND, FAST neg
Rectal-decreased tone, guaiac neg
Foley in place, obvious hematuria
Open R distal femoral fracture,
Open L tibial fractures w/ assoc compartment sx, lac in medial L
calf
Palp DP pulses
Pertinent Results:
See attached CD-ROM for significant rads images.
On presentation: hct 32.7
[**6-25**] sputum culture: Pseudomonas aeruginosa, heavy growth
[**2189-6-4**] 04:50PM FIBRINOGE-167
[**2189-6-4**] 04:50PM PT-14.4* PTT-26.4 INR(PT)-1.4
[**2189-6-4**] 04:50PM PLT COUNT-189
[**2189-6-4**] 04:50PM WBC-26.9* RBC-3.85* HGB-11.8* HCT-32.7*
MCV-85 MCH-30.7 MCHC-36.1* RDW-12.8
[**2189-6-4**] 04:50PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2189-6-4**] 04:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2189-6-4**] 04:50PM CK-MB-8 cTropnT-<0.01
[**2189-6-4**] 04:50PM CK(CPK)-1145* AMYLASE-36
[**2189-6-4**] 04:50PM UREA N-15 CREAT-1.1
[**2189-6-4**] 05:03PM GLUCOSE-141* LACTATE-3.5* NA+-140 K+-4.4
CL--110 TCO2-24
[**2189-6-4**] 05:07PM TYPE-ART PO2-68* PCO2-50* PH-7.27* TOTAL
CO2-24 BASE XS--4 INTUBATED-INTUBATED
[**2189-6-4**] 06:49PM HCT-26.2*
[**2189-6-4**] 07:40PM FIBRINOGE-122*
[**2189-6-4**] 07:40PM PT-14.6* PTT-30.7 INR(PT)-1.4
[**2189-6-4**] 07:55PM freeCa-1.01*
[**2189-6-4**] 07:55PM HGB-8.7* calcHCT-26
[**2189-6-4**] 07:55PM GLUCOSE-150* LACTATE-3.7* NA+-135 K+-4.4
CL--113*
Brief Hospital Course:
[**6-4**] Patient was admitted after transfer from [**Hospital3 46817**], and taken emergently to the OR by orthopedics. Please
refer to catalog of interventions that Mr. [**Known lastname 63895**] received
during this admission. After surgery, he was admitted to the
TSICU. Please refer to the medical record for the details of
his extended ICU stay. Below is an organ system-based synopsis
of Mr. [**Known lastname 63896**] relevant medical issues during this admission.
NEURO: Mr [**Known lastname 63895**] had high pain medication requirements during
this stay, and was slow to awaken after his sedation was
discontinued after tracheostomy. He is on a regimen of standing
methadone with PO Dilaudid prn for pain. At the time of DC, he
was able to follow commands & to express himself through sign
language. He is able to move his arms but movement of his legs
was not seen, likely because of transection of the spinal cord
at the level of T12. However, he does appear to have retained
sensation in his legs.
CV: He has a high baseline heart rate, which has been controlled
with lopressor. [**6-5**] Echo showed good retained LV function and
no valvular abnormalities.
RESP: He had bilateral pulmonary contusions on presentation,
which contributed to his ARDS/[**Doctor Last Name **]. He had high PEEP
requirements early in his ICU course, which were gradually
weaned. A chest tube was placed perioperatively around the 1st
operation, and was DC'd without complication. After the
tracheostomy was performed, he weaned off the ventilator. 4 days
prior to presentation, the tracheostomy tube fell out post
coughing. The patient has tolerated breathing without the
tracheostomy.
FEN: He was sustained on enteral tube feeds via a postpyloric
dobhoff. Prior to DC, he passed a swallow evaluation and has
been able to maintain nutrition on a PO diet. He is on prevacid
as well.
HEME: He received multiple transfusions for blood loss anemia,
especially around the time of his 1st surgery, during which he
lost about 11 L of blood. He has been prophylaxed against
DVT/PE with lovenox & an IVC filter. He has had a persistent
mild leukocytosis (15-18k), the etiology of which has not been
discovered despite triple antibiotic therapy and repeated
workups.
ID: He developed several line infections, with + blood cultures
with staph epidermidis. After removal of the lines, he promptly
defervesced. A sputum culture from [**6-25**] revealed pseudomonas
and he was started on levoquin & zosyn. He then developed
copious diarrhea and was started empirically on flagyl while
stool cultures were sent. See above under heme for brief
discussion of leukocytosis.
ENDO: regular insulin sliding scale to FBS 80-120.
DISPO: full code, father [**Name (NI) **] is HCP (cell [**Telephone/Fax (1) 63897**], home
[**Telephone/Fax (1) 63898**])
Medications on Admission:
none
Discharge Medications:
1. Methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*270 Tablet(s)* Refills:*2* On for pain management.
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
Disp:*60 syringe* Refills:*2*
4. Acetaminophen 160 mg/5 mL Solution Sig: Four (4) teaspoons PO
Q6H (every 6 hours).
Disp:*300 ML* Refills:*2*
5. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO four
times a day as needed for thrush.
Disp:*250 ML(s)* Refills:*3*
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) teaspoon PO
BID (2 times a day).
Disp:*60 teaspoon* Refills:*2*
7. Multivit-Iron-Min-Folic Acid Syrup Sig: One (1) dose PO
once a day.
Disp:*250 ML* Refills:*2*
8. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: Ten (10) Recon
Soln Intravenous Q8H (every 8 hours) for 10 days.
Disp:*30 doses* Refills:*0*
9. Regular insulin sliding scale
Fingersticks q6. Dose insulin as follows: less than 70, 4 oz
juice via dobhoff; 121-160, 3 units; 161-200, 6 units; 201-240,
9 units; 241-280, 12 units; more than 281, 15 units & notify MD.
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-14**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*5*
11. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO twice a day as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
12. Haloperidol Lactate 5 mg/mL Solution Sig: [**12-17**] ml Injection
Q1-2H () as needed for agitation: follow QTc regularly.
Disp:*250 ml* Refills:*0*
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H
(Every 3 to 4 Hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Continue for 5 more days.
15. Tobramycin Sulfate 10 mg/mL Solution Sig: One (1) Injection
Q8H (every 8 hours): Continue for 7 more days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]
Discharge Diagnosis:
s/p plane crash
T12 burst fracture
retroperitoneal hematoma
multiple rib fractures
bilateral pulmonary contusions
ARDS/acute lung injury
paraplegia
right femur fracture
bilateral tibia/fibula fractures
left leg compartment syndrome
respiratory failure
pseudomonas pneumonia
line sepsis
allergic dermatitis
kefzol allergy
Discharge Condition:
improved
Discharge Instructions:
Tube feeding & medications via dobhoff tube as prescribed.
Check patient's swallowing function as he becomes more
responsive.
Culture for fevers or leukocytosis as appropriate. Feel free to
contact [**Hospital1 18**] trauma team with any questions or concerns.
Culture for fevers or leukocytosis as appropriate. Patient has
had history of mild leukocytosis (15K to 18K) on triple therapy
antibiotics, with repeated negative work-ups.
We are reccomending that the patient continues his current
antibiotic regimen so he recieves a 2 week course of each
medicine. As of today ([**7-9**]) he is on day [**11-25**] of IV Zosyn,
[**8-26**] po Flagyl, and [**6-25**] of IV tobramycin.
Patient has been undergoing PT/OT and currently is able to get
out of bed with assist to chair daily.
Feel free to contact [**Hospital1 18**] trauma team with any questions or
concerns.
Followup Instructions:
You will be an inpatient at the [**Hospital **] [**Hospital **] Hospital in
[**State 531**].
Contact the Trauma Surgery office at [**Telephone/Fax (1) 6439**] with any
questions or concerns.
Completed by:[**2189-7-9**]
|
[
"821.30",
"806.26",
"285.1",
"518.5",
"998.11",
"278.01",
"482.1",
"824.2",
"873.1",
"958.8",
"958.4",
"389.9",
"E841.5",
"861.21",
"823.10",
"996.62",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.06",
"79.66",
"78.15",
"96.6",
"03.53",
"79.65",
"79.36",
"86.22",
"83.65",
"39.98",
"96.72",
"86.05",
"78.17",
"81.05",
"81.62",
"84.51",
"38.7",
"81.04",
"83.09",
"81.63",
"89.64",
"77.79",
"79.35",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
8529, 8576
|
3566, 6415
|
279, 1504
|
8941, 8951
|
2349, 3543
|
9868, 10090
|
1937, 1954
|
6470, 8506
|
8597, 8920
|
6441, 6447
|
8975, 9845
|
1969, 2330
|
224, 241
|
1532, 1830
|
1852, 1858
|
1874, 1921
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,194
| 119,417
|
43031
|
Discharge summary
|
report
|
Admission Date: [**2180-10-5**] Discharge Date: [**2180-10-11**]
Date of Birth: [**2114-9-18**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Bactrim /
SEROVENT / fentanyl / midazolam
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
Anemia, epigastric pain
Major Surgical or Invasive Procedure:
Endoscopy with biopsy
History of Present Illness:
66yo female w/ h/o rheumatic heart disease, HTN, DM2 presenting
with indigestion following exertion, severe anemia and guaiac
positive stool. For 2 weeks now, with walking or going up
stairs, she has had a burning feeling in her epigastrum and
shortness of breath. Has also had lightheadedness with standing.
Has never had symptoms like this before, all of which started 2
weeks ago after a plane trip back to [**Location (un) 86**] from [**State 9512**]. This
morning around 3am she awoke with dyspepsia that persisted,
accompanied by bilateral shoulder pain. She made an appointment
with her PCP, [**Name10 (NameIs) 1023**] found her to be dyspneic and hypoxic 92-94%
with ambulation, so referred her to the ED.
.
In the ED, initial vs were: 97.2 100 164/48 20 96%. Initial
concern for PE, but d-dimer and LE dopplers negative. Hct 18.
Heme positive black stool on rectal. Has 2 PIVs (18G+20G), tough
access, then can't use one arm b/c of h/o breast cancer. NG
lavage negative. GI aware, but did not come in given negative NG
lavage. Started pantoprazole drip. Small lateral ST depressions
on EKG. Vitals prior to transfer 91 160/90 19 96% RA. Just
started first unit of blood prior to transfer.
.
On the floor, patient is pain free and resting comfortably. She
denies bloody bowel movements, and has not had a bowel movement
today. No F/C, diarrhea/constipation, dysuria. Mild nausea, but
no vomiting. Has never had a GI bleed before. Other ROS
negative.
Past Medical History:
- hypertension
- HLD
- IDDM
- Hx of breast cancer, s/p mastectomy in [**2174**]
- chronic LE venous insufficiency
- OSA, doesn't use CPAP
- asthma
- rheumatic heart disease
Social History:
Works as a social worker. Lives with her husband. [**Name (NI) 4084**] [**Name2 (NI) 1818**],
occ EtOH, no drugs.
Family History:
No family history of early MI, gastric ca or liver dz. Mother
with a history of a stroke.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur loudest at L lower sternal border
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses. L>R 1+ pitting edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
Pertinent Results:
Admission labs:
[**2180-10-5**] 08:30PM WBC-6.1 RBC-2.11*# HGB-5.8*# HCT-18.5*#
MCV-88 MCH-27.6 MCHC-31.5 RDW-15.1
[**2180-10-5**] 08:30PM NEUTS-70.2* LYMPHS-21.9 MONOS-7.0 EOS-0.9
BASOS-0
[**2180-10-5**] 08:30PM PLT COUNT-422
[**2180-10-5**] 08:30PM D-DIMER-250
[**2180-10-5**] 08:30PM proBNP-1057*
[**2180-10-5**] 08:30PM GLUCOSE-152* UREA N-20 CREAT-0.9 SODIUM-140
POTASSIUM-6.1* CHLORIDE-106 TOTAL CO2-26 ANION GAP-14
[**2180-10-5**] 11:01PM K+-5.1
Hematocrit trend:
[**2180-10-5**] 08:30PM BLOOD WBC-6.1 RBC-2.11*# Hgb-5.8*# Hct-18.5*#
MCV-88 MCH-27.6 MCHC-31.5 RDW-15.1 Plt Ct-422
-->transfused 2 units
[**2180-10-6**] 05:01AM BLOOD WBC-5.3 RBC-2.53* Hgb-7.3*# Hct-22.2*
MCV-88 MCH-28.7 MCHC-32.6 RDW-15.1 Plt Ct-366
[**2180-10-6**] 03:02PM BLOOD Hct-24.6*
[**2180-10-6**] 08:57PM BLOOD WBC-6.2 RBC-2.69* Hgb-7.7* Hct-23.5*
MCV-87 MCH-28.7 MCHC-32.9 RDW-15.2 Plt Ct-336
[**2180-10-7**] 04:01AM BLOOD WBC-6.2 RBC-2.62* Hgb-7.6* Hct-22.9*
MCV-87 MCH-29.0 MCHC-33.2 RDW-15.2 Plt Ct-331
-->transfused 2 units
[**2180-10-7**] 01:48PM BLOOD Hct-27.3*
[**2180-10-7**] 08:56PM BLOOD Hct-28.4*
[**2180-10-8**] 02:35AM BLOOD WBC-8.0 RBC-3.41*# Hgb-10.3*# Hct-30.2*
MCV-89 MCH-30.2 MCHC-34.1 RDW-15.2 Plt Ct-382
Brief Hospital Course:
66yo female w/ h/o rheumatic heart disease, HTN, DM2 presenting
with indigestion following exertion, severe anemia and guaiac
positive stool.
.
#. Anemia: Likely from a slow ooze, considering she has not
noticed a change in her bowel movements, and is relatively well
compensated for a Hct of 18. She was originally started on a
pantoprazole infusion, which was switched to pantoprazole 40mg
[**Hospital1 **]. She had peripheral IVs for access. The morning after
admission had a small, tarry stool. Her Hct originally came up
to 22, then transfused two more units PRBCs with Hct to 28.
Upper endoscopy showed a large, ulcerated, bleeding mass in the
antrum highly suspicious for gastric carcinoma. A repeat
endoscopy was performed after stabilization of her hematocrit,
and pathology showed poorly differentiated adenocarcinoma. The
patient was set up with oncology follow-up for possible
neo-adjuvant chemotherapy and partial gastrectomy. The patient
received a total of 8 units of PRBCs and her hematocrit was
stable at discharge.
.
#. SOB and dyspepsia with exertion: almost definitely related to
severe anemia, however story also suspicious for ACS. EKG shows
possible mild strain, but not ACS. Troponins were negative, and
mild ST depressions resolved. Once she was hemodynamically
stable she was restarted on her metoprolol pre-op.
.
#. Diabetes: While NPO she was kept on a reduced lantus dose
with a humalog sliding scale. Her lantus was titrated up back
to her home dose once no longer NPO.
.
# CAD: continued rosuvastatin. Stopped Aspirin in setting of GI
bleed.
.
# Asthma: continued montelukast and fluticasone
Medications on Admission:
- albuterol 90 mcg 1-2 puffs Q6hrs PRN
- ASA 325mg daily
- duloxetine DR 60mg daily
- fluticasone 220mcg [**Hospital1 **]
- furosemide 40/20mg daily
- insulin lispro sliding scale
- insulin lantus 30 units QHS
- metoprolol tartrate 50mg [**Hospital1 **]
- montelukast 10mg daily
- rosuvastatin 10mg daily
- omeprazole 40mg daily
- valsartan 320mg daily
- verapamil ER 180mg daily
- Ambien 10mg QHS
- CaCo3-Vit D3 600/400
Discharge Medications:
1. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO in the
morning.
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. insulin lispro 100 unit/mL Solution Sig: Sliding scale
Subcutaneous three times a day: Use your regular sliding scale.
7. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. 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*
11. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. valsartan 160 mg Tablet Sig: One (1) Tablet PO twice a day.
13. verapamil 180 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q24H (every 24 hours).
14. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastric cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 50155**],
You were admitted to the hospital because you had a GI bleed.
You had an endoscopy that showed that unfortunately showed that
you have gastric cancer. You were seen by our oncologists, who
feel that you will likely need chemotherapy and surgery in order
to treat this cancer. You have an appointment to follow up with
our oncologists this coming Monday.
Your omeprazole has been increased to twice daily to prevent
further GI bleeding. Your aspirin has also been discontinued,
and you should discuss with your primary care doctor when you
should restart this.
Followup Instructions:
You have the following appointments coming up:
Department: [**State **]When: TUESDAY [**2180-10-17**] at 10:45 AM
With: [**Name6 (MD) **] [**Name8 (MD) 9862**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2180-10-16**] at 10:00 AM
With: DR. [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2180-10-16**] at 10:00 AM
With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2180-10-12**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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4191, 5819
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376, 400
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2961, 4168
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1910, 2084
|
2100, 2215
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,667
| 166,854
|
21885
|
Discharge summary
|
report
|
Admission Date: [**2112-11-20**] Discharge Date: [**2112-11-28**]
Date of Birth: [**2040-5-31**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 72 year old gentleman was
admitted to [**Hospital3 1280**] for elective cardiac catheterization
which showed three vessel disease. He had had shortness of
breath and chest pain with ambulating approximately two to
three blocks. He also reported angina at rest relieved with
Nitroglycerin. Last chest pain was last evening prior to
admission which resolved with sublingual Nitroglycerin. He
had no family history of heart disease. No use of tobacco
and admitted to one to two drinks per day.
This gentleman had been treated medically for his history of
angina over approximately twenty years.
PAST MEDICAL HISTORY: Noninsulin dependent diabetes
mellitus.
Hypertension.
Status post appendectomy.
ALLERGIES: He had no known allergies.
PAST SURGICAL HISTORY: Appendectomy
MEDICATIONS ON ADMISSION:
1. Cartia unknown dose.
2. Lisinopril 40 mg p.o. daily.
3. Lipitor 40 mg p.o. daily.
4. Glipizide 10 mg p.o. q.a.m., Glipizide 5 mg p.o. q.p.m.
5. Aspirin 81 mg p.o. daily.
6. Valium 2.5 mg p.o. daily.
7. Hydrochlorothiazide 12.5 mg p.o. daily.
8. Aciphex 20 mg p.o. daily.
9. Atenolol 25 mg p.o. daily.
10. IMDUR 60 mg p.o. daily.
PHYSICAL EXAMINATION: On examination, his temperature was
97.7, heart rate 44, blood pressure 152/67, respiratory rate
18, oxygen saturation 98 percent in room air. He is alert
and oriented times three with bilateral equal strength. His
lungs were clear bilaterally. His heart was regular rate and
rhythm. His abdomen was soft, nontender, nondistended. He
had bilateral palpable femoral, dorsalis pedis and radial
pulses with no carotid bruits.
LABORATORY DATA: Carotid ultrasound preoperatively showed
bilateral stenosis of less than 40 percent.
Preoperative laboratories as follows: White blood cell count
9.3, hematocrit 44.7, platelet count 288,000. Sodium 142,
potassium 4.5, chloride 96, bicarbonate 32, blood urea
nitrogen 15, creatinine 1.1 with a blood sugar of 175, total
bilirubin 0.9, ALT 26, AST 47, alkaline phosphatase 98.
Cardiac catheterization showed 80 to 95 percent blockage of
the left anterior descending coronary artery, 100 percent
blockage of obtuse marginal one, 80 percent blockage of
diagonal, 95 percent blockage of the circumflex, 90 percent
blockage of the right coronary artery, and ejection fraction
of 71 percent.
HOSPITAL COURSE: The patient was referred to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] for possible coronary artery bypass grafting and
was seen by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 70**]. He remained
in-house one more day prior to his operation. That day was
unremarkable. Additional laboratories were prothrombin time
13.5 and partial thromboplastin time 47.2 with an INR of 1.2.
The rest of the laboratory work was as follows: ALT 46, AST
27, alkaline phosphatase 77, total bilirubin 0.5, albumin
3.6. Amylase 37, lipase 35. His examination was unchanged.
The patient was also started on Pantoprazole 40 mg p.o.
daily. He was also started on Heparin 800 units per hour.
The patient was also seen by case management.
On [**2112-11-22**], the patient underwent coronary artery bypass
grafting times four with left internal mammary artery to the
left anterior descending coronary artery, saphenous vein
graft sequentially from the right posterior descending to the
left posterolateral and a saphenous vein graft to the left
anterior descending coronary artery/diagonal by Dr.
[**Last Name (STitle) 70**]. He was transferred to the Cardiothoracic
Intensive Care Unit in stable condition on Propofol drip at
10 mcg/kg/minute. The patient was extubated later that
evening and was on four liters of nasal cannula with
acceptable blood gases.
On postoperative day number one, he was in sinus rhythm in
the 90s with a blood pressure of 170/67, saturating 97
percent with cardiac index of 2.72, pulmonary artery pressure
of 35/17. He was alert and oriented times three. His heart
was regular rate and rhythm. His chest tubes were in place.
He had decreased breath sounds bilaterally. His abdomen was
soft. He had one to two plus peripheral edema. Swan was to
be discontinued along with his chest tubes. Lopressor beta
blockade was restarted. Lasix diuresis was also begun and
the patient was transferred to the floor. The patient was
also seen by physical therapy on postoperative day number
two. The patient was receiving Toradol for pain, was
restarted on his oral diabetes medications. Postoperative
laboratories were as follows: White blood cell count 13.0,
hematocrit 32.5, platelet count 191,000. Potassium 4.3,
blood urea nitrogen 13, creatinine 0.9 with a blood sugar of
141. The patient was oriented appropriately. Incisions were
clean, dry and intact. His chest tubes had remained in place
overnight for a slightly elevated chest tube output of 540 in
the 24 hours prior at 110 since midnight. Chest tubes
remained in place. That afternoon, Lopressor was increased
to 50 twice a day and the patient was encouraged to ambulate
with his nurse in physical therapy. On postoperative day
number three, his Lopressor was increased again, had a blood
pressure of 155/66, with a pulse of 62 now. He continued to
do very well. His chest tubes and pacing wires were pulled
without incident. Lisinopril was restarted at 10 mg p.o.
daily. The patient was encouraged to ambulate and increase
his p.o. intake. On postoperative day number four, his
Lopressor was decreased as his heart rate had dropped into
the 50s but with an adequate blood pressure of 164/66. His
blood urea nitrogen was 19 and creatinine was 0.9, hematocrit
stable at 34.5, white blood cell count dropped slightly to
10.5. The patient had one syncopal episode while doing the
stairs. His electrocardiogram was normal sinus rhythm with
no ischemic changes. The heart rate has been low so
Lopressor was decreased. Lisinopril was increased to 20 mg
twice a day. The patient otherwise was doing very well. On
postoperative day number five, his blood pressure was up
slightly. He had some dizziness with stairs in physical
therapy but his blood pressure was stable. He did not
receive any Lasix diuresis. His examination was
unremarkable. His Lopressor was decreased to 25 mg twice a
day. He continued to be out of bed with physical therapy
pending doing stairs at which time he could be able to go
home. His Lisinopril was increased to 40 mg p.o. daily. On
postoperative day number six, he was in sinus rhythm a heart
rate of 74, blood pressure 120/70, weight 87.9 kilograms,
temperature maximum 99.6. His lungs were clear. He was
alert and oriented. He had bowel sounds. He had one plus
peripheral edema. His incisions were clean, dry and intact.
The plan was to discharge him home.
DISCHARGE DIAGNOSES: Status post coronary artery bypass
grafting times four.
Coronary artery disease.
Noninsulin dependent diabetes mellitus.
Hypertension.
Status post appendectomy.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. twice a day for seven days.
2. Potassium Chloride 20 mEq p.o. twice a day for seven days.
3. Colace 100 mg p.o. twice a day.
4. Enteric Coated Aspirin 325 mg p.o. daily.
5. Percocet 5/325 one tablet p.o. q4-6hours p.r.n. for pain.
6. Lipitor 80 mg p.o. daily.
7. Glipizide 10 mg p.o. q.a.m., Glipizide 5 mg p.o. q.p.m.
8. Metoprolol Tartrate 25 mg p.o. twice a day.
9. Lisinopril 40 mg p.o. daily.
10. Aciphex enteric coated delayed release 20 mg p.o.
daily.
DISCHARGE STATUS: The patient was discharged to home in
stable condition on [**2112-11-28**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2112-12-30**] 12:24:18
T: [**2112-12-30**] 14:27:26
Job#: [**Job Number 57391**]
|
[
"E942.6",
"780.2",
"401.9",
"411.1",
"250.00",
"272.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6952, 7118
|
7144, 7984
|
979, 1318
|
2497, 6930
|
939, 953
|
1341, 2479
|
167, 769
|
792, 915
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,299
| 135,783
|
11281
|
Discharge summary
|
report
|
Admission Date: [**2108-11-12**] Discharge Date: [**2108-12-6**]
Date of Birth: [**2041-5-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
"sleepy"
Major Surgical or Invasive Procedure:
placement of bronchial stent
mechanical ventilation
tracheotomy
History of Present Illness:
67yo with hx of metastatic colon CA s/p lung mets and R mainstem
bronchus stent who presents with worsening DOE and hemoptysis.
Scheduled for rigid bronch [**2108-11-12**] but did not wake up after
procedure and became progressively apneic and hypotensive. Pt
has recent hx of stent placements due to occlusion [**1-2**]
metastatic lesions. Pt returned for bronch on day of admission
and had debridement of mucous and granulation tissue. After
bronchoscope removed pt as unresponsive and apneic. Pt was
paralysed and intubated and required initiation of pressors to
maintain BP after pt sedated with propofol.
Past Medical History:
1) Colon Ca (dx'd '[**00**])stage 2B, with mets to lung, R kidney (s/p
radical nephrectomy). S/p 5FU, leucovorin and R mainstem bronch
stent '[**07**].
2) HTN
3) Afib
4) GERD
5) DM2
6) Gout
Social History:
Retired from [**Company 378**]. Origiannly from Poland.
Quit tob 8 years ago.
No Etoh
Family History:
N/C
Physical Exam:
Vitals: 98.1, HR 50-60, BP: 106/58, O2: 99%, RR:14.
General: middle aged male, intubated, sedated
HEENT: PERRL
Neck: trach in place
Pulm: Ant and lat fields with coarse BS b/l.
Cor: irreg, nl s1,s2. No mumur appreciated.
Abd: soft non tender non distended, +bs
Ext: WWP, tatoo on left upper extremity, DP 2+ bilaterally
Pertinent Results:
[**2108-11-12**] 09:42PM CORTISOL-40.8*
[**2108-11-12**] 06:25PM TYPE-ART TEMP-36.4 RATES-16/3 TIDAL VOL-475
PEEP-5 O2-40 PO2-72* PCO2-55* PH-7.40 TOTAL CO2-35* BASE XS-6
INTUBATED-INTUBATED VENT-CONTROLLED
[**2108-11-12**] 04:00PM TYPE-ART TEMP-36.7 PO2-171* PCO2-66* PH-7.32*
TOTAL CO2-36* BASE XS-5
[**2108-11-12**] 03:55PM PT-13.6 PTT-30.6 INR(PT)-1.2
[**2108-11-12**] 03:13PM freeCa-0.97*
[**2108-11-12**] 03:00PM GLUCOSE-57* UREA N-14 CREAT-0.5 SODIUM-129*
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-23 ANION GAP-9
[**2108-11-12**] 03:00PM WBC-3.2*# HCT-20.0*#
ECG: Atrial fibrillation with slow ventricular response
Q waves inferiorly - consider inferior myocardial infarction
CT CHEST BEFORE AND AFTER IV CONTRAST: There is adequate
opacification of the pulmonary arterial vasculature without
evidence of embolus or thrombus. There is a large right upper
lobe perihilar mass with branching soft tissue structures
extending into the right upper lobe consistent with mucus
plugging or tumor. The right upper lobe airways are not patent
proximally. The right upper lobe pulmonary artery is encased by
mass and is obstructed proximally. There are moderate-sized
bilateral pleural effusions with compressive atelectasis in both
lower lobes. There are air bronchograms seen peripherally at the
right base and this can suggest pneumonia. Multiple rounded
nodules are seen scattered throughout the right middle lobe and
left lung, consistent with the given history of metastatic
disease. Early arterial views of the upper abdomen show a large
liver without focally-enhancing masses but the timing of
contrast is not optimal for detecting liver metastases. No
suspicious lesions are seen in the bones.
1. No pulmonary embolus. Complete compression of the right upper
lobe pulmonary artery by tumor mass. Branching tubular opacities
in the left upper lung can relate to mucus plugging, tumor
infiltration, and infection there is certainly not excluded.
2. Large effusions with bibasilar atelectasis/consolidation.
3. Multiple rounded nodules consistent with metastatic disease.
Brief Hospital Course:
A/P: 67 year-old male with progressive metastatic colon cancer
to lung, s/p RMSB stent placement, admitted with respiratory
failure post procedure.
1) Respiratory failure: Post procedure resp failure. Repeat
bronch on [**11-13**] showed 50% occlusion of R mainstem bronchus,
aspirated. No evidence of post-obstructive pneumonia. Rebronch
on [**11-14**] revealed 50% occluded stent which was removed, tumor
debrided and stent replaced with residual distal granulation
tissue. Rebronch on [**11-15**] showed again plugging of stent with
mucous. Repeat bronch on [**11-16**] -- stent removed.
Sputum cx from [**11-25**] eventually grew out Enterobacter, sensitive
to all abx. On [**11-27**] pt grew gram neg rods on sputum gram stain,
likely contaminate. In light of patient's fevers and worsening
secreations pt was placed on Vanco and Levo initially, then
Zosyn to replace Levo. [**11-27**]: restarted vanco/levo/gent for
worsening secretions and fever. [**11-28**]: vanco/gent discontinued
and decided to treat with levofloxacin x 14 days.
Following this, attempts to wean off ventilator were
unsuccessful. Serial NIFs showed NIF -10, then -30. Etiology of
such weakness unclear, but likely secondary to increased dead
space with tumor infiltration of pulmonary vasculature
(demonstrated by CT scan) + respiratory muscle deconditioning.
After multiple attempts to wean pt off vent a trach was placed
on [**11-28**]. Pt steadily improved with trach mask trials and prior
to discharge was tolerating approximately 3 hrs off the vent.
2) HTN: pt started on captopril
3) AF: Patient with intermittent episodes of afib with slow
ventricular response. Stable on Metoprolol 25 mg PO BID.
4) DM: good glycemic control was achieved with SSI and standing
NPH
5) MS changes: pt was extremely agitated at times initially
treated with Haldol and then well controlled with zyprexa 2.5mg
TID
6) Nutrition: a PEG tube was placed on [**2108-12-5**] without
complication and tube feeds were initiated via the PEG the next
day.
Medications on Admission:
Oxycontin, celexa 40, dyazide, allopurinol 300, glyburide 7.5,
avapro 0.5, atenolol 50
Discharge Medications:
1)Insulin SS
2)captopril 75mg TID
3)citalopram hydrobromide 40mg QD
4)pantoprazole 40mg IV Q24
5)heparin 5000 SQ TID
6)Colace 100mg po BID
7)Metoprolol 25mg po BID
8)fentanyl patch 50 mcg/hr TP Q72 hrs
9)levofloxacin 500 mg po QD x 14 days (ending [**2107-12-10**])
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1)Metastatic Colon cancer
2)Respiratory Failure
3)pneumonia
Discharge Condition:
Stable
Discharge Instructions:
1)Trach care as per rehab facility protocol.
2)PEG tube care and use as per rehab facility protocol.
Followup Instructions:
1) Follow up with hematology-oncology, pulmonology in one to two
weeks to discuss events of most recent hospital stay, options
for further treatment, prognosis.
|
[
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"519.1",
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"518.84",
"V10.05",
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icd9cm
|
[
[
[]
]
] |
[
"32.01",
"00.17",
"43.11",
"96.6",
"31.1",
"96.56",
"33.24",
"98.15",
"96.05",
"38.91",
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"96.04"
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icd9pcs
|
[
[
[]
]
] |
6283, 6355
|
3833, 5855
|
325, 390
|
6458, 6466
|
1722, 3810
|
6615, 6778
|
1362, 1367
|
5992, 6260
|
6376, 6437
|
5881, 5969
|
6490, 6592
|
1382, 1703
|
277, 287
|
418, 1030
|
1052, 1243
|
1259, 1346
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,244
| 110,646
|
33816
|
Discharge summary
|
report
|
Admission Date: [**2101-5-16**] Discharge Date: [**2101-6-14**]
Date of Birth: [**2032-12-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Right renal tumor.
Major Surgical or Invasive Procedure:
[**2101-5-16**]: Open partial nephrectomy from the transplanted kidney
[**2101-5-24**]: Exploratory laparotomy with lysis of adhesions
History of Present Illness:
68 y/o male who developed renal failure likely secondary to
hypertension and underwent a cadaveric kidney transplant at
[**Hospital6 **] in [**2097**]. He has done well since his
transplant, but on routine screening he was found to
have a mass in the upper pole of his transplant kidney in the
right iliac fossa as well as a left adrenal mass. He has no
complaint of pain and has been feeling fine. He has not had
chest pain, shortness of breath, hematuria or flank pain. He has
been seen by Dr [**Last Name (STitle) 3748**] in urology and is to undergo surgery with
Drs [**Last Name (STitle) 3748**] and [**Name5 (PTitle) 816**] for mass excision from the transplant
kidney.
Past Medical History:
HTN
s/p cadaveric renal transplant [**2097**] at [**Hospital1 2177**]
s/p cataract surgery
Social History:
Married with 2 grown children. Moved to US from Bangaladesh
Family History:
Mother with HTN, father with DM
Physical Exam:
Post Op
VS: 97.8, 73, 134/51, 17, 98% 3LNC
Gen: Sleepy, NAD Pain [**3-26**] on pCA
Card: RRR
Lungs: CTA bilaterally
Abdomen: distended, soft, appropriately tender
Pertinent Results:
On Admission: [**2101-5-16**]
WBC-17.5*# RBC-3.57* Hgb-10.5* Hct-30.8* MCV-86 MCH-29.3
MCHC-34.0 RDW-13.5 Plt Ct-169
Glucose-184* UreaN-18 Creat-1.7* Na-134 K-4.8 Cl-107 HCO3-20*
AnGap-12
Calcium-8.2* Phos-3.3 Mg-2.3
On Discharge: [**2101-6-14**]
WBC-10.0 RBC-3.13* Hgb-9.1* Hct-28.4* MCV-91 MCH-29.0 MCHC-31.9
RDW-15.8* Plt Ct-374
PT-14.6* PTT-31.2 INR(PT)-1.3*
Glucose-104 UreaN-30* Creat-1.5* Na-139 K-4.8 Cl-110* HCO3-23
AnGap-11
Albumin-3.1* Calcium-8.9 Phos-2.7 Mg-1.8
tacroFK-6.8
Iron Studies [**2101-6-12**]:
Iron-24* calTIBC-237* Ferritn-676* TRF-182*
Brief Hospital Course:
68 y/o male admitted following partial transplant nephrectomy
for mass in transplant kidney found on routine screening. Due to
the complex nature of this case, patient went to the OR with Dr
[**Last Name (STitle) 3748**] from urology and Dr [**Last Name (STitle) 816**] with Transplant. It was stated
that due to the complex nature of this case, two attendings were
present for the case involving Open partial nephrectomy from the
transplanted kidney.
In summary, the transplanted kidney was completely encased in a
large amount of scar
tissue making dissection difficult. The tumor was excised, and
JP drain was placed. Please see the surgical notes of both Dr
[**Last Name (STitle) 816**] and Dr [**Last Name (STitle) 3748**] for details.
In the post op period, his pain was controlled using a PCA.
Urine output and residual renal function were excellent.
Pathology of the tumor revealed "Oncocytoma, margin free of
tumor"
On about POD 6, the patient was noted to be increasingly
distended. Bowel function was very sluggish post op, in addition
to a notation on labs of increased WBC as well as development of
fever. A CT of the abdomen was obtained showing "Moderate grade
partial small bowel obstruction with transition point noted
within the right lower quadrant, slightly anterior to the
transplant kidney."
He was taken back to the OR on [**2101-5-24**] again with Drs' [**Name5 (PTitle) 816**] and
[**Name5 (PTitle) 3748**] for Exploratory laparotomy with lysis of adhesions and
freeing up obstruction. Per the operative report lysis of
adhesions of the bowel was done and the finding that the
terminal ileum had been plastered down to the area of the
kidney. This was felt to be the transition point seen on CT and
this was the cause of the obstruction. No bowel perforation was
found or other evidence of intra-abdominal pathology seen. There
was a significant amount of fluid encountered when the patient
was opened. This fluid was sent for culture and lab tests.
Creatinine was low, so it was not felt to be a urine leak.
Enterococcus (Vanco sensitive) did grow from the fluid as well
as from blood cultures obtained the same day. Urine cultures
from the day previous were also positive for Enterococcus and he
was started on Vancomycin and Flagyl which were given x 7 days.
An ID consult was obtained.
He was switched to Ampicillin on [**2101-5-27**] and this was continued
for 9 days. In addition he received Levaquin for a total of 11
days.
The patient was started on TPN via a PICC line, this was
continued for about two weeks. PO diet was started back slowly,
he will be seen as an outpatient by nutrition. PICC line was
d/c'd prior to his discharge.
The patient started with increased stooling, and C diff A&B was
sent. The cultures were negative x 5, however he was started on
PO Vanco as his WBC remained elevated, and no other source was
identified. A CMV viral load was sent which was positive at 909
copies, he was started on a 3 week course of Valcyte. He also
has a positive HSV screen from a lesion on his lip. The Valcyte
will cover both. In addition, he had a stool for CMV sent, which
was negative up to this time, but had not yet been finalized.
Approximately 2 weeks into the hospitalization, the patient
developed new onset AFib. He was chemically converted on
Amiodarone and was started on a heparin drip. Due to the
interaction between amiodarone, Prograf and Coumadin, the
patient was started on half dose Coumadin on [**6-3**]. Over the next
2 days, his Hct was noted to fall from 27% to 17%. The
anticoagulation was stopped and he received 3 units of pRBC's.
Of note, his stool at this time was noted to be dark and guaiac
positive. The heparin drip and coumadin were placed on hold. The
amiodarone was discontinued and it was decided to rate control
the patient which was well achieved with beta blockade. The
coumadin was restarted at an even lower dose, as well, the
heparin remained off and he was started on Lovenox injection,
which he will be continuing at home short term.
Dr [**Last Name (STitle) 3748**] performed a cystoscopy on [**6-7**] due to concern for
fluid from the JP drain from initial surgery was found to have a
creatinine of 22.9. He underwent cystoscopy, a 4.8 French x 10
cm double-J stent was placed with the proximal coil in the
collecting system and distal coil in the bladder. A Foley drain
was left in place which should be left in place for two weeks.
Patient to be seen in followup clinic with Dr [**Last Name (STitle) 3748**]. A JP drain
is also in place, removal will be following Foley removal by
several days and will be determined by urology.
Patient was given a glucometer and will check blood sugars at
home. Given signs and symptoms of low blood sugar and started on
Glipizide [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations.
Scripts were given to the patient for new medications which will
be filled at patients home transplant center [**Hospital 86**] Med Center
at their free pharmacy as this has been his usual source for his
medications.
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (pager [**Telephone/Fax (1) 78181**], fax [**Telephone/Fax (1) 77542**], his PCP
will be monitoring PT/INR and was contact[**Name (NI) **] on [**6-14**] to verify
this. VNA will draw and fax results of first two INRs and then
they will be arranged as an outpatient.
Medications on Admission:
lopressor 100", cozaar, hctz, spironolactone, hydralazine,
lipitor 10, asa 81, colace, hytrin
Discharge Medications:
1. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
2. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*15 Tablet(s)* Refills:*0*
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
7. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
twice a day.
9. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Hytrin 10 mg Capsule Sig: One (1) Capsule PO at bedtime.
11. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
12. Losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
13. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 17 days.
Disp:*17 Tablet(s)* Refills:*0*
14. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
15. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2*
16. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous once
a day for 5 days.
Disp:*5 syringes* Refills:*0*
17. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*0*
18. One Touch II Test Strip Sig: One (1) strip In [**Last Name (un) 5153**] once
a day.
Disp:*1 vial* Refills:*2*
19. Lancets Misc Sig: One (1) Miscellaneous once a day.
Disp:*1 vial* Refills:*2*
20. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right renal tumor - oncocytoma
Afib
CMV
anemia
urinary leak
ileus, resolved
Discharge Condition:
stable
Discharge Instructions:
Please call Dr. [**Last Name (STitle) 816**] at [**Telephone/Fax (1) 673**] if you have
temperature>101.5, chills, nausea or vomiting, worsening
abdominal pain, vomiting blood or bloody/black bowel movements,
redness/pus or drainage around incision, or drains, cloudy foul
smelling urine, or drain output stops or increases
Empty the drain (JP) and foley (urine bag) when half full and
record volume of outputs. Bring this record of drain/urine
outputs to next appointment with Dr. [**Name (NI) 816**]
PT and INR will be drawn by the visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 16337**] [**6-16**]
and Monday [**6-20**]. Results to be faxed to Dr [**Last Name (STitle) **], who will be
managing your anticoagulation
Check your blood sugar by fingerstick at least once daily. If
you feel sweaty, clammy, confused or anxious, these can be signs
of low blood sugar. Have some juice and then check your blood
sugar. A low [**Location (un) 1131**] is less than 70
No Heavy lifting
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD (Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2101-6-16**]
8:30
DR. [**First Name (STitle) **] [**Doctor Last Name **] (Urology) Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2101-6-23**] 9:45
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Infectious Disease) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2101-7-8**] 10:00
Completed by:[**2101-6-14**]
|
[
"427.32",
"482.30",
"997.4",
"584.9",
"996.81",
"995.92",
"591",
"998.59",
"560.81",
"997.3",
"038.0",
"427.31",
"560.1",
"997.5",
"233.0",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"55.01",
"87.74",
"55.4",
"99.15",
"57.32",
"59.8",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9558, 9616
|
2203, 7586
|
335, 471
|
9736, 9745
|
1617, 1617
|
10791, 11261
|
1385, 1418
|
7731, 9535
|
9637, 9715
|
7612, 7708
|
9769, 10768
|
1433, 1598
|
1848, 2180
|
276, 297
|
499, 1178
|
1631, 1834
|
1200, 1292
|
1308, 1369
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,586
| 182,059
|
29610
|
Discharge summary
|
report
|
Admission Date: [**2189-2-28**] Discharge Date: [**2189-3-6**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
change in mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a [**Age over 90 **] yo RH woman with PMH sig for PAF/flutter,
hypothyroidism, GERD, B12 deficiency, h/o colon CA, osteoporosis
with several T and L vertebral compression fractures, s/p right
hip fracture/repair, and untreated papillary transitional cell
bladder CA who was transferred for concern of ICH and
anisocoria.
The patient was admitted to an OSH 2 days ago after an apparent
fall at home. She doesn't know why she fell and is unable to
recall if she lost consciousness. She thinks she didn't. She
doesn't think she hit her head. Unclear if she had a prodrome.
At the OSH, she was treated with her home meds as well as
fentanyl and percocet for pain. She was working with PT and
doing slightly better(still pain limited), but became more
confused, disoriented, and less cooperative on the afternoon of
hyperdensity in the right IC, initially read as blood, but then
read as calcification by their neuroradiologist this morning.
She was still not well oriented this morning. The patient was
transferred here for both her anisocoria and for her initially
suspected ICH. On her transfer note, the MD at the OSH was
concerned that the narcotics may be what is causing her mental
status changes.
Of note, she had bilateral cataract surgery ~10 years ago
according to her family. The pt does not remember this
happening.
Past Medical History:
PMH:
PAF/flutter since [**11/2188**]
Hypothyroidism
GERD
B12 deficiency
h/o colon CA(details unknown, pt not able to tell me)
Osteoporosis with several T and L vertebral compression
fractures(T10, T12, L1)
s/p right hip fracture/repair
untreated papillary transitional cell bladder CA(not pursuing
w/u)
Social History:
No EtOH or smoking. She lives alone and has a home health aide.
Her daughter helps with her medication. She does her own ADLs.
She stopped driving several years ago.
Family History:
Apparently several members with PNA
Physical Exam:
Exam:Vitals:98.9, 83 in flutter, 111/50, 17, 95% on 3LNC
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear
Neck: No Carotid bruits
CV: RRR, Nl S1 and S2, [**3-10**] sys murmur?
Lung: Clear to auscultation bilaterally
Ext:No cyanosis/edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect
Orientation: Oriented to person, "[**Hospital1 1474**]", not to date. Knows
Winter. Pres=[**Doctor Last Name 780**].
Attention: Able to do DOWF and B
Registration: 0/3 at 30 secs
Recall: 0/3 at 5 minutes
Language: Fluent with good comprehension and repetition. Naming
intact. No dysarthria or paraphasic errors
No apraxia, no neglect
[**Location (un) **] intact. Writing intact
Calculation poor
Clock fairly normal with correct time set
Cranial Nerves:
I: not tested
II: Pupils: Right is 1.5 mm and min reactive(with light off,
pupil gets only slightly larger and still min reactive). Left is
surgical and ~4mm(min reactive).
Visual fields are full to finger movement. Unable to vis fundi
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus. Slight right ptosis.
V, VII: Facial strength and sensation intact and symmetric,
except for mild right NLF flattening.
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, intact movements
Motor:
[**Month (only) **] bulk and sl inc tone bilaterally
No tremor
Full strength except for 5-/5 triceps bilat.
No pronator drift
Sensation: Intact to light touch, pinprick, temperature (cold),
vibration, and propioception throughout upper extremities. In
LEs, normal LT, PP, prop, but [**Month (only) **] vib in toes and temp [**Month (only) **] in
stocking fashion to mid calf.
Reflexes: B T Br Pa Ankle
Right 3 3 3 3 2
Left 3 3 3 3 2
Toes were downgoing right, mute left
Coordination: Normal on finger-nose-finger, rapid alternating
movements normal, FFM normal.
Gait: Did not walk in ICU
Pertinent Results:
[**2189-3-1**] 03:30AM BLOOD WBC-6.9 RBC-4.07* Hgb-13.4 Hct-40.9
MCV-101* MCH-32.8* MCHC-32.7 RDW-14.4 Plt Ct-173
[**2189-3-1**] 03:30AM BLOOD PT-11.2 PTT-27.8 INR(PT)-0.9
[**2189-3-1**] 03:30AM BLOOD Glucose-102 UreaN-25* Creat-1.2* Na-138
K-4.5 Cl-96 HCO3-31 AnGap-16
[**2189-3-1**] 03:30AM BLOOD ALT-16 AST-22 CK(CPK)-41 AlkPhos-66
Amylase-69 TotBili-0.4
[**2189-3-1**] 03:30AM BLOOD Lipase-19
[**2189-3-1**] 03:30AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2189-3-1**] 03:30AM BLOOD Albumin-3.6 Calcium-9.7 Phos-3.7 Mg-1.7
.
Imaging:
EKG ([**3-1**]): Atrial fibrillation with a controlled ventricular
response. Left anterior fascicular block. Possible incomplete
right bundle-branch block. Prolonged QTc interval. No previous
tracing available for comparison.
.
Microbiology:
Screen positive for MRSA
VRE negative
RPR non-reactive
.
Labs at discharge:
Hct 39.2
creatinine 1.2
TSH 0.65
B12 1222
folate 7.7
Brief Hospital Course:
# Mental status change/fall: The patient was admitted to
Neurology Service for evaluation of intracranial hemorrhage. On
review of OSH CT scan, it was thought the hyperdensity in
internal capsule was calcification rather than true hemorrhage.
Patient's anisocoria was thought to be secondary to cataract
surgery though primary physician did not have this documented.
Patient's daughter felt eyes were noted to be unequal several
months ago. Patient's confusion cleared with holding narcotic
medication. On HOD #2 night, it was noted that patient was very
agitated and aggressive and she required Haldol after pulling
out IV. Her neurological evaluation was unchanged with clear
speech, normal motor movement, and baseline mental status. Her
daughter and PCP both confirm patient has mood swings and can
get "mean". Once transferred to the floor, the patient was
oriented to person and situation but not place or time. She had
no further aggressive behavior and was actually quite pleasant.
She was encouraged by the idea of returning closer to home.
- Workup for dementia, including B12, folate, and TSH were
normal. RPR was non-reactive.
- Physical therapy evaluated the patient and recommended a rehab
setting for further PT. The patient uses a walker at baseline.
.
# Paroxysmal atrial fib/flutter: The patient has history of
afib/flutter and was monitored on telemetry. Her heart rate was
below <100 with manual pulse checks and her BPs were stable.
Cardiac enzymes x 1 were normal. She did not require any rate
controlling medications after her initial presentation.
.
# Creatinine: Baseline creatinine up to 1.2 per PCP. [**Name10 (NameIs) **] was at
baseline during her stay.
.
# Respiratory status: The patient had an oxygen saturation of
88% overnight one evening on first arrival from the ICU. Her
lungs were clear. She was afebrile with no sign of infection. At
the time of discharge, her oxygen saturation was 94-95% on room
air.
# FEN/GI: Patient needed encouragement to take po to which she
responded. She was tolerating a regular diet at the time of
discharge.
.
long-standing concern about patient's safety at home and ability
to perform self-care. She has had two falls in last couple of
months. Daughter does not feel she can care for her mother at
home. The primary care doctor [**First Name (Titles) 70975**] [**Last Name (Titles) **] hospital
screening now and feels in long term, patient will need long
term nursing home care.
Contacts: Daughter [**Telephone/Fax (1) 70976**]/ PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 70977**] [**Telephone/Fax (1) 70978**] or
[**Telephone/Fax (1) 5317**]
Medications on Admission:
Patient's daughter tells me that she thinks patient takes
synthroid daily but does not think that she takes much else. The
daughter gives her aspirin, actonel, and caltrate when she sees
her on Sundays.
.
ASA 81
Ca+D
Actonel 5 mg daily
Protonix 40
Synthroid 100 mcg(down from 125 recently)
B12
Astelin nasal tid prn
--
at OSH also:
Fentanyl 25 mcg prn
Percocet prn
SQ hep q12h
Ativan hs prn
Ambien 5 hs prn
Tylenol
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. CALCIUM 500+D 500-200 mg-unit Tablet Sig: One (1) Tablet PO
three times a day.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Actonel 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Azelastine 137 mcg Aerosol, Spray Sig: One (1) spray to each
nostril Nasal three times a day as needed for congestion.
9. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of Silver [**Doctor Last Name **]
Discharge Diagnosis:
Mechanical fall
Atrial fibrillation/flutter, rate controlled
.
Secondary:
Hypothyroidism
Vitamin B12 deficiency
Gastroesophageal reflux disease
History of colon cancer
Osteoporosis with compression fractures
Untreated papillary transitional cell bladder cancer
Discharge Condition:
Afebrile, hemodynamically stable, comfortable on room air
Discharge Instructions:
Please take your medications as prescribed. Please call your
doctor or return to the emergency room should you develop any of
the following symptoms: fever > 101, chills, nausea or vomiting
with inability to keep down liquids or medications, diarrhea,
increased confusion, further falls with resultant injuries, or
any other concerns.
Followup Instructions:
Please follow up with your primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5311**],
within 1-2 weeks. Please call [**Telephone/Fax (1) 5317**] for an appointment.
Completed by:[**2189-3-6**]
|
[
"188.9",
"530.81",
"266.2",
"427.31",
"733.13",
"244.9",
"733.00",
"V71.4",
"V10.05",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9097, 9181
|
5197, 7829
|
241, 247
|
9486, 9546
|
4269, 5101
|
9929, 10148
|
2144, 2182
|
8295, 9074
|
9202, 9465
|
7855, 8272
|
9570, 9906
|
2197, 2430
|
178, 203
|
5120, 5174
|
275, 1616
|
2977, 4250
|
2469, 2961
|
2454, 2454
|
1638, 1943
|
1959, 2128
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,278
| 189,032
|
8698
|
Discharge summary
|
report
|
Admission Date: [**2179-5-7**] Discharge Date: [**2179-5-14**]
Date of Birth: [**2130-3-23**] Sex: M
Service: Internal Medicine-[**Location (un) **]
CHIEF COMPLAINT: Abdominal pain and shortness of breath.
HISTORY OF PRESENT ILLNESS: This 49-year-old man with
cirrhosis was recently admitted on [**2179-4-28**] to [**2179-5-5**] for
GI bleed secondary to colonic angiomas. He presented with
subjective increase in abdominal girth and pain. His pain
seemed to worsen on the day of admission, which is the reason
he presented to the Emergency Department. He stated that he
had been compliant with his medications including diuretics
and Lactulose. He felt that he had some subjective fevers on
the morning of admission with some nausea but no vomiting.
He had had small amounts of hematochezia which was chronic
for him. He stated that he had not felt well since leaving
the hospital.
While in the Emergency Department a paracentesis was
performed with 2.7 liters removed and a drop in his blood
pressure from 86/60 to 66/40. He received 4 liters of normal
saline and 50 grams of albumin however his blood pressure did
not respond and therefore the intensive care unit team was
contact[**Name (NI) **] and he was admitted to the medical intensive care
unit. He was given one dose of ceftriaxone empirically and a
right internal jugular triple-lumen catheter was placed.
While in the intensive care unit he was transfused two units
of packed red blood cells and was on Levophed transiently.
Once he was hemodynamically stable for nearly 24 hours he was
transferred to the [**Location (un) **] medicine team.
PAST MEDICAL HISTORY: 1. Cirrhosis secondary to hepatitis C
and alcohol abuse. 2. Portal hypertension. 3. History of
upper GI bleed secondary to varices. 4. History of
hemorrhoids. 5. Lower GI bleed in [**2179-4-13**] secondary to
colonic angiomas. 5. Alcohol abuse. 6. Type 2 diabetes
mellitus. 7. Chronic pancreatitis. 8. Depression. 9.
History of positive PPD. 10. History of hepatic
encephalopathy.
HOME MEDICATIONS: 1. Spironolactone 100 mg p.o. q.d. 2.
Lasix 20 mg p.o. q.d. 3. Nadolol 5 mg p.o. q.d. 4. Prevacid
30 mg p.o. q.d. 5. Zoloft 50 mg p.o. q.d. 6. Remeron 45 mg
p.o. q.h.s. 7. Lactulose 30 cc q.i.d. titrate to three to
four bowel movements per day. 8. Multivitamin. 9. Lantus 40
units subcutaneous q.h.s. 10. Humalog insulin sliding scale.
SOCIAL HISTORY: He is on disability. He is divorced with
seven children. There is no history of tobacco use.
Significant alcohol abuse history: He started drinking at
age 15 and reports drinking approximately two bottles of
rectourethralis muscle per day. Remote history of
intravenous drug use.
PHYSICAL EXAMINATION: On transfer his temperature was 97.1,
blood pressure 106/60, heart rate 76-105, respiratory rate
18, oxygen saturation 95% on two liters. In general the
patient was a chronically ill-appearing man in no apparent
distress. HEENT: Mucous membranes were moist. Pupils were
equal, round, and reactive to light. Extraocular muscles
were intact. Neck: Supple, no jugular venous distension.
Cardiovascular: Tachycardic but regular, no murmurs,
gallops, or rubs. Chest: Lungs were clear to auscultation
bilaterally. Abdomen: Soft but distended with normal active
bowel sounds, nontender, positive fluid wave. Extremities:
2+ bilateral lower extremity edema. Neurologic: Alert and
oriented x 3, no asterixis. Cranial nerves two through 12
were intact. Psychiatric: Flat affect.
LABORATORY DATA: Complete blood count with a white count of
8.1, hematocrit 25 which increased to 31.7 after two-unit
transfusion, platelet count 124, MCV 89, PTT 36.5, INR 2.0,
sodium 138, potassium 3.4, chloride 111, bicarbonate 18, BUN
29, creatinine 1.4, glucose 87, ALT 13, AST 30, LDH 161,
alkaline phosphatase 68, amylase 107, total bilirubin 1.1,
albumin 2.8. Urinalysis was negative. Blood culture and
urine culture were both negative.
Peritoneal fluid showed a white blood cell count of 73, red
blood cell count of 163 with 4% polys.
IMPRESSION: This is a 49-year-old man with hepatitis C and
alcohol abuse now with cirrhosis and refractory ascites,
difficult to manage given hypotension from paracentesis,
recently discharged for lower GI bleed and persistent guaiac
positive stools.
HOSPITAL COURSE: 1. Gastrointestinal: Given the patient's
refractory ascites, he required three therapeutic
paracenteses during the hospitalization removing 2.7 liters,
2.5 and 1.3 liters. On each incident his abdominal girth
decreased significantly and he became less short of breath.
As described above, during the first paracentesis performed
in the Emergency Department the patient became hypotensive
requiring transient Levophed and two units of packed red
blood cell transfusion. He was in the intensive care unit
for approximately 24 hours and transferred to the floor when
hemodynamically stable.
Given his hypotension, his diuretics and nadolol were
transiently held until blood pressure normalized. Diuretics
were slowly restarted and at the time of discharge he was
back on spironolactone 50 mg p.o. b.i.d. and Lasix 20 mg p.o.
q.d. His nadolol continues to be held.
He was continued on Lactulose 30 cc q.i.d. without any
evidence of asterixis during hospitalization. He
consistently had approximately three to four bowel movements
per day on this current dosage.
2. Infectious disease: Given hypotension and reported
subjective fevers at home, there was concern for spontaneous
bacterial peritonitis, however cell count sent on all three
therapeutic paracenteses showed white blood cell count of
less than 100. He was afebrile with a normal white count
throughout hospitalization. Blood cultures were performed as
well and showed no evidence of infection. Urinalysis and
urine culture likewise showed no evidence of infection.
3. Renal: Admission laboratory studies showed an elevated
creatinine from baseline of 1 to 1.2 to 1.4. With
rehydration the patient's creatinine normalized to 0.6 to
0.7. However despite IV fluid resuscitation, the patient's
urine output remained minimal throughout the majority of the
hospitalization. His urine output at best was approximately
500 to 700 cc per 24-hour period. The renal team was
consulted given his decreased urine output, who felt that
this was not hepatorenal syndrome. His urine output remained
unresponsive to fluid boluses and it was felt that fluid was
accumulating in the abdomen only. Therefore, once the
patient no longer had orthostatic changes in blood pressure,
his fluid was discontinued.
A second urinalysis showed too numerous to count red blood
cells, which was thought secondary to Foley catheter trauma
and this was promptly discontinued. Of note, the patient had
moderate scrotal and penile swelling which was noted two days
prior to discharge. This was thought secondary to either
Foley catheter trauma or more likely due to anasarca from
hypoalbuminemia given chronic liver disease.
4. Pulmonary: On admission the patient had a two-liter
oxygen requirement and complaints of dyspnea. Oxygen
requirement and symptoms resolved after therapeutic
paracentesis and his dyspnea was felt to be secondary to
volume loss from ascites.
5. Hematology: He has a history of chronic guaiac positive
stools from lower GI bleed. During previous admission three
to four days prior to current admission a colonoscopy was
performed and found colonic AVMs/angioma and hemorrhoids.
The angiomas were ablated during the procedure. His
hematocrit remained stable after a two-unit packed red blood
cell transfusion around 30 and he did not require any further
blood products. Of note, his platelets hovered around
100,000 likely secondary to splenic sequestration from
chronic liver disease.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Cirrhosis secondary to hepatitis C and alcohol abuse.
2. Recurrent ascites.
3. Hypotension secondary to large volume paracentesis
requiring medical intensive care unit admission.
4. Diabetes mellitus, type 2.
5. Chronic lower gastrointestinal bleed secondary to colonic
angiomas.
6. Dyspnea secondary to ascites.
7. Scrotal edema secondary to hypoalbuminemia.
DISCHARGE MEDICATIONS:
1. Prevacid 30 mg p.o. q.d.
2. Zoloft 50 mg p.o. q.d.
3. Remeron 45 mg p.o. q.h.s.
4. Lactulose 30 cc q. 6 hours.
5. Lantus 40 units subcutaneous q.h.s.
6. Humalog insulin sliding scale.
7. Multivitamin q.d.
8. Anusol suppository 1 p.r. b.i.d.
9. Lasix 20 mg p.o. q.d.
10. Miconazole powder applied to groin area t.i.d. x 10 days.
11. Spironolactone 50 mg p.o. b.i.d.
12. Percocet 1 tablet b.i.d. p.r.n. pain #10.
FOLLOW UP:
1. He is to follow up with his primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], on regularly scheduled appointment time, [**2179-5-18**].
2. He is to follow up with Dr. [**Last Name (STitle) **] in approximately one
week for repeat paracentesis.
DISPOSITION: He was discharged to home with VNA assistance
for medication compliance and wound care for drainage from
paracentesis sites.
[**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D: [**2179-5-14**] 17:27
T: [**2179-5-20**] 11:00
JOB#: [**Job Number 30462**]
|
[
"458.2",
"572.3",
"070.54",
"280.0",
"571.2",
"578.9",
"276.5",
"250.00",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
7868, 8232
|
8255, 8670
|
4348, 7813
|
2069, 2415
|
8681, 9395
|
2740, 4330
|
184, 225
|
254, 1635
|
1658, 2050
|
2432, 2717
|
7838, 7847
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,460
| 172,222
|
51247
|
Discharge summary
|
report
|
Admission Date: [**2137-12-7**] Discharge Date: [**2137-12-14**]
Date of Birth: [**2095-4-26**] Sex: F
Service: LIVER TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: This is a 42-year-old female,
status post orthotopic liver transplant on [**2136-6-4**]
secondary to ETOH cirrhosis which was complicated by hepatic
artery thrombosis, bilomas and cholangitis including biliary
strictures. She was recently admitted secondary to
intermittent fevers from [**Date range (1) 106332**]/[**2137**], during which no
obvious source was isolated. The patient underwent a biliary
tube check which illustrated patent side holes. She was
discharged tolerating a regular diet and was sent out on po
antibiotics of linezolid, as her bile culture had grown out
Enterococcus.
She presented on [**2137-12-7**] for a liver retransplant
and came in with a temperature of 101.1. On admission, she
was started immediately on linezolid 600 mg IV and Zosyn 4.5
mg prior to surgery. In addition, blood cultures were drawn,
as well as a urinalysis and a urine culture. Standard preop
liver orders were followed with a small modification. In
addition, caspofungin was started 50 mg IV prior to surgery.
PAST MEDICAL HISTORY: A liver transplant in [**2136-5-31**]
secondary to ETOH cirrhosis.
Cholangitis.
Hepatic artery thrombosis.
Cholecystitis.
Hypertension.
Bilomas.
SOCIAL HISTORY: Includes alcohol.
MEDS ON ADMISSION:
1. Bactrim.
2. Protonix.
3. Ursodiol.
4. Azathioprine.
5. Ciprofloxacin.
6. Flagyl.
7. Linezolid which was started on [**11-25**] for a total of 2
weeks.
8. Neurontin 600 mg tid.
9. Cyclosporin 100 mg [**Hospital1 **].
HOSPITAL COURSE: This patient underwent a complicated
initial admission, in which she was febrile, as mentioned
prior, and with an elevated potassium of 6.0, creatinine 4.1,
which was up from her baseline of 1.4. The patient was given
glucose, given insulin and bicarb. Repeat labs were drawn in
the holding area. Consent was obtained for the procedure,
and was continued on linezolid, Zosyn and caspofungin while
awaiting the blood and urine culture. Please see operative
note by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for more information regarding the
operative procedure.
Postoperatively, the patient was admitted to ICU for acute
hemodynamic management and did well. Her immunosuppression
was continued, and respiratory wise she was kept on the
ventilator and CMV with serial ABGs. She was given D5 1/2NS
as per post liver transplant, and continued on Protonix.
Liver ultrasound was obtained. LFTs were followed.
Immunosuppression and was kept on Bactrim, caspofungin,
ganciclovir, linezolid.
On postop day 1, the patient did quite well. She had a total
of JP drains, in addition to a tube drain. She was following
commands and was still on the ventilator. She was making
good urine. She was complaining of some pain, but was
otherwise stable. She was managed towards weaning off the
vent. The PA catheter was removed on [**12-8**] by the ICU
team. By [**2137-12-9**], she was weaned and extubated, and
was doing incredibly well with minimal complaints. Her
immunosuppression continued to be managed with ATG and Solu-
Medrol. She was continued on antibiotics of meropenem,
caspofungin, Bactrim and linezolid.
On [**2137-12-10**], she was transferred to the floor and was
doing very well with an amylase and lipase of 308 and 212 the
day prior. However, these values continued to decrease. She
was continued on antibiotics of linezolid, caspofungin and
meropenem. She was started on TPN the day prior and was
given a total of three days of TPN, as we waited for her to
regain her diet. Her albumin overall, however, was 2.5.
The patient underwent a cholangiogram on [**2137-12-11**]
which showed patent biliary structures, and was continued on
her regular immunosuppression. Her lateral JP on [**12-11**]
put out only 50 cc and was DC'd. Her T-tube was capped as
well overnight. The patient was tolerating a regular diet
and had no complaints.
On [**2137-12-13**], the patient remained on the
caspofungin, linezolid, meropenem and ganciclovir, and she
was on a house diet. She will be discharged with her home
medications of OxyContin and oxycodone for pain relief. Her
medial JP was DC'd. She was given 2 units of packed red
blood cells the day prior secondary to hypovolemia, and 2
units of platelets as well. A PICC line was placed on the
morning of the 13, and the patient was discharged with
approximately 8 days of meropenem, which totals a 2-week
course of meropenem.
The patient was discharged to home with services, and was
told to keep her incision clean and dry, and is to have
routine lab work drawn q Monday and Thursday. Prior to
discharge, the patient was seen by the transplant coordinator
and given additional information.
FINAL DIAGNOSES: Liver transplant on [**2137-12-7**].
Alcoholic cirrhosis.
Another liver transplant on [**2136-6-4**].
History of cholangitis.
History of hypertension.
History of hepatic artery thrombosis.
History of bilomas.
History of hemachromatosis.
History of neuropathy.
Bacteremia.
FOLLOW UP: The patient has a follow-up appointment with Dr.
[**Last Name (STitle) **] on [**2137-12-16**] at noon.
MAJOR SURGICAL AND INVASIVE PROCEDURES: Liver transplant on
[**2137-12-7**]; PICC line placement on [**2137-12-14**].
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg once daily.
2. Neurontin 600 mg tid.
3. Aspirin 81 mg once daily.
4. Plavix 75 mg once daily.
5. Bactrim single strength once daily.
6. Azathioprine 50 mg once daily.
7. Lopressor 12.5 mg [**Hospital1 **].
8. Prednisone 10 mg for 1 remaining dose.
9. Oxycodone 5 mg q 6 h.
10.Fluconazole 400 mg once daily.
11.Valcyte 450 mg once daily.
12.Lasix 20 mg po once daily as directed by the [**Hospital1 18**]
transplant surgery office.
13.Meropenem 1 gm q 12 h for approximately another 8 days.
14.Cyclosporin 250 mg [**Hospital1 **] to be adjusted as per the
transplant surgery office.
The patient's microbiology during this admission included
Enterobacter cloacae from a blood culture on [**2137-12-7**], and a urine culture which showed the same organism on
[**2137-12-7**]. A repeat blood culture on [**2137-12-9**]
was negative.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Doctor Last Name 31967**]
MEDQUIST36
D: [**2137-12-16**] 10:37:20
T: [**2137-12-16**] 12:53:14
Job#: [**Job Number 106333**]
|
[
"276.5",
"790.7",
"530.81",
"E878.0",
"790.6",
"576.8",
"575.10",
"996.82",
"401.9",
"572.0",
"041.85",
"444.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"38.93",
"50.59",
"99.15",
"99.04",
"00.93",
"99.05",
"00.14",
"51.22",
"87.54"
] |
icd9pcs
|
[
[
[]
]
] |
5430, 5437
|
5460, 6582
|
1677, 4871
|
4889, 5171
|
5183, 5408
|
187, 1206
|
1435, 1659
|
1229, 1380
|
1397, 1421
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,831
| 154,421
|
21088
|
Discharge summary
|
report
|
Admission Date: [**2118-6-15**] Discharge Date: [**2118-6-18**]
Date of Birth: [**2076-10-11**] Sex: F
Service: PSU
INDICATIONS FOR ADMISSION: The patient is a 41-year-old
Caucasian female with an acquired right breast deformity from
prior lumpectomies x4 for squamous metaplasia and a
subareolar fungal abscess, which dates back several years.
She presented on the day of admission for elective
reconstructive surgery of her right breast utilizing the [**Last Name (un) 5884**]
flap technique.
SUMMARY OF CLINICAL COURSE: The patient was admitted on
[**2118-6-15**] and underwent the above-mentioned procedure, which
she tolerated without complication. Postoperatively, she
recovered in the Postanesthesia Care Unit where she received
every-one-hour vital signs and flap monitoring. The patient
had adequate pain control on a Dilaudid PCA and was
ultimately transferred to the Neuro SICU for continued
frequent monitoring. On postoperative day number one, the
patient was having some difficulty sleeping secondary to
monitor noise, but was otherwise doing well. Her flap was
warm and well perfused with a strong Doppler signal. Her
diet was advanced to clears with permission to advance as
tolerated. The patient was out of bed to the chair. An
incentive spirometer was encouraged. The patient was
transferred later in the day to a regular surgical floor for
every-four-hour flap checks and vital sign monitoring. On
postoperative day number two, the patient continued to do
well and all incision lines were clean, dry, and intact. Her
flap remained warm with good capillary refill and a strong
Doppler signal. The patient was allowed to ambulate as
tolerated with assistance and was also allowed to shower with
assistance. Her Foley catheter was discontinued.
On postoperative day number three, the patient again remained
afebrile, was ambulating without difficulty, was tolerating a
regular diet, and had adequate pain control. She was also
voiding spontaneously. Her incision lines were all healing
well and her flap was viable with good Doppler signal and
capillary refill. The patient was felt to be in stable and
satisfactory condition for discharge to home.
DISCHARGE DISPOSITION: To home with visiting nurse
arrangements.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg 1-1/2 tablets p.o. q.d.
2. Duricef 1 g p.o. b.i.d. for 7 days.
3. Dilaudid 2 mg 1 to 2 tablets p.o. q.4 h. p.r.n. for pain.
4. Colace 100 mg p.o. b.i.d.
FOLLOW UP: The patient was instructed to schedule a follow-
up appointment with Dr. [**First Name (STitle) 3228**] in approximately seven to ten
days.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3228**], M.D. [**MD Number(2) 8076**]
Dictated By:[**Last Name (NamePattern1) 8077**]
MEDQUIST36
D: [**2118-8-9**] 16:37:32
T: [**2118-8-9**] 20:21:40
Job#: [**Job Number 55981**]
|
[
"V58.42",
"V10.3",
"V45.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.89"
] |
icd9pcs
|
[
[
[]
]
] |
2231, 2274
|
2297, 2469
|
2481, 2894
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,172
| 114,177
|
11538
|
Discharge summary
|
report
|
Admission Date: [**2119-2-22**] Discharge Date: [**2119-3-3**]
Date of Birth: [**2044-6-2**] Sex: M
Service: BLUE [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 36733**] was transferred
from [**Hospital **] Hospital for management of congestive heart
failure. He is a 74 year-old male with a long standing
history of coronary artery disease status post coronary
artery bypass graft in [**2108**], ischemic cardiomyopathy with an
ejection fraction of 10 to 15%, history of recurrent
ventricular tachycardia status post automatic internal
cardiac defibrillator placement, diabetes, hypothyroid now
presenting with shortness of breath. The patient initially
presented approximately one week ago to [**Hospital6 23442**] with abdominal discomfort. He underwent an
endoscopic retrograde cholangiopancreatography and was also
treated for congestive heart failure. His liver enzymes were
noted to be elevated. Endoscopic retrograde
cholangiopancreatography was unremarkable. The patient was
discharged home and returned two days later with congestive
heart failure. He was then transferred to [**Hospital1 346**].
PAST MEDICAL HISTORY: 1. Insulin dependent diabetes
mellitus. 2. Coronary artery bypass graft [**2108**]. 3. Stress
SPECT showed a small to moderate ischemic deficit in the
lateral and inferolateral wall. 4. Cardiac catheterization
revealed three vessel coronary artery disease, severe global
systolic dysfunction, normal right ventricular systolic
dysfunction, occluded saphenous vein graft - RI occluded
saphenous vein graft to obtuse marginal, patent saphenous
vein graft to left anterior descending coronary artery and
saphenous vein graft to D3. 5. Congestive heart failure
with an ejection fraction of 10%. 6. Hypercholesterolemia.
7. Hypothyroidism. 8. Status post appendectomy. 9.
Status post hernia repair.
ALLERGIES: Penicillin with a reaction of hives.
SOCIAL HISTORY: He is a retired liquor store owner. He
smoked tobacco for fifteen years. He quit [**2090**]. He reports
positive ethanol use.
FAMILY HISTORY: Significant for coronary artery disease and
diabetes.
MEDICATIONS ON ADMISSION: 1. Potassium chloride. 2.
Coreg. 3. Digoxin. 4. Ecotrin. 5. Colace. 6. Synthroid.
7. Accupril. 8. Bumex. 9. Aldactone. 10.
Amitriptyline.
PHYSICAL EXAMINATION: Temperature 95.5. Blood pressure
98/62. Heart rate 64. Respirations 20. 98% on room air.
His neck had positive JVD to the angle of the jaw.
Cardiovascular examination regular rate and rhythm. S1 and
S2 present. 2 out of 6 holosystolic murmur laterally
displaced point of maximal impulse. Lungs had crackles one
third of the way up his lungs. His abdomen was soft and
nontender. His extremities had 2+ edema.
LABORATORY: White blood cell count 6.3, hematocrit 40.8,
platelets 137, INR 1.5, PTT 33.5, sodium 133, potassium 4.9,
chloride 94, bicarb 32, BUN 28, creatinine 1.6, glucose 192,
ALT 125, AST 36, alkaline phosphatase 145, total bili was
1.0, digoxin was .7, calcium 8.4, magnesium 1.7, phosphorus
3.9.
HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**]
Service and placed on telemetry. He was continued on
intravenous diuresis with 80 mg of Lasix intravenous b.i.d.
His ace inhibitor dose was increased as tolerated.
Electrophysiology consultation was obtained to consider
biventricular pacing. Insulin was continued for the control
of his diabetes and Synthroid was continued for the control
of his hypothyroidism. On [**2119-2-23**] the patient underwent
cardiac catheterization for further evaluation of his cardiac
anatomy. This revealed severe three vessel coronary artery
disease and occluded saphenous vein graft to obtuse marginal
and D3, patent saphenous vein graft to left anterior
descending coronary artery and saphenous vein graft to ramus.
This also revealed moderately elevated left and right sided
filling pressures with mild pulmonary hypertension. A
electrophisiology study was performed. His AICD was
reprogrammed to AV paced at 80. On [**2119-2-24**] electrophysiology
reported that their plan was to wait for the FDA approval of
an in since device and put it in under research protocol.
The patient is to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one
to two months.
On [**2119-2-24**] the patient was transferred to the Coronary Care
Unit for inotropics and observation. PA catheter was placed
and intravenous Milrinone was started. The patient did well
with Milrinone and experienced symptomatic improvement and
diuresed approximately 7 liters. The patient experienced
thrombocytopenia down to 78. Heparin antibodies were
negative. On [**2119-3-1**] the patient was transferred back to the
[**Hospital Unit Name 196**] Service. He reported that he felt well and denied chest
pain, shortness of breath, nausea, vomiting fevers or chills.
He was afebrile with stable vital signs. His platelet count
had increased to 105. On [**2119-3-2**] overnight events for the
patient was mildly hypotensive with a systolic pressure of 86
to 98. His examination was remarkable for fine crackles one
third of the way up his lungs. His weight was 75.4
kilograms. He had no JVD. He had no peripheral edema.
Coumadin was started. On [**2119-3-3**] the patient was doing well
with no complaints. Blood pressure ranges from 82 to 90/60
to 62. His Is and Os were negative 100 AV cc the previous
day. His weight was stable at 75.4 kilograms. His
examination was unchanged. His PTT was 150 and his INR was
2.1. This was rechecked at 4:00 p.m. and his INR was found
to be 1.3 after his heparin had been turned off. His
creatinine was 1.6.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to home.
DISCHARGE DIAGNOSES:
1. Congestive heart failure, severe.
2. Status post cardiac catheterization.
3. Status post electrophysiology studies.
4. Insulin dependent diabetes mellitus.
5. Status post coronary artery bypass graft.
6. Hypercholesterolemia.
7. Hypothyroidism.
8. Automatic implanted cardioverter defibrillator in place.
9. Known ejection fraction of 10 to 15%.
DISCHARGE MEDICATIONS: 1. Coumadin 7.5 mg po q.h.s. 2.
Digoxin .125 mg po q.d. 3. Protonix 40 mg po q.d. 4. Lasix
120 mg po b.i.d. 5. Elavil 25 mg po q.h.s. 6. Enteric
coated aspirin 325 mg po q.d. 7. Potassium chloride 20
milliequivalents po b.i.d. 8. Synthroid .125 mg po q day.
9. Aldactone 25 mg po b.i.d. 10. Coreg 12.5 mg po b.i.d.
11. Lente insulin 12 units subQ b.i.d.. 12. Colace 100 mg
po b.i.d. 13. Zestril 20 mg po q.h.s. 14. Lovenox 60 mg
subQ b.i.d. times three days.
DISCHARGE DIET: Cardiac low salt diet.
FOLLOW UP: The patient is instructed to follow up with Dr.
[**Last Name (STitle) **] on [**3-22**] at 11:00 a.m. The patient should follow up
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one to two months for possible in
since pacemaker placement. The patient is instructed to
follow up with his primary care physician in three days to
have his INR checked. An appointment has been scheduled for
Monday.
[**Last Name (LF) **],[**Name8 (MD) 2064**] M.D.
Dictated By:[**Last Name (NamePattern1) 4827**]
MEDQUIST36
D: [**2119-3-3**] 21:40
T: [**2119-3-6**] 08:16
JOB#: [**Job Number 36734**]
cc:[**Hospital 36735**]
|
[
"414.02",
"244.9",
"427.1",
"414.8",
"V45.81",
"428.0",
"414.01",
"287.5",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.55",
"37.26",
"37.21",
"89.64",
"88.52"
] |
icd9pcs
|
[
[
[]
]
] |
2112, 2167
|
5823, 6182
|
6206, 6730
|
2194, 2346
|
3109, 5728
|
6742, 7422
|
2369, 3091
|
189, 1165
|
1188, 1948
|
1965, 2095
|
5753, 5802
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,893
| 158,970
|
1820
|
Discharge summary
|
report
|
Admission Date: [**2166-10-7**] Discharge Date: [**2166-10-15**]
Date of Birth: [**2102-4-8**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Patient is a 64-year-old female
with CRS of tobacco, age, hypertension, who was admitted
electively [**2166-10-7**] for resection of left lung mass when upon
induction of anesthesia, she was noted to be hypotensive and
telemetry showed ST elevations. It was unclear. A 12-lead
electrocardiogram was done at that time, but intraoperative
transesophageal echocardiogram showed inferior hypokinesis.
She was subsequently admitted to the CCU for further
monitoring care currently.
Patient had findings of large left hilar mass extending into
the mediastinum. CT appearance of the lesions suggested T4
primary, but no evidence of mediastinal lymph nodes spread or
peripheral metastases. Head CT was done previous to
admission and spinal MRI was also done, both were negative.
Cervical mediastinoscopy was done on [**2166-5-17**] and
frozen section analysis demonstrated it was poorly
differentiated nonsmall cell lung cancer, mast cell was not
adherent to the trachea or left main stem bronchus at that
level. Patient was discussed in Multidisciplinary Thoracic
[**Hospital **] Clinic for further surgical intervention when she
was admitted to the CCU on the 16th.
PAST MEDICAL HISTORY:
1. Poorly differentiated large cell lung carcinoma,
involvement of left laryngeal nerve.
2. Hiatal hernia diagnosed by endoscopy. Patient is on
Protonix.
3. Radiation esophagitis.
4. Hypertension.
5. Anxiety.
6. Status post tubal ligation.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Protonix 40 q.d.
2. Ativan 0.5 q.d.
FAMILY HISTORY: Father with MI at 60. Mother with breast
cancer. Sister with breast cancer.
SOCIAL HISTORY: Patient is a bus driver. Positive 40 pack
year smoker, quit several months ago.
PHYSICAL EXAM ON ADMISSION: Temperature is 96, heart rate
62, blood pressure 123/69, respiratory rate of 10, and O2
saturation is 100%. Generally she is an elderly female in no
acute distress. HEENT was pupils are equal, round, and
reactive to light. Normocephalic, atraumatic. Mucous
membranes were moist. Neck is supple without bruits or
adenopathy. Chest was clear to auscultation bilaterally, no
wheezes. Heart was regular, no murmurs, rubs, or gallops
appreciated. No S3, S4 sounds appreciated. Abdominal
examination showed soft, nontender, nondistended. Abdomen
with positive bowel sounds. Extremities were negative for
clubbing, cyanosis, or edema, palpable pulses bilaterally at
DP and PT. Neurologic: Patient could move all four
extremities.
On admission to CCU, the patient was intubated but responded
to voice.
LABORATORIES ON ADMISSION: Patient's white count is 6.1,
hematocrit 36.4, and platelets of 191. Chemistries: 149,
3.9, 111, 25, 11.7, 92, ALT of 14, AST of 12, alkaline
phosphatase 64, T bilirubin 0.3, CK 54. Albumin 3.7, calcium
8.8, magnesium 1.9, phosphorus 4.8.
EKG on admission showed sinus rhythm at 60 beats per minute,
normal axis, normal intervals, no left ventricular
hypertrophy by voltage criteria, LAA 0.3 mm, ST elevations in
II, III, and aVF, T-wave inversions V1, V2, and aVL.
Chest x-ray on [**2166-10-1**] showed interval decrease in size of
left aortopulmonary window mass with residual irregular
opacity remaining. Heart size and pulmonary vasculature
appeared within normal limits without cardiac failure. No
pleural effusions or areas of focal consolidation or evidence
of metastatic disease visualized. No acute cardiopulmonary
abnormalities.
MR of the chest on [**2166-4-22**] with and without contrast
showed no clear invasion of the major airways and pulmonary
vasculature by AP window mass and a clear fat plain was
defined between mass, left main bronchus, and mass could not
be clearly separated, however, from the adjacent proximal
descending aorta, left main pulmonary artery, and proximal
left upper lobe pulmonary arteries.
Patient had cardiac catheterization on admission. It showed
right dominant LMCA, LAD, .................. RCA, no
angiographically apparent coronary artery disease, small PDA
branches.
Patient was taken to the operating room on [**2166-10-9**] with a
preoperative diagnosis of Stage T4 nonsmall cell lung cancer
of the left upper lobe and procedures that were done were:
1) median sternotomy with interpericardial left
pneumonectomy, 2) radical mediastinal lymph node dissection
under general endotracheal anesthesia.
The patient did well on postoperative day one and was
transferred to the unit to CSRU on Neo-Synephrine and,
propofol. Neo-Synephrine was weaned off on postoperative day
one. All drips were weaned off on postoperative day two.
Renal team was consulted on [**2166-10-12**] for
perioperative acute renal failure secondary to transient
decreased renal perfusion, and recommended avoidance of
further nephrotoxins such as NSAIDs, contrast, and
recommended starting erythropoietin.
On postoperative day three, patient continued to do well on
no drips, and was transferred to the floor on postoperative
day four. Physical Therapy continued to see her throughout
her course, and patient's saturation was 97% on 2 liters on
postoperative day four. The patient was discharged on
postoperative day five in no acute distress without event to
home.
DISCHARGE DIAGNOSIS: Stage T4 nonsmall cell lung cancer left
upper lobe.
PROCEDURES:
1. Diagnostic left thoracoscopy.
2. Pedicle vascularized pedicle pericardial flap.
3. Diagnostic esophagoscopy.
4. Flexible bronchoscopy.
5. Median sternotomy with interpericardial left
pneumonectomy.
6. Radial mediastinal lymph node dissection.
DISCHARGE MEDICATIONS:
1. Levofloxacin 250 mg tablets one p.o. q.d. for one week.
2. Acetaminophen 325 mg tablet 1-2 tablets p.o. q.4-6h. as
needed for pain.
3. Protonix 40 mg tablet one p.o. q.d.
4. Percocet 5/325 mg tablets 1-2 tablets p.o. q.4-6h. for
pain.
5. Ativan 0.5 mg tablet one p.o. b.i.d.
6. Iron complex.
7. Colace 100 mg one p.o. b.i.d.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D.
Dictated By:[**Last Name (NamePattern4) 10197**]
MEDQUIST36
D: [**2166-10-15**] 10:28
T: [**2166-10-15**] 11:07
JOB#: [**Job Number 10198**]
cc:[**Last Name (NamePattern4) 10199**]
|
[
"V64.1",
"458.9",
"553.3",
"934.0",
"280.9",
"584.5",
"997.5",
"530.81",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"89.68",
"32.5",
"96.05",
"37.22",
"37.12",
"88.56",
"42.23",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
1732, 1811
|
5736, 6479
|
5401, 5713
|
1675, 1715
|
184, 1352
|
2776, 5379
|
1374, 1654
|
1828, 1924
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,095
| 173,425
|
53479
|
Discharge summary
|
report
|
Admission Date: [**2192-7-16**] Discharge Date: [**2192-7-23**]
Date of Birth: [**2153-12-18**] Sex: F
Service: MED
Allergies:
Penicillins / Keflex
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
38 y/o woman with SLE, HTN, presenting with tremors and
confusion since [**7-11**]. On admission, the patient was extremely
confused and a poor historian. Per discussion with the pt's
sister by the primary admitting team, the patientt had been
feeling tired, confused, lethargic, reporting occ fevers and
chills, also with signifcant word finding difficulty. Seen by
neuro in ER. Concern is mainily toxic metabolic--?Meningitis
(possibly fungal given long-term prednisone use). Tox screen
(urine/serum) neg, blood cx, urine cx pending.
Past Medical History:
Pulm HTN, SLE: rash, arthritis, nephritis (on
cytoxan/steroids), (recent flare [**6-15**]), TTP (s/p splenectomy
'[**88**], tx w/plasmapheresis in past), APLA on coumadin (h/o DVT),
s/p splenectomy, alpha thalasemmia, Hgb C
Social History:
lives alone, no tob, occ etoh, no ivdu;
Worked previously as a systems analyst, but now on disability
for her [**Year (2 digits) **]
brother [**Telephone/Fax (1) 109960**]
Family History:
4 sisters, 1 brother:
1 sister w/ colitis
1 sister w/ arthritis (unknown type)
1 sister w/ thyroiditis
Physical Exam:
Exam on admission (per Medicine team): 190's SBP, alert and
oriented to person/place. Over course of day [**7-16**] she had
worsening mental status, not able to follow commands, echolalia.
PE
T 102 p120 bp150/110 RR 24 Pox 97%/RA
Gen - thin African American F lying in bed, NAD but appears
anxious
HEENT - PERRLA, not able to follow commands for EOM; no scleral
icterus, MMM
Neck - supple, no LAD
CV - nl S1 S2 tachy RRR no m/r/g
Pulm - CTA bilat, no wheezes/rales
Abd - + bs, soft NT/ND, no HSM
Ext - no edema, warm, thin, no palpable cords
Neuro - echolalia, only able to follow some commands, no
hyperreflexia
Pertinent Results:
ON admission:
CBC- WBC 2.0, HGb 10.4, HCT 33.2, plat's 482
Chem 7- Na 133, Potassium 5.0, Chloride 101, Bicarb 20, BUN 54
Cr 1.8 , Glucose 144
PTT 39.2, INR 3.9
Urine: nitrates neg, luek's neg, protein 500, glucose neg.
Blood tox screen: neg
TSH 2.0
Ammonia 32
ON transfer from MICU:
CBC: WBC-3.3, Hgb 10.5, HCT 35.7, Plat's 401
Chem 7: Na 135, K 4.2, Cl 105, Bicarb 19, BUN 35, Cr 1.1 Glucose
83
Ca- 8.6, Phos 4.4 , Mag 2.7
INR 1.4, PTT 67.7
HSV from CSF negative
Complement levels: C3-74, C4-25
On transfer back to the floor:
[**2192-7-19**] 09:05AM BLOOD Glucose-102 UreaN-53* Creat-1.7* Na-131*
K-4.2 Cl-100 HCO3-20* AnGap-15
[**2192-7-20**] 05:50AM BLOOD Glucose-106* UreaN-43* Creat-1.1 Na-136
K-4.3 Cl-106 HCO3-19* AnGap-15
[**2192-7-16**] 04:00PM BLOOD C3-74* C4-25
[**2192-7-16**] 02:00AM BLOOD TSH-2.0
[**2192-7-16**] 10:00AM BLOOD Ammonia-32
[**2192-7-16**] 02:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Admitted to general medicine service:
Consults-
1) Neuro: found to be confused, lack of anterograde memory,
disorientation, inattention; ddx included vascular abn (but NOT
explained by MRI finding of acute L corpus callosum stroke),
uremia, vit B deficiency, "infection"
-LP, labs, infection screen tox screen, EEG for [**7-17**], goal SBP
140/90s
2) Renal: pre-renal azotemia in acute illness, SLE flare, ? TTP;
-u lytes, fena, u osm, u pr/cr ratio; volume challenge w/NS 1L
3)Rheum Eval: ddx of delta MS [**First Name (Titles) **] [**Last Name (Titles) 11168**] cerebritis, APA syndrome
causing stroke, infection, uremia, steroid toxicity (less
likely)
Course-
Transfused with 4 U FFP to correct INR for LP; multiple LP
attempts unsuccessful by floor team/Attg; plan for Neuro to try
this PM. Pt empirically started on CTX 2gm IV, vanco 1gm IV,
acyclovir 5mg/kg IV. Pt w/worsening mental status, difficult to
control HTN and lack of adequate IV access -> xfer to ICU for
closer monitoring and w/u.
Ms.S's AMS and renal function improved over the next 2 days and
she was transferred back to the floor.
1)AMS--Ms.S presented with worsening confusion, difficulty with
word finding, and echolalia. The differential diagnosis was
initially meningitis of infectious etiology, [**Last Name (Titles) 11168**] cerebritis,
stroke secondary to APLA, or toxic metaboloic encephalopathy. LP
came back negative and her ABX were stopped. MRI showed evidence
of acute infarction in the corpus callosum, but nothing that
would explain her symptomatology. EEG report: possibly normal
EEG but the excessive amount of drowsiness and sleep in this
record raises the suspicion of an early diffuse
encephalopathy. [**Last Name (Titles) **] cerebritis was considered less likely, as
she had been on 60 mg of Prenisone when the AMS occurred, she
had never had neuro presentation of a [**Last Name (Titles) 11168**] flare, and her
behavior did not fit in the classic description of [**Last Name (Titles) 11168**]
cerebritis and her C3 and C4 levels were only slightly
decreased. Toxic-metabollic encephalopathy to Bactrim is the
most likely explanation, as the only real intervention that was
done between time of presentation and time of resolution was to
withhold Bactrim PCP prophylaxis and Bactrim encephalitis has
been described in the literature. One other possibility is that
the AMS was secondary to Ms.S's HTN; however, her BP was never
at a level to charaterize it as a hypertensive emergency. It was
noted, though, that on several occasions, Ms.S's behavior seemed
a bit altered and at these times, her BP was in the 110/160
range. At the time of this dictation, the etiology of her AMS
remains unclear. Neurology was re-consulted to determine whether
a repeat EEG was indicated and psych was consulted to evaluate
whether Mrs.[**Last Name (STitle) **] was competent to make medical decisions.
2) [**Last Name (STitle) **] nephritis--Ms.S has grade IV nephropathy by biospy on a
prior admission. At presentation, she was in acute renal
insufficiency, with Cr of 1.8. She was found to be pre-renal, as
it corrected to 1.1 with fluid administration. She was kept on
60mg prednisone throughout her stay and received her monthly
pulse cytoxan prior to d/c. Nephrology was consulted and followd
the course of her hospitalization. It was thought that her
kidneys were very sensitive and hydration, renal dosing, and
continuing prednisone and cytoxan were the most appropriate
measures to undertake.
3) APLA--Because Ms.S has anti-phospholipid antibody syndrome,
she was anticoagulated on heparin then lovenox and bridged to
coumadin. Ms.S was discharged on 7.5mg coumadin and is to
follow-up with her PCP on [**Name9 (PRE) **], [**7-24**] to adjust her
regimine. Her MRI showed evidence of micro-infarction, likely
related to her APLA, she has had a DVT in the past, and there is
a mention of pulmonary HTN that may be related to small PE's
that did not require medical intervention, all of which suggest
fairly aggressive anti-coagulation to a goal INR of [**3-14**].5.
4) Hypertension--Ms.S's BP was difficult to control. Initially,
she was on her home meds of Lopressor 50qd and HCTZ 12.5 qd. In
the MICU she was sitched to hydralazine. When she returned to
the floor, her BP was labile with a range ot 130's/80's to
160's/110's. The metoprolol was increased to 75BID and Norvasc 5
mg QD was added, with the possibility fo increasing to 10QD. She
tolerated this regimen and remained in the...range throughout
the duration of her stay.
5) Leukopenia--Ms.S's WBC ranged from the high 2.0's to the low
4.0's. It was thought that this was related to either the
Cytoxan or SLE. As her WBC were stable for several days prior to
scheduled cytoxan treatment, she received her dose as scheduled.
Medications on Admission:
prednisone 60, cytoxan, metoprolol, bactrim, coumadin, folate
Protonix 40, Ca, Vit D, Alendronate, NaCitrate, Norvasc 5, HCTZ
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
[**Date Range **]:*30 Cap(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Date Range **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
[**Date Range **]:*90 Tablet, Chewable(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO QD (once a day).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
7. Alendronate Sodium 5 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
8. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Thirty (30) ML PO BID (2 times a day).
[**Date Range **]:*1800 ML(s)* Refills:*2*
9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO QD (once a
day).
10. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
[**Date Range **]:*180 Tablet(s)* Refills:*2*
12. Lovenox 60 mg/0.6mL Syringe Sig: One (1) injection
Subcutaneous twice a day for 6 doses: as directed by a
physician.
[**Name Initial (NameIs) **]:*6 injections* Refills:*0*
13. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
1. Acute change in mental status.
2. New hyperintensity on MRI in Corpus Callosum c/w CVA.
Secondary:
1. Systemic [**Company **] Erythematosis.
2. Class III Diffuse Proliferative Glomeronephritis.
3. Nephrotic syndrome.
4. Antiphospholipid Antibody Syndrome.
5. ITP s/p splenectomy.
6. TTP/Microangiopathic hemolytic anemia.
7. Hemoglobin C variant.
8. Anemia of Chronic disease.
9. Immunosuppresion: High dose Prednisone and Cytoxan.
10. Hypertension.
Discharge Condition:
Good.
Discharge Instructions:
Please return to hospital for worsening pain, confusion,
muscle/joint aches, chest pain, fever, or any other serious
complaints.
Please follow-up with Dr.[**Last Name (STitle) **] on wed to get your INR checked
if not theraputic today. We will call today regarding INR
instructing whether to take lovenox.
Follow up on [**7-30**] at the [**Hospital **] clinic for your cytoxan
treatment.
Followup Instructions:
Please follow-up with Dr.[**Last Name (STitle) **] on [**7-27**] at 10:15am.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2192-7-30**] 9:00
Provider: [**Name Initial (NameIs) 4426**] 2 Date/Time:[**2192-7-30**] 9:00
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2192-8-16**] 4:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1366**],[**Hospital **]
[**Hospital 2793**] Clinic [**Telephone/Fax (1) 60**] Date/Time: [**2192-8-30**] 1:30
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"583.81",
"282.49",
"287.3",
"710.0",
"584.9",
"285.21",
"434.91",
"401.9",
"283.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9713, 9762
|
3076, 7861
|
298, 304
|
10268, 10275
|
2091, 2091
|
10714, 11568
|
1327, 1431
|
8038, 9690
|
9783, 10247
|
7887, 8015
|
10299, 10691
|
1446, 2072
|
237, 260
|
332, 871
|
2106, 3053
|
893, 1120
|
1136, 1311
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,717
| 184,533
|
22100
|
Discharge summary
|
report
|
Admission Date: [**2172-3-21**] Discharge Date: [**2172-3-25**]
Date of Birth: [**2113-2-16**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Liver hemorrhage
Major Surgical or Invasive Procedure:
right chest tube, removed [**2172-3-25**]
History of Present Illness:
59 y/o female transferred from [**Hospital 8**] Hospital for question
of liver hemorrhage s/p placement of biliary drain. Initial
admission was for RUQ pain, nausea and fever to 103. U/S had
shown intrahepatic ductal dilitation and patient subsequently
had an ERCP with diagnosis of cholangitis likely secondary to
recurrent stones and possible stricture. Intrahepatic ducts were
inaccessible due to prior Roux-en-Y so percutaneous biliary
drainage was attempted, the CBD was inaccessible, and a
re-attempt was to be tried a few days later. In the meantime the
patient developed bleeding from the drain site, the drain was
removed and the intrahepatic ducts were no longer dilated.
Patient appeared to be clinically improving and was to be
discharged home, however on [**2172-3-20**] the Hct was found to have
dropped to 20%, CT abdomen revealed heterogeneous liver
consistent with intrahepatic bleeding. Patient received 1 unit
RBCs and was transferred to [**Hospital1 18**] for further evaluation.
Past Medical History:
S/P roux-en-Y hepaticojejujonostomy in [**Country 47535**] in [**2166**] s/p
sclerosing cholangitis
DM2
PUD
constipation
anemia
hysterectomy [**2162**]
Social History:
Lives with son, daughter in law and two grandchildren
Family History:
N/C
Physical Exam:
VS: 99.3, 94, 131/61, 21, 100% 2L
Gen: Lying in bed, appears sl anxious
HEENT: sclera mildly icteric
Chest: RRR, no audible murmurs
Abd: RUQ tenderness, soft, diminished BS. Dressing present over
procedure site, no drainage
Extr: warm, well perfused
Pertinent Results:
OnAdmission [**2172-3-21**]
WBC-11.6*# RBC-2.88*# Hgb-9.2*# Hct-25.3*# MCV-88 MCH-31.9
MCHC-36.3* RDW-16.0* Plt Ct-180
PT-12.7 PTT-25.0 INR(PT)-1.1
Glucose-132* UreaN-6 Creat-0.8 Na-134 K-4.5 Cl-97 HCO3-30
AnGap-12
ALT-251* AST-110* AlkPhos-364* Amylase-155* TotBili-2.1*
Albumin-3.4 Calcium-8.3* Phos-3.3 Mg-2.3
On Discharge [**2172-3-24**]
WBC-9.5 RBC-3.46* Hgb-10.5* Hct-30.5* MCV-88 MCH-30.5 MCHC-34.6
RDW-15.7* Plt Ct-269
PT-11.8 PTT-26.4 INR(PT)-1.0
Glucose-109* UreaN-6 Creat-0.6 Na-131* K-4.1 Cl-96 HCO3-27
AnGap-12
ALT-87* AST-29 AlkPhos-318* TotBili-1.2
Albumin-3.1* Calcium-8.0* Phos-3.1 Mg-2.1
Brief Hospital Course:
As per HPI, patient admitted from [**Hospital 8**] Hospital, with
admission to the SICU
Patient received Vanco and Meropenem. Blood cultures sent which
are currently no growth but are pending finalization.
Received one unit of blood on admisssion.
Liver team and Thoracics were both consulted.
CT performed on [**2172-3-21**] showed:
- Intraparenchymal hemorrhage involving largely segments V and
VI of the liver, with a moderately large right subcapsular
hematoma.
- Moderately enlarged right hemorrhagic pleural effusion.
- Small perinephric free fluid. The kidney appears to be intact
and functioning normally.
A chest tube was placed by Thoracic surgery on [**2172-3-21**], 300 cc of
serosanguinous fluid was immediately obtained from the chest
tube, a second tube was used to replace the first with an
additional 400 cc removed. The chest tube was initially to
suction, then waterseal and finally removed on [**3-25**] with marked
improvement in the chest x-ray findings. Patient does remain
with atelectasis.
Hct has remained stable, (32% at discharge)
Patient will remain on Cipro and Flagyl in the outpatient
setting and have a follow-up visit with surgery next week.
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*42 Tablet(s)* Refills:*0*
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*28 Tablet(s)* Refills:*0*
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
subhepatic fluid collection
right pleural effusion
right apical pneumothorax
sclerosing cholangitis s/p roux-en-y hepaticjejunostomy/ccy [**2166**]
Discharge Condition:
good
Discharge Instructions:
Call Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 673**] if fever, chills, shortness of
breath, jaundice, nausea, vomiting, or pain in abdomen/chest
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2172-4-3**] 2:10
Completed by:[**2172-3-25**]
|
[
"998.11",
"511.8",
"250.00",
"573.8",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4601, 4676
|
2585, 3763
|
330, 374
|
4868, 4875
|
1955, 2562
|
5080, 5251
|
1665, 1670
|
3786, 4578
|
4697, 4847
|
4899, 5057
|
1685, 1936
|
274, 292
|
402, 1403
|
1425, 1578
|
1594, 1649
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,295
| 135,637
|
32123
|
Discharge summary
|
report
|
Admission Date: [**2179-2-5**] Discharge Date: [**2179-2-16**]
Date of Birth: [**2132-1-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Pedestrian who got hit by car at unknown speed + LOC
Major Surgical or Invasive Procedure:
Left ORIF distal tibial and Right ORIF humerus, and IVC filter
placement
History of Present Illness:
42M pedestrian vs car at unknown speed. + ETOH +LOC, found
unresponsive with FS 20-30, given 1 Amp D50 and transferred to
[**Hospital1 18**] for further management.
Past Medical History:
PMhx: DM2, ETOH abuse, neuropathy, previous hip fx, lumbar spine
fx, right non-displaced humeral neck fx 4-5 days ago, ?HIV and
Hep C
[**Last Name (un) 1724**]: Amitriptyline 25 PM, tramadol 50", Actos 15', Metformin
1000", lunesta 3 PM, Lyrica 75", percocet PRN
All: NKDA
Social History:
ETOH abuse
Family History:
non-contributory
Physical Exam:
On discharge:
Pt is afebrile, VSS
Gen: NAD, A+Ox2 (got year wrong), NAD
CV: RRR
Resp: CTAB
Abd: Soft, NT/ND
MSK: right arm in sling, LLE in splint, senation and movement
intact distal ext X 4
Pertinent Results:
Admit Hct: 26.9
Discharge Hct: 27.3
Serum ETOH admit: 184
CTOH [**2-5**]: no ICH/fx
CT C-spine [**2-5**]: no fx, DJD with mild central canal narrowing
CT Torso [**2-5**]: R Sup and inf pubic rami fx and L Sup pubic
ramus fx, with small b/l hematomas adjacent to the bladder,
Acute comminuted fx of the R greater trochanter. Old L greater
trochanteric fx, Acute nondisplaced fx along anterior R sacrum,
Comminuted fx through the R humeral head and neck, Ant wedge
compression deformity of T12 of indeterminate age, Acute L L2
and L3 TP fx
MRI of CTL spine: Prevertebral and retropharyngeal edema
extending from the skull base to approximately C4. No definite
fx is noted, no abnormalities of Ant/Post Long Ligaments, no fx
of T spine, mild chronic compression deformity of L1, without
significant retropulsion into the canal.
Brief Hospital Course:
After being seen by the trauma surgical team in the ED, the
patient was admitted to the trauma service. Orthopedic surgery
saw him and performed a L ORIF distal tib and a R ORIF humerus.
In addition, IR placed an IVC filter in him as he is NWB on his
LLE.
Post-operatively the patient did well. Ortho requested the
patient be started on Lovenox 40 [**Hospital1 **], however given the
patient's dislike for being stuck twice a day and because
treatment would be costly, an alternate more cost effective
regimen with low dose coumadin was initiated. The patient will
take 1 mg of Coumadin daily. He will not need INR follow-up on
this low dose.
On the day of discharge his INR is 1.7. He is tolerating a
regular diet and moving his bowels. He will be discharged to
rehab.
Medications on Admission:
1. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
3. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Lunesta 3 mg Tablet Sig: One (1) Tablet PO qPM ().
5. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
10. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Lunesta 3 mg Tablet Sig: One (1) Tablet PO qPM ().
12. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Pedestrian vs. Car s/p multiple injuries with Left ORIF distal
tibial and Right ORIF humerus, and IVC filter placement.
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your 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.
Followup Instructions:
Follow up in [**Hospital **] clinic in 10 days. Please call
[**Telephone/Fax (1) 1228**] to make an appointment.
Follow up in Trauma clinic. Please call [**Telephone/Fax (1) 6429**].
Completed by:[**2179-2-16**]
|
[
"868.09",
"577.1",
"070.54",
"276.52",
"V08",
"805.6",
"812.01",
"263.9",
"820.20",
"823.02",
"805.4",
"808.2",
"291.81",
"356.9",
"250.80",
"E814.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"79.36",
"79.31",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4194, 4249
|
2076, 2855
|
365, 440
|
4413, 4420
|
1222, 2053
|
5164, 5381
|
976, 994
|
3243, 4171
|
4270, 4392
|
2881, 3220
|
4444, 5141
|
1009, 1009
|
1024, 1203
|
273, 327
|
468, 634
|
656, 932
|
948, 960
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,260
| 199,473
|
52236+52237
|
Discharge summary
|
report+report
|
Admission Date: [**2166-3-1**] Discharge Date: [**2166-3-4**]
Date of Birth: [**2100-10-22**] Sex: M
Service: MEDICINE
Allergies:
Darvocet-N 50
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Nose bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65yo man w/ CVA x4, CAD, diastolic CHF, s/p AVR [**2159**], on
coumadin here with apistaxis that started this afternoon after
bending over. There was some blood going back down his throat,
but most seemed to be anterior. He did not remember choking on
any blood. The bleeding didn't improve with pressure and was
profuse, so he came in to the ED.
.
He has also continued to have melena since his prior admission,
with black stools twice a day. He is not having any nausea or
hematemesis. He is out of breath walking to the car, but this
has been pretty stable. Today he is more lightheaded than prior
when standing. No chest pain.
.
Of note, he was recently admitted [**Date range (1) 20565**] with anemia,
epistaxis and melena. He received 8 units pRBCs and his warfarin
was held. His epistaxis resolved spontaneously. An EGD showed
gastritis so his pantoprazole dose was increased. When his INR
was sub-therapeutic, he was bridged with a heparin gtt. Afrin
was given for 3 days as well as nasal saline, humidified air and
vaseline to nasal mucosa.
.
He saw Dr. [**Last Name (STitle) 17680**] in ENT [**2166-2-26**] who felt that he had
significant nasal vestibulitis with crusting and subsequent
epistaxis. He prescribed 12-14 days of topical bactroban
ointment, followed by saline nasal gel QHS. There were no
appropriate areas for cautery.
.
In the ED, initial VS: 99 82 92/48 16 100%. Labs showed Hct
20.3. Has been having melena for 3 weeks. Noted on last
admission. EGD on last admission showed only gastritis, d/c'ed
on pantoprazole, but he has not been taking it. Consented for 2
units. EKG unconcerning. Got pantoprazole 40mg IV x1. CXR read
as RLL consolidation, ? pneumonitis, so he got
levofloxacin/flagyl for an aspiration pneumonia. Therapeutic on
coumadin at 3.4, no vitamin K given. Vitals on transfer were
100/53, 73, 100% RA.
.
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, dysuria, hematuria.
Past Medical History:
- recurrent melena and epistaxis in [**2165**]
- CVA x 4 (most recent [**7-9**] while on warfarin, ASA and plavix)
- HTN
- CAD - single vessel distal LAD
- MI - in [**2164**], 3 stents unknown type unknown date
- s/p ICD implantation [**2163-12-8**] Parciology PC [**Telephone/Fax (1) 107924**]
- CHF - preserved EF, diastolic
- AVR - Mechanical valve [**2159-3-31**]
- DM-II
- COPD
- Low Back Pain
- Nephrolithiasis
- Duodenal ulcer on EGD [**2161-9-28**]
.
MEDICATIONS:
-x Albuterol 90mcg 1-2 puffs Q6hrs PRN
-x Lipitor 80mg daily
-x Flovent 110mcg [**Hospital1 **]
-x Folate 1mg daily
-x Lasix 20mg daily
- Glyburide 10mg daily
- Combivent 18/102mcg [**Hospital1 **] PRN
- Lisinopril 5mg daily
- Metoprolol 12.5mg daily - stopped per patient
- Bactroban 2% cream to nares [**Hospital1 **]
- SL Nitroglycerin 0.3mg PRN
- oxycodone 10mg Q6-8hrs PRN back pain
- Miralax 17gm daily PRN
- warfarin 3mg daily? unclear on [**Name (NI) **] sheet
- Aspirin 81mg daily
- Calcium-Vitamin D 250/200 5 tabs daily
- Colace 100mg [**Hospital1 **]
Social History:
-Smoking/Tobacco: 60 pack years, quit 2 years ago
-EtOH: seldom
-Illicits: IV drugs once in his life when young, never again
-Lives at/with: daughter and her family. She assists with his
medications. Independent with ADLs and ambulates with cane. From
[**2162**]-[**2164**] he lived in [**State 9512**] and so we have no records of his
care at that time. He states that he has never been in the
military, never been incarcerated although he has been around
individuals who have. He is not currently sexually active and
has had female partners in the past.
Family History:
There is diabetes mellitus, hypertension and dyslipidemia in
several immediate family members. His sister had CHF/?MI
begining in her late 40s. His mother had breast cancer and CHF.
Physical Exam:
VS: 97.6 86 92/40 20 97%RA
GENERAL: Well-appearing AA man in NAD, appropriate. Having small
drops of epistaxis during interview.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, JVP at clavicle when upright.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
HEART: RRR, III/VI harsh systolic murmur throughout precordium,
nl S1-S2.
ABDOMEN: Protuberant, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES: WWP, 2+ pitting edema up to knees, 2+ peripheral
pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-3**] throughout, sensation grossly intact throughout, shuffling
gait but steady.
.
Discharge Exam: Unchanged other than, no epistaxis, JVP not
elevated, CTAB, [**12-1**]+ LE pitting edema
Pertinent Results:
Admission Labs:
.
[**2166-3-1**] 09:00PM WBC-5.6 RBC-2.11* HGB-6.9* HCT-20.3* MCV-96
MCH-32.7* MCHC-34.0 RDW-17.6*
[**2166-3-1**] 09:00PM NEUTS-48.4* LYMPHS-29.0 MONOS-9.2 EOS-12.6*
BASOS-0.8
[**2166-3-1**] 09:00PM PLT COUNT-146*
[**2166-3-1**] 09:00PM PT-33.3* PTT-44.3* INR(PT)-3.4*
[**2166-3-1**] 09:00PM GLUCOSE-129* UREA N-24* CREAT-1.1 SODIUM-138
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-21* ANION GAP-11
[**2166-3-1**] 09:00PM cTropnT-<0.01
.
Imaging:
[**2166-3-1**] CXR AP:
New right lower lobe consolidation might represent aspiration,
less likely atelectasis.
.
[**2166-3-2**] Tagged RBC Study:
No evidence of acute bleeding.
.
[**2166-3-2**] CXR AP:
Again seen is a left-sided pacemaker with stable enlargement of
the cardiac silhouette. Vascular congestion has increased. Right
basilar opacity has decreased, consistent with resolving
aspiration or atelectasis. There is hazy opacity over both lung
bases consistent with small pleural effusions. Left retrocardiac
atelectasis is stable.
.
Discharge Labs:
.
[**2166-3-4**] 07:30AM BLOOD WBC-6.1 RBC-2.68* Hgb-8.7* Hct-24.4*
MCV-91 MCH-32.6* MCHC-35.9* RDW-19.3* Plt Ct-169
[**2166-3-4**] 12:23PM BLOOD PT-24.7* PTT-41.6* INR(PT)-2.3*
[**2166-3-4**] 07:30AM BLOOD Plt Ct-169
[**2166-3-4**] 07:30AM BLOOD Glucose-125* UreaN-15 Creat-0.9 Na-137
K-4.2 Cl-109* HCO3-24 AnGap-8
[**2166-3-4**] 07:30AM BLOOD ALT-29 AST-58* LD(LDH)-263* AlkPhos-86
TotBili-1.7* DirBili-0.7* IndBili-1.0
[**2166-3-4**] 07:30AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9
Brief Hospital Course:
65M with a known history of diffuse gastritis by EGD [**2166-2-18**],
mechanical AVR on coumadin, CVA x 4, dCHF (45%), recently
hospitalized for epistaxis/melena 3/19-28/11, who now
re-presents with epistaxis and melena in the setting of a Hct of
20.
.
# Hct Drop, Melena, Epistaxis: Presenting Hct was 20 in the
setting of epistaxis and melena; the patient was managed
emergently with 2 peripheral IVs, IV PPI, afrin, and 2 units of
pRBCs. Epistaxis resolved. Repeat Hct was about 21, prompting 2
more units of pRBCs and GI consult, who recommended tagged RBC
scan, which was negative. About 24h after presentation, Hct rose
to 26 and melena ceased, with brown soft stool that was guaiac
positive; epistaxis resolved. The patient was transitioned to PO
PPI and discharged on Omeprazole 40mg [**Hospital1 **] with GI follow-up. ENT
saw patient prior to discharge and did not recommend any further
procedures. Working diagnosis was an acute on chronic process;
chronic gastritis with acute GI bleed in the setting of
non-adherence to PPI by report and acute epistaxis. Discharged
on ENT's outpatient regimen with follow-up.
.
# HTN: Antihypertensive medications were held in the setting of
upper GI bleed and epistaxis. **Restarting anti-hypertensives
will be addressed on follow-up with PCP.**
.
# CHF: Presented clinically mildly hypervolemic, with 1-2+ lower
extremity pitting edema, but CTAB and satting high 90s on RA.
Lasix 20 IV given per 2 units of pRBCs and diuresed further
after Hct stabilized. Discharged on a short course of twice
daily (from once daily) lasix. Discharged in mildly hypervolemic
condition.
.
# New Indirect Bilirubinemia: Working Dx = Macro-angiopathic
hemolytic anemia [**1-1**] mechanical AVR in the setting of
transfusions and high flow state due to anemia and hypovolemia.
Smear showed no helmet cells or schistocytes. Direct coombs was
negative. Indirect bilirubinemia improved by discharge.
.
Inactive Issues:
.
# DM2: Held glyburide; glucose well controlled on HISS.
Discharged on glyburide unchanged.
.
# CAD: Continued Lipitor 80mg daily. Held ASA 81mg. **Restarting
of ASA per PCP after discharge.**
.
# COPD: Managed with nebs as an inpatient and continued home
regimen on discharge as below:
-Albuterol/Ipratrop nebs prn
-Flovent 110mcg [**Hospital1 **]
-Combivent 18/102mcg [**Hospital1 **] PRN
.
# Back pain: Continued home regimen as inpatient and on
discharge as below:
-oxycodone 10mg Q8hrs PRN back pain.
.
Transitional Issues:
As above in **.
Medications on Admission:
- Albuterol 90mcg 1-2 puffs Q6hrs PRN
- Lipitor 80mg daily
- Flovent 110mcg [**Hospital1 **]
- Folate 1mg daily
- Lasix 20mg daily
- Glyburide 10mg daily
- Combivent 18/102mcg [**Hospital1 **] PRN
- Lisinopril 5mg daily
- Metoprolol 12.5mg daily - stopped per patient
- Bactroban 2% cream to nares [**Hospital1 **]
- SL Nitroglycerin 0.3mg PRN
- oxycodone 10mg Q6-8hrs PRN back pain
- Miralax 17gm daily PRN
- warfarin 3mg daily? unclear on [**Name (NI) **] sheet
- Aspirin 81mg daily
- Calcium-Vitamin D 250/200 5 tabs daily
- Colace 100mg [**Hospital1 **]
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lasix twice daily for 3 days
Take Lasix 20 mg twice daily for 3 days ([**Date range (1) 108045**]), then resume
Lasix 20 mg once daily.
7. glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
8. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation twice a day as needed for shortness of breath or
wheezing.
9. Hold Lisinopril
Stop Lisinopril 5mg daily until directed to re-start by your
primary care physician
10. Hold Metoprolol
Stop Metoprolol 12.5mg daily until directed to re-start by your
primary care physician
11. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **]
(2 times a day) for 7 days.
12. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) puff Nasal
three times a day.
[**Hospital1 **]:*1 bottle* Refills:*2*
13. Vaseline Gel Sig: One (1) application Topical [**Hospital1 **] (2
times a day): apply to inside of both nostrils to moisten and
prevent bleeding.
14. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual once a day as needed for chest pain.
15. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every 6-8 hours
as needed for back pain.
[**Hospital1 **]:*90 Tablet(s)* Refills:*2*
16. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
17. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
18. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
[**Hospital1 **]:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
19. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: Two
(2) Tablet PO once a day.
20. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
21. Outpatient Lab Work
[**2166-3-6**] VNA Lab Draw:
-CBC
-PT/PTT/INR
.
Please fax to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 3382**]
22. VNA Blood pressure check
Check blood pressure [**2166-3-6**] and fax results to primary care
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 3382**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary: Epistaxis (nose bleed); Upper gastrointestinal bleed
Secondary: Congestive systolic heart failure, chronic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It has been a privilege to take care of you at the [**Hospital1 18**].
.
You were hospitalized for a nose bleed and black tarry stool
concerning for a reoccurence of a bleed from your stomach.
.
You were treated with 4 blood transfusions, which raised your
blood levels. Your nose bleed stopped with Afrin. Your black
tarry stool (known as melena) stopped with treatment with IV
acid blocker for your stomach. You are being discharged on an
oral acid blocked known as omeprazole that you are to take twice
a day. This medication is the best intervention to prevent
future stomach bleeds.
.
You were also treated with a diuretic because of the additional
fluid given to you with blood and your known congestive heart
failure.
.
Changes were made to your medications as detailed below.
Continue to take your ther medications as previously prescribed.
# CONTINUE: Omeprazole 40mg twice daily
# STOP: Aspirin until you are told to restart the medication by
your primary care physician; this medication can increase your
risk of bleeding
.
# CONTINUE: Bactroban to prevent nose bleeds
# START: Saline nasal spray to prevent nose bleeds
# START: Vaseline applied to the inside of your nose to prevent
nose bleeds
.
# INCREASE: Lasix from 20mg daily to 20mg TWICE daily for 3 days
([**Date range (1) 108045**]) THEN starting [**2166-3-8**] take Lasix 20mg only ONCE daily.
# STOP: Lisinopril until directed to start by your PCP
# [**Name Initial (NameIs) **]: Metoprolol until directed to start by your PCP
.
Return to the hospital if you have another nose bleed that does
not stop with pressure or if you have more episodes of black
tarry stool.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2166-3-10**] at 11:40 AM
With: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], NP [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2166-3-18**] at 1:30 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: OTOLARYNGOLOGY (ENT)
When: TUESDAY [**2166-3-18**] at 3:15 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Admission Date: [**2166-3-8**] Discharge Date: [**2166-3-31**]
Date of Birth: [**2100-10-22**] Sex: M
Service: MEDICINE
Allergies:
Darvocet-N 50
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
Black stools, relative hypotension.
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
The patient is a 65 yo M with Hx of multiple CVAs, CAD with
stents (DES to RCA [**2164**], off plavix), HTN, pacemaker, Mechanical
Aortic valve who has had several recent admissions to [**Hospital1 18**] for
anemia (thought secondary to epistaxis and hematuria).
.
He was admitted to the ICU with similar symptoms [**Date range (1) 108046**] A
total of 8 units of pRBC, EGD showed gastritis, medically
managed with pantoprazole he had epistaxis which was managed
with affrin.
.
Most recent admission was ([**Date range (1) 76337**]), where he initially
presented with melena and epistaxis and HCT 25->20. He was
transfused 4 units PRBCs. He underwent negative taged RBC scan
and bleeding was attributed to combination of gastritis and
epistaxis with microangiopathic hemolysis related to his
mechanical valve. He also appeared volume overloaded in that
admission and was treated with furosemide IV prior to PRBc, at
the time of discharge, he remained volume up with peripheral
edema.
.
Following discharge, patient was feeling well initially but
developed vertigo and dark stools and worsening lower extremity
edema and called [**Company 191**] on call. HCT was checked and was 23 and
stable from HCT 24 at discharge. He was told to continue to
monitor symptoms. He called again to [**Company 191**] today reporting BRBPR
x3 and dizziness and was instructed to present to the ED.
.
In the ED, initial vs were 97.8 80 154/90 16 100RA. Labs
notible for HCT 23.8 Platelets 188, INR 2.4. CXR showed
vascular congestion. Tender in LLQ. CT abdomen/pelvis was
negative for acute process. He developed hypotension with SBP
154->90s. He appeared volume up and was not transfused or
volume resuscitated in the ED, he was given pantoprazole 80mg
IV. VS prior to transfer 98.2, 80, 103/64, 20, 98 2 L.
.
On the floor, vitals were 97.6 96 110/63 75 20 97% 2lNC.
Patient reports dizziness, which he states he has had on and off
for weeks. Denies epistaxis.
.
Review of systems:
(+) Per HPI, also reports recent constipation the past week
(relieved with today's melena, as well as intermittent black
stools for the past several months.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- CVA x 4 (most recent [**7-9**] while on warfarin, ASA and plavix)
- HTN
- CAD - single vessel distal LAD
- MI - in [**2164**], 3 stents unknown type unknown date
- s/p ICD implantation [**2163-12-8**] Parciology PC [**Telephone/Fax (1) 107924**]
- CHF - preserved EF, diastolic
- AVR - Mechanical valve [**2159-3-31**]
- DM-II
- COPD
- Low Back Pain
- Nephrolithiasis
- Duodenal ulcer on EGD [**2161-9-28**]
Social History:
Smoking/Tobacco: 60 pack years, quit 2 years ago.
-EtOH: seldom.
-Illicits: IV drugs once in his life when young, never again.
-Lives at/with: daughter and her family. She assists with his
medications. Independent with ADLs and ambulates with cane. From
[**2162**]-[**2164**] he lived in [**State 9512**] and so we have no records of his
care at that time. He states that he has never been in the
military, never been incarcerated although he has been around
individuals who have. He is not currently sexually active and
has had female partners in the past.
Family History:
There is diabetes mellitus, hypertension and dyslipidemia in
several immediate family members. His sister had CHF/?MI
begining in her late 40s. His mother had breast cancer and CHF.
Physical Exam:
Vitals: 97.6 96 110/63 75 20 97% 2lNC
General: elderly AA man, appearing agitated and annoyed.
HEENT: NCAT, Sclera anicteric, MMM, oropharynx clear,
Lungs: left posterior basilar rales otherwise CTA
CV: Regular rate and rhythm, normal S1 + S2, II-III/VI systolic
murmur loudest RUSB
Abdomen: soft, non-distended, bowel sounds present, nontender,
no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, 2+ pitting edema b/l
Pertinent Results:
.
[**2166-3-20**] 07:11AM BLOOD WBC-6.0 RBC-2.86* Hgb-8.8* Hct-26.8*
MCV-94 MCH-30.9 MCHC-33.0 RDW-17.4* Plt Ct-138*
[**2166-3-19**] 11:33PM BLOOD Hct-26.0*
[**2166-3-19**] 03:15PM BLOOD Hct-28.1*
[**2166-3-19**] 07:25AM BLOOD WBC-5.7 RBC-2.74* Hgb-8.3* Hct-25.6*
MCV-94 MCH-30.1 MCHC-32.2 RDW-16.9* Plt Ct-151
[**2166-3-18**] 03:01PM BLOOD Hct-28.5*
[**2166-3-18**] 09:15AM BLOOD Hct-25.2*
[**2166-3-18**] 02:01AM BLOOD WBC-6.8 RBC-2.90* Hgb-8.8* Hct-26.8*
MCV-93 MCH-30.5 MCHC-33.0 RDW-17.1* Plt Ct-121*
[**2166-3-17**] 07:25PM BLOOD WBC-6.8 RBC-2.85* Hgb-8.7* Hct-26.1*
MCV-92 MCH-30.7 MCHC-33.4 RDW-17.4* Plt Ct-133*
[**2166-3-17**] 12:34PM BLOOD Hct-26.8*
[**2166-3-17**] 04:17AM BLOOD WBC-7.3 RBC-2.88* Hgb-8.8* Hct-26.2*
MCV-91 MCH-30.4 MCHC-33.4 RDW-17.3* Plt Ct-126*
[**2166-3-16**] 07:59PM BLOOD Hgb-8.7* Hct-26.4*
[**2166-3-16**] 01:53PM BLOOD WBC-7.2 RBC-2.95* Hgb-9.0* Hct-27.0*
MCV-92 MCH-30.6 MCHC-33.5 RDW-17.1* Plt Ct-127*
[**2166-3-16**] 07:59AM BLOOD Hct-23.5* Plt Ct-127*
[**2166-3-16**] 03:54AM BLOOD WBC-5.5 RBC-2.51* Hgb-7.7* Hct-23.2*
MCV-92 MCH-30.5 MCHC-33.1 RDW-16.9* Plt Ct-139*
[**2166-3-9**] 09:30AM BLOOD WBC-6.4 RBC-2.48* Hgb-7.4* Hct-23.9*
MCV-97 MCH-29.8 MCHC-30.9* RDW-18.3* Plt Ct-170
[**2166-3-8**] 09:45PM BLOOD Hct-23.3*
[**2166-3-8**] 04:34PM BLOOD Hct-24.5*
[**2166-3-8**] 02:27PM BLOOD WBC-6.7 RBC-2.61* Hgb-7.9* Hct-24.8*
MCV-95 MCH-30.4 MCHC-31.9 RDW-18.4* Plt Ct-158
[**2166-3-8**] 01:15AM BLOOD WBC-5.4 RBC-2.53* Hgb-7.9* Hct-23.8*
MCV-94 MCH-31.3 MCHC-33.3 RDW-18.5* Plt Ct-188
[**2166-3-16**] 03:54AM BLOOD Neuts-66.4 Lymphs-22.2 Monos-7.5 Eos-3.7
Baso-0.3
[**2166-3-8**] 01:15AM BLOOD Neuts-56.4 Lymphs-23.4 Monos-7.7
Eos-11.7* Baso-0.8
[**2166-3-20**] 07:11AM BLOOD Plt Ct-138*
[**2166-3-20**] 07:11AM BLOOD PT-18.6* PTT-64.9* INR(PT)-1.7*
[**2166-3-8**] 01:15AM BLOOD PT-25.4* PTT-40.2* INR(PT)-2.4*
[**2166-3-16**] 07:59AM BLOOD Fibrino-234
[**2166-3-16**] 03:54AM BLOOD Fibrino-226
[**2166-3-9**] 09:30AM BLOOD ESR-73*
[**2166-3-17**] 04:17AM BLOOD Ret Aut-3.3*
[**2166-3-8**] 01:15AM BLOOD Ret Aut-5.4*
[**2166-3-20**] 07:11AM BLOOD Glucose-132* UreaN-10 Creat-0.9 Na-138
K-3.8 Cl-108 HCO3-25 AnGap-9
[**2166-3-19**] 07:25AM BLOOD Glucose-126* UreaN-12 Creat-0.8 Na-139
K-3.8 Cl-109* HCO3-23 AnGap-11
[**2166-3-18**] 02:01AM BLOOD Glucose-137* UreaN-20 Creat-0.8 Na-139
K-3.9 Cl-109* HCO3-23 AnGap-11
[**2166-3-17**] 04:17AM BLOOD Glucose-187* UreaN-28* Creat-0.8 Na-141
K-3.8 Cl-109* HCO3-26 AnGap-10
[**2166-3-8**] 01:15AM BLOOD Glucose-217* UreaN-17 Creat-0.8 Na-138
K-3.9 Cl-108 HCO3-23 AnGap-11
[**2166-3-17**] 04:17AM BLOOD LD(LDH)-245 TotBili-3.1*
[**2166-3-16**] 01:53PM BLOOD CK(CPK)-52
[**2166-3-8**] 01:15AM BLOOD ALT-25 AST-54* LD(LDH)-292* CK(CPK)-77
AlkPhos-120 TotBili-1.1
[**2166-3-16**] 03:54AM BLOOD Lipase-48
[**2166-3-16**] 01:53PM BLOOD CK-MB-3 cTropnT-<0.01
[**2166-3-16**] 03:54AM BLOOD CK-MB-2 cTropnT-<0.01
[**2166-3-8**] 01:15AM BLOOD cTropnT-<0.01
[**2166-3-20**] 07:11AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8
[**2166-3-19**] 07:25AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.8
[**2166-3-17**] 04:17AM BLOOD Hapto-<5*
[**2166-3-8**] 01:15AM BLOOD Hapto-<5*
[**2166-3-8**] 01:15AM BLOOD Cortsol-2.8
[**2166-3-8**] 02:27PM BLOOD CRP-6.6*
[**2166-3-8**] 10:16AM BLOOD STRONGYLOIDES ANTIBODY,IGG-Test Name
.
Time Taken Not Noted Log-In Date/Time: [**2166-3-16**] 1:18 pm
SEROLOGY/BLOOD CHEM # 20354F-[**3-16**].
**FINAL REPORT [**2166-3-17**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2166-3-17**]):
EQUIVOCAL BY EIA.
(Reference Range-Negative).
.
STool antigen for H.pylori-negative.
.
[**3-8**] EKG-Sinus rhythm. Prolonged Q-T interval. Possible lateral
myocardial infarction. Compared to the previous tracing of
[**2166-3-2**] Q-T interval has increased.
.
CT abd/pelvis-[**3-8**]-IMPRESSION:
1. Mild wall thickening of the 3rd portion of the duodenum with
suggestion of slight surrounding fat-stranding might indicate
mild duodenitis.
2. Descending colon and sigmoid colon diverticulosis but no
diverticulitis.
.
CXR [**3-8**]-IMPRESSION:
Cardiomegaly, pulmonary edema, and small effusions.
.
[**3-16**] CXR-FINDINGS:
Frontal view of the chest is compared to multiple prior
examinations.
Left-sided dual-lead pacemaker unchanged. Heart top normal in
size.
Mediastinum within normal limits. Multiple lines and leads
project over the chest. Small bilateral pleural effusions with
mild bibasilar atelectasis, increased since prior study of
[**2166-3-8**]. Mild congestive failure.
.
EGD [**3-16**]-Impression: Old blood and food seen in the distal
esophagus, which was pushed into the stomach with the endoscope.
Abnormal mucosa in the stomach consistent with severe
hemorrhagic gastritis.
.
[**3-22**]-HISTORY: Shortness of breath. Volume overload.
One view. Comparison with the previous study of [**2166-3-16**]. There
is continued evidence of pulmonary venous congestion and small
bilateral pleural effusions. The patient is status post median
sternotomy as before. Mediastinal structures are unchanged. An
ICD remains in place.
IMPRESSION: No significant change.
Brief Hospital Course:
This is a 65yo M with hx of mechanical AVR c/b multiple CVAs on
coumadin, p/w black tarry stools, course c/b ICU stay for
hematemesis.
.
# Severe hemorrhagic gastritis/acute blood loss anemia: Pt a/w
acute on chronic anemia, chronic component previously determined
to be multifocal [**1-1**] chronic hemolysis related to AVR,
epistaxis, and possible GI bleed. Course c/b hematemesis in
setting of supratherapeutic INR, requiring multiple units pRBCs
to maintain Hct, and FFP to normalize INR. EGD demonstrated
severe hemorrhagic gastritis. Treated IV PPI and PO sucralfate
w stabilization of Hct. PPI switched to PO 40mg [**Hospital1 **]. Biopsy of
gastritis was equivocal for H. pylori, so at the suggestion of
GI, stool H. pylori antigen was sent and is negative. After, ICU
stay, pt's HCT had remained stable for days without transfusion
on heparin gtt. However, when asa and coumadin were restarted,
pt began to have epistaxis again and brown stools tinged with
blood. INR was <2 during this and PTT was at goal ~50. Due to
continued need for transfusion as well as recurrent epistaxis it
was thought that dual [**Doctor Last Name 360**] therapy (asa/coumadin) was the cause
of continued bleeding. Therefore, with thoughtful discussion
with patient's PCP and cardiologist Dr. [**First Name (STitle) 437**], it was decided to
stop patient's ASA therapy and continue with coumadin as it
appears that constant hypotension, daily blood transfusion risk
is greater than the potential benefit from continued aspirin
therapy. Pt will continue 40mg [**Hospital1 **] PPI and sucralfate after
discharge. HCT on discharge was 26.
# Epistaxis: Pt w chronic epistaxis with recurrence during this
admission. Required afrin and subsequent cauterization with
silver nitrate, after which epistaxis resolved. Episodes did
reoccur after coumadin/asa were restarted as above. Pt was
continued on mupirocin ointment [**Hospital1 **], nasal spray. ENT evaluated
the patient as well. Aspirin was stopped, see above. He had no
epistaxis for several days prior to discharge.
.
# Chronic congestive heart failure LVEF 45%: Pt appeared fairly
euvolemic through admission with standing lasix held given
hematemesis. At last discharge metoprolol and lisinopril had
been held. Metoprolol was started after episode of ventricular
ectopy as discussed below, but was often held due to
hypotension. Lasix was restarted on [**3-21**], and titrated to 20mg
daily. An ACE inhibitor was due to low blood pressures. His
blood pressure improved near the end of his stay, but his ACEI
was continued to be held; this may be restarted as an outpt if
his BP remains stable. His weight on discharge was 196 lbs (he
reports his dry weight to be 194 lbs); he was satting well on
room air with clear lungs and appeared euvolemic on discharge.
.
# Mechanical AVR: Coumadin held in anticipation of [**Last Name (un) **], then
held in setting of bleed. Once hemodynamically stable, he was
started on a conservative heparin bridge with PTT goal 50-80.
Due to the above, constant struggle that patient has had over
the last few months with epistaxis and GI bleeding while on
anticoagulation goals of care weere discussed with the patient
and his family. Discussed the rationale for taking asa/coumadin
for decreased risk of stroke and secondary MI prevention.
However, also discussed that this continued therapy will
continue to place patient at risk for GI bleeding and epistaxis.
Pt states that he "just wants to live". Pt was placed on therapy
for GIB-[**Hospital1 **] PPI 40mg and sucralfate. As above, pt placed on
heparin drip and when bleeding/HCT stable, asa and coumadin were
restarted. AS above, with continued bleeding and transfusion and
with discussion with pt's PCP and cardiologist decision was made
to discontinue asa therapy for now. Per, cardiologist Dr. [**First Name (STitle) 437**]
INR goal [**1-2**]. Coumadin was restarted on [**3-21**] and titrated to
target INR. There was some discussion during admission of
whether there may be a consideration of changing patient's
mechanical valve over to a tissue valve in order to avoid
coumadin. However, pt has had a prior stoke while on
anticoagulation with coumadin, ASA and plavix and therefore, pt
may never be without the need for anticoagulation. However, this
discussion can continue in the outpatient setting to determine
even if patient would be a candidate for a high risk surgery.
.
# Coronary artery disease: ASA 81mg was held given hematemesis,
but reinitiated after hematocrit had stabilized and overt
bleeding had abated. When bleeding returned, asa was
discontinued, see above and patient will continue on coumadin
monotherapy for now. Atorvastatin continued. Metoprolol
initially held then restarted as tolerated.
.
#intermittent epistaxis-continued Oxymetazoline and nasal
ointment. ENT evaluated the patient.
.
# DM: Held oral agents, started on ISS while in the hospital.
Oral agents can be resumed upon discharge.
.
# COPD: He did have some SOB with wheezing during this
admission. He was treated effectively with nebulizers prn.
.
FULL CODE
Medications on Admission:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lasix twice daily for 3 days
Take Lasix 20 mg twice daily for 3 days ([**Date range (1) 108045**]), then resume
Lasix 20 mg once daily.
7. glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
8. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation twice a day as needed for shortness of breath or
wheezing.
9. Hold Lisinopril
Stop Lisinopril 5mg daily until directed to re-start by your
primary care physician
10. Hold Metoprolol
Stop Metoprolol 12.5mg daily until directed to re-start by your
primary care physician
11. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **]
(2 times a day) for 7 days.
12. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) puff Nasal
three times a day.
[**Hospital1 **]:*1 bottle* Refills:*2*
13. Vaseline Gel Sig: One (1) application Topical [**Hospital1 **] (2
times a day): apply to inside of both nostrils to moisten and
prevent bleeding.
14. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual once a day as needed for chest pain.
15. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every 6-8 hours
as needed for back pain.
[**Hospital1 **]:*90 Tablet(s)* Refills:*2*
16. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
17. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
18. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
[**Hospital1 **]:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
19. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: Two
(2) Tablet PO once a day.
20. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1)
Inhalation twice a day.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours)
as needed for pain.
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
[**Hospital1 **]:*qs Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
[**Hospital1 **]:*120 Tablet(s)* Refills:*2*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
14. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **]
(2 times a day).
[**Hospital1 **]:*qs qs* Refills:*2*
15. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-1**] Sprays Nasal
TID (3 times a day).
16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
17. docusate sodium 100 mg Capsule Sig: [**12-1**] Capsules PO BID (2
times a day).
18. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
[**Month/Day (2) **]:*30 Tablet(s)* Refills:*2*
19. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BIDWM (2 times a day (with meals)).
[**Month/Day (2) **]:*qs Tablet(s)* Refills:*2*
21. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
acute blood loss anemia
severe hemorrhagic gastritis
epistaxis
hematemesis
mechanical AVR
CAD
DM
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with bleeding from your nose and
gastrointestinal tract. For this, you were followed by the
gastroenterology team and underwent and endoscopy that showed
"hemorrhagic gastritis" (bleeding stomach) and you were placed
on a new medication-sulcralfate for this. Unfortunately, you
will continue to require coumadin therapy for your mechanical
heart valve. However, this also will place you at continued risk
for bleeding from your gastrointestinal tract and nose. Because
of the frequent episodes of recurrent bleeding, it was decided
that you should no longer take aspirin therapy. You should
continue to follow up with your PCP, [**Name10 (NameIs) 2085**], and
gastroenterologist for further care.
.
Medication changes:
1.start sulcralfate
2.stop aspirin
3.continue coumadin at 2.5 mg daily
4.stop lisinopril; this may be restarted by your primary care
doctor on follow up if your blood pressure is stable
4.stop metoprolol; this may be restarted by your primary care
doctor on follow up if your blood pressure is stable
5.mupirocin ointment for any nasal irritation
6.iron supplementation
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: RADIOLOGY
When: THURSDAY [**2166-4-24**] at 9:00 AM
With: ULTRASOUND [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Department: LIVER CENTER
When: WEDNESDAY [**2166-5-28**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2166-4-1**] at 3:30 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: [**Hospital3 249**]
When: THURSDAY [**2166-4-10**] at 10:20 AM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"285.1",
"288.3",
"280.0",
"496",
"571.5",
"V45.82",
"V15.82",
"V43.3",
"428.0",
"428.33",
"412",
"535.41",
"V12.54",
"784.7",
"401.9",
"V45.02",
"250.02",
"V58.61",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
34478, 34549
|
25078, 30170
|
15757, 15763
|
34695, 34695
|
19951, 25055
|
36163, 37434
|
19282, 19465
|
32334, 34455
|
34570, 34674
|
30196, 32311
|
34846, 35564
|
6125, 6606
|
19480, 19932
|
4990, 5080
|
9105, 9123
|
17769, 18258
|
35584, 36140
|
15682, 15719
|
15791, 17750
|
8575, 9084
|
5115, 6109
|
34710, 34822
|
18280, 18691
|
18707, 19266
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
623
| 177,331
|
7638
|
Discharge summary
|
report
|
Admission Date: [**2112-10-31**] Discharge Date: [**2112-11-13**]
Service: NEUROSURGERY
Allergies:
Novocain / Fentanyl
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Thoracic mass
Major Surgical or Invasive Procedure:
Thoracic spinal mass resection
History of Present Illness:
83y/o male with hx of recal cell carcinoma presented with
abdominal pain over the past one month. The pain located at the
left side of umbilicus, almost as band like distribution. The
pain was also sensed as dull, uncomfortable feeling.
Besides this pain, he did not have any other symptoms such as
weakness, numbness, difficulty in ambulation, urination,
stooling.
Last weekend, he felt the symptom did not imporved and visited
OSH ED. There he was obtained CT scan and eventually follow up
MRI, and found to have T9 mass lesion. He was referred to [**Hospital1 18**]
for further evaluation.
ROS: No headache, fever, trauma hx, urinary/bowel incontinence.
Past Medical History:
Renal cell carcinoma: s/p L nephrectomy in [**2104**]. Pathology was
renal cell ca, clear cell type, grade III, size 8.5 cm, invasion
into renal vein was present. Has had surveillance CT scans
yearly
at OSH - all negative.
Atrial fibrillation - has been in sinus, anti-coagulated
TURP for BPH
hyperlipidemia
Social History:
Married, 6 children. Retired from the air force, was a fighter
pilot. Drinks 3-4 drinks/week. Tobacco - smoked 40 yrs, ~1
pack/wk - quit in [**2089**]. No illicits.
Family History:
father - MI, mother - AD, brother - colon ca at age 73.
Physical Exam:
Vitals: 97.8 HR 64, reg BP 105/64 RR 16 SO2 100% r/a
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear. Extra ear canals, ear drums
clear.
Neck: No Carotid bruits
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Tenderness at the left side of umbilicus. No defenese,
rebound.
Ext: No arthralgia, no cyanosis/edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect
Orientation: Oriented to person, place, and date
Language: Fluent with good comprehension and repetition. Naming
intact. No dysarthria or paraphasic errors
No apraxia, no neglect
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally. Visual fields are full to finger movement. Fundi
normal bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to tuning fork bilaterally. No tinnitus. No
nystagmus.
IX, X: Palatal elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations, intact movements
Motor:
Normal bulk and tone bilaterally
No tremor, no asterixis
Full strength throughout
MMT [**Doctor First Name **] Tri [**Hospital1 **] WExt WFlx IO IP Quad HS TA GC [**Last Name (un) 938**] ToeExt ToeFlx
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Slightly unstable one foot standing at the left.
No pronator drift
Sensation: Hyperestesia at the left T9-T10 both
anterior/posterior trunk. Intact to light touch, pinprick,
temperature (cold), vibration, and propioception throughout all
extremities.
Position sense slightly decreased at the left toe.
Reflexes: B T Br Pa Ankle
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes were downgoing bilaterally
Coordination: Normal on finger-nose-finger, rapid alternating
movements normal, FFM normal.
Gait: stance is narrow based, with stable gait. Stable tandem
gait
Meningeal sign: Negative Brudzinski sign. No nucal rigidity.
Pertinent Results:
6.1>13.4/37.7<202
SED-Rate: 17
PT: 37.5 PTT: 37.7 INR: 4.2
139 107 29 99 AGap=14
------------------
4.3 22 1.6
Ca: 9.4 Mg: 2.4 P: 3.1
T-spine CT ([**11-1**]):
1. Large mass involving the posterior elements at the level of
T9 on the left which is invading the central canal and causing
thecal sac compression.
2. Multiple masses in the lung consistent with metastases.
Findings were discussed with you the day of the study.
L-spine CT ([**11-1**]):
1. Congenitally narrowed central spinal canal as described
above. Mild degenerative changes at L4-5 with a diffuse
broad-based disc bulge. There is no evidence for neural
foraminal narrowing.
2. No bony lesions are identified to indicate metastatic isease
in the lumbar spine. Please see thoracic spine report of the
same date for significant findings regarding likely metastatic
disease.
Chest CT ([**11-1**]):
1. Numerous bilateral soft tissue density pulmonary nodules
consistentwith pulmonary metastases. Given the history of prior
nephrectomy, metastatic renal cell carcinoma is likely.
2. Destructive osseous lesion in the T9 vertebral body with
encroachment upon the spinal canal. Urgent Neurosurgery consult
and further characterization with dedicated MRI is required.
3. Coronary artery calcifications.
Brief Hospital Course:
Patient was admitted to Medicine service for initial work up. CT
guided biospy was performed on [**2112-11-3**], pathology result was
renal cell carcinoma and the T9 lesion was considered
metastasis.
Right after receiving this result, patient was scheduled for (1)
tumor embolization by interventional radiology and (2)t7-11
laminectomies/mass resection and fusion on [**2112-11-8**] by Dr.
[**Last Name (STitle) 548**].
Post operatively he was moving all extremities with full
strength he had a drain placed interoperatively.
On POD#2 his hematocrit was 22.8 he received 2 units of PRBCs,
follow up crit was:
Physical therapy was consulted and cleared patient for discharge
to home.
Medications on Admission:
Coumadin
Tricor
Zocor
Discharge Medications:
1. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Metastic Renal Cell Carcinoma
Discharge Condition:
Neurologically stable.
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound(s) clean and dry / No tub baths or pools for two
weeks from your date of surgery
?????? If you have steri-strips in place ?????? keep dry x 72 hours. Do
not pull them off. They will fall off on their own or be taken
off in the office
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for signs of
infection
?????? If you are required to wear one, wear cervical collar or back
brace as instructed
?????? You may shower briefly without the collar / back brace unless
instructed otherwise
?????? Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. unless directed by your doctor
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Restart Coumadin in a month
Followup Instructions:
Have staples removed in 10 days.
Follow up in 6 weeks with Dr. [**Last Name (STitle) 548**], [**Hospital 18**] [**Hospital 4695**] Clinic,
[**Telephone/Fax (1) 1669**].
Follow up with Renal Oncology Clnic at 4pm on [**2112-12-5**] with Dr.
[**Last Name (STitle) 1729**]/Dr. [**Last Name (STitle) **], [**0-0-**].
Completed by:[**2112-11-12**]
|
[
"198.5",
"V16.0",
"V15.82",
"E947.8",
"V45.73",
"197.0",
"336.3",
"272.4",
"V10.52",
"584.9",
"427.31",
"401.9",
"756.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"03.4",
"99.05",
"81.63",
"99.04",
"77.49",
"81.05",
"00.33"
] |
icd9pcs
|
[
[
[]
]
] |
6278, 6346
|
5045, 5731
|
247, 279
|
6420, 6445
|
3734, 5022
|
8101, 8446
|
1498, 1556
|
5804, 6255
|
6367, 6399
|
5757, 5781
|
6469, 8078
|
1571, 1925
|
194, 209
|
307, 967
|
2214, 3715
|
1964, 2198
|
1949, 1949
|
989, 1299
|
1315, 1482
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,622
| 192,816
|
33703
|
Discharge summary
|
report
|
Admission Date: [**2177-10-7**] Discharge Date: [**2177-10-26**]
Date of Birth: [**2125-11-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Severe stenosis of the left main stem bronchus with complete
left lung obstruction
Major Surgical or Invasive Procedure:
Bronchoscopy, left pneumonectomy
History of Present Illness:
52M trached with relapsing polychondritis and associated
tracheobronchomalacia status post multiple airways endobronchial
interventions including stent
placement and subsequent removal now presenting with lung
collapse secondary to endobronchial obstruction with granulation
tissue.
One month ago, patient underwent left bronchotomy for removal of
metal stent,
subsequently developed progressive stenosis in the left main
stent with subsequent total collapse of the left lung.
Past Medical History:
PMH: Polychondritis, TBM, GERD
PSH: s/p orchiectomy for seminoma, s/p B BMS to the [**Hospital1 **] and LMSB
(both have since removed), Y stent placement and [**Location (un) **]
T-tube placement in [**Location (un) 5622**], Y-stent and T-tube
removal/perc
trach [**2177-6-19**] by Dr. [**Last Name (STitle) **], s/p L thoracotomy, posterior main
stem bronchotomy w/ bronchial stent removal and primary closure,
LLLobectomy
Social History:
SocHx: former smoker, quit x1yr; occasional alcohol; no
recreational drugs
Family History:
Non-contributory.
Pertinent Results:
[**2177-10-8**] 07:00AM BLOOD WBC-11.7* RBC-4.96# Hgb-12.6* Hct-38.7*#
MCV-78* MCH-25.4* MCHC-32.6 RDW-15.4 Plt Ct-291
Brief Hospital Course:
Mr. [**Known lastname **], who is well known to the thoracic surgery service,
was admitted on [**2177-10-7**] with a left lung collapse secondary to
endobronchial obstruction with granulation tissue. Bronchoscopy
was performed on this date by Interventional Pulmonology, who
found that around the mid distal left mainstem the lumen was
progressively narrowed until it was a pinpoint size. The distal
left mainstem or the upper or the lower lobe orifices could not
be visualized. The patient returned to the floor after the
procedure in good condition and resumed a regular diet.
On [**2177-10-9**], repeat bronchoscopy was performed by Interventional
Pulmonology, who at this point found severe stenosis of the left
main stem bronchus with no visible distal airways that could be
visualized during this procedure. Plans were consequently made
for left pneumonectomy as endobronchial attempts to open up the
left mainstem bronchus had failed.
On [**10-12**] the patient's trach was converted from a cuffed
non-fenestrated to a noncuffed fenestrated in order to allow him
to speak.
On [**10-14**], the patient underwent a left pneumonectomy. He
tolerated the procedure well and spent 2 days in the SICU.
On [**10-15**], he was seen by ENT who performed a bedside
laryngoscopy and found left vocal cord paralysis. His left IJ
was rewired. He was transfused 1 unit of pRBCsfor an Hct of
24.5, which had dropped from 28.9. His Hct was 24.8 after the
unit of blood
On [**10-16**], his fluids were stopped for mild volume overload on
CXR. He recieved another unit of pRBCs, and his post-tranfusion
Hct was 28.2. He had a video swallowing study, which showed
laryngeal penentration of liquids but no aspiration; safe for
regular solids and thin liquids
On [**10-17**], his hct was stable, and was transferred to the floor.
He was started on clear liquids.
On [**10-21**], he underwent video stroboscopic exam with ENT, which
showed left vocal cord paralysis. He then underwent vocal cord
medialization on [**10-24**] with ENT for correction of this problem
The staples from his abdomen and thorax, as well as his sutures
from his former chest tube site were removed on [**10-25**].
Pt was d/c'd to home on [**2177-10-26**].
Medications on Admission:
Albuterol nebs, lovenox 40mg SQ daily,
pulmozyme 5mg [**Hospital1 **], Tessalon 100mg po TID, Protonix 40mg daily,
Solumedrol 30mg IV q12h, Claritin 10mg daily, Pipracil 3gm IV
q4h, Novolog 7 units before each meal
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fexofenadine 60 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) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
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. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed.
9. Diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO QID (4 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours.
11. Mucinex 600 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO twice a day.
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
13. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
14. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: [**12-4**]
Tablet, Delayed Release (E.C.)s PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
recurrent relapsing polychondritis
s/p left sided completion pneumonectomy
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if experience:
-Fever > 101 or chills.
-Increased shortness of breath, cough or chest pain.
-Incision develops drainage.
No driving while taking narcotics. Take stool softners with
narcotics.
You may take motrin for pain. Take with food and water
Followup Instructions:
Please follow up with your primary care physician for evaluation
and for recommendations regarding the new cardiac medication we
have prescibed for you.
Call Dr.[**Hospital 4738**] clinic office at [**Telephone/Fax (1) 4741**] to arrange for
follow up. Please call Dr.[**Name (NI) 37917**] clinic office at
[**Telephone/Fax (1) 41**] to arrange for follow-up in your area for your
vocal chords.
Completed by:[**2177-11-4**]
|
[
"519.19",
"338.12",
"733.99",
"V55.0",
"276.6",
"288.60",
"E878.6",
"V10.47",
"530.81",
"515",
"518.0",
"478.31",
"E932.0",
"416.8",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.48",
"97.23",
"38.93",
"32.59",
"33.21",
"31.42",
"31.0",
"99.04",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
5604, 5665
|
1688, 3915
|
405, 439
|
5784, 5791
|
1544, 1665
|
6160, 6588
|
1505, 1525
|
4181, 5581
|
5686, 5763
|
3941, 4158
|
5815, 6137
|
283, 367
|
467, 946
|
968, 1396
|
1412, 1489
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,018
| 178,900
|
54446
|
Discharge summary
|
report
|
Admission Date: [**2128-7-11**] Discharge Date: [**2128-7-25**]
Service: MEDICINE
Allergies:
Feldene / Ceftriaxone / Augmentin
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
Fatigue, UTI
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a [**Age over 90 **] y/o Russian speaking F with a PMHx of CHF with 4+
MR, dementia, parkinson's, recurrant UTIs, who presented to
[**Hospital1 18**] ED for evaluation of UTI, malasie, hypernatremia and renal
failure. Per Pt's daughter has not been feeling well for 7 days.
States mental status was intact but was just feeling
"uncomfortable, miserable" with out any localizing complaints. A
CXR was done at that time that per the daughter's report was
normal. She was felt by the nursing home staff to be dehydrated
and was given IV fluids. Per daughter's report she remained the
same few the next few days. This morning had fevers, tachypnea
and so was transferred to [**Hospital1 18**] ERD for evaluation.
.
Per NH records, on [**7-6**] had elevated WBC count of 12.7 with 76%
PMNs and 12% bands. Chemistries on that day are notable for
BUN/Cr of 62/3.2 (appears to be elevated from baseline of 1.6 to
2.0), NA of 141 and HCO3 of 21. U/A sent on [**2128-7-7**] cloudy with
LE and 187 WBC. She was started on levo/flagyl on [**7-8**]. Culture
from that urine was positive for e. coli resistant to FQs. Abx
were changed to ceftriaxone and flagyl. On [**7-9**] BUN/Cr was
77/4.2, HCO3 20 and Na 143. On [**7-10**] Na jumped to 150 BUN/Cr to
78/4.4.
.
On arrival to the ED, her VS were:T 101.6, BP 135/89 HR 150s, RR
34 97% on RA. She was given 2 L NS, 1 g vancomycin, 3.375g
pip/tazo, dilt (total of 20mg) then dilt drip, and albuterol
nebs
.
Past Medical History:
#Recurrent urinary tract infections
#Bipolar disorder
#Parkinson's disease
#Asthma
#Congestive heart failure with a normal EF, 4+ MR. [**First Name (Titles) **] [**Last Name (Titles) 113**]
[**2121**]
#OA
#s/p DDD pacer in [**2121**] for bradycardia.
Social History:
Lives [**Hospital3 **]. Daughter is [**First Name5 (NamePattern1) 335**] [**Last Name (NamePattern1) 111445**] who is on
staff at [**Hospital1 18**] as Russian interpreter (beeper [**Numeric Identifier 111446**])
Family History:
non contributory
Physical Exam:
VS:T 96.3, HR 140, BP 130/70 RR 32 98% on 3L
GEN: elderly woman breathing fast and moaning
HEENT: PERRL, sclera white OP clear
NECK: Obese unable to assess JVP
CV: tachycardiac, difficult to hear over moaning
RESP: crackles at bases (again difficult to hear [**2-12**] moaning)
ABD: Obese, soft NT/ND BS+
EXT: contracted trace edema
NEURO: AOX3, CN II-XII intact. resting tremor
Pertinent Results:
CXR [**7-11**]: small left effusion, with atelectasis. No clear
infiltrate.
.
EKG: rapid AFib with LAD and LBBB.
Renal u/s [**2128-7-12**]-. The right kidney measures 8.3 cm. The left
kidney measures 11.5 cm. The left kidney contains a 2.1 x 2.1 x
2.2 cm rounded anechoic structure in the upper pole, most
consistent with a simple renal cyst. Neither kidney demonstrates
hydronephrosis or contains stones. The visualized bladder is
unremarkable IMPRESSION: No evidence for hydronephrosis or other
renal abnormality on this limited examination.
[**2128-7-11**] 11:20AM WBC-20.3*# RBC-3.76* HGB-12.3 HCT-35.5*
MCV-94 MCH-32.8* MCHC-34.7 RDW-14.6
[**2128-7-11**] 11:20AM NEUTS-93.1* LYMPHS-4.8* MONOS-1.3* EOS-0.7
BASOS-0.1
[**2128-7-11**] 11:20AM PLT COUNT-308
[**2128-7-11**] 11:20AM PT-16.3* PTT-21.7* INR(PT)-1.5*
[**2128-7-11**] 11:20AM GLUCOSE-100 UREA N-78* CREAT-4.4*#
SODIUM-151* POTASSIUM-4.8 CHLORIDE-120* TOTAL CO2-18* ANION
GAP-18
[**2128-7-11**] 11:20AM ALT(SGPT)-5 AST(SGOT)-21 ALK PHOS-130*
AMYLASE-33 TOT BILI-0.5
[**2128-7-11**] 11:20AM LACTATE-1.7 K+-4.6
[**2128-7-11**] 11:20AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2128-7-11**] 11:20AM URINE RBC-0-2 WBC-[**3-14**] BACTERIA-FEW YEAST-NONE
EPI-<1
Brief Hospital Course:
1) UTI/sepsis:
Admitted to ICU for early sepsis. Did not require pressors. Pt
started on ceftriaxone initially. E.coli from urine culture at
[**Hospital3 2558**] that was pansensitive except fluroquinolones.
However, due to concern of AIN from ceftriaxone, changed to
augmentin after 7 days. Completed 12 day course and stopped due
to drug rash. Likely cannot tolerate any PCNs or beta lactams.
.
2) Rapid Atrial fibrillation:
Has had a-fib in the past. Likley worsened given acute illness
and dehydration. On long acting Beta blocker and amio as a
outpt. Loaded with IV amio and put on PO. Also on metoprolol
25 po tid to control HR as long as BP is stable. After leaving
ICU, has been in NSR or paced. Discharged on amio 200 mg daily,
f/u in device clinic.
.
3) Valvular heart disease:
TTE showed 4+MR with normal EF. As she cannot be on an ACEI due
to renal function, was started on imdur and hydalazine.
.
4) Renal Failure:
Creatinine was up to 5 on admission while baseline is in 1's.
Renal ultrasound did not show evidence of obstruction. There
were rare urine eos on exam and renal consult felt this was
acute interstitial nephritis from ceftriaxone. The antibiotic
was changed. Cr trending down slowly, but now stable in mid 3s.
This may be her new baseline. She will f/u with Dr. [**Last Name (STitle) **].
.
5) Hypernatremia:
Secondary to poor PO intake. Has resolved with IVF with D5W.
Will need to monitor to assure stays ok.
.
6) Parkinson's - Restarted Sinemet
.
7) Arthritis - Hip XR neg for fracture but consistent with
arthritis although a limited study.
- Holding NSAIDs and ultram in light of renal failure. Daugther
brought in capasacian cream.
- Pt much more comfortable on regimen of Tylenol RTC and
dilaudid.
.
8) Drug Rash: seen by dermatology, felt to be drug rash from
augmentin, which was discontinued. Cannot tolerate beta lactams.
.
8) DVT: in right common femoral vein. Started on heparin gtt
and coumadin. Continue coumadin goal INR [**2-13**].
.
#Code - DNR/DNI and no central line (discussed with HCP/daughter
and [**Name (NI) **] Dr.[**Last Name (STitle) **])
.
Comm: Daughter's home # [**Telephone/Fax (1) 111447**]
[**Hospital1 18**] beeper #[**Numeric Identifier 111446**]
Medications on Admission:
Synthroid 88 q.d.
Multivitamin q.d.
Bisacodyl PR q.d. p.r.n.
Vitamin E.
Polyvinyl alcohol eye drops.
Senna h.s. p.r.n.
Colace b.i.d.
Tramadol 50 mg tid
Pantoprazole 40 once a day.
Carbidopa-Levodopa 25/100 one tab po q3 hours while awake.
Amiodarone 100 q.d.
Toprol XL 12.5 q.d.
Imdur 30 mg q.d.
Remeron 12.5 qhs
Trazodone 25 qhs
Lasix 10 mg qd (on hold)
Megace 100 mg qd
Seroquel 12.5 qam / 25 mg qhs
Capsaicin 0.025% cream to knees and shoulders [**Hospital1 **]
Premarin vag cream 1 applicator full qhs
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Capsule Sig: One (1) Tablet 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. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-12**]
Drops Ophthalmic PRN (as needed).
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
9. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
10. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
Q3H (every 3 hours): While awake.
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for sleep time agitation.
14. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
15. Hydralazine 10 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours).
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
17. Megestrol 20 mg Tablet Sig: Five (5) Tablet PO QD ().
18. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
19. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
20. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
21. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
22. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
23. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
24. Epoetin Alfa 3,000 unit/mL Solution Sig: 3,000 units
Injection QMOWEFR (Monday -Wednesday-Friday).
25. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
26. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary: Urosepsis
Secondary:
Pneumonia
Acute Renal Failure
Drug Rash
Congestive Heart Failure
Discharge Condition:
stable
Discharge Instructions:
Please continue your regular medications. Please continue to
hold your coumadin until your INR is less than 3. Goal [**2-13**].
Please continue to weigh yourself daily and if you gain more
than 3lbs please call your doctor. Please continue a low salt
diet.
Followup Instructions:
1. Please follow up with your PCP in the next week.
2. Please also follow up with your new nephrologist, Dr. [**Last Name (STitle) **],
in the next 1-2 weeks.
3. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2128-8-6**] 10:00
|
[
"584.9",
"403.91",
"693.0",
"427.31",
"428.0",
"453.41",
"995.92",
"486",
"599.0",
"038.42",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9115, 9185
|
4020, 6247
|
254, 261
|
9324, 9333
|
2694, 3997
|
9638, 9913
|
2262, 2280
|
6803, 9092
|
9206, 9303
|
6273, 6780
|
9357, 9615
|
2295, 2675
|
202, 216
|
289, 1742
|
1764, 2016
|
2032, 2246
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,061
| 181,541
|
31743+31778+57762
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2136-8-8**] Discharge Date: [**2136-8-14**]
Date of Birth: [**2073-9-29**] Sex: M
Service: MEDICINE
Allergies:
Bee Pollens
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Shortness of breath and worsening ascites
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 976**] is a 62 year-old man with alcoholic cirrhosis
complicated by encephalopathy and ascites with HCC liver lesions
s/p recent RFA now admitted with ascites and concerning lab
values. He presented to clinic today to see Dr. [**Last Name (STitle) 497**] and he was
found to have elevated bilirubin and a slight elevation in WBC.
He was advised to present to [**Hospital1 18**] for evalution of his newly
elevated bilirubin and to rule out infectious causes.
Of note patient was recently admitted ([**Date range (1) 74547**]) for monitoring
after RFA to his liver lesions and liver biopsy. After ablation
of the 3rd lesion there was mild extravasation and the tract was
ablated. He was hemodynamically stable throughout the procedure
however that evening he became hypotensive with a drop in HCT
and was foudn to have a right-sided hemothorax on CT. He had a
chest tube and was given blood and octreotide. Chest tube was
removed and he was discharged home.
Pt reports he has been feeling fairly well since discharge
except for feeling a bit tired. He also has had some decreased
po intake. Abdomen has been slightly more distended but not
uncomfortable or as bad as it has been in the past. Denies pain,
f/c, n/v/d, constipation, SOB, orthopnea
Past Medical History:
-ETOH cirrhosis (MELD 12 in [**11-16**]) with history of
decompensations with hepatic encephalopathy, ascites, and
varices. Currently listed for transplant at [**Hospital1 18**]. Recent RFA
treatment for HCC.
-Osteoarthritis
-S/p multiple back/neck surgeries for "disc disease"
-S/p bowel resection & anastamosis ~15 yrs ago for perforation
-chronic nail changes and arthritis in hands
Social History:
Married. Retired. Was previously salesman in software company.
Former smoker. No EtOH currently. Hobbies include fly fishing
and golf.
Family History:
Father and brother with prostate CA. Two brothers with DM type 2
Physical Exam:
ADMISSION EXAM
Vitals: 97.2 135/66 65 16 93% RA
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur
loudest over L upper sternal border
Abdomen: NABS. soft but distended. +fluid wave. Nontender. No
rebound or guarding.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: jaundiced
Neuro: mild asterixis
DISCHARGE EXAM
Vitals: 98.0 100/60 69 16 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB no wheezes, rales, ronchi
CV: RRR normal S1 + S2, 3/6 systolic murmur over LUSB
Abdomen: NABS. soft but distended. Nontender. No rebound or
guarding.
Ext: Warm, well perfused, 2+ DP pulses
Skin: jaundiced
Neuro: mild asterixis
Pertinent Results:
ADMISSION LABS:
[**2136-8-8**] 03:25PM BLOOD WBC-13.7* RBC-3.40* Hgb-12.2* Hct-33.6*
MCV-99* MCH-35.8* MCHC-36.3* RDW-18.6* Plt Ct-135*
[**2136-8-8**] 03:25PM BLOOD Neuts-86.9* Lymphs-5.9* Monos-5.8 Eos-1.0
Baso-0.4
[**2136-8-8**] 03:25PM BLOOD PT-20.1* PTT-44.0* INR(PT)-1.8*
[**2136-8-8**] 03:25PM BLOOD Glucose-147* UreaN-20 Creat-1.0 Na-127*
K-3.4 Cl-86* HCO3-33* AnGap-11
[**2136-8-8**] 03:25PM BLOOD ALT-201* AST-199* LD(LDH)-342* AlkPhos-96
TotBili-27.9* DirBili-21.3* IndBili-6.6
[**2136-8-8**] 03:25PM BLOOD TotProt-6.0* Albumin-2.6* Globuln-3.4
Calcium-9.1 Phos-3.1 Mg-2.0
IMAGING STUDIES/OTHER WORK UP
ECG: Sinus rhythm with premature atrial contractions. Prolonged
Q-T interval. Non-specific inferior ST-T wave changes. Compared
to the previous tracing of [**2135-7-23**] the T waves are more
flattened in leads II, III and aVF. No other significant change
noted.
GUIDANCE FOR PARACENTESIS
Successful diagnostic ultrasound-guided paracentesis yielding 1
L
of straw-colored ascites. Fluid was sent for laboratory
assessment as
requested.
CXR: As compared to the previous radiograph, there is no
relevant
change. The clips in the left axilla. Minimal thickening along
the right
minor fissure. Normal size of the cardiac silhouette. No
evidence of
pneumonia. Slight elevation of the right hemidiaphragm. Normal
size of the
cardiac silhouette.
RUQ ULTRASOUND
1. Cirrhotic liver. Main portal vein not well seen, but some
hepatopetal
flow seen within. Hepatofugal flow in the right portal vein with
evidence of thrombus within. Prominent patent left portal vein
with hepatopetal flow which drains into a patent umbilical vein.
Small-to-moderate amount of ascites.
2. Gallbladder sludge.
3. Right pleural effusion.
CT ABDOMEN W/CONTRAST
1. Near-occlusive thrombus within the right portal vein,
extending into the right anterior and posterior portal veins.
The left portal vein is widely patent, draining into a dilated
recanalized paraumbilical vein.
2. Cirrhotic liver, with three hypodense lesions corresponding
to prior RFA sites. Mild splenomegaly and ascites suggest the
presence of portal
hypertension.
3. Decreased size of now nonhemorrhagic right pleural effusion,
with small
residual right basilar atelectasis.
DISCHARGE LABS:
[**2136-8-14**] 04:45AM BLOOD WBC-12.3* RBC-3.19* Hgb-11.7* Hct-32.3*
MCV-102* MCH-36.8* MCHC-36.3* RDW-18.1* Plt Ct-97*
[**2136-8-14**] 04:45AM BLOOD PT-34.3* PTT-57.9* INR(PT)-3.4*
[**2136-8-14**] 04:45AM BLOOD Glucose-109* UreaN-19 Creat-0.7 Na-126*
K-4.0 Cl-90* HCO3-28 AnGap-12
[**2136-8-14**] 04:45AM BLOOD ALT-249* AST-226* AlkPhos-105
TotBili-24.1*
[**2136-8-14**] 04:45AM BLOOD Albumin-2.8* Calcium-8.7 Phos-2.2* Mg-2.1
Brief Hospital Course:
62 yo M with hx of alcoholic cirrhosis c/b HCC s/p RFA ablation
on [**7-18**] presents from liver clinic for further evalation of
elevated LFTs, bili, and WBC count.
.
#. Right portal vein thrombosus - Pt was found to have portal
vein thrombus on RUQ ultrasound which was confirmed with follow
up CT scan of the abdomen. He was started on anticoagulation
with heparin and coumadin. He was given 5 mg of coumadin for the
first 2 days. INR then jumped to 13. Coumadin and heparin were
both discontinued. He was given 2 units of FFP which temporarily
reduced the INR to 3.3. However, the following day INR again
increased and pt was given vitamin K. On day of discharge INR
was 3.4. Patient was discharged with plans to take 0.5 mg of
warfarin daily with follow up INR checks on [**8-15**] and [**8-17**] and
further monitoring by the transplant center.
.
#. Cirrhosis/HCC - Pt presented with elevated LFTs and WBC
count. DDx included SBP, obstructive process, decompensated
cirrhosis, or remote complication of RFA procedure. Could also
consider other infectious process or medication effect, however,
afebrile with no recent medication changes. Abdominal exam was
benign. Patient's infectious work up including blood cultures,
urine culture, and CXR were all negative. Had diagnostic
paracentesis which was negative for SBP. Had RUQ ultrasound
which showed no evidence of gallstones or cholecystitis. He was
continued on his home medication regimen of rifaxamin and
lactulose as well as spironolactone and lasix.
.
#. leukocytosis. Unknown etiology. Infectious work up negative
including CXR, urine and urine culture, blood cultures, and
peritoneal fluid. WBC count remained stable throughout
admission. Patient afebrile and asymptomatic. Likely secondary
to hepatitis.
.
#. Osteoarthritis - continued tramadol
.
# GERD - continued omeprazole
.
Transitional issues:
- patient will need regular INR checks, and will likely need
further warfarin dosage adjustment.
Medications on Admission:
-multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
-rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
-nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
-lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): titrate to [**2-10**] bowel movements per day. (takes
daily at home)
-spironolactone 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
-alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for insomnia.
-calcipotriene 0.005 % Ointment Sig: One (1) application
Topical twice a day: Apply to hands and feet twice daily Monday
through Friday. .
-clobetasol 0.05 % Ointment Sig: One (1) application Topical
twice a day: Apply to hands and feet twice daily. Use 2
wks/month. Do not apply to face, skin folds, armpits, groin. .
-EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection
Intramuscular once as needed for anaphylaxis.
-omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
-tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
-furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. spironolactone 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. clobetasol 0.05 % Cream Topical
7. calcipotriene 0.005 % Ointment Topical
8. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS:PRN as
needed for insomnia.
9. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
11. multivitamin Oral
12. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection
Intramuscular ONCE as needed for anaphylaxis.
13. Coumadin 1 mg Tablet Sig: 0.5 Tablet PO once a day: please
adjust as directed by transplant center .
Disp:*30 Tablet(s)* Refills:*0*
14. tramadol 50 mg Tablet Sig: One (1) Tablet PO BID:PRN as
needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnoses: Portal vein thrombosis. Hepatocellular
carcinoma. Alcoholic cirrhosis.
secondary diagnoses: GERD, osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 976**],
It was a pleasure caring for you while you were in the hospital.
You were admitted after a clinic visit because you were found to
have elevated liver tests. We did several tests while you were
in the hospital, including an ultrasound and a cat scan which
showed a clot in your right portal vein (the vein going to your
liver). You were started on some blood thinning medications for
your clot, however your levels became very elevated requiring
you to stay in the hospital a few additional days while this
value (INR) corrected. Initially you were given fresh frozen
plasma and ultimately a small dose of vitamin K which helped
improve this value. At the time of discharge your INR was in an
acceptable range and you were feeling well.
You will need to follow up tomorrow ([**8-15**]) and Friday ([**8-17**]) for
blood draws to check your INR at either the [**Hospital Unit Name **]
laboratory or the [**Hospital Ward Name 23**] building laboratory. You will be
contact[**Name (NI) **] by the transplant center with instructions on dose
adjustments of warfarin and continued monitoring.
The following changes have been made to your medication regimen:
Please START the following medications:
- coumadin
No other medication changes have been made.
Followup Instructions:
Department: RADIOLOGY
When: MONDAY [**2136-8-20**] at 11:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Address: [**Street Address(2) 74548**], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 74549**]
Phone: [**Telephone/Fax (1) 74550**]
*It is recommended that you see Dr. [**First Name (STitle) 2405**] within a week. His
administrative assistant will contact you to schedule an
appointment.
Department: TRANSPLANT
When: WEDNESDAY [**2136-8-29**] at 8:20 AM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2136-8-14**] Admission Date: [**2136-8-15**] Discharge Date: [**2136-8-20**]
Date of Birth: [**2073-9-29**] Sex: M
Service: SURGERY
Allergies:
Bee Pollens
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
ETOH cirrhosis
Major Surgical or Invasive Procedure:
liver [**First Name3 (LF) **] [**2136-8-15**]
History of Present Illness:
Patient presents today to receive a liver transplantation.
Patient states that he has been doing well, eating and drinking
and going to the bathroom normally. He says that he feels well
and is excited that a liver has become available. The patient
has
no complaints.
Past Medical History:
-ETOH cirrhosis (MELD 12 in [**11-16**]) with history of
decompensations with hepatic encephalopathy, ascites, and
varices. Currently listed for [**Date Range **] at [**Hospital1 18**]. Recent RFA
treatment for HCC.
-Osteoarthritis
-S/p multiple back/neck surgeries for "disc disease"
-S/p bowel resection & anastamosis ~15 yrs ago for perforation
-chronic nail changes and arthritis in hands
Social History:
Married. Retired. Was previously salesman in software company.
Former smoker. No EtOH currently. Hobbies include fly fishing
and golf.
Family History:
Father and brother with prostate CA. Two brothers with DM type 2
Physical Exam:
Vitals: 97.5 , 72, 101/58, 18, 100% RA
HEENT: icteric sclerae, MMM, no cervical or supraclavicular
lymphadenopathy.
CV: RRR, normal S1S2, no Rubs or gallops, systolic ejection
murmur heard throughout precordium.
Lungs: CTAB
Abdomen: soft, NT ND, no rebound or guarding, large old incision
scar seen from prev bowel resection.
Skin: jaundiced
Extremities: warm, well perfused, no edema.
Labs:
WBC RBC Hgb Hct MCV MCH MCHC RDW PltCt
14.4* 3.45* 12.6* 34.4* 100* 36.6* 36.7* 18.0* 106*
PT PTT INR(PT)
25.7 49.0 2.4*
Glucose UreaN Creat Na K Cl HCO3 AnGap
112 26* 0.9 125* 5.4 88* 30 12
Albumin Globuln Calcium Phos Mg
2.7*
9.3 3.0 2.11
Pertinent Results:
[**2136-8-20**] 04:39AM BLOOD WBC-6.2 RBC-3.91* Hgb-12.3* Hct-34.5*
MCV-88 MCH-31.6 MCHC-35.8* RDW-17.0* Plt Ct-63*
[**2136-8-19**] 06:10AM BLOOD PT-12.7 PTT-28.4 INR(PT)-1.1
[**2136-8-20**] 04:39AM BLOOD Glucose-144* UreaN-26* Creat-0.9 Na-132*
K-5.0 Cl-97 HCO3-28 AnGap-12
[**2136-8-19**] 06:10AM BLOOD ALT-256* AST-47* AlkPhos-83 TotBili-5.2*
[**2136-8-20**] 04:39AM BLOOD ALT-209* AST-32 AlkPhos-89 TotBili-4.6*
[**2136-8-19**] 06:10AM BLOOD Albumin-2.9* Calcium-8.9 Phos-1.7* Mg-2.0
[**2136-8-20**] 04:39AM BLOOD tacroFK-7.6
Brief Hospital Course:
On [**2136-8-15**], he underwent Orthotopic liver [**Date Range **]. Two JPs
were placed. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to
operative note for details. JP output was non-bilious. LFTs
initially increased then decreased daily. Liver duplex
demonstrated patent vasculature with appropriate flows.
He was extubated in the SICU. NG was removed and sips were
started. Diet was slowly advanced and tolerated. Medications
were converted to po meds. [**Last Name (NamePattern1) 1326**] immunosuppresion consisted
of Cellcept which was well tolerated. Steroid were tapered
daily. Insulin drip was required. This was converted to Glargine
and Humalog. He was taught how to check his blood sugars and
administer insulin.
The lateral JP was removed. Medical JP output averaged
520-650ml/day on [**8-19**]. JP remained in place. He was taught how
to empty and record outputs. Incision was intact with staples
and without redness/drainage.
He was cleared for home by Physical therapy and was ambulating
independently. Vital signs remained stable. He was ready for
discharge to home.
Medications on Admission:
rifaximin 550'', omeprazole 20'', spironolactone 100'',
furosemide 80', cholecalciferol 400', clobetasol 0.05 cream,
calcipotriene 0.005 ointment, alprazolam 0.25 HS:PRN, nadolol
20', lactulose 10 gram/15 mL Syrup 30ml''', multivitamin, EpiPen
PRN, Coumadin 0.5', tramadol 50'' PRN
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day:
follow printed taper schedule.
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 DAILY (Daily).
5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Glucagon Emergency 1 mg Kit Sig: One (1) mg Injection if
needed: if blood sugar is low and you are unable to drink or
eat.
Disp:*1 kit* Refills:*2*
10. insulin glargine 100 unit/mL Solution Sig: Seven (7) units
Subcutaneous once a day: at lunch.
Disp:*1 bottle* Refills:*2*
11. insulin lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous four times a day.
Disp:*1 bottle* Refills:*2*
12. Insulin Syringes
Low dose U-100 with
25-26 gauge needle
supply: 1 box
refill: 2
13. One Touch Ultra System Kit Kit Sig: One (1) kit
Miscellaneous once a day.
Disp:*1 kit* Refills:*2*
14. One Touch UltraSoft Lancets Misc Sig: One (1)
Miscellaneous four times a day.
Disp:*1 box* Refills:*2*
15. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
ETOH cirrhosis
hyperglycemia from steroids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the [**Month/Year (2) 1326**] Office [**Telephone/Fax (1) 673**] if you have any
of the following:
fever (101 or greater), shaking chills, nausea, vomiting,
jaundice, inability to take any of your medications, increased
abdominal/incision pain, incision redness/bleeding/drainage,
constipation/diarrhea
You will need to have blood drawn for lab monitoring every
Monday and Thursday.
Check your
You may shower, but not tub baths or swimming
No driving while taking pain medications
No heavy lifting/straining (nothing heavier than 10 pounds)
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2136-8-27**] 9:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2136-9-3**] 10:20
Provider: [**Name10 (NameIs) **] SOCIAL WORKER Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2136-9-3**] 11:00
Completed by:[**2136-8-20**] Name: [**Known lastname **],[**Known firstname 651**] Unit No: [**Numeric Identifier 12286**]
Admission Date: [**2136-8-15**] Discharge Date: [**2136-8-20**]
Date of Birth: [**2073-9-29**] Sex: M
Service: SURGERY
Allergies:
Bee Pollens
Attending:[**First Name3 (LF) 2800**]
Addendum:
please note, patient had acquired coagulation factor deficiency
due to cirrhosis
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**]
Completed by:[**2136-8-26**]
|
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"715.90",
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icd9cm
|
[
[
[]
]
] |
[
"50.59",
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icd9pcs
|
[
[
[]
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20159, 20324
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15443, 16582
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13166, 13214
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18540, 18540
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14889, 15420
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16914, 18424
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13112, 13128
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13242, 13511
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3267, 5485
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18555, 18667
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13533, 13928
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13944, 14083
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,293
| 124,663
|
29634
|
Discharge summary
|
report
|
Admission Date: [**2171-11-22**] Discharge Date: [**2171-11-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
Central Line Placement
History of Present Illness:
Patient is a 86F tx from OSH with hypotension requiring
dopamine, and R PNA on CXR. Pt was at in rehab s/p orif [**2171-10-10**].
On [**11-8**], patient was sent to NW er for evaluation of increased
wbc count where she had 3 sets blood cx drawn and given
levoquin. [**11-19**] she was sent back to the ER for eval. She
returned to rehab that same day to finish a 14 d course of
levaquin which ended today, [**2171-11-22**]. This a.m. patient
ambulated to bathroom and fell on buttock (no head
trauma/loc/obvious limb deformities). Her v/s at that time were
T 102.8, BP 108/47, O2 87-89% RA (increased to 96% with 2L O2).
Also found to be lethargic.
Patient was first transferred to NW ed where she was found to be
hypotensive 70/p, 90's on RA. She rec'd zosyn, vanco and 3L NS.
She made 300 cc urine 3.5 hours at OSH. Patient taken off of
dopamine before transfer to [**Hospital1 **]. Here SBPs low 100s, but
lactate elevated 5.6 and T103.4. RIJ sepsis catheter was placed.
Her initial cvp was 8. After total of 5L ivf it increased to
[**9-12**]. Patient started on levophed drip during line placement
for bp systolic 80's. u/o 200 cc over 5 hours. Cxr here revealed
right hilar mass vs. pna, cta with nl lungs and no pe.
.
In ICU was found to have Cdif colitis, in addition transiently
required levophed, off pressures, stabilized, being treated for
cdif. on history only complains of diarrhea and bilateral hand
pain. denies f/c, n/v, cp/sob.
Past Medical History:
neuropathy
L orif [**2174-10-10**]
hypothyroid
s/p L total knee replacement [**2154**]
Social History:
NC
Family History:
NC
Physical Exam:
v/s-T 96.7 85 (83-105) 87-121/57-73 14-20 94% 2LNC I/O
1534/850
Gen: NAd, pleasant, speaking in full sentences
HEENT: PERRL, EOMI, OP Clear, No JVD
Lungs: CAT b/l
Heart: s1 s2 tach no murmur
Abd: soft, nt/nd +bs
Ext: bilateral mcp erythema and swelling L>R, stiffness, wrist
erythema/mild swelling
Neuro: mentated normally per family but somewhat fatigued
Pertinent Results:
Hip Films
Single radiograph of the left hip demonstrates the patient to be
status post ORIF of left femur intertrochanteric fracture with
gamma nail. No hardware loosening. The distal interlocking screw
is unremarkable. The proximal interlocking screw projects over
the center of the femoral head. Femoral head contour is smooth.
Soft tissues are unremarkable. The intertrochanteric fracture
line remains visible.
Hand Films
Nonspecific polyarticular arthropathy. Correlation with patient
presentation and serology are requested. The distribution of
joint involvement in the absence of frank periarticular erosion
would support a diagnosis of osteoarthritis.
CTA
IMPRESSION:
1. No evidence of central or segmental pulmonary embolism.
2. Enlarged main pulmonary artery suggestive of pulmonary
arterial hypertension.
3. No abnormalities in the right infrahilar region of concern.
There is bibasilar atelectasis and small pleural effusions.
4. 4mm RML nodule. Follow up in one year in the absence of known
malignancy.
[**2171-11-22**] 11:36PM LACTATE-1.2
[**2171-11-22**] 11:31PM CORTISOL-36.3*
[**2171-11-22**] 09:11PM TYPE-[**Last Name (un) **] TEMP-36.4 PO2-36* PCO2-43 PH-7.32*
TOTAL CO2-23 BASE XS--3 INTUBATED-NOT INTUBA
[**2171-11-22**] 09:11PM HGB-9.2* calcHCT-28 O2 SAT-72
[**2171-11-22**] 07:34PM LACTATE-0.9
[**2171-11-22**] 07:34PM O2 SAT-90
[**2171-11-22**] 05:35PM LACTATE-1.3
[**2171-11-22**] 04:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2171-11-22**] 04:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2171-11-22**] 04:00PM URINE RBC-[**2-3**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2171-11-22**] 04:00PM URINE HYALINE-0-2
[**2171-11-22**] 03:48PM LACTATE-5.4*
[**2171-11-22**] 03:40PM GLUCOSE-77 UREA N-14 CREAT-0.8 SODIUM-138
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-23 ANION GAP-17
[**2171-11-22**] 03:40PM estGFR-Using this
[**2171-11-22**] 03:40PM ALT(SGPT)-16 AST(SGOT)-30 CK(CPK)-43 ALK
PHOS-166* AMYLASE-37 TOT BILI-0.5
[**2171-11-22**] 03:40PM LIPASE-13
[**2171-11-22**] 03:40PM cTropnT-<0.01
[**2171-11-22**] 03:40PM CK-MB-NotDone
[**2171-11-22**] 03:40PM CORTISOL-42.4*
[**2171-11-22**] 03:40PM CRP-257.9*
[**2171-11-22**] 03:40PM NEUTS-92* BANDS-5 LYMPHS-1* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2171-11-22**] 03:40PM PT-13.2* PTT-26.3 INR(PT)-1.2*
Brief Hospital Course:
Patient is a 86F with recent ORIF in rehab admitted with fevers,
hypotension found to have cdif
.
# Fever/hypotension: She was admitted to the ICU for
hypotension, transiently required pressors, was originally
started on broad spectrum antibiotics, her clostrium difficule
test returned positive and she was transitioned to flagyl with
good response. In addition her hip radiological images were
negative for suggestion of osteomyelitis, and her blood cultures
remained negative. She is to finish a two week course of flagyl
to end on [**2171-12-6**]
.
# MCP/wrist joint swelling- She received 6L of IVF while in the
ICU, and she subsequently complained of bilateral wrist joint
swelling, which was in the distribution consistent with RA, but
her RF was negative, her symptoms improved with diuresis during
her hospital course.
.
# Neuropathy- Stable continued on neurontin
.
# S/P L orif- pain controlled with outpatient regiment of
celecoxib, methadone, and oxycodone.
.
# hypothyroid- stable on synthroid
.
Code: DNR/DNI confirmed with family
DISP: [**Doctor Last Name **] [**Hospital **] Rehab
Contact: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 71046**]
cell [**Telephone/Fax (1) 71047**]
Medications on Admission:
NC
Discharge Medications:
1. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO qd ().
2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days: Please finish your antibiotics on
[**2171-12-6**].
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO DAILY (Daily) for 7 days.
10. Methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
12. Vitamin D 50,000 unit Capsule Sig: Two (2) Capsule PO once a
day for 2 weeks.
13. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a
day: to start AFTER two week course of 100,000 u daily.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Green Nursing & Rehab Center - [**Hospital1 **]
Discharge Diagnosis:
Primary:
1. Septic shock.
2. C. difficile colitis.
3. Anemia of chronic inflammation.
4. Vitamin D deficiency.
5. 4mm RML nodule - Follow up in one year in the absence of
known
malignancy.
Secondary:
1. Peripheral neuropathy.
2. Hypothyroidism.
3. Left TKR
4. S/P Left THR.
5. Status: DNR/DNI
Discharge Condition:
Good
Discharge Instructions:
You were admitted for an infection and hypotension. You were
found to have an infection with C. Difficile.
Please take your medications as instructed
If you experience increased fevers, chills, nausea, vomitting,
diarrhea, or other concerning symptoms please call your doctor
or go to the Emergency Deparment
Followup Instructions:
Please follow up with your Primary Care doctor within two weeks
|
[
"244.9",
"008.45",
"785.52",
"518.89",
"356.9",
"268.9",
"995.92",
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] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
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icd9pcs
|
[
[
[]
]
] |
7286, 7384
|
4766, 5981
|
269, 293
|
7725, 7732
|
2314, 4743
|
8092, 8159
|
1914, 1918
|
6034, 7263
|
7405, 7704
|
6007, 6011
|
7756, 8069
|
1933, 2295
|
223, 231
|
321, 1768
|
1790, 1878
|
1894, 1898
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,496
| 111,521
|
6733
|
Discharge summary
|
report
|
Admission Date: [**2135-3-9**] Discharge Date: [**2135-3-14**]
Date of Birth: [**2104-9-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Nausea/Vomiting/Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
30M with hypothyroidism x 5 years, presented 24 hours prior to
admission with diffuse lower abdominal pain, nausea, bilious
vomiting, and watery green/brown diarrhea associated with
fevers/chills. Temperature at home was 104. He was referred from
PCP's office. In the ED he was hydrated with 7 liters of saline,
and he continued to be tachycardic with SBPs in the 90's. He was
found to have a pancytopenia, ARF (CR 1.8), a coagulopathy (INR
= 2, PTT = 49), and an indirect hyperbilirubinemia (TB = 9). A
central line was placed in the ED and he was started on
levo/flagyl, then admitted to MICU. He was found to have serum
Cortisol of 0.1, and placed on stress-dose steroids as well.
.
Of note he was recently seen in the ED 2-3 weeks ago with
suspected gastroenteritis, admitted briefly for IVF and d/c'd
home. He had N/V and abdominal pain, but abdominal U/S was
negative. At that time he was diagnosed with [**Doctor Last Name 9376**] given an
isolated elevated indirect bili. He felt well between these
episodes. On ROS, parents may have noted skin darkening, wt
loss, fatigue over last 1-2 years
Past Medical History:
Hypothyroidism
Possible [**Doctor Last Name 9376**] Disease
Social History:
Pt works as an auditor. Is married with 2 children, ages 5 weeks
and 16 months. His wife had an episode of N/V 3 weeks ago which
resolved. Denies tobacco use, occ Etoh use. Originally from [**Location 10050**]. Denies recent travel.
Family History:
grandparents w/ colon ca and DM2; no [**Doctor Last Name 9376**], thryoid, or
known autoimmune disorders
Physical Exam:
VITALS: T=86.4, BP=87/39-105/59, HR=74-85, RR=13-17, O2=98-100%
on RA
PE:GEN: Pt is well appearing in NAD
HEENT: icteric, mm, OP clear
CHEST: CTA bilaterally
CV: RRR, mild I/VI SEM
ABD: soft, NT, ND; no stigmata of chronic liver disease
EXT: no LE edema
NEURO: CN's intact, nonfocal exam; no aterixis
Pertinent Results:
[**2135-3-9**] 03:40PM WBC-5.0 RBC-5.34 HGB-15.8 HCT-44.2 MCV-83
MCH-29.6 MCHC-35.9* RDW-13.3
[**2135-3-9**] 07:30PM PT-18.0* PTT-47.2* INR(PT)-2.0
[**2135-3-9**] 07:30PM FIBRINOGE-283
[**2135-3-9**] 07:30PM RET AUT-2.2
[**2135-3-9**] 07:30PM HAV Ab-NEGATIVE
[**2135-3-9**] 07:30PM CORTISOL-0.1*
[**2135-3-9**] 07:30PM TSH-0.74
[**2135-3-9**] 07:30PM HAPTOGLOB-<20*
[**2135-3-9**] 10:50PM CRP-5.09*
[**2135-3-9**] 10:50PM FDP-40-80
[**2135-3-9**] 09:14PM LACTATE-1.2
ABD CT - [**2135-3-10**] - Multiple prominent inguinal and pelvic lymph
nodes are seen, which do not meet CT criteria for pathologic
enlargement.
IMPRESSION: No evidence of colitis or obstruction. Moderate free
fluid at the level fo the pancreas. If clinically warranted, MRI
or CT with contrast should be performed.
Brief Hospital Course:
A/P: 30 yo male with hypothyroidism and [**First Name9 (NamePattern2) 10260**] [**Doctor Last Name 9376**], with
newly diagnosed adrnenal insufficiency and [**Doctor Last Name 10260**] gastroenteritis,
with resolving ARF, coagulopathy, and hyperbilirubinemia.
.
1. Hypotension - BP improved with IVFs and stress-dose steroids.
Intially there was suspected sepsis vs gastroenteritis with
underlying adrenal insufficiency. Initial temps to 104 were
concerning, but he quickly became afebrile off antibiotics.
Lactates were normal. He recieved >7L NS with good urine output.
After steroid replacement, he still had SBP's in 90's while
ambulating and was asymptomatic.
.
2. Endocrine - Endocrine was consulted. He was transitioned from
Hydrocort to Prednisone, and tapered to 5mg in AM and 2.5 in PM.
Multiple [**Last Name (un) 104**] stim tests revealed very low Cortisol levels of
0.1, 0.7, ans 2.0 without appropriate bump. ACTH was pending at
the time of d/c as well as Vit D level. He was increased per
Endocrine to 125mcg of Levoxyl, to f/u TSH, T4, and T3 at
[**Hospital 1800**] clinic. He was told to get a medical alert bracelet
and will be given IV Solumedrol prescription at [**Hospital 6091**]
clinic.
.
3. Hematology - he intially presented with elevated INR with
concern for slight DIC. DIC labs were negative, and his
coagulopathy improved. He also had evidence of mild pancytopenia
with low WBC and Hct, and borderline low platelets. Hematology
was consulted. It was felt that his sx's may be related to
underlying infection, and likely had resolving viral illness.
HAV and HIV were negative, CMV and EBV were ordered. His anemia
appeared to have combined picture with evidence of mild
hemolysis with low haptoglobin(but NL LDH and NL smear), but
also with retic count of 2.2. Iron studies not c/w clear iron
deficiency, vit B12/folate pending at the time of dischrage.
Haptoglobin normalized, and Hct began to rise. It was felt that
his elevated indirect bilirubin may be related to [**Doctor Last Name 9376**]
and/or mild hemolysis in setting of acute stress with
starvation/dehydration. He was also noted to have diffuse but
non pathological lyphadenopathy on abd CT of unclear
significance. This may due to his underlying infectious process.
He may recieve outpatient chest CT during Hematology follow-up.
If his pancypenia persists, he may get bone marrow biopsy as
well.
.
4. GI - stool studies were negative and hepatitis A was
negative. It was felt that his N/V/D may be related to
underlying adrenal insufficiency, or possible superimposed viral
gastroenteritis. Given degree of diarrhea and underlying
autoimmune disorders, anti-TTG was sent for Celiac Sprue which
pending at the time of discharge. He was guiac negative.
.
5. CARDIAC - upon presentation he has possible STE's in V1 and
V2, which then resolved as the patient clincally improved. The
patient had an episode of syncope earlier that day after severe
N/V/D (but no prior episodes), but there was concern for Brugada
syndrome. These EKG changes resolved after the patient
clinically improved. He was told to follow-up in cardiology
clinic with EP, and may need further cardiac evaluation with
Echo or Holter monitor.
Medications on Admission:
Levoxyl 25mcg QD
Discharge Medications:
1. Fludrocortisone Acetate 0.1 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Prednisone 2.5 mg Tablet Sig: 1-2 Tablets PO twice a day:
Please take 2 tablets (5mg) in the morning, and 1 tablet (2.5mg)
in the afternoon. This may be changed by Dr [**First Name (STitle) **].
Disp:*90 Tablet(s)* Refills:*2*
3. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Adrenal Insufficiency
Hypothyroidism
Possible Brugada Syndrome
Resolving Pancytopenia
Discharge Condition:
Stable
Discharge Instructions:
Please continue Prednisone, Fludricortsone, and Levothyroxine as
prescribed. Please be sure to arrnge for a Medical Alert
Bracelet because of your Adrenal Insufficiency. If you develop
any nausea/vomiting, fevers/chills, diarrhea, lightheadedness,
or any other concerning symptoms whatsoever please go directly
to the Emergency Department because of your severe adrenal
insufficiency.
Followup Instructions:
Please be sure to follow-up with your PCP [**Name Initial (PRE) 176**] 1 week of
discharge.
[**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 2660**]
Please be sure to follow-up with Dr [**First Name (STitle) **] from Endocrinology
within 1-2 weeks of discharge. Please call ([**Telephone/Fax (2) 25600**]for an
appointment. Please discuss a prescription for a Solumedrol in
times of stress.
Please be sure to follow-up with Hematology, please call
([**Telephone/Fax (1) 25601**] for an appointment. You should follow-up with Dr
[**Last Name (STitle) 25602**], in conjunction with Dr [**Last Name (STitle) **](Tuesday morning) OR Dr
[**Last Name (STitle) 410**] (Weds afternoon).
Please be sure to follow-up with Cardiology. Please make a
follow-up appointment with Dr [**Last Name (STitle) 2357**] and/or Dr [**Last Name (STitle) 171**] at
([**Telephone/Fax (1) 22784**]. You require require further cardiac testing such
as a cardiac Echo and/or Holter monitor.
Completed by:[**2135-3-14**]
|
[
"584.9",
"276.5",
"277.4",
"255.4",
"244.9",
"284.8",
"577.0",
"746.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6819, 6825
|
3075, 6277
|
315, 321
|
6955, 6963
|
2243, 3052
|
7396, 8412
|
1801, 1907
|
6344, 6796
|
6846, 6934
|
6303, 6321
|
6987, 7373
|
1922, 2224
|
251, 277
|
349, 1452
|
1474, 1535
|
1551, 1785
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,797
| 133,145
|
29189
|
Discharge summary
|
report
|
Admission Date: [**2186-5-25**] Discharge Date: [**2186-6-9**]
Date of Birth: [**2113-2-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Shellfish / Gabapentin / Tetracycline
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**6-2**] AVR(23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]), CABGx2(SVG>OM, SVG>PDA)
History of Present Illness:
Mr. [**Known lastname 70223**] 73 M history of CAD sp stent in mid RCA, LAD, L
Circ, PAD who s presented to [**Hospital6 2910**] on
[**2186-5-23**] for SOB.
Pt recently seen by Dr. [**Last Name (STitle) **] earlier this year and had
common femoral endarterectomy on left complicated with injury to
vein and subsequent DVT. He was placed on coumadin.
Pt recently reports SOB and presented to OSH where he was found
to have echo revealing EF drop from baseline 30% down to 10%,
progressed aortic stenosis with highly calcified immobile alve
and 0.5cm2 by echo. At OSH he received IV lasix diuresis. He was
given Vit K to reverse coumadin. (U/S showed no acute DVT on
left thigh) He had cardiac cath revealing critical AS with 45mm
peak gradient. No changed with dobutamine. Mid RCA had 80%
lesion and was not stented. Left circ stents widely patent. LAD
stents patent. right ostial left circ lesion proximal to prior
stent. LV function depressed at 20-25% by LV gram with global
moderate hypokinesis, [**12-25**]+MR. Pt also found to have high grade
PAD in right common femoral artery, highly calcified plaque with
100% occlusion after SFA, and profunda femoris high grade
disease. Post-cath BP in the 85-90s.
Pt transfered to [**Hospital1 18**] for consult with Dr [**Last Name (STitle) **]. Plan for
aortic valve replacement, CABG. Needs carotid studies and vein
mapping.
.
On arrival to the floor, patient says he is comfortable. Feels
SOB but no different from prior. States he cant walk more then 3
yards without feeling very SOB. This has been occuring since
3/[**2185**]. He also reports productive cough of white sputum that
has been getting progressively worse this past year. Denies any
CP, no palpitations.
.
On review of systems, he denies any prior history of pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis. he denies recent fevers, chills or
rigors. he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
CAD s/p LAD, LCX and RCA DES. PAD:failed bypass to left leg x2,
bilateral iliac artery stents SFA occlusions bilaterally
Claudication Hypertension, Dyslipidemia, Diabetes(peripheral
neuropathy), Aortic Stenosis-severe, Chronic Systolic Heart
Failure (EF 25%)Thrombocytopenia, CVA(x2) 15 years ago;
residual memory, speech problems, right sided weakness, walks
with a cane [**1-1**] admit for GIB (while on Coumadin) with Hct of
16, requiring 8 units PRBC. Endoscopy- no acute source of bleed
found, Urosepsis, Sleep Apnea(does not use CPAP), COPD,
Constipation, Anxiety/ Depression Erectile
dysfunction-prosthesis, Prior ETOH abuse(quit 34 yrs ago),
DVT-[**4-3**] after common femoral endarterectomy, s/p Appendectomy,
s/p tonsillectomy, cardiac cath x 5 w/ PCI (DES to LAD, Cx, RCA,
proximal Cx), L fem-[**Doctor Last Name **] bypass w/SV c/b failure and re-do bypass
w/ L-arm vein, bilateral iliac stents
Social History:
SH: A retired physicist, writer. Smoked for 40 yrs at 1.5ppd,
quit 6 yrs ago. EtOH - quit 6 yrs ago.
Family History:
non-contributory
Physical Exam:
Admission Exam:
VS: T= 95.2 BP= 105/63 HR=74 RR= 18 O2 sat= 100% 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7cm.
CARDIAC: systolic murmur right sternal border.
LUNGS: coarse rhonchi and crackles bilaterally, pt with cough
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. right groin site in
tact, no bruits, dopplerable right TP and left TP and DP pulses
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
palp bilateral radial pulses
.
Pertinent Results:
[**2186-6-9**] 05:06AM BLOOD WBC-7.9 RBC-3.43* Hgb-10.1* Hct-30.3*
MCV-89 MCH-29.4 MCHC-33.3 RDW-16.9* Plt Ct-156
[**2186-6-9**] 05:06AM BLOOD Plt Ct-156
[**2186-6-9**] 05:06AM BLOOD PT-12.6 PTT-25.5 INR(PT)-1.1
[**2186-6-8**] 05:07AM BLOOD Plt Ct-157
[**2186-6-7**] 05:13AM BLOOD Plt Ct-109*
[**2186-6-9**] 05:06AM BLOOD Glucose-69* UreaN-17 Creat-0.9 Na-136
K-4.3 Cl-102 HCO3-27 AnGap-11
[**2186-6-8**] 05:07AM BLOOD Glucose-83 UreaN-16 Creat-0.8 Na-138
K-4.3 Cl-104 HCO3-27 AnGap-11
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 275**] [**Hospital1 18**] [**Numeric Identifier 70224**] (Complete)
Done [**2186-6-2**] at 11:38:23 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2113-2-3**]
Age (years): 73 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for CABG/AVR
ICD-9 Codes: 428.0, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2186-6-2**] at 11:38 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW4-: Machine: U/S 6
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.5 cm <= 4.0 cm
Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 10% to 15% >= 55%
Aorta - Annulus: 2.4 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm
Aortic Valve - Peak Gradient: *42 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 26 mm Hg
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 1.3 m/sec
Mitral Valve - Mean Gradient: 2 mm Hg
Mitral Valve - MVA (P [**12-25**] T): 2.1 cm2
Findings
LEFT ATRIUM: Dilated LA. Mild spontaneous echo contrast in the
body of the LA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Depressed LAA
emptying velocity (<0.2m/s)
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mildly dilated LV cavity. Severe
regional LV systolic dysfunction. Severely depressed LVEF.
RIGHT VENTRICLE: Severe global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Complex (mobile)
atheroma in the aortic arch. Normal descending aorta diameter.
Complex (mobile) atheroma in the descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Critical AS (area
<0.8cm2). Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Minimally increased
gradient consistent with trivial MS. Moderate (2+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Moderate
[2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
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. Left pleural effusion.
Conclusions
PRE BYPASS The left atrium is dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. No
mass/thrombus is seen in the left atrium or left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No atrial septal defect is seen by 2D or
color Doppler. The left ventricular cavity is mildly dilated.
There is severe regional left ventricular systolic dysfunction
with apical, mid-distal anterior, septal, and lateral akinesis.
The only segments with legitimate systolic function are the
basal lateral, inferolateral, and inferior walls although these
are moderately hypokinetic. No apical thrombus is seen but views
are limited. Overall left ventricular systolic function is
severely depressed (LVEF= [**10-7**] %). The right ventricle displays
severe mid and distal free wall hypokinesis. There are complex
(mobile) atheroma in the distal aortic arch. There are complex
(mobile) atheroma in the descending aorta. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2) with fusion of the right and left coronary
cusps. Trace aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. There is likely trivial
mitral stenosis though the smallish area may be due to poor
cardiac function.. Moderate (2+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the study.
POST BYPASS The patient is receiving milrinone, epinephrine, and
norepinephrine by infusion. The patient is atrially paced. The
right ventricle displays normal free wall systolic function
other than some focal apical hypokinesis. The left ventricle
displays septal dyskinesis but with improved function of the
basal to mid anterior, anterolateral, lateral and inferior
walls. Apical akinesis remains. Overall ejection fraction is now
about 20%. There is a bioprosthesis located in the aortic
position. It appears well seated. Initially after separation
from bypass one trace valvular and one trace paravalvular jet of
aortic regurgitation were seen. Later on they could not be
found. The peak gradient through the aortic valve was 19 mmHg
with a mean of 9 mmHg at a cardiac output of 4.4 liters/minute.
The mitral regurgitation is improved - it is now mild to
moderate. The tricuspid regurgitation may be slightly improved.
The thoracic aorta appears intact after decannulation. The left
pleural effusion is reduced.
Brief Hospital Course:
Mr. [**Known lastname 70223**] is a 73 year old with a history of coronary artery
disease status post a stent placed in the mid RCA, LAD, L Circ
who presented to an OSH on [**2186-5-23**] for shortness of breath.
He was found to have critical aortic stenosis and was transfered
to [**Hospital1 18**] for aortic valve replacement and a coronary artery
bypass. On [**6-2**] he underwent an aortic valve replacement with a
porcine valve and a coronary artery bypass grafting. Please see
the operative note for details. He tolerated the procedure well
and was transferred in critical but stable condition to the
surgical intensive care unit. He extubated and was weaned from
his pressors. stopped. His chest tubes were removed. He was
transferred to the surgical step down floor. His epicardial
wires were removed. Physical therapy saw him in consult. By
post-operative day 7 he was ready for discharge to home. All
follow-up appointments were advised. He did develop atrial
fibrillation and was started on coumadin and amiodarone.
Medications on Admission:
. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. glyburide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take while on narcotic pain medications, hold for
loose stools.
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*6*
11. warfarin 5 mg Tablet Sig: Two (2) Tablet PO once a day: INR
goal is [**1-26**].
Disp:*60 Tablet(s)* Refills:*2*
12. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
13. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
14. trazodone 100 mg Tablet Sig: One (1) Tablet PO once a day.
.
Medications at Transfer:
Albuterol prn
Coreg 12.5mg [**Hospital1 **] (on both metoprolol and carvedilol, will
continue carvedilol since alpha blockade as well to decrease
afterload)
Desyrel 100-300 qhs (takes 100 at home)
Ecotrin 81mg qd
Imdur 30mg qd
Micronase 5mg qd
Paxil 80mg qd (but takes 60mg daily at home)
Proscar 5mg qd
Protonix 40mg [**Hospital1 **]
Remeron 30mg qd
Toprol XL 100mg daily (hold for now since on carvedilol)
Lisinopril 10mg QD
Zocor 80mg QD
Warfarin: on hold for anticipated surgery
Plavix: on hold for anticipated surgery
Discharge Medications:
1. furosemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day
for 1 weeks.
2. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 1
weeks.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
6. paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
14. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
18. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
19. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO DAILY (Daily).
20. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily.
22. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
24. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for 1
doses: dose to change daily for goal INR 2-2.5, dx: afib.
25. Outpatient Lab Work
Labs: PT/INR
Coumadin for A-fib
Goal INR 2-2.5
First draw day after discharge, [**2186-6-10**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr.
[**Last Name (STitle) 357**] arrange coumadin follow up prior to discharge from rehab
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
aortic stenosis, CAD
s/p AVR, coronary artery bypass
PMH:
CAD s/p LAD, LCX and RCA Drug eluting stents
PAD:failed bypass to left leg x 2, bilateral iliac artery stents
SFA occlusions bilaterally
Claudication
Hypertension
Dyslipidemia
Diabetes (peripheral neuropathy)
Aortic Stenosis- severe
Chronic Systolic Heart Failure (EF 25%)
Thrombocytopenia
CVA (x2) 15 years ago; residual memory, speech problems, right
sided weakness, walks with a cane
[**12/2183**] admit for GIB (while on Coumadin) with Hct of 16,
requiring 8 units PRBC. Endoscopy- no acute source of bleed
found.
Urosepsis
Sleep Apnea (does not use CPAP)
COPD
Constipation
Anxiety/ Depression
Erectile dysfunction/prosthesis
Prior ETOH abuse, quit 34 yrs ago
DVT [**2186-3-24**] after common femoral endarterectomy
Past Surgical History:
s/p Appendectomy
s/p tonsillectomy
cardiac cath x 5 w/ PCI (DES to LAD, Cx, RCA, proximal Cx),
L fem-[**Doctor Last Name **] bypass w/ SV c/b failure and re-do bypass w/ L-arm
vein, bilateral iliac stents
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
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
Wound check on [**6-13**] at 11:15am in [**Hospital Ward Name **] [**Hospital Unit Name **]
surgeon: Dr.[**Last Name (STitle) **] on [**6-29**] at 1:00pm
cardiologist: Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**7-6**] at 11:30am
Please call your PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 70225**] for follow
up in 4 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2186-6-9**]
|
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"438.89",
"280.0",
"785.51",
"414.01",
"428.0",
"V15.82",
"438.10",
"401.9",
"250.60",
"729.89",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.61",
"35.21",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
16459, 16489
|
10946, 11988
|
336, 446
|
17542, 17753
|
4429, 10923
|
18677, 19304
|
3665, 3683
|
13881, 16436
|
16510, 17291
|
12014, 13858
|
17777, 18654
|
17314, 17521
|
3698, 4410
|
277, 298
|
474, 2596
|
2618, 3530
|
3546, 3649
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,680
| 114,829
|
11630+11631
|
Discharge summary
|
report+report
|
Admission Date: [**2107-1-10**] Discharge Date: [**2107-1-27**]
Date of Birth: Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 49 year old male with
a past medical history of Hepatitis C and alcoholic hepatitis
and cirrhosis which is complicated by three to four months of
ascites and spontaneous bacterial peritonitis. He had
extensive ascites and a history of a gastrointestinal bleed.
No history of encephalopathy; no history of hypertension;
diabetes mellitus; asthma or epilepsy.
He was admitted for an elective TIPSS procedure for the
indication of his refractory ascites which was requiring
paracentesis every five days. Prior to the procedure a
routine EKG showed normal sinus rhythm with decreased
voltage. A chest x-ray showed question of interstitial lung
disease with reticular shadowing. An echocardiogram showed
mild pulmonary artery hypertension but normal systolic
function with an ejection fraction greater than 55%.
PAST MEDICAL HISTORY:
1. Cirrhosis secondary to hepatitis C and alcohol.
2. Spontaneous bacterial peritonitis.
3. History of upper gastrointestinal bleed.
4. Hypertension.
5. Chronic obstructive pulmonary disease.
ALLERGIES: Codeine.
MEDICATIONS:
1. Aldactone 50 mg p.o. q. day.
2. Lasix 120 mg twice a day.
3. Inderal 10 mg twice a day.
4. Imdur 30 mg q. day.
5. Lactulose.
6. Protonix.
SOCIAL HISTORY: The patient lives with his mother. [**Name (NI) **] has
a history of tobacco and extensive alcohol use.
PHYSICAL EXAMINATION: Temperature 98.5 F.; blood pressure
94/66; respiratory rate 20; pulse 86; oxygen saturation 91%
on room air. The patient in general is in no acute distress.
He is alert and oriented times three. His Head, Eyes, Ears,
Nose and Throat are remarkable for the absence of icterus.
His neck is supple without bruits. His chest is clear
bilaterally without crackles or wheezes. His heart has a
regular rate and rhythm with no murmurs, rubs or gallops.
His abdomen is soft and nontender, with extensive ascites to
percussion. His extremities have no edema. Neurologically,
he has no flap.
LABORATORY: White blood cell count 10.9; hematocrit 47.3,
platelets 116. Sodium 129, potassium 4.2, chloride 97;
bicarbonate 28, BUN 19, creatinine 1.1, glucose 96. ALT 37,
AST 66, alkaline phosphatase 120, total bilirubin 1.0, direct
bilirubin 0.4, albumin 2.3. Alpha fetoprotein 1.7. HIV
serology is negative.
EKG as noted above. Echocardiogram as noted above. Chest
x-ray as noted above.
HOSPITAL COURSE: The patient was admitted for elective
TIPSS procedure for his refractory ascites. Prior to
admission he was noted to have a question of interstitial
lung disease on routine chest x-ray. An echocardiogram
showed mild pulmonary hypertension and normal systolic
function. He underwent the procedure on [**2107-1-11**].
The procedure was complicated by desaturation of his oxygen
levels to 89% and drop in his blood pressure to the 80s. His
heart rate was also in the 150s. He became agitated and his
oxygen saturation dropped further. He was given Adenosine
without effect. His endotracheal tube was suctioned with
copious white clear secretions and improved compliance. He
was then given Esmolol which, as his heart rate was elevated,
with a decrease in his heart rate to 116 and the blood
pressure in the 120s.
Extubation was then attempted, however, the patient did not
tolerate extubation and he was quickly re-intubated. His
blood pressure again dropped to 80 systolic and a STAT chest
x-ray showed that he was in congestive heart failure. He was
given Lasix, Midazolam, and transferred to the Post
Anesthesia Care Unit where he became unstable. He was
started on Levophed which initially had good effect with
elevation in his blood pressure to 130s and heart rate to
100.
His oxygen saturation remained in the 90s. At that point,
the Medical Intensive Care Unit Service was consulted. An
emergent echocardiogram revealed extensive left ventricular
dysfunction and an ejection fraction of less than 20% with
global hypokinesis, right ventricular dilatation and
dysfunction. The patient was continued on Levophed. A
Swan-Ganz catheter was passed which revealed a pulmonary
wedge pressure of 30 and a systemic vascular resistance of
1,016 and a cardiac output of 4.8 with an index of 2.58.
The patient was started empirically on broad-spectrum
antibiotics. His ascitic fluid which had been removed prior
to the TIPSS procedure was not indicative of SBP. Cardiac
enzymes indicated that the patient did not have a myocardial
infarction.
The patient was started on Dobutamine in addition to Levophed
for inotropic support. During his hospital course, the
patient remained hypoxic and hypotensive. The source for his
heart failure remained unclear. It was felt that most likely
he had an underlying cardiomyopathy that was exacerbated
and/or revealed by the hemodynamic changes from the TIPSS
procedure. Repeated blood cultures and ascites cultures were
negative. The patient was continued on pressors and
broad-spectrum antibiotics and remained intubated.
He did develop low-grade DIC as indicated by his hematology
labs. Repeated attempts to wean off his pressor support were
unsuccessful. Ultimately, given the patient's extensive
underlying disease and poor overall prognosis, after
extensive discussion between the Medical Team and the
patient's family, the family elected to withdraw care.
Care was withdrawn on [**2107-1-26**], after meeting with
the family and answering all their questions. The patient
expired on [**2107-1-26**], of cardiac failure and hepatic
failure following TIPSS for refractory ascites from alcoholic
and viral hepatitis.
DIAGNOSES AT DEATH:
1. Congestive heart failure.
2. Hepatic failure.
3. Status post TIPSS.
4. DIC.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2107-5-23**] 12:15
T: [**2107-5-23**] 19:56
JOB#: [**Job Number 36898**]
Admission Date: [**2107-1-10**] Discharge Date: [**2107-1-27**]
Date of Birth: Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 49 year old male with
a past medical history of Hepatitis C and alcoholic hepatitis
and cirrhosis which is complicated by three to four months of
ascites and spontaneous bacterial peritonitis. He had
extensive ascites and a history of a gastrointestinal bleed.
No history of encephalopathy; no history of hypertension;
diabetes mellitus; asthma or epilepsy.
He was admitted for an elective TIPSS procedure for the
indication of his refractory ascites which was requiring
paracentesis every five days. Prior to the procedure a
routine EKG showed normal sinus rhythm with decreased
voltage. A chest x-ray showed question of interstitial lung
disease with reticular shadowing. An echocardiogram showed
mild pulmonary artery hypertension but normal systolic
function with an ejection fraction greater than 55%.
PAST MEDICAL HISTORY:
1. Cirrhosis secondary to hepatitis C and alcohol.
2. Spontaneous bacterial peritonitis.
3. History of upper gastrointestinal bleed.
4. Hypertension.
5. Chronic obstructive pulmonary disease.
ALLERGIES: Codeine.
MEDICATIONS:
1. Aldactone 50 mg p.o. q. day.
2. Lasix 120 mg twice a day.
3. Inderal 10 mg twice a day.
4. Imdur 30 mg q. day.
5. Lactulose.
6. Protonix.
SOCIAL HISTORY: The patient lives with his mother. [**Name (NI) **] has
a history of tobacco and extensive alcohol use.
PHYSICAL EXAMINATION: Temperature 98.5 F.; blood pressure
94/66; respiratory rate 20; pulse 86; oxygen saturation 91%
on room air. The patient in general is in no acute distress.
He is alert and oriented times three. His Head, Eyes, Ears,
Nose and Throat are remarkable for the absence of icterus.
His neck is supple without bruits. His chest is clear
bilaterally without crackles or wheezes. His heart has a
regular rate and rhythm with no murmurs, rubs or gallops.
His abdomen is soft and nontender, with extensive ascites to
percussion. His extremities have no edema. Neurologically,
he has no flap.
LABORATORY: White blood cell count 10.9; hematocrit 47.3,
platelets 116. Sodium 129, potassium 4.2, chloride 97;
bicarbonate 28, BUN 19, creatinine 1.1, glucose 96. ALT 37,
AST 66, alkaline phosphatase 120, total bilirubin 1.0, direct
bilirubin 0.4, albumin 2.3. Alpha fetoprotein 1.7. HIV
serology is negative.
EKG as noted above. Echocardiogram as noted above. Chest
x-ray as noted above.
HOSPITAL COURSE: The patient was admitted for elective
TIPSS procedure for his refractory ascites. Prior to
admission he was noted to have a question of interstitial
lung disease on routine chest x-ray. An echocardiogram
showed mild pulmonary hypertension and normal systolic
function. He underwent the procedure on [**2107-1-11**].
The procedure was complicated by desaturation of his oxygen
levels to 89% and drop in his blood pressure to the 80s. His
heart rate was also in the 150s. He became agitated and his
oxygen saturation dropped further. He was given Adenosine
without effect. His endotracheal tube was suctioned with
copious white clear secretions and improved compliance. He
was then given Esmolol which, as his heart rate was elevated,
with a decrease in his heart rate to 116 and the blood
pressure in the 120s.
Extubation was then attempted, however, the patient did not
tolerate extubation and he was quickly re-intubated. His
blood pressure again dropped to 80 systolic and a STAT chest
x-ray showed that he was in congestive heart failure. He was
given Lasix, Midazolam, and transferred to the Post
Anesthesia Care Unit where he became unstable. He was
started on Levophed which initially had good effect with
elevation in his blood pressure to 130s and heart rate to
100.
His oxygen saturation remained in the 90s. At that point,
the Medical Intensive Care Unit Service was consulted. An
emergent echocardiogram revealed extensive left ventricular
dysfunction and an ejection fraction of less than 20% with
global hypokinesis, right ventricular dilatation and
dysfunction. The patient was continued on Levophed. A
Swan-Ganz catheter was passed which revealed a pulmonary
wedge pressure of 30 and a systemic vascular resistance of
1,016 and a cardiac output of 4.8 with an index of 2.58.
The patient was started empirically on broad-spectrum
antibiotics. His ascitic fluid which had been removed prior
to the TIPSS procedure was not indicative of SBP. Cardiac
enzymes indicated that the patient did not have a myocardial
infarction.
The patient was started on Dobutamine in addition to Levophed
for inotropic support. During his hospital course, the
patient remained hypoxic and hypotensive. The source for his
heart failure remained unclear. It was felt that most likely
he had an underlying cardiomyopathy that was exacerbated
and/or revealed by the hemodynamic changes from the TIPSS
procedure. Repeated blood cultures and ascites cultures were
negative. The patient was continued on pressors and
broad-spectrum antibiotics and remained intubated.
He did develop low-grade DIC as indicated by his hematology
labs. Repeated attempts to wean off his pressor support were
unsuccessful. Ultimately, given the patient's extensive
underlying disease and poor overall prognosis, after
extensive discussion between the Medical Team and the
patient's family, the family elected to withdraw care.
Care was withdrawn on [**2107-1-26**], after meeting with
the family and answering all their questions. The patient
expired on [**2107-1-26**], of cardiac failure and hepatic
failure following TIPSS for refractory ascites from alcoholic
and viral hepatitis.
DIAGNOSES AT DEATH:
1. Congestive heart failure.
2. Hepatic failure.
3. Status post TIPSS.
4. DIC.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2107-5-23**] 12:15
T: [**2107-5-23**] 19:56
JOB#: [**Job Number 36899**]
|
[
"518.81",
"496",
"428.0",
"789.5",
"785.50",
"571.2",
"998.12",
"486",
"571.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"39.1",
"99.15",
"38.93",
"33.24",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
8639, 12197
|
7632, 8620
|
6257, 7080
|
7102, 7484
|
7502, 7608
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,682
| 109,985
|
39065
|
Discharge summary
|
report
|
Admission Date: [**2190-11-23**] Discharge Date: [**2190-12-6**]
Date of Birth: [**2110-1-21**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
5.6-cm infrarenal abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2190-11-23**] Resection and repair of abdominal aortic aneurysm
with 20-mm Dacron tube graft.
History of Present Illness:
This 80-year-old gentleman has a juxtarenal, 5.6-cm, infrarenal
abdominal aortic aneurysm, enlarging over the last year. His
anatomy was not suitable for endovascular repair due to a lack
of a proximal neck, and he was electively scheduled open repair
via a retroperitoneal approach.
Past Medical History:
Hyperlipidemia
COPD
Possible CAD based on nuclear imaging stress test (2 months
prior to admission, small mild fixed perfusion abnormality of
the inferior wall with hypokinesis and an EF of 53%)
Left internal carotid stenosis 70-90%
Dysphagia
Aortic aneurysm -measured at 4.2 x 3.9cm by U/S dated [**2189-7-7**]
Right common iliac artery aneurysm measuring 1.9cm from study
dated [**11-30**]
cataract surgery bilaterally [**11-2**]
Skin cancer removed left ear
Left hand growth removed
Eczema
Social History:
-Tobacco history: 62 pack year history of smoking, quit 3
months ago
-ETOH: on wednesdays
Family History:
father died at 87, mother died of 89. 1 of 14 siblings.
Brother with MI in 40s.
Physical Exam:
T: 99 HR: 68 BP: 122/73 RR: 18 Spos: 96%
NAD, Alert and oriented x3
Neuro: CN II-XII
Cardiac: RRR
Lungs: CTA bilaterally
Abd: soft, NT, mildly distended, + BS x 4, + BM [**12-5**]
Abdominal incisions open to air, staples removed. Steri strips
intact. NO s/sx of infection.
Pulses: Fem DP PT
Left palp palp palp
Right palp palp palp
Pertinent Results:
[**2190-12-6**] 05:01AM BLOOD WBC-9.2 RBC-3.07* Hgb-9.5* Hct-28.8*
MCV-94 MCH-31.0 MCHC-33.1 RDW-14.0 Plt Ct-265
[**2190-12-5**] 05:27AM BLOOD WBC-9.3 RBC-3.02* Hgb-9.5* Hct-28.7*
MCV-95 MCH-31.3 MCHC-33.0 RDW-13.6 Plt Ct-250
[**2190-12-6**] 05:01AM BLOOD Plt Ct-265
[**2190-12-5**] 05:27AM BLOOD Plt Ct-250
[**2190-12-6**] 05:01AM BLOOD Glucose-86 UreaN-33* Creat-1.0 Na-135
K-4.3 Cl-106 HCO3-22 AnGap-11
[**2190-12-5**] 05:27AM BLOOD Glucose-94 UreaN-35* Creat-0.9 Na-136
K-4.6 Cl-107 HCO3-23 AnGap-11
[**2190-12-4**] 06:00AM BLOOD Glucose-121* UreaN-35* Creat-0.9 Na-138
K-4.4 Cl-107 HCO3-25 AnGap-10
[**2190-11-26**] 05:34AM BLOOD ALT-33 AST-59* LD(LDH)-302* AlkPhos-46
Amylase-24 TotBili-0.7
[**2190-11-23**] 12:55PM BLOOD CK(CPK)-136
[**2190-12-6**] 05:01AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.0
[**2190-12-5**] 05:27AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.0
[**2190-12-4**] 06:00AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0
[**2190-12-3**] 05:10AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.1
[**2190-11-26**] 05:34AM BLOOD calTIBC-168* Ferritn-565* TRF-129*
[**2190-11-29**] 03:00AM BLOOD Triglyc-153*
[**2190-11-24**] 05:28AM BLOOD Type-ART pO2-75* pCO2-38 pH-7.36
calTCO2-22 Base XS--3
[**2190-11-23**] 08:10PM BLOOD Type-ART pO2-85 pCO2-36 pH-7.39
calTCO2-23 Base XS--2
[**2190-11-23**] 08:10PM BLOOD O2 Sat-95
[**2190-11-24**] 05:28AM BLOOD freeCa-1.12
[**2190-11-23**] 08:10PM BLOOD freeCa-1.16
Brief Hospital Course:
On [**2190-11-23**] The patient was taken to the OR for a open AAA
repair. Tolerated procedure without complications. He was
transferred to the CVICU post op. He was kept intubated and
sedated overnight and was on a nitroglycerin drip for blood
pressure management. Epidural was placed for pain management
with morphine as needed. No acute issues overnight. [**2190-11-24**] The
patient was extubated POD #1. Continued with a-line monitoring,
epidural infusing and ICU management. Transferred to VICU status
[**2190-11-25**]
[**2190-11-25**]-Vitals stable. Epidural intact. Keep npo. OOB to chair.
Abdomen distended with discomfort and nausea. Abdominal Xray
confirmed an ileus. The patient was kept NPO and an NGT was
placed. [**2190-11-26**] Continued abdominal girth. NGT to low
continuous wall suction. Nutrition was consulted and started on
TPN. Abdominal wound stable and epidural was discontinued. On
[**2190-11-28**] a rectal tube was placed. Repeat KUB showed dilation in
the small and large bowel. The patient had multiple small BMS.
Bowel regimen was continued. On [**2190-11-29**] NG tube was removed.
Continued on TPN and kept NPO. PICC Line placed and confirmed
with Xray. Physical therapy following Mr. [**Known lastname **] and initially
recommended Rehab. On [**2190-11-30**] the patient was continued to be
diuresised with daily TPN with lipids. NGT was removed and the
patient was having small bowel movements but continues to have
abdominal distention. On [**2190-12-1**] Colorectal surgery was
consulted for continued [**Last Name (un) 3696**] syndrome with non improving
KUBs. They recommended continuing rectal tube, discontinuing
narcotics and repleted electrolytes as needed. The plan included
a dose of Neostigmine if no improvement of colonic distention.
On [**2190-12-2**] a dose of Neostigmin was given with positive results
of flatus and bowel movement. Abdominal distention improved. On
[**2190-12-3**] the patient was slowly started on a clear liquid diet
and by the evening was increased to full diet. The patient
tolerated this well without nausea and vomiting. Tolerated
regular diet on [**12-4**] and [**12-5**]. On [**2190-12-6**] the patient was re
screened by Physical therapy which cleared him for home. He was
discharged home on post op day 13. He will follow up with Dr.
[**Last Name (STitle) **] in 2 weeks. Abdominal staples were removed prior to
discharge and the patient was in stable condition.
Medications on Admission:
albuterol sulfate 90 mcg HFA Aerosol Inhaler 2 puffs QID,
fluticasone-salmeterol 250 mcg-50 mcg/Dose Disk with Device 2
puffs [**Hospital1 **], simvastatin 20, tiotropium bromide 18 cg Capsule,
w/Inhalation Device 1 puff PRN, aspirin 81, calcium
carbonate-vitamin D3, multivitamin omega-3 fatty acids-vitamin E
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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take as needed .
Disp:*60 Capsule(s)* Refills:*2*
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take as needed for GERD.
Disp:*60 Tablet(s)* Refills:*2*
11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Omega 3-6-9 Fatty Acids 400-400-200 mg Capsule Sig: One (1)
Capsule PO once a day: Resume home dose.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
AAA (preop)
Postoperative ileus/ogilvies
PMH:
Hyperlipidemia
COPD
Right common iliac artery aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-1**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**1-27**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2191-1-6**] 3:00
Completed by:[**2190-12-6**]
|
[
"305.1",
"272.4",
"V70.7",
"442.2",
"560.1",
"V10.83",
"441.4",
"560.89",
"412",
"V45.61",
"496",
"997.4",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.44",
"03.90",
"96.07",
"99.15",
"96.09"
] |
icd9pcs
|
[
[
[]
]
] |
7553, 7572
|
3377, 5823
|
348, 447
|
7718, 7718
|
1971, 3354
|
10584, 10770
|
1404, 1488
|
6187, 7530
|
7593, 7697
|
5849, 6164
|
7869, 10131
|
10157, 10561
|
1503, 1952
|
265, 310
|
475, 761
|
7733, 7845
|
783, 1278
|
1294, 1388
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,707
| 198,949
|
10316
|
Discharge summary
|
report
|
Admission Date: [**2180-10-9**] Discharge Date: [**2180-10-22**]
Date of Birth: [**2120-10-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea with climbing 1 flight of stairs
Major Surgical or Invasive Procedure:
[**2180-10-10**] Aortic Valve Replacement ([**First Name8 (NamePattern2) 17167**] [**Male First Name (un) 923**] Mechanical),
Mitral Valve Replacement (25mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Mechanical)
[**2180-10-11**] Exploratory Laparotomy
History of Present Illness:
59 year old female with known rheumatic heart disease with
serial echo that showed 4+ mitral regurgitation and +2 aortic
regurgitation. Has dysonea with climbing 1 flight of stairs or
walking fast. Now admitted for mitral and aortic valve
replacement.
Past Medical History:
Atrial Fibrillation (last episode [**2175**])
Rheumatic heart disease
Positive PPD [**2163**] s/p INH therapy one year
Pulmonary sarcoidosis
C section
Social History:
Married and lives with spouse, works [**Name2 (NI) 34289**] as a psychiatrist.
Denies alcohol
Denies tobacco
Family History:
No known family history of CAD
Physical Exam:
Admission:
Temp 96.5, B/P 119/62 HR 59 (SR), RR 18, Sat 96% on room air
Ht 53.5" Wt 70.8kg
General: No acute distress
Skin: Intact, warm, dry
HEENT: PERRLA, EOMI
Neck: No JVD, Full ROM, Supple
Lungs: Clear to ausculation anterior and posterior
Heart: Regular, S1, S2, no gallops/rubs, murmur [**2-28**] diastolic
Abdomen: Soft, nondistended, nontender, + bowel sounds, no
palpable masses
Ext: warm, no edema, no varicosities, pulses palpable
Neuro: alert and oriented x3, nonfocal, strength 5/5
Discharge:
Temp 98.2, B/P 102/47, HR 62(SR), RR 18, Sat 94% on room air, wt
74.5kg
General: No acute distress
Skin: warm, dry
Incisions: midline sternal and midline abdominal - no erythema
or drainage
Lungs: Clear to ausculation anterior and posterior
Heart: Regular, S1, S2, no gallops/rubs/murmur
Abdomen: Soft, nondistended, nontender, + bowel sounds
Ext: warm, no edema, no varicosities, pulses palpable
Neuro: alert and oriented x3
Pertinent Results:
[**2180-10-22**] 05:00AM BLOOD WBC-11.4* RBC-4.47 Hgb-13.2 Hct-38.7
MCV-87 MCH-29.5 MCHC-34.1 RDW-16.0* Plt Ct-401
[**2180-10-22**] 05:50AM BLOOD PT-25.8* PTT-78.9* INR(PT)-2.6*
[**2180-10-21**] 06:27AM BLOOD Glucose-84 UreaN-11 Creat-0.7 Na-137
K-4.1 Cl-98 HCO3-29 AnGap-14
[**2180-10-9**] 05:43PM BLOOD ALT-38 AST-44* LD(LDH)-183 AlkPhos-79
TotBili-0.2
[**2180-10-10**] 09:56PM BLOOD ALT-49* AST-276* AlkPhos-35* Amylase-74
TotBili-0.7
[**2180-10-16**] 02:21AM BLOOD ALT-45* AST-91* LD(LDH)-800* AlkPhos-71
Amylase-96 TotBili-0.8
[**2180-10-9**] 05:43PM BLOOD Glucose-95 UreaN-16 Creat-0.9 Na-143
K-4.9 Cl-105 HCO3-32 AnGap-11
[**2180-10-9**] 05:43PM BLOOD PT-13.0 PTT-30.2 INR(PT)-1.1
CHEST (PA & LAT) [**2180-10-20**] 9:08 AM
CHEST (PA & LAT)
Reason: eval post op
[**Hospital 93**] MEDICAL CONDITION:
60 year old woman s/p AVR/MVR/Exlap
REASON FOR THIS EXAMINATION:
eval post op
INDICATION: 60-year-old woman status post AVR/MVR.
COMPARISON: [**2180-10-15**].
FINDINGS: Since prior examination, there has been interval
improvement in the aeration in both lungs. The Swan-Ganz
catheter has been removed. The lungs are clear aside for left
lower lobe atelectasis. Bilateral small pleural effusions. The
cardiac silhouette and mediastinal contours are unchanged. No
evidence of pneumothorax. Stable appearance of the sternotomy
wires.
IMPRESSION: Interval improvement in the aeration, bilaterally.
Minimal left lower lobe atelectasis with small bilateral pleural
effusions. Interval removal of the Swan-Ganz catheter.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17726**]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
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 patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
post-bypass
data
Conclusions:
PRE-BYPASS:
1. The left atrial appendage emptying velocity is depressed
(<0.2m/s). A
patent foramen ovale was suspected, but a saline bubble study
was done at rest
and with valsalva with no flow across the septum.
2. Regional left ventricular wall motion is normal. Overall left
ventricular
systolic function is mildly depressed. [Intrinsic left
ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.]
3. Right ventricular chamber size and free wall motion are
normal.
4. There are three aortic valve leaflets. The aortic valve
leaflets are mildly
thickened. There is mild aortic valve stenosis. Trace aortic
regurgitation is
seen.
5. The mitral valve leaflets are severely thickened/deformed.
The mitral valve
shows characteristic rheumatic deformity. There is severe mitral
stenosis.
Severe (4+) mitral regurgitation is seen.
6. There is a trivial/physiologic pericardial effusion.
POST-BYPASS 1: Pt is being AV paced and is receiving an infusion
of
phenylephrine
1. A mechanical valve is well seated in the mitral position,
trace wash in
jets are seen. A mean gradient of 5 mm of Hg is noted across the
valve. Both
leaflets appear to be moving well.
2. A mechanical valve is well seated in the aortic position,
trace wash in
jets are seen. A mean gradient of 6 mm of Hg is noted across the
valve. Both
leaflets appear to be moving well.
3. RV systolic function is preserved and LV systolic function is
improved.
Severe RV dysfunction with moderate Inferior and infero-septal
dysfunction iis
noted with hemodynamic changes. CPB reinitiated to support
circulation.
POST- BYPASS 2: Pt is being AV paced and is receiving an
infusion of
Phenylephrine, Norepinephrine and Epinephrine
1. RV function is mildly depressed, and Inferior and
inferoseptal LV is back
to baseline
2. Valve function appears normal
Severe RV dysfunction with mild inferior and infero-septal
dysfunction was
noted after chest closure.
POST- IABP:
1. IABP noted in the descending thoracic aorta below take off of
Lt subclavian
artery
2. RV function is mildly depressed and inferior and infero
septal wall in back
to baseline
3. Other findings are unchanged
4. All findings discussed with surgeons at the time of the
exams.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2180-10-10**] 16:39.
[**Location (un) **] PHYSICIAN:
[**Last Name (NamePattern4) 4125**]ospital Course:
Brief Hospital Course:
Mrs. [**Known lastname 34290**] was admitted preoperatively for heparin. On
[**2180-10-10**], Dr [**Last Name (Prefixes) **] performed mitral valve
replacement and aortic valve replacement. For further surgical
details, please see separate
dictated operative note. Following the operation, she was
brought
to the CSRU for invasive monitoring with an intra aortic balloon
pump. Was supported on pressors (Epinephrine and Neosynephrine,
then vasopressin) and inotrope (Milirone). Remained intubated
and sedated due to increasing lactate level and surgery was
consulted, stress steroids started. Limited abdominal ultrasound
indicated portal vein open. Under went exploratory laparotomy
with normal abdominal structures and no evidence of ischemia.
POD 1 lactate decreasing, remained intubated with sedation due
to metabolic acidosis. Epinephrine weaned off, steroid taper
started, continued with Vasopressin, Neosynephrine, and Milirone
with intra aortic balloon pump 1:1. POD 2 IABP weaned and
removed, lactate nl, Chest tube removal. POD 3 continued to
wean pressors, inotropes, and sedation. Then POD 4 was
extubated and was neurologically intact, milirone and sedation
weaned off but continued with vasopressin. Lasix drip started.
POD 5 all drips weaned off and coumadin started, remained in
CSRU for close monitoring and then POD 7 transfered to [**Hospital Ward Name 121**] 2
and continued to progress. Underwent cardioversion on POD 9 for
atrial fibrillation - converted with 200 J. Continued with
physical therapy, diuresis, and coumadin. On POD 11 was
discharged home with services. To have INR checked [**10-24**] and
follow up with Dr [**Last Name (STitle) **].
Medications on Admission:
Cordarone 200mg daily
Lopressor 25mg daily
Synthroid 125mcg daily
Coumadin 5 mg daily stopped [**10-3**]
Discharge Medications:
1. Docusate Sodium 100 mg PO 2 times a day
2. Multivitamin One Cap PO DAILY
3. Levothyroxine 125 mcg Tablet PO DAILY
4. Warfarin 5 mg [**10-22**] and 7.5mg [**10-23**] - VNA to check INR [**10-24**]
6. Amiodarone 400 mg po twice a day until [**10-26**] then decrease to
400mg daily for 1 week then decrease to 200mg daily
7. Tramadol 50 mg Tablet PO every 4-6 hours as needed for pain.
8. Metoprolol Tartrate 25 mg po three times a day
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
AI - s/p AVR
MR/MS - s/p MVR
Afib - cardioverted to SR
RHD
pulmonary sarcoidosis
past +PPD s/p INH
Discharge Condition:
Stable
Discharge Instructions:
Call with fever redness or drainage from incision or weight gain
more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No heavy lifting or driving until follow up with surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Date/Time:[**2180-11-8**] 2:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2180-11-8**] 3:20
Dr. [**Last Name (Prefixes) **] 4 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Completed by:[**2180-10-23**]
|
[
"396.8",
"429.9",
"287.4",
"398.90",
"427.31",
"285.8",
"135",
"276.2",
"517.8",
"787.01",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.44",
"88.50",
"54.11",
"37.61",
"38.91",
"93.90",
"35.22",
"96.6",
"35.24",
"96.71",
"99.61",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9024, 9058
|
6720, 8407
|
364, 639
|
9201, 9210
|
2239, 3012
|
1237, 1269
|
8562, 9001
|
3049, 3085
|
9079, 9180
|
8433, 8539
|
9234, 9471
|
9522, 9939
|
1284, 2220
|
6697, 6697
|
284, 326
|
3114, 6612
|
667, 920
|
6646, 6646
|
942, 1094
|
1110, 1221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,341
| 159,381
|
13856
|
Discharge summary
|
report
|
Admission Date: [**2137-2-26**] Discharge Date: [**2137-3-14**]
Date of Birth: [**2064-4-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Chest pain with activity, dyepnea on exertion, paroxysmal
nocturnal dyspnea, 2 pillow orthopnea, palpitations, and
diaphoresis. With positive stress test [**2137-1-24**], referred for
cardiac cath.
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x 3.
History of Present Illness:
Mr. [**Known lastname **] is a 72 yo male patient with known history
coronary artery disease, s/p PTCA x two eleven years ago
(details unknown). He reports exertional chest pain for a
couple years with a positive stress test in [**2134**] three which he
filed to follow-up with. He had a repeat stress in [**Month (only) 404**]
showing severe fixed inferior defect with an EF of 47% and was
referred for cardiac cath.
Past Medical History:
Osteo arthritis.
Diabetes type 2.
Diabetic retinopathy.
Left foot ulcer.
Coronary artery disease.
Hypertension.
Hyperlipidemia.
Congestive heart failure.
Left fem-[**Doctor Last Name **] bypass bypass [**5-31**].
Social History:
Lives in [**Location 34697**] with wife. Retired. Drives. Uses cane on
occasion. 56 pack year smoking history -- quit in [**2095**]. ETOH:
Denies current use.
Family History:
Mother with CAD, deceased at age 73.
Father with CAD, deceased at age 73.
Physical Exam:
On presentation:
Height: 5'[**42**]", Weight: 240 pounds.
VS: T 97.4 BP 158/80 HR 78 RR 18 SPO2 95% RA
General: Laying in bed in NAD.
Neuro: A+O x 3. Appropriate. MAE.
Neck: Supple. Negative carotid bruit.
Resp: CTA
CV: RRR. S1S2. + II/VI SEM at USB.
GI: soft, obese, non-tender, non-distended, positive bowel signs
throughout
Extremities: Warm. No edema. No varicosities. Positive color
changes bilat LE with hair loss and shiny appearance.
Pertinent Results:
[**2137-3-12**] 05:48AM BLOOD WBC-8.0 RBC-3.10* Hgb-8.7* Hct-27.9*
MCV-90 MCH-27.9 MCHC-31.0 RDW-14.0 Plt Ct-255
[**2137-3-14**] 05:35AM BLOOD PT-24.2* INR(PT)-3.7
[**2137-3-13**] 01:16PM BLOOD PT-19.4* PTT-41.0* INR(PT)-2.4
[**2137-3-12**] 05:48AM BLOOD UreaN-30* Creat-1.8* K-5.4*
Brief Hospital Course:
Mr. [**Known lastname **] was admitted [**2137-2-27**] for a cardiac cath showing
three vessel disease with total LCx occlusion, LAD 50%
occlusion, D1 60% ostial occlusion, RCA serial 90% occlusions.
A cardiac surgery consult was obtained. On [**2137-3-1**] he proceeded
to the operating room with Dr. [**Last Name (STitle) **] and underwent a CABG x 3
with LIMA to the LAD, SVG to the OM, and SVG to the RCA. Please
see OR report for complete details.
He was successfully weened and extubated on the evening of his
operative day.
On POD one his creatinine was elevated to 1.9 (pre-op 1.3) so he
remained in the ICU for ongoing management. [**Last Name (un) **] was also
contact[**Name (NI) **] to see the patient for recommendations for management
of diabetes.
On POD 2, Mr. [**Known lastname **] experienced some bursts of rapid
atrial fibrillation for which an amiodarone bolus was given with
conversion to NSR and subsequent 7 second asystolic pause. He
was stable with this and was later on POD 2 transferred to the
inpatient floor for ongoing recovery and rehabilitation.
On POD 4, Mr. [**Known lastname **] foley catheter was discontinued and
he filed to void with re-insertion of the catheter and
initiation of flopmax for presumed BPH. On POD 5 his [**Last Name (un) **] was
again removed and he successfully voided.
ON POD five he experienced furtehr bursts of atrial
fibrillation, treated with IV lopressor (no amiodarone). He was
also started on a heparin drip for anticoagulation.
On POD six ([**3-7**]) he continued in a rate controlled atrial
fibrillation and was started on PO warfarin.
Over the next several days, he continued to be in atial
fibrillation. He was very difficult to work with, frequently
refusing to participate in his care. On POD#7, a psychiatry
consult was obtained, and it was felt that the patient was not
delerious or depressed, just very controlling and wanted to have
control over his care. His wife stated that this was typical
behavior for him when he stops his carbamazapine. It was
restarted with good results. The patients atrial fibrillation
continued to be difficult to rate control and on POD#11 and EP
consult was obtained. It was recomended that the patient
undergo DCCV, but the patient refused. He was started on
digoxin for rate control and continued on coumadin for
anticoagulation. His heart rate was intermittently elevated in
his atrial fibrillation, but the patient remained
hemodynamically stable with it. On POD#13, he was cleared for
discharge to rehab.
Medications on Admission:
Hydralazine 25 tid.
Imdur 60 daily.
Norvasc 10 daily.
Lopid 600 [**Hospital1 **].
Keflex 500 [**Hospital1 **].
Pravachol 40 daily.
Carbamezepine 200 [**Hospital1 **].
Aspirin 325 daily.
Insulin 70/30 52units q AM, 36u qdinner
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
3. Tramadol HCl 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Warfarin Sodium 1 mg Tablet Sig: no coumadin [**3-14**] Tablet PO
DAILY (Daily): check PT/INR [**3-15**] and dose coumadin for INR
2.0-2.5.
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours) for 7 days.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
three times a day.
12. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
Maples in [**Location (un) 6151**]
Discharge Diagnosis:
CAD
s/p CABG
post op atrial fibrillation
Type 2 DM
L foot ulcer
HTN
diabetic retinopathy
renal insufficiency
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incisions with mild soap and
water
do not swim or take a bath for 1 month
do not drive for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
do not lift anything heavier than 10 pounds for 1 month
Followup Instructions:
follow up with Dr. [**First Name (STitle) **] in [**12-30**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**12-30**] weeks
follow up with Dr. [**Last Name (STitle) 70**] in 1 month
Completed by:[**2137-3-14**]
|
[
"707.15",
"997.1",
"401.9",
"362.01",
"593.9",
"250.50",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"88.56",
"36.15",
"39.61",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
6349, 6410
|
2312, 4843
|
521, 556
|
6563, 6569
|
2005, 2289
|
6877, 7099
|
1438, 1513
|
5119, 6326
|
6431, 6542
|
4869, 5096
|
6593, 6854
|
1528, 1986
|
283, 483
|
584, 1005
|
1027, 1241
|
1257, 1422
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,752
| 129,909
|
2672
|
Discharge summary
|
report
|
Admission Date: [**2178-4-9**] Discharge Date: [**2178-4-28**]
Date of Birth: [**2123-7-9**] Sex: F
Service: GENERAL SURGERY
ADMITTING DIAGNOSIS: Rapid atrial fibrillation.
DISCHARGE DIAGNOSIS:
1. Rapid atrial fibrillation.
2. Hemoperitoneum secondary to bleeding of the vaginal cuff
status post hysterectomy.
3. Urinary tract infection.
PROCEDURES DURING ADMISSION: Exploration and evacuation of a
hemoperitoneum and oversewing of the left aspect of the
vaginal cuff on [**4-16**].
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
female with a history of rheumatic heart disease with
valvular dysfunction, coronary artery disease, status post
myocardial infarction secondary to atrial thrombus,
congestive heart failure, atrial fibrillation, and anemia,
who presented with palpitations on [**2178-4-9**], and was
found to be in rapid atrial fibrillation. The patient was
rate controlled with beta-blockers and started on intravenous
Heparin considering the fact that it was unknown whether she
had been on her Coumadin at home, and her INR was
subtherapeutic.
Once the patient was stable from a cardiac standpoint, she
underwent exam under anesthesia and a total abdominal
hysterectomy and bilateral salpingo-oophorectomy for fibroids
and pelvic pain and menorrhagia on [**2178-4-13**].
Postoperatively the patient was started on a Heparin drip.
On postoperative day #2, she was noted to be slightly
tachycardiac with good urine output with a slightly distended
abdomen and a hematocrit drop from 31 to 25 for which she was
given 3 U of packed red blood cells. Her posttransfusion
hematocrit was 26. The patient however became progressively
tachycardiac and oliguric, and on postoperative day #3, a CT
of the abdomen revealed an intraperitoneal hematoma with
portal venous air. The patient continued to hemorrhage with
a hematocrit drop to 19 and became progressively
coagulopathic despite FFP. General Surgery was consulted for
further care of this patient.
PAST MEDICAL HISTORY: 1. Rheumatic heart disease, moderate
MS, and trivial AS. 2. Coronary artery disease status post
myocardial infarction secondary to atrial thrombus embolizing
to a coronary artery. 3. Congestive heart failure. 4.
Atrial fibrillation. 5. Depression. 6. Gastritis. 7.
Menorrhagia and fibroids.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS AT HOME: Coumadin, Aspirin, Zantac, Lasix,
..................., Risperdal, Ativan, Desipramine.
PHYSICAL EXAMINATION: General: On admission the patient was
generally in no apparent distress. Vital signs: She was
afebrile. Heart rate was in the 110s, and she was in atrial
fibrillation. Neck: Supple. Chest: Clear with no crackles
or wheezes. Heart: Irregularly irregular. Abdomen: Soft,
nontender, nondistended. Rectal: Guaiac negative.
Extremities: Soft. No clubbing, cyanosis,or edema.
Neurological: She was neurologically intact.
LABORATORY DATA: White count on admission was 8.3,
hematocrit 38.2; INR 1.3.
HOSPITAL COURSE: The patient was admitted on [**2178-4-9**],
and her atrial fibrillation was managed by the Medicine Team.
Once she was stable from that standpoint, she was taken to
the Operating Room for a total abdominal hysterectomy and
bilateral salpingo-oophorectomy.
Postoperatively the patient became tachycardiac. She dropped
her hematocrit despite being transfused 2 U packed red blood
cells. CT scan of the abdomen revealed an intraperitoneal
hematoma with portal venous air. She continued to hemorrhage
and became hemodynamically unstable. General Surgery was
consulted, and she was taken to the Operating Room on [**2178-4-16**], for exploration and evacuation of the hematoma and
oversewing of the posterior aspect of the vaginal cuff. The
patient tolerated the procedure well. She was transferred to
the SICU intubated and sedated.
Her postoperative course in the Intensive Care Unit was
notable for several episodes of rapid atrial fibrillation.
She was cardioverted for the first time on [**4-18**], and then
went back into atrial fibrillation on [**4-20**] with
unsuccessful. She was again cardioverted on [**4-22**] and
remained in sinus.
She underwent an echocardiogram on [**4-23**] which showed some
pulmonary hypertension. Also of note, the patient's white
count was noted to be elevated, and she was pancultured. Her
urine and sputum were positive for growth, and she was
started on Levofloxacin and Ceftazidime. Otherwise her
Intensive Care Unit course was uneventful. The patient was
eventually transferred to the floor on [**2178-4-27**]. Her
diet was advanced. She was restarted on her Coumadin, and on
[**4-28**], postoperative days 15 and 12, the patient was
discharged home in stable condition.
DISCHARGE MEDICATIONS: Risperdal 2 mg p.o. q.d., Desipramine
100 mg p.o. q.d., Zantac 150 mg p.o. b.i.d., Coumadin to be
dosed for an INR of [**12-28**], Aspirin, Toprol 75 mg p.o. t.i.d.,
Amiodarone 400 mg t.i.d. x 7 days, then 400 mg b.i.d. x 7
days, then 400 mg q.d., Diltiazem 30 mg p.o. q.i.d.,
Metoprolol 75 mg p.o. t.i.d., Clonidine 2 mg patch once
q.week.
FOLLOW-UP: She was told to follow-up with her cardiologist,
and she was also discharged with VNA for INR draws.
DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 02.365
Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36
D: [**2178-5-11**] 14:19
T: [**2178-5-11**] 14:33
JOB#: [**Job Number 13331**]
|
[
"412",
"998.11",
"428.0",
"427.31",
"E878.8",
"396.1",
"218.9",
"626.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"68.4",
"54.12",
"65.61"
] |
icd9pcs
|
[
[
[]
]
] |
4783, 5482
|
217, 512
|
3034, 4759
|
2393, 2481
|
2504, 3016
|
541, 2007
|
168, 196
|
2030, 2371
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,874
| 143,929
|
39839+58330
|
Discharge summary
|
report+addendum
|
Admission Date: [**2169-6-25**] Discharge Date: [**2169-6-30**]
Date of Birth: [**2116-8-13**] Sex: F
Service: MEDICINE
Allergies:
Niacin / Heparin Agents / Vistaril / Propofol / Naprosyn
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 52-year-old woman with a history of IDDM Type II
complicated by nephropathy and neuropathy, CHF with LVEF of 30%,
HTN, HLD, CAD s/p CABG x2 complicated by sternal wound abscess
(MSSA/MRSA), CKD, HIT and COPD recently discharged from [**Hospital 87678**] on [**2169-6-15**] presenting with subdural hematoma, acute
renal failure and altered mental status. Patient was admitted to
MEEI for endophthalmitis panophthalmitis and L sinus disease
treated empirically with Vanco/Ceftaz/Levofloxacin while
inpatient at [**Hospital 13128**]. ENT evaluated patient and drained
maxillary sinus which grew MSSA and VSE. CT chest showed
possible phlegmon of lower portion of chest surgery wound but
seen by CT surgery who did not feel there was concern for
sternal wound infection. Her course was also complicated by ARF
[**3-16**] supratherapetic Vancomycin levels, continued leukocytosis
(WBC 16), LUE superficla clot, lymphadenopathy noted on
abdominal CT of uncertain significance, polyarticular pain for
which she was seen by rheumatology (thought to have gout though
crystals not found on knee arthrocentesis). Patient was
discharged home to complete Levofloxacin and Linezolid 4 week
course (aniticipated completion [**2169-7-4**]).
Per husband, patient began having body twitches and confusion
one day following discharge from the hospital. She was having
auditory and visual hallucinations. She then fell at home last
Friday but did not inform anyone that she had hit her head.
During this time, she was drinking 2.5-3L water daily. Then
due to increasing confusion, patient's husband took her to
[**Name (NI) **] Hospital ED. On eval at OSH, CT head showed small
tentorial SDH and so was transferred here for neurosurgery
evaluation. Neurosurgery evaluated patient in the ED indicating
"very small intracranial bleed, no surgical indication
currently. Patient does not need any AED at this time. Plan to
admit to medicine for multiple medical problems and further
workup of AMS and plan for rescan with NCHCT in 24hrs."
In the ED, no initial vitals were recorded. Nursing staff
indicates patient was experiencing l eye blurry from recent
infxn being treated with erythromcyin and cipro drop. Patient
was attentive with non-specific neruologic examination. Mild
right nasolabial fold flattening and asterixis.
.
Currently, patient denies pain. Otherwise unable to give
reliable history due to altered mental status.
Past Medical History:
MEDICAL HISTORY:
- DM Type II, c/b nephropathy, neuropathy
- CAD s/p many PCIs, s/p CABG x2, last [**2167**] (LIMA->LAD, SVG->
RCA)
- sCHF with LVEF 30% ([**2167**] last TTE)
- Chronic sternal wound infections (MSSA, MRSA)
- Recent endophthal/panophthalmitis and L sinusitis (MSSA/VSE)
[**Month (only) 547**]-[**2169-6-13**]
- Recent Pneumonia [**2169-4-13**]
- Gout
- HTN
- HLD
- Heparin Induced Thrombocytopenia
- Morbid Obesity
- Cardiac arrest during anesthesia induction [**2161**]
.
SURGICAL HISTORY:
s/p Maxillay sinus drainage (MEEI)
s/p femoral fracture [**2166**]
s/p hysterectomy [**2144**]
s/p several eye surgeries
Social History:
-Married, husband is a nurse. Lives in [**Location **], MA. 11 year
old son.
-On disability; formerly ran a nursing agency
-Tobacco history: 29 year smoking history, quit 9 years ago
-ETOH: Occasional
-Illicit drugs: None
Family History:
--CAD
Physical Exam:
Admission exam:
GENERAL - obese female, lethargic, intermittent twitches of all
extremities
HEENT - NC/AT, PERRL, EOMI, left eye injected, dry MM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, S1-S2 clear and of good quality
without murmurs, rubs or gallops
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c, [**2-13**]+ nonpitting edema of LE, 2+
peripheral pulses (radials, DPs)
NEURO - awake, A&Ox2 (knows place, not date), CNs II-XII grossly
intact, muscle strength 5/5 throughout, sensation grossly intact
throughout
Discharge exam:
O: Tm 98.4 BP 114/60, 80, 18, 98% on RA
GENERAL - obese female, appears comfortable, in NAD
HEENT -left eye injected, OP clear
NECK - supple, no JVD
LUNGS - CTAB b/l. No wheezes/crackles. Moving air well and
symmetrically, resp unlabored, no accessory muscle use
HEART - RRR, nl S1-S2, [**4-18**] cres-decres systolic murmur best
heard at the sternal border radiating to the neck. No rubs or
gallops.
Back - no paraspinal tenderness
ABDOMEN - Obese, NABS, soft/NT/ND, difficult to assess masses
due to body habitus, no rebound/guarding
EXTREMITIES - WWP, no c/c, 2+ pitting edema of LE, 2+ peripheral
pulses (radials, DPs). PICC inplace.
NEURO - awake, A&Ox3, non-focal.
Pertinent Results:
Labs upon admission:
[**2169-6-25**] 12:15PM BLOOD WBC-13.4* RBC-3.71* Hgb-8.8* Hct-29.4*
MCV-79* MCH-23.7*# MCHC-29.9* RDW-17.2* Plt Ct-237
[**2169-6-25**] 12:15PM BLOOD Neuts-79.0* Lymphs-12.2* Monos-1.5*
Eos-7.0* Baso-0.2
[**2169-6-25**] 12:15PM BLOOD PT-12.4 PTT-34.0 INR(PT)-1.1
[**2169-6-25**] 12:15PM BLOOD Glucose-142* UreaN-93* Creat-6.0*#
Na-125* K-5.5* Cl-87* HCO3-24 AnGap-20
[**2169-6-25**] 12:15PM BLOOD ALT-8 AST-12 AlkPhos-86 TotBili-0.2
[**2169-6-25**] 12:15PM BLOOD Lipase-266*
[**2169-6-25**] 12:15PM BLOOD Albumin-3.0*
[**2169-6-25**] 07:52PM BLOOD Albumin-2.9* Calcium-7.6* Phos-7.8*#
Mg-2.2
[**2169-6-25**] 07:52PM BLOOD Osmolal-289
[**2169-6-25**] 07:52PM BLOOD TSH-3.0
[**2169-6-26**] 05:55AM BLOOD Cortsol-12.8
[**2169-6-26**] 12:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2169-6-25**] 09:51PM BLOOD Lactate-0.9
[**2169-6-25**] 09:51PM BLOOD freeCa-0.94*
URINE CULTURE (Final [**2169-6-26**]): YEAST >100,000 ORGANISMS/ML.
MRSA SCREEN (Final [**2169-6-28**]): No MRSA isolated.
Labs upon discharge:
[**2169-6-29**] 10:21PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2169-6-29**] 10:21PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2169-6-29**] 10:21PM URINE RBC-<1 WBC-9* Bacteri-NONE Yeast-NONE
Epi-1 TransE-<1
[**2169-6-29**] 10:21PM URINE Eos-NEGATIVE
[**2169-6-30**] 04:07AM BLOOD WBC-5.2 RBC-2.99* Hgb-7.1* Hct-24.1*
MCV-81* MCH-23.9* MCHC-29.6* RDW-17.2* Plt Ct-106*
[**2169-6-30**] 04:07AM BLOOD Neuts-60.4 Lymphs-21.4 Monos-5.0
Eos-13.1* Baso-0.2
[**2169-6-30**] 04:07AM BLOOD Plt Ct-106*
[**2169-6-30**] 04:07AM BLOOD Glucose-70 UreaN-80* Creat-2.1* Na-139
K-4.9 Cl-101 HCO3-28 AnGap-15
[**2169-6-30**] 04:07AM BLOOD CK(CPK)-52
[**2169-6-30**] 04:07AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.1
CXR [**2169-6-25**]: IMPRESSION: Interstitial prominence may represent
vascular crowding but mild volume overload is not excluded.
CT head [**2169-6-26**]:
IMPRESSION: Stable appearance of a small left subdural
hematoma, tracking
along the falx cerebri and tentorium cerebelli. No
intraparenchymal or
intraventricular hemorrhage or fractures. Calcifications in the
bilateral
cavernous, carotid and vertebral arteries. The ventricles and
sulci are
prominent, compatible with age-related involutional changes.
CT head [**2169-6-27**]: IMPRESSION: No significant change from prior
study.
CXR [**2169-6-25**] IMPRESSION:
1. Right-sided PICC line tip in the right atrium.
2. Improvement in mild pulmonary vascular congestion and
cardiomegally.
Echo [**2169-6-28**]
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild to moderate
regional left ventricular systolic dysfunction with hypokinesis
of the inferior wall, distal septum and apex. The remaining
segments contract normally (LVEF = 40 %). No masses or thrombi
are seen in the left ventricle (with Optison). The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction c/w
multivessel CAD. Moderate pulmonary artery systolic
hypertension. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2168-1-8**],
global and regional left ventricular systolic function is now
improved. Pulmonary artery hypertension is now identified.
Brief Hospital Course:
This is a 52-year-old woman with a history of DM2 c/b
nephropathy and neuropathy, CHF with LVEF of 30%, CAD s/p CABG
x2, CKD, recent sinus infection c/b endopthalmitis, admitted for
subdural hematoma, acute renal failure, hyperkalemia, altered
mental status, in the setting of supratherapeutic gabapentin
levels, s/p hypertonic saline treatment with good response.
# ACUTE KIDNEY INJURY: Patient's creatinine was 2.2 on
discharge from Mass Eye & Ear and presented to [**Hospital1 18**] with a
creatinine of 6.0. Of note, patient had received CT with
contrast at [**Hospital 13128**] on [**2169-6-11**]. Urine sediment showed
muddy brown casts suggesting ATN. Other etiologies of renal
failure include medication effect and AIN. Gabapentin,
gemfibrozil and diuretics were held. Other medications such as
allopurinol, levofloxacin, and linezolid were renally dosed.
Creatinine slowly improved to 2.1 at discharge.
# HYPONATREMIA: Patient's sodium was 125 on admission.
Etiologies of hyponatremia include renal failure and excessive
fluid intake, decompensated heart failure, or medications.
Patient was given hypertonic saline and her fluids were
restricted. Sodium subsequently improved to 139 at discharge.
# SUBDURAL HEMATOMA: Patient fell at home likely in the setting
of altered mental status. She was taken to OSH where there was
concern for subarachnoid bleed; upon transfer to [**Hospital1 18**], thought
was that bleed was more consistent with subdural hemtoma.
Neurosurgery felt that surgical intervention was not indicated
and did not recommend initiation of antiepileptics. Plavix was
held (last stent in [**2162**]) but ASA was restarted. Patient will
follow up with Neurosurgeon, Dr. [**First Name (STitle) **], on [**2169-7-27**].
# GABAPENTIN TOXICITY: patient's gabapentin level was 41 on this
admission, which was likely related to her acute on chronic
kidney disease. Her gabapentin was held.
# ALTERED MENTAL STATUS: The patient initially presented with
confusion, hallucinations and associated muscle twitching.
Likely multifactorial in the setting of gabapentin toxicity,
ARF, SDH and hyponatremia.
# ENDOPTHALMITIS: Recently diagnosed at OSH. Unclear whether it
seeded from her sinus infection or from other source (?sternal
wound infection) Patient was continued on eye drops and
antibiotics. She will follow-up with an infectious disease
physician close to her house.
# PANCYTOPENIA: Likely in setting of prolonged Linezolid
course. Patient was admitted on levofloxacin and linezolid for
endopthalmitis (course was to be finished on [**7-4**]). However,
she was seen by ID who suggested that antibiotic regimen be
switched to levofloxacin and daptomycin (in setting of marrow
suppression). Patient was discharged with a PICC. She will
finish her levofloxacin and daptomycin course on [**7-4**]. The
linezolid may have also been contributing to patient's
peripheral eosinophilia.
# EOSINOPHILIA: Etiology not completely clear, but possibly in
the setting of Linezolid. Antibiotics were switched to
levofloxacin and daptomycin (as above) to complete course on
[**7-4**].
# CHF: Systolic CHF with LVEF of 30%, no evidence of acute
exacerbation on admission. Likely ischemic etiology given
multiple PCIs and 2 CABGs most recently [**2167**]. Her echo showed no
significant changes from prior. Metoprolol was initially held
given low BP but soon resumed after BP normalized. Lasix was
initially held due to [**Last Name (un) **], but soon resumed because she was
volume overloaded. After kidney function recovered, she was
actively diuresed (first 60 mg IV Lasix [**Hospital1 **], then 120 mg PO
Lasix [**Hospital1 **]) with goal of negative 1-2 L a day. At discharge her
Lasix dose was decreased to 80 mg [**Hospital1 **].
.
# DM II: complicated by nephropathy and neuropathy. She was kept
on home lantus with insulin sliding scale.
.
# LYMPHADENOPATHY: Per d/c summary from Mass Eye & Ear, she had
CT abdomen that showed lymphadenopathy. This will need
follow-up as outpatient.
# PULMONARY HYPERTENSION: Evidence from Echo. Likely from OSA
given her obesity. Outpatient sleep study is recommended.
# TRANSITIONAL ISSUES:
1. Follow up lymphadenopathy on CT abdomen
2. Follow up volume status and adjust Lasix dose as needed
3. Sleep study is recommended given pulmonary hypertension
4. Follow up final blood culture
5. Check CK now that patient is on daptomycin. CK upon leaving
the hospital on [**2169-6-30**] was 52.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientPharmacywebOMR.
1. Gabapentin 300 mg PO TID
2. Gemfibrozil 600 mg PO BID
3. Levofloxacin 500 mg PO Q24H
4. Glargine 10 Units Breakfast
Glargine 80 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Lisinopril 5 mg PO DAILY
6. Allopurinol 300 mg PO DAILY
7. Atorvastatin 40 mg PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezes
9. Clopidogrel 75 mg PO DAILY
10. Metoprolol Tartrate 25 mg PO BID
11. Lorazepam 1 mg PO HS:PRN insomnia
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
13. Linezolid 600 mg PO/NG Q12H
14. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE DAILY
15. Ciprofloxacin 0.3% Ophth Soln 1-2 DROP LEFT EYE Q2H
16. Cyclopentolate 1% 1 DROP LEFT EYE Q12H
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Ciprofloxacin 0.3% Ophth Soln 1-2 DROP LEFT EYE Q2H
3. Cyclopentolate 1% 1 DROP LEFT EYE Q12H Duration: 1 Doses
4. Allopurinol 100 mg PO EVERY OTHER DAY
5. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE DAILY
6. Glargine 10 Units Breakfast
Glargine 80 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Levofloxacin 250 mg PO Q24H
Please take through [**2169-7-4**].
RX *levofloxacin 250 mg Once a day Disp #*5 Tablet Refills:*0
8. Metoprolol Tartrate 25 mg PO BID
hold if SBP < 100 or HR < 60
9. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) Once a day Disp #*30
Tablet Refills:*0
10. Furosemide 80 mg PO BID
Please discuss with your doctor when to resume your previous
dose of this medication.
RX *furosemide 80 mg Twice a day Disp #*60 Tablet Refills:*0
11. Gemfibrozil 600 mg PO BID
12. Lisinopril 5 mg PO DAILY
hold if systolic blood pressure < 100
13. Lorazepam 1 mg PO HS:PRN insomnia
14. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg Once a day Disp #*30 Tablet Refills:*0
15. Daptomycin 450 mg IV Q24H
Through [**2169-7-4**].
RX *CUBICIN 500 mg Every 24 hours Disp #*5 Pack Refills:*0
16. Epinephrine 1:1000 0.3 mg IM ONCE MR1 Allergic reaction
Duration: 1 Doses
For allergic reaction while receiving daptomycin.
RX *EpiPen 0.3 mg/0.3 mL (1:1,000) Once for anaphylactic
reaction (shortness of breath); call 911 if you use this
medication Disp #*1 Unit Refills:*0
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary diagnosis:
# metabolic encephalopathy of multifactorial etiology
# acute kidney injury, possibly ATN secondary to hypotension
and/or AIN due to antibiotic
# subdural hematoma
Secondary diagnoses:
# hyponatremia, hypervolemic: attributed to decompensated CHF,
possibly evolving SIADH, treated with hypertonic saline;
resolved as of [**6-28**]
# acute on chronic systolic CHF
# recent left endophthalmitis (MSSA & VSE)
# gabapentin toxicity
# CKD stage III
# DM II
# intraabdominal LAD, incidentally noted on CT scan at [**Hospital1 2025**]:
needs outpatient f/u
# CAD s/p CABG [**2167**], s/p stents [**2162**]: Plavix discontinued,
primary cardiologist aware
# HIT
# microcytic anemia: consistent with mixed ACD and iron
deficiency; needs screening colonoscopy
# gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 10162**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted to the hospital because you experienced confusion and
hallucinations, and you fell and hit your head. You were found
to have acute kidney injury, low sodium level, and a brain bleed
(subdural hematoma). Your gabapentin level was also high. You
were treated with fluid with high sodium content and Lasix.
Your symptoms improved and you were no longer confused. Your
kidney function and your electrolytes were back to your baseline
level. Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight
goes up more than 3 lbs.
The following medications were changed:
START taking Daptomycin 450mg through your PICC line every 24
hours through [**2169-7-4**]. An infusion company will help you with
this.
STOP taking gabapentin. This medication can build up in your
body if you have kidney problems.
RESTART you home aspirin 81mg once a day. The neurosurgery team
was in agreement with this.
STOP taking plavix until you see neurosurgery. You can discuss
this with your cardiologist and primary care doctor as well.
EPIPEN: Use once intramuscularly as needed for anaphylactic
reaction to daptomycin.
Lasix: Please take 80 mg by mouth twice a day for the next 4
days until you see your primary care doctor. This is an
increase from your home dose.
Followup Instructions:
Please keep the following appointments:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Address: [**Street Address(2) 75551**] [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 87435**]
Phone: [**Telephone/Fax (1) 67560**]
When: Monday [**2169-7-3**] at 9:45 AM
You will need to have blood work drawn at this appointment: CBC,
chemistry panel, liver function tests, and CK (because of the
daptomycin).
You had an appointment with an infectious disease specialist,
[**First Name4 (NamePattern1) 794**] [**Last Name (NamePattern1) 4334**] Barshak but you prefer to see an infectious disease
specialist closer to your home. Please have Dr. [**Last Name (STitle) 19154**] help you
arrange this.
Please have Dr. [**Last Name (STitle) 19154**] help you arrange a rheumatology
appointment closer to your home.
Department: NEUROSURGERY
When: THURSDAY [**2169-7-27**] at 9:30 AM
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
Department: RADIOLOGY
When: THURSDAY [**2169-7-27**] at 8:45 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Name: [**Known lastname 13914**],[**Known firstname **] Unit No: [**Numeric Identifier 13915**]
Admission Date: [**2169-6-25**] Discharge Date: [**2169-6-30**]
Date of Birth: [**2116-8-13**] Sex: F
Service: MEDICINE
Allergies:
Niacin / Heparin Agents / Vistaril / Propofol / Naprosyn
Attending:[**First Name3 (LF) 1472**]
Addendum:
Of note, patient's vitals upon presentation to the ED on [**2169-6-25**]
at 1300 were recorded. They are as follows: BP 121/92, pulse
67, RR 18. At 1330, vitals were again recorded: BP 147/70,
pulse 69, RR 16. (Please disregard sentence in original
discharge summary stating that vitals in the ED were not
recorded). Moreover, it should be noted that the discharging
medical team had a conversation with Ms. [**Known lastname 13916**] PCP about
transitional issues and further follow-up. A discharge summary
was faxed to Ms. [**Known lastname 13916**] PCP's office.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1473**]
Completed by:[**2169-7-21**]
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13111, 13410
|
2825, 3454
|
3470, 3694
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,572
| 110,345
|
3635
|
Discharge summary
|
report
|
Admission Date: [**2184-12-4**] Discharge Date: [**2184-12-7**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 79 year-old
male with a past medical history of esophageal carcinoma
status post esophagectomy who was recently diagnosed with
ampullar adenocarcinoma status post three endoscopic
retrograde cholangiopancreatographies. The first endoscopic
retrograde cholangiopancreatography was to evaluate
cholangitis with resultant in plastic stent placement. The
secondary endoscopic retrograde cholangiopancreatography was
done to evaluate for another bout of cholangitis and showed
occlusion therefore the plastic stent was replaced with metal
stent on [**2184-12-3**]. The patient also had a
sphincterotomy the next morning. The procedure went well and
the patient was discharged to home. However, the next
morning he spiked temperatures of 104.2 and was taken to [**Hospital6 16522**] where his blood pressure was found to be
70/palpable. CT of the abdomen there showed no bowel
perforation, but some inflammation in the pancreatic head.
The patient was then transferred to [**Hospital1 190**] MICU. In the MICU he was aggressively
hydrated with fluids and started on Ampicillin, Levofloxacin
and Flagyl. Since then the patient has remained afebrile and
normotensive. Repeat endoscopic retrograde
cholangiopancreatography was done on [**12-5**] and showed a
well positioned stent and no biliary obstruction.
Sigmoidoscopy for diarrhea with increased white blood cell
count and fever was done as well at that time and was normal.
The patient started po, which she tolerated well on [**2184-12-6**] and was transferred to the floor.
PAST MEDICAL HISTORY: Esophageal adenocarcinoma status post
[**Last Name (un) 16523**]-[**Doctor Last Name **] esophagectomy in [**2178**]. Ampullary adenocarcinoma
as above. Bilateral deep venous thrombosis with subsequent
PE in [**2174**]. The patient is on long term anticoagulation for
that. Gastroesophageal reflux disease, benign prostatic
hypertrophy and history of colonic polyps.
ALLERGIES: Aspirin and codeine. The patient has
anaphylaxis.
MEDICATIONS ON TRANSFER: Levofloxacin 500 mg po q day,
Pantoprazole 40 mg intravenous q.d., Flagyl 500 mg
intravenous q 8, Ampicillin 2 grams intravenous q 6.
OUTPATIENT MEDICATIONS: Coumadin, Hytrin, Prilosec and
Imodium.
SOCIAL HISTORY: He quit smoking tobacco in the [**2141**] and
denies significant alcohol use. Retired CPA.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature max 99.2, blood pressure
112/68, heart rate 80, respirations 16, oxygen saturation is
99% on room air. General examination no acute distress,
alert and oriented times three. Oropharynx is clear. Mucous
membranes are moist. Sclera mildly icteric, red, beefy tone,
no lymphadenopathy. Lungs clear to auscultation bilaterally.
Cardiovascular examination regular rate and rhythm and normal
S1 and S2. No murmurs, rubs or gallops. Abdomen soft,
nontender, nondistended. Positive bowel sounds. Extremities
no edema. Good pulses in all four extremities.
LABORATORY: White blood cell count 15.2, which was decreased
down from 29.2 on admission. Hematocrit stable at 29.1,
platelets 128, INR 1.3, sodium 140, potassium 3.5, chloride
109, bicarb 20, BUN 20, creatinine 1.0, glucose 140, ALT 38,
AST 29, alkaline phosphatase 217, amylase 87, total bilirubin
0.6, LD 127, lipase 72. CT of the chest, abdomen and pelvis
showed no perforation and focal pancreatitis.
HOSPITAL COURSE: The patient was transferred from the MICU
to the floor where he remained normotensive and afebrile. He
tolerated regular diet well. He was discharged to home on
[**2184-12-7**] on a regular diet.
DISCHARGE MEDICATIONS: Protonix 40 mg po q day, Levofloxacin
500 mg po q day for a total of fourteen day course.
DISCHARGE DIAGNOSIS:
Endoscopic retrograde cholangiopancreatography induced
pancreatitis.
FOLLOW UP: The patient is to follow up with his
hematology/oncology physician as an outpatient.
DISCHARGE CONDITION: Good.
DISCHARGE DIET: Regular.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D.
[**MD Number(1) 7855**]
Dictated By:[**Doctor Last Name 16524**]
MEDQUIST36
D: [**2184-12-13**] 10:35
T: [**2184-12-13**] 10:44
JOB#: [**Job Number 16525**]
|
[
"V12.72",
"530.81",
"600.0",
"E879.8",
"V58.61",
"V12.52",
"V10.03",
"577.0",
"156.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
4040, 4335
|
2476, 2494
|
3738, 3829
|
3850, 3920
|
3515, 3714
|
3932, 4018
|
2308, 2349
|
2517, 3497
|
113, 1663
|
2148, 2283
|
1686, 2122
|
2366, 2459
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,797
| 122,933
|
4314
|
Discharge summary
|
report
|
Admission Date: [**2196-4-1**] Discharge Date: [**2196-4-8**]
Date of Birth: [**2140-8-14**] Sex: F
Service: HEPATOPANCREATIC BILIARY
HISTORY OF PRESENT ILLNESS: The patient is a 56 year old
female with a history of hypertension, fibroids and obesity
who presents with a two week history of lower abdominal pain.
The patient noted approximately one and one half weeks ago
that the pain which had slowly started had increased. The
patient has a long history of uterine fibroids to which she
attributed her pain and did not seek medical attention at
that time.
Four to five days prior to admission, the patient's pain
escalated and she then developed anorexia, nausea and
diarrhea. On the day of admission, she was taken to see her
gynecologist who upon examining her thought the pain
secondary to an intra-abdominal process and referred the
patient to the Emergency Department.
On presentation to the Emergency Department, the patient
reported a constant, sharp pain located in the right lower
quadrant with no prior history of similar pain. The patient
has never had a colonoscopy before.
PAST MEDICAL HISTORY:
1. Uterine fibroids.
2. Hypertension.
3. Coronary artery disease with ETT Thallium test in [**2191**],
showing mild inferior wall ischemia, ejection fraction of
55%, and distant history of prior questionable
catheterization before arrival in this country which showed a
"blockage". The patient had been offered catheterization in
the past and refused.
PAST SURGICAL HISTORY: None.
ALLERGIES: Intravenous contrast.
LABORATORY DATA: Significant for a white blood cell count of
18.6, hematocrit 33.3, platelet count 408,000. Chemistries
were significant for potassium of 3.1. Liver function tests
were within normal limits. Amylase and lipase were 25 and
15, respectively.
KUB was unremarkable. CT of the abdomen showed an
inflammatory mass in the right cecum, question appendicitis
versus cecal tumor with perforation.
Electrocardiogram showed ST depression in I, aVL, V5 and V6.
HOSPITAL COURSE: The patient presented to the Emergency
Department with the above signs and symptoms. Based on her
CT findings, she was taken to the operating room on [**2196-4-1**],
with diagnosis of inflammatory mass of the right lower
quadrant. She underwent a right hemicolectomy under general
endotracheal anesthesia with intraoperative findings of an
inflammatory mass in the right lower quadrant with a
perforated appendix and necrosis of the cecum. There was
also purulent fluid in the right lower quadrant. There were
no complications. The patient received one unit of blood
intraoperatively. Please see the operative note dated
[**2196-4-1**], for further details of this procedure. The patient
tolerated the procedure well, however, secondary to the large
amount of fluid given intraoperatively she remained intubated
and was transferred to the Surgical Intensive Care Unit.
Electrocardiogram done postoperatively as described above.
She was ruled out by enzymes and a cardiology consultation
was called with recommendations for intravenous beta
blockers, changing to p.o. beta blockers postoperatively with
outpatient follow-up for further workup.
She self extubated on postoperative day number three and
remained without respiratory distress. Of note, she had been
diuresed prior to that. She was also hypertensive requiring
intravenous Nitroglycerin which was eventually weaned and
when she was taking p.o. she was switched to her preoperative
regimen. However, she continued to have elevated pressure
and her dosages were increased. In addition, Imdur was added
per cardiology recommendations.
She was started on sips on postoperative day number four
after flatus. Her diet was advanced to clear without
difficulty and she was tolerating a regular diet on
postoperative day number eight. She was transferred out of
the Intensive Care Unit on postoperative day number five.
She overall remained hemodynamically stable from the
infectious disease standpoint. Intraoperative cultures were
done which grew Propionibacterium acnes. The patient was
kept on Levofloxacin, Ampicillin and Flagyl intravenous and
upon taking p.o. she was switched to p.o. Levofloxacin,
Flagyl with Augmentin to complete a fourteen day course. She
remained afebrile throughout her hospital stay.
She was seen by physical therapy with clearance to go home.
Postoperative day eight, the patient was deemed stable for
discharge home in the afternoon pending adequate blood
pressure control on her augmented oral regimen.
CONDITION ON DISCHARGE: Stable, tolerating a regular diet,
ambulating independently, hemodynamically stable.
DISCHARGE STATUS: The patient is discharged to home without
services.
DISCHARGE DIAGNOSES:
1. Status post right hemicolectomy for perforated
appendicitis.
2. Hypertension.
3. Coronary artery disease.
4. History of uterine fibroids.
MEDICATIONS ON DISCHARGE:
1. Potassium Chloride 10 meq p.o. q.d.
2. Percocet one p.o. q4-6hours p.r.n.
3. Vaseretic 20/50 one p.o. q.a.m.
4. Enalapril 20 mg one p.o. q.p.m.
5. Imdur 60 mg p.o. q.d.
6. Lopressor 150 mg p.o. b.i.d.
7. Levofloxacin 500 mg p.o. q.d. times seven days.
8. Augmentin 875 mg p.o. b.i.d. times seven days.
9. Flagyl 500 mg p.o. t.i.d. times seven days.
FOLLOW-UP: The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**]
in two weeks. She is to follow-up with her primary care
physician in one week. She is to follow-up with Dr.
[**Last Name (STitle) **] from cardiology on [**2196-4-20**].
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 2682**]
MEDQUIST36
D: [**2196-4-8**] 11:23
T: [**2196-4-9**] 11:38
JOB#: [**Job Number 18677**]
|
[
"401.9",
"540.0",
"276.8",
"414.01",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
4762, 4908
|
4934, 5835
|
2048, 4558
|
1516, 2030
|
180, 1113
|
1135, 1492
|
4583, 4741
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,010
| 182,601
|
51932
|
Discharge summary
|
report
|
Admission Date: [**2166-5-10**] Discharge Date: [**2166-5-14**]
Date of Birth: [**2091-7-12**] Sex: F
Service: MEDICINE
Allergies:
Enalapril / Shellfish
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Tagged RBC scan
History of Present Illness:
Mrs. [**Known lastname 1557**] is a 75 yo female with h/o HTN, DM, CAD, CHF, breast
cancer, and chronic kidney disease, who presents with one
episode of BRBPR at home with a bowel movement. She states that
she has been constipated without a bowel movement for 2 weeks,
and began taking "sugar candy" which she states helps her move
her bowels. She states that she started having bowel movements
without problem, until 3 am on the morning of admission. At that
point, she had crampy abdominal pain, that was relieved with a
bowel movement, which she noticed had blood in it. She states
that she felt weak after having this bowel movement and sat on
the toilet for a while. She returned to bed eventually, and had
another bowel movement with blood in the stool later that
morning. At this point, she came to the ED.
.
On ROS, the patient denies previous h/o BRBPR, bleeding
disorders, CP, PND, syncope. She reports feeling lightheaded and
week, and states that she has a h/o dark stools (which she
believes is [**1-10**] iron pills), h/o bleeding gums with brushing
teeth, and previous history of epistaxis (now s/p cautery). She
also reports SOB, and orthopnea, now improved.
.
Her most recent colonoscopy/EGD was in [**2159**], and was normal.
.
In the ED, her VS were stable at 98.6, 81, 159/79, 16, 100%RA.
She was found to have BRBPR on rectal exam. While in the ED she
had another episode of BRPBR and was found at that time to have
a hematocrit of 37.9.
Past Medical History:
HTN
DM (dx [**2130**])
CAD
CHF
Chronic kidney disease (eGFR = 11; baseline Cr 3.4-3.7).
Anemia [**1-10**] chronic kidney disease
Breast cancer (invasive ductal, dx [**2156**]). diagnosed [**9-/2157**]
with a 1.5 cm grade II infiltrating ductal cancer of the right
breast, clean lymph nodes, ER positive, HER-2/neu negative. In
remission s/p five years on tamoxifen
Renal osteodystrophy
Hypercholesterolemia
TB @ 21 yo, s/p lobectomy
Fibroids, s/p hysterectomy
Diverticulosis
Social History:
The patient lives with her daughter, who is [**Initials (NamePattern4) **] [**Name (NI) 86**] police
officer. She denies smoking, EtOH, or IVDU.
Family History:
Mother -- breast cancer
[**Name (NI) **] -- breast cancer
Brother -- melanoma
Physical Exam:
Tm/Tc 99.9 BP 163/65 (140-170/60-70) HR 99 (89-102) RR 23 O2
97%RA
I/O 290/775
.
Gen: Elderly female lying in bed in nad
HEENT: MMM, PERRL
CV: RRR, +systolic murmor LUSB.
Chest: CTAB, no c/w/r
Abd: no tenderness, no rebound or guarding. +BS.
Ext: WWP, 2+ DP bilaterally
Pertinent Results:
[**2166-5-10**] 02:00PM BLOOD WBC-15.2* RBC-4.78 Hgb-12.5 Hct-37.9
MCV-79* MCH-26.1* MCHC-33.0 RDW-16.8* Plt Ct-252
[**2166-5-11**] 02:38AM BLOOD WBC-15.1* RBC-3.98* Hgb-10.5* Hct-30.6*
MCV-77* MCH-26.3* MCHC-34.2 RDW-16.4* Plt Ct-204
[**2166-5-14**] 06:02AM BLOOD WBC-8.9 RBC-4.16* Hgb-11.3* Hct-33.7*
MCV-81* MCH-27.2 MCHC-33.6 RDW-17.2* Plt Ct-200
[**2166-5-10**] 02:00PM BLOOD PT-10.9 PTT-26.5 INR(PT)-0.9
[**2166-5-10**] 02:00PM BLOOD Glucose-162* UreaN-78* Creat-3.9* Na-141
K-4.6 Cl-104 HCO3-21* AnGap-21*
[**2166-5-14**] 06:02AM BLOOD Glucose-104 UreaN-51* Creat-3.0* Na-139
K-4.2 Cl-107 HCO3-22 AnGap-14
[**2166-5-10**] 02:00PM BLOOD ALT-11 AST-26 AlkPhos-97 Amylase-125*
TotBili-0.5
[**2166-5-10**] 08:45PM BLOOD ALT-9 AST-19 LD(LDH)-386* AlkPhos-92
Amylase-97 TotBili-0.7
[**2166-5-10**] 08:45PM BLOOD Calcium-9.5 Phos-4.0# Mg-2.4
[**2166-5-14**] 06:02AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.1
[**2166-5-11**] 04:30PM BLOOD Lactate-1.0
[**5-10**]:
CT ABDOMEN WITHOUT CONTRAST: The lung bases are clear without
nodule, opacity or effusion. The heart is grossly normal in
appearance without pericardial effusion.
Limited evaluation of the intraabdominal organs can be made
given lack of contrast administration. However, no abnormality
is detected within the liver, gallbladder, pancreas, spleen, or
adrenal glands. Multiple cystic lesions are identified in the
kidneys bilaterally including a hyperdense cyst within the lower
pole of the left kidney measuring 1.2 cm in diameter and a right
interpolar region hyperdense cyst measuring 3.2 cm in diameter.
These cysts are unchanged aside from a slight increase in size
of an exophytic hemorragic cyst within the right interpolar
region.
There is no free fluid or free air present within the abdomen.
No pathologically enlarged mesenteric or retroperitoneal
lymphadenopathy identified.
CT PELVIS WITHOUT CONTRAST: Wall thickening and submucosal edema
with surrounding fat strandings identified within a long segment
of the colon including the entire descending and majority of
transverse colon. There is sigmoid diverticulosis without
evidence of diverticulitis. Atherosclerotic changes within the
descending abdominal aorta without aneurysmal dilatation. The
rectum, bladder and distal ureters are visualized and
unremarkable.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are
identified within the osseous structures.
IMPRESSION:
1. Wall thickening with submucosal edema vs hemmorage and
surrounding fat stranding within a long segment of the
transverse and descending colon consistent with colitis with
ischemic etiology less likely.
2. Multiple simple and hyperdense renal cysts in the kidneys
bilaterally, generally unchanged in appearance since MRI, [**4-20**], [**2163**] aside from a slight increase in a previously
characterized hemmoragic cyst within the right interpolar
region.
3. Diverticulosis without evidence of diverticulitis.
Chest radiographs:
PA and lateral radiographs of the chest demonstrate mild
cardiomegaly, unchanged when compared to multiple previous
examinations. Right upper lung volume loss also remains
unchanged. Remodeling of the posterior right third rib is
similar in appearance. Biapical pleural thickening is unchanged.
Increased opacity projecting over the right upper lung is more
conspicuous than seen on [**2166-2-4**]. The costophrenic angles are
sharp. No pneumothorax. Appearance of the right lateral fourth
and fifth ribs is unchanged.
IMPRESSION:
Right upper lung volume loss and biapical pleural thickening,
unchanged.
Increased opacity projecting over the right upper lung, seen on
the PA view only. The finding may represent summation of soft
tissue structures, but a pulmonary opacity is not excluded.
Assessment with routine CT examination of the chest is
recommended for more specific evauation.
[**2166-5-11**]:
Tagged RBC scan:
NTERPRETATION: Following intravenous injection of autologous red
blood cells
labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the
abdomen for minutes
were obtained.
Blood flow images show no abnormality.
Dynamic blood pool images show no active GI bleeding.
IMPRESSION:
No active bleeding source identified after 90 minutes of
scanning.
[**2166-5-13**]:
FINDINGS:
There is no evidence of acute fracture or dislocation. There is
diffuse bony osteopenia. The ankle mortise is intact, and the
joint spaces appear well preserved. Minimal plantar calcaneal
spurring is identified. Small well- corticated osseous fragments
are noted just distal to the lateral malleolus, likely
degenerative.
IMPRESSION:
No evidence of acute fracture or dislocation. Diffuse
osteopenia. Please note, a repeat examination with a marker
device over site of greatest pain may be beneficial.
Brief Hospital Course:
75 yof with htn, h/o CAD, CHF, CKD, breast CA who presented with
BRBPR.
GIB - Initially concerning given her risk factors and hematocrit
drop initially. However, the tagged RBC scan did not show a
significant area of bleeding. Given that her hct was stable and
she did not have signficnat BRBPR after the initial episode, GI
recommended having a colonoscopy in 1 months time. Cause of the
bleeding was likely mesenteric ischemia vs. diverticulosis vs.
AVM. However given stranding on CT and no symptoms while NPO,
mesenteric ischemia likely. Regardless, she was continued on
treatment for presumed colitis.
Renal:She has baseline chronic renal failure; baseline Cr
3.4-3.7. Admission Cr 3.7 that returned to baseline by
discharge. Nephrotoxic agents were avoided and Procrit was
continued.
CV: H/o HTN, CAD(although daughter denies previous MI), CHF.
Most recent Echo ([**2-12**]) shows EF 55-60%.
- Continue metoprolol 100 tid (outpt dose toprol XL 300),
amlodipine.
- Clonidine was held initially. Aspirin was restarted on
discharge and telemetry was without significant events.
Endo: H/o IDDM. She was continued on NPH at 1/2 home dose (13
units)
That was returned to her home schedule on discharge
.
# FEN: tolerating a full diet at discharge
# PPX: PPI.
# Code: Full
# Comm: [**Name (NI) **], daughter, [**Telephone/Fax (1) 107512**] (c)
Medications on Admission:
Omeprazole 40 mg daily
Clonidine 2 mg daily
Toprol XL 300 mg daily
Norvasc 10 mg daily
Furosemide 80 mg in the morning, 40 mg in the evening
Lovastatin 20 mg daily
ASA 81 mg daily
Iron 325 mg daily
Calcitriol 0.25 mcg every M-W-F
Colace 100 mg daily
Procrit 5000 u/0.25 ml s/c weekly
Novolin 26 u every AM
Humalog 2 units every AM
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
3. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
9. Furosemide 40 mg Tablet Sig: as dir Tablet PO BID (2 times a
day): 2 tablets every morning, 1 tablet each night.
10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as dir
Subcutaneous QIDACHS: Please resume your home regimen (26 U in
the morning with a sliding scale).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
12. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
13. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day.
14. Epogen Injection
15. Ferrous Gluconate 325 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
16. Hectorol 2.5 mcg Capsule Sig: One (1) Capsule PO three times
a week: Monday, wed, friday.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: colitis, hematochezia
Secondary: diabetes, chronic kidney disease, anemia,
diverticulosis, fibroids, heart failure, hypertension
Discharge Condition:
stable hct, asymptomatic
Discharge Instructions:
You were admitted with bleeding in your stool. This was likely
caused by inflammation in your bowels. The inflammation may
have been caused by infection and you are being treated with
antibiotics.
Please keep all follow up appointments.
Please take all medications as prescribed
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2166-5-21**] 10:30
Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2166-5-27**] 11:50
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2166-6-25**] 10:00
You have a colonoscopy scheduled for [**6-17**], tuesday [**Hospital Ward Name 12837**] [**Hospital Ward Name 121**] 12:30 PM. Dr. [**First Name (STitle) 2643**]. They will call you regarding
the preparation for this. You also need a follow up appointment
with GI. Please call ([**Telephone/Fax (1) 17114**] to make this appointment.
Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Date/Time:[**2166-6-17**] 12:30
|
[
"285.1",
"403.90",
"557.1",
"250.00",
"729.5",
"428.30",
"428.0",
"009.1",
"272.0",
"585.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10942, 11000
|
7658, 9012
|
310, 327
|
11181, 11207
|
2880, 7635
|
11538, 12409
|
2494, 2574
|
9394, 10919
|
11021, 11160
|
9038, 9371
|
11231, 11515
|
2589, 2861
|
243, 272
|
355, 1816
|
1838, 2316
|
2332, 2478
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,572
| 136,075
|
14869
|
Discharge summary
|
report
|
Admission Date: [**2138-8-3**] Discharge Date: [**2138-8-20**]
Date of Birth: [**2099-2-5**] Sex: F
Service: HEPATOBILIARY SURGERY
CHIEF COMPLAINT: Acute pancreatitis.
HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old
woman transferred from [**Hospital6 43614**] Center for
treatment of severe pancreatitis. She was transferred to
[**Hospital6 43614**] Center on [**2138-8-1**], after
presenting to another hospital the day before with the sudden
onset of severe epigastric pain with nausea and vomiting. On
admission she was tachycardiac and tachypneic and febrile.
She had significant abdominal tenderness at this time. She
had a leukocytosis with WBC of 15.7 and 5 bands. Amylase was
1128, and lipase was 5856. She was resuscitated with fluids
but became hypotensive and required 9 L of Crystalloid on
[**8-3**]. A CT scan of the abdomen and pelvis without
contrast was performed which demonstrated marked
peripancreatic inflammation with phlegmon and fluid. She
developed significant bandemia to 33. Her hematocrit was 45
on [**8-2**] which fell to 35 on [**7-3**]. Given the
severity of her pancreatitis and concern for pancreatic
necrosis, the patient was started on Imipenem. Her amylase
upon presentation to the [**Hospital6 256**]
was 243. Her LFTs had normalized. She was intubated for
transport with a pO2 of 65 on 60% FI02. She required an
Insulin drip for hyperglycemia.
PAST MEDICAL HISTORY: 1. Insulin-dependent diabetes
mellitus. 2. Hypertension. 3. Hypercholesterolemia.
PAST SURGICAL HISTORY: 1. Total hip replacement. 2. Open
reduction and internal fixation. 3. Deviated septum. 4.
Bunionectomy.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Insulin, Aspirin, Zocor, Prinivil.
SOCIAL HISTORY: The patient does not smoke. She is a social
drinker.
PHYSICAL EXAMINATION: Vital signs: Temperature 100.8??????,
pulse 217, blood pressure 127/68, respirations 13, oxygen
saturation 98%, vent settings for CMV of 650 x 10 space 5
space 100%. Arterial blood gas on admission was 7.33, 46,
127, 25, -1. General: The patient was intubated, sedated,
but was responsive to painful stimuli. HEENT: Pupils equal,
round and reactive to light and accommodation. Extraocular
eye movements intact. She was anicteric. Nasogastric tube
in place. Chest: Coarse bilaterally. Heart: Tachycardiac
but regular. Abdomen: Distended and tympanitic. Tender to
palpation. Extremities: Without clubbing, cyanosis, or
edema.
HOSPITAL COURSE: The patient was admitted to the Surgical
Intensive Care Unit for further evaluation and treatment for
pancreatitis. The patient was continued on Imipenem. She
remained intubated and sedated on Fentanyl and Ativan.
Insulin drip was continued for control of her hyperglycemia.
The patient continually spiked fevers with a T-max of 102?????? on
hospital day #2 and 103?????? on hospital day #3. Blood cultures
were obtained with these spikes. She also had decreased PA
O2s during her hospital stay.
Sputum cultures were obtained which revealed 2+ gram-negative
rods, 1+ gram-positive rods, and 1+ gram-positive cocci.
Sputum cultures grew Haemophilus influenza and Imipenem was
continued for her pancreatitis and pneumonia. Repeat CT scan
was also performed which revealed no evidence of pancreatic
necrosis.
Due to her continued pulmonary issues, on hospital day #4, an
esophageal balloon manometer was used to calculate
transpulmonary pressures. The patient was also started on
TPN for nutritional supplementation. On hospital day #5, it
was decided to also add trophic tube feeds through an NG
which was placed extending to the third to fourth portion of
the duodenum. The patient tolerated these feeds well.
The patient continued to be treated with fluid resuscitation,
as well as treatment for her pneumonia and pancreatitis.
Serial chest x-rays revealed improvement in her pulmonary
status. She also continued to spike fever over the next
several days. Cultures were obtained with these fever
spikes; however, no organisms were isolated.
Pulmonary status did progressively improve; however, it
remained very serious with the appearance of ARDS. With the
progressive resolution of her pancreatitis, she became more
hemodynamically stable, and she was able to be progressively
diuresed with Lasix as needed.
On hospital day #7, the patient was transfused 2 U of packed
red blood cells for a falling hematocrit which had decreased
to 22.3. She was also started on Epogen once a week.
On SICU day #8, the patient began having loose stools which
were found to be C-diff positive. She was started on Flagyl,
in addition to the Imipenem. Repeat CT scan on SICU day #11
revealed no obvious abscess or fluid collections in the
abdomen. Chest was remarkable for bilateral pleural
effusions which were progressively improving.
The patient's pulmonary status continued to improve. Her
vent settings were weaned, and she was extubated on hospital
day 12. Her fever curve continued to trend down as well.
Her tube feeds were increased to goal, and she continued to
be diuresed. Imipenem was discontinued after a two-week
course. NG tube was discontinued, and the patient was slowly
progressed on an oral diet. She continued to do well and was
transferred to the floor on hospital day #16.
By [**2138-8-21**], the patient was tolerating a regular
diet. Her abdominal pain had completely resolved. She was
ambulating well without assistance. She completed a 10-day
course of Flagyl. Repeat CBC, CHEM10, LFTs, amylase, and
lipase were within normal limits. She was started on Lipitor
80 mg q.d. and Niacin SR 500 mg b.i.d. because of the
possibility that hypertriglyceridemia was the cause of her
acute pancreatitis. Triglyceride levels at the outside
hospital were measured to be over 1000.
On hospital day #18, the patient was felt stable for
discharge home.
DISCHARGE PHYSICAL EXAMINATION: Vitals signs: Temperature
99.8??????, pulse 66, blood pressure 120/70, respirations 20,
oxygen saturation 95% on room air. Heart: Regular, rate and
rhythm. Lungs: Clear to auscultation bilaterally. Abdomen:
Soft, nontender, nondistended. Normoactive bowel sounds.
Extremities: Without clubbing, cyanosis, or edema.
DISCHARGE MEDICATIONS: Insulin 30 U NPH in the morning and
at dinner, Lipitor 80 mg q.d., Niacin SR 500 mg b.i.d.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient is to be discharged home.
DISCHARGE DIAGNOSIS:
1. Acute pancreatitis likely secondary to
hypertriglyceridemia.
2. Systemic inflammatory response syndrome.
3. Acute respiratory distress syndrome.
4. Haemophilus pneumoniae.
6. Clostridium difficile colitis.
7. Insulin-dependent diabetes mellitus.
8. Hypertriglyceridemia.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Name8 (MD) 11235**]
MEDQUIST36
D: [**2138-8-20**] 13:59
T: [**2138-8-20**] 14:18
JOB#: [**Job Number 43615**]
|
[
"250.01",
"518.82",
"401.9",
"272.1",
"785.0",
"008.45",
"577.0",
"790.01",
"482.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"96.6",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
6296, 6388
|
6501, 7034
|
1740, 1776
|
2532, 5925
|
1564, 1713
|
5948, 6272
|
170, 191
|
220, 1429
|
1452, 1540
|
1793, 1848
|
6413, 6480
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,882
| 177,888
|
46480
|
Discharge summary
|
report
|
Admission Date: [**2173-11-23**] Discharge Date: [**2173-12-19**]
Date of Birth: [**2103-11-27**] Sex: F
Service: MEDICINE
Allergies:
A.C.E Inhibitors / Ativan / Ambien / Lisinopril
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
change in mental status
Major Surgical or Invasive Procedure:
L BKA
History of Present Illness:
69 yo female w/ malignant HTN, DM, ESRD on HD, CAD, CHF (EF
55%), CVA, s/p R BKA 3 weeks ago, recent MSSA bacteremia s/p
line change,recent colitis, who was taken to [**Hospital 8**] Hospital
from [**Hospital **] rehab after 24hrs of hypotension to SBP 80's-90's
and new mental status changes s/p HD. Pt was found unresponsive
this AM with SBP in 60's, FS of 163. At [**Name (NI) 8**] Hospital, pt
was noted to have R fixed and dilated pupil. Pt was also found
to be lethargic and aphasic. At [**Name (NI) 8**] Hospital, pt had the
following vitals: T 97.9 BP 91/53 HR 97 RR 20 sat 100% 15L FM.
CXR showed RLL infiltrate, sugestive of aspiration PNA. Pt was
transferred to [**Hospital1 18**] for further workup. In the [**Name (NI) **], pt was
hypotensive to 80's-90's, was seen by neuro and found to have L
facial droop with L sided weakness. Pt also had fever to 101
rectally. Pt was given 2L NS, vanc/levo/flagyl, and 2mg IV
morphine.
Past Medical History:
DM >30 years with neuropathy, nephropathy, and retinopathy
ESRD on HD MWF
PVD s/p multiple bypasses and Right BKA [**2173-11-1**]
CAD s/p MI in [**2158**], CHF, EF on TTE [**2172**] was normal
stroke [**2158**], [**2170**] - both presented with right sided weakness,
found to have parapontine stroke in [**2170**] and was placed on
aggrenox, MRA [**2171**] shows left vertebral stenosis of the neck and
intracranial atherosclerotic disease
DVT - (?treatment)
hyperhomocysteinemia
anemia
HTN
cervical spondylosis s/p C4-7 fusion [**2168**]
question of dementia ?
h/o multiple delirium admissions due to drugs (benzos, etc)
indwelling foley cath
MSSA bacteremia
? aspiration pneumonia
Colitis
Social History:
DNR/DNI, daughter is HCP [**Name (NI) **] [**Name (NI) 1661**] [**Telephone/Fax (1) 98751**].
Former [**Male First Name (un) **] at NE [**Location (un) **], has 4 PhD's. 5 kids. Widowed. No
tob/etoh/drugs. Has not lived at home since [**Month (only) 205**] (formerly
lived with her kids).
Family History:
HTN
CAD/MI
Physical Exam:
On admission:
Vitals: T 98.6 BP 121/61 HR 99 RR 20 O2 97% 3L
Gen: Elderly woman, lying in bed, uncomfortable. Lethargic,
but arousable and responsive to commands.
HEENT: PERRL. EOMI intact, but sluggish. OP dry.
Neck: R tunneled cath on R side. Unable to appreciate JVD.
Cardio: RRR, no m/r/g appreciated.
Resp: Course BS anteriorly.
Abd: soft, diffusely tender, +BS, no rebound/guarding, no
masses.
Ext: s/p R BKA, wound appears intact, but tender. L extremity
cold, with gangrenous foot and necrotic toes.
Neuro: Lethargic. Oriented to person and place only. Able to
follow commands. Mild L sided weakness and L facial droop.
Pertinent Results:
REPORTS:
MR HEAD W/O CONTRAST [**2173-11-23**] 7:49 PM
IMPRESSION:
1. MRI of the brain demonstrates two areas of diffusion signal
abnormality, which indicates recent infarction. There are new
areas of susceptibility artifacts since the old study, but
stable appearance of multiple chronic microvascular infarctions.
2. MRA of the circle of [**Location (un) 431**] is extremely limited due to
motion artifact. Flow is observed in the major branches of this
circulation, but vessels cannot be further assessed.
CTA ABD W&W/O C & RECONS [**2173-11-23**] 3:05 PM
IMPRESSION:
1. Right lower lobe collapse/consolidation with small bilateral
pleural effusions.
2. Prominence of the intra and extrahepatic biliary duct system,
which is more than expected given the patient's age and history
of prior cholecystectomy. Clinical correlation with the
patient's LFTs is recommended.
3. Atrophic kidneys bilaterally with multiple complex cysts
demonstrated. One of these cysts within the mid pole of the
right kidney demonstrates enhancement after contrast
administration, which is concerning for a neoplastic process.
Further evaluation of these renal cysts can be performed with
MRI.
4. Patent mesenteric vessels without evidence of mesenteric
ischemia.
TTE:
Conclusions:
1. The left atrium is normal in size.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal
(LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation
seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation
seen.
6.Moderate [2+] tricuspid regurgitation is seen.
7.There is mild pulmonary artery systolic hypertension.
8.There is no pericardial effusion.
EKG:
Sinus rhythm
Consider left atrial abnormality
Prior anteroseptal myocardial infarction
Modest nonspecific low amplitude T waves
Since previous tracing of [**2173-11-23**], ventricular ectopy absent
CHEST (PA & LAT) [**2173-11-28**] 11:00 AM
IMPRESSION: Probable atelectasis and/or scarring at both bases.
Slight blunting right costophrenic angle, which is equivocally
more prominent than on prior exams. Otherwise, no evidence of
acute pulmonary process.
CT ABDOMEN W/O CONTRAST [**2173-12-1**] 3:45 PM
1. Hyperdense bilateral kidney cysts, stable from the previous
examination and worrisome for neoplastic process in partcular in
the right kidney. Further evaluation of these cysts with MRI is
recommended.
2. Interval improvement of the right lower lobe consolidation
with small bilateral pleural effusions. The remaining right
nodular consolidation is worrisome for metastasis given the
appearance of the kidneys and followup is recommended.
3. Prominence of the intra and extrahepatic biliary ductal
system, stable compared to the prior examination.
4. Subcutaneous nodule in the left lateral abdominal wall of
uncertain clinical significance.
5. No evidence of colitis.
CTA HEAD W&W/O C & RECONS [**2173-11-26**] 1:49 PM
IMPRESSION:
1. Bilateral exuberant calcifications at the carotid
bifurcations with approximately 60% stenosis at the right
internal and 30-40% stenosis at the left internal origins.
2. Moderate-to-severe stenosis of the bilateral cavernous and
supraclinoid internal carotid arteries with exuberant
calcifications.
3. Exuberant calcifications involving distal vertebral arteries
with more than 50% stenosis involving both distal vertebral
arteries, Left > Right.
4. Diffuse atherosclerotic disease involving the basilar artery.
5. Somewhat poor opacification of the vascular structures could
be related to low contrast injection rate from inadequate IV
access.
6. Other changes as described above.
Abdominal MRI (prelim):
Likely bilateral renal cell carcinoma
PATH:
DIAGNOSIS:
Left below-the-knee amputation:
Gangrenous necrosis, distal foot.
Severe atherosclerosis.
Resection margins free of inflammation and necrosis.
LABS:
[**2173-12-5**] 06:05AM BLOOD WBC-14.1* RBC-2.75* Hgb-8.7* Hct-28.8*
MCV-105* MCH-31.7 MCHC-30.3* RDW-23.5* Plt Ct-505*
[**2173-12-1**] 03:56AM BLOOD WBC-18.8* RBC-2.75* Hgb-8.7* Hct-29.3*
MCV-106* MCH-31.5 MCHC-29.6* RDW-21.8* Plt Ct-561*
[**2173-11-29**] 06:20AM BLOOD WBC-18.1* RBC-3.10* Hgb-10.0* Hct-32.2*
MCV-104* MCH-32.3* MCHC-31.0 RDW-21.4* Plt Ct-498*
[**2173-11-27**] 06:27AM BLOOD WBC-15.1* RBC-3.08* Hgb-10.3* Hct-31.5*
MCV-103* MCH-33.4* MCHC-32.5 RDW-20.8* Plt Ct-405
[**2173-11-24**] 05:20AM BLOOD WBC-14.5* RBC-3.17* Hgb-10.3* Hct-34.3*
MCV-108* MCH-32.5* MCHC-30.0* RDW-20.8* Plt Ct-383
[**2173-11-23**] 09:50AM BLOOD WBC-12.4* RBC-3.08* Hgb-10.2* Hct-32.3*
MCV-105* MCH-33.0* MCHC-31.4 RDW-20.5* Plt Ct-411
[**2173-11-29**] 06:20AM BLOOD Neuts-84.6* Lymphs-10.6* Monos-2.8
Eos-1.5 Baso-0.4
[**2173-11-25**] 06:00AM BLOOD Neuts-82.2* Lymphs-11.5* Monos-3.8
Eos-2.4 Baso-0.2
[**2173-11-23**] 09:50AM BLOOD Neuts-83.0* Lymphs-12.7* Monos-3.8
Eos-0.4 Baso-0.2
[**2173-12-5**] 06:05AM BLOOD Plt Smr-VERY HIGH Plt Ct-505*
[**2173-12-4**] 05:56AM BLOOD PT-12.9 PTT-39.2* INR(PT)-1.1
[**2173-12-2**] 06:11AM BLOOD Plt Smr-HIGH Plt Ct-586*
[**2173-11-30**] 04:05AM BLOOD Plt Smr-HIGH Plt Ct-532*
[**2173-11-29**] 05:21PM BLOOD PT-13.9* PTT-40.8* INR(PT)-1.3
[**2173-11-29**] 06:20AM BLOOD PT-15.1* PTT-56.5* INR(PT)-1.5
[**2173-11-28**] 06:32AM BLOOD PT-15.1* PTT-51.2* INR(PT)-1.6
[**2173-11-27**] 06:27AM BLOOD PT-14.2* PTT-49.2* INR(PT)-1.4
[**2173-11-26**] 05:55AM BLOOD PT-14.6* PTT-72.1* INR(PT)-1.5
[**2173-11-25**] 06:00AM BLOOD PT-14.7* PTT-49.8* INR(PT)-1.5
[**2173-11-24**] 05:20AM BLOOD Plt Smr-NORMAL Plt Ct-383
[**2173-11-24**] 05:20AM BLOOD PT-39.1* PTT-96.0* INR(PT)-11.9
[**2173-11-23**] 11:45AM BLOOD PT-14.1* PTT-52.5* INR(PT)-1.3
[**2173-11-26**] 05:55AM BLOOD Ret Aut-1.8
[**2173-12-5**] 06:05AM BLOOD Glucose-188* UreaN-32* Creat-4.8*# Na-140
K-3.3 Cl-99 HCO3-27 AnGap-17
[**2173-12-2**] 06:11AM BLOOD Glucose-99 UreaN-22* Creat-4.2* Na-141
K-4.0 Cl-103 HCO3-25 AnGap-17
[**2173-11-29**] 05:21PM BLOOD Glucose-183* UreaN-13 Creat-3.2*# Na-138
K-3.9 Cl-98 HCO3-27 AnGap-17
[**2173-11-28**] 06:32AM BLOOD Glucose-74 UreaN-16 Creat-3.9* Na-138
K-3.7 Cl-98 HCO3-26 AnGap-18
[**2173-11-26**] 05:55AM BLOOD Glucose-107* UreaN-19 Creat-4.8* Na-135
K-3.5 Cl-100 HCO3-25 AnGap-14
[**2173-11-25**] 06:00AM BLOOD Glucose-88 UreaN-24* Creat-5.6* Na-136
K-4.3 Cl-99 HCO3-23 AnGap-18
[**2173-11-23**] 09:50AM BLOOD Glucose-131* UreaN-15 Creat-4.0*# Na-137
K-3.6 Cl-98 HCO3-26 AnGap-17
[**2173-11-29**] 05:21PM BLOOD CK(CPK)-111
[**2173-11-26**] 05:55AM BLOOD CK(CPK)-250*
[**2173-11-25**] 06:00AM BLOOD CK(CPK)-348*
[**2173-11-24**] 05:20AM BLOOD CK(CPK)-378*
[**2173-11-24**] 12:12AM BLOOD CK(CPK)-330*
[**2173-11-23**] 09:50AM BLOOD ALT-5 AST-15 CK(CPK)-159* AlkPhos-110
Amylase-34 TotBili-0.2
[**2173-11-29**] 05:21PM BLOOD CK-MB-5 cTropnT-0.17*
[**2173-11-26**] 05:55AM BLOOD CK-MB-4 cTropnT-0.16*
[**2173-11-25**] 06:00AM BLOOD CK-MB-6 cTropnT-0.17*
[**2173-11-24**] 05:20AM BLOOD CK-MB-6 cTropnT-0.18*
[**2173-11-24**] 12:12AM BLOOD CK-MB-7 cTropnT-0.17*
[**2173-11-23**] 09:50AM BLOOD CK-MB-6 cTropnT-0.12*
[**2173-12-5**] 06:05AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0
[**2173-12-1**] 03:56AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.5
[**2173-11-29**] 07:40AM BLOOD Albumin-1.9* Calcium-8.7 Phos-3.7 Mg-2.2
[**2173-11-27**] 08:50AM BLOOD Albumin-1.9* Calcium-8.2* Phos-2.7 Mg-1.6
[**2173-11-24**] 05:20AM BLOOD Calcium-8.0* Phos-5.8*# Mg-1.7
[**2173-11-26**] 05:55AM BLOOD calTIBC-46* Ferritn-GREATER TH TRF-35*
[**2173-11-23**] 09:50AM BLOOD Folate-7.0
[**2173-11-25**] 06:00AM BLOOD Triglyc-102 HDL-24 CHOL/HD-2.0 LDLcalc-4
[**2173-11-23**] 09:50AM BLOOD Homocys-3.0*
[**2173-11-24**] 12:45PM BLOOD TSH-2.3
[**2173-11-25**] 08:25AM BLOOD PTH-218*
[**2173-11-25**] 06:00AM BLOOD Cortsol-36.4*
[**2173-11-25**] 05:09AM BLOOD Cortsol-30.0*
[**2173-11-25**] 04:17AM BLOOD Cortsol-13.0
[**2173-12-5**] 06:05AM BLOOD Vanco-14.3*
[**2173-12-4**] 05:56AM BLOOD Vanco-15.5*
[**2173-12-3**] 05:37AM BLOOD Vanco-20.2*
[**2173-12-2**] 06:11AM BLOOD Vanco-8.4*
[**2173-12-1**] 03:56AM BLOOD Vanco-9.1*
[**2173-11-30**] 04:05AM BLOOD Vanco-8.8*
[**2173-11-25**] 06:00AM BLOOD Vanco-22.4*
[**2173-11-24**] 05:20AM BLOOD Vanco-12.7*
[**2173-11-24**] 12:12AM BLOOD Vanco-15.2*
[**2173-11-23**] 09:50AM BLOOD Valproa-<3*
[**2173-11-29**] 05:38PM BLOOD Type-ART pO2-84* pCO2-40 pH-7.44
calHCO3-28 Base XS-2
[**2173-11-29**] 01:02PM BLOOD Type-ART O2 Flow-5 pO2-161* pCO2-57*
pH-7.39 calHCO3-36* Base XS-8 Intubat-NOT INTUBA
[**2173-11-29**] 05:37PM BLOOD Lactate-3.0*
[**2173-11-23**] 10:03AM BLOOD Lactate-1.1
MICRO:
Blood cx: NGTD (x 14 cultures)
Stool cx: C.dif negative (x 3)
Brief Hospital Course:
A/P: Pt is 69 yo female with multiple medical problems,
including ESRD on HD, recent MSSA bacteremia, and CAD who
presented s/p multiple episodes of hypotension, fever, and acute
R frontal and R cerebellar infarcts. Pt was s/p L BKA last week.
.
#) Neuro: Pt with R frontal and R cerebellar infarcts. Pt with
hx of multiple strokes in the past. Pt had decreased
responsivenes for past 3 days.
- previously followed by stroke service. Stroke workup
completed.
- ASA was given
- strict BP control instituted (goal SBP 140-180's, MAP <110)
- TTE negative for source of embolus
- unclear reason for pt's decreased responsiveness over past
several days, possible infection vs. stroke, although likely
multifactorial
.
#) CV: Pt with hx of MI, hx of CHF (EF 55% by last TTE).
- ASA
- lipitor
- held all antihypertensives given hx of hypotension.
- vascular followed. Pt was s/p L BKA last week.
.
#) ID: Pt with hx of MSSA bacteremia, with episodes of
hypotension and fever. Pt afebrile over past several days.
- pt afebrile overnight. Blood cx's negative to date.
- pt was on vanc/levo/flagyl empirically, given hx of
hypotension and fever
- sacral decub possible source of pt's prior fevers
- WBC count had been trending down
- urine cx from [**12-7**] growing yeast, pt unable to take PO
treatment
.
#) Renal: Pt with ESRD on HD.
- prelim MRI read shows that BL renal masses are very suspicious
for renal cell carcinoma
- pt was dialyzed every MWF
- Abd CT findings:
1. Hyperdense bilateral kidney cysts, stable from the previous
examination and worrisome for neoplastic process. Further
evaluation of these cysts can be performed with MRI.
2. Interval improvement of the right lower lobe consolidation
with small bilateral pleural effusions. The remaining right
nodular consolidation is worrisome for metastasis given the
appearance of the kidneys and followup is recommended.
3. Prominence of the intra and extrahepatic biliary ductal
system, stable compared to the prior examination.
4. Subcutaneous nodule in the left lateral abdominal wall of
uncertain clinical significance.
5. No evidence of colitis.
.
#) GI: Pt had frequent episodes of liquid green stool.
- C. dif negative x 3, O&P negative x 1. Stool negative for
salmonella/shigella.
.
#) Endocrine: DM was stable.
- TSH normal
- cosyntropin stim test normal
- RISS was given
.
#) L leg pain/cramping: Pt s/p recent BKA on R, now s/p L BKA.
- PRN oxycodone was used for pain
- occasional dosees of toradol (between dialysis sessions) were
given as well
- Pt's pain was difficult to control without oversedation or
decreased BP.
.
#) Anemia: iron studies consistent with ACD.
- pt was transfused occasionally at dialysis for goal hct>30
.
#) FEN: Pt passed swallow eval on admission, but has been unable
to take PO the past several days [**3-3**] somnolence. TPN also given
since poor PO intake. Family was not in favor of PEG/Dobhoff for
long-term feeding.
.
#) PPX: Hep SC, PPI.
.
#) Code: Pt was DNR/DNI. Health care proxy then made pt [**Name (NI) 3225**].
Pt was given morphine titrated to comfort. All additinoal meds
and blood draws were d/c'd. Dialysis was stopped. The attending
and pt's PCP were aware of the change to [**Name (NI) 3225**].
Addendum:
Pt expired after several days of [**Name (NI) 3225**] care.
Medications on Admission:
(per [**Hospital1 **] records)
Insulin
cholestyramine/sucro 4 gram [**Hospital1 **] (?) PO
trypsin/balsam [**Location (un) 15555**] to excoriations q 12 hrs TP
bismuth prn
neurontin 300mg ([**Hospital1 **]?) PO
Zinc sulfate 220 mg PO daily
ascorbic acid 500mg daily
valsartan 40mg daily
metoprolol 100mg PO (frequency?)
amlopidine 10mg PO daily
topical lidocaine
epo 5000 units IV q WMF
diphenhydramine prn
heparin [**2168**] units IV q MWF
glycerin prn
mvi
latanoprost one drop to each eye (daily?)
SC heparin 5000 units q 8
tylenol 975 mg PO QID
isosorbide mononitrate 30mg PO daily
cyanocobalomin 25 mcg daily
atorvastatin 40mg daily
sertraline 50mg [**Hospital1 **]
lansoprazole 30mg daily
oxycodone 2.5mg q 6 hrs prn
vancomycin 250mg PO (frequency?)
nafcillin 2g q 4 hr IV, another order for q6
diphenoxylate PO QID
loperamide 2mg PO
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
ESRD
HTN
CAD
CHF
? renal cell CA
s/p multiple strokes
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2173-12-21**]
|
[
"997.69",
"112.2",
"507.0",
"250.40",
"403.91",
"428.0",
"263.9",
"585.6",
"458.21",
"434.11",
"440.24",
"707.03",
"189.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"39.95",
"99.15",
"84.15"
] |
icd9pcs
|
[
[
[]
]
] |
15988, 15997
|
11785, 15071
|
334, 342
|
16095, 16105
|
3036, 11762
|
16156, 16312
|
2354, 2366
|
15961, 15965
|
16018, 16074
|
15097, 15938
|
16129, 16133
|
2381, 2381
|
271, 296
|
370, 1317
|
2395, 3017
|
1339, 2032
|
2048, 2338
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,403
| 137,641
|
15259
|
Discharge summary
|
report
|
Admission Date: [**2131-12-18**] Discharge Date: [**2131-12-22**]
Date of Birth: [**2072-6-18**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Reglan / Iodine; Iodine Containing / Fentanyl
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
59F PMH neuroendocrine tumor with recurrent metastatic disease
(see below), complicated by recurrent hyperglycemia for over 2
months--FS values >500 frequently, who presents with
hyperglycemia. She had been taking [**First Name3 (LF) **] 30u [**Hospital1 **] at home, as
well as [**Hospital1 **] 30-60u 8 times a day. She continued to note
elevated FS, and after discussion with the [**Last Name (un) **], she was
advised to come in. She also reports increased fatigue,
polydipsia, polyuria, and nausea without vomiting. Denies any
abd pain, changes in BMs, F/C/NS, cough, URI-type symptoms, CP,
SOB.
*
In the ED, glucose was 688. Endocrine was consulted, and she was
placed on an insulin gtt at 5u/hr for several hours with
improvement in her BS to 418, then 327 with d/c of the drip and
10u of regular insulin given. Following BS were 274 and 141, and
she was determined to be okay to go to the floor. She was
additionally given 1L NS.
Past Medical History:
-Primary Oncologist: Dr. [**Last Name (STitle) 44380**] (prev [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
-Primary Encocrinologist: Dr.[**Name (NI) 4849**] ([**Last Name (un) **])
-pancreatic neuroendocrine tumor; s/p pancreatectomy/splenectomy
[**2126**], with recurrence in pancreatic tail in [**2129**] treated
initially with octreotide, then bevacizumab/temodar until cycle
15 day 15 on [**2131-7-18**] when it was stopped due to decrease of tumor
burden; however, she was found later to have liver mets treated
with chemoembolization c/b fevers that resolved with cipro
-stress-related migraines
-rest-less leg syndrome
-hypertension
-depression
-two benign breast cysts surgically removed
-tonsillectomy and fractured skull at age 3
Social History:
The patient is divorced and has two children. She was the
principal of a high school. Her friend, [**Name (NI) 553**], with whom she
shares a house in [**Location (un) 5450**], [**Location (un) 3844**] is her HCP and a
wonderful support system.
She denies drinking alcohol, smoking.
Family History:
hx of pancreatic cancer
hx of gastic cancer
CAD, DM
Physical Exam:
Vitals: T 97.4
BP 117/84
HR 80
R 20
Sat 98% RA
*
PE: G: NAD, WN, WD
HEENT: Clear OP, Dry MM
Neck: Supple, No LAD, No JVD
Lungs: CTA, BS BL, No W/R/C
Cardiac: RR, NL rate. NL S1S2. 2/6 systolic murmur RUSB, no rad.
Abd: Soft, NT, ND. NL BS. No HSM.
Ext: No edema. 2+ DP pulses BL.
Pertinent Results:
[**2131-12-18**] 06:40PM WBC-4.1# RBC-3.77* HGB-13.1 HCT-39.8 MCV-105*
MCH-34.7* MCHC-33.0 RDW-16.3*
[**2131-12-18**] 06:40PM NEUTS-57.6 LYMPHS-27.0 MONOS-8.5 EOS-5.3*
BASOS-1.6
[**2131-12-18**] 06:40PM PLT COUNT-258
[**2131-12-18**] 06:40PM GLUCOSE-688* UREA N-20 CREAT-0.8 SODIUM-130*
POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-26 ANION GAP-15
[**2131-12-18**] 06:22PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.032
[**2131-12-18**] 06:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
CXR: No evidence of pneumonia.
CT Torso:
1. No evidence of tumor progression since the studies of
[**11-13**] and [**2131-10-1**].
2. Soft tissue mass in the splenectomy bed which could be
splenules; NM study could help characterize if indicated.
3. Stability of multiple hepatic lesions.
4. Gallbladder fundal intermediate attenuation structures could
be stones or polyps but have also demonstrated stability.
Brief Hospital Course:
1) HYPERGLYCEMIA:
Despite severely elevated BG, there was no evidence of HNK or
DKA. Pt was initially placed on insulin drip and then her
regimen of [**Year (4 digits) **] and SS were adjusted by [**Last Name (un) **] consult. After
about 24-26 hours, her BG was much better controlled in the 100
to 200s range but with no excursions above 400. The exact cause
of her extreme hyperglycemia was not clear. There was no
underlying infection. CT scan showed no recurrence of cancer.
However, there was concern that she could have disease
progression with production of glucagon.
.
2) HEADACHE:
By history and exam, could be consistent with sinusitis. She
was empirically treated with nasal decongestant and augmentin
and will complete a short course of abx.
.
3) ONC:
Her oncologists, Dr. [**First Name (STitle) 1058**] and Dr. [**Last Name (STitle) **] saw her in the
hospital. As above, CT did not show any evidence of recurrence.
A chromogrannin A level was sent and is pending at time of
discharge.
Medications on Admission:
Polyethylene Glycol 3350 17 g as needed for constipation.
Senna 8.6 mg PO BID
Docusate Sodium 100 mg PO BID
Simethicone 80 mg PO TID
Insulin Glargine and [**Last Name (STitle) **] SS
Aspirin 81 mg PO DAILY
Miripex 1mg qhs
Celexa 20 mg PO daily
Amitryptiline 10mg qhs
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Amitriptyline 10 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Pramipexole 1 mg Tablet Sig: One (1) Tablet PO qhs ().
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-18**] Sprays Nasal
QID (4 times a day) as needed for 2 weeks.
Disp:*1 bottle* Refills:*0*
6. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous qAM.
7. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35)
units Subcutaneous qPM.
8. Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding
scale units Subcutaneous qACHS.
9. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for headache.
11. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for headache.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*qs for one month* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperglycemia
Diabetes mellitus, type 2
Discharge Condition:
Good.
Discharge Instructions:
Take medications as prescribed.
Note the changes made to your insulin regimen. Use attached
sliding scale for [**Month/Day (2) **] before meals and at bedtime.
Please call Dr. [**First Name (STitle) 1058**] or [**Last Name (un) **] for BG persistently elevated
above 400, fevers, chills, worsening headache, abdominal pain,
or any other symptoms that concern you.
Followup Instructions:
Please call Dr. [**First Name (STitle) 1058**]/[**Doctor Last Name **] office [**Telephone/Fax (1) 22**] to schedule a
follow up appointment in the next week.
Please call [**Last Name (un) **] Diabetes Center to set up a follow up
appointment.
|
[
"250.02",
"311",
"V58.67",
"V10.09",
"346.90",
"333.94",
"112.89",
"473.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6544, 6550
|
3797, 4806
|
333, 341
|
6634, 6642
|
2783, 3774
|
7057, 7305
|
2412, 2466
|
5124, 6521
|
6571, 6613
|
4832, 5101
|
6666, 7034
|
2481, 2764
|
280, 295
|
369, 1309
|
1331, 2095
|
2111, 2396
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,551
| 155,969
|
24702
|
Discharge summary
|
report
|
Admission Date: [**2101-1-1**] Discharge Date: [**2101-1-29**]
Date of Birth: [**2035-8-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Demerol / Iodine / Latex / Betadine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
bilateral lower extremity weakness x 6 weeks.
Major Surgical or Invasive Procedure:
OPERATIONS:
1. Transpedicular decompression, T7.
2. Fusion T3 to T11.
3. Multiple thoracic laminotomies.
4. Instrumentation T3-T11.
5. Epidural catheter placement.
6. Left iliac crest bone graft.
.
Procedures:
1. Lumbar puncture.
2. Right internal jugular central catheter placement,
subsequently removed.
History of Present Illness:
65 yo woman with hx of PVD, HTN, CRI presents with lower
extremity weakness and numbness which has been ongoing for 6
weeks. The pt reports that about six weeks ago she started to
have some hives over her arms and then developed severe pain in
her arms. Her w/u at [**First Name9 (NamePattern2) **] [**Hospital1 1474**] was negative and she
decided to have "shots" into her spine, done by Dr. [**Last Name (STitle) 62314**] in
[**Location (un) 2498**]. The initial injection brought her relief, however she
also developed some numbness in her finger tips. She then had
her 2nd injection and started to feel unbalanced afterwards,
leaning more to the left. She fell once. Then she had her 3rd
injection and immediately afterward fell again. In between the
injections she also started to note weakness in her legs and new
onset ptosis of her R eye with double vision. She saw a
neurologist who attributed it to "bell's palsy". She denies any
incontinence of stool or urine. She states she has lost 37
pounds over the past 2 months.
.
ROS: negative for CP, SOB, abdominal pain, diarrhea,
constipation, f/c/ns, dysuria, changes in the color of the urine
or stool, n/v/ bowel or bladder incontinence, palpitations.
.
In the ED, initial vitals 98.1, 76, 151/57, 18, 98% on RA, the
pt was seen by ortho spine. No decreased sphincter tone. No
medications were given.
Imaging from the outside was read as: MRI T spine: T6 edema
with ? SC edema.
MRI Brain: diffuse perivascular changes c/w chronic ischemic
changes vs MS [**First Name (Titles) **] [**Last Name (Titles) **]
Past Medical History:
HTN
COPD
Osteopenia
CRI (baseline Cr 1.6)
PVD: s/p aortobifem [**2091**] and [**2095**], s/p right SFA and [**Doctor Last Name **] angio,
s/p right SFA stenting, s/p a right common iliac to left renal
artery bypass, s/p right renal artery stenting, s/p right
profunda femoris to posterior tibial bypass
AAA repair with stenting
Hypercholesterolemia
Social History:
Former heavy smoker. Quit [**2092**] but with 40 pack years. Denies
other drugs. Uses EtOH rarely. Widowed with 5 children.
Family History:
Mother had CABG in her 60's. Father died at age 45 from a "clot
to the brain". Son has aorta grafting at age 37 and has had
clots in the leg. Daughter has a "leaky valve".
Physical Exam:
VS: 98.3 140/59 80 20 94RA
Gen: NAD, AAOx3, lying flat in bed
HEENT: NC/AT, PERRLA, mmm
NECK: no LAD, no JVD, no carotid bruit
COR: S1S2, regular rhythm, no m/r/g
PULM: CTA b/l, no wheezing or rhonchi
ABD: + bowel sounds, soft, nd, nt
Skin: warm extremities, no rash
EXT: 2+ DP, no edema/c/c, no CVA tenderness
Neuro: moving all extremities, 3/5 strength in HF, KE [**3-24**], arms
[**4-23**] following commands, PERRLA, CN2-12 intact, except for ptosis
R eye, double vision in all directions, reflexes absent b/l,
babinsky upgoing b/l, cerebellar sign not tested
Pertinent Results:
[**2101-1-1**] 12:15AM PT-10.9 PTT-21.8* INR(PT)-0.9
[**2101-1-1**] 12:15AM PLT COUNT-385
[**2101-1-1**] 12:15AM NEUTS-72.1* LYMPHS-20.9 MONOS-4.8 EOS-1.8
BASOS-0.4
[**2101-1-1**] 12:15AM WBC-12.5* RBC-4.42# HGB-13.5# HCT-38.2#
MCV-87 MCH-30.6 MCHC-35.3* RDW-13.7
[**2101-1-1**] 12:15AM CALCIUM-10.4* PHOSPHATE-4.4 MAGNESIUM-2.4
[**2101-1-1**] 12:15AM estGFR-Using this
[**2101-1-1**] 12:15AM GLUCOSE-99 UREA N-18 CREAT-1.3* SODIUM-138
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16
[**2101-1-1**] 04:10PM PTH-70*
Micro:URINE CULTURE (Final [**2101-1-4**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
.
Imaging from the outside was read as:
MRI T spine: T6 edema with ? SC edema.
MRI Brain: diffuse perivascular changes c/w chronic ischemic
changes-v- MS-v- [**Month/Day/Year **]
.
[**2101-1-2**] MR C/T SPINE
1. Signal abnormality within the T7 vertebral body with
enhancing component extending into the epidural space at this
level concerning for a neoplastic process. Probable abnormal
signal is seen within the cord at this level suggestive of
edema. 2. Probable area of signal abnormality within the pons
appears to be demonstrated on limited views, that in retrospect
appears to be confirmed on the dedicated MRI brain. It is likely
an area of chronic infarction.
.
[**2101-1-2**] CT TORSO W/ CONTRAST
1. No paraaortic masses present.
2. Large prevascular and pretracheal lymph nodes, concerning for
malignancy as described above. Clinical correlaion is
recommended.
.
[**2101-1-3**] MRI HEAD
Findings. There is no evidence of hemorrhage, edema, masses,
mass effect, or infarction. There are periventricular white
matter hyperintensities suggesting chronic small vessel
ischemia. There is no abnormal enhancement after contrast
administration. Conclusion: Chronic small vessel ischemic
changes, otherwise normal study.
.
[**2101-1-7**] BONE SCAN
1. Focal increased abnormal uptake in the T7 vertebral body
consistent with
osseous metastasis. 2. Atrophic right kidney. 3. Degenerative
change as
above.
.
[**2101-1-12**] MRI HEAD
FINDINGS: Since prior exam, there has been no significant
interval change. No new intracranial mass lesion, hydrocephalus,
shift of normally midline structures, minor or major [**Month/Day/Year 1106**]
territorial infarct is apparent. Stable appearance of the
multiple T2 hyperintense foci in the periventricular white
matter suggestive of chronic microvascular infarcts, as well as
the solitary left paracentral pontine lesion, also probably a
chronic lacunar infarct, are both observed. Following
intravenous contrast administration, no abnormal enhancement is
noted. IMPRESSION: No significant interval change from the prior
study, without clear indication as to the cause of the right
sided ptosis. As was discussed today ([**2101-1-14**]) with the house
staff, follow-up dedicated imaging of the orbits and cavernous
sinuses, as well as MR angiography, could be helpful.
.
[**2101-1-13**] T7 BONE/TISSUE BIOPSY
1. T7 bone biopsy #1 (A-B): Malignant neoplasm, most likely
carcinoma.
2. T7 bone biopsy #2 (C-D): Malignant neoplasm, most likely
carcinoma.
3. Epidermal soft tissue (E-F): Malignant neoplasm, most likely
carcinoma.
4. Bone tissue tumor (G-H): Malignant neoplasm, most likely
carcinoma.
Note: Immunohistochemical studies for keratin AE1/AE1, CAM 5.2,
and chromogranin show focal immunoreactivity. No
immunoreactivity is seen with LCA, synaptophysin, or TTF-1.
Additional stains will be performed, and reported in an
addendum.
.
[**2101-1-14**] T7 MASS BIOPSY FLOW CYTOMETRY
Non-diagnostic study. Cell marker analysis was performed but
was non-contributory in this case due to insufficient number of
lymphoid cells for analysis.
.
[**2101-1-16**] LUE U/S
Left cephalic vein thrombosis at antecubital fossa. The
remainder of the veins of left upper extremity are unremarkable.
.
[**2101-1-17**] SKELETAL SURVEY
The patient has a known T7 lesion. There are bilateral spinal
rods and a right IJ line as well as skin staples. Metallic
densities overlie two disc levels in the mid thoracic spine.
Lucency in this area are presumably relates to the site of
recent surgery. Fine assessment of bony detail somewhat limited
by high-contrast technique. Some scattered [**Month/Day/Year 1106**]
calcification and clips are seen anterior to the lumbar spine.
There are mild degenerative changes and more pronounced facet
arthrosis in the lumbar spine. Vertebral body heights are
preserved throughout the cervical, thoracic, and lumbar spine.
Additional clips are seen in the abdomen. Prominent facet
arthrosis is seen at the lumbosacral junction. Irregular density
adjacent to the left SI joint is noted. If this does not
represent a bone graft donor site, then further evaluation for
bony lesion would be recommended. There are moderate- to
moderately-severe degenerative changes involving both hips.
Clips are seen over the right inguinal area. Probable mild
degenerative changes in the right and to a greater extent left
knee. Surgical clips noted along the right inner thigh. With the
exception of known areas in the thoracic spine, no focal lytic
lesion is identified on this skeletal survey. Degenerative
changes in the lower lumbar spine and hips noted.
.
[**2101-1-25**] PET-CT
1. Extensive mediastinal lymphadenopathy with focal abnormal
uptake
of FDG with a 2.3 cm prevascular node with SUV of 15, and a 1 cm
precarinal node with SUV 16. Focal FDG uptake in bilateral hila.
2. Destructive bone lesion at T7 with SUV 12, and postoperative
changes of the thoracic spine. 3. Focal uptake in rectum.
Digintal exam is recommended. 4. Focal FDG uptake toward the
pelvis of the atrophic right kidney with SUV of 7.9, probably
due to excretion.
.
[**2101-1-27**] T-L AP AND LATERAL SPINE XRAY
Posterior thoracic spinal fusion without hardware loosening.
Brief Hospital Course:
Mrs. [**Known lastname 7046**] is a 65 year old woman with a history of PVD, HTN
and CKD who presented with bilateral lower extremity weakness
and numbness for six weeks.
.
1. T7 mass: The patient presented with lower extremity weakness
and numbness. MRI of her T-spine showed a mass at the T7 level
with extension to the epidural space and cord edema concerning
for malignancy. A lumbar puncture was performed to evaluate for
leptomeningeal involvement. CSF studies showed atypical
plasmacytoid cells but it was not felt that the cells were
malignant in nature. A biopsy was taken of the T7 mass for
further diagnosis. The biospy revealed poorly differentiated
carcinoma of unknown primary. The patient was seen by Neurology,
Neuro-Oncology and Radiation Oncology. Ortho-Spine performed a
T3 to T11 fusion without complication. A skeletal survey was
performed and did not demonstrate any evidence of lytic bone
disease. The patient began XRT on [**2101-1-28**]. She will receive a
total of 10 days of XRT. She was started on dexamethasone which
should be tapered after completion of XRT. She will also follow
up with Dr. [**Last Name (STitle) 4253**] in Neuro-Oncology. DVT prophylaxis was
provided with lovenox and should be continued after discharge.
.
2. Third cranial nerve dysfunction: The patient was noted to
have right eye ptosis on admission. Neurology was consulted.
Leptomeningeal disease was considered but not supported by the
results of lumbar puncture. The ptosis is most likely secondary
to microvascular disease. Right eye ptosis improved with use of
an eye patch that is alternated between eyes every 3 to 4 hours.
The patient was instructed to continue using the patch after
discharge.
.
3. Left upper extremity cephalic vein clot: The patient was
noted to have swelling and tenderness of the left upper
extremity. Ultrasound demonstrated superficial clot. A heparin
drip was initiated then stopped because the clot was in a
superficial vein.
.
4. Hypercalcemia: The patient was hypercalcemic on admission and
was found to have an elevated parathyroid hormone (PTH). PTHRP
was normal, but vitamin D was low. Because her calcium
normalized, no further work-up or intervention was pursued.
Vitamin D supplementation was initiated.
.
5. Microvascular disease on MRI: The patient likely had old
disease. It was treated with aspirin, clopidogrel and a statin.
.
6. Anemia: The patient experienced a significant drop in
hematocrit post-operatively. She required 2 units of PRBCs after
which her hematocrit responded appropriately and was stable for
the remainder of her stay.
.
7. UTI (enterococcus): The patient completed a 7-day course of
vancomycin.
.
8. CAD/PVD: The patient had a history of RCA stenting. She had
no signs of active ischemia during this admission. She was
continued on a statin, beta-blocker, aspirin and clopidogrel.
.
9. HTN: The patient has a history of hypertension and was well
controlled on this admission with amlodipine and a beta-blocker.
Medications on Admission:
Amlodipine 5 mg once daily
Plavix 75 mg daily
Lovastatin 10 mg daily
Percocet prn
Aspirin 325 mg daily
Metoprolol tartrate 100 mg twice a day
Lasix 20 mg prn daily
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): this is your plavix.
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
Disp:*150 Tablet(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*0 Capsule(s)* Refills:*0*
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
QD ().
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
15. OxyContin 10 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO every twelve (12) hours:
Administer with 40 mg tablet for a total of 70mg q 12 hours.
16. OxyContin 40 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO every twelve (12) hours:
Administer with three 10 mg tablets of oxycontin for total dose
of 70mg q12h.
17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
18. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
19. 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:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Metastatic Cancer - Unknown Primary.
2. T7 Epidural Mass - Cord Compression - T5 level, BLE Paresis.
3. Pontine Infarct c/b Right 3rd Nerve Palsy.
4. Left Antecubital Superficial Thrombophebitis
5. Vitamin D Deficiency
6. Secondary Hyperparathyroidism
7. Enterococcal Urinary Tract Infection
8. CAD s/p RCA Stent ([**Hospital1 336**])
9. Diastolic Dysfunction Heart Failure.
10. Anemia of Chronic Inflammation.
11. Oral Candidiasis.
Secondary:
1. S/P Aortobifemoral Bypass Graft
2. RLE SFA Stenosis s/p unsuccessful PCI
3. Anemia of Chronic Inflammation.
4. Hypertension
5. Right arm fasciotomy/grafting (iatrogenic compartment
syndrome)
Discharge Condition:
stable, afebrile, tolerating po
Discharge Instructions:
You presented to the hospital with lower extremity weakness and
you were found to have a mass in your thoracic spine. A biopsy
was performed and you were found to have poorly differentiated
cancer of unknown primary. You also underwent an operation for
T3 to T11 vertebral fusion. You will require radiation therapy
and chemotherapy for your cancer.
.
Please return to the emergency room or call your doctor if you
experience any of the following symptoms: fever > 101.5, new
numbness or weakness, severe pain or any other concerning
symptoms.
.
Please take all medications as prescribed.
.
You should wear an eye patch and alternate between eyes every 3
to 4 hours.
.
Please follow up with all appointments as scheduled.
Followup Instructions:
1. Radiation Oncology: Monday, [**2101-1-31**] at 10:15AM. Phone: ([**Telephone/Fax (1) 54862**].
2. Oncology - Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2038**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2101-2-8**] 11:00
3. Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2101-2-9**] 9:00
4. Call Dr. [**Last Name (STitle) **],[**First Name3 (LF) 177**] J. [**Telephone/Fax (1) 62315**] for a follow-up in 1
week after discharge.
5. Neuro-Oncology: Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2101-2-14**] 9:30
|
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"112.0",
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"428.30",
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"198.5",
"344.1",
"401.9",
"374.30",
"599.0",
"783.21",
"041.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.05",
"81.63",
"77.79",
"99.04",
"92.29",
"03.90",
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icd9pcs
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[
[
[]
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14855, 14934
|
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|
353, 669
|
15643, 15677
|
3568, 9726
|
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|
2796, 2969
|
12948, 14832
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14955, 15622
|
12760, 12925
|
15701, 16425
|
2984, 3549
|
268, 315
|
697, 2265
|
2287, 2638
|
2654, 2780
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,559
| 142,348
|
21542
|
Discharge summary
|
report
|
Admission Date: [**2196-10-29**] Discharge Date: [**2196-12-20**]
Date of Birth: [**2132-7-16**] Sex: M
Service: MEDICINE
Allergies:
cefepime / vancomycin / Allopurinol
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Bone/ thigh pain
Major Surgical or Invasive Procedure:
Tunneled line removal [**11-9**]
PICC line placement [**11-11**]
PICC removal [**11-19**]
Bone marrow biopsy [**11-19**]
History of Present Illness:
64-year-old man 51 days after a matched unrelated donor,
non-myeloablative transplant for AML, after a history of
polycythemia [**Doctor First Name **] with myeloid metaplasia and myelofibrosis and
previous splenectomy. Patient presents after a morning episode
where he developed gradual throbbing/ pulsating in his right
thigh when he was walking. He rates the pain [**3-28**] with walking
and improved with putting his feet up. He has never had this
sort of episode in the past. Patient also endorses a single
temperature f 99 and a brief episode of sweats, but no chest
pain or shortness of breath, after walking around during this
time. He sat down and noted that his stomach was queasy. He
endorses a chronic runny nose, but otherwise has been
asymptomatic with no localizing symptoms including no fevers,
chills, neck stiffness, cough, dysuria, diarrhea.
Of note, patient was recently seen by Dr. [**Last Name (STitle) 410**] in clinic
[**2196-10-27**] and had a CT torso with contrast. That evening, he
developed a single fever of 100.3, called in, but was told to
wait it out.
Past Medical History:
Past Oncologic History:
Longstanding history of polycythemia [**Doctor First Name **] with myeloid
metaplasia s/p splenectomy [**2188**], previously treated with
hydroxyurea and splenectomy. He was diagnosed with acute
myelogenous leukemia on the [**2196-6-6**], negative for NPM
mutation and for the FLT 3 mutation, treated with induction
chemotherapy of idarubicin and Ara-C, but had persistent disease
and was therefore reinduced with mitoxantrone, etoposide and
Ara-C on the [**2196-6-1**]. His hospital course was complicated by
febrile neutropenia, E. coli and VRE bacteremia, a questionable
fungal pneumonia. He had a drug rash to cefepime. He developed
A-Fib with rapid ventricular response that was treated and
resolved. He had significant edema and hypoxia, which at one
point required an ICU admission. He recovered from those, was
discharged from the hospital on [**2196-7-26**] to complete a course
of IV meropenem and daptomycin for his E. coli and VRE
bacteremia. A followup bone marrow showed him to have persistent
fibrosis, but no evidence of leukemia. He did not have a sibling
donor, but a [**5-24**] matched unrelated donor was identified and the
patient has agreed to participate in protocol 07-384, reduced
intensity conditioning for an allo hematopoietic stem cell
transplant using clofarabine, total lymphoid radiation and ATG.
.
Anklyosing spondylitis
Hypothyroidism
Social History:
Patient lives in [**Hospital1 392**]. Married with children. Previously lived
in [**Location (un) 3844**]. He is a retired schoolteacher (World and
American History). He regularly spends 6 months of the year in
[**State 108**] in a retirement home. Denies tobacco or drug use. Rare
social EtOH use (none since transplant).
Family History:
Mother was a heavy smoker and passed away from lung cancer.
Father passed away from complications from DM. No thistory
hematologic disorders.
Physical Exam:
Admission Exam:
100.3, 112/84, 94, 97%
Gen: Pleasant, NAD
HEENT: No OP erythema or exudate. NO LAD.
Pulm: CTAB.
CV: RRR. No m/r/g.
Abd: +BS. NTND. No HSM.
Ext: No c/c/e.
LINES: Hickman tunnelled line with scant dry blood.
Neuro: CN2-12 intact, 5/5 strength bilaterally. Decreased LE
sensation.
.
Floor->ICU transfer exam [**11-19**]
GEN ill-appearing fatigued diaphoretic, minimally verbal
HEENT atraumatic but w/R lower check tender swollen fluctuant
mass 2x2 cm, difficulty speaking and swallowing (new today),
high soft voice (new x3 days), hearing loss (chronic), EOMI,
PERRL, OP otherwise clear
NECK supple no JVD no LAD
CV RRR nl S1 S2 no murmur
CHEST CTAB no r/r/w
ABD soft nontender nondistended +BS (no longer tender to
palpation LLQ)
EXT wwp no edema, pulses palpable
NEURO AOX3 CN intact except hearing loss, strength 4/5
symmetrically throughout, reflexes 2+ throughout.
.
ICU->FLOOR PHYSICAL EXAM [**12-6**]:
VS T99.0 HR 107 BP 102/65 RR 17 02 96%/RA
24H Urine outpu 2L
ICU LOS fluid balance +4L
GEN: gaunt, pale man resting in bed in NAD, very hard-of-hearing
HEENT: NCAT EOMI PERRL OP notable for large (2x3 cm) R
retropharyngeal eschar w/no active bleeding, no tonsillomegaly,
erythema or exudate
NECK: no edema, anatomic landmarks visible, no LAD, no JVD
PULM: good aeration, unlabored breathing, prominent L basilar
rales; L CVL removed, site w/minor ecchymosis but nontender, no
erythema
CV: RRR, nl S1 S2, PMI nondisplaced, no m/r/g
ABD: flat, nontender nondistended, active bowel sounds,
spleen/liver non-palpable
EXT: no cyanosis or edema, pulses palpable
Foley in place draining clear yellow urine
L arm PICC nontender, non-erythematous, dressing c/d/i
Neuro: alert, Ox3, poor hearing to loud voice, CN otherwise
intact, strength 3/5 throughout, reflexes intact, gait and
cerebellar signs not assessed
.
DISCHARGE EXAM
Patient deceased
Pertinent Results:
ADMISSION LABS
[**2196-10-29**] 02:40PM BLOOD WBC-14.5* RBC-3.21* Hgb-10.9* Hct-30.9*
MCV-96 MCH-33.8* MCHC-35.2* RDW-18.1* Plt Ct-211
[**2196-10-29**] 02:40PM BLOOD Neuts-69 Bands-0 Lymphs-15* Monos-6 Eos-3
Baso-1 Atyps-2* Metas-2* Myelos-0 Promyel-1* Blasts-1* NRBC-1*
[**2196-10-30**] 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Target-OCCASIONAL Acantho-1+
[**2196-10-29**] 02:40PM BLOOD PT-14.8* PTT-24.7 INR(PT)-1.3*
[**2196-10-29**] 02:40PM BLOOD Glucose-96 UreaN-22* Creat-1.2 Na-139
K-4.2 Cl-101 HCO3-26 AnGap-16
[**2196-10-29**] 02:40PM BLOOD ALT-9 AST-47* LD(LDH)-[**2200**]* CK(CPK)-26*
AlkPhos-95 TotBili-0.5
[**2196-10-29**] 02:40PM BLOOD Albumin-4.3 Calcium-10.5* Phos-3.5 Mg-1.6
[**2196-10-29**] 02:40PM BLOOD TSH-4.2
.
OTHER NOTABLE LABS
[**2196-11-3**] 01:28PM BLOOD IgG-609*
[**2196-11-4**] 05:55AM BLOOD IgA-55* IgM-12*
[**2196-10-30**] 12:00AM BLOOD Hapto-280*
[**2196-11-17**] 12:00AM BLOOD WBC-0.1* Lymph-91* Abs [**Last Name (un) **]-91 CD3%-31
Abs CD3-28* CD4%-28 Abs CD4-26* CD8%-5 Abs CD8-5* CD4/CD8-5.6*
[**2196-11-17**] 12:00AM BLOOD CD3%-34.3 CD3Abs-31 16/56%-11.6
16/56Ab-11
[**2196-11-18**] 07:19PM BLOOD WBC-0.1* RBC-2.01* Hgb-6.2* Hct-19.6*
MCV-98 MCH-30.9 MCHC-31.7 RDW-17.9* Plt Ct-35*
[**2196-11-18**] 07:19PM BLOOD Neuts-0* Bands-0 Lymphs-80* Monos-0 Eos-0
Baso-0 Atyps-10* Metas-0 Myelos-0 Blasts-10*
[**2196-11-17**] 12:00AM BLOOD Fibrino-781*
[**2196-11-18**] 09:22PM BLOOD Lactate-1.5
.
SERIAL URINALYSIS
[**2196-10-29**] 05:48PM URINE Mucous-RARE
[**2196-10-31**] 10:34PM URINE CastGr-1* CastHy-1*
[**2196-10-29**] 05:48PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
[**2196-10-31**] 10:34PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2196-11-8**] 05:54PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2196-10-29**] 05:48PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2196-10-31**] 10:34PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2196-11-8**] 05:54PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2196-10-29**] 05:48PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2196-10-31**] 10:34PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2196-11-8**] 05:54PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
.
PERTINENT MICRO:
[**Date range (1) 33661**] BCX NEGATIVE
[**10-30**] VIRAL SWAB NEGATIVE
C DIFF TOXIN [**11-9**] (NEGATIVE) [**11-10**] (NEGATIVE) [**11-13**] (NEGATIVE)
[**2196-11-13**] 6:57 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2196-11-16**]**
MICROSPORIDIA STAIN (Final [**2196-11-14**]): NO MICROSPORIDIUM
SEEN.
CYCLOSPORA STAIN (Final [**2196-11-14**]): NO CYCLOSPORA SEEN.
FECAL CULTURE (Final [**2196-11-16**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2196-11-15**]): NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final [**2196-11-15**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2196-11-15**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2196-11-15**]):
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final [**2196-11-14**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
.
[**2196-11-16**] 4:48 am BLOOD CULTURE (X2 BOTTLES)
Blood Culture, Routine: PSEUDOMONAS AERUGINOSA.
FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in MCG/ML
_______________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2196-11-16**]): GRAM NEGATIVE
ROD(S).
[**11-18**] BCx: PSEUDOMONAS AERUGINOSA
[**11-19**] BCx: PSEUDOMONAS AERUGINOSA.
[**11-20**] BCx: NO GROWTH.
[**11-19**] PICC TIP CX: NEGATIVE
[**11-21**] - [**11-30**] BLOOD CX: NEGATIVE
[**11-22**] BAL- GRAM STAIN (Final [**2196-11-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2196-11-23**]):
~1000/ML Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final [**2196-11-28**]): NO LEGIONELLA
ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2196-11-22**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2196-12-5**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2196-11-22**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD):
Negative
[**11-23**] SPUTUM CX
GRAM STAIN (Final [**2196-11-22**]):
<10 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2196-11-25**]):
MODERATE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ 2 S
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
[**11-24**] Blood MYCOLYTIC CX: NO FUNGUS ISOLATED. NO MYCOBACTERIA
ISOLATED.
[**11-25**] STOOL CX negative for C.diff (REPEAT NEGATIVE)
[**11-24**], [**11-26**], [**11-28**] URINE CULTURE - NEGATIVE
[**12-2**] SPUTUM GRAM STAIN (Final [**2196-12-1**]):
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2196-12-3**]):
Commensal Respiratory Flora Absent. PSEUDOMONAS
AERUGINOSE-MOD GROWTH
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ 2 S
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
.
[**2196-12-12**] 11:26 pm SWAB Source: soft palate mass.
GRAM STAIN (Final [**2196-12-13**]):
Reported to and read back by DR. [**Last Name (STitle) **]. [**Doctor Last Name **] ON [**2196-12-13**]
AT 0450.
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Preliminary):
ESCHERICHIA COLI. MODERATE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
AMIKACIN , DORIPENEM AND COLISTIN SENSITIVITIES
REQUESTED PER DR.
[**Doctor Last Name 56782**] #[**Numeric Identifier 17770**] [**2196-12-15**].
DORIPENEM NON-SUSCEPTIBLE Sensitivity testing performed
by Etest.
MIC interpretations are based on manufacturer's
guidelines that
are FDA approved.
ESCHERICHIA COLI. SPARSE GROWTH #2.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PSEUDOMONAS AERUGINOSA
| | ESCHERICHIA
COLI
| | |
AMIKACIN-------------- <=2 S 16 S <=2 S
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- <=1 S =>64 R <=1 S
CEFTAZIDIME----------- <=1 S =>64 R <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R =>4 R
GENTAMICIN------------ =>16 R 8 I =>16 R
MEROPENEM-------------<=0.25 S =>16 R <=0.25 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ =>16 R <=1 S =>16 R
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
.
[**2196-12-18**] 1:29 pm BLOOD CULTURE Source: Line-picc.
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2196-12-19**]):
Reported to and read back by DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 37752**] [**2196-12-19**] AT
11:50.
GRAM NEGATIVE ROD(S).
.
.
VIRAL/FUNGAL STUDIES:
[**10-30**], [**11-12**], [**12-2**] CMV VIRAL LOAD (NEGATIVE) ([**12-10**] PENDING)
[**11-9**], [**11-18**], [**11-28**], [**12-5**] GALACTOMANNAN NEGATIVE ([**12-10**]
PENDING)
[**11-9**], [**11-18**], [**11-22**], [**11-28**], [**12-5**] B GLUCAN - NEGATIVE ([**12-10**]
PENDING)
[**11-14**] BLOOD VORICONAZOLE LEVEL - WNL
[**11-17**] Adenovirus PCR NEGATIVE
[**11-17**], [**12-2**] EBV PCR NEGATIVE
[**11-17**] HHV6 PCR <500 (NEGATIVE) (REPEAT [**12-10**] PENDING)
.
SELECTED IMAGING, SEE OMR FOR FULL COLLECTION
.
[**2196-11-7**] CT chest:
FINDINGS: There is no pathologic enlargement of central lymph
nodes by size criteria. Tiny pericardial effusion is
physiologic. Apparent thickening along the right posterior
costal pleural surface deep in the medial pleural gutter is more
likely atelectasis. There is no pleural effusion. This study is
not designed for subdiaphragmatic diagnosis, but shows there is
no adrenal mass or lesions in the imaged portions of the
unenhanced solid organs of the upper abdomen suspicious for
malignancy. The spleen is absent, presumably resected. The
previous multifocal opacities of various sizes in both lungs,
have resolved leaving small areas of scarring and atelectasis.
The lungs are otherwise clear. There is no evidence of active
intrathoracic infection
currently.
IMPRESSION:
1. No evidence of intrathoracic infection or malignancy.
Previous multifocal pulmonary abnormality, presumably infectious
has resolved since [**7-21**].
.
[**2196-11-11**] CT ABD/PELVIS:
CT OF THE ABDOMEN: There is mild linear bibasilar atelectasis.
The visualized heart and pericardium are unremarkable.
The liver enhances homogeneously, without focal lesions or
intrahepatic biliary duct dilatation. The gallbladder is
collapsed compared to [**2196-10-27**] and contains several gallstones.
The portal vein is patent. The pancreas does not show focal or
diffuse abnormalities. There is no evidence of peripancreatic
stranding or fluid collection. The patient is post splenectomy.
The adrenal glands are unremarkable. The kidneys do not show
solid or cystic lesions and present symmetric nephrograms and
excretion of contrast. No pelvicaliceal dilatation or
perinephric abnormalities are present.
The intra-abdominal vasculature is unremarkable. There are no
retroperitoneal or mesenteric lymph node enlargement. No ascites
or abdominal wall hernias are noted.
The stomach, duodenum and small bowel are within normal limits
without evidence of wall thickening or obstruction. The appendix
is not visualized but there is no evidence of appendicitis.
Examination of the sigmoid and descending colon including the
splenic flexure demonstrates thickening of the bowel walls with
areas of surrounding fat stranding as well as areas of mucosal
enhancement. No fluid collection is identified. No free air is
seen. There are multiple diverticula. No dilitation of the small
or large bowel.
PELVIC CT: The urinary bladder and terminal ureters are normal.
No pelvic wall or inguinal lymph node enlargement is seen. There
is no pelvic free fluid. The prostate, seminal vesicles, and
rectum are unremarkable.
OSSEOUS STRUCTURES: Multilevel degenerative disease of the
lumbar and thoracic spine. Diffuse mixed sclerotic and lucent
appearance of the bones which is unchanged.
Coronal and sagittal images were reviewed confirming the axial
findings.
IMPRESSION:
1. Thickening of the bowel wall including the entire sigmoid and
descending colon including the splenic flexure with surrounding
fat stranding and areas of mucosal enhancement may represent
infectious, inflammatory, or ischemic etiology. Given the extent
of the involement, diverticulitis is unlikely. No evidence of
perforation, obstruction, or abscess formation.
2. Diffuse mixed sclerotic and lucent appearance of the bones
which is unchanged and consistent with AML.
.
CT SINUS [**11-16**]
FINDINGS: There is mucosal thickening of the ethmoid air cells
as well as
minimal mucosal thickening of the inferior left maxillary sinus
and
frontethmoidal recess on the left. No aerosolized secretions to
suggest
significant acute component are seen. No notable air-fluid
levels except for minimal amount in the left maxillary sinus.
There is S-shaped deviation of the nasal septum with a shallow
bony spur on the left which does not cause significant occlusion
of the middle meatus. There is mucosal thickening around the
ostiomeatal units with obstruction of the infundibulum on the
right.
The olfactory fossae are [**Last Name (un) 36826**] type [**1-20**] bilaterally with some
demineralization of the cribriform plate and lateral lamellae;
left cribriform plate is higher than right. The lamina papyracea
are intact. The right anterior clinoid process is pneumatized.
Altered attenuation of some of the bones- c spine and mandibular
condyles is noted and may relate to osteopenia/ underlying
marrow disorder- inadequately imaged.
IMPRESSION: Mucosal thickening of the ethmoid air cells with
minimal mucosal thickening of the left frontoethmoidal recess
and left maxillary sinus. No aerosolized secretions or notable
air-fluid levels except for minimal amount in the left maxillary
sinus.
.
CT CHEST [**11-16**]
1. No evidence of intrathoracic malignancy or infection.
2. Longstanding widespread blastic and lytic involvement of the
entire chest cage.
.
CT ABDOMEN [**11-17**]
1. Increased thickening of the bowel wall of the descending
colon with
increased fat stranding consistent with worsening colitis of
unclear etiology.
No evidence of perforation, obstruction or abscess formation.
2. Diverticulosis of the sigmoid colon.
3. Diffuse mixed sclerotic lucent appearance of the bones, which
is unchanged and consistent with AML.
.
CT MAXILLOFACIAL [**11-19**]
1. Extensive soft tissue swelling, which is centered in the
right
oropharyngeal mucosal space and palatine fossa, extends into the
right
pyriform sinus of the hypopharynx and likewise involves the
right
submandibular space and right neck soft tissue planes. While
these changes
likely represent diffuse phlegmon, there is no discrete or
drainable abscess and no lymphadenopathy.
2. No CT evidence of odontogenic abscess or mandibular
osteomyelitis.
3. Unchanged predominantly ethmoid sinus disease.
.
MANDIBLE FILMS [**11-19**]
There is amalgam, a metallic bridge and a dental implant in the
incisor
region. There is a lucency in the maxilla, seen on the lateral
view, but it is unclear as to whether this represents some
rarefaction in the normal
trabecular markings or a frank abscess adjacent to the incisors.
Otherwise, no discrete abscess is seen subjacent to the lower
mandible molars or incisors.
.
CT CHEST [**11-22**]
1. Rapidly progressive right upper lobe consolidation,
consistent with
pneumonia.
2. Bibasilar atelectasis and/or infectious consolidation.
3. Pulmonary arterial hypertension. Consider echo for initial
further
evaluation if not already performed.
4. Mild paraseptal emphysema.
5. Multifocal lytic and sclerotic bone lesions, unchanged since
[**2196-5-18**].
.
CT SINUS [**11-22**]
1. Extensive bilateral peripharyngeal soft tissue induration,
markedly worse than three days ago, with no drainable abscess or
fluid collection identified. The origin of the infection is
unlikely to be from a sinus because of the lack of marked acute
sinusitis seen on the prior study.
2. Evidence of new right lung pneumonia and atelectasis, better
evaluated by the chest CT performed on the same day.
3. New fluid opacification of the bilateral sphenoidal sinuses,
which may
represent acute infection or may be due to pooling of secretions
after
endotracheal intubation.
.
PORTABLE CXR [**12-1**]
Left internal jugular line ends at mid SVC. The endotracheal
tube terminates approximately 5 cm above the carina and is
appropriate. Orogastric tube is seen to course below the
diaphragm into the stomach; however, the distal end is beyond
radiographic view. Right upper lobe pneumonia, though unchanged
since prior radiograph dated [**2196-11-28**], is smaller as
compared to radiographs through [**11-22**] to [**2196-11-23**].
Bilateral lower lung consolidations have also improved. No new
lung opacities. No pleural effusion. or pneumothorax.
Cardiomediastinal contour is stable.
.
CXR [**2196-12-18**]
Compared with [**2196-12-17**] at 19:40 p.m. and allowing for
differences in
technique, the radiographic appearance is similar. The right
apical opacity is grossly unchanged. Again seen is some patchy
opacity in the left infrahilar area and, to a lesser extent, in
the right infrahilar area. These raise concern for multifocal
pneumonic infiltrates or, possibly, areas of aspiration. The
differential could include atypical pattern of fluid overload,
but this is considered much less likely, as no upper zone
redistribution is identified
.
PATHOLOGY
.
[**2196-10-31**] BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:Increased blasts consistent with residual myeloid
leukemia, see note.
Note: The findings are somewhat similar to that biopsy done
previously. There are circulating blasts and marrow blasts are
enumerated at 18%. The constellation of findings are suggestive
of a residual acute myeloid leukemia. The dysplastic
megakaryocytes are also suggestive of residual megakaryoblastic
lineage, as discussed in the BMT conference on [**2196-10-25**] and
[**2196-11-1**].
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The peripheral smear is adequate for evaluation. Erythrocytes
are decreased in number, have marked poikilocytosis, including
burr cells, red cell fragments, spherocytes, nucleated red blood
cells, and inclusions ([**Location (un) **]-Jolly, Pappenheimer).
Granulocytes are in normal numbers and are dysplastic (large
elements, with vacuoles, toxic granulations, and polylobation).
Platelets are mildly decreased in number; large and giant forms
are numerous.
Differential shows: 70% neutrophils, 13% lymphocytes, 4%
monocytes, 4% eosinophils, 2% meta, 1% myelo, 4% blasts, 2%
nRBC.
Aspirate Smear:
The aspirate is sub-optimal for evaluation. It contains no
marrow spicules. Erythroid precursors are virtually absent.
Myeloid precursors exhibit dysplastic maturation. Erythroids
are virtually absent, only rare orthonormoblasts are seen.
Granulocytes are markedly increased and are dysplastic.
Megakaryocytes are not seen. Blasts focally constitute 20 to
30% of cellularity. Touch preparations are similar.
Differential (500 cell): 18% Blasts, 2% Myelocytes, 5%
Metamyelocytes, 60% Bands/Neutrophils, 12% Lymphocytes.
Clot Section and Biopsy Slides:
The core biopsy is adequate for evaluation. It consists of 12
mm long core of trabecular, cortical bone with some crush
artifacts. Overall, 80% of the marrow has an atypical cellular
infiltrate with streaming of nuclear debris and histiocytes.
The rest of the evaluable marrow has a 60% cellularity. The M:E
ratio is increased. Erythroid precursors are rare. Myeloid
precursors are decreased, are left shifted, and mildly
dyspoietic. Eosinophils are scattered. Megakaryocytes and
dysplastic forms are increased and loosely/tightly clustered.
Immature cells are present in clusters and singly and are
estimated at 20-30% of marrow cells.
[**2196-10-31**]:
INTERPRETATION:
40~44,[**Last Name (LF) **],[**First Name3 (LF) **](3)(p13),[**Doctor First Name **](5)(q12q32),-7,-8,-9,-13,-14,-15,de
l(16)(q22),-17,-18,+[**2-16**]-5[cp14]/46,XY[1]
This ABNORMAL karyotype is characteristic of a male with
numerous structural and numerical chromosomal aberrations.
Small chromosome anomalies may not be detectable
using the standard methods employed.
This finding is similar to that previously reported on
[**2196-10-11**].
.
[**11-19**] BM BIOPSY
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:
HYPOCELLULAR MARROW WITH EXTENSIVE MYELOFIBROSIS AND DYSPLASTIC
HEMATOPOIESIS (SEE NOTE).
Note: By immunohistochemistry, CD34 highlights blasts
comprising 20-30% of marrow cellularity. CD42 highlights rare
dysplastic megakaryocytes. Overall, most of the findings are
similar to those seen in a previous biopsy (S11-48147M;
[**2196-10-31**]). However, although the relative number of blasts is
increased in comparison with the previous biopsy, the absolute
number is lower.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The peripheral smear is adequate for evaluation. Erythrocytes
are decreased in number and exhibit anisopoikilocytosis
including targets, elliptocytes, dacrocytes, and occasional red
cell fragments. [**Location (un) **]-Jolly bodies are seen. The white cell
count is markedly decreased. Neutrophils are absent.
Lymphocytes are markedly decreased, and include large granular
forms. A rare immature monocyte is seen. Platelets are
decreased in number; large forms are not seen. Blasts are not
present.
Aspirate Smear:
The aspirate is inadequate for evaluation. In contains no
marrow spicules. No hematopoietic precursors are seen.
Clot Section and Biopsy Slides:
The core biopsy is adequate for evaluation. It consists of 13
mm long core of trabecular marrow with focal aspiration
artifact. The majority of marrow is replaced by fibrosis, with
scattered dysplastic erythroid, myeloid, and megakaryocytic
cells and overall cellularity not greater than 10%. As in the
previous biopsy, extensive bone remodelling with woven bone
formation is present.
(rpt negative [**12-5**])
.
[**2196-11-30**] 14:45
ENGRAFTMENT/CHIMERISM TEST, POST-TRANSPLANT
Transplant Information
Collected Diagnosis Transplant Date Donor Last Name
Donor Sample --------- --------- ---------------
--------------- --------------[**2196-11-30**] AML
[**2196-9-8**] ID#0447-3457-2 [**2196-9-6**]
Engraftment/Chimerism Analysis
Collected Sample Type Locus Tested Recipient
Sensitivity (%)
[**2196-11-30**] Blood SE33 [**1-22**]
Donor Sensitivity (%) Recipient Results (%) Donor Results
(%)
[**1-22**] 45 55
.
[**2196-12-6**] BONE MARROW BIOPSY
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:
BONE MARROW WITH EXTENSIVE INVOLVEMENT BY PATIENT'S KNOWN
LEUKEMIA, WHICH EXHIBITS EXTENSIVE MEGAKARYOCYTIC
DIFFERENTIATION.
Note: By immunohistochemistry CD34 highlights the majority of
cells, including cells with obvious megakaryocyte
differentiation. CD117 stains approximately 30% of all cells,
which are predominantly mononuclear. CD42 stains differentiating
magakaryocytes and many mononuclear cells. A similar pattern is
observed with vWF. CD68 stains histiocytes as well as a small
subset of mononuclear cells. CD33 stains a majority of cells.
E-cadherin and glycophorin stain only rare small clusters of
cells. Combined these findings are consistent with acute myeloid
leukemia with megakaryocytic differentiation. The findings in
this biopsy are similar to those seen at first diagnosis of
acute leukemia (see biopsy S11-25476M; [**2196-6-7**]).
.
[**2196-12-12**] SOFT PALATE BIOPSY
SQUAMOUS MUCOSA AND SOFT TISSUE WITH EXTENSIVE NECROSIS AND
SUPERINFECTION WITH MIXED BACTERIAL FLORA. NO EVIDENCE OF VIRAL
INFECTION OR LYMPHOID TUMOR SEEN IN THE SECTIONS EXAMINED (SEE
NOTE).
BLAST TREND
[**2196-10-29**] 02:40PM BLOOD Neuts-69 Bands-0 Lymphs-15* Monos-6 Eos-3
Baso-1 Atyps-2* Metas-2* Myelos-0 Promyel-1* Blasts-1* NRBC-1*
[**2196-11-1**] 12:00AM BLOOD Neuts-69 Bands-3 Lymphs-14* Monos-7 Eos-3
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-4*
[**2196-11-3**] 12:00AM BLOOD Neuts-66 Bands-1 Lymphs-10* Monos-3 Eos-2
Baso-1 Atyps-0 Metas-1* Myelos-0 Blasts-16* NRBC-1*
[**2196-11-3**] 04:28PM BLOOD Neuts-63 Bands-1 Lymphs-17* Monos-5 Eos-3
Baso-1 Atyps-0 Metas-0 Myelos-0 Blasts-10*
[**2196-11-5**] 12:41AM BLOOD Neuts-64 Bands-1 Lymphs-12* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0 Blasts-20*
[**2196-11-6**] 06:43PM BLOOD Neuts-86* Bands-0 Lymphs-8* Monos-2 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-2* NRBC-7*
[**2196-11-10**] 06:00AM BLOOD Neuts-46* Bands-0 Lymphs-36 Monos-10
Eos-3 Baso-1 Atyps-0 Metas-0 Myelos-0 Blasts-4*
[**2196-11-11**] 12:00AM BLOOD Neuts-26* Bands-0 Lymphs-42 Monos-0 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-30*
[**2196-11-12**] 12:00AM BLOOD Neuts-4* Bands-0 Lymphs-60* Monos-0
Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-28*
[**2196-11-14**] 10:40PM BLOOD Neuts-14* Bands-0 Lymphs-51* Monos-14*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-21*
[**2196-11-17**] 12:00AM BLOOD Neuts-0* Bands-0 Lymphs-87* Monos-6 Eos-0
Baso-0 Atyps-4* Metas-0 Myelos-0 Blasts-3*
[**2196-11-17**] 03:32PM BLOOD Neuts-0* Bands-0 Lymphs-80* Monos-0 Eos-0
Baso-0 Atyps-10* Metas-0 Myelos-0 Blasts-10*
[**2196-11-17**] 11:46PM BLOOD Neuts-0 Bands-0 Lymphs-65* Monos-5 Eos-0
Baso-0 Atyps-5* Metas-0 Myelos-0 Blasts-25*
[**2196-11-23**] 05:14PM BLOOD Neuts-84* Bands-0 Lymphs-0 Monos-0 Eos-0
Baso-0 Atyps-0 Metas-10* Myelos-0 Blasts-6*
[**2196-11-26**] 02:17AM BLOOD Neuts-81* Bands-4 Lymphs-12* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-0
[**2196-11-29**] 02:07AM BLOOD Neuts-73* Bands-1 Lymphs-12* Monos-6
Eos-0 Baso-0 Atyps-1* Metas-2* Myelos-0 Blasts-5* NRBC-3*
[**2196-12-2**] 03:26AM BLOOD Neuts-58 Bands-0 Lymphs-3* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-15* NRBC-2* Other-24*
[**2196-12-4**] 03:53AM BLOOD Neuts-43* Bands-1 Lymphs-4* Monos-3 Eos-0
Baso-1 Atyps-4* Metas-0 Myelos-2* Blasts-42* NRBC-1* Other-0
[**2196-12-7**] 12:00AM BLOOD Neuts-37* Bands-0 Lymphs-2* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-59* NRBC-2*
[**2196-12-11**] 12:15AM BLOOD Neuts-30* Bands-4 Lymphs-9* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-52*
[**2196-12-15**] 12:00AM BLOOD Neuts-6* Bands-0 Lymphs-5* Monos-0 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0 Blasts-88*
[**2196-12-18**] 12:52AM BLOOD Neuts-2* Bands-0 Lymphs-3* Monos-1* Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-94*
Brief Hospital Course:
64M with hx AML admitted w/R thigh pain, found during this
admission to have relapsed AML after [**2196-9-8**] MUD allo transplant
and AML relapse after MEC reinduction during this admission,
hospital course complicated by febrile neutropenia, descending
colitis/diarrhea, pseudomonas sepsis/PNA, and R buccal
inflammation requiring ICR transfer & intubation with residual R
retropharyngeal ulcer. Given persistent relapse in face of
overwhelming infection, patient was made DNR/DNI and ultimately
comfort measures only on [**2195-12-20**]. Patient expired overnight
[**2196-12-20**] from overwhelming pseudomonas sepsis secondary to
refractory AML.
.
# RELAPSED AML
Patient was s/p MUD transplant at time of admission. R thigh
pain was imaged and seen to be c/w AML recurrence; bone marrow
biopsy confirmed disease relapse. Chimerism studies showed
50%/50% donor/host. Given disease relapse after allotransplant,
immunosuppression tapered off. He underwent MEC reinduction d1
[**11-5**] with Hydroxyurea [**11-4**] and [**11-5**]. LDH elevation >4000
dropped markedly after MEC & pt tolerated MEC well, but initial
post-treatment course was complicated by neutropenic fevers (see
below). Repeat BM bx on [**11-19**] (day 15) and [**12-7**] showed AML
relapse again. Blast count continued to rise to a maxium of 94%
peripherally on [**2196-12-18**]. Given persistent relapse in face of
overwhelming infection, patient was made DNR/DNI and ultimately
comfort measures only on [**2195-12-20**].
# FEBRILE NEUTROPENIA
Patient had fevers intermittently throughout admission.
Initially, given history of E. coli and VRE bacteremia, he was
empirically started on meropenem and daptomycin, then broadened
to voriconazole given hx fungal PNA. Micro (including line
cultures) and pan-CT scans were negative for sources of
infection until on [**11-16**] BCx grew GNR which speciated as
Pseudomonas auruginosa initially pan-sensitive except to
meropenem. Soon thereafter, he developed PNA seen on chest
imaging & BAL sputum Cx grew pseudomonas now with evolved
resistances only sensitive to Cipro/Tobra/Gent. Neck soft tissue
infection also likely contributed to fevers. In the ICU,
antibiotics were switched to tobra, linezolid, ambisome, zosyn.
He was afebrile on [**12-7**] at time of ICU callout on
dapto/cipro/vori. He became febrile again on [**12-9**]; at that
time, possible infectious sources included PNA and, although
cultures remained negative, possible bacteremia from oral flora
seeding from retropharyngeal ulcer site was considered an
ongoing possibility. Fever briefly subsided after restarting
daptomycin, but returned shortly thereafter. Pseudomonas from
throat swab noted to have evolved resistance to ciprofloxacin
along with MDR E. coli. Patient was started on colistin on
[**12-16**]. Fevers persisted and blood cutlures from [**2196-12-18**] showed
GNR bacteremia.
.
# DIARRHEA/COLITIS
Diarrhea started [**2196-11-8**]. Patient had hx PCR+ C diff so he was
empirically started on PO vancomycin. He also developed LLQ
pain; a CT abd/pelvis obtained with concernf or tiflitis showed
descending colitis. Gastroenterology was consulted for question
of infectious colitis vs GVH (especially off immunosuppression).
He was made NPO for bowel rest. TPN started [**11-13**]. Serial stool
studies and CMV testing was negative.
.
# PSEUDOMONAS SEPSIS
Patient became septic with pseudomonal bacteremia from likely GI
source. At time of ICU transfer his urine output was wnl and he
was mentating at baseline but he was having relative hypotension
with BP ~15 pts below his baseline. Briefly required levophed
and vasopressin for BP support. He was persistently febrile even
after blood pressure stabilized.
.
# RIGHT MANDIBULAR/TONSILLAR SWELLING, SOFT TISSUE INFECTION
Pt developed acute-onset R buccal swelling and tenderness on the
morning of [**11-19**] which evolved rapidly throughout the subsequent
8 hours. Swelling was intitially localized in right peri-molar
buccal mucosa. There was initial question of whether the
infection might have arisen from a R posterior molar, but OMFS
evaluation including CT face and panorex showed that the
infection did not involve bone. Urgent ENT consult followed
closely; no biopsy was performed given lack of drainable
collection on imaging. As swelling evolved to includer
peri-tonsillar soft tissue it caused airway obstruction which
prompted ICU transfer and intubation. Repeated CT scans showed
soft tissue swelling, no collection or abscess to drain.
Antibiotics were empirically broadened to tobra/linezolid/
ambisome/zosyn. Soft tissue swelling gradually resolved but left
residual R retropharyngeal ulcer after extubation persisted and
was cleaned daily by ENT.
.
# RESPIRATORY DISTRESS/INTUBATION
Patient developed acute airway compromise [**1-19**] neck/tonsillar
soft tissue infection, with stridor on exam. Intubated for
airway protection for 11 days until patient had cuff leak,
decreased secretions, and improvement in swelling.
.
#TONSILLAR NECROSIS/R RETROPHARYNGEAL ULCER
Upon extubation necrosis of the right tonsil with open
ulceration became apparent. Tonsillar necrosis was treated
supportively with normal saline washes and daily debridement by
ENT. Ulcer continued to bleed at a low-level and patient was
unable to manage oral secretions, so he required frequent
suctioning. Continued on daptomycin for gram positive coverage
of oral bacteria, in case of translocation through necrotic
tissue. Flagyl was added for oral anaerobe coverage. Given
inability to swallow liquids or solids without aspirating, he
was kept NPO on TPN.
.
# PNEUMONIA
In the ICU he developed a RUL seen on CXR which was treated as
ventilator associated pneumonia. Sputum originally grew
pseudomonas, with the same sensitivities as in blood, which was
treated with zosyn with double coverage with tobramycin. Sputum
culture from [**2196-12-1**] showed that pseudomonas had evolved
resistance to zosyn, at which time he was switched to
ciprofloxacin. CXRs on the floor in setting of ongoing fevers
showed persistent RUL opacity c/w known PNA. He continued to
produce thick yellow-white sputum which was difficult to manage
in combination with low-level bleeding from oral ulcer. Repeat
cultures from throat showed evolution of cipro resistance to the
Cipro and colistin was started as above.
# Tachycardia:
Patient with history of Afib with RVR. Patient was in sinus
rhythym throughout this admission. Ocasionally tachycardic in
setting of fever but EKGs confirmed sinus tachycardia. Became
persistenly tachycardic with fevers and had two episodes of SVT
>200 on [**12-18**] and [**12-18**] broken by carotid massage.
.
# Hx GERD:
Continued omeprazole 20 mg PO DAILY, then transitioned to IV PPi
once he was no longer tolerating POs.
Medications on Admission:
acyclovir 400 mg Tablet TID
cyclosporine modified 75 mg Capsule q12h
fluconazole 400 mg Tablet qd
folic acid 1 mg qd
levothyroxine 75 mcg Tablet qd
metoprolol tartrate 12.5 mg daily
mycophenolate mofetil 750 mg q 12 hours
nystatin 100,000 unit/mL Suspension 10 Suspension(s) by mouth
QID omeprazole 20 mg Capsule daily
saliva substitution combo no.2 Solution 5 Solution(s) QID
sodium fluoride [DentaGel] 1.1 % Gel 1 Gel(s) HS
sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg Tablet qd
ursodiol 300 mg Capsule [**Hospital1 **]
* OTCs *
aluminum hydroxide gel 600 mg/5 mL 30 Suspensions q4h PRN
dyspepsia
bisacodyl 10 mg Tablet, Delayed Release (E.C.) qd PRN
constipation docusate sodium 100 mg Capsule [**Hospital1 **] PRN
constipation
magnesium oxide-Mg AA chelate [Mg-Plus-Protein] 133 mg Tablet
TID
magnesium sulfate (bulk) [Epsom Salt] 100 % Crystals
multivitamin Tablet qd
Not taking:
clotrimazole 10 mg Troche 5x/day
Discharge Medications:
Patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Relapsed acute myelogenous leukemia, pseudomal septic
shock
Secondary: Polycythemia [**Doctor First Name **] with myeloid metaplasia, Ankylosing
spondylitis, Hypothyroidism
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
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"276.2",
"276.8",
"276.0",
"277.88",
"286.9",
"519.8",
"238.76",
"720.0",
"482.1",
"288.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"27.22",
"33.24",
"00.14",
"41.31",
"86.28",
"96.6",
"86.05",
"96.72",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
40472, 40481
|
32669, 39448
|
315, 437
|
40707, 40717
|
5364, 10363
|
40769, 40775
|
3326, 3469
|
40431, 40449
|
40502, 40686
|
39474, 40408
|
40741, 40746
|
3484, 5345
|
10399, 12615
|
14571, 32646
|
259, 277
|
12650, 14527
|
465, 1553
|
1575, 2970
|
2986, 3310
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,704
| 137,343
|
28382
|
Discharge summary
|
report
|
Admission Date: [**2182-7-22**] Discharge Date: [**2182-8-2**]
Date of Birth: [**2118-10-20**] Sex: F
Service: NEUROSURGERY
Allergies:
Percocet / Morphine Sulfate
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Bilateral LE weakness
Major Surgical or Invasive Procedure:
revi T2 transpedicular decompression of epidural metastasis.
History of Present Illness:
63 y/o female with a history of renal cell carcinoma with
metastases to the spine underwent a C5-T2posterior fusion and
was discharged to rehab on [**2182-7-16**]. She presented from OSH after
c/o bilateral lower extremity weakness x 6 days. The patient
states that she first noticed weakness in her lower extremities
on [**2182-7-17**]. While at the rehab hospital,she reports that she was
unable to stand and fell over.She was sent to [**Hospital3 26615**]
hospital for MRI of her C-spine to determine the cause of her
weakness. She was then transferred to [**Hospital1 18**] for direct admit for
compression of T2.
Past Medical History:
Diabetes,Hyperlipidemia,Hypertension,Peripheral vascular
disease,s/p R superficial femoral artery stenting x 2,CAD,
cardiac catheterization revealing a 95-99% proximal
stenosis of the LAD; s/p PCI stenting in [**2181-3-29**]
C5-T2posterior fusion and was discharged to rehab on [**2182-7-16**]
Social History:
She continues to live in [**Hospital1 392**] and will occasionally help out
at her relatives' Chinese restaurant answering phones
does not drink or smoke
Family History:
non-contributory
Physical Exam:
PE on admission:
T:97.8 BP:146/76 HR:83 R:18 O2Sats:96%
Gen: WD/WN, comfortable, NAD.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 0 0 0 0 0 0
L 5 5 5 0 0 0 0 0 0
Sensation: Intact to light touch
+ Clonus
PE on discharge:
incision well healing with sutures intact
motor:
IP Q H AT [**Last Name (un) 938**] G
R 3 4 4 4 4 5
L 2 4 4 4 4 5
On discharge:
A&Ox3
Motor: B T D IP Q H AT [**Last Name (un) 938**] G
R 4+ 4+ 4 2 5 5 5 5 5
L 4+ 4+ 4 2 5 5 5 5 5
Abd- soft, positive bowel sounds
NG tube in place not to suction
Pertinent Results:
[**2182-7-22**] 11:38PM TYPE-ART PO2-273* PCO2-43 PH-7.47* TOTAL
CO2-32* BASE XS-7 INTUBATED-NOT INTUBA
[**2182-7-22**] 11:38PM GLUCOSE-234* LACTATE-0.7 NA+-136 K+-4.3
CL--95*
[**2182-7-22**] 11:38PM HGB-11.8* calcHCT-35
[**2182-7-22**] 11:38PM freeCa-1.21
[**2182-7-22**] 11:30PM GLUCOSE-257* UREA N-17 CREAT-0.7 SODIUM-137
POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15
[**2182-7-22**] 11:30PM estGFR-Using this
[**2182-7-22**] 11:30PM WBC-3.1* RBC-3.85*# HGB-10.6*# HCT-33.5*#
MCV-87 MCH-27.6 MCHC-31.8 RDW-17.2*
[**2182-7-22**] 11:30PM PLT COUNT-253#
[**2182-7-22**] 11:30PM PT-10.7 PTT-23.4 INR(PT)-0.9
MR CERVICAL SPINE W/O CONTRAST: [**2182-7-22**]
FINDINGS: In comparison with the most recent examination of the
thoracic
spine dated [**2182-5-30**], there is significant change consistent
with a
pathological fracture, involving the T2 vertebral body with
associated right paraspinal and epidural mass causing narrowing
of both neural foramina and also producing spinal cord
compression with more than 55% of spinal canal narrowing. Again
seen is evidence of post-surgical changes, consistent with
posterior decompression and fusion, apparently unchanged since
the prior examination and causing multiple metal artifacts,
however, there is no evidence of abnormal signal within the
thoracic spinal cord at T2 level. The sagittal STIR images
demonstrate low signal intensity within the vertebral body of
T2, consistent with bone cement from a prior vertebroplasty.
Bilateral pleural effusions are again visualized.
Soft tissue edema and minimal amount of fluid is visualized at
the surgical bed and also in the prevertebral space, apparently
unchanged since the most recent examination.
IMPRESSION: Evidence of pathological fracture at T2 vertebral
body, causing at least 50% of spinal canal stenosis and spinal
cord compression as described in detail above. There is no
evidence of frank signal changes within the thoracic spinal cord
at the level of the vertebral collapse. There is evidence of
post-vertebroplasty changes at T2 level, with right paraspinal
mass and epidural mass involving both neural foramina.
C-SPINE NON-TRAUMA [**1-1**] VIEWS; T-SPINE
C1 through the upper portion of C7 is visualized. No
prevertebral soft tissue swelling. Skin staples noted
posteriorly. There is diffuse osteopenia. The posterior spinous
process of C3 appears truncated and there is some overlying
subcutaneous emphysema. Otherwise, no focal lytic or sclerotic
lesion is detected. Bony alignment is normal and no subluxation
is seen. Allowing for beam angulation, hardware alignment is
nominal, without loosening. Placement of the pedicle screws in
the cervical spine. Assessment is somewhat limited due to beam
angulation, but is likely unremarkable.
THORACIC SPINE: There are bilateral spinal rods. No hardware
loosening is
identified. An intervertebral fusion device is seen at the level
of T6, in
nominal alignment. The T2 vertebral body and associated
retropulsed methyl
methacrylate was better demonstrated on the CT scan from [**2182-7-15**]
-- this area is obscured by overlying humerus. From T3-T12,
vertebral body heights and alignment are preserved. No obvious
focal lytic or sclerotic lesion. There is increased retrocardiac
density, consistent with left lower lobe collapse and/or
consolidation. Possible fluid tracking along right lung minor
fissure, not fully evaluated here.
IMPRESSION:
1. Stabilization hardware extending from the lower cervical
through upper/mid thoracic spine. No hardware displacement or
failure.
2. Poor visualization of the posterior tip of the C3 spinous
process, with
nearby locule of subcutaneous air -- ? related to bony
destruction.
3. C7-T2 not well visualized due to overlying anatomy. The
patient is s/p C6 vertebrectomy. Otherwise, cervical and
thoracic vertebral bodies are intact and normally aligned.
However, subtle bone lesions might not be apparent
radiographically.
4. Please refer to [**2182-7-15**] CT scan for assessment of
abnormalities of C2.
5. Left pleural collapse and/or consolidation and possible fluid
layering in the minor fissure.
LE Doppler [**2182-7-22**]
Final Report
IMPRESSION: No evidence of deep vein thrombosis in either leg.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
63F w/ met renal cell cancer s/p C5-T2 POSTERIOR FUSION by Dr
[**Last Name (STitle) 548**] on [**2182-7-11**] was admitted with bilateral LE weakness. MRI
and X-ray imaging revealed evidence of pathological fracture at
T2 vertebral body, causing at least 50% of spinal canal stenosis
and spinal cord compression. She was taken to the OR urgently
for a decompression. She was transfered to the ICU in an
intubated state postoperatively.
She was an a decadron taper. On [**7-23**] she was extubated. [**7-24**] she
had significant improvement in her Leg strength. Her JP drain
was pulled. Transfer orders were written. She had minimally
distended abdomen but was passing flatus. KUB done [**7-26**] showed
dilated loops of bowel. She became more distended [**7-27**] and NGT
placed. After multiple bowel meds, she had bowel movement. NGT
was kept to low continuous suction.
Radiation oncology was consulted for future treatment which has
been arranged for [**2182-8-7**].
She was evaluated by PT/OT and found appropriate for acute
rehab. On [**8-1**] her abdomen was less distended with bowels sounds,
NG tube was taken off suction to allow for a diet and see if she
tolerates small amounts of food. On [**8-2**], patient has been able
to tolerate sips and we will advance diet. She will be
discharged to rehab facility with NG tube in place not to
suction and continue aggressive bowel regimen.
Medications on Admission:
Aspirin 81 mg PO DAILY
2. Fentanyl 50 mcg/hr Patch 72 hr 72 hr
Transdermal Q72H
3. Cholecalciferol (Vitamin D3) 400 unit Tablet PO DAILY
4. Simvastatin 40 mg (2) Tablet PO DAILY
5. Pioglitazone 15 mg (2) Tablet PO DAILY
6. Insulin Regular Human 100 unit/mL Solution SLIDING SCALE
COVERAGE
7. Glipizide 5 mg Tablet PO BID
8. Levetiracetam 500 mg PO BID
9. Docusate Sodium 100 mg PO BID
10. Acetaminophen 325 mg PO Q6H
11. Valsartan 40 mg Tablet PO DAILY
12. Metoprolol Tartrate 25 mg PO BID
13. Methocarbamol 500 mg PO TID
14. Famotidine 20 mg PO BID
15. Calcium Carbonate 500 mg PO TID
17. Senna 8.6 mg Tablet PO BID
18. Bisacodyl 5 mg Delayed Release (E.C.) PO DAILY prn
constipation.
19. Hydromorphone 2 mg PO Q4H as needed for pain.
20. Clopidogrel 75 mg PO DAILY START ON [**2182-7-17**].
21. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg
Injection Q6H (every 6 hours) as needed for nausea.
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Calcium Carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension Sig:
One (1) PO TID (3 times a day).
3. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for vertigo.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for Pain.
9. Methylnaltrexone 12 mg/0.6 mL Solution Sig: One (1)
Subcutaneous EVERY OTHER DAY (Every Other Day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
12. Glycerin (Adult) Suppository Sig: One (1) Suppository
Rectal DAILY (Daily).
13. Ondansetron 4-8 mg IV Q8H:PRN Nausea/vomiting
14. Ciprofloxacin 400 mg IV Q12H Duration: 7 Days
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
met renal cell cell cancer
hardware failure C5-T2 POSTERIOR FUSION [**2182-7-11**].
Discharge Condition:
stable
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound clean / No tub baths or pool swimming until
seen in follow up/daily showers
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. for 3 months.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Follow Up Instructions/Appointments
PLEASE RETURN [**2182-8-7**] TO [**Hospital Ward Name **] 5 ON [**Hospital Ward Name **] FOR RADIATION
THERAPY
??????Please return to Dr[**Doctor Last Name **] office for removal of your sutures
after you have finished Radiation Therapy.
??????Please call ([**Telephone/Fax (1) 2726**] to schedule an appointment with Dr.
[**Last Name (STitle) 548**] to be seen in 6 weeks.
??????You will need x-rays/CT-scan prior to your appointment.
The following appointments have already been scheduled for you:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2182-12-3**] 10:00
Completed by:[**2182-8-2**]
|
[
"V10.52",
"414.01",
"250.00",
"V45.4",
"344.1",
"564.00",
"336.3",
"401.9",
"198.3",
"272.4",
"560.1",
"V45.82",
"599.0",
"518.89",
"198.4",
"198.5",
"443.9",
"733.13",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"03.4"
] |
icd9pcs
|
[
[
[]
]
] |
10362, 10409
|
6800, 8200
|
314, 377
|
10537, 10546
|
2476, 6777
|
11811, 12484
|
1531, 1550
|
9162, 10339
|
10430, 10516
|
8226, 9139
|
10570, 11788
|
1565, 1568
|
2267, 2457
|
253, 276
|
405, 1025
|
1582, 1667
|
1682, 2051
|
1047, 1343
|
1359, 1515
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,180
| 159,256
|
24843
|
Discharge summary
|
report
|
Admission Date: [**2122-8-8**] Discharge Date: [**2122-8-12**]
Date of Birth: [**2055-8-26**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
mesenteric arteriogram with attempted stent placement
History of Present Illness:
41-year-old woman,
who has a very complex medical history. She is a known
vasculopath with history of mesenteric ischemia now with just
greater than 24 hour history of acute onset abdominal pain,
which
was severe, achy, and crampy in nature and was in the left
greater than right lower quadrants. She also noted at least one
or two episodes of bloody stool. Of note, this feels exactly the
same as her most recent bout of mesenteric ischemia for which
she
underwent an exploratory laparotomy and small bowel resection in
[**2122-6-22**]. She has had no fevers or chills, nausea or
vomiting. She has had no food fear or weight loss until recently
after her small bowel resection at [**Hospital6 204**] and
it
turns out she has lost approximately 20 pounds in the last
several weeks.
Past Medical History:
Hypertension, COPD, diabetes mellitus,
coronary artery disease, myocardial infarction, ischemic colon
and small intestine, chronic diarrhea, congestive heart failure,
gastroesophageal reflux, hiatal hernia, low back pain with
degenerative joint disease, and ejection fraction of 50-60% with
a dilated atrium.
bilateral carotid
endarterectomies 6 years ago, left carotid subclavian bypass,
coronary artery bypass with mitral valve repair, commissurotomy
2
years ago, subtotal colectomy for ischemia in [**2118**], exploratory
laparotomy, small bowel resection, and 32 cm of resection on
[**2122-6-30**], incarcerated ventral hernia repair with mesh,
L4-L5 fusion, a cholecystectomy and appendectomy.
Social History:
She is a former smoker. She lives alone. She
is retired. She does not drink excessively.
Family History:
Notable for heart disease, rheumatic heart
disease, breast cancer, and colonic polyps.
Physical Exam:
VITAL SIGNS: Pulses in the 90s, blood pressure is 120.
GENERAL: She is alert, oriented and in no acute distress.
HEENT: Normocephalic and atraumatic. Sclerae anicteric. Pupils
were equal, round, reactive to light. Extraocular movements were
intact.
NECK: Supple. No lymphadenopathy. There are no nodules or
bruits.
LUNGS: Clear, except for occasional expiratory wheezes.
HEART: Regular.
ABDOMEN: Soft, with minimal bilateral lower quadrant tenderness,
left greater than right. There is no rebound. There are no
obvious hernias. Guaiac positive with normal tone.
EXTREMITIES: Warm. She has 2+ femoral pulses bilaterally. She
has dopplerable bilateral dorsal pedal pulses.
Pertinent Results:
[**2122-8-8**] 02:36AM BLOOD WBC-9.1 RBC-3.50* Hgb-10.6* Hct-33.8*
MCV-97 MCH-30.4 MCHC-31.5 RDW-16.2* Plt Ct-246
[**2122-8-11**] 03:09AM BLOOD WBC-7.3 RBC-2.99* Hgb-9.0* Hct-28.2*
MCV-94 MCH-30.0 MCHC-31.9 RDW-16.2* Plt Ct-250
[**2122-8-8**] 02:36AM BLOOD PT-14.3* PTT-27.0 INR(PT)-1.4
[**2122-8-9**] 09:30AM BLOOD PT-15.4* PTT-79.5* INR(PT)-1.6
[**2122-8-11**] 03:09AM BLOOD PT-14.4* PTT-71.5* INR(PT)-1.4
[**2122-8-8**] 02:36AM BLOOD Glucose-124* UreaN-6 Creat-0.7 Na-145
K-3.5 Cl-111* HCO3-22 AnGap-16
[**2122-8-11**] 03:09AM BLOOD Glucose-98 UreaN-4* Creat-0.5 Na-142
K-4.1 Cl-106 HCO3-23 AnGap-17
[**2122-8-10**] 02:50AM BLOOD ALT-11 AST-17 LD(LDH)-202 CK(CPK)-56
AlkPhos-85 Amylase-103* TotBili-0.4
[**2122-8-10**] 02:50AM BLOOD CK-MB-6 cTropnT-<0.01
[**2122-8-10**] 07:27PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2122-8-8**] 02:36AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.4*
[**2122-8-11**] 03:09AM BLOOD Calcium-7.7* Phos-2.4* Mg-1.9
[**2122-8-8**] 08:52PM BLOOD Type-ART pO2-146* pCO2-34* pH-7.41
calHCO3-22 Base XS--1
[**2122-8-8**] 08:52PM BLOOD Lactate-1.1
RADIOLOGY Final Report
CT 150CC NONIONIC CONTRAST [**2122-8-8**] 4:26 AM
CT ABD W&W/O C; CT PELVIS W&W/O C
Reason: ? closed loop
Field of view: 40 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with ? closed loop obstruction
REASON FOR THIS EXAMINATION:
? closed loop
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 66-year-old female with history of prior ischemic
bowel status post resection. CT in outside hospital demonstrated
very dilated loops of small bowel.
COMPARISONS: Comparison is made to CT performed at an outside
hospital at [**2122-8-7**], at 7 p.m.
TECHNIQUE: 64-MDCT axial images of the abdomen and pelvis were
obtained without IV contrast after administration of IV contrast
(40 seconds and 80 seconds). Nonionic IV contrast was used due
to rapid bolus of this study. 150 cc of Optiray-350 were
administered.
CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There are
bilateral small pleural effusions. There are no focal
consolidations. There is no pericardial effusion. There is
calcification of the mitral annulus of the heart. The heart is
otherwise of normal size.
No focal lesions are seen in the liver, and there is no
intrahepatic bile duct dilatation. However, the extrahepatic
bile duct measures up to 12 mm and appears in the pancreas.
Correlation with LFTs is recommended.
There is an NG tube with the tip in the stomach. The stomach is
otherwise unremarkable. The spleen and pancreas are
unremarkable. There are several small hypodensities in the
kidneys bilaterally that are too small to characterize (less
than 5 mm). The aorta is heavily calcified. There is stenosis at
the origin of the celiac, and there is likely complete occlusion
or near complete occlusion of the SMA at the origin in an 8-mm
segment. Although contrast filled the distal aspect of the SMA,
this could be due to retrograde filling.
When compared to the prior study, the contrast now reaches the
rectum, and there is no evidence of obstruction or closed loop
obstruction. The small bowel also is less dilated than it was in
the prior study and now no definite thickening of the small
bowel can be appreciated. However, in the prior study performed
approximately 8 hours earlier, there was definite thickening of
the small bowel. Now, there is thickening of a short segment of
colon, which can be seen for example in series 3B, image 152.
There is also mild stranding of the mesentery. There are
postoperative changes in the anterior abdominal wall. There is
no evidence of air in the portal vein or pneumatosis. There is
no free fluid in the abdomen.
CT OF THE PELVIS WITH ORAL WITHOUT AND WITH IV CONTRAST: There
is a Foley catheter within the urinary bladder. The rectum
appears to be unremarkable. The uterus and adnexa are within
normal limits.
BONE WINDOWS: There is a small amount of air in the spinal canal
at the level of L3/L4 likely related to degenerative changes of
no significance. There are severe degenerative changes of the
lumbar spine. There is a cage at the level of L4/L5. No
suspicious lytic or blastic lesions are seen. Another air bubble
is seen in the left SI joint, likely due to degenerative
changes.
CT reformations were important to evaluate the bowel.
IMPRESSION:
1. Interval improvement in the degree of dilatation of the
colon, and small bowel. Small bowel thickening cannot be
appreciated anymore but was definitely present in the prior
study performed at the outside hospital. There is no evidence of
small bowel obstruction since the contrast reaches the colon and
the caliber of the small and large bowel are markedly decreased
in size.
2. There is mild stranding of the mesenteric fat.
3. Thickening of a short segment of the colon in the right lower
quadrant could be ischemic.
4. Complete or near complete occlusion of the origin of the SMA
and celiac artery stenosis at the origin. The [**Female First Name (un) 899**] is patent.
Given the patient's history and considering these findigns, the
thickening of the colon in this study could be secondary to
acute ischemia superimposed on chronic ischemic process.
Clinical correlation is recommended.
5. Bilateral pleural effusions.
6. Dilatation of the common bile duct without intrahepatic bile
duct dilatation in this patient status post cholecystectomy.
Correlation with LFTs is recommended. If there is increase in
LFTs, MRCP should be performed.
Brief Hospital Course:
Patient was transferred from OSH directly to the SICU where she
continued to be NPO with and NGT, foley, and IVF as well as
levo/flagyl antibiotics. HD 1 patient had a-gram with attempted
unsuccessful celiac stent placement via femoral approach -
celiac a 50% thrombosed, SMA 100%, has no [**Female First Name (un) 899**]. hep drip was then
restarted. Patient remained NPO with NGT because of initial
thought to reattempt stenting on HD3. HOwever, vascular surgery
felt that given the aptient's improvement and resolution of
symptoms, emergent a-gram could wait. On HD 3 patient had NGT &
foley removed, and a right subclavian central line placed
because no peripheral access could be obtained. Of note, patient
had acute, intense, 2 minute shoulder pain in the middle of the
night - ecg, cxr, and enzymes x 3 were done and patient was
ruled out for an MI. Patient was started on clears and then
advanced to regular diet. HD 4 a-line was dc'd. Heparin to
coumadin bridge as well as home meds were restarted. Patient was
discahrged on HD 5 in good condition with instructions for
follow-up with Dr. [**Last Name (STitle) 1391**], 5 days of lovenox, and a new lasix
dose of 40 [**Hospital1 **].
Medications on Admission:
Protonix, subcutaneous heparin t.i.d., albuterol,
Atrovent, sliding scale insulin, levoflox, and Flagyl.
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Nitroglycerin 0.8 mg/hr Patch 24HR Sig: One (1) Transdermal
Q24H (every 24 hours): remove at bedtime.
7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
13. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe (70mg)
Subcutaneous every twelve (12) hours for 5 days. Disp:*10
syringes* Refills:*0*
14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
mesenteric ischemia
Discharge Condition:
good
Discharge Instructions:
please seek medical attention if you experience fever > 101.5,
severe nausea, vomitting, pain
please resume home meds and take new ones as directed
Followup Instructions:
please follow up with dr [**Last Name (STitle) **] - call [**Telephone/Fax (1) 1393**]
Completed by:[**2122-8-12**]
|
[
"496",
"427.31",
"511.9",
"333.99",
"401.9",
"414.01",
"250.00",
"530.81",
"557.0",
"787.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"88.47",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11005, 11011
|
8324, 9518
|
328, 384
|
11075, 11082
|
2845, 4080
|
11279, 11397
|
2047, 2136
|
9673, 10982
|
4117, 4166
|
11032, 11054
|
9544, 9650
|
11106, 11256
|
2151, 2826
|
274, 290
|
4195, 8301
|
412, 1199
|
1221, 1924
|
1940, 2031
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,092
| 192,655
|
34049
|
Discharge summary
|
report
|
Admission Date: [**2105-4-19**] Discharge Date: [**2105-4-23**]
Date of Birth: [**2022-9-28**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Codeine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
.
HPI collated via OSH ED, CT surgery, and [**Hospital1 18**] notes and briefly
corroborated with daughter as pt. intubated at time of
admission.
.
82 yo woman with history of COPD, who initially presented to [**Hospital **] for dyspnea and chest pain. Per family had been dyspneic
x 3 weeks with increasing fatigue, wanting to sleep all the
time, with chills, cough but no fever. Dyspnea was exertional
and worse with increasing anxiety. She began to have
intermittent chest pain radiating to back yesterday so went to
[**Hospital3 **] for evaluation. At [**Hospital3 **] she had stable EKG, CT
scan which showed thoracic aortic aneurysm with concern for
dissection/leak. She was also noted to have some wheezes and was
given solumedrol 125mg x 1 (sats 97% on her home o2). SBPs at
that time 130s, so she was started on labetalol, and transferred
to [**Hospital1 18**] for CT surgical evaluation.
When she arrived in ED, VS showed SBP in 70s, 02 sats 97%, HR 68
Labetalol stopped and given IVFs with return of SBPS to
90s-100s. She had bedside ECHO which showed small pericardial
effusion. At this point, pt. was intubated given some borderline
O2 sats, potential for directly going to OR, and for TEE
requested by Cardiac Surgery. Cardiology performed TEE which
showed small effusion without tamponade and large intramural
aortic hematoma with echogenic texture suggestive of chronicity
and no evidence of aortic dissection. Per ED resident, pt. was
felt to be a high risk operative candidate, so decision with
family was for medical management. Pt. remained hypotensive and
started on levophed after placement of IJ in ED.
.
On review of symptoms per OSH ED note, she denied any prior
history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. He denies
recent fevers, chills or rigors. He denies exertional buttock or
calf pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for chest pain and dyspnea
on exertion as above. No reports of paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
.
Past Medical History:
- Hypertension
- COPD on home o2 2.5L
- hypothyroidism
- thoracic aortic aneurysm
- multiple hospitalizations for PNA
- hysterectomy [**2071**] for uterine cancer
- anxiety
.
Cardiac Risk Factors: no Diabetes, Dyslipidemia, + Hypertension
.
Cardiac History: no CABG
Percutaneous coronary intervention: n/a
Pacemaker/ICD: n/a
.
Social History:
Social history is significant for the absence of current tobacco
use, but long history of smoking quit in [**2093**]. There is no
history of alcohol abuse. Lives alone and is independent with
ADLs in past per family.
.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 95.3, BP 122/71 on levophed 0.03, HR 64, RR 18, O2 100% on
vent FiO2 40%/Tv 500/PEEP 5/RR 18
Gen: pale appearing elderly woman, intubated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with flat JVP
CV: PMI located in 5th intercostal space, midclavicular line.
RRR normal S1, S2. NoMRGs
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi anteriorly.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas. no
edema
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
MEDICAL DECISION MAKING
.
Studies:
CT Chest with contrast: no filling defects, minor atelectasis
without infiltrates, aneurysmal dilatation of ascending thoracic
aorta with with rupture and mediastinal hematoma per OSH
hospital read.
CXR:
SINGLE VIEW CHEST, SUPINE PORTABLE: The ET tube is approximately
3.9 cm above the carina. The NG tube courses below the diaphragm
into the stomach. There is widening of the superior mediastinum,
which correlates to ascending aortic
intramural hematoma with aneurysm formation as seen on outside
hospital CT.
The pulmonary vasculature is within normal limits allowing for
technique.
.
IMPRESSION: Appropriate placement of NG and ET tubes.
.
ECG demonstrated sinus bradycardia at 57, with Qtc 483, stable
from OSH, non specific TWF in inferior and lateral leads with no
old comparison. Per OSH ECG read, has been brady to 47 before.
.
TELEMETRY form [**Hospital3 **] demonstrates 11 episode of SVT, ?
Afib, spontaneously reverted.
.
2D-ECHOCARDIOGRAM performed on [**4-19**] demonstrated:
Transesophageal ECHO:
The left atrium is dilated. No thrombus/mass is seen in the body
of the left atrium. No mass or thrombus is seen in the right
atrium or right atrial appendage. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is moderately dilated. A
crescent-shaped, eccentric, laminar thickening of the distal
ascending aorta is seen, which is consistent with an intramural
hematoma or possible thrombosed dissection flap. It measures
18mm in maximal thickness and appears relatively echogenic,
which is suggestive of chronicity. There are complex (>4mm)
atheroma in the descending thoracic aorta. The majority of the
descending thoracic aorta and arch is not well seen due to poor
probe contact. [**Name (NI) **] aortic dissection flap is seen. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis or regurgitation. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. The pulmonic valve leaflets are
thickened. There is a small pericardial effusion, which is
largest at the apex (0.9cm) with no evidence of tamponade or
right ventricular diastolic invagination.
.
IMPRESSION: Moderate dilatation of the ascending aorta with
large eccentric intramural aortic hematoma or thrombosed
dissection flap with echogenic texture suggestive of chronicity.
No evidence of free aortic dissection flap. Small pericardial
effusion with no echocardiographic evidence of tamponade. Normal
biventricular function.
.
PRELIMINARY REPORT developed by a Cardiology Fellow. Not
reviewed/approved by the Attending Echo Physician.
.
[**2105-4-19**] 10:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2105-4-19**] 10:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2105-4-19**] 10:05PM URINE RBC-0-2 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-0
[**2105-4-19**] 08:03PM GLUCOSE-165* UREA N-13 CREAT-1.0 SODIUM-137
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
[**2105-4-19**] 08:03PM CK(CPK)-52
[**2105-4-19**] 08:03PM cTropnT-<0.01
[**2105-4-19**] 08:03PM CK-MB-NotDone
[**2105-4-19**] 08:03PM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-2.4
[**2105-4-19**] 08:03PM TSH-0.059*
[**2105-4-19**] 08:03PM WBC-10.0 RBC-3.92* HGB-11.2* HCT-35.8* MCV-91
MCH-28.6 MCHC-31.3 RDW-13.2
[**2105-4-19**] 08:03PM NEUTS-94.1* BANDS-0 LYMPHS-4.7* MONOS-1.0*
EOS-0.1 BASOS-0.1
Brief Hospital Course:
# Aortic Aneurysm: Patient was initially transfered from an OSH
with a concern for leaking of known thoracic aortic aneurysm.
TEE done here showed moderate dilatation of the ascending aorta
with large eccentric intramural aortic hematoma or thrombosed
dissection flap with echogenic texture suggestive of chronicity.
No evidence of free aortic dissection flap. CT surgery was
consulted and they did not recommend surgical intervention, but
did recommend good blood pressure control. She remained chest
and back pain free while here. Goal systolic blood pressure is
90-130. Her blood pressures were relatively low when discharged
but ideally if her blood pressures increase above low-normal
levels, a beta-blocker should be started for BP control.
.
# Rhythm: Patient had a short run of SVT, in sinus rhythm with
PVCs at time of discharge. Metoprolol can be titrated as her BP
tolerates.
# Pericardial effusion: small on TEE, no evidence of tamponade
on TEE or exam.
.
# Respiratory: Patient intially came in intubated. She was
weaned and successfully extubated. She is on home oxygen per
her report. At the time of discharge she wa on her baseline
oxygen. We continued her home pulmonary medications.
.
# Blood pressure: The patient was initially started on a
labetalol drip at the OSH emergency room because of a concern of
ruptured aneurysm. When she was transfered she was hypotensive
and initially maintained on levophed in the ICU. Pressors were
weaned and her blood pressure remained well controlled without
anti-hypertensive medications. The goal blood pressure for her
is 90-130. If needed, Beta-blockers should be started to
control her pressures.
# Hypothyroidism: continued home levothyroxine. TSH should be
checked by her primary care physician.
.
# Psychiatric: continued home paroxetine, ativan
Medications on Admission:
- ipratropium
- albuterol qid
- tiotropium 1 cap daily
- advair 250/50 [**Hospital1 **]
- cyanocobalamin 1000mcg
- levothyroxine 25 mcg
- asa 81
- furosemide 80mg daily
- lorazepam 0.5mg [**Hospital1 **]
- pantoprazole 40mg qdaily
- paroxetine 10mg qdaily
Discharge Medications:
1. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed for sob, wheezing.
11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
12. Home Oxygen
Discharge Disposition:
Extended Care
Facility:
Oaks Long Term Care Facility - [**Location (un) 5503**]
Discharge Diagnosis:
Aortic aneurysm
COPD
Hypertension
hypothyroidism
Discharge Condition:
stable, BP well controlled
Discharge Instructions:
You were seen in the hospital for work up of an aortic aneurysm.
The imaging studies done here did not indicate that it was
leaking. You were evaluated by CT surgery while in house and
they did not think surgery was needed.
.
You will need to have tight control of your blood pressure as an
outpatient.
.
Please keep your follow up appointments listed below
.
If you have any chest pain, back pain, shortness of breath,
altered mental status, or other symptoms of concern to you
either return to the emergency room or call your primary care
physician.
Followup Instructions:
Primary Care/Pulmonary: Dr. [**Last Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 50234**]. You
have an appointment on [**5-8**] at 1:15pm
.
Cardiology: Please call Dr.[**Name (NI) 42421**] office and make a follow up
appointment in [**1-12**] weeks.
|
[
"276.2",
"E947.8",
"401.9",
"E849.7",
"458.29",
"300.00",
"244.9",
"496",
"423.9",
"427.89",
"441.01",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.04",
"96.71",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
10936, 11018
|
7759, 9585
|
302, 309
|
11111, 11140
|
4064, 7736
|
11742, 12012
|
3134, 3216
|
9892, 10913
|
11039, 11090
|
9611, 9869
|
11164, 11719
|
3231, 4045
|
252, 264
|
337, 2529
|
2551, 2881
|
2897, 3118
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,939
| 102,220
|
43174
|
Discharge summary
|
report
|
Admission Date: [**2160-4-2**] Discharge Date: [**2160-4-7**]
Date of Birth: [**2091-10-4**] Sex: F
Service: MEDICINE
Allergies:
Pseudoephedrine / Levofloxacin / Ampicillin
Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
Bleeding after dental extractions
Major Surgical or Invasive Procedure:
NG tube placement and removal
History of Present Illness:
Ms [**Known lastname 4135**] is a 68 year old woman with alcoholic cirrhosis,
suspected HCC, hepato-pulmonary syndrome, presenting with
hemorrhage after molar extraction x 5 earlier today.
.
She underwent the extraction of 5 of her upper molars without
difficulty the day of admission, around 3 pm. There was no
premedication with fresh frozen plasma or vitamin K. Patient
returned home and husband found her around 8pm in bed with
"blood everywhere". Per report, patient has swallowed blood and
had some vomiting.
.
Patient denies feeling light headed or dizzy, no chest pain,
shortness of breath, reports feelig very tired. Last drink
during lunch time today, denies having a history of withdrawal
or seizures in the past.
In the emergency department, initial vitals: 99.5, BP 140/80, RR
16, O2 Sat 95% RA. Patient given 10mg Oral Vitamin K and
admitted for further management.
Past Medical History:
PAST MEDICAL HISTORY:
1. s/p R-basal ganglia hemorrhage ([**2154**]) with residual L-sided
hemiparesis
2. ETOH cirrhosis: first admission for mental status in fall
[**2156**], has had multiple episodes of encephalopathy since.
3. Hepatopulmonary syndrome with peristent hypoxemia at rest,
she
has been instructed to use her home oxygen at all times.
4. Hypothyroidism
5. Anxiety/Depression
6. Insomnia
.
Social History:
Lives with husband, long history of alcohol abuse, currently in
outpatient rehab program, drinking 3 drinks of 1 [**11-30**] oz hard
liquor.
Family History:
Family History:
Father: Died at 47 from MI
Mother: Died at 37 from cerebral hemorrhage
Brother: Died at 24 from heart bacterial infection
-no other siblings
Physical Exam:
VS: 99.4 130/70, HR 73, RR 16, O2 sat 94% 4L NC
GENERAL: Elderly woman, appears older than stated age
HEENT: (+) mild scleral icterus. Very poor dentition. MMM, no
cervical lymphadenopathy
CARDIAC: RR. Normal S1, S2. II/VI early systolic murmur heard at
LUSB.
LUNGS: CTA B, no rales.
ABDOMEN: NABS. Soft, NTND
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
NEURO: A&Ox3. Appropriate. Left hemibody weakness.
Pertinent Results:
Admission ECG: NSR at 92 BPM, small inferior Q waves, diffuse
precordial T wave flattening with inversions at V1 to V3,
unchanged from tracing of [**2159-12-13**].
[**2160-4-7**] 05:15AM BLOOD WBC-3.8* RBC-3.29* Hgb-11.6* Hct-34.7*
MCV-105* MCH-35.1* MCHC-33.4 RDW-23.5* Plt Ct-57*
[**2160-4-7**] 05:15AM BLOOD PT-22.4* PTT-40.7* INR(PT)-2.1*
[**2160-4-7**] 05:15AM BLOOD Glucose-150* UreaN-15 Creat-0.8 Na-141
K-3.0* Cl-107 HCO3-25 AnGap-12
[**2160-4-7**] 05:15AM BLOOD ALT-24 AST-94* AlkPhos-141* TotBili-4.6*
[**2160-4-7**] 05:15AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.4*
[**2160-4-2**] 01:20AM BLOOD WBC-3.9* RBC-3.08* Hgb-11.8* Hct-37.0
MCV-120* MCH-38.2* MCHC-31.7 RDW-17.9* Plt Ct-62*
[**2160-4-2**] 01:20AM BLOOD PT-24.2* PTT-40.2* INR(PT)-2.4*
[**2160-4-2**] 04:32AM BLOOD Glucose-135* UreaN-9 Creat-0.6 Na-142
K-3.9 Cl-113* HCO3-17* AnGap-16
[**2160-4-2**] 09:31PM BLOOD ALT-30 AST-123* LD(LDH)-400* CK(CPK)-567*
AlkPhos-125* TotBili-6.6*
[**2160-4-2**] 04:32AM BLOOD Calcium-7.8* Phos-2.7 Mg-1.3*
[**2160-4-2**] 09:31PM BLOOD CK-MB-64* MB Indx-11.3* cTropnT-0.95*
[**2160-4-3**] 04:26AM BLOOD CK-MB-93* MB Indx-11.0* cTropnT-1.99*
[**2160-4-3**] 08:06PM BLOOD cTropnT-1.74*
CXR [**4-2**]
Cardiomegaly is mild-to-moderate predominantly involving the
left ventricle.
The mediastinal position, contour and width are unremarkable.
There is
interval slight worsening of the right basilar opacity that has
been present
before but appears to be more obvious and might represent either
interval
aspiration or worsening of atelectasis. Left lower lobe opacity
is unchanged,
most likely representing either chronic scarring or area of
atelectasis.
CXR [**4-4**]
FINDINGS: In comparison with the study of [**4-3**], the bilateral
areas of
opacification are decreasing. This could reflect clearing of
aspiration or
reduction in pulmonary venous congestion. Enlargement of the
cardiac
silhouette persists. Nasogastric tube again extends well into
the stomach
ECHO:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 40-50 %) secondary to inferior and posterior
wall hypokinesis. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. There are focal
calcifications in the aortic arch. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
RUQ U/S w/ doppler
IMPRESSION:
1. Hepatofugal flow in the main portal vein is new since
[**2159-12-12**]. There is
no evidence of venous thrombosis.
2. Evaluation of the hepatic parenchyma is markedly limited for
assessment of
known hepatic lesions, which are better demonstrated on CT.
Brief Hospital Course:
68 year-old female with alcoholic cirrhosis, likely HCC,
presented with profuse post-procedure bleeding after elective
tooth extraction, course complicated by NSTEMI and pulmonary
edema. Hospital course was as follows.
On admission, patient was noted to have considerable
bleeding from her mouth. She was given vitamin K 10mg PO once
and admitted to the medicine [**Hospital1 **] for further management. She
was initially hemodynamically stable,. Her hematocrit dropped
from 37 to 22 in less than 24 hours, requiring transfer to MICU.
Prior to transfer, she received 2 units FFP given an INR of 2.9
(underlying liver disease). Dentistry was consulted and
recommended contacting oral surgery. Oral surgery could not be
reached in house through several attempts; the case was
discussed with oral surgery residents at [**Hospital1 2025**] who suggested
pressure and xerofrom dressing. [**4-2**] evening around 5pm, patient
developed sinus tachycardia to 130's, with low grade temp of
100.0. Patient was tremulous. HCT trend [**4-2**] 1:20 AM 37, 4:30 AM
33.8, 9AM 26.8, 4:30 PM 22.1. She got FFP as above, ordered for
2 units PRBC and cultured. She received clindamycin for
prophylaxis after tooth extraction. She was transferred to the
ICU for further management.
In the MICU, she was transfused 4 units PRBCs, FFP, and
mouth was packed with aminocaproic-acid soaked gauze, with good
hemostasis. She ruled in for NSTEMI with trop peak 1.99; started
ASA and metoprolol. After transfusions, she had mild-mod volume
overload, and she was gently diuresed. She was transferred back
to the medicine service for further management.
Remainder of hospital course was as follows.
1. NSTEMI: Peri-MI EF 35-40%, with mild-mod volume overload.
Troponin peaked at 1.99, as above. Patient was started on
aspirin 325mg daily. Plavix was not started given concern for
bleeding (mouth, esophageal varices). She was also started on a
low-dose cardioselective beta-blocker. She was evaluated by PT
and sent home with cardiac rehabilitation.
2. Alcoholic cirrhosis: RUQ ultrasound on [**2160-4-4**] showed reversal
of flow in portal vein, new since [**12-7**]. Concern for worsening
hepatic disease/cirrhosis vs. thrombosis. She was continued on
rifaxamin and beta-blocker, as above. She was also started on a
PPI. A CTA liver to further assess flow reversal was scheduled
as an outpatient.
3. Alcohol abuse: Actively using alcohol as outpatient. Patient
not interested in alcohol cessation at this time.
4. Hypothyroidism: Continued levothyroxine per outpatient
regimen.
5. Depression: SSRI temporarily held given interference with
platelet aggregation.
6. Hepatopulmonary syndrome: Patient with chronic hypoxemia. Due
to fluid overload, her oxygen requirement was increased after
transfer from the ICU. On discharge, she was with baseline O2
saturation on home oxygen requirement (2-3L).
Medications on Admission:
ESCITALOPRAM [LEXAPRO] - 5 mg Tablet - One Tablet by mouth daily
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
LEVOTHYROXINE [SYNTHROID] - 25 mcg Tablet - 1 Tablet(s) by mouth
daily
NADOLOL - 20 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
NYSTATIN [NYAMYC] - 100,000 unit/gram Powder - apply daily to
area
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth daily
OXYGEN - (Prescribed by Other Provider; not using at all) -
Dosage uncertain
POTASSIUM CHLORIDE [KLOR-CON M20] - 20 mEq Tab Sust.Rel.
Particle/Crystal - 1 Tab(s) by mouth daily
RIFAXIMIN [XIFAXAN] - 200 mg Tablet - 3 Tablet(s) by mouth two
times a day
MULTIVITAMIN [CENTRAL VITE] - Tablet - 1 Tablet(s) by mouth
DAILY (Daily)
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
2. Lexapro 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Klor-Con M20 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One
(1) Tab Sust.Rel. Particle/Crystal PO once a day.
12. Outpatient Lab Work
Please check CBC in 1 week. Please fax results to Dr. [**Last Name (STitle) **]:
[**Telephone/Fax (1) 716**])
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Gingival hemorrhage
NSTEMI
Alcoholic cirrhosis with portal hypertension
Hepatopulmonary syndrome
Discharge Condition:
Hemodynamically stable. Chest pain-free.
Discharge Instructions:
You were admitted to [**Hospital1 69**] on
[**2160-4-2**] for bleeding from you mouth following multiple dental
extractions. You lost a considerable amount of blood, and
required a short stay in the ICU for management. You suffered a
heart attack and suffered a likely temporary reduction in your
heart function; given this and fluids that you required due to
blood loss, you experienced fluid build up in your lungs. This
improved prior to your discharge, and on discharge, your oxygen
requirement is at your baseline.
You also underwent a liver ultrasound which showed a reversal of
flow in one of the blood vessels which goes to the liver.
-You will need a CT-scan angiography of your liver to be done as
an outpatient
Your medication regimen has changed. Please review your
medication list closely.
Please call your physician or return to the emergency department
for bleeding, chest pain or pressure, shortness of breath, or
for any other symptoms which are concerning to you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2160-7-18**] 12:00
**Please have your a CT-scan angiography performed of your
liver. Please call Dr. [**Last Name (STitle) 497**] or Dr. [**Last Name (STitle) **] to arrange this
study.
You have an appointment with your PCP [**Last Name (NamePattern4) **] [**4-15**] at 10am
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 719**]
Completed by:[**2160-4-10**]
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icd9pcs
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6,038
| 108,002
|
1050
|
Discharge summary
|
report
|
Admission Date: [**2104-8-21**] Discharge Date: [**2104-8-26**]
Service: MEDICAL
HISTORY OF PRESENT ILLNESS: This is a 78 year old woman with
a history of severe chronic obstructive pulmonary disease,
ulcerative colitis, status post ileostomy in [**2097**], aortic
stenosis, status post valvuloplasty in [**2097**], and then aortic
valve replacement with a porcine aortic valve in [**2098**], and a
left below the knee amputation in [**2065**], who has had one week
of cough and sputum production that was treated with Levaquin
and Flagyl.
Two days prior to admission, the patient developed nausea and
vomiting and stopped taking her Flagyl but still had nausea.
She stopped being able to eat well and had some respiratory
distress and had diarrhea. She was sent to the Emergency
Department for evaluation. She denied any chest pain, denied
any blood in the diarrhea, denied any blood in her vomit,
denied fever, chills.
PHYSICAL EXAMINATION: On arrival in the Emergency
Department, the patient's examination revealed she was an
uncomfortable dyspneic woman on oxygen via nasal cannula who
had to pause while speaking secondary to her dyspnea. She
was afebrile. Her blood pressure was 116/60 with a pulse of
86, respiratory rate 20s with oxygen saturation of 95% in
room air. Head, eyes, ears, nose and throat - She was
normocephalic and atraumatic with no icterus. Her mucous
membranes were dry. She had no jugular venous distention.
Her chest had basilar crackles bilaterally, diffusely
decreased breath sounds. The heart was regular. She had a
III/VI midsystolic murmur. Her abdomen was obese, soft,
nontender, no hepatosplenomegaly. The ileostomy bag was in
place. Her extremities revealed status post left below the
knee amputation. Her right lower extremity was cool with
chronic erythema and venous stasis changes and trace edema.
LABORATORY DATA: On admission, white count 13.9, hematocrit
42.5, platelets 308,000. INR 2.1. Chem7 revealed a sodium of
136, potassium 5.7, chloride 111, bicarbonate 6, blood urea
nitrogen 120, creatinine 3.0, glucose 110. A troponin was
less than 0.3. Urinalysis had 30 protein, specific gravity
of 1.016, three white cells, two red cells and a few
bacteria. ALT was 8, AST 20, alkaline phosphatase 102, total
bilirubin 0.4, amylase 111, CK 53.
Her chest x-ray showed no congestive heart failure and no
pneumonia. Arterial blood gases at that time revealed pH
7.21, pCO2 22, pO2 153.
Electrocardiogram showed sinus rhythm at 90 beats per minute.
Q wave in III, aVF and V2, 1.[**Street Address(2) 2811**] depressions in
II, V3 through V6. T wave inversions in I, II, aVL, V4
through V6 and biphasic in V3.
HOSPITAL COURSE: She was admitted to the Medical Intensive
Care Unit for correction of her metabolic acidosis and acute
renal failure and for ruling out acute myocardial infarction.
1. Metabolic acidosis - She was given three amps of
bicarbonate in one liter of fluid. She had blood cultures
drawn. She was treated with oxygen. Calcium, phosphorus and
magnesium levels were drawn and found to be low. She was
repleted with those intravenously and her acidosis responded
so that on the day of transfer to the floor, her bicarbonate
was 19 and she was able to tolerate p.o.
2. Acute renal failure - She had a creatinine of 3.0 when
her baseline is 1.1. This responded well to intravenous
fluid hydration so that on the day of transfer to the floor
her creatinine was 1.8 and on the day of discharge from the
hospital her creatinine was 1.3.
It was thought that both metabolic acidosis and the acute
renal failure were secondary to severe volume depletion from
diarrhea and decreased p.o. intake. She has responded well
to intravenous rehydration and repletion of her electrolytes.
3. Rule out myocardial infarction - Serial CKs were done
which were negative. Her troponin was always less than 0.3.
Despite the changes on the electrocardiogram, she was found
not to have had a myocardial infarction. It was thought that
these changes were secondary to some ischemia probably
induced by the volume depletion.
4. Respiratory - She began to have some increasing shortness
of breath on the day of transfer to the floor and stated that
at home she takes Albuterol nebulizer twice a day. These
were started on the floor and her breathing improved. She
continued on her normal respiratory medications, inhalers and
was continued on b.i.d. nebulizers.
5. Gastrointestinal - The patient presented with nausea,
vomiting, diarrhea and decreased p.o. intake. Over her
hospital stay, the diarrhea decreased and her stools became
more formed. She was able to tolerate p.o. and hydrate
herself and replete her electrolytes through p.o. Amylase and
lipase were within normal limits throughout her hospital
stay.
6. Infectious disease - The patient was diagnosed with
pneumonia prior to admission and stopped her antibiotics
during her illness. No consolidation was seen on chest x-ray
but it was decided to treat her with Levaquin and Flagyl.
Flagyl was discontinued two days prior to discharge and she
will be continued on Levaquin for a total of ten days and
will stop her course on [**2104-9-1**]. Her blood cultures have
been negative throughout as has a urine culture and she has
been afebrile since her transfer from the Medical Intensive
Care Unit.
7. Hematology - Her INR was 2.1 on admission and it was
subsequently checked and found to be 1.9. Her liver function
tests were normal and it was felt that this was due to
Vitamin K depletion from poor nutrition. She was given
Vitamin K p.o. for three days and her INR will be checked
again as an outpatient.
She will follow-up with her regular primary care physician
when she gets home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: She will be discharged to a rehabilitation
facility for further assistance with her activities of daily
living, respiratory status and her p.o. repletion.
MEDICATIONS ON DISCHARGE:
1. Albuterol and Atrovent nebulizers b.i.d.
2. Atrovent MDI two puffs b.i.d.
3. Vanceril MDI four puffs b.i.d.
4. Humibid 600 mg p.o. b.i.d.
5. Zantac 150 mg p.o. q.d.
6. Isordil 10 mg p.o. t.i.d.
7. Metoprolol 25 mg p.o. b.i.d.
8. Levofloxacin 250 mg p.o. q.d. to finish on [**2104-9-1**].
9. Heparin 5000 units subcutaneous q.d.
10. Magnesium Oxide 420 mg p.o. t.i.d.
11. Elavil 10 mg p.o. q.h.s. p.r.n.
12. Calcium Carbonate one gram p.o. q.d.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease.
2. Ulcerative colitis, status post ileostomy.
3. Left below the knee amputation.
4. Aortic stenosis, status post porcine aortic valve
replacement.
5. Acute renal failure which is resolving.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**]
Dictated By:[**Last Name (NamePattern1) 6857**]
MEDQUIST36
D: [**2104-8-25**] 18:28
T: [**2104-8-25**] 19:36
JOB#: [**Job Number 6858**]
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6456, 6970
|
5978, 6435
|
2703, 5743
|
961, 2685
|
122, 938
|
5768, 5952
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,514
| 125,949
|
9706
|
Discharge summary
|
report
|
Admission Date: [**2134-10-1**] Discharge Date: [**2134-10-11**]
Date of Birth: [**2081-7-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
CC: SOB
Reason for MICU Admission: Respiratory distress
Major Surgical or Invasive Procedure:
Endotracheal Intubation from [**Date range (1) 32787**]
History of Present Illness:
This is a 53 y.o with Multiple Sclerosis and Asthma with 2 days
of cough, SOB, and fever upto 102 per husband. She had increased
agitation, AMS, and unwitnessed fall per husband.
.
In the ED, inital vitals were Tm 101.6, BP 129/60, HR 88, RR 16,
sat 96% on 6L. ABG 7.31/44/65. CXR found opacification of the
left lung with question of layering pleural effusion vs. lobar
collapse. The right lung with patchy airspace opacity with
concern for PNA. She received dose of levofloxacin and
ceftriaxone. Pt also given nebs and lorazepam. EKG unchanged,
head and neck CT was negative.
.
Per neurology, she has limited o2 sats, advanced MS, and sleep
disturbances.
.
Upon speaking with pt's family, pt normal waxes and wanes in
terms of alertness.
.
Of note, she was admitted and treated for left sided pneumonia
with flagyl/levo. However, abx switched to
vanco/azithro/flagyl/cefepime. Her symptoms gradually improved.
.
ROS: Unable to assess for complete ROS as pt with altered MS.
.
Past Medical History:
Multiple Sclerosis
Venous Stasis Dermatitis
Constipation
Disruption of sleep wake cycle
Depression
Chronic pain
.
Social History:
Lives with husband in [**Name2 (NI) **]. Quit smoking for seven years and
just restarted this past summer. Currently smoking a pack a
week.
Family History:
Mother with breast cancer at 76. Alzheimer's disease
Son with asthma
Physical Exam:
On Presentation:
Vitals: T. 99.7 BP 127/61, HR 97, RR 23 sat 99% on 15% NRB
GEN: obese,ill appearing, mild respiratory distress, 2 word
sentences, confused, lethargic
HEENT: +L.eye abrasion, ~3cm, dried blood. +ecchymoses L.eye.
EOMI, anicteric, PERRLA, MMM
neck: supple, unable to assess for JVP 2/2 body habitus, no LAD
chest: b/l AE, anterior exam, +diffuse rhonchi L.lung, exp
wheezing L.lung
heart: s1s2 rrr no m/r/g
abd:+bs, TTP LLQ, soft, distended, obese, no guarding/rebound
ext: no c/c/ trace edema, 2+pulses, chronic venous status
changes.
neuro: AAOx2 (name/place) perseveration over place, +full body
intermittent twitching, FROMx4, no tremor.
.
Pertinent Results:
Admission Labs:
[**2134-10-1**] 05:05AM WBC-7.4 RBC-3.68* HGB-11.7*# HCT-35.3* MCV-96
MCH-31.7 MCHC-33.1 RDW-14.0
[**2134-10-1**] 05:05AM NEUTS-90.6* LYMPHS-6.2* MONOS-2.8 EOS-0.1
BASOS-0.2
[**2134-10-1**] 05:05AM PLT COUNT-163
[**2134-10-1**] 04:55AM TYPE-ART PO2-65* PCO2-44 PH-7.31* TOTAL
CO2-23 BASE XS--4 INTUBATED-NOT INTUBA
[**2134-10-1**] 05:05AM ALBUMIN-4.0 CALCIUM-9.6 PHOSPHATE-2.9#
MAGNESIUM-2.0
[**2134-10-1**] 05:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2134-10-1**] 05:05AM CK-MB-8 cTropnT-<0.01 proBNP-1300*
[**2134-10-1**] 05:05AM LIPASE-16
[**2134-10-1**] 05:05AM ALT(SGPT)-22 AST(SGOT)-52* LD(LDH)-656*
CK(CPK)-184* ALK PHOS-117 TOT BILI-0.5
[**2134-10-1**] 05:05AM GLUCOSE-126* UREA N-22* CREAT-1.0 SODIUM-141
POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-22 ANION GAP-13
[**2134-10-1**] 05:10AM URINE HYALINE-0-2
[**2134-10-1**] 05:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2134-10-1**] 05:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2134-10-1**] 05:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2134-10-1**] 05:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
.
CTA [**10-1**]:
1. No evidence of pulmonary embolus or dissection.
2. Multifocal confluent airspace opacities, left lung greater
than right. The pattern is similar to [**2133-8-17**], and the
differential diagnosis includes atypical pneumonia, aspiration.
Less likely etiologies of pulmonary hemorrhage and drug reaction
are also possibilities.
Brief Hospital Course:
53 y.o woman with h.o MS, asthma, chronic pain who presents with
SOB/cough/ fever s/p fall.
.
# Atypical vs CAP: She presented with dyspnea on [**10-1**]. CT and
CXR of lung showed opacification of the left lung (effusion
vs.collapse), and right lung with patchy airspace opacity. CT
findings of ground glass opacities in both lungs suggested
atypical pneumonia. On [**10-3**], she was started on
Methylprednisolone 60 Q 8 and given lasix 20 IV x 1. Pt
continued to have worsening dyspnea and was intubated on [**10-3**]
until [**10-6**]. Pt's abx was broadened to Zosyn for 5 days and
after extubation, she was placed on Levaquin again by ICU to
finish a 7 day course of abx. ON floor, pt continued to have
productive cough but oxygen requirement is stable at 0 liters
and has remained afebrile. Pt finished levaquin on [**2134-10-10**]. For
ongoing cough, pt is on frequent nebs, guaifenisen, prn
suctioning and also ordered for chest PT.
.
# S/P Fall: She had a fall with no available history for
pre/post symptoms to suggest syncope from vasovagal,
orthostatic, or cardiac cause. Pt remembers the fall and she
denies pre-syncopal/syncopal sx. She thinks she tripped. She has
an L eyelid superficial lac which was steri-stripped in ICU. CT
head and C spine are negative.
# Altered Mental Status: Pt appeared delerious upon admission.
It was believe that the pt was AOx3 at baseline, however had
been noted to be suffering from hallicinations/paranoia prior to
admission. DDx included infection, narcotic intake (although tox
negative), toxic metabolic. Pt is s/p fall but CT head/neck
negative for acute process. Following extubation on [**10-6**], the
patient's mental status cleared and she was subsequently AOx3 on
the morning of [**10-8**] and has continued to remain oriented and
calm on floor.
.
# advanced MS (multiple sclerosis). Neurology was consulted for
help on medical management, they recommended continuing all her
MS meds but they were inaccurately dosed in ICU. Home meds
reconciled with husband on [**10-9**] and except for soma, pt is on
all of her MS meds again as of [**10-9**].
# Chronic Pain: Per husband, pt is on oxycontin 40mg [**Hospital1 **]. Pt
continued on Oxycontin 20mg [**Hospital1 **] here with prn oxycodone and
appeared to be doing well.
# Diarrhea - in ICU. Stool studies sent when came to floor.
Cdiff X 1 neg. Cdiff X 2 pending. Stool cx ordered. She was
started on flagyl for 14 days for high clinical suspecion.
.
.
.
total discharge time 36 minutes.
Medications on Admission:
The following list verified with husband on [**2134-10-9**]:
1. [**Name2 (NI) 32788**]on 0.3mg SQ QOD
2. KCL 10meq TID
3. Lamictal 400mg TID
4. Azetazolamide 250mg [**Hospital1 **]
5. Amantadine 100mg [**Hospital1 **]
6. Baclofen 20mg at 8AM, 40mg at noon, 20mg at 6pm and 70mg QHS
7. Celexa 20mg QD
8. Wellbutrin XL 150mg QD
9. Oxycontin 40mg [**Hospital1 **] (and prn - advised husband and pt to not
do prns w long acting agents)
10. Meclizine 25mg QID
11. Soma 350mg QAM, 700mg QHS
12. Flonase NS prn
13. Colace QOD
14. FeSO4 325mg twice a week
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Lamotrigine 100 mg Tablet Sig: Four (4) Tablet PO TID (3
times a day).
7. Betaseron 0.3 mg Recon Soln Sig: One (1) Subcutaneous QOD
().
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-18**]
Drops Ophthalmic PRN (as needed).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Pain.
15. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
17. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
18. Bupropion 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
19. Amantadine 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
21. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*15 Patch 24 hr(s)* Refills:*2*
22. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
23. Baclofen 10 mg Tablet Sig: Four (4) Tablet PO NOON (At
Noon).
24. Baclofen 10 mg Tablet Sig: Seven (7) Tablet PO HS (at
bedtime).
25. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
26. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
27. Carisoprodol 350 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
28. Carisoprodol 350 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
29. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
Discharge Condition:
excellent
Discharge Instructions:
you had pneumonia and you were in the ICU. you finished
treatment. you developed diarrhea while on antibiotics. this
could be related to infection called C-Diff. you were started on
Flagyl. please follow with your PCP the stool studies testing
for that bacteria.
Followup Instructions:
[**Last Name (LF) 1576**],[**First Name3 (LF) 1575**] [**Telephone/Fax (1) 1579**]
|
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"340",
"293.0",
"918.0",
"493.91",
"E888.9",
"518.81",
"338.29",
"008.45",
"486",
"867.0",
"E928.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9896, 9902
|
4208, 5494
|
372, 429
|
9956, 9968
|
2515, 2515
|
10279, 10365
|
1749, 1820
|
7307, 9873
|
9923, 9935
|
6735, 7284
|
9992, 10256
|
1835, 2496
|
277, 334
|
457, 1437
|
2531, 4185
|
5509, 6709
|
1459, 1575
|
1591, 1733
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,624
| 118,491
|
31648
|
Discharge summary
|
report
|
Admission Date: [**2106-5-27**] Discharge Date: [**2106-6-20**]
Date of Birth: [**2060-12-28**] Sex: F
Service: MEDICINE
Allergies:
Benzodiazepines / Furosemide
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Evaluation for liver transplant
Major Surgical or Invasive Procedure:
1. EGD
2. Post-pyloric feeding tube x 3
3. Paracentesis
4. PICC line placement x 2
History of Present Illness:
45F with ESLD secondary to EtOH, AIHA due to lasix recently on
prednisone who was initially presented to OSH with hepatic
encephalopathy transferred from OSH on [**5-27**] for liver transplant
evaluation whose course has been complicated by coagulopathy
with recurrent epistaxis, VRE bacteremia, new onset Afib with
RVR and now with worsening leukocytosis and diffuse bilat
pulmonary infiltrates.
.
To summarize her recent course, the patient was admitted to OSH
from [**Date range (1) 74368**] for hemolytic anemia thought to be [**1-15**] lasix and
was started on prednisone 50mg. On [**5-22**], she represented with
hepatic encephalopathy and T [**Age over 90 **]F where she underwent
paracentesis with negative cultures. CXR showed b/l infiltrates
and she received tx with vanco, levoflox, and zosyn and she was
transferred to [**Hospital1 18**] for liver transplant eval.
.
At [**Hospital1 18**], she was noted to have numerous small pulmonary nodules
on [**5-29**] chest CT of unclear significance. Pulm consulted for
?bronch given concern for infection vs. malignancy. Due to
worsening confusion the patient underwent repeat paracentesis
with 135 WBC. Eventually blood cultures from [**6-11**] returned [**12-17**]
bottles +ve for VRE and was started on daptomycin. Likely source
was colonization of urine discovered on [**5-30**]. Also on [**6-11**], the
patient was started on CTX for positive U/A which was then
continued per ID to empirically cover possible SBP. Also treated
for hepatorenal syndrome (cre 1.5 which improved to 0.4) with
albumin, midodrine, and octreotide x 4 days, which was d/c'd on
[**6-16**] given improvement in renal function.
.
On [**6-14**], the patient developed significant epistaxis requiring
multiple FFP, platelet, and RBC transfusions. There was concern
for aspiration given altered mental status. Despite continued G+
black stools her Hct has been stable since [**6-15**]. On [**6-16**], the
medical team repeated her CT chest to eval for progression of
pulmonary nodules and found bilateral infiltrates concerning for
infection, bleeding, or aspiration. She was started on bactrim
for possible PCP given her recent prolonged predinsone course
that had been discontinued on [**6-15**]. Also on [**6-16**] developed
new-onset Afib with RVR 150s that responded to diltiazem. Due to
increased volume of diarrhea and climbing WBC count she was
started on empiric flagyl on [**2106-6-17**].
.
On transfer to the MICU, the patient denies any complaints
including shortness of breath, chest pain, headache, confusion.
Past Medical History:
EtOH cirrhosis s/p TIPS for varices in [**2102**] with multiple
revisions
gastric varices
hepatic encephalopathy
spur cell anemia
chronic hyponatremia
autoimmune hemolytic anemia (from lasix?) on prednisone
h/o ovarian cysts
Social History:
Lives with husband, [**Name (NI) **], who is very involved in her care. No
children. No tobacco use ever. Significant EtOH history, sober
since [**2105-11-28**]. Involved in AA. Reported PTSD s/p attack by
father as a child/teenager.
.
Previously worked as a lawyer, studied at [**Name (NI) 17448**] Law School.
Family History:
No liver disease. Alcoholism in father.
Physical Exam:
Admission Physical Exam
Vitals: T: 99.3 BP: 100/60 P: 74 RR: 20 SpO2: 96% RA wt 47 kg
General: Awake, alert, lying flat in bed in NAD. grossly
jaundiced, thin.
HEENT: EOMI, sclera icteric. MMM, OP without lesions
Neck: supple, no JVD appreciated
Pulm: mild crackles to b/t bases
Cardiac: RRR, nl S1/S2, 2/6 systolic murmur
Abdomen: soft, tender to deep palpation to epigastrum. no
rebound/guarding. ND, + BS, no hepatomegaly noted.
Rectal: guaiac negative at OSH
Ext: No edema b/t, warm.
Skin: spider telangiectasias to chest, grossly jaundiced
Neurologic:
-mental status: Alert & Oriented x 3. Able to relate history,
but with some memory lapses.
-cranial nerves: II-XII intact
-motor: [**3-18**] UE strength, [**4-17**] LE.
-sensory: No deficits to light touch throughout.
-no asterixis
.
ICU Admission Physical Exam:
T 96.1 HR 125 BP 113/59 RR 23 SaO2 98% on RA
General: Ill-appearing, jaundiced
HEENT: PERRL, EOMi, icteric sclera, mouth and nares with crusted
blood, OP clear
Neck: supple, trachea midline, no masses, no LAD
Cardiac: tachycardic, [**Last Name (un) 3526**] [**Last Name (un) 3526**], s1s2 normal, friction rub noted
at LUSB 4th intercostal space, no m/g
Pulmonary: bilateral crackles (L>R)
Abdomen: +BS, soft, nontender, distended, +ascites
Extremities: warm, 2+ bilateral LE edema
Neuro: A&Ox3, speech clear, CNII-XII intact, no asterixis
Pertinent Results:
Admission Labs:
==============
[**2106-5-27**] CBC/DIFF: WBC-19.9* RBC-2.56* HGB-9.3* HCT-24.5* MCV-96
MCH-36.3* MCHC-37.8 PLT 39 NEUTS-91.4* LYMPHS-4.1* MONOS-4.3
EOS-0.1 BASOS-0.1
[**2106-5-27**] ALBUMIN-2.4* CALCIUM-9.5 PHOSPHATE-2.5* MAGNESIUM-2.2
IRON-183* CHOLEST-92
[**2106-5-27**] LFTs: ALT(SGPT)-51* AST(SGOT)-89* LD(LDH)-990* ALK
PHOS-114 TOT BILI-32.0* DIR BILI-15.2* INDIR BIL-16.8
[**2106-5-27**] CHEM 7 GLUCOSE-101 UREA N-38* CREAT-0.6 SODIUM-121*
POTASSIUM-4.0 CHLORIDE-87* TOTAL CO2-29 ANION GAP-9
[**2106-5-27**] 11:40PM PT-23.0* PTT-49.0* INR(PT)-2.3*
.
Serologies:
==========
[**2106-5-27**] HCV Ab-NEGATIVE
[**2106-5-27**] HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-NEGATIVE HAV
Ab-POSITIVE
.
MICRO:
======
-Blood Cultures 6/15, [**5-30**]: Negative
-RPR non-reactive
-Rubella Immune
-Varicella IgG positive
.
Lipids:
======
[**2106-5-27**] LIPIDS: TRIGLYCER-87 HDL CHOL-45 CHOL/HDL-2.0
LDL(CALC)-30
.
IRON STUDIES: TIBC-181* HAPTOGLOB-<20* FERRITIN-1524* TRF-139*
.
RADIOLOGY:
=========
[**5-28**] ABD U/S- DOPPLER LIVER ULTRASOUND: No prior studies are
available for comparison. The TIPS is patent with wall-to-wall
color flow. There is appropriate flow reversal (hepatofugal)
within the left portal vein. The assessment of the right
anterior and posterior portal veins was limited as the liver is
extremely shrunken and nodular. The following velocities were
obtained: Main portal vein 35 cm/sec; proximal TIPS 67 cm/sec;
mid TIPS 73 cm/sec; distal tips 74 cm/sec. The receiving hepatic
vein is patent.
.
There is a small amount of ascites surrounding the liver,
relatively less in the lower quadrants. The liver is extremely
shrunken and nodular with very heterogeneous echotexture.
Anterior to the TIPS stent are multiple tubular hypo-to-anechoic
structures which could represent dilated ducts or less likely,
thrombosed veins. No frank mass lesion is identified but
assessment is limited due to the shrunken appearance of the
liver. The spleen is within normal limits in size measuring 10.7
cm.
.
IMPRESSION:
1. Patent TIPS with wall-to-wall flows and appropriate
velocities as listed above.
2. Shrunken cirrhotic liver without overt hepatic mass.
Questionable biliary dilatation anterior to TIPS stent
.
[**5-29**] CT A/P-
IMPRESSION:
1. Numerous noncalcified subcentimeter nonspecific pulmonary
nodules. Comparison with prior CT scans if available is
recommended to evaluate for stability. If no prior examinations
are available for comparison, and the patient is a high risk
patient i.e. is a smoker or has a known primary malignancy, a
followup with CT of the chest in [**5-25**] months is recommended. If
the patient is at low risk i.e., is not a smoker or has no known
malignancy, followup with CT of the chest in twelve months is
recommended.
2. TIPS in the right hepatic lobe.
3. Chronic occlusion of the left portal vein and posterior
division of the right portal vein with corkscrew hepatic
arteries which are patent. There is a tiny left hepatic artery
off of the proper hepatic artery with an accessory branch off
the left gastric artery. No suspicious hepatic lesions.
4. Moderate intraabdominal and intrapelvic ascites with
extensive intraabdominal varices as described consistent with
portal hypertension.
.
ECHO (TTE) [**2106-6-1**]-
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Regional
left ventricular wall motion is normal. 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 gradient is likely related to high cardiac output.
Trace aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. 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: Normal/hyperdynamic biventricular systolic function.
Mild mitral regurgitation. Trivial aortic regurgitation.
.
Portable CXR [**6-4**]:
Cardiomediastinal contour is unchanged. NG tube tip is below
the diaphragm out of view. Right PICC line tip is in the mid
SVC. There is no pneumothorax. New ill-defined opacity in the
left lower lobe in the
retrocardiac area is consistent with atelectasis and/or area of
aspiration
Small left pleural effusion is also new.
.
CT Chest [**6-8**]:
IMPRESSION:
1. Interim improvement in diffuse predominantly peribronchiolar
nodular
opacities, though numerous nodular opacities persist on the
current study. The coalescing airspace disease adjacent to the
minor fissure appears much
improved. Given the improved appearance over the short
interval, an
infectious process is considered likely. Eventual CT followup
(three months) is recommended after treatment.
2. Small bilateral pleural effusions and moderate-to-large
ascites as well as subcutaneous edema are unchanged from the
prior exam.
.
Abdominal U/S [**6-11**]:
IMPRESSION:
1. Moderate to large amount of ascites. A spot was marked for
paracentesis to be performed by the clinical service.
2. _____ TIPS unchanged from the prior studies.
3. Cirrhotic liver. No focal lesions identified.
.
Portable CXR [**6-14**]:
IMPRESSION: AP chest compared to [**2106-6-12**]:
Pulmonary vascular congestion has worsened and new opacification
at the lung bases is probably a combination of atelectasis and
mild edema. Pleural effusion is small, on the left, unchanged
acutely. Heart size is top normal. Left PIC catheter ends at
the superior cavoatrial junction. Esophageal tube and right PIC
line have been removed.
.
ECHO [**6-15**]:
Conclusions:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. No
masses or vegetations are seen on the aortic valve. There is no
valvular aortic stenosis. The increased transaortic gradient is
likely related to high cardiac output. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
.
Compared with the findings of the prior study (images reviewed)
of [**2106-6-1**], the tricuspid regurgitation is somewhat
increased.
.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
.
[**6-16**] Chest CT
FINDINGS: Since the prior study there has been marked worsening
of the alveolar opacities involving both lungs, predominantly in
the upper zones. The periphery of the lungs is relatively
spared. There are small bilateral pleural effusions. The heart
size appears slightly enlarged. There is no pericardial
effusion. There are borderline lymph nodes in the paratracheal
region measuring up to 9 mm in short axis. The central airways
are patent without endoluminal lesions. A left-sided PICC is
seen extending into the superior vena cava.
.
In the visualized upper abdomen again seen is a cirrhotic liver
with the TIPS shunt in place. There is a large amount of ascites
noted. Coils are noted in the region of the splenic vessels. The
osseous structures appear unremarkable.
.
IMPRESSION:
1. Marked worsening of bilateral extensive alveolar opacities
particularly centrally. The rapidity of development and
distribution is most concerning for pulmonary edema, however,
atypical infection or less likely pulmonary hemorrhage cannot be
excluded. Small bilateral pleural effusions.
2. Cirrhotic liver with a moderate amount of ascites and TIPS
shunt in place.
.
OTHER STUDIES:
==============
EGD [**2106-6-2**] -
Grade 1 esophageal varices
A trans-endoscopic NJ feeding tube (8 fr) was placed to 120 cm.
Otherwise normal EGD to second part of duodenum.
Brief Hospital Course:
45 yo female with ESLD [**1-15**] EtOH cirrhosis s/p TIPS who presented
from OSH for liver transplant evaluation, recent severe
bleeding, who developed sepsis, DIC, and multiorgan failure. A
brief hospital course by problem is outlined below:
.
#Sepsis/DIC: The patient required multiple vasopressors to
maintain SvO2 >70 and MAP>60s. Lactate continued to rise and she
became progressively acidotic. End organ hypoperfusion was
demonstrated by anuria. She was treated broadly with antibiotics
and aggressively transfused with blood products and albumin for
intravascular volume support and to correct her underlying
coagulopathy. HCO3 was utilized prn given worsening acidosis.
The patient was made CMO after an extensive family discussion
regarding her poor prognosis and she rapidly expired after
removal of vasopressors and respiratory support.
.
# Respiratory Failure: Progressively worsening bilateral lung
infiltrates resulting in hypoxia requiring intubation.
Differential included DAH given coagulopathy, infection (e.g.
PCP/fungal given recent course of steroids), or TRALI (though
unlikely). She was afebrile with rapidly progressive
leukocytosis. The patient was treated with steroids and bactrim
for PCP, [**Name10 (NameIs) 74369**] for fungal coverage, and levaquin to cover
mycoplasma, and flagyl for anaerobic coverage. Given worsening
infiltrates and P/F ratio suggestive of ARDS, she was ventilated
on ARDSnet protocol to minimize barotrauma and allowed
permissive hypercapnea.
.
# Acute renal failure: Cr progressively worsened in the setting
of sepsis and the patient became anuric. Differential included
HRS, ATN [**1-15**] renal hypoperfusion, prerenal [**1-15**] hypoalbuminemia
and 3rd spacing. She was unable to take po octreotide, midodrine
due to increased GI secretions and poor absorption. Attempted to
increased intravascular volume with albumin and blood products.
Pressors were utilized to maintain renal perfusion. The patient
developed a severe lactic acid metabolic acidosis due to tissue
hypoxia requiring HCO3 pushes.
.
# ETOH Cirrhosis: Decompensated liver disease s/p TIPS, with
hepatic encephalopathy, coagluapathy, elevated Tbili,
hyponatremia. On admission, aldactone held given hyponatremia
and hypotension. Lasix held given auto-immune hemolytic anemia.
She was given lactulose and rifaxamin for hepatic
encephalopathy. Ultrasound perfomed on admission and showed
patent TIPS, cirrhotic liver, no hepatoma. Diagnostic
paracentesis was performed, and was negative for SBP.
.
During hospitalization, she was evaluated for liver transplant,
and was transiently placed on the transplant list but was
removed after becoming septic. TTE showed a hyperdynamic EF,
with no pulmonary hypertension or significant valvular disease.
Liver CT completed. PFT's performed, with noted mild diffusion
abnormality. Chest CT demonstrated pulmonary nodules (see below)
which were stable on repeat CT chest one week later. Chest CT
from [**2106-6-16**] showed marked worsening (see below).
.
Hospitalization was complicated by hepatic encephalopathy,
hyponatremia and hepatorenal syndrome. HRS improved after
midodrine and octreotide, and albumin steadied hyponatremia near
baseline of 127-129. She was fluid restricted, but continued to
have worsening peripheral edema; diuretics were held given her
recently diagnosed AIHA [**1-15**] lasix.
.
# Arrhythmia: The patient had two asymptomatic episodes of
stable Vtach on the floor. On [**2106-6-16**], pt developed atrial
fibrillation to 160's. She was converted with lopressor and
diltiazam, but then reverted to Afib/flutter rate-controlled on
diltiazem. On transfer to the MICU, she had bursts of atrial
flutter with variable block and rate-dependent bundle branch
block. She remained asymptomatic but nodal agents were held
given hypotension.
.
# Leukocytosis: Initially with nosocomial pneumonia at outside
hospital treated with a course of IV antibiotics. Upon admission
to [**Hospital1 18**], no infectious etiology was found, with negative blood,
urine and stool cultures. Although pulmonary nodules were seen
on chest CT, this was not felt to represent an acute infectious
process given lack of associated signs or symptoms of infection,
therefore no further antibiotics were given. Acute alcoholic
hepatitis was considered as a possible cause of leukocytosis,
however there was no recent alcohol use to go along with this
diagnosis.
.
On [**6-5**], UCx with VRE. On [**6-11**], pt's blood cultures positive
for VRE. Felt that PICC line was possible source; however,
wound tip culture showed no growth. She was started on
daptomycin and ceftriaxone per ID. Echocardiogram was negative
for vegetation. On [**6-16**], a repeat chest CT was performed for
further characterization of pulmonary nodules which revealed the
interval development of diffuse hazy opacities thought to be
consistent with PCP, [**Name10 (NameIs) 7470**] given that she was weaned off
steroids for AIHA only days earlier. She was started emperically
on treatment doses of bactrim however she continued to worsen.
Diagnostic bronchoscopy was considered upon transfer to the ICU
however the patient was too unstable for the procedure. Flagyl
also emperically started for C. diff.
.
# Coagulopathy: [**1-15**] liver disease. Pt has had multiple red blood
cell transfusions, FFP, cryo, and platelets during admission.
Also received ddAVP for uremic platelets. She had an episode of
profuse epistaxis in the setting of trauma from Doboff feeding
tube that could only be controlled with packing, Afrin and
pressure by ENT. She also bled from her paracentesis site,
requiring transfusion and sutures. She developed DIC and diffuse
mucosal bleeding after becoming septic.
.
# Auto-Immune Hemolytic Anemia: Diagnosed with auto-immune
hemolytic anemia at outside hospital, felt to be secondary to
lasix. Re-consulted hematology here who agreed with this
diagnosis. Lasix was held during admission and repeat coombs
antibody negative. Reticulocyte count high on admission (29%),
with elevated LDH, tbili, and decreasing hematocrit suggestive
of ongoing hemolysis. However, hemolysis indices improved on
prednisone, and slow prednisone taper initiated as indices
stabilized. Blood counts supported as needed with blood
transfusions (for hgb <7 given difficult crossmatch (she has two
antibodies).
.
# GI: EGD performed on this admission demonstrated grade 1
esophageal varices, a trans-endoscopic NJ feeding tube, and
otherwise normal EGD to second part of the duodenum.
.
Medications on Admission:
folic acid 1 mg Qday
MVI with minerals
thiamine 100 mg Qday
prednisone 45 mg Qday
spironolactone 50 mg Qday
lactulose 30 ml [**Hospital1 **]
Mg oxide 400 [**Hospital1 **]
levoflox 500 mg IV Qday (day 1: [**5-23**])
vancomycin 750 mg IV Qday (day 1: [**5-23**])
ceftaz 2g Q8H (day 1: [**5-23**])
zofran 4 mg PO prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnoses:
1. Alcoholic Cirrhosis
2. Hepatic Encephalopathy
3. Nutritional Deficiency
Secondary Diagnoses:
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
none
|
[
"427.31",
"286.6",
"136.3",
"571.2",
"303.90",
"572.3",
"427.32",
"513.0",
"784.7",
"572.2",
"E944.4",
"456.21",
"276.2",
"995.92",
"309.81",
"518.81",
"285.1",
"599.0",
"572.4",
"584.9",
"789.5",
"283.0",
"038.0",
"572.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"21.01",
"96.6",
"45.13",
"38.93",
"99.04",
"99.05",
"96.04",
"96.70",
"99.07",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
20307, 20316
|
13386, 19913
|
321, 405
|
20476, 20486
|
5019, 5019
|
20542, 20550
|
3583, 3624
|
20278, 20284
|
20337, 20432
|
19939, 20255
|
20510, 20519
|
4304, 4444
|
4459, 5000
|
20455, 20455
|
250, 283
|
433, 2988
|
5035, 13363
|
4212, 4287
|
3010, 3237
|
3253, 3567
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,165
| 100,517
|
21344
|
Discharge summary
|
report
|
Admission Date: [**2154-6-12**] Discharge Date: [**2154-7-4**]
Date of Birth: [**2088-5-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SOB, volume overload
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This 66WF underwent an AVR(21mm St. [**Male First Name (un) 923**] mechanical) on [**2154-5-17**].
She was discharged to rehab and over the past 3 days had gotten
progressively SOB and was anuric. She presented to the clinic
and was very edematous and SOB.
Past Medical History:
Aortic Stenosis-s/p AVR [**2154-5-17**]
Type II Diabetes Mellitus
Hypertension
Hyperlipidemia
Obesity
Hysterectomy
Cholecystectomy
Appendectomy
Tonsillectomy
Post op afib
Social History:
Quit tobacco in [**2116**]. Denies ETOH. She is married and retired.
Family History:
Father died of MI ?age
Physical Exam:
At the time of discharge, Ms. [**Known lastname **] was found ot be in no
acute distress. She was awake, alert, and oriented times three.
Her heart was of regular rate and rhythm. Her sternal incision
was noted to have no drainage and no erythema. Her abdomen was
soft, non-tender, and she had bowel sounds. Her extremities
were warm and she had 1+ edema.
Pertinent Results:
Cardiology Report ECHO Study Date of [**2154-6-13**]
PATIENT/TEST INFORMATION:
Indication: Aortic valve disease s/p AVR. Small ericardial
effusion, r/o tamponade.
Height: (in) 61
Weight (lb): 306
BSA (m2): 2.27 m2
BP (mm Hg): 174/75
HR (bpm): 74
Status: Inpatient
Date/Time: [**2154-6-13**] at 15:26
Test: Portable TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W000-0:00
Test Location: West Other
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: >= 65% (nl >=55%)
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the
RA/RAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA.
No ASD by 2D or color Doppler.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in aortic arch. Simple atheroma in
descending aorta.
AORTIC VALVE: Mechanical aortic valve prosthesis (AVR). AVR
leaflets move
normally.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of
tamponade.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was monitored
by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. Local
anesthesia was
provided by benzocaine topical spray. The patient was sedated
for the TEE.
Medications and dosages are listed above (see Test Information
section). The
posterior pharynx was anesthetized with 2% viscous lidocaine. No
TEE related
complications. 0.2 mg of IV glycopyrrolate was given as an
antisialogogue
prior to TEE probe insertion.
Conclusions:
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. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the
aortic arch and simple atheroma in the descending thoracic
aorta. A mechanical
aortic valve prosthesis is present. The aortic prosthesis
leaflets appear to
move normally. There is no paravalvular leak. The mitral valve
appears
structurally normal with trivial mitral regurgitation. There is
a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD on [**2154-6-13**] 16:21.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Brief Hospital Course:
Ms. [**Known lastname **] was admitted on [**2154-6-2**] from [**Hospital 38**] Rehab, to
which she was discharged after undergoing a St. [**Male First Name (un) 923**] mechanical
AVR on [**2154-5-17**] with Dr. [**First Name (STitle) **] and [**Hospital1 827**]. [**Hospital 38**] rehab reported increased dyspnea,
tachypnea, diarrhea, and failure to thrive over the past 36-48
hours.
Upon admission she was seen in consultation by the renal
service. She was dialyzed during her stay and her renal
function improved markedly. It was determined that she likely
wound not need long term dialysis. She was also seen in
consultation by the infectious disease service during her
admission and she was placed on Vancomycin per their
recommendations. Once it was determined that she would not
require long term dialysis access, she was re-coumadinized for
her mechanical aortic valve. By hospital day ###### she was
ready for discharge to a rehabiliation facility.
Medications on Admission:
Metformin 1000mg PO BID
Oxybutynin 5 mg PO BID
Senna 2 tabs qhs
Lactinex [**Hospital1 **]
Lasix 20 mg PO BID
Amiodorone 200 mg PO daily
Lopressor 75 mg PO BID
Digoxin mg PO daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
5. Insulin Glargine 100 unit/mL Solution Sig: One (1) 35
Subcutaneous at breakfast.
Disp:*1 35* Refills:*0*
6. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
10. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day:
Target INR 2-2.5
Pt received 0.5/1/1mg doses over the last 3 days-.
11. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Acute renal failure
s/p AVR [**5-4**]
IDDM
Obdsity
^chol.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for sternal drainage, temp>101.5
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**First Name (STitle) **] for 4 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2154-7-4**]
|
[
"584.5",
"V43.3",
"286.9",
"V15.82",
"511.9",
"250.00",
"423.9",
"272.4",
"401.9",
"008.45",
"276.1",
"997.1",
"428.0",
"285.9",
"276.52",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"34.91",
"93.90",
"88.72",
"38.93",
"99.07",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
6970, 7044
|
4375, 5342
|
293, 300
|
7146, 7154
|
1306, 1362
|
7455, 7715
|
886, 910
|
5572, 6947
|
7065, 7125
|
5368, 5549
|
7178, 7432
|
1388, 4220
|
925, 1287
|
233, 255
|
328, 588
|
4252, 4352
|
610, 783
|
799, 870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,868
| 198,187
|
42279
|
Discharge summary
|
report
|
Admission Date: [**2170-9-10**] Discharge Date: [**2170-9-17**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
Left heart catheterization: Performed by Dr. [**First Name (STitle) **] on
[**2170-9-11**]
History of Present Illness:
This is an 88yoF with h/o dementia who intially presented to
BIDN with chest pain after a mechanical fall and c/f STEMI, now
transferred for acute hypoxia requiring intubation. accepted in
transfer from [**Hospital1 18**] [**Location (un) 620**]. Patient is currently unable to
provide a history, but per BIDN records on the DOA she had an
unwitnessed mechanical fall at home (her 2nd in 2 days), and
while being transported to BIDN by granddaughter c/o chest pain.
In the ED she was noted to have a positive troponins (.36)
with an EKG showing concerning changes (c/w inferior STEMI)
compared to 3 days prior to her admission. In the [**Location (un) 620**] ED
she received a plavix load, full dose ASA, heparin and beta
blockers and she was noted to be slightly bradycardic
thereafter. She continues on heparin. Dr [**Last Name (STitle) **] was consulted,
and initally offered the family cardiac catheterization which
they refused. Her troponins peaked at her admission value as did
her CKs at 310.
On the morning of [**9-9**] the patient beame agitated and
hypertensive (SBP 180's), shortly thereafter she became
hypoxemic (O2 sats as low as 68%) she failed 100% non-rebreather
and BiPAP, and was intubated [**2-21**] work of breathing and failure
to protect her airway. She was given IV nitro, IV Lasix,
Etomidate, Versed and fentanyl and her blood pressure dropped to
70. She was given 300cc IVF and her SBP increased to 90's. Per
family's request, she was transferred to [**Hospital1 18**] for further
evaluation and care.
.
On transfer, she was intubated and sedated, with stable VS (T
98.2 HR 88 BP 131/57 O2 99% on 70% FIO2).
.
ROS: Unable to obtain
Past Medical History:
1. GERD.
2. Anxiety.
3. Depression.
4. Dementia, not well characterized
.
No known cardiac history. No h/o HTN, HLD, or DM.
Social History:
She lives with her family and has a home health aid for all ADLs
and IADLs. She is a nonsmoker, no ETOH or IVDU.
Family History:
No known h/o cardiac disease.
Physical Exam:
Admission Exam:
GENERAL: Intubated, sedated.
HEENT: NCAT. Sclera anicteric. PERRL. ET tube and OG tube in
place.
NECK: Supple with JVP of 3cm above clavicle at 30 degrees.
CARDIAC: RRR, III/VI crescendo systolic murmur that radiates to
the carotids.
LUNGS: Faint rales heard in R lung anteriorly, L lung clear
anteriorly.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
.
.
Discharge:
GENERAL: sitting in bed, asleep but arousable
HEENT: NCAT. Sclera anicteric. PERRL
NECK: Supple with no JVD
CARDIAC: RRR, III/VI crescendo systolic murmur that radiates to
the carotids.
LUNGS: Faint rales b/l
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
Admission Labs [**2170-9-10**]:
WBC-13.7* RBC-3.91* Hgb-11.0* Hct-32.4* MCV-83 MCH-28.1
MCHC-33.9 RDW-14.8 Plt Ct-103*
PT-14.3* PTT-25.7 INR(PT)-1.2*
Glucose-177* UreaN-17 Creat-0.7 Na-139 K-3.9 Cl-104 HCO3-26
AnGap-13
Calcium-8.6 Phos-2.7 Mg-1.7
CK(CPK)-63 CK-MB-4 cTropnT-0.23*
EKG [**2170-9-10**]: Normal sinus rhythm is present. The QTc interval is
prolonged. There are also widely splayed symmetric T wave
changes consistent with a cerebral event or consistent with drug
effect or ischemia. These changes are global. NKo previous
tracing for comparison. Clinical correlation is suggested for
ischemia and/or cerebral event is required.
CXR [**2170-9-10**]:
AP chest compared to [**9-8**] through [**9-10**] at 11:39 a.m.
at
[**Hospital 4068**] Hospital. Previous left PIC line is no longer visible,
and presumably has been withdrawn either completely at least
outside the field of view at the left shoulder. ET tube is in
standard placement and nasogastric tube passes below the
diaphragm and out of view. Large scale pulmonary consolidation
which developed between [**9-8**] and [**9-10**] and worsened
appreciably over the course of the day continues to improve, but
the focal nature of the consolidation suggests that what remains
could be pneumonia, particularly in the right lower lobe. The
rest was edema. Heart size is normal. Pleural effusion is small
if any. No
pneumothorax.
CXR [**2170-9-12**]: In the interim from the previous examination, an
endotracheal tube and esophageal catheter have been removed.
Multifocal opacities, greatest at the right base, continue to
improve. No pneumothorax or pleural effusion is seen. The heart
size is normal.
TTE [**2170-9-11**]: The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is probably mild regional left
ventricular systolic dysfunction with probable mid
inferoseptal/apical septal hypokinesis and distal inferior
hypokinesis although views are technically suboptimal. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. 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 mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Cardiac cath [**2170-9-11**]:
1) Selective coronary angiography of this right-dominant system
demonstrated severe 2 vessel CAD. The LMCA had no
angiographically-apparent flow-limiting lesions. The LAD was
totally
occluded after a high diagonal. There were significant left-left
and
right-left collaterals supplying the LAD territory. The LCX was
a
moderate caliber vessel with a 50% stenosis in OM1. The dominant
RCA had
a 90% calcified ostial lesion.
2) Resting hemodynamics showed severe left-sided filling
pressures with
an LVEDP of 50 mmHg.
3) Left ventriculography was deferred.
4) Successful primary angioplasty of the ostial RCA lesion with
a 3.0
15mm Vision BMS. Final angiography revealed TIMI 3 flow with no
residual
stenosis or angiographically-apparent dissection.
FINAL DIAGNOSIS:
1. Severe two vessel CAD with probable chronic LAD disease.
2. Successful angioplasty of the ostial RCA lesion with a 3.0 x
15mm
Vision BMS.
3. Severely elevated left-sided filling pressures.
4. ASA 81mg daily indefinitely and plavix 75mg daily x 30 days.
Video swallow [**2170-9-13**]: Barium passes freely through the
oropharynx and esophagus without evidence of obstruction. There
was penetration and aspiration with thin liquids. No aspiration
or penetration with any other consistency of barium. Small
posterior wall diverticulum above the upper esophageal sphincter
is observed. For details please refer to speech and swallow
division note in OMR.
.
IMPRESSION:
1. Penetration and aspiration of thin liquids.
2. Small diverticulum of the posterior wall of the upper
esophagus.
Brief Hospital Course:
Primary Reason for Hospitalization:
88yoF with no cardiac history presents to BIDN with chest pain
after recent mechanical fall and e/o STEMI on EKG, transferred
for hypoxia requiring intubation.
.
Active issues:
.
# STEMI: On transfer, pt's family expressed that they wanted to
proceed with cardiac cath. She went to cath lab on [**9-11**] which
showed severe two-vessel disease, chronic LAD disease, and 90%
occlusion of RCX. BMS x1 was placed in RCX. She was started on
ASA 325mg daily, Plavix 75mg daily, atorvastatin 80mg daily,
metoprolol tartrate 12.5mg [**Hospital1 **], and lisinopril 10mg daily. She
will need to continue plavix for 6 months and ASA indefinitely.
She was initially started on heparin gtt, and after 48 hours
this was discontinued and she was started on lovanox SC.
.
# Hypoxia: Thought likely [**2-21**] pulmonary edema in setting of
STEMI and decreased EF. CXR initially c/f multifocal pna and she
was continued on vanc/levofloxacin/flagyl (started at BIDN). By
HD#3 her CXR showed significant improvement and her antibiotics
were discontinued. She was breathing comfortably on room air
with O2 sats >95%.
.
# Dementia: Per family, patient has dementia at baseline. She
often exhibited sundowning behavior but responded well with
frequent re-orientation, and standing trazadone 25mg HS to
maintain sleep/wake cycle. Due to family concerns about her
safety at home, she was transitioned to an ECF on discharge.
.
# Aspiration: Patient had a witnessed episode of aspiration when
taking pill with applesauce. She was evaluated by speech and
swallow service, and video swallow showed dysphagia with
esophageal diverticulum above UES. She was initially started on
a diet of nectar-thick liquids and pureed solids, however she
was very frustrated with these limitations. After discussion
with family it was decided not to restrict her diet in interest
of her quality of life.
.
Stable issues:
.
# Lacerations [**2-21**] fall: Patient was started on doxycycline on
her last ED visit, however this was discontinued as she did not
show evidence of cellulitis or wound infection. Her sutures
were removed on HD#6.
.
# Urinary Icontinence - Stable. The patient has a pessary in
place.
.
Transitional issues:
- Patient maintained full code status throughout
hospitalization.
- She should continue ASA 325mg daily indefinitely and plavix
75mg daily for at least 6 months.
- During hospitalization, family expressed concern about the
patient's safety at home. She was screened by PT who felt she
would benefit from a skilled nursing facility. She was
transitioned to a LTAC facility.
- will need staples in occiput removed on [**9-18**]
Medications on Admission:
Omeprazole ER 20 mg daily.
Risperidone 1 mg daily.
Sertraline 25 mg daily.
Doxycycline 100 mg twice daily for 7 days, started on
[**2170-9-5**].
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. risperidone 1 mg/mL Solution Sig: One (1) PO DAILY (Daily).
4. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for agitation.
9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare & Rehabilitation Center - [**Location (un) 620**]
Discharge Diagnosis:
ST segment elevation myocardial infarction
Dementia
esophageal diverticulum
Urinary Incontinence
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
It was a pleasure participating in your care. As you know you
had chest pain when you fell and it was determined that you had
a heart attack. You were started on several new medications
that you will need to continue to take for your heart. These
medications are:
1. Aspirin 325 mg once a day
2. Atorvastatin 80 mg once a day
3. Plavix 75 mg once a day
4. Lisinopril 10 mg daily
5. Metoprolol 12.5 mg twice a day
You were also started on Risperidone 1 mg daily and trazodone 25
mg at night to help you sleep.
It was felt that the safest place for you would be a long term
care center and that is where you will be going on discharge.
Followup Instructions:
PCP
Cardiology
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: INTERNAL MEDICINE
Address: [**State 8536**] [**Apartment Address(1) 8537**], [**Location (un) **],[**Numeric Identifier 8538**]
Phone: [**Telephone/Fax (1) 58624**]
**Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge.**
Department: CARDIAC SERVICES
When: MONDAY [**2170-10-15**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"294.8",
"428.0",
"428.21",
"780.09",
"518.81",
"507.0",
"788.30",
"799.02",
"719.7",
"530.6",
"410.41",
"530.81",
"787.22",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"00.40",
"37.22",
"00.45",
"88.56",
"96.71",
"00.66",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
11062, 11170
|
7474, 7672
|
227, 319
|
11311, 11311
|
3372, 6648
|
12185, 12929
|
2314, 2345
|
10332, 11039
|
11191, 11290
|
10163, 10309
|
6665, 7451
|
11489, 12162
|
2360, 3353
|
9708, 10137
|
180, 189
|
7687, 9687
|
347, 2018
|
11326, 11465
|
2040, 2166
|
2182, 2298
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,723
| 171,311
|
35655
|
Discharge summary
|
report
|
Admission Date: [**2176-9-2**] Discharge Date: [**2176-9-4**]
Date of Birth: [**2109-7-21**] Sex: M
Service: MEDICINE
Allergies:
Fiber / Gemfibrozil / Atorvastatin Calcium / Haldol
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
overdose
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 81133**] is a 67 y.o. M with HCV, HBV, hypertension, and
depression, who presented s/p overdose. The patient noted
tremors in all of his extremities; thus, he took 35 tablets of
800 mg of Neurontin over 36 hours starting at 6 pm night prior
to admission. Then he continued to take this overnight given
continued extremity tremors. His last dose was likely around 5
or 6 AM. Pt reportedly was trying to get "high." He also notes
that he was taking ASA 325 mg x 15 since 6 pm night prior to
admission. He did this to help relieve a headache and chills
that he gets every night. Last dose was around 6 AM on morning
of admission. He continued to feel shaky in all extremities, and
decided that he should come and get evaluated in the [**Hospital1 18**] ED.
The patient denies SI, HI, AH, and VH.
In the ED, initial VS: T 99.2 HR 102 BP 159/107 RR 16 100% RA
Labs drawn, significant for ASA level of 35. EKG, CXR, head CT
completed. Given levofloxacin 750 mg po x 1, 1 L D5W with 3 amps
sodium bicarbonate, valium 10 mg IV x 1 per CIWA, Charcoal 50 g
po x 1. Neurology and toxicology consulted.
Past Medical History:
- COPD (emphysema)
- Spiculated Lung nodule, follow by thoracics
- Chronic Aspiration
last stress six years ago, pt reports was fine.
- Hypertension
- 'Lazy Bowel' syndrome causing chronic constipation
- Hernia repair x2
- Deviated septum repair x3
- Chronic Sinusitis
- Scoliosis
- Depression, longstanding
- Hepatitis C
- h/o Hepatitis B, cleared
- Benign Prostatic Hypertrophy
- Cataracts
- Renal Cyst
- h/o syphilis in [**2126**] and gonorrhea in [**2127**].
- h/o TB exposure.
Social History:
The patient lives at home in [**Hospital3 4634**] in JP/[**Location (un) 2312**]
area and is retired. Combat medic in [**Country 3992**], bartender, ran
nightclub in [**University/College **] square. Worked in steel industry in
[**Location (un) 19061**] (powder paint, sprayed paint applied to steel).
Divorced, no children. Smokes 1ppd.
Family History:
Positive for HTN and breast cancer in the family, as well as
depression
Physical Exam:
Vitals - T: 99.1 BP: 125/68 HR: 89 RR: 25 02 sat: 95% 3 L NC
GENERAL: elderly male in NAD
HEENT: anicteric, EOMI, PERRL, OP - adentulous, MMM, no cervical
LAD
CARDIAC: RRR, nl S1, S2
LUNG: decreased BS throughout, rhonchi scattered, prolonged exp
phase
ABDOMEN: slightly distended, could not appreciate fluid wave,
NABS
EXT: no c/c/e
NEURO: A&O, 5/5 strength in bilateral UE and LE, sensation in
tact, EOMI, shoulder shrug [**4-2**]
DERM: no rashes noted
Pertinent Results:
[**2176-9-2**] 02:10PM BLOOD WBC-13.5* RBC-4.78 Hgb-14.7 Hct-42.1
MCV-88 MCH-30.7 MCHC-34.9 RDW-14.6 Plt Ct-372
[**2176-9-3**] 02:06AM BLOOD WBC-11.8* RBC-4.35* Hgb-13.5* Hct-38.9*
MCV-90 MCH-31.1 MCHC-34.8 RDW-14.1 Plt Ct-361
[**2176-9-2**] 02:10PM BLOOD Neuts-79.6* Lymphs-14.5* Monos-3.7
Eos-1.8 Baso-0.4
[**2176-9-3**] 02:06AM BLOOD Plt Ct-361
[**2176-9-3**] 02:06AM BLOOD PT-14.6* PTT-27.2 INR(PT)-1.3*
[**2176-9-2**] 02:10PM BLOOD Glucose-82 UreaN-16 Creat-1.2 Na-141
K-3.7 Cl-100 HCO3-30 AnGap-15
[**2176-9-3**] 02:06AM BLOOD Glucose-86 UreaN-15 Creat-1.3* Na-139
K-3.5 Cl-101 HCO3-30 AnGap-12
[**2176-9-2**] 02:10PM BLOOD ALT-24 AST-28 AlkPhos-85 TotBili-0.2
[**2176-9-3**] 02:06AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.9
[**2176-9-2**] 06:26PM BLOOD VitB12-552 Folate-15.5
[**2176-9-2**] 06:26PM BLOOD TSH-0.62
[**2176-9-2**] 02:10PM BLOOD ASA-35* Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2176-9-2**] 10:12PM BLOOD ASA-23
[**2176-9-3**] 02:06AM BLOOD ASA-19
[**2176-9-2**] 10:32PM BLOOD Lactate-0.8
CT HEAD [**2176-9-2**]: IMPRESSIONS:
1. No acute intracranial abnormality.
2. Stable small vessel chronic ischemic change
CHEST X-RAY [**2176-9-2**]: IMPRESSION: Linear opacity at the left lung
base is most likely atelectasis; developing consolidation is
also a consideration in the right clinical setting. Spiculated
nodules seen on CT not well seen.
Brief Hospital Course:
Hospital Course - Patient is medically clear for discharge to
inpatient psychiatry unit for further treatement. No sign of
infection. No adverse effect from ASA/neurontin ingestion.
MRSA screen negative to date. This has been discussed with
attending.
# Salicylate overdose: ASA level 35 on presentation to ED, but
unknown timing of last dose of ASA. Levels were in a [**Doctor Last Name 352**] zone
for toxicity at 35, but were downward trending. Toxicology was
consulted in the ED, and the patient was managed by intravenous
bicarbonate to alkalanize the urine. No dialysis was required.
The bicarb infusion was stopped when the asa level was <30. On
hospital day 2, his serum ASA level was 19. At this time,
toxicology signed off. At no time did the patient experience
symptoms of salicylate overdose--no nausea, vomiting or
respiratory depression. EKG had no new changes and was normal
sinus rhythm. Patient removed his IV access on his own and
began to refuse further lab draws and vital signs, however he
was medically stable when he started this behavior.
# Psych: Because of the overdose, a psychiatric consultation was
obtained, and felt that the patient needed to be observed. A
section 12 was placed. Overall, it is doubtful that this was an
intentional overdose, and more likely a result of impulsivity.
Psych f/u was obtained and recommended inpatient psychiatry unit
for further management. Psychiatry has seen him daily and made
recommendations as needed.
# Neurontin Overdose: No effects were seen. Neurology was
consulted in the ED and felt his history regarding his Neurontin
overdose and tremors was inconsistent. Neurontin was
discontinued during the admisison and patient't tremor was much
improved per his on account.
# Tremors: Felt to be due to albuterol use, however they seem to
be chronic. Patient states he had overdosed on nuerontin to
treat these symptoms. On evaluation by neurology, he was
non-compliant with exam. On [**9-4**], the neurology consult
formally signed off on the patient and felt that he was having
no acute neruological issue and had no focal neurological
deficits. On admission, TSH, vit B12 and Folate were sent and
determined to be within normal limits. Gabapentin not to be
restarted on discharge.
# Leukocytsosis - Patient was admitted with white blood cell
count of 13.5, which declined to 11.5 over 24 hours. Chest
x-ray was not consistent with infiltrate and most likely
atelectasis. Patient was entirely asymptommatic during
admission. Patient refused further blood draws. He had a
previous admission with positive blood culture for coagulase
negative staph, however this was felt to be contamminent.
Repeat blood cultures 2 days after that culture were negative.
Blood culture drawn on admission (~10 days after last blood
cultures) are pending but negative to date. MRSA screen in the
ICU is still pending, but as of 12:00 on [**2176-9-4**] is negative.
At no time during the admission did patient have a fever. On
[**9-3**] patient started refusing vital signs. He shows no sign of
infection at this time. No cough. Patient did have a headache
prior to admission and had complained about it to Neurology.
There was notation of possible LP, however patient refused. CT
Head was negative for acute process on admission. On [**9-4**],
neurology re-visited patient and he stated he had not headache
or tremor and the team signed off. Medically, the patient is
clear for discharge.
# COPD: No sign of exacerbation at this time. Continue
albuterol and ipratropium prn while admitted. On discharge,
plan to restart Albuterol inhaler, Fluticasone, Formoterol,
Tiotropium and Montelukast.
# Alcohol abuse: By history, patient has history of alcohol
abuse, however stated to physicians during admission that he had
not recently drank. Initially, he was place on CIWA to monitor
for withdrawal. CIWA was discontinued after no sign of
withdrawal and history confirmed.
# Renal Function - Based on data availabile to team at this
time, renal function appears to be near baseline. Creatinine
levels in [**Hospital1 18**] system have ranged from 0.8-1.3. Patient has
good urine output. He is likely close to or at his baseline.
Patient refusing medications and evaluation.
# Hypertension - Well controlled during admission. Plan for
restart of Triameterene-Hydrochlorothiazide on discharge.
# BPH - continued outpatient regime on Doxasin
# GERD - continued omeparazole
# History of Positive PPD - No signs of active disease. Patient
has not been on precautions during admission. Patient with
history of postive PPD. Notation in medical record that he had
bronchoscopy in [**12-8**] which was negative for AFB on concentrated
smear. CXR on admission negative.
Medications on Admission:
Albuterol sulfate 90 mcg 2 puffs q 4 hours
- Amitryptyline 50 mg po daily
- Doxazosin 2 mg po daily
- Fluticasone 220 mcg 2 puffs inh [**Hospital1 **]
- Formoterol Fumarate 12 mcg capsule 2 puffs inhaled [**Hospital1 **]
- Gabapentin 800 mg po QAM and QPM
- Gabapentin 1200 mg po qhs
- Ipratropium Bromide 1 neb QID prn
- Montelukast 10 mg po qhs
- Polyethylene Glycol 17 gm po daily
- Pravastatin 40 mg po daily
- Tiotropium 18 mcg 1 inhaled daily
- Triamterene-HCTZ 75-50 mg po daily
- Aspirin 325 mg po daily
- Ensure 1 can TID
- MOM
- Ranitidine 150 mg po BID
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
6. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Fluticasone 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO at bedtime.
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
11. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Foradil Aerolizer 12 mcg Capsule, w/Inhalation Device Sig:
Two (2) puff Inhalation twice a day.
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
puff Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
14. Singulair 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
16. Triamterene-Hydrochlorothiazid 75-50 mg Tablet Sig: One (1)
Tablet PO once a day.
17. Lorazepam 2 mg/mL Syringe Sig: Two (2) mg Injection Q4H
(every 4 hours) as needed for agitation.
18. Fluphenazine HCl 2.5 mg/mL Solution Sig: Five (5) mg
Injection every four (4) hours as needed for agitation.
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
20. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
21. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for agitation.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis:
1. Toxic Ingestion of Aspirin and Neurontin
2. Depression
Secondary Diagnosis:
1. COPD
2. Hypertension
3. BPH
Discharge Condition:
Hemodynamically Stable. Medically stable.
Discharge Instructions:
You were admitted to [**Hospital1 18**] after you came to the ED after
overdosing on Aspirin and Neurontin (Gabapentin). You were
admitted to the Intensive Care Unit out of concern for side
effects from your ingestion. You recieved IV fluids to help
your body excrete the aspirin into your urine. In the Intensive
Care Unit you pulled out all your IVs then refused medical care.
On recommendations from psychiatry, you were discharged from
[**Hospital3 **] Deaconness directly to an inpatient psychiatry unit
for futher evaluation. Please follow-up with your PCP once you
are discahrged from the inpatient psychiatry unit.
CHANGES IN MEDICATION:
DISCONTINUE Neurontin
Continue all other medications as previously prescribed.
If you experience fever > 101, shortness of breath refractory to
treatment with your scheduled medication, chest pain, loss of
conciousness, incontinence or any other symptom that concerns
you, please call your PCP or go to the nearest emergency room
for evaluation.
Followup Instructions:
Please follow-up with your PCP and outpatient psychiatrist once
you are discharged from inpatient care.
|
[
"304.03",
"305.1",
"600.00",
"966.3",
"473.9",
"496",
"965.1",
"518.0",
"E950.4",
"530.81",
"070.30",
"304.31",
"784.0",
"304.21",
"795.5",
"V64.2",
"296.90",
"564.09",
"070.70",
"272.4",
"333.1",
"288.60",
"303.91",
"401.9",
"295.70",
"E950.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11596, 11611
|
4318, 9073
|
319, 325
|
11785, 11830
|
2914, 4295
|
12878, 12985
|
2350, 2423
|
9689, 11573
|
11632, 11632
|
9100, 9666
|
11854, 12855
|
2438, 2895
|
271, 281
|
353, 1469
|
11731, 11764
|
11651, 11710
|
1491, 1977
|
1993, 2334
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,454
| 131,746
|
42062
|
Discharge summary
|
report
|
Admission Date: [**2169-11-3**] Discharge Date: [**2169-11-7**]
Date of Birth: [**2104-7-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Cipro / Lactose
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2169-11-3**]:
Coronary artery bypass grafting x3 with left internal mammary
artery to left anterior descending coronary; reverse saphenous
vein single graft from aorta to the 1st obtuse marginal
coronary; reverse saphenous vein single graft from aorta to
posterior descending coronary artery. Left anterior descending
coronary artery endarterectomy and vein patch angioplasty.
Replacement of ascending aorta with a 28-mm Dacron tube graft.
History of Present Illness:
65 yo male with chronic atrial fibrillation with new onset
dyspnea on exertion. Recent stress testing showed mild
anteroseptal ischemia. Subsequent cardiac catheterization
revealed multivessel coronary artery disease. He was referred
for surgical revascularization. He continued to experience
dyspnea on exertion but remains very active at home. He performs
routine ADL without difficulty. He denies chest pain, orthopnea,
PND, pedal edema and palpitations. Of note, patient has never on
Warfarin anticoagulation for chronic atrial fibrillation. He has
been maintained on Aspirin only and has declined/refused
Warfarin.
Past Medical History:
- Hypertension
- Diabetes Mellitus Type II
- Chronic Atrial fibrillation(since teenage years)
- Right Leg/Groin Shotgun Injury, now with prosthetic right leg
- History of MRSA(right thigh/stump ulcer)
- History of Gout
- "Blood Antigens" from history of multiple blood transfusions
related to his shot gun injury
- Obesity
Past Surgical History:
- Right Femoral Artery/Vein Repair with Grafting [**2142**] secondary
to shot gun injury complicated by recurrent cellulitis
eventually
requiring Right Leg Above Knee Amputation [**2165**]
- Hernia Repair
- Tonsillectomy
- Right Eyelid
- Basal Cell Carcinoma
Social History:
Lives: alone
Occupation: Disabled
Cigarettes: 30PYH, quit over 20 years ago
ETOH: social, no history of abuse
Illicit drug use: Denies
Family History:
Sister MI at age 47
Physical Exam:
Pulse: 68-82 Resp: 16 O2 sat: 97% room air
B/P Right: 151/105 Left: 148/93
Height: 72inches Weight: 290 lbs
General: Obese male in no acute distress. Pleasant, alert and
oriented.
Skin: Dry [x] intact [x] - multiple scars/incisions right groin
and proximal thigh - healed with no evidence of cellulitis
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur []
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: trace
Varicosities: Left GSV appears suitable. Right thigh GSV not
assessed secondary to prosthesis
Neuro: Grossly intact [x]
Pulses:
Femoral Right: - Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2169-11-3**] TTE: PRE BYPASS The left atrium is dilated. No
mass/thrombus is seen in the left atrium or left atrial
appendage. Mild spontaneous echo contrast is present in the left
atrial appendage. The right atrium is dilated. No atrial septal
defect is seen by 2D or color Doppler. There is an inferobasal
left ventricular aneurysm. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricle displays
normal free wall contractility. The ascending aorta is mildly to
moderately dilated. There are simple atheroma in the aortic
arch. The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is a trivial/physiologic pericardial effusion.
POST BYPASS The patient is atrially paced. There is normal right
ventricular systolic function. The left ventricle displays
overall normal systolic function with the exception of the
inferobasal aneurysm. The mitral regurgitation is slightly
worsened but remains mild. The ascending aortic graft is only
very poorly seen. The portions of the ascending, arch, and
descending thoracic aorta that are seen are free of dissection.
[**2169-11-4**] CXR: There is dense retrocardiac opacity consistent
with combination of volume loss/infiltrate/effusion. The extreme
left CP angle is off the film. Right IJ line tip is in the SVC.
Increased opacity at the right base suggesting an area of volume
loss/infiltrate in this region. This is new compared to the
prior study. Sternal wires and mediastinal clips are again seen.
[**2169-11-3**] 05:53PM BLOOD WBC-15.4*# RBC-3.85* Hgb-11.8* Hct-34.8*
MCV-90 MCH-30.7 MCHC-34.0 RDW-14.0 Plt Ct-180
[**2169-11-6**] 05:14AM BLOOD WBC-11.9* RBC-3.39* Hgb-10.2* Hct-30.9*
MCV-91 MCH-30.1 MCHC-33.0 RDW-14.0 Plt Ct-151
[**2169-11-3**] 04:32PM BLOOD PT-16.6* PTT-40.3* INR(PT)-1.5*
[**2169-11-3**] 05:53PM BLOOD PT-15.5* PTT-34.9 INR(PT)-1.4*
[**2169-11-3**] 05:53PM BLOOD UreaN-24* Creat-0.6 Na-144 K-3.9 Cl-116*
HCO3-22 AnGap-10
[**2169-11-7**] 05:35AM BLOOD UreaN-22* Creat-0.7 Na-141 K-4.5 Cl-103
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2169-11-3**] where the patient underwent coronary
artery bypass grafting x3 with left internal mammary artery to
left anterior descending coronary; reverse saphenous vein single
graft from aorta to the 1st obtuse marginal coronary; reverse
saphenous vein
single graft from aorta to posterior descending coronary artery,
left anterior descending coronary artery endarterectomy and vein
patch angioplasty and replacement of ascending aorta with a
28-mm Dacron tube graft. Please see operative note for surgical
details. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically stable
on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. Additionally, Occupational Therapy was
consulted given the patient's AKA and dependence on prosthesis.
He does have long history of atrial fibrillation and remained in
AF post-op. As in the past, he declined/refused Warfarin and was
continued on Aspirin. In addition, Plavix was started for the
LAD endarterectomy and vein patch angioplasty
By the time of discharge on POD 4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to rehab ([**Hospital3 **]
in [**Hospital1 3597**], NH) in good condition with appropriate follow up
instructions.
Medications on Admission:
ALLOPURINOL 300 mg Tablet once a day
DIGOXIN 125 mcg Tablet once a day
FUROSEMIDE 40 mg Tablet once a day
LISINOPRIL 10 mg Tablet twice a day
METFORMIN 500 mg Tablet twice a day
METOPROLOL TARTRATE 50 mg twice a day
ASPIRIN 325 mg Tablet once a day
MULTIVITAMIN 1 tablet once a day
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 10
days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft x 3
Past medical history:
Diabetes Mellitus Type II
Chronic Atrial fibrillation(since teenage years)
Right Leg/Groin Shotgun Injury, now with prosthetic right leg
History of MRSA(right thigh/stump ulcer)
History of Gout
"Blood Antigens" from history of multiple blood transfusions
related to his shot gun injury
Obesity
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 -Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr [**Last Name (STitle) 914**] on [**2169-12-11**] at 1:15pm
Cardiologist: Dr [**Last Name (STitle) **] on [**2169-12-7**] at 1:00pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 40798**] in [**4-11**] weeks [**Telephone/Fax (1) 40799**]
**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:[**2169-11-7**]
|
[
"414.01",
"274.9",
"V49.76",
"441.2",
"V12.04",
"250.00",
"428.22",
"428.0",
"V10.83",
"427.31",
"278.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"38.45",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8993, 9040
|
5432, 7333
|
311, 755
|
9460, 9684
|
3145, 5409
|
10524, 11056
|
2200, 2221
|
7665, 8970
|
9061, 9122
|
7359, 7642
|
9708, 10501
|
1772, 2032
|
2236, 3126
|
252, 273
|
783, 1404
|
9144, 9439
|
2048, 2184
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,428
| 195,680
|
11801
|
Discharge summary
|
report
|
Admission Date: [**2142-2-8**] Discharge Date: [**2142-2-11**]
Date of Birth: [**2086-1-28**] Sex: F
Service: Gynecology/Oncology
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 3444**] is a 55 year old
gravida 3, para 2 who initially presented with a history of
vaginal bleeding. An endometrial biopsy revealed a grade II
endometrial carcinoma. The patient has had no known medical
problems. She was noted to have had bleeding and has had no
signs of weight loss, bowel or bladder problems. The patient
denied fever or chills. She has had no chest pain or
shortness of breath. She is otherwise doing well.
PAST MEDICAL HISTORY: Negative.
PAST SURGICAL HISTORY: Tubal ligation.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: The patient has no known drug allergies.
PAST OBSTETRIC HISTORY: The patient has had two normal
spontaneous vaginal deliveries.
PAST GYNECOLOGIC HISTORY: The patient had a normal PAP smear
in [**2141**] and normal mammogram in [**2141**].
SOCIAL HISTORY: The patient does not drink or use tobacco.
She is currently unemployed.
PHYSICAL EXAMINATION: On physical examination, the patient
was oriented to place and time. Chest: Clear to
auscultation bilaterally. Cardiovascular: Regular rate and
rhythm. Abdomen: Soft, nontender, nondistended, patient is
fairly thin. Pelvic examination: Normal Bartholin glands,
normal urethra and Skene gland, good uterine descensus, small
eight week size uterus which is anteverted and anteflexed, no
adnexal masses. Extremities: No cyanosis, clubbing or
edema. Rectovaginal examination: Negative.
HOSPITAL COURSE: The patient was counseled regarding the
need for surgery given her endometrial cancer and the
decision was made between her and Dr. [**Last Name (STitle) 5166**] to proceed with a
staging procedure. The patient was admitted on [**2142-2-8**] and scheduled to undergo a laparoscopic pelvic and
para-aortic node dissection and laparoscopic assisted vaginal
hysterectomy.
On [**2142-2-8**], the patient underwent a laparoscopic
pelvic and para-aortic node dissection, laparoscopic assisted
vaginal hysterectomy and a subsequent exploratory laparotomy
for intraoperative bleeding. Intraoperatively, it was noted
that the patient had normal appearing tubes and ovaries as
well as normal appearing fallopian tubes. She had two small
fibroids on the uterus. Intraoperative pathology consult
revealed 50% invasion and the lymph nodes appeared grossly
normal. Her estimated blood loss was 2,500 cc and she
received 5,800 cc of intravenous fluids as well as one liter
of Hespan and four units of packed red blood cells during the
procedure. An intraoperative hematocrit was 12. Please see
the operative dictation for further details.
The patient was initially admitted to the Surgical Intensive
Care Unit postoperatively, given extensive blood loss and
need for blood products. The patient also remained intubated
on postoperative day zero.
Pulmonary: The patient remained intubated until
postoperative day number one. At that time, she was
successfully extubated and quickly weaned to room air. The
patient remained with good oxygen saturations in room air,
with no pulmonary difficulties.
Hematology: The patient had extensive blood loss of
approximately 2,500 cc intraoperatively. An intraoperative
hematocrit was 12 and, intraoperatively, the patient received
four units of packed red blood cells. Postoperatively, the
patient had a hematocrit of 27.7, which later fell to 25.3
and the patient received an additional two units of packed
red blood cells between postoperative days zero and one.
The patient also had a coagulopathy, evidenced by a drop in
her platelet count into the low 70s as well as an INR that
went as high as 1.9. The patient received two units of fresh
frozen plasma on postoperative day zero and an additional two
units of fresh frozen plasma on postoperative day number one.
After the additional of the blood products, the patient's
coagulopathy resolved. Her platelet count slowly resolved
over her hospital admission and the last count on
postoperative day number three was in the 90s. The patient's
hematocrit was followed every day during her hospital
admission and stabilized out at approximately 33.
Neurology: The patient was initially maintained on morphine
as needed for pain and then was changed to intramuscular
Demerol for pain. By postoperative day number two, the
patient was taken Percocet with good pain management. The
patient was not given Toradol or non-steroidal
anti-inflammatory drugs due to her low platelet count and
coagulopathy.
Gastrointestinal: The patient was initially maintained on
nothing by mouth on postoperative day zero and postoperative
day number one. She was then advanced to clears and then a
regular diet on postoperative day number two without
difficulty. For gastrointestinal prophylaxis in the
Intensive Care Unit, the patient received Protonix.
Fluids, electrolytes and nutrition: The patient's
electrolytes were followed throughout her hospital admission.
She did require some potassium supplementation as well as
magnesium and calcium supplementation. The patient's
electrolytes stabilized by postoperative day number one and
the patient received no further supplementation. The patient
did received intravenous fluids until postoperative day
number three, when these were stopped as the patient was
tolerating a regular diet.
Oncology: The patient has a known grade III endometrial
adenocarcinoma. She is now status post her staging
procedure, with pathology pending. The patient will be
discussed at the upcoming Tumor Board. Further treatment at
this time has not yet been decided.
Deep vein thrombosis prophylaxis: The patient was maintained
on pneumatic boots for deep vein thrombosis prophylaxis until
she was fully ambulatory.
Infectious disease: The patient remained afebrile throughout
her hospital course. She received no additional antibiotics
after the usual operative antibiotics.
DISCHARGE STATUS: Good, the patient is tolerating a regular
diet and ambulating without difficulty. Her pain is well
controlled on oral pain medication. Her electrolytes and
hematocrit have been stable for the last two days, without
requiring any additional replacement.
DISCHARGE MEDICATIONS:
Percocet one to two tablets p.o.q.4-6h.p.r.n.
Iron supplementation.
Colace p.r.n.
DISCHARGE FOLLOW-UP: The patient was instructed to follow up
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5166**] in one week.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 26060**]
Dictated By:[**Name8 (MD) 6269**]
MEDQUIST36
D: [**2142-2-11**] 14:27
T: [**2142-2-14**] 09:03
JOB#: [**Job Number 37292**]
|
[
"790.92",
"182.0",
"V64.4",
"998.11",
"285.1",
"218.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.25",
"65.63",
"40.3",
"54.19",
"39.31",
"68.51"
] |
icd9pcs
|
[
[
[]
]
] |
6325, 6823
|
736, 999
|
1625, 6302
|
692, 709
|
1112, 1607
|
176, 634
|
657, 668
|
1016, 1089
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,122
| 172,627
|
45516
|
Discharge summary
|
report
|
Admission Date: [**2106-5-5**] Discharge Date: [**2106-5-13**]
Date of Birth: [**2032-1-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
Weakness, confusion, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74-year-old gentleman with multiple medical problems including
ESRD on HD (last dialysis on [**5-4**]), cryptogenic cirrhosis,
history of PEs, and chronically low BPs who is brought in by his
partner for 2-3 days of worsening confusion and weakness.
Patient was recently admitted to [**Hospital1 18**] on [**2106-3-1**] for
orthostatic symptoms; admission was complicated by an iatrogenic
peritonitis (induced by paracentesis) for which the patient
received a 14 day course of antibiotics. He has been feeling
well since this time, though did present to his PCP recently for
bilateral pitting edema (DVT ruled out at that time). Pt
currently denies weakness and reports that he would like coffee.
He denies fever, chills, nausea, vomiting, constipation, urinary
symtpoms, cough, chest pain, shortness of breath or
palpitations. He does endorse recent anorexia for the past few
days that he relates to fatigue.
.
In the ED, patient's Temp was 97, BP was 67/47, HR of 96, and
SP02 of 91% on RA. Bibasilar crackles bilaterally and
significant pedal edema. Neuro exam was reportedly normal
(A&Ox3, no asterixis) and there was no ascites on abdominal
exam. Elevated white count, INR, and LFTs. Troponin of 0.25,
which is higher than baseline. EKG with NSR in the 90s and no ST
changes. Patient received vanc/zosyn and ASA in ED. Received 3L
NS in ED, but still had an elevated lactate. At baseline pt is
hypotensive, P 75-80, RR 18, 98% 2L NC.
Past Medical History:
1. Cryptogenic cirrhosis: A portal hypertension, splenomegaly,
and ascites per MRI of abdomen. Portal vein thrombosis noted on
MRI from [**1-/2105**] as well as more recent ultrasound.
2. Chronic kidney disease stage IV-V currently undergoing
hemodialysis, possibly due to chronic nephrolithiasis, in turn
caused by a bowel surgery, possibly combined with chronic
hypokalemia and nonsteroidal use. More recently suggested that
the possibility of amyloidosis be explored. The patient has
secondary hyperparathyroidism due to renal failure.
3. Chronic secretory diarrhea: Carcinoid syndrome,
neuroendocrine tumors, pellagra, microscopic colitis,
hyperthyroidism, and infectious etiologies have been ruled out
with an extensive workup in 06/[**2104**]. Currently, attributed to a
history of ileal resection.
4. History of PE during hospitalization [**7-/2104**] at [**Hospital1 18**].
Formerly on Coumadin is stopped in 01/[**2105**].
5. A history of likely gallstone pancreatitis with lipase
greater than 900 during hospitalization in 06/[**2104**].
6. H. pylori gastritis treated in [**2104**].
7. MGUS by SPEP.
8. A 1.2-cm hypoechoic nodule on the left thyroid lobe without
enlargement on ultrasound, follow up in [**2105**]. TSH remains normal
in 01/[**2105**].
9. Left inguinal hernia.
10. Status post ileal resection in [**2056**] for possible Crohn's
disease.
11. Status post surgical repair perforated ulcer in the [**2066**].
12. Status post surgical removal of renal stone in [**2066**].
13. Cataracts
14. Paracentesis induced bowel perforation in [**2-14**]
Social History:
No tobacco, rare ETOH. Lives alone in [**Location (un) 2312**]. Supportive
family. His friend [**Name (NI) **] [**Name (NI) 28181**] is a particularly important
person in his life.
Family History:
Denies family history of liver or kidney disease.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: [**Hospital1 **]
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs: [**2106-5-5**]
WBC-12.7*# RBC-5.37 Hgb-13.1* Hct-43.5 MCV-81* RDW-20.3* Plt
Ct-57*#
Neuts-82.8* Lymphs-13.1* Monos-3.6 Eos-0.2 Baso-0.3
Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL
Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Target-1+
Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+
PT-17.4* PTT-33.5 INR(PT)-1.6*
Glucose-138* UreaN-15 Creat-5.1*# Na-143 K-4.3 Cl-100 HCO3-32
AnGap-15
ALT-23 AST-53* CK(CPK)-92 AlkPhos-146* TotBili-2.0* DirBili-0.3
IndBili-1.7
Lipase-22
Albumin-2.4* Calcium-8.7 Phos-2.1* Mg-1.4*
.
Cardiac Enzymes:
[**2106-5-5**] 03:35PM BLOOD CK-MB-NotDone cTropnT-0.25*
[**2106-5-6**] 01:38AM BLOOD CK-MB-3 cTropnT-0.24*
[**2106-5-6**] 05:33PM BLOOD CK-MB-3 cTropnT-0.21*
[**2106-5-7**] 01:33AM BLOOD CK-MB-NotDone cTropnT-0.23*
.
Discharge labs: [**2106-5-13**]
WBC-11.2* RBC-5.24 Hgb-13.3* Hct-41.5 MCV-79* RDW-20.9* Plt
Ct-64*
Glucose-104* UreaN-18 Creat-4.7* Na-142 K-4.1 Cl-103 HCO3-30
AnGap-13
ALT-17 AST-22 LD(LDH)-283* AlkPhos-180* TotBili-1.7*
Calcium-8.4 Phos-2.9 Mg-1.9
.
[**2106-5-7**] 5:00 pm STOOL CONSISTENCY: FORMED
RECEIVED SAMPLE IN LAB ON [**2106-5-8**] @ @1022.
**FINAL REPORT [**2106-5-10**]**
CYCLOSPORA STAIN (Final [**2106-5-10**]): NO CYCLOSPORA SEEN.
MICROSPORIDIA STAIN (Final [**2106-5-10**]): NO MICROSPORIDIUM
SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2106-5-8**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Cryptosporidium/Giardia (DFA) (Final [**2106-5-10**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
FECAL CULTURE (Final [**2106-5-10**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2106-5-10**]): NO CAMPYLOBACTER
FOUND.
.
IMAGES/STUDIES:
CXR [**2106-5-5**]: FINDINGS: Single AP upright portable view of the
chest was obtained. Bibasilar atelectasis/scarring is again
seen. There is persistent elevation of the right hemidiaphragm.
Medial right base opacity may be summation of cardiac and
diaphragmatic shadows, although appears more confluent than as
compared to the prior examination. An underlying consolidation
cannot be excluded. The aorta is tortuous. The cardiac
silhouette is not enlarged.
IMPRESSION:
1. Bibasilar atelectasis/scarring. Persistent elevation of the
right
hemidiaphragm.
2. Opacity seen in the medial right lung base, more confluent
than on prior studies, underlying consolidation cannot be
excluded.
PORTABLE SUPINE ABDOMEN X-ray [**2106-5-6**]: SUPINE ABDOMEN: Bowel gas
pattern is nonobstructive with air seen in non-dilated loops of
small and large bowel. There is no intraperitoneal air or
pneumatosis. IMPRESSION: No evidence of bowel obstruction. No
free intraperitoneal air.
ABDOMINAL US WITH DOPPLER [**2106-5-6**]:
IMPRESSION:
1. Cholelithiasis.
2. Ascites.
3. Vascular findings consistent with the prior CT appearance,
including portal venous thrombosis with occlusion and
development of collateral flow.
4. Splenomegaly.
ECHOCARDIOGRAM [**2106-5-7**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Regional left
ventricular wall motion is normal. Doppler parameters are most
consistent with Grade I (mild) left ventricular diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. IMPRESSION: Mild symmetric left
ventricular hypertrophy with normal global and regional
biventricular systolic function. Mild diastolic LV dysfunction.
Mild pulmonary hypertension. Echocardiography is unable to
exclude cardiac amyloidosis (CA), however classic CA features
such as restrictive LV filling, polyvalvular regurgitation or
very low/absent mitral annular E' waves are NOT present on this
study. Compared with the report of the prior study (images
unavailable for review) of [**2104-7-21**], findings appear similar.
[**2106-5-7**] Clavicle Xray: Superiorly displaced left distal
clavicular fracture with subluxation of the humeral head and
narrowing of the acromiohumeral space.
Brief Hospital Course:
&4 year old man with of ESRD on HD (last dialysis [**5-6**]),
cryptogenic cirrhosis and ascites requiring paracentesis
admitted with weakness and confusion.
.
# HYPOTENSION: It was not clear initially if the blood pressures
(his systolics in the 70s measured in the patient's arm) were
his baseline or relative hypotension. Further investigation of
records revealed that this was his baseline. He interemittently
received fluid boluses for SBP<70. Blood pressure was re-checked
in his leg and was found to be ranging from 100-120 systolic. He
remained afebrile with normal white count and lactate level.
Blood cultures to date have been negative. Given his stable
blood pressures midodrine was discontinued. Of note, patient's
baseline HR is in the 110s and he is asymptomatic at this heart
rate.
.
# WEAKNESS/CONFUSION: Patient was brought into the ED by his
partner who related a history of weakness and confusion for the
past 3 days. Patient states that he has had a lack of appetite
for the past few days. Possibilites for weakness and confusion
in this patient include metabolic derangements (likely from
liver failure and hepatic encephalopathy). Albumin is
significantly lower at 2.4 than it was in [**Last Name (LF) 404**], [**First Name3 (LF) **]
malnutrition may be contributing to weakness. Additionaly
patient is at risk for HIV (partner is [**Name2 (NI) 97111**] positive, but
patient has historically refused testing). Testing did not
reveal any infectious etiology. Patient's confusion improved
prior to discharge. Physical therapy evaluated him and
recommended rehab for his weakness.
.
# Clavicular fracture: Patient had a fall prior to admission.
Xray shows displaced clavicular fracture. Orthopedics evaluated
him and recommened a sling for comfort. He has outpatient
orthopedics follow up. Pain control with tylenol.
.
# DIARRHEA: Patient has had chronic diarrhea and extensive GI
work up. GI feels like most like etiology is from illeal
resection he had years ago. Started cholestyramine and this
decreased his stool output. Patient to continue on loperamide.
He also has follow up with GI as an outpatient.
.
# ELEVATED TROPONIN: He was found to have elevated troponins but
normal CK. These were trended and given stable elevatation and
unchanged EKG were thought to be due to his poor renal function.
.
# Thrombocytopenia: Patient has chronically low platelets [**3-9**]
splenic sequestration. Platlet count was stable prior to
discharge.
.
#ESRD. The renal team was [**Month/Day (2) 4221**]. He was continued on
T/Th/Sat hemodialysis schedule.
Medications on Admission:
Midodrine 10mg pre-HD
Xifaxan 200 mg tid
Nadolol 40 mg tid
Omeprazole 20 mg Cap [**Hospital1 **]
Loperamide 2 mg q6h
Calcium Acetate 667 mg Cap, 2caps tid
Nephrocaps 1 mg Cap once a day
Cipro 250 daily for SBP ppx
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
3. Loperamide 2 mg Capsule Sig: One (1) Capsule PO three times a
day as needed for loose stool.
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnosis:
ESRD on dialysis
Clavicle fracture
Chronic Diarrhea
.
Secondary Diagnosis:
Cryptogenic cirrhosis
CKI
h/o PE
MGUS on SPEP
Left inguinal hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with chronic diarrhea and
after a fall. For your diarrhea the GI doctors [**First Name (Titles) **] [**Last Name (Titles) 4221**].
We believe that your diarrhea is chronic and related to the
illeal surgery you had years ago. We have adjusted your
medications, as written below, to help with manage this issue.
For your history of falling physical therapy evaluated you and
recommends a rehabiliatation program. You had a left clavicle
fracture from your last fall. You should follow up with the
orthopedics appointment listed below. You may use a sling for
comfort if you need it.
.
We have made the following changes to your medications:
1. Stop Midodrine
2. Stop Nadolol
3. Stop Calcium acetate
4. Stop Ciprofloxacin
5. Start Cholestyramine 4mg by mouth twice a day
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2106-5-25**] at 2:40 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2106-5-25**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2106-6-16**] at 4:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], 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: LIVER CENTER
When: MONDAY [**2106-6-14**] at 9:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2106-5-13**]
|
[
"707.07",
"707.22",
"810.00",
"458.9",
"787.91",
"273.1",
"287.5",
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"550.90",
"789.59",
"V12.51",
"263.9",
"571.5",
"E885.9",
"585.6",
"707.03",
"574.20",
"V45.72",
"588.81",
"572.2",
"403.91",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11970, 12043
|
8666, 11237
|
347, 354
|
12248, 12248
|
4167, 4167
|
13257, 14484
|
3631, 3682
|
11501, 11947
|
12064, 12064
|
11263, 11478
|
12431, 13075
|
4967, 8643
|
3697, 4148
|
13104, 13234
|
4733, 4951
|
275, 309
|
382, 1823
|
12158, 12227
|
4183, 4716
|
12083, 12137
|
12263, 12407
|
1845, 3416
|
3432, 3615
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,771
| 193,971
|
37645
|
Discharge summary
|
report
|
Admission Date: [**2173-10-7**] Discharge Date: [**2173-11-9**]
Date of Birth: [**2104-1-28**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
L1/2 Decompressive Lumbar Laminectomy
Intubation
Tracheostomy
EGD
History of Present Illness:
69 year old Spanish speaking female transferred from [**Hospital **]
Rehab facility for evaulation of progressively worsening lower
extremity weakness and a constellation of other symptoms. Per
reports, patient had a questionable CVA 3 weeks ago, and at that
time, was also reported to have developed bilateral lower
extremity weakness. The weakness has progressed to the point
where she can no longer walk or move her legs. She also reports
pain and numbness to her L leg, as well a as "dullness" to her
thoracic/abdominal region. She denies urinary or bowel
incontinence, other than her usual stress urinary incontinence,
and also denies any saddle anesthesia.
Past Medical History:
PMHx:
1. Diabetes Type II
2. Arthritis
3. Cervical Spondylosis
4. Degenerative disc disease
5. Hyperlipidemia
Social History:
Social Hx: She is Spanish Speaking only. She is on medical
disability. She does not have a history of smoking, EtOH, or
Drugs abuse.
Family History:
Family Hx: Father with Diabetes
Physical Exam:
PHYSICAL EXAM:
O: T: 98 BP: 156/68 HR:73 R: 18 O2Sats:99%
Gen: WD/WN, comfortable, NAD.
HEENT: Normocephalic, Atraumatic. Pupils: PERRLA. [**2-7**]
bilaterally
EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person and place only.
Motor:
D B T IP Q H AT [**Last Name (un) 938**] G
R 4 4 4 0-1 0-1 0-1 0-1 0-1 0-1
L 5 5 5 0-1 0-1 0-1 0-1 0-1 0-1
Sensation: Patient reports "dullness" to abdominal area without
a
specific sensory level or dermatomal distrubution deficit. Was
able to feel anterior pinprick, but describes it as dull.
Reflexes: Pa Ac
Right N/A(knee replacement) 0
Left N/A (knee replacement) 0
Toes downgoing bilaterally - Negative Babinski
Rectal exam normal sphincter control
Pertinent Results:
Admission Labs:
.
CSF Analysis:
wbc 1, rbc 24, poly 1, lymph 87, mo 0, mac 12
TP 197, glu 77
.
VZV: Neg
HSV: Neg
Oligoclonal Bands: Neg
IMAGING
.
MRI from [**Hospital 8**] Hospital, [**2173-9-29**]:
LUMBAR SPINE: L1-L2: There is a focal left paracentral disc
protrusion and a broad based right paracentral to extraforaminal
disc protrusion, with associated spondylitic ridging. Facet
arthritis is asymmetrically moderate on the right and mild on
the left. There is resultant severe spinal canal stenosis with
complete effacement of SCF in the thecal sac, and severe
foraminal encroachment which is worse on the right.L2-L3: The
disc is severely degenerated with bulging of spondylitic ridging
and there is moderate facet arthritis, with resultant moderate
to severe canal stenosis, severe encroachment of the left neural
foramen and moderate right foraminal encroachment.L3-L4, and
L4-L5: There is a shallow broad based dorsal disc protrusion and
moderate facet arthrisit causing moderate to canal stenosis
which is asymmetrically most prominent along the left lateral
recess, moderate foraminal encroachment on the right, and severe
froaminal encroachment of the left.
.
CERVICAL MRI:
Motion degraded study showing mild cervical spondylosis.
.
MRI HEAD:
Results are unavailable
Brief Hospital Course:
Ms. [**Known lastname **] is a 69 year-old woman with a past medical history
including obesity, DMII, hyperlipidemia, and cervical
spondylosis who was admitted to the [**Hospital1 18**] [**2173-10-7**] with with
lower extremity weakness and was found to have stenosis at L1-2
for which she underwent laminectomy; she subsequently developed
progressive weakness in the lower extremities, upper
extremities, and face and was discovered to have evidence of
AIDP. She was initially admitted to the Neurosurgery Service
and subsequently transferred to the Neurology Service.
.
# NEURO:
When the patient first presented, she was evaluated by both
Neurosurgery and Neurology, where she was found to have diffuse
weakness, R>L, a R sided facial palsy, decreased pinprick to the
mid thighs, saddle anesthesia, brisk reflexes in the upper
extremities, but no reflexes in her lower extremities. It was
suspected that her inability to walk was due to her lumbar
stenosis, and that her facial and upper extremity weakness were
due to a lacunar stroke, that was too small to pick up on MRI.
She was initially scheduled to go to the ER on [**10-8**] for
laminectomy, however this was delayed for further work-up. She
had a repeat MRI with DWI to rule out possible infarction to
explain her symptoms, which was negative for infarct. On [**10-12**]
she went to the OR for L1-L2 laminectomy. During surgery on
[**10-12**], a CSF sample was obtained, which showed an elevated
protein of 197, with 1 WBC and 24 RBCs. On [**10-13**], patient
complained of increased pain and was observed to have
progressive increase in weakness in her upper extremities as
well as a bilateral facial droop, R>L. She also increased her
requirement for O2 due to dyspnea. She was re-evaluted by
Neurology, who found her facial weakness to be worse, with
complaints of dysarthria, dysphagia, and mild dyspnea. Concern
was raised for either GBS vs. CIDP vs. new stroke affecting her
left side. As her respiratory status continued to decline, she
was transferred to the ICU and intubated. An EMG was consistent
with the concern for [**First Name9 (NamePattern2) 7816**] [**Location (un) **]. Accordingly, a five-day
course of IVIG was prescribed. Thereafter the patient
experienced gradual increases in strength and a return of
reflexes, most notable in the left biceps. After transfer to
the floor, her strength continued to improve, particularly in
her upper extremities.
# RESP:
Because of worsening respiratory status, on [**10-13**] the patient was
transferred to the ICU and intubated. On [**10-19**], after
completing her course of IVIG, she underwent a successful SBT
and was extubated. However, shortly after extubation she
desaturated and had to be emergently reintubated. Ultimately, a
tracheostomy was performed. She continued to receive oxygen
supplementation via tracheostomy during the remainder of her
hospital stay.
.
# ID
In the course of the hospitalization, the patient developed a
fever. Sputum culture demonstrated gram positive cocci in
clusters for which IV vancomycin was begun ([**2173-10-28**]) and
subsequently switched to nafcillin after it was determined to be
coagualase positive staph sensitive to nafcillin. Nafcillin was
discontinued after one week. Stool was positive for c.
difficile toxin for which flagyl was started ([**2173-10-29**]). For a
concurrent urinary tract infection, ciprofloxacin was initiated
([**2173-10-28**]) and continued for a ten day course. It was determined
that flagyl should be continued for a 14 day course. The last
dose of flagyl should be given on [**2173-11-12**].
.
# GI
Tube feeds were provided to ensure adequate nutritional intake
throughout the hospitalization. Initial attempts to place a PEG
in conjunction with the trach were thwarted as the patient was
found to have "concretions" in the esophagus. A follow-up EGD
demonstrated a clear esophagus, suggesting the concretions had
spontaneously passed. As the patient seemed to attain improved
attention and motor function following the IVIG treatments, the
placement of a PEG was ultimately delayed with the hope she
could begin oral intake. After transfer to the neurology floor,
speech and swallow study was attempted but tracheostomy size was
too large. On repeat study, she passed to receive NGT diet of
ground consistency and nectar prethickend liquids. So that she
could receive adequate nutritional support, she had a PEG tube
placed on [**2173-11-5**]. She is on goal tubefeeding of fiber full
strength at 60 ml/hr and flush with 30 mL water q4h. Also, per
repeat swallowing evaluation, she is permitted ground
(dysphagia) consistency regular diet and nectar prethickened
liquids, but the trach cuff must be deflated while feeding.
Medications on Admission:
1. Metformin 500mg daily
2. Tylenol PRN
3. Vitamin D
4. ASA 81mg Daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: Please give via PEG.
2. Glycerin (Adult) Suppository Sig: One (1) Suppository
Rectal DAILY (Daily) as needed for constipation.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): Please give via PEG.
5. Docusate Sodium 50 mg/5 mL Liquid Sig: 100 mg PO BID (2
times a day) as needed for constipation: [**Last Name (un) 6267**] give via PEG.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Please give via PEG.
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep : Please give via PEG.
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for dysesthetic leg pain: Please give via
PEG.
9. 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.
10. Lorazepam 0.5-1 mg IV Q8H:PRN anxiety
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
12. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
13. Insulin Regular Human 100 unit/mL Solution Sig: AS DIR units
Injection four times a day: sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Acute Idiopathic Demyelinating Polyneuropathy ([**First Name9 (NamePattern2) 7816**] [**Location (un) **]
Syndrome)
Discharge Condition:
Stable condition with trach. Neurologic exam notable for
paraparesis with limited movement at proximal legs and none
distally; moderate weakness of UEs but at least antigravity.
Discharge Instructions:
You were transferred to [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for
evaulation of progressively worsening lower extremity weakness.
You underwent neurosurgery for a procedure called a laminectomy.
Following diagnosis of [**First Name9 (NamePattern2) 30065**] [**Location (un) **] Syndrome, you were
treated with IVIG. You are currently begin treated with Flagyl
for a 14 day course for a previously postive C. diff toxin.
Repeat C. diff toxin in negative. The last day of treatment
with Flagyl will be on [**2173-11-12**]. With improving examination, you
are now ready for transfer back to [**Hospital1 **] for continued
rehabilitation.
Followup Instructions:
You will be contact[**Name (NI) **] by Dr. [**Last Name (STitle) **] and Dr.[**Name (NI) 11858**] office
to schedule a follow-up appointment.
.
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] OF NEUROSURGERY TO BE SEEN IN 6 WEEKS for follow-up after
laminectomy.
YOU WILL NOT NEED XRAYS PRIOR TO YOUR APPOINTMENT
Completed by:[**2173-11-9**]
|
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"682.3",
"278.00",
"998.32",
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] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"38.93",
"96.72",
"99.14",
"96.04",
"45.13",
"03.09",
"31.1",
"96.6",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
10012, 10091
|
3690, 8439
|
325, 393
|
10250, 10429
|
2384, 2384
|
11236, 11631
|
1384, 1417
|
8561, 9989
|
10112, 10229
|
8465, 8538
|
10453, 11213
|
1447, 1654
|
277, 287
|
421, 1085
|
2401, 3667
|
1669, 2365
|
1107, 1218
|
1234, 1368
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,129
| 154,930
|
40142
|
Discharge summary
|
report
|
Admission Date: [**2145-12-29**] Discharge Date: [**2146-1-14**]
Date of Birth: [**2078-7-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Sternal drainage
Major Surgical or Invasive Procedure:
[**2146-1-3**] repeat debridement
[**2145-12-31**] sternal debridement and VAC
[**2146-1-5**] Delayed closure of a sternotomy dehiscence with 5
talon plates and bilateral pectoralis musculocutaneous
advancement flaps.
History of Present Illness:
Mr. [**Known lastname 88185**] is a 67 year-old male three weeks post mechanical
MVR and mitral myxoma resection. His postoperative course was
relatively uneventful. He had maintained sinus rhythym and was
discharged on POD7 with an INR of 2.5 for his mechanical valve.
He presented to [**University/College 23925**] ED today with dyspnea and subacute
onset of pain, erythema and purulent discharge from the superior
pole of his skin incision in the context of palpitations. New
onset atrial fibrillation was demonstrated on EKG, for which he
was started on diltiazem gtt and converted to sinus. His cardiac
enzymes were normal. His WBC was 15.9K and his INR 2.6, for
which 1500mg vancomycin and 2.5mg coumadin were given,
respectively, in ED prior to transfer to [**Hospital1 18**] for management of
his superficial wound.
He denies fevers, chills, rigors, sweats, angina or incisional
pain, with the exception of mild pain and moderate tenderness at
the aforementioned superior aspect of his incision.
Past Medical History:
s/p mechanical mitral valve replacement and myxoma resection
[**2145-12-10**]
Coronary artery disease s/p stent [**2140**]
Diabetes Mellitus II
Hypertension
Hyperlipidemia
Gastroesophageal reflux disease
Tonsillectomy
Social History:
Lives with: wife
Occupation: sales- dairy products
Tobacco: none recently
ETOH: social
Family History:
father died at 88yo secondary to complications of valvular
surgery
mother living at [**Age over 90 **]yo
Race: caucasian
Last Dental Exam: 2 weeks ago
Physical Exam:
Temp: 98.9
Pulse: 98 Resp: 18 SaO2: 95%/3L NC
B/P Left: 125/75
Height: Weight:
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [ ] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] but diminished at R base
Sternal incision with erythema and fluctuance at superior
pole spontaneously draining brown pus; stable, no click
Heart: RRR [x] Irregular [] Murmur-none [x]mechanical S1/S2
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm & well-perfused [x] Edema (mild) [x]
Neuro: Grossly intact
Pulses:
Femoral Right: nd Left: nd
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: nd Left: nd
Radial Right: 2+ Left: 2+
Carotid Bruit: no bruits bilaterally
Pertinent Results:
[**2145-12-30**] Chest CT: 1. Status post median sternotomy with
loculated fluid collections tracking along the anterior
mediastinum, as detailed. 2. Sternal wires appear intact,
without evidence of sternal osteomyelitis. 3. Bilateral pleural
effusions, right larger than left, associated with lower lobe
atelectases.
[**2146-1-11**] CXR: There is no change in the sternal plating
appearance, replaced valve, left basal AA consolidation and
right internal jugular line. No evidence of pulmonary edema is
demonstrated. There is interval increase in left pleural
effusion as compared to prior study but no evidence of
pneumothorax is demonstrated. Part of the effusion might be
loculated in the fissure.
[**2146-1-10**] Renal U/S: Slightly limited study as above, without
evidence to suggest renal artery stenosis
[**2146-1-14**] 05:25AM BLOOD WBC-8.9 RBC-3.56* Hgb-10.9* Hct-31.9*
MCV-90 MCH-30.5 MCHC-34.1 RDW-15.1 Plt Ct-410
[**2146-1-13**] 05:41AM BLOOD WBC-10.2 RBC-3.76* Hgb-11.5* Hct-33.5*
MCV-89 MCH-30.4 MCHC-34.2 RDW-14.8 Plt Ct-406
[**2146-1-14**] 05:25AM BLOOD PT-27.6* INR(PT)-2.7*
[**2146-1-13**] 05:41AM BLOOD PT-21.1* PTT-66.8* INR(PT)-2.0*
[**2146-1-12**] 04:36AM BLOOD PT-18.3* PTT-27.2 INR(PT)-1.7*
[**2146-1-11**] 04:10PM BLOOD PT-21.2* INR(PT)-2.0*
[**2146-1-11**] 09:23AM BLOOD PT-31.0* PTT-32.8 INR(PT)-3.1*
[**2146-1-11**] 02:59AM BLOOD PT-39.7* PTT-32.6 INR(PT)-4.2*
[**2146-1-10**] 10:51PM BLOOD PT-38.0* PTT-31.4 INR(PT)-3.9*
[**2146-1-10**] 05:38PM BLOOD PT-37.0* PTT-32.2 INR(PT)-3.8*
[**2146-1-10**] 12:26PM BLOOD PT-61.4* PTT-35.8* INR(PT)-7.0*
[**2146-1-10**] 03:23AM BLOOD PT-45.5* PTT-110.3* INR(PT)-4.9*
[**2146-1-9**] 07:48PM BLOOD PT-28.2* PTT-58.8* INR(PT)-2.8*
[**2146-1-9**] 06:23AM BLOOD PT-20.4* PTT-41.8* INR(PT)-1.9*
[**2146-1-9**] 01:04AM BLOOD PT-18.6* PTT-37.4* INR(PT)-1.7*
[**2146-1-8**] 01:09AM BLOOD PT-18.0* PTT-60.6* INR(PT)-1.6*
[**2146-1-7**] 03:27AM BLOOD PT-17.4* PTT-40.7* INR(PT)-1.6*
[**2146-1-6**] 10:40PM BLOOD PT-17.7* PTT-38.9* INR(PT)-1.6*
[**2146-1-6**] 03:34PM BLOOD PT-18.5* INR(PT)-1.7*
[**2146-1-14**] 05:25AM BLOOD UreaN-34* Creat-1.8* Na-137 K-4.0 Cl-103
[**2146-1-13**] 05:41AM BLOOD Glucose-113* UreaN-39* Creat-1.9* Na-138
K-3.7 Cl-102 HCO3-27 AnGap-13
[**2146-1-12**] 04:36AM BLOOD Glucose-101* UreaN-46* Creat-2.0* Na-141
K-4.0 Cl-103 HCO3-30 AnGap-12
[**2146-1-11**] 02:59AM BLOOD Glucose-82 UreaN-54* Creat-2.2* Na-146*
K-3.6 Cl-107 HCO3-32 AnGap-11
[**2146-1-10**] 10:51PM BLOOD Glucose-72 UreaN-54* Creat-2.4* Na-148*
K-3.4 Cl-106 HCO3-32 AnGap-13
Echo [**2146-1-14**]
Report Pending
Brief Hospital Course:
Mr. [**Known lastname 88185**] was admitted with erythema and purulent discharge
from the superior pole of his sternal incision. He was placed on
antibiotics and underwent appropriate work-up for return to
operating room for sternal debridement. Chest CT on [**12-30**] showed
left and right sternal segments separated by a distance of up to
5 mm superiorly without evidence of osteomyelitis. In addition
immediately superior to the sternoclavicular junctions, is a
small pocket of fluid that tracks deep to the sternum and
extends into the anterior mediastinum by approximately 2 cm at
the level of the brachiocephalic confluence. On [**12-31**] he was
brought to the operating room where he underwent sternal
debridement and placement of wound VAC. Please see operative
report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Infectious disease was consulted for help in his
management. He remained paralyzed and sedated with an open chest
for several days and then returned to the operating room on
[**1-3**] with a plan to close his chest. In the operating room
their appeared to be residual parasternal abscess which made
closure inadvisable. Please see operative note for surgical
details. A VAC was again placed and he was transferred back to
the CVICU. A left chest tube was placed in the CVICU for
effusion seen on CXR. On [**1-4**] he had a drop in his HCT, became
hypotensive with increased bloody output from his chest tube. He
was brought back to the operating room for an exploration of his
bleeding. Thoracic surgery was consulted to assist in the
operating room and chest wall bleeding near the chest tube
placement site was brought under control. Please see operative
note for surgical details. He chest remained open, he again
returned to the CVICU and on [**1-5**] was brought back to the
operating room again. On this day his chest was finally brought
back together with plates and pec flaps. Please see operative
note for surgical details. He returned to the CVICU for further
monitoring. Heparin was continued for mechanical valve
thrombotic prophylaxis. When INR became therapeutic, heparin
was discontinued and patient was maintained on coumadin with
goal INR 2.5-3.5 for mechanical mitral valve.
The patient did sustain acute kidney injury with a rise in
creatinine from 1.1 to 2.7mg/dL. Renal was consulted. His
urine output remained adequate, and creatinine would trend down
following discontinuation of Nafcillin. Antibiotics were
changed to Cefazolin for [**7-20**] week course. ID will follow the
patient closely to determine further antibiotic course. PICC
was placed to facilitate IV antibiotics.
The patient was discharged to [**Hospital6 **] in [**Location (un) 24402**],
[**State 1727**] for further recovery.
Medications on Admission:
Lopressor 25 TID
Plavix 75 daily
Coumadin 2.5(MTWThSa)/1.5(FSu)
Metformin 500 daily
Simvastatin 40 daily
Omeprazole 20 daily
ASA 81 daily
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing.
11. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
12. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
13. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-13**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
18. tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q12H (every 12
hours) as needed for pain.
19. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: MD to dose daily for goal INR 2.5-3.5, mechanical mitral
valve.
20. cefazolin 10 gram Recon Soln Sig: Two (2) Recon Soln
Injection Q8H (every 8 hours) for 33 days: Cefazolin 2g Q8hours
IV- through [**2145-2-16**].
21. 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.
22. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Regular Insulin per attached
sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 24402**], ME
Discharge Diagnosis:
Sternal wound infection
Past medical/surgical history:
s/p mechanical mitral valve replacement and myxoma resection
[**2145-12-10**]
Coronary artery disease s/p stent [**2140**]
Diabetes Mellitus II
Hypertension
Hyperlipidemia
Gastroesophageal reflux disease
Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Lower extremity edema: [**4-15**]+ bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: [**Doctor Last Name **] [**Telephone/Fax (1) 1504**] on Thurs. [**2146-1-27**] 1:45
[**Hospital1 18**], Division of Cardiothoracic Surgery
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]
Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 1416**] (plastic surgery): Thurs. [**2146-1-27**], 11am
[**Hospital1 1426**] Plastic Surgery, PC
[**Apartment Address(1) 1414**]
[**Location (un) **], [**Numeric Identifier 1415**]
Inf Disease: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2146-1-25**] 3:00
Inf Disease: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2146-2-25**] 11:30
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **],[**First Name3 (LF) 539**] A. [**Telephone/Fax (1) 58293**] in [**5-17**] weeks
Cardiologist: Dr. [**Last Name (STitle) 80724**] #[**Telephone/Fax (1) 8226**] in [**4-15**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: Mechanical Mitral valve
Goal INR: 2.5-3.5
First draw: day after discharge [**2146-1-15**]
Once discharged from rehab, results to Dr. [**Last Name (STitle) 48239**] att: [**Doctor First Name **]
phone:[**Telephone/Fax (1) 26035**] fax:[**Telephone/Fax (1) 88184**]
Weekly CBC, BUN, creatinine, LFT's, ESR, and CRP: All laboratory
results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
Completed by:[**2146-1-14**]
|
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icd9cm
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[
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|
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2885, 5453
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|
1839, 1927
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77,383
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39255
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Discharge summary
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report
|
Admission Date: [**2147-4-21**] Discharge Date: [**2147-5-22**]
Date of Birth: [**2102-5-28**] Sex: F
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
alcoholic hepatitis
Major Surgical or Invasive Procedure:
Intubation [**2147-4-23**], Extubated [**2147-5-4**]
Temporary dialysis line placed [**2147-5-3**], replaced over wire
[**2147-5-15**]
Tunneled dialysis line placed [**2147-5-19**]
Upper endoscopy [**2147-5-16**]
Blood transfusions
Dialysis
History of Present Illness:
This is a 44 yo F w/hx of severe alcoholism who initially
presented to an OSH with acute liver failure and was transferred
to [**Hospital1 18**] on [**2147-4-21**]. She has a history of alcohol use and drinks
1.5 bottles of champagne per day. She has a history of atenolol
overdose in [**2-22**] as a suicide attepmt. Prior to admission she
experienced nausea, diarrhea, fatigue and increased abdominal
girth. She was found to be jaundiced with acute liver failure.
At the OSH, labs significant hct of 29.8, plt 90K, Na 115 Cre
2.1. Tbili 21.9. While she was there, she was placed IV fluids
and given lactulose. She was also seen by Psychiatry and was
treated for a UTI with cipro.
.
On arrival to [**Hospital1 18**], she was noted to have worsening
encephalopathy. She was treated with ativan 0.5mg PO PRN on the
floor for alcohol withdrawal. She has a history of DTs in the
past. She required intubation [**2147-4-23**] and was given 2 units of
FFP for INR of 3.6. Renal failure has been worsening with a
creatinine of 3.8 this morning. She was transferred to the ICU.
Past Medical History:
Alcoholism
Pancreatitis
DTs
Depression (Admissions for SI attempts, atenolol OD [**2-22**])
Obsessive Compulsive Disorder
h/o bariatric surgery in [**2138**] (Roux en Y)
s/p CCY
peripheral neuropathy
s/p abdominoplasty
s/p breast lift
Social History:
single, with 2 kids. denies tobacco. 1.5 bottles of champagne
per days. Long hx of EtOH, but relapsed EtOH after gastric
bypass in [**2138**]
Family History:
+ETOH abuse in family.
Physical Exam:
Exam on admission [**2147-4-21**]:
Vitals - T: 97.4 BP: 96/58 HR: 79 RR: 20 02 sat: 100% RA Wt
87.5 kg
GENERAL: Extremely jaundiced please woman in NAD
HEENT: scleral icterus, jaundice on top and bottom of tongue.
Also with thrush. O/P clear. No JVD, LAD or thyromegaly
CARDIAC: RRR no m/g/r
LUNG: CTAB no w/r/r
ABDOMEN: soft, ttp epigastric region and more mild RUQ. NABS.
Obese. Unable to appreciate ascites. + splenomegaly. liver edge
palpable at costal margin
EXT: 3+ clubbing BLE to knees. no clubbing or cyanosis. no
palmar erythema or contractures.
NEURO: alert. language difficulties. Says "there are too many
pots in the soup," when trying to describe how she felt that the
doctors at the OSH did not communicate
DERM: jaundiced. no angiomata, bruising
PSYCH: anxious appearing
Exam on discharge [**2147-5-22**]:
T 98.2 BP 123/78 HR 82 98% RA Wt 83.3 kg (post dialysis)
GEN: NAD
HEENT: icteric; no dobhoff
CV: RRR, SM, 2/6 systolic LSB
PULM: CTA b/l
ABD: +BS, soft, mildly distended, nontender; no rebound or
guarding
EXT: warm, well perfused, 2+ pitting edema
NEURO: AOx3, no asterixis
Skin: jaundiced, anterior surfaces of both arms with large
ecchymosis; R tunneled dialysis line with dressing c/d/i
Pertinent Results:
Labs on admission [**2147-4-21**]:
WBC-13.3* RBC-2.93* Hgb-9.3* Hct-27.7* MCV-94 MCH-31.9 MCHC-33.7
RDW-20.0* Plt Ct-115*
Neuts-84.2* Lymphs-10.9* Monos-3.8 Eos-0.7 Baso-0.3
PT-30.6* PTT-66.2* INR(PT)-3.1*
Glucose-90 UreaN-12 Creat-3.2* Na-139 K-4.5 Cl-114* HCO3-14*
AnGap-16
ALT-27 AST-101* LD(LDH)-279* AlkPhos-183* Amylase-10
TotBili-30.4*
Albumin-2.2* Calcium-8.6 Phos-4.3 Mg-1.8
Other Labs:
[**2147-4-21**]
calTIBC-91* Ferritn-709* TRF-70*
Osmolal-307
HBsAg-NEGATIVE
HBsAb-BORDERLINE
HBcAb-NEGATIVE
HAV Ab-POSITIVE IgM
HAV-NEGATIVE
Smooth-POSITIVE *
[**Doctor First Name **]-POSITIVE * Titer-1:320
AFP-2.4
IgG-1887*
HIV Ab-NEGATIVE
HCV Ab-NEGATIVE
[**2147-5-11**] calTIBC-133* Ferritn-GREATER TH TRF-102*
[**2147-5-18**] VitB12-1273* Folate-16.9
[**2147-5-21**] PTH-67*
[**2147-5-14**] tTG-IgA-18
[**2147-5-21**] Vitamin 25(OH) D Pending
Labs on discharge [**2147-5-22**]:
WBC-13.9* RBC-2.88* Hgb-9.2* Hct-26.7* MCV-93 MCH-31.9 MCHC-34.4
RDW-22.0* Plt Ct-73*
PT-19.9* INR(PT)-1.8*
Glucose-107* UreaN-49* Creat-3.8* Na-131* K-3.8 Cl-95* HCO3-25
AnGap-15
ALT-95* AST-73* AlkPhos-130* TotBili-14.2*
Lipase-28
Albumin-3.2* Calcium-9.2 Phos-3.4 Mg-1.9
MICROBIOLOGY:
[**2147-4-23**] MRSA screen - negative
[**2147-5-7**] VRE Swab - negative
[**2147-5-7**] UCx - yeast >100,000 org/ml; asymptomatic; noted in all
urine cultures throughout hospitalization
[**2147-5-5**] A-line tip - negative
All blood, stool cultures negative; C diff negative x6
throughout hospital course
IMPORTANT STUDIES:
[**2147-4-21**] CXR: PA and lateral chest x-rays were obtained. There is
no comparison. The right PICC line terminates at the atriocaval
junction, in satisfactory position. There is minimal left lower
lobe subsegmental atelectasis. There is no focal consolidation
or pleural effusion. There is no pneumothorax.
[**2147-4-21**] Abd US:
1. Extremely echogenic liver consistent with the history of
liver disease.
Ascites in three of four quadrants.
2. Patent portal vein, but with reversal of flow (hepatofugal).
[**2147-4-29**] CT ABDOMEN/PELVIS w/o contrast:
1. Large left rectus abdominis wall fluid collection, suggestive
of hematoma. Given lack of contrast, abscess is not excluded. No
retroperitoneal hematoma is identified, however blood may be
present in extraperitoneal space.
2. Diffuse colonic wall thickening highly suggestive of
colitis/edema. Differential considerations include primarily
infectious (C. diff should be considered given patient's ICU
status), inflammatory causes, and much less likely ischemic
colitis.
3. Perihepatic and right lower quadrant ascites with diffuse fat
stranding throughout the mesentery, consisent with volume
overload.
4. Bilateral pleural effusions, slightly greater on the left
when compared to the right with scattered opacities.
5. Mild cardiomegaly.
6. Gastric post-surgical changes.
[**2147-4-30**] R Lower exrremity ultrasound:
REASON FOR EXAM: Status post right femoral line placement.
Clinical concern for hematoma.
ULTRASOUND IMAGES OF THE RIGHT GROIN: This study is minimally
limited due to a bandage overlying the right groin. No definite
hematoma was visualized. The right common femoral artery and
vein demonstrate normal color and Doppler flow. There is no
evidence of pseudoaneurysm.
[**2147-5-1**]:
INDICATION: 44-year-old female with liver failure, DIC, right
upper extremity swelling. Evaluate for DVT.
IMPRESSION: No evidence for right upper extremity DVT.
[**2147-5-8**] CXR 2 view:
The position of the Dobbhoff catheter is unchanged and
satisfactory. Multifocal consolidation remains unchanged with no
newly
developed areas of consolidation.
[**2147-5-8**] Abd US:
1. Echogenic liver consistent with history of liver disease.
2. Slow and reversal flow in the main portal vein. Reversal flow
in the left portal vein.
3. Sufficient fluid to mark site for paracentesis.
4. Extra-hepatic biliary duct dilatation, and mild intra-hepatic
biliary duct dilatation.
[**5-15**] Liver biopsy pathology:
Liver, transjugular needle core biopsy:
1. Nodular fragments of hepatic parenchyma and broad fibrous
septal tissue, consistent with cirrhosis (trichrome stain
evaluated; a focal sinusoidal fibrotic component is identified).
2. Mild, mixed steatosis (involving <33% of the parenchyma),
with prominent associated intracytoplasmic hyalin.
3. Moderate septal and lobular mixed inflammation with a marked
neutrophilic component.
4. Moderate canalicular and hepatocellular cholestasis.
5. Iron stain shows mild iron deposition in periportal
hepatocytes and Kupffer cells.
Note: The findings are consistent with an acute-on-chronic
toxic/metabolic injury. No diagnostic features of autoimmune
hepatitis are identified in this limited sample. Discussed with
pathologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7017**] - While prednisone will affect the
histologic appearance of autoimmune hepatitis and she does have
robust [**Doctor First Name **], her [**Last Name (un) 15412**] is low titer and Ig levels being low also
argues against autoimmune hepatitis.
[**5-16**] EGD:
No varices noted.
Previous gastric bypass noted, dobhoff tube in place.
No stigmata of bleeding.
No stigmata of bleeding.
Otherwise normal EGD to duodenum/jejunum
[**2147-5-19**] Uncomplicated conversion of temporary hemodialysis
catheter to a
tunneled hemodialysis catheter, in the right jugular vein;
tip-to-cuff length is 19 cm; tip is in the right atrium; the
line is ready for use.
Brief Hospital Course:
Ms [**Known lastname **] is a 44 year old woman with long history of alcohol
use and recent onset of end-stage liver disease and rapidly
declining renal function transferred to [**Hospital1 18**] for higher level
of care.
At [**Hospital1 18**], she was getting lorazepam for withdrawal on the floor.
She was progressively encephalopathic and was intubated on [**4-23**]
for worsening respiratory status and transferred to the ICU.
MICU COURSE [**2147-4-23**] - [**2147-5-7**]:
# Alcoholic hepatitis: Most likely secondary to ETOH with
probable underlying cirrhosis. Her discriminant function is >
140 which predicts high 30 day mortality of at least 50%. In
this case, steroids would be recommended as soon as infection
can be ruled out. She does have a leukocytosis. She was
pan-cultured. She was treated with octreotide and midodrine, 50
albumin x 3 days for HRS. Continued lactulose, added rifaximin.
MICU COURSE: On hospital day #2, the patient developed worsening
mental status and respiratory distress requiring intubation and
was transferred to the medical ICU. She was started on
prednisone on [**2147-4-24**] as well as on tube feeds for nutritional
support. Her LFTs and coags were trended daily. Over the course
of 1 week her total bilirubin trended down significantly from
~30 to ~16-18 so she was planned for a full 28-day course of
steroids. In the setting of acute liver failure she developed
acute renal failure (HRS vs. ATN) and coagulopathy with
significant complications from bleeding (see below). She
developed hypotension requiring pressure support (see below).
After ~9 days of unresponsiveness, she began following commands
and making eye contact and was able to be extubated 3 days
later. She was initially confused (attributed to hepatic
encephalopathy and recent extreme critical illness) but within
48 hours following extubation was alert, speaking regularly, and
oriented to person, place [**Hospital1 18**] and date [**2147-5-6**]. She was
therefore transferred back to the liver floor service.
# Respiratory distress: The patient was intubated for 12 days
and maintained on sedation with propofol. Initially, she was
unresponsive even with decreasing sedation, but after
approximately 1 week began opening her eyes to voice and
following commands. Multiple spontaneous breathing trials failed
presumably secondary to excess fluid, so CVVH parameters were
titrated to remove additional fluid and the patient was
successfully extubated after ~12 days. During her MICU stay, she
was treated empirically for HCAP based upon elevated WBC count
and CXR findings for an 8-day course of vanco/Zosyn ([**2147-4-29**] =
Day #1).
# Acute renal failure: The patient developed worsening renal
failure over the early course of her admission and was started
on CVVH after transfer to the ICU. Per renal team recs, the
etiology of her renal failure was more consistent with ATN than
HRS, so octreotide was discontinued. Despite efforts to maintain
fluid balance, the patient became virtually anuric and remained
significantly volume overloaded. Efforts to remove additional
fluid by CVVH were limited by hypotension initially. On [**2147-5-5**]
CVVH was stopped and on [**2147-5-6**] hemodialysis was initiated. The
patient tolerated her initial HD session very well with SBPs >
100.
# Coagulopathy, rectus sheath bleed: In the setting of liver
failure as above, the patient developed anemia and
thrombocytopenia (presumed secondary to suppressed production
and splenic sequestration). However, on [**2147-4-29**] her Hct and
platelet counts dropped significantly; imaging by CT ultimately
revealed a large rectus sheath hematoma. She simultaneously
developed oozing at all line sites with resulting ecchymoses
(ultrasound of the groin revealed no hematoma). Over the ensuing
2-3 days, she received 12 units of pRBCs, 10 units of FFP, 5
units of platelets, and 4 units of cryoprecipiate. She was also
treated with DDAVP x 2 days. Her blood counts ultimately
stabilized at prior baseline values.
# Hypotension: The patient developed hypotension to SBPs 70s-80s
after initiation of CVVH. She ultimately required pressors to
support her blood pressure, and an A-line was placed for closer
monitoring. She was able to be weaned from pressors shortly
prior to extubation and blood pressures remained stable until
transfer to the floor.
# Leukocytosis: The patient had an elevated WBC count during
most of her hospital stay. This may have been partially due to
therapy with prednisone, but given differential with > 90% PMNs
and low grade bandemia, likely represented infection. She was
treated for presumed HCAP with vanco/Zosyn but rising WBC count
persisted. C. difficile was negative x 3, and urine showed
persistent yeast despite 5-day treatment course of fluconazole,
though this was in the setting of very low UOP. Final culture
results were negative.
# ETOH dependence with h/o DTs. Placed on CIWA. Continued
thiamine, folate, MVI.
FLOOR COURSE [**2147-5-7**] - DISCHARGE:
# ETOH hepatitis/EtOH Cirrhosis - Pt's bilirubin slowly
decreased and stabilized at 14-16 with overall trend down from
peak of 31.9 on [**4-22**]. Pt was also noted to be [**Doctor First Name **] positive
(1:320) and AMA positive (1:20) but liver biopsy was not c/w
autoimmune hepatitis. TTG-IgA negative. EGD [**5-16**] normal s/p
gastric bypass, without varices. Pt's prednisone (started 40mg
daily on [**4-24**] in the ICU) was continued and tapered as per
discharge medications (end [**2147-6-8**]). Rifaximin and lactulose
were continued. She did not get nadolol given low BPs and lack
of varices on EGD. She received nutritional support with tube
feeds until the Dobhoff came out after her endoscopy. She had
extensive nutrion counseling to maintain her calorie and protein
intake in balance with her diet for her gastric bypass.
# Acute renal failure, now with chronic kidney disease: [**2-14**] ATN
from hypotention and DIC. Pt was on CVVH, now on HD. She began
to make small amounts of urine (300-500cc/day). Per renal, there
is possible slow recovery but at this time, it seems less likely
and she will require long term dialysis. Her electrolytes and
volume status remained stable. PPD negative (0 mm). Tunneled
line placed [**5-19**] for outpatient dialysis (will be followed by Dr.
[**Last Name (STitle) 9419**]. Epo will be given with dialysis. She is at high risk
for osteoporosis. PTH 67 (high-normal). Vitamin D will be givein
with dialysis. Renal did not recommend calcium supplementation
and her Ca levels will be monitored with HD. Vitamin D level is
pending at discharge. She will require bone density testing as
outpatient to determine baseline, which can be arranged by her
PCP.
#Anemia - Pt with slowly decreasing Hct during her floor stay,
requiring occassional transfusions. Her DIC had resolved and
there was no evidence of recurrence. She had EGD that was
unremarkable and her stools were consistently guaiac negative.
Iron studies demonstrated underlying anemia of chronic disease
and marrow supression likely from acute illness and renal
failure. B12 and folate normal. Haptoglobin was low concerning
for hemolysis, although reticulocyte count low and Direct bili
trending down rather than up. Indirect bili likely elevated [**2-14**]
liver disease. Pt was started on epogen with dialysis. She will
require Hct checks as outpatient. Hct on discharge was 26.7.
# h/o HTN - As above, pt was hypotensive requiring pressors in
the ICU. She remained low-normotensive on the floor. Her home
atenolol was stopped.
# Leukocytosis: By arrival to the floor, pt had completed 8 day
course of abx for VAP and 5 day fluconazole course for fungal
UTI as above. C diff neg x6 (last three sent recently given
persistent leukocytosis), stool cultures negative, sputum only
with sparse yeast. She did not have paracentesis due to minimal
ascites. L LENI negative for DVT. Repeat UA negative. Her WBC
trended down in setting of resolving acute alcoholic hepatitis
and taper of steroids. WBC [**12-25**] at discharge was likely due to
prednisone.
# Epigastric pain - Likely indigestion. Improved with maalox.
Exam unremarkable and abdomen nontender. It is not associated
with food and amylase/lipase normal making pancreatitis less
likely. It improves with ambulation, so unlikely to be cardiac
and EKG during episodes were unchanged from prior.
# Loose stools - Pt had frequent loose stools, most likely in
setting of antibiotics received in ICU. All stool cultures and C
diff negative. Her stools became more formed and her lactulose
was resumed at 15mL daily.
# ETOH abuse - Pt had discussions with medical team and social
work and understood the consequences of continued use. She was
continued on thiamine. Folate and MVI included in nephrocaps. Pt
will require close follow up for relapse prevention. Her
boyfriend [**Name (NI) **] is a good source of support.
# Depression - Pt was on zoloft on admission, which was held
because all SSRIs are hepatically cleared. Pt has h/o recent
suicide attempt. Zoloft 50mg daily restarted [**5-20**] and can be
uptitrated as outpatient. Her mood remained stable during her
hospitalization.
Medications on Admission:
Home Medications:
Atenolol 50 mg PO daily
Librium dose [**Last Name (un) 5487**]
Prilosec OTC
Zoloft 25 mg PO daily
Campral prn
.
Medications on Transfer:
Lactulose 30 mL PO/NG TID titrate to [**4-17**] BMs per day
Ondansetron 4 mg IV Q8H:PRN nausea
Rifaximin 400 mg PO/NG TID
Thiamine 100 mg PO/NG DAILY
FoLIC Acid 1 mg PO/NG DAILY
Multivitamins 1 TAB PO/NG DAILY
Pantoprazole 40 mg PO Q12H
Sarna Lotion 1 Appl TP QID:PRN itching
Octreotide Acetate 200 mcg SC Q8H
Midodrine 12.5 mg PO TID
Phytonadione 10 mg PO/NG DAILY Duration: 3 Days
Lorazepam 0.5 mg PO/NG Q6H:PRN CIWA > 10
Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN vaginal/groin fold
irritation
Albumin 25% (12.5g / 50mL) 100 g IV DAILY Duration: 2 Days
please give 100grams of albumin (1g/kg) on [**4-22**] and [**4-23**]
Vancomycin 1000 mg IV X1 Duration: 1 Doses
CeftriaXONE 2 gm IV Q24H Start: Stat
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simethicone 40 mg Strip Sig: [**1-14**] strips PO four times a day
as needed for indigestion.
Disp:*60 strips* Refills:*1*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for itching, anxiety.
6. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY
(Daily): HOLD if you are having more than 5 loose bowel
movements a day. This medication if very important to prevent
confusion.
Disp:*450 ML* Refills:*2*
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
8. Maalox 200-200-20 mg/5 mL Suspension Sig: 5-10 MLs PO QID (4
times a day) as needed for indigestion.
Disp:*300 ML(s)* Refills:*0*
9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO BID (2 times
a day) as needed for pain: Do not take more than 4 tablets
(1300mg) a day.
11. Prednisone 10 mg Tablet Sig: As directed Tablet PO once a
day for 17 days: 2 tablets (20mg) daily x 3 days ([**Date range (1) 86872**]);
1 tablet (10mg) daily x 7 days ([**Date range (1) 86873**]); 0.5 tablets (5mg)
daily x 7 days ([**Date range (1) 86874**]); then STOP.
Disp:*17 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Acute alcoholic hepatitis
Alcoholic cirrhosis
Acute renal failure progressing to chronic kidney disease,
requiring dialysis
Disseminated Intravascular Coagulopathy
Acute repiratory failure
Anemia
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:
Ms. [**Known lastname **], you were admitted to [**Hospital1 18**] with inflammation of your
liver due to alchol use (acute alcoholic hepatitis) and found to
have scarring of your liver (cirrhosis) from long term drinking.
You required a lengthy stay in the intensive care unit for
mental status changes and developed kidney injury requiring
dialysis. Your health has significantly improved since your
admission. Your liver function will continue to improve with
time, increased nutrition, and abstinence from alcohol.
Continued improvement in your health will be dependent on you.
It is VERY important that you no longer drink any alcohol. When
you see your primary care doctor, you should talk to her about
ways to help you abstain from alcohol. You had extensive
nurition counseling in the hospital about things you should eat
to ensure adequate calorie intake. You did well with physical
therapy, which will continue as an outpatient to help you get
stronger. It is also very important that you keep all your
follow up appointments with your primary care doctor, your
kidney doctor and the liver specialists.
You have been started on many new medications. Please see your
discharge medication list for the new medications. Please take
all of them exactly as prescribed.
Your prednisone taper is as follows:
Prednisone 10 mg tablets:
Take 2 tablets (20mg) daily x 3 days ([**5-23**] - [**2147-5-25**])
Take 1 tablet (10mg) daily x 7 days ([**5-26**] - [**2147-6-1**])
Take [**1-14**] tablet (5mg) daily x 7 days ([**6-2**] - [**2147-6-8**])
Then STOP.
Changes to your prior medications:
1. STOP Atenolol - your blood pressure is now low due to your
liver disease.
2. STOP Librium - you no longer need this medication
3. CONTINUE Prilosec (Omeprazole) 20 mg twice a day- we have
given you a prescription for this medication.
4. INCREASE Zoloft to 50mg daily
5. STOP Campral. Discuss with your primary care doctor if you
should continue this medication.
It was a pleasure taking care of you during your stay!
Followup Instructions:
Primary Care Doctor
Name: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 34405**]
Friday [**2147-5-26**] at 11:10AM
[**Location (un) **]- [**Location (un) **] Dialysis Center
330 [**Last Name (un) 69155**] Industrial [**First Name9 (NamePattern2) 86875**]
[**Location (un) **], [**Numeric Identifier 18367**]
Tel: [**Telephone/Fax (1) 26161**]
Nephrologist: Dr. [**Last Name (STitle) 9419**]
Confirmed to begin outpt HD on Wednesday, [**2147-5-24**] at 4:00pm
Outpt HD scheduled will be every Mon., Wed., & Fr. at 4:30pm.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD
Phone: [**Telephone/Fax (1) 2422**]
Date/Time: [**2147-6-8**] 3:00
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **] LIVER CENTER
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
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288, 531
|
20826, 20826
|
3340, 3725
|
23048, 24148
|
2064, 2088
|
18889, 20512
|
20607, 20805
|
17995, 17995
|
21009, 23025
|
2103, 3321
|
18013, 18125
|
229, 250
|
559, 1631
|
20841, 20985
|
18150, 18866
|
1653, 1889
|
1905, 2048
|
3737, 8789
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,522
| 191,482
|
2269
|
Discharge summary
|
report
|
Admission Date: [**2174-12-5**] Discharge Date: [**2174-12-13**]
Date of Birth: [**2140-2-19**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient admitted for weight reduction surgery
Major Surgical or Invasive Procedure:
Status Post Laparoscopic Gastric Bypass with Revision for
Ischemic roux limb.
History of Present Illness:
[**Known firstname **] has class III morbid obesity with weight of 234.2 pounds
as of [**2173-11-25**] (initial screen weight on [**2173-10-18**] was 230.2
pounds), height of 62.5 inches and BMI of 42.2. Her previous
weight loss efforts have included couple of months of Diet
Workshop in [**2171**] without results, 5 months of Weight Watchers in
[**2170**] losing 10 pounds and two months Slim-Fast without
significant results. She had been prescribed prescription
weight
loss medication Xenical but stopped secondary to no results. She
has not taken over-the-counter ephedra-containing appetite
suppressants, dietary aids or herbal supplements. She states
she
has had a significant [**Last Name 4977**] problem since a very young age and
cites as factors contributing to her excess weight large
portions, inconsistent meal schedules, too many fats and
carbohydrates, emotional and compulsive eating as well as lack
of
exercise regimen although she tries to walk for 30 minutes 4
times a week. She denied history of eating disorders or
depression.
Past Medical History:
Polycystic ovary disease, superficial
thrombophlebitis, obstructive sleep apnea on CPAP, dyslipidemia,
bilateral carpal tunnel syndrome, and knee and back pain.
Social History:
She has no known drug or food allergies. She
denied tobacco, or recreational drug usage, has one to two
alcoholic beverages occasionally and drinks 1 cup of coffee
daily
and a can of soda 2-3 times a week. She is
employed as a manager in the travel industry business. She is
married living with her husband age 34 and they have no
children.
Family History:
Her family history is noted
for father living with hyperlipidemia; Grandfather deceased with
diabetes and grandmother with history of arthritis.
Physical Exam:
Her blood pressure was 121/87, pulse 75 and O2 saturation 100%
on
room air. On physical examination [**Known firstname **] was casually dressed,
pleasant and in no apparent distress. Her skin was warm, dry
with no rashes, mild acne and mild facial hirsutism with
moderate
hirsutism on chest/abdomen as well as the extremities. Sclerae
were anicteric, conjunctiva clear, pupils were equal round and
reactive to light, fundi were normal with sharp optic disks,
moist mucous membranes, time was pink and the oropharynx was
without exudates or hyperemia. Trachea was in the midline and
the neck was supple with no adenopathy, thyromegaly or carotid
bruits. Chest was symmetric and the lungs were clear to
auscultation bilaterally with good air movement. Cardiac exam
was regular rate and rhythm with normal S1 and S2, no murmurs,
rubs or gallops. The abdomen was obese but soft and non-tender,
non-distended with good bowel sounds activity, no organomegaly
or
appreciable masses, there were well-healed trocar scars and no
hernias. There was no spinal tenderness or flank pain. Lower
extremities were without edema, venous insufficiency or
clubbing.
There was no evidence of joint swelling/inflammation.
Neurologically there were no focal deficits and gait was normal.
Pertinent Results:
[**2174-12-7**] 01:38PM BLOOD WBC-8.6 RBC-3.46* Hgb-11.3* Hct-31.2*
MCV-90 MCH-32.7* MCHC-36.3* RDW-13.4 Plt Ct-188
[**2174-12-8**] 03:30AM BLOOD WBC-10.1 RBC-2.43*# Hgb-7.9*# Hct-21.5*
MCV-89 MCH-32.5* MCHC-36.7* RDW-14.2 Plt Ct-150
[**2174-12-11**] 06:51PM BLOOD WBC-12.0* RBC-3.60*# Hgb-10.9* Hct-31.2*
MCV-87 MCH-30.2 MCHC-34.8 RDW-15.7* Plt Ct-298
[**2174-12-12**] 08:06AM BLOOD Hct-32.1*
[**2174-12-6**] 11:00AM BLOOD Plt Ct-330
[**2174-12-7**] 11:36AM BLOOD PT-17.3* PTT-33.1 INR(PT)-1.6*
[**2174-12-8**] 03:30AM BLOOD PT-18.5* PTT-38.2* INR(PT)-1.7*
[**2174-12-11**] 06:51PM BLOOD Plt Ct-298
[**2174-12-7**] 06:30AM BLOOD Glucose-79 UreaN-8 Creat-0.9 Na-138 K-3.8
Cl-101 HCO3-25 AnGap-16
[**2174-12-8**] 03:30AM BLOOD Glucose-169* UreaN-11 Creat-0.7 Na-134
K-4.0 Cl-107 HCO3-24 AnGap-7*
[**2174-12-11**] 06:51PM BLOOD Glucose-104 UreaN-6 Creat-0.6 Na-137
K-3.8 Cl-104 HCO3-29 AnGap-8
[**2174-12-7**] 06:30AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.6
[**2174-12-8**] 03:30AM BLOOD Calcium-6.7* Phos-2.1* Mg-2.0
[**2174-12-11**] 06:51PM BLOOD Calcium-7.8* Phos-2.5* Mg-1.9
[**2174-12-7**] 09:28AM BLOOD Type-ART pO2-107* pCO2-32* pH-7.47*
calTCO2-24 Base XS-0
[**2174-12-7**] 05:06PM BLOOD Type-ART pO2-197* pCO2-34* pH-7.38
calTCO2-21 Base XS--3
[**2174-12-8**] 07:35AM BLOOD Type-ART pO2-167* pCO2-34* pH-7.43
calTCO2-23 Base XS-0
[**2174-12-7**] 09:28AM BLOOD Glucose-103 Lactate-1.0 Na-132* K-3.4*
Cl-99*
[**2174-12-7**] 01:51PM BLOOD Glucose-132* Lactate-0.9 Na-132* K-4.1
Cl-105
[**2174-12-8**] 07:35AM BLOOD Glucose-80 Lactate-0.7
[**2174-12-7**] 09:28AM BLOOD freeCa-1.05*
[**2174-12-8**] 07:35AM BLOOD freeCa-1.02*
Brief Hospital Course:
Patient admitted and underwent a laparoscopic gastric bypass.
During the postoperative course patient was noted to be febrile
and tachycardic on day 2. She was taken back to the operating
room with Intra-abdominal sepsis and
Postoperative ischemic Roux limb found. Bleeding from the spleen
was also identified and repaired. She was monitored in the
intensive care unit for 2 days and when stable was transferred
back to the floor.
Her vital signs are completely stable. She remains afebrile with
a last hematocrit of 32.1. She was slowly progressed to a stage
3 diet and is tolerating that well. Her pain is well controlled
on oral roxicet. We will send her home today with VNA to follow
up on her abdominal wound and g-tube care teaching. She will
follow up in the bariatric clinic on [**2174-12-28**]. She has been
instructed on her new medications, will continue her cpap at
home and follow up with her primary care provider as well.
Medications on Admission:
MVI
Discharge Medications:
1. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day: Please
take for one month.
Disp:*600 ml* Refills:*0*
2. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day as
needed for constipation.
Disp:*500 ml* Refills:*0*
3. Roxicet 5-325 mg/5 mL Solution Sig: [**4-30**] ml PO every four (4)
hours as needed for pain.
Disp:*500 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
Primary Diagnosis: Obesity
Discharge Condition:
Stable
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance
diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a Flintstones chewable complete
multivitamin. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
Activity:
No heavy lifting of items [**10-5**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], RD,LDN Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2174-12-28**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2174-12-28**] 2:45
Completed by:[**2174-12-13**]
|
[
"997.4",
"256.4",
"327.23",
"557.0",
"E878.2",
"998.11",
"278.01",
"285.1",
"272.4",
"V85.4",
"724.2",
"719.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"44.5",
"99.04",
"39.98",
"44.38",
"43.19"
] |
icd9pcs
|
[
[
[]
]
] |
6558, 6628
|
5191, 6131
|
360, 440
|
6699, 6708
|
3544, 5168
|
8553, 8890
|
2088, 2234
|
6185, 6535
|
6649, 6649
|
6157, 6162
|
6756, 7322
|
2249, 3525
|
275, 322
|
8196, 8530
|
468, 1522
|
6668, 6678
|
7347, 8184
|
1544, 1708
|
1724, 2072
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,557
| 190,038
|
37419
|
Discharge summary
|
report
|
Admission Date: [**2148-11-11**] Discharge Date: [**2148-11-14**]
Date of Birth: [**2086-2-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
bleeding gastric varices
Major Surgical or Invasive Procedure:
TIPS procedure with direct portal vein access on [**2148-11-11**]
History of Present Illness:
62 yo F with cirrhosis transferred from OSH with bleeding
gastric varices for evaluation for TIPS. Patient has a hsitroy
of gastric banding 6 months ago for coffee ground emesis. She
was initially admitted to [**Hospital6 3105**] on [**2148-11-7**]
with vomiting and mild associated hemetemesis. She was started
on an IV Protonix and had an upper endoscopy on [**11-9**] that
showed chronic esophageal varicles an gastric varix with a
vessel, and and a duodenal ulcer. that was not banded at the
time due to hemodynamic stability. Pt continued to have coffee
ground emesis and dark melanotic stools (which progressed to
BRBPR), with nadir of Hct to 24 while at OSH. Was transferred to
the ICU on [**11-11**]. Had a repeat EGD on [**11-11**] which showed an
actively bleeding gastric varix that obscured vision. Patient
was intubated for airway protection and transferred to the [**Hospital1 18**]
for emergent TIPS.
.
On admission to the MICU, patient was intubated and sedated.
Admission VS were 76 138/59 100% on vent.
.
ROS: Unable to obtain due to sedation.
Past Medical History:
1. Cirrhosis due to EtOH use
2. Osteoporosis
3. Fractured pelvis
4. GERD
5. Alopecia
6. Gallstones
Social History:
on disability ([**12-26**] cig/day xmany years) current smoker (1 pack
Q3-4 days, smoking for 38 years). previous history of EtOH
abuse, but has not had a drink for 2-3 years. lives with husband
Family History:
No history of liver or gastrointestinal disease.
Physical Exam:
On admission
Vitals - T: BP: 138/59 HR: 76 RR: 02 sat:
GENERAL: intubated, sedated
HEENT: PERRLA. MMM.
CARDIAC: RRR S1/S2 present no m/g/r
LUNG: ventilated breath sounds
ABDOMEN: soft, NT +BS
EXT: wwp no edema
NEURO: sedated
LINES: gross blood noted from rectal flexiseal
On transfer from MICU
Vitals - T: 98.1 BP: 132/60 HR: 86 RR: 17 02 sat: 98% on 2L NC
GENERAL: NAD
HEENT: PERRLA. MMM. No LAD. No icterus.
CARDIAC: regular rate, nl S1/S2, III/VI SEM at LUSB
LUNG: crackles to mid lung fields bilaterally
ABDOMEN: soft, NT +BS. site of TIPS c/d/i
EXT: wwp no edema
NEURO: No asterixis, AAOx3
Pertinent Results:
Labs on admission:
[**2148-11-11**] 03:19PM WBC-5.9 RBC-4.43 HGB-14.1 HCT-38.9 MCV-88
MCH-31.9 MCHC-36.3* RDW-17.1*
[**2148-11-11**] 03:19PM NEUTS-79.8* LYMPHS-14.2* MONOS-4.0 EOS-1.8
BASOS-0.1
[**2148-11-11**] 03:19PM PLT SMR-VERY LOW PLT COUNT-51*
[**2148-11-11**] 03:19PM PT-18.3* PTT-36.5* INR(PT)-1.7*
[**2148-11-11**] 03:19PM FIBRINOGE-128*
[**2148-11-11**] 03:19PM ALBUMIN-2.6* CALCIUM-7.0* PHOSPHATE-3.0
MAGNESIUM-1.6 IRON-199*
[**2148-11-11**] 03:19PM ALT(SGPT)-17 AST(SGOT)-27 CK(CPK)-76 ALK
PHOS-70 TOT BILI-5.6*
[**2148-11-11**] 03:19PM CK-MB-NotDone cTropnT-<0.01
[**2148-11-11**] 03:19PM GLUCOSE-124* UREA N-12 CREAT-0.7 SODIUM-142
POTASSIUM-4.5 CHLORIDE-114* TOTAL CO2-21* ANION GAP-12
[**2148-11-11**] 07:00PM WBC-6.4 RBC-3.61* HGB-11.3* HCT-31.6* MCV-87
MCH-31.2 MCHC-35.7* RDW-17.1*
[**2148-11-11**] 07:03PM GLUCOSE-111* LACTATE-1.2 NA+-139 K+-3.9
CL--109
[**2148-11-11**] 09:34PM HGB-11.0* calcHCT-33
Micro:
[**2148-11-12**] MRSA SCREEN MRSA SCREEN-NEGATIVE
[**2148-11-11**] MRSA SCREEN MRSA SCREEN-NEGATIVE
[**2148-11-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
Brief Hospital Course:
62 yo F with cirrhosis and bleeding gastric varices transferred
from OSH for emergent TIPS, now with stable HCT and vitals.
.
# GI bleed [**12-25**] Esophageal varices: Pt was transferred for TIPS
and procedure on [**11-11**] was complicated by difficulty cannulating
jugular and ultimately required direct portal vein access
through the abdominal wall. She had a therapeutic paracentesis
(2L removed) and underwent TIPS followed by foam packing and
surgicel.
Pt was brought back to the MICU and was extubated on [**11-12**]
without incident. Octreotide was weaned on [**11-12**] and PPI gtt
was transitioned to [**Hospital1 **] on [**11-13**]. Pt received 3 units of prbcs
on [**11-11**] prior to transfer and she has received FFP x 2, 1 unit
of plts since arrival to [**Hospital1 18**]. Her hct has remained stable in
the low 30s and SBP>110s throughout her stay. Started IV
ceftriaxone on [**11-11**], switched to ciprofloxacin on [**11-14**] and
needs to be continued for total seven day course until [**11-18**].
Patient will have RUQ ultrasound to evaluate TIPS on [**11-18**] as
well. Discharged on [**Hospital1 **] protonix as well.
.
# Mild pulmonary edema: Patient had not had her regular
spironolactone since day of presentation to OSH, and developed
crackles on exam on [**11-13**]. Lasix and spironolactone were given
for further diuresis. She was saturating 100% on room air and
had a stable ambulatory sat. She was coughing up some mucous
prior to discharge, but no evidence of pneumonia.
.
# Cirrhosis [**12-25**] ETOH use: Patient is s/p paracentesis with two
liters off on [**2148-11-11**]. Patient is unknown to our system,
unclear if she is a transplant candidate though it does seem
that she has not had ETOH in over one year. Patient discharged
on home spironolactone dose. Also discharged on lactulose TID in
light of increased susceptibility for encephalopathy given TIPS.
Spoke with outpatient hepatologist, who would like her
evaluated for transplant here at [**Hospital1 18**]. She is scheduled for f/u
as below.
Medications on Admission:
Prilosec 40 mg PO daily
Vitamin D 5000 U IV weekly
MVI
Spiranolactone 25 mg PO PRN
Lactulose 10 grm/15 ml [**Male First Name (un) **] as needed
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three
times a day: Titrate to [**1-25**] bowel movements per day.
Disp:*3600 ML(s)* Refills:*2*
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 3 days: take through [**2148-11-17**].
Disp:*6 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
6. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Upper GI bleed secondary to Esophageal Varices
SECONDARY DIAGNOSIS:
1. End Stage Liver Disease secondary to Alcohol
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2148-11-11**] after being transferred
from another hospital for GI bleeding. The blood vessel could
not be easily stopped from bleeding, so you had a TIPS
procedure. Because of the TIPS, you will be prone to becoming
more confused from your liver disease. For this reason is is
ESSENTIAL that you take your lactulose everyday as prescribed.
You also need to take an antibiotic called ciprofloxacin twice a
day until [**2148-11-17**] to protect from infection.
While you were here, you also had a cough. We did a chest XRAY
which showed some fluid. We gave you some extra medicine to take
the fluid off, and you should continue your spironolactone
diuretic when you leave.
Please make the following medication changes:
STOP omeprazole, take pantoprazole twice a day instead.
START ciprofloxacin until [**2148-11-17**].
START lactulose three times a day.
Followup Instructions:
You will have an ultrasound on Monday, [**11-18**] at 1pm in the
[**Hospital Ward Name **] Clinical Center [**Location (un) 470**]. Please do not have
anything to eat for 6 hrs prior to the procedure.
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2148-11-25**] 10:00
Please also follow up with your regular hepatologist, Dr.
[**Last Name (STitle) 84113**] at [**Hospital3 **].
|
[
"578.9",
"537.89",
"532.90",
"789.59",
"286.6",
"303.90",
"571.2",
"733.00",
"456.8",
"530.81",
"456.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"54.91",
"39.1"
] |
icd9pcs
|
[
[
[]
]
] |
6623, 6629
|
3682, 5733
|
342, 410
|
6812, 6812
|
2541, 2546
|
7883, 8352
|
1853, 1903
|
5927, 6600
|
6650, 6650
|
5759, 5904
|
6957, 7703
|
1918, 2522
|
7723, 7860
|
278, 304
|
438, 1502
|
6741, 6791
|
6669, 6720
|
2561, 3659
|
6826, 6933
|
1524, 1625
|
1641, 1837
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,953
| 169,748
|
40378
|
Discharge summary
|
report
|
Admission Date: [**2179-1-25**] Discharge Date: [**2179-2-7**]
Date of Birth: [**2116-11-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Cefazolin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
collapse while cleaning snow off of car
Major Surgical or Invasive Procedure:
[**2179-1-27**] cerebral angiogram
History of Present Illness:
HPI:
64F (right handed) who was shoveling snow and per witness
account
patient collapsed. She was brought to an OSH where a Head CT
revealed a large SAH. Per OSH ER report, patient was nonfocal
and
being given Dilantin and being transferred to [**Hospital1 18**] ER for
further Neurosurgical evaluation. On arrival, patient was
intubated and sedated. Per EMS report, at OSH she became more
lethargic and was sedated and given Vex, intubated.
Past Medical History:
PMHx:
High Cholesterol
Hypothyroidism
Neck surgery during childhood
Social History:
Social Hx:
Married, lives with husband. [**Name (NI) **] at bedside. Previous smoker but
quit 6 months ago. No ETOH. No recreational drugs. Works for the
courthouse.
Family History:
Family Hx:
Unknown
Physical Exam:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 3 [**Doctor Last Name **]: 3
GCS E: 1 V: 1 Motor: 4 = 6 (on arrival)
GCS E: 3 V: 1 Motor: 5 = 9 (post CTA, off sedation)
O: T: 98.1 BP: 127/86 HR: 89 R 9 O2Sats 97% ETT
Gen: Intubated
HEENT: normocephalic
Extrem: Warm and well-perfused. L wrist bruising.
Neuro:
Initial Exam on arrival: No EO, no commands, nonverbal,
withdrawing all 4 extremities to noxious stim. PERRL. +
cough/gag
Repeat Exam off sedation: Weak EO to loud voice, no verbal, no
commands, BUE localizes to noxious, BLE withdraw to noxious.
UPON DISCHARGE:
non-focal
sutures at VP Shunt site
Pertinent Results:
Head CT [**2179-1-25**]:
Extensive SAH along the suprasellar cistern, sylvian fissures,
paramedian frontal lobes. No midline shift, no herniation.
Ventricles appear slightly dilated. There is minimal layering of
hyperdense blood within the occipital horns and fourth
ventricle.
Head CTA [**2179-1-25**]:
1.Large SAH in the suprasellar cistern, bilateral sylvian
fissure and
paramedian frontal sub arachnoid spaces.
2. 5 mm ACOM aneurysm. The remainder of the anterior and
posterior circulation is unremarkable. No vessel occlusion or
stenosis.
Head CT [**2179-1-26**]:
IMPRESSION:
1. New right frontal approach ventricular shunt catheter ends in
the right
lateral ventricle. Mild interval decrease in the size of the
ventricles.
Minimal pneumocephalus, right frontal scalp swelling and
emphysema relate to the recent procedure
2. Stable appearance of the extensive subarachnoid hemorrhage
R Shoulder Xray [**2179-1-26**]:
No fractures
CXR [**2179-1-31**]:
FINDINGS: The endotracheal tube and feeding tube have been
removed since the previous study. The cardiac silhouette is
upper limits of normal.
Atelectasis is at the left base remains, however, the
atelectasis of the right base has resolved. There is no focal
consolidation or pleural effusion.
CTA Head [**2179-2-2**]:
1. Decreasing conspicuity of diffuse subarachnoid hemorrhage
compared to
[**2179-1-25**].
2. No hydrocephalus. Right intraventricular drain remains in
place.
3. Patient is status post coiling of anterior communicating
artery aneurysm.
[**2179-2-5**]: CT HEAD: IMPRESSION: Newly placed ventriculoperitoneal
shunt taking a right frontal approach with its tip terminating
in the frontal [**Doctor Last Name 534**] of the right lateral ventricle. There is no
acute intracranial hemorrhage, and no mass effect.
Brief Hospital Course:
Pt was admitted to the hospital via transfer from OSH after
imaging revealed SAH. She was intubated for the transfer. Her
exam was limited on arrival due to sedation for intubation. An
EVD was placed.
Her exam improved and a diagnostic cerebral angiogram was
performed the following am. Her ACOMM aneurysm was coiled and
she was on Aspirin and a heprain drip. She was extubated in the
early evening of [**1-26**]. She had an ICP elevation to 28 and her
EVD was opened. She was oriented and MAE to command.
On [**1-27**] rounds her exam was nonfocal and her EVD was clamped
but required it to be reopened on [**1-27**] eve.
A right shoulder X-ray was done due to pain after her fall on
[**1-27**] and this showed no fracture. On [**1-28**] she reported
improved shoulder pain.
On [**1-28**] the EVD was clamped again but required to be reopened.
Early [**1-29**] she spiked a fever and cultures were sent.
On [**1-30**], the patient exam was oriented to person place and time,
the motor and sensation exam was full, the left upward drift was
unchanged from prior exams. The patient complained of headache
that was worse with exposure to light. She reported that this
was consistent with her regular migraines that she has a history
of. A EVD clamping trial was performed and the patients ICP
elevated to 30 and the EVD was opened to drainage at 20 H2O cm.
The patient was febrile to 101.7 and a CSF sample was sent for
culture which have shown no growth to date. Blood and Urine was
sent for culture as well.
On [**2-1**] she was febrile again and cultures were sent with no
growth noted to date. Dilantin was discontinued.
On [**2-2**] a CTA head was done as patient's affect appeared altered.
The CTA was stable and showed no vasospasm. On [**2-3**] patient was
to go to OR for placement of a VP shunt but after checking her
INR her case was cancelled as her INR came back as 4.6 and 5.2
on repeat. LFTs were checked which were normal. Medicine was
consulted and Hematology was also consulted. She was given
Vitamin K 5mg PO x1 and her INR trended down to 2. Mixing
studies and a Factor VII level was sent. Her EVD was clamped
again in attempt to challenge her but she had increased ICPs and
headache late [**2-4**] and her drain was unclamped. On [**2-4**] her INR
was 1.4 on morning labs. Medicine and Heme felt her elevated INR
was from a Vit K deficiency and Cefazolin. She was ordered to
receive two additional doses of Vit K.
On [**2-5**] the patient was taken to the OR for VP Shunt placement.
This was done without complication. Post operatively she
returned to the floor. CT scan revealed good shunt placement.
On [**2-6**] & [**2-7**] she remained neurologically stable. She worked with
physical and occupational therapy who cleared her for discharge
home.
Medications on Admission:
Bupropion SR 150mg [**Hospital1 **]
Levothyroxine 75mcg Daily
Pravastatin 80mg Daily
Discharge Medications:
1. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-31**]
Tablets PO Q4H (every 4 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acomm Aneurysm
SAH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
* Please call the office of Dr. [**First Name (STitle) **] [**Telephone/Fax (1) **] for an
appointment to be seen in 4 weeks. You will need an MRI/MRA
before this appointment.
* You have sutures that need to be removed approximately on
[**2-15**]. These can be removed by your PCP. [**Name10 (NameIs) **] they have questions
or problems please call the office at [**Telephone/Fax (1) 1669**]
Completed by:[**2179-2-7**]
|
[
"244.9",
"430",
"272.0",
"269.0",
"435.9",
"331.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.34",
"88.41",
"02.39",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
7044, 7050
|
3620, 6401
|
312, 349
|
7113, 7113
|
1808, 3340
|
9275, 9698
|
1113, 1134
|
6537, 7021
|
7071, 7092
|
6427, 6514
|
7263, 8333
|
8359, 9252
|
1164, 1737
|
233, 274
|
1753, 1789
|
377, 821
|
3349, 3597
|
7128, 7239
|
843, 913
|
929, 1097
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,862
| 152,179
|
17503+17554+56862+56865+56871+56872
|
Discharge summary
|
report+report+addendum+addendum+addendum+addendum
|
Admission Date: [**2159-7-9**] Discharge Date: [**2159-7-15**]
Date of Birth: [**2104-2-11**] Sex: M
Service: MICU
CHIEF COMPLAINT: Alcohol withdrawal.
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
male with a history of panic attacks who came to the hospital
on [**2159-7-9**], for a preoperative arteriogram for a
scheduled left femoral popliteal bypass. While in the far
lobby the patient began to feel anxious and short of breath
accompanied by chills and uncontrollable shaking. The
patient denied chest pain, headache, nausea, vomiting or
abdominal pain. The patient denied lightheadedness. The
patient thought he was having a panic attack but did feel
that this was different than any prior panic attack that he
had had. The patient was taken to the Emergency Department
where he was noted to be diaphoretic, tachypneic and
tachycardic with a heart rate of 105, a respiratory rate of
28 and a temperature of 101.5 degrees. In addition, the
patient was extremely anxious. The patient was given 2 mg IV
of Ativan. Subsequently, the patient's blood pressure was
178/94 with a heart rate of 130, a respiratory rate of 32 and
an oxygen saturation of 92% on room air. The patient's heart
rate increased to 150's and his respiratory rate increased to
36. The patient became more agitated with slurred speech.
The patient received 10 mg of Valium and was given a
nonrebreather mask which he did not tolerate. The patient
was thought to be in alcohol withdrawal versus PE versus
myocardial infarction. The patient was taken for a CT
arteriogram of the chest to rule out pulmonary embolus which
showed no evidence of pulmonary embolus. The CT did show
evidence of tracheomalacia. At this time the patient's wife
admitted that the patient drinks one case of beer a day which
he stopped on Saturday. The patient received a total of 14
mg of Ativan and 40 mg of Valium plus 5 mg of droperidol and
20 mg of labetalol in the Emergency Room. The patient's
blood pressure rose of a value of 225/110. The patient also
received four liters of normal saline with a urine output of
100 cc. The patient was brought to the Medical Intensive
Care Unit where he continued to be tachypneic and tachycardic
and received 80 mg IV of Valium which had no effect. He then
received 120 mg of Valium. The patient continued to be
tachypneic and hypertensive with a systolic blood pressure of
150. He was therefore put on noninvasive positive pressure
ventilation at a pressure support of 20 and a PEEP of 8. The
patient's arterial blood gas on these settings was 7.39, 47
and 179. The patient continued to be febrile with a
temperature of 102.6, a heart rate of 130, a blood pressure
of 180/106 and a respiratory rate of 36 to 40. The patient
continued to require Valium 10 mg every 20 minutes in order
to maintain adequate anxiolytic effect. It was decided to
intubate the patient in order to achieved adequate sedation.
The patient was sedated with dexmedetomidine per Anesthesia
recommendation and intubated in the Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Bilateral carotid stenosis 100% on the left and 80% on
the right.
2. Hypertension.
3. Panic disorder.
4. Left leg claudication.
5. Tobacco use 60 pack year history, quit two years ago.
MEDICATIONS AT HOME:
1. Paxil.
2. Atenolol 50 mg b.i.d.
3. Xanax 0.25 mg p.r.n.
4. Pletal.
ALLERGIES: Penicillin causes hives.
SOCIAL HISTORY: The patient is a sales representatives,
married with no children.
PHYSICAL EXAMINATION ON ADMISSION: The patient's temperature
was 102.6 degrees, his heart rate was 130, blood pressure
184/106, respiratory rate 36 and oxygen saturation was 99% on
assist control ventilation. In general, the patient was
obese, now sedated on Ativan and Valium, with an erythematous
face, very diaphoretic. On head, eyes, ears, nose and
throat, the pupils equal, round and reactive to light and
accommodation. Extraocular movements intact. There were
moist mucus membranes. The patient was noted to have a thick
neck. The lung examination revealed clear lungs bilaterally.
The chest examination revealed tachycardia, regular rhythm
with no murmurs, rubs or gallops. The abdominal examination
revealed a soft distended belly with positive bowel sounds.
The extremity examination revealed no clubbing, cyanosis or
edema. Cool extremities bilaterally with a palpable dorsalis
pedis pulse on the right and a dopplerable dorsalis pedis
pulse on the left.
RADIOLOGY: Chest x-ray revealed a rib fracture of the fourth
rib of indeterminate age and presence of consolidation or
effusion at the left base that could not be excluded. Chest
CT angiogram showed no evidence of pulmonary embolus. It was
positive for dependent atelectasis. Negative for effusion.
It was also noted that the trachea and major bronchi
bilaterally demonstrated excessive collapsibility. There was
no mediastinal adenopathy. The heart was enlarged. There
were multiple rib fractures and the liver was noted to have
fatty infiltrates.
LABORATORY ON ADMISSION: Revealed white blood count of 8.6,
hematocrit 44.9, platelet count 305,000 with a differential
as follows: 87% neutrophils, 5% bands, 5% leukocytes, 1%
monocytes, 2% eosinophils. The PT was 13.9, INR 1.3, PTT
24.2. Sodium 135, potassium 4.4, chloride 93, bicarb 30, BUN
11, creatinine 1.0, glucose 157, anion gap 16. Urinalysis
revealed pH 7.0, specific gravity of 1.010, negative nitrite,
negative leukocyte esterase, negative ketones, negative
glucose, no red blood cells and no white blood cells.
Arterial blood gas revealed a pH of 7.36, pCO2 of 46, paO2 of
74. Blood cultures and urine cultures were taken at this
time.
HOSPITAL COURSE:
1. Alcohol withdrawal: The patient required very large
amounts of benzodiazepines on admission for withdrawal. The
patient received 260 mg of Valium in his first six hours in
the Medical Intensive Care Unit and was, therefore, intubated
and sedated with an Ativan infusion dexmedetomidine. On [**7-10**] the patient was put on a standing Valium in order to wean
the Ativan infusion. Initially the patient did well,
however, he became very agitated on the 9th requiring 280 mg
of Valium in six hours and 420 mg of Valium in 12 hours plus
55 mg of Ativan. At this time Pharmacy was consulted and it
was decided to discontinue the dexmedetomidine and start
propofol for proper sedation. In addition, the Ativan drip
was changed to a Versed drip to avoid renal toxicity that is
associated with Ativan. Toxicology consult was obtained
which recommended using phenobarbital as a long acting [**Doctor Last Name 360**]
with Valium as needed and propofol as needed while the
patient was still febrile. The patient received 500 mg of
phenobarbital q. 8h. starting on [**7-12**] and continuing
until [**7-15**]. We were able to discontinue the Versed drip
on [**7-12**]. The patient was still requiring Valium 60 mg
IV q. 4h. In addition, a labetalol drip was started on [**7-13**] as it was determined that the patient's labile blood
pressure was due partly to withdrawal symptoms and partly to
underlying hypertension. Phenobarbital levels on [**7-14**]
were 19.7, below the toxic range. On [**7-15**] the propofol
was able to be weaned and the patient remained on
phenobarbital and Valium. It is anticipated that the patient
will not need additional doses of phenobarbital and will
self-taper the phenobarbital dose.
2. The patient was persistently febrile since admission with
temperatures of 102.6 to 101.8. On [**7-11**] culs from [**7-9**] and [**7-10**] came back positive for Gram negative rods
growing in the anaerobic bottle. The patient was started on
ciprofloxacin and gentamicin on the 9th but, the patient
continues to remain febrile on this drug regimen, therefore
an abdominal ultrasound was obtained to rule out biliary
obstruction. This study was nonconclusive so a HIDA scan was
ordered which showed no abnormalities of the gallbladder or
biliary tree. A follow-up abdominal CT showed an inflamed
appendix with a fluid collection consistent with perforated
appendicitis. A CT of the abdomen showed a fluid collection
in the right lower quadrant measuring 3 cm x 2.8 cm inferior
to the cecum in addition to a possible second fluid
collection of 1 cm adjacent to the terminal ileum, an 8 mm
tubular structure that could represent an inflamed appendix
was noted on reconstructed images. This was thought to be
consistent with perforated appendicitis. Surgery was
consulted and recommended antibiotic treatment with Flagyl,
gentamicin, levofloxacin and one dose of vancomycin which the
patient received on [**7-12**]. The patient was followed by
continued to spike fevers. Therefore, an abdominal CT was
repeated on [**7-15**] in order to evaluate for possible
abscess around the appendix which could be drained
surgically. In addition, sinus CT was obtained to rule out
other sources of fevers. At this time the blood cultures
came back positive for Clostridium non perfringens, non
septicum in one bottle and bacterial species in the other
bottle.
3. Respiratory: Initially the patient was hypoxic with a CT
angiogram on admission which showed no evidence of pulmonary
embolus but did show severe tracheomalacia of unclear
etiology. The patient was intubated for progressive hypoxia
for airway protection given his high benzodiazepine
requirement. The patient was initially given Lasix for some
findings of EHF on chest x-ray. The patient was switched to
pressure control ventilation on [**7-14**] as he was noted to
have some asynchronous breathing with the vent. Thereafter,
the patient was ventilated and oxygenating air. Thereafter,
the patient maintained good ventilation and oxygenation on
the ventilator. It is anticipated that when the patient is
no longer febrile and no longer in alcohol withdrawal, he
will be fairly simple to extubate.
4. Fluids, Electrolytes and Nutrition: The patient was
started on tube feeds on [**7-12**] with thiamine, folate,
insulin, heparin and ranitidine in the tube feeds. The
patient was kept NPO due to his appendicitis.
5. Hypertension: The patient continued to have labile blood
pressure during his MICU stay with blood pressures rising to
200/110 usually late at night and in the early morning. The
patient was initially treated with Valium as it was thought
that the hypertension was secondary to withdrawal but then
the patient was switched over to a labetalol drip for blood
pressure control as it was thought that his hypertension was
more long-standing in origin. On [**7-15**], the patient was
switched to a clonidine patch and labetalol was weaned. The
patient had an echocardiogram on admission which was limited
due to the patient's size but showed a normal sized left
ventricle with normal systolic function. The patient had had
a preoperative cardiac Persantine ETT and cardiac perfusion
scan. These were also limited studies due to the patient not
achieving his goal heart rate. In addition, the cardiac
perfusion scan showed an enlarged left ventricle with a
calcified left ventricular end diastolic volume of 285 mL
with a moderate defect of 8, inferior wall that was a fixed
defect, a calculated left ventricular ejection fraction of
49%.
6. Renal: The patient's creatinine remained stable
throughout his hospital stay. He was given _________ before
any CT dye loads. The patient's acid based abnormalities on
admission resolved quite quickly when he was started on
ventilatory support.
MEDICATIONS ON DISCHARGE TO FLOOR:
1. Insulin sliding scale.
2. Albuterol ipratropium nebulizers q. 2h.
3. Metronidazole 500 mg IV q. 8h.
4. Levofloxacin 500 mg IV q. 24h.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 5615**]
MEDQUIST36
D: [**2159-7-15**] 16:49
T: [**2159-7-15**] 16:01
JOB#: [**Job Number 48861**]
Admission Date: [**2159-7-9**] Discharge Date: [**2159-8-28**]
Date of Birth: [**2104-2-11**] Sex: M
Service: Medical Intensive Care Unit, Green Team
ADDENDUM: This is an Addendum to a Discharge Summary
documenting hospital course through [**2159-8-27**]. This
Addendum will cover the hospitalization from [**8-27**]
through [**2159-8-28**]. Please see the previous Discharge
Summary for the full hospital course from [**Month (only) 205**] through [**8-27**].
HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED): The patient is
a 55-year-old gentleman with a past medical history
significant for severe peripheral vascular disease and
carotid artery stenosis and occlusion in the left carotid
artery who presented to [**Hospital1 69**]
on [**7-9**] for left lower extremity preoperative arteriogram
for ongoing claudication.
While in the Waiting Room for this procedure, the patient
went into alcohol withdrawal syndrome with delirium tremens
and was then taken to the Emergency Department.
The patient was subsequently admitted from the Emergency
Department to the Medical Intensive Care Unit. His
subsequent hospital course is documented per previous
Discharge Summary.
1. WITHDRAWAL SYNDROME ISSUES: The patient continued to
spike fevers but continued to have negative blood cultures.
No other fossae of infection was found. He had an ultrasound
of his left groin site which was negative for any localized
infection.
2. RESPIRATORY ISSUES: The patient's respiratory status
remained stable. He remained on 35% FIO2 via his
tracheostomy site.
3. CARDIOVASCULAR ISSUES: The patient remained stable. He
remained in a normal sinus rhythm and was continued on
metoprolol and amiodarone for his previous atrial
fibrillation. His blood pressure was well controlled, and
his ACE inhibitor was decreased to avoid any hypotension.
4. LEFT BELOW-KNEE AMPUTATION ISSUES: His left below-knee
amputation site continued to heal well with dressing changes
every other day. His last dressing change was on [**8-27**].
5. NEUROLOGIC ISSUES: Neurology continued to follow the
patient. He was started on Lipitor, Plavix, and aspirin
given his recent cerebrovascular accident.
Given his acute medical issues, a repeat carotid Doppler
imaging was not done while in the hospital. The patient was
to receive carotid Doppler studies as an outpatient within
one week and he was then to follow up with Neurology in one
month for further evaluation and possible plans for surgical
treatment of his carotid artery stenosis.
6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient
continued to be followed by Nutrition. He had a follow-up
Speech and Swallow study which showed no overt aspiration;
although a modified barium swallow was unable to be obtained
due to the patient not fitting in the scanner.
It was recommended that his diet continued to be advanced.
The patient was started on thin liquids and on ground solids
which he tolerated well.
7. PROPHYLAXIS ISSUES: He was continued on proton pump
inhibitors and Lovenox anticoagulation prophylaxis.
8. CODE STATUS: The patient remained a full code throughout
his hospitalization.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DIAGNOSES:
1. Delirium tremens/alcohol withdrawal.
2. Distal superficial femoral artery occlusion.
3. Near occlusion left common femoral artery.
4. Left lower extremity gangrene.
5. Respiratory failure.
6. Bacteremia.
7. Tracheomalacia.
8. Perforated appendix.
9. Peripheral vascular disease.
10. Carotid artery stenosis.
11. Right posterior frontal cerebrovascular accident.
12. Arterial line sepsis.
13. Ventilator-associated pneumonia.
14. Atrial fibrillation.
15. Hypertension.
PROCEDURE PERFORMED:
1. Fasciotomy of the left leg.
2. Aortogram, left lower extremity runoff.
3. Left below-knee amputation.
4. Tracheostomy.
5. Percutaneous gastrostomy placement.
6. Drainage of pericecal abscess.
7. Left common femoral endarterectomy.
8. Left superficial femoral artery thrombectomy.
9. Magnetic resonance imaging of the head.
10. Computed tomography scan of the abdomen.
11. Speech and Swallow evaluation.
12. Ultrasound of the left groin.
13. Multiple chest x-rays.
MEDICATIONS ON DISCHARGE:
1. Captopril 6.25 mg by mouth three times per day.
2. Lasix 80 mg by mouth once per day.
3. Olanzapine 2.5 mg by mouth q.a.m.
4. Lovenox 100 mg subcutaneously q.12h.
5. Levaquin 500 mg by mouth q.24h. (times two days).
6. Fentanyl patch 25 mcg transdermally q.72h.
7. Multivitamin 5 mL by mouth once per day (via feeding
tube).
8. Olanzapine 5 mg by mouth q.h.s.
9. Metoprolol 100 mg by mouth three times per day.
10. Amiodarone 400 mg by mouth twice per day.
11. Zinc sulfate 220 mg by mouth every day.
12. Linezolid 600 mg by mouth q.12h. (times 2.5 days).
13. Senna two tablets by mouth twice per day as needed.
14. Bisacodyl 10 mg per rectum once per day as needed.
15. Ibuprofen 400 mg by mouth q.8h. as needed.
16. Albuterol/ipratropium inhaler 6 to 8 puffs inhaled q.4h.
17. Tylenol 325 mg to 650 mg by mouth q.4-6h. as needed.
18. Lansoprazole 30 mg by mouth once per day.
19. Colace 200 mg by mouth three times per day.
20. Miconazole powder 2% twice per day as needed.
21. Nystatin oral suspension twice per day as needed.
22. Lipitor 10 mg by mouth once per day.
23. Aspirin 81 mg by mouth once per day.
24. Plavix 75 mg by mouth once per day.
ALLERGIES: VANCOMYCIN.
DISCHARGE INSTRUCTIONS ON DISCHARGE:
1. Dressing changes to left below-knee amputation site every
other day (last changed on [**8-27**]).
2. Down-size tracheostomy to size 6.
3. Carotid Doppler study within one week.
4. Follow Promote with fiber full-strength diet at 95 cc per
hour via percutaneous endoscopic gastrostomy tube.
5. Advance diet to thin liquids and ground solids as
tolerated.
6. Followup as scheduled.
7. The patient was to call his primary care physician or go
to the Emergency Department for chest pain, difficulty
breathing, abdominal pain, nausea, vomiting, fevers, chills,
or other concerning symptoms.
DISCHARGE FOLLOWUP ON DISCHARGE:
1. The patient was to follow up with Neurology (Dr. [**Last Name (STitle) 48962**]
on [**10-2**] at 1 p.m. (telephone number [**Telephone/Fax (1) 1694**]);
please call this number to give insurance information.
2. The patient was to follow up with Vascular Surgery; the
patient to call telephone number [**Telephone/Fax (1) 3121**] to schedule an
appointment in two to four weeks.
3. The patient was to follow up with Cardiology (Dr.
[**First Name (STitle) **] [**Name (STitle) 1911**]) on [**9-6**] at 4:15 p.m.
(telephone number [**Telephone/Fax (1) 2207**]); the patient to call to
confirm appointment.
4. The patient was to follow up with primary care physician
as soon as possible. The patient was to call for an
appointment.
DISCHARGE DISPOSITION: The patient was discharged to
[**Hospital3 **].
CONDITION AT DISCHARGE: Condition on discharge was stable.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 5212**]
MEDQUIST36
D: [**2159-8-28**] 13:45
T: [**2159-8-28**] 14:01
JOB#: [**Job Number 48963**]
Name: [**Known lastname 9064**], [**Known firstname **] L. Unit No: [**Numeric Identifier 9065**]
Admission Date: [**2159-7-9**] Discharge Date: [**2159-7-15**]
Date of Birth: [**2104-2-11**] Sex: M
Service: MICU
DISCHARGE MEDICATIONS:
1. Insulin sliding scale.
2. Albuterol Ipratropium nebulizers q. two hours.
3. Metronidazole 500 mg intravenously q. eight.
4. Levofloxacin 500 mg intravenously q. 24.
5. Valium 80 mg intravenously q. two hours p.r.n.
6. Diazepam 60 mg intravenously q. four hours.
7. Clonidine one patch transdermal q. week.
8. Oxymetazoline one spray twice a day.
9. Sodium chloride nasal, one to two sprays four times a
day.
10. Beclomethasone Nasal two twice a day.
11. Phenobarbital 500 mg intravenously q. eight.
12. Acetyl 15 600 mg p.o. twice a day times four doses.
13. Labetalol 3 mg per minute.
14. Gentamicin 520 mg intravenously q. 24 hours.
DISCHARGE STATUS: The patient remained in the Medical
Intensive Care Unit.
The patient was in guarded condition.
[**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D. [**MD Number(1) 965**]
Dictated By:[**Last Name (NamePattern1) 662**]
MEDQUIST36
D: [**2159-7-15**] 16:53
T: [**2159-7-15**] 17:28
JOB#: [**Job Number 9066**]
Name: [**Known lastname 9064**], [**Known firstname **] L. Unit No: [**Numeric Identifier 9065**]
Admission Date: [**2159-7-9**] Discharge Date: [**2159-7-31**]
Date of Birth: [**2104-2-11**] Sex: M
Service:
ADDENDUM: This is an Addendum to a previous Discharge
Summary. I am dictating his hospital course in the Medical
Intensive Care Unit from the dates of [**7-16**] through [**7-28**].
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. FEVERS: During his hospital course, Mr. [**Known lastname **] continued to
spike fevers ranging from 101 to 104. He had numerous
workups that he received; including a fine-needle biopsy on
[**7-17**] which was intended to drain the pericecal abscess
that he had. This pericecal abscess was sent for culture and
grew out Streptococcus milleri and [**Female First Name (un) **] albicans, and the
patient was continued on vancomycin and started on
fluconazole.
The patient had numerous further workups for these fevers;
including head computed tomographies which did show worsening
of sinus opacities. However, Ear/Nose/Throat was consulted
and they did not feel the worsening sinusitis was
contributing to his fevers, and they said that no further
intervention was required at this time.
Numerous blood, urine, and bronchoalveolar lavage specimens
were sent for culture. None of these specimens were
productive for any bacteria.
It was then felt that these fevers might be secondary to drug
fevers. The patient was being treated with metronidazole,
fluconazole, vancomycin, and gentamicin. These were
eventually switched clindamycin and aztreonam. It was felt
that metronidazole may possibly have been the drug that was
contributing to his drug fever; he was receiving this
medication throughout his hospital course.
2. ATRIAL FIBRILLATION: On [**7-23**], the patient went from a
normal sinus rhythm into atrial fibrillation with rapid
ventricular response. He was started on amiodarone as well
as a diltiazem drip. He was also started on an esmolol drip
for rate control. He was also started on a heparin drip for
atrial fibrillation.
I talked with Cardiology over the telephone, and they did not
recommend direct current cardioversion as the patient was
continuing to spike fevers and would likely revert back into
atrial fibrillation.
3. LEFT LOWER LEG ISCHEMIA: As per the initial History and
Physical, Mr. [**Known lastname **] originally presented to the hospital for a
workup of left lower leg claudication.
During his hospital course it was noted that he was having
elevated creatine kinases, and there was concern for severe
left lower leg ischemia possibly causing his fevers.
Vascular Surgery had been following the patient, and on [**7-24**] he was taken to the operating room for exploration of the
left lower extremity. There was no evidence for fasciitis,
or necrosis, or compartment syndrome. His creatine kinases
continued to decline throughout the rest of his hospital
course.
4. ETHANOL WITHDRAWAL: The patient's Valium dose was weaned
throughout the past weeks, and he was continued on a Fentanyl
drip for sedation.
5. RESPIRATORY FAILURE: The patient was continued on the
ventilator, and a tracheostomy was scheduled for [**2159-7-31**].
6. INCREASED CREATININE: On [**7-20**], a Renal consultation
was obtained as the patient started developing an increased
creatinine. Per their evaluation, the patient had acute
tubular necrosis likely secondary to immunoglycoside
administration. They recommended discontinuing all
nephrotoxic agents and continuing to follow his renal
function.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 5452**]
Dictated By:[**Name8 (MD) 6500**]
MEDQUIST36
D: [**2159-7-31**] 08:42
T: [**2159-7-31**] 08:58
JOB#: [**Job Number 9076**]
Name: [**Known lastname 9064**], [**Known firstname **] L. Unit No: [**Numeric Identifier 9065**]
Admission Date: [**2159-7-9**] Discharge Date: [**2159-8-27**]
Date of Birth: [**2104-2-11**] Sex: M
Service: Medical Intensive Care Unit - Green Team
Addendum to discharge summary that documented events of
hospital course up until [**2159-7-31**]. This dictation is
the subsequent hospital course through [**2159-8-27**].
HOSPITAL COURSE: This is a 55 year old male with a history
of severe peripheral vascular disease and known carotid
artery stenosis and occlusion on the left who presented to
[**Hospital6 2003**] on [**7-9**] for a left
lower extremity preoperative arteriogram for ongoing
claudication but the patient went into delirium tremens from
alcohol withdrawal and was brought to the Emergency
Department for evaluation. The patient was managed in the
Medical Intensive Care Unit with large doses of
Benzodiazepines and a Phenobarbital course for marked
withdrawal symptoms. During his hospital course he was found
to have tracheomalacia in addition to a perforated appendix.
The patient is now status post tracheostomy and percutaneous
endoscopic gastrostomy placement and status post an
antibiotic course for perforated appendix and drainage of the
pericecal abscess. The patient is status post antibiotic
treatment for ongoing fevers related to line sepsis and
management of fevers due to likely drug fever. The patient
is also status post a left below the knee amputation for
extensive left calf necrosis despite a revascularization by a
left common femoral artery endarterectomy and a left
superficial femoral artery thrombectomy. The patient now has
a weak left arm from a right-sided posterior frontal stroke,
discovered by an magnetic resonance imaging scan done on
[**2159-8-23**]. Otherwise the patient is doing well with
adequate oxygen saturations on a tracheostomy mask and has
had no significant fevers in three days while on an
antibiotic course for a vent-associated pneumonia and
suspected line sepsis from an arterial line that was removed
five days ago.
1. Vascular - The patient presented for preoperative
evaluation of his left lower extremity claudication through
an arteriogram, however, this evaluation was delayed
secondary to his delirium tremens. During his hospital
course he was noted to have elevated creatinine kinase level,
possibly related to ischemia. Therefore, the patient was
brought to the Operating Room for a fasciotomy on [**7-24**],
which showed no evidence of necrotic tissue or fasciitis.
His creatinine kinase level subsequently declined. On [**7-30**], aortography and left lower extremity runoff showed a
distal superficial femoral artery occlusion and a near
occlusion of the common femoral artery on the left side. On
[**8-1**], a left common femoral artery endarterectomy and left
superficial femoral artery thrombectomy was completed. The
patient was noted to have a well perfused left foot following
the procedure. On [**8-8**], the patient was brought back to
the Operating Room for debridement of necrotic tissue seen in
the left lower extremity. However, during this procedure the
patient was noted to have extensive necrosis of his left calf
without viable tissue remaining. Therefore on [**8-17**], the
patient was brought back to the Operating Room for a left
below the knee amputation for gangrenous tissue. Currently
the site of his left below the knee amputation is healing
well and dressing changes are continuing every other day.
Other vascular issues were addressed during this hospital
stay including the patient's carotid stenosis which on [**8-14**] was evaluated by ultrasound, persistence of his left
internal carotid artery occlusion was noted and worsening of
his right internal carotid artery to greater than 80%
stenosis was noted. The patient was continued on
anticoagulation for his vascular intervention with a Lovenox
regimen, likely to be changed to Coumadin in the future.
2. Respiratory - The patient was maintained on a ventilator
for the majority of his hospital stay. On [**7-31**] the
patient had bronchoscopy with removal through suctioning of
multiple copious secretions in all of his lower airways. A
tracheostomy was placed at that time. On [**8-23**], the
patient was weaned to a tracheostomy mask and has maintained
adequate oxygen saturations. He was then fitted with a
Passy-Muir valve to allow him to communicate. He continues
Albuterol and Atrovent nebulizers.
3. Infectious disease - The patient is currently finishing a
course of Linezolid for suspected line sepsis from an
arterial line that was removed [**8-22**]. The culture from
this line grew coagulase negative Staphylococcus. The
patient has a Vancomycin allergy and is therefore continued
on Linezolid. Also the patient was noted to have a left
lower lobe pneumonia by chest x-ray and recent sputum culture
on [**8-24**] did grow Acinetobacter and Klebsiella and is
currently being treated with Levaquin for this pneumonia.
The patient is status post antibiotic course for his
perforated appendix that had a pericecal abscess drained. He
will need to have his perforated appendix removed in the
future. A subsequent computerized axial tomography scan of
his abdomen showed no recollection of an abscess at this
site. Also the patient had a course of Linezolid and Flagyl
prior to his left below the knee amputation due to
Enterococcus growing on tissue cultures and suspected
anaerobe infection at the site of his left necrotic leg.
4. Renal/genitourinary - The patient had no evidence of
urinary tract infection despite longterm Foley catheter in
place. Also his creatinine has been maintained within normal
limits for the last month of his hospital stay.
5. Neurology - The patient had an magnetic resonance imaging
scan/magnetic resonance angiography on [**8-23**] that
confirmed a cerebrovascular accident during his hospital
course. Following debridement of his left lower leg, the
patient was noticed to have no movement of his left arm. On
[**8-14**] a computerized axial tomography scan showed no
acute infarct but the subsequent magnetic resonance imaging
scan did confirm a right posterior frontal stroke. Neurology
recommendations were followed and follow up arranged. Also
physical therapy and occupational therapy were ordered to
work with the patient to address this issue and Intensive
Care Unit neuromyopathy which had also been confirmed by
electromyogram during his hospital stay.
6. Cardiovascular - During his hospital course the patient
had atrial fibrillation that resolved spontaneously on [**8-5**] while on a Diltiazem and Esmolol drip. The patient
subsequently had an episode of nonsustained ventricular
tachycardia approximately 40 beats long. He continues on a
course of Amiodarone 400 mg p.o. b.i.d. until [**9-11**] and
will then need to be tapered. His ongoing hypertension was
controlled with Metoprolol, Captopril and Hydralazine prn.
The patient will require cardiology follow up in the near
future to address these issues.
7. Fluids, electrolytes and nutrition - After placement of a
percutaneous endoscopic gastrostomy tube on [**7-31**], the
patient had adequate nutrition through daily tube feedings.
The patient recently had a speech and swallow evaluation
which did allow for minimal oral intake and will likely be
advanced in the near future. The patient had dramatic
diuresis throughout the final month of his hospital stay to
bring him closer to his presenting weight.
8. Pain - The patient is noted to have left arm pain and is
continued on a Fentanyl patch to control this ongoing issue.
9. Psychiatry - As the patient has a history of anxiety
disorder, alcohol abuse and panic attacks, he was started on
Olanzapine q.h.s. and as needed for psychosis and agitation.
10. Hematology - The patient was noted to have a decreased
hematocrit during his hospital stay, often this was suspected
to be due to fluid shift, however, at one point he was
transfused with 2 units of packed red blood cells to bring
him back to acceptable hematocrit.
11. Prophylaxis - The patient was continued on a proton pump
inhibitors and anticoagulation with heparin and then later
Lovenox.
12. Code status - The patient was a full code throughout his
hospital stay.
13. Access - On [**8-27**], the patient is scheduled to have
a PICC line placed for ongoing antibiotic and intravenous
therapy.
DISCHARGE STATUS/MEDICATIONS/FOLLOW UP PLANS: To be
addressed in a subsequent discharge addendum.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3662**]
Dictated By:[**Last Name (NamePattern1) 8843**]`
MEDQUIST36
D: [**2159-8-26**] 18:16
T: [**2159-8-26**] 18:38
JOB#: [**Job Number 9095**]
cc:[**Last Name (NamePattern1) 9096**] Name: [**Known lastname 9064**], [**Known firstname **] L. Unit No: [**Numeric Identifier 9065**]
Admission Date: [**2159-7-9**] Discharge Date: [**2159-8-27**]
Date of Birth: [**2104-2-11**] Sex: M
Service:
Please see previous dictation summaries and addendums for
hospital course from [**7-9**] through [**8-27**].
Dictated By:[**Last Name (NamePattern1) 9097**]
MEDQUIST36
D: [**2159-8-28**] 13:25
T: [**2159-8-28**] 13:29
JOB#: [**Job Number 9098**]
|
[
"428.0",
"291.0",
"728.89",
"440.24",
"518.5",
"540.1",
"038.9",
"303.90",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.18",
"84.15",
"99.15",
"96.04",
"33.22",
"31.1",
"83.09",
"83.45",
"43.11",
"96.72",
"83.21",
"96.6",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
18894, 18953
|
15220, 16226
|
19566, 21042
|
16253, 17489
|
24963, 33886
|
3310, 3423
|
21076, 24945
|
18968, 19543
|
18132, 18869
|
154, 175
|
204, 3073
|
5066, 5697
|
3095, 3289
|
3440, 3528
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,971
| 125,163
|
39802
|
Discharge summary
|
report
|
Admission Date: [**2131-10-7**] Discharge Date: [**2131-10-9**]
Date of Birth: [**2107-4-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Motorcycle accident
Major Surgical or Invasive Procedure:
Multiple facial lacerations
Anterior nasal fracture (closed reduction with packing and
tubing)
History of Present Illness:
Mr. [**Known lastname **] is a 24 yo man with a PMH significant for ADD as
well as prior episodes of trauma involving a motorcycle. He
presents today after seemingly having been involved in a
motorcycle accident, thrown from his bike. Per
report, GCS in field was conflicting, with some reports of a GCS
of 3, necessitating intubation in the field and some reports of
him needing intubation because of agitation and poor MS.
In addition, it seems that alcohol was on board. He was taken to
[**Hospital **] hospital where he had a blood alcohol level in the 160's
and a head CT showed a ? small L frontal SDH.
Past Medical History:
pelvic fx [**2130**] after bike accident
Social History:
+ETOH
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: Upon admission [**2131-10-7**]
HR:80 BP:1:30 over palp Resp:12 intubated on ventilator
O(2)Sat:99% normal
Constitutional: Intubated and sedated
HEENT: Multiple facial lacerations and contusions. Pupils
equal, round and reactive to light, Extraocular muscles
intact
Oropharynx with nasotracheal tube in place
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash scattered abrasions on right thorax and right
flank.
Neuro: Speech fluent
Pertinent Results:
CT Torso [**10-7**]
1. Grade 3 hepatic laceration predominantly involving segments V
and VI, not
significantly changed in appearance from prior study.
2. Right adrenal hematoma, unchanged.
3. Grade [**3-21**] laceration in the inferior pole of the right
kidney.
4. Small amount of hemoperitoneum surrounding the liver, as well
as a
moderate amount of hematoma within the right Gerota's fascia,
which is
unchanged.
5. Slight cortical irregularity at the right aspect of the
symphysis pubis,
may be chronic. Correlation with point tenderness is suggested,
as a
nondisplaced fracture is not excluded.
CTH [**10-7**]
1. Longitudinal fracture of the left mastoid air cells, with
extension into
the middle ear cavity. Opacity surrounds the left ossicles, and
an ossicular
injury is not excluded. Recommend dedicated CT of the temporal
bone for
further evaluaton.
2. Mildly displaced squamosal left temporal bone fractures,
associated with
probable tiny subdural hematoma.
3. Mildly displaced bilateral nasal bone fractures.
4. Right frontal scalp laceration.
[**2131-10-7**] 09:55PM HCT-34.9*
[**2131-10-7**] 05:14AM GLUCOSE-103* UREA N-10 CREAT-0.7 SODIUM-142
POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14
[**2131-10-7**] 05:14AM ALT(SGPT)-141* AST(SGOT)-237* ALK PHOS-47
AMYLASE-101* TOT BILI-0.6
[**2131-10-7**] 03:20AM ASA-NEG ETHANOL-155* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2131-10-7**] 03:20AM PLT COUNT-279
Brief Hospital Course:
The patient was admitted to the TSICU intubated and sedated.
Neurosurgery was consulted regarding the skull fracture and
?IPH/SDH. They recommended a repeat CT scan which was stable.
Plastic surgery was consulted regarding his facial fractures and
facial lacerations. They did a closed reduction of the nasal
fracture at the bedside and closed his lacerations. On HD1 the
patient was extubated without incident. A repeat CT torso on HD1
did not show any progression of his liver or renal laceration.
His hematocrits were stable and he remained hemodynamically
stable with an intact mental status. On HD2, his diet was
advanced to regular and he was transferred to the floor in
stable condition. Since his tranfer to CC6, he has been stable.
He is tolerating a regualar diet, although still has difficulty
fully opening his mouth. He has had his nasal packing removed.
He has been out of bed and ambulating in the room. He denies
headache, dizziness, visual changes. He does report decreased
hearing in his left ear. He was seen by Otolaryngology who
recommended repeat cat scan, which was done He was also
prescribed ear drops for his left ear.
He will discharge to home with the assistance of his parents.
He has received discharge follow-up instructions.
Medications on Admission:
none
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
4. CIPRODEX 0.3-0.1 % Drops, Suspension Sig: Four (4) drops Otic
once a day for 10 days: apply 4 drops to left ear daily for 10
days.
Disp:*5 cc* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
liver lac grade 2
renal lac grade 3
SDH/skull fx L temporal bone
anterior nasal fracture
pubic rami fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - assistance for first 48 hours
Discharge Instructions:
You have been involved in a motor-cycle accident. You will be
discharged today. Please follow up in the emergency room if you
experience the following:
*headache
*abdominal pain
*nausea and vomitting
*dizziness
*fever or chills
You will also need to observe CSF precautions:
These include: -CSF leak precautions (HOB elevation, stool
softeners, sneeze
with mouth open, no nose blowing).
-ciprodex 4gtts TID AS x 10 days
-Keep ear dry until follow up (Cotton ball in ear, then vaseline
smeared over ear and cotton when washing hair
Followup Instructions:
Please follow up with the Acute Care Service. The telephone
number is [**Telephone/Fax (1) 600**].
You will also need to follow up with Dr. [**Last Name (STitle) **]. The
telephone number is [**Telephone/Fax (1) 41**]. Also schedule an audiogram at
this same number [**Telephone/Fax (1) 41**]
Completed by:[**2131-10-9**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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5152, 5158
|
3337, 4604
|
334, 431
|
5305, 5305
|
1856, 3314
|
6029, 6355
|
1175, 1179
|
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|
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|
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275, 296
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460, 1072
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,186
| 118,756
|
40633
|
Discharge summary
|
report
|
Admission Date: [**2121-7-18**] Discharge Date: [**2121-7-28**]
Date of Birth: [**2070-12-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
Dyspnea, chest discomfort
Major Surgical or Invasive Procedure:
Thoracentesis
Pericardiocentesis
History of Present Illness:
50 year old gentleman with metastatic renal cell carcinoma on
chemotherapy (axitinib which the patient was told to stop on
[**2121-7-15**] given his worsening fatigue), hypertension, Factor V
Leiden and PFO. He is on lovenox for PE. He presents with
fatigue and brief dyspnea and lower chest discomfort on changing
from lying->sitting and sitting->standing that is worse over the
last 3 days but started about 1-2 weeks ago. Also worse when he
coughs, sneezes or takes a deep breath in. He has dry cough. All
these symptoms are over the last few days. Reported dry cough
for a few days. low appetite over the last 1-2 weeks.
Denies fever,chills,night sweats,nausea, vomiting, diarrhea,
constipation, abdominal pain. denies dysuria or frequency but
reports urinary retention due to prior spine metastases that
also had lead to left lower extremity weakness. He also reports
right lower extremity weakness secondary to "spread of tumor".
Initial vitals were T 97.4 HR 124 BP 88/53 RR 20 Sat96%RA. Labs
were notable for WBC 15.6 with 79%N. Lactate 4.5 and normal
coagulation profile (patient on lovenox, last received [**7-18**] AM).
CXR was notable for worsened right pleural effusion compared to
prior [**2121-7-1**] along with partial lung collapse. Bedside echo was
significant for large pericardial effusion that is new compared
to echo in [**2119**] but was present in series of CT chests in [**2120**]
with progressive slight increase in size in between. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. No right ventricular diastolic collapse
is seen. In the ED he received 1 L NS, Vancomycin and
levofloxacin (PCN allergy). Vitals on transfer were: Temp: 97.9
??????F (36.6 ??????C), Pulse: 114, RR: 22, BP: 106/76, O2Sat: 95, O2Flow:
RA, Pain: 0.
Per cardiology assessment in the ED, the patient does not have
pulsus nor kussmaul sign. Recommended checking pulsus paradoxus
every 12 hour with possible pericardiocentesis on [**2121-7-21**].
On arrival to the MICU, patient's VS were: T 99, HR 126, BP
107/74, HR 88, RR 22, Sat 95%RA. His [**Hospital Unit Name 153**] course was notable for
continued tachycardia and borderline hypotension. He received
fluid resuscitation and pulsus paradoxicus was trended. IP
placed a right pigtail catheter with drainage of 2100cc of
serosanguinous fluid. A small basilar pneumothorax was seen
post-procedure though was felt to represent trapped lung.
Cardiology consult team further recommended checking pulsus
paradoxus every 12 hour and even though there was no tamponade
on echo, pericardiocentesis was performed on [**2121-7-21**] due to the
maligant nature and liklihood of future tamponade. There was
some concern re: malignant infiltration of the myocardium. He
was transferred to the CCU for observation post-procedure.
In the CCU he was found to have a small apical left
pneumothorax, which has been treated with high flow nasal
oxygen. He was persistently tachycardic and received roughly 5L
of NS with improvement in his hemodynamics. Pain control was a
significant problem treated with IV dilaudid with good effect.
He had a cool right foot with poor pulses concerning for
ischemia. Vascular surgery was consulted and did not recommend
intervention, and instead opted to continue anticoagulation with
heparin gtt. He was transferred to the floor, with vitals of VS
T97.6 BP100/60 P111 RR18 Sat 96/2L. He was broadly covered with
vancomycin and cefepime due to a positive urinalysis and
persistent tachycardia, but cultures were persistantly negative
and his antibiotics were discontinued a few days after to the
floor. There were ongoing conversations between the patient and
his family, palliative care and his outpatient oncology team
regarding goals of care, as his prognosis was judged to be very
poor, with very limited treatment options. He was initially
restarted on axitinib for palliation, but this was later
discontinued as patient and his family elected for comfort
measures only. His pigtail was pulled [**7-26**], and patient and
family elected against Pleur-X placement, which was initially
planned for [**7-28**]. He was discharged home with hospice and
symptomatic management.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- [**2120-7-5**]: presented to [**Hospital6 1597**] with cold left arm,
found to have brachial and radial tumor thrombi in his left arm,
s/p thrombectomy. CT revealed a 11.4 x 8.6 cm right kidney
enhancing mass with central necrosis and calcification,
pulmonary
and adrenal metastases and lytic lesions in his right acetabulum
and lesser trochanter. He was also noted to have thrombus in
the
superior pulmonary vein. A TTE showed an atrial PFO. MRI Brain
showed multifocal intracranial metastases. Biopsy of L arm
thrombus confirmed poorly differentiated carcinoma.
- [**2120-7-24**]: XRT to R hip, 5 treatments
- [**2120-8-1**]: Cyberknife to brain mets
- [**2120-8-9**]: Laparoscopic right radical nephrectomy with
adrenalectomy with Dr. [**Last Name (STitle) 3748**].
- [**2120-9-2**]: Repeat MRI with new metastatic lesions.
- [**Date range (3) 88900**]: WBXRT
- [**Date range (3) 88901**]: Admitted to [**Hospital1 18**] for syncope and
hypotension,
found to have a PE as well as RP bleed. Coumadin stopped and pt
transitioned to Lovenox.
- [**2120-10-5**]: Started Sutent 50 mg daily, took for 8 days and had
side effects.
- [**2120-10-19**]: Re-started Sutent at 37.5, developed diarrhea,
nausea, vomiting, stopped after 7 days.
- [**2120-10-30**]: Due to persistent nausea, dexamethasone restarted
with
resolution of symptoms.
- [**2120-11-1**]: Restarted Sutent 25 mg daily, [**2120-11-6**] increased to
37.5 mg daily.
- [**2120-12-6**]: Cycle 2 Sutent, 37.5 mg daily, stopped at day 20 due
to nausea, vomiting.
- [**2121-1-15**]: Cycle 3 Sutent, 37.5 mg daily
.
PAST MEDICAL HISTORY:
Hypertension
Factor V Leiden (heterozygous, 3-8x incr risk)
Hx of PE while on Coumadin, transitioned to Lovenox
Social History:
Married, no children. Lives w/ wife. on disability. Was working
as a computer consultant. No tobacco, alcohol or drug use.
walks with cane and walker
Family History:
Mother with multiple blood clots diagnosed with factor V leiden
mutation on chronic anti-coagulation and s/p IVC filter
placement. Father-MI at age 76. Maternal uncle-prostate ca
diagnosed at age 50, deceased in 60's. Maternal grandfather-[**Name (NI) **]
ca (was a smoker). Paternal aunt-ovarian cancer-diagnosed at age
65.
Physical Exam:
Gen: calm pleasant gentleman in no acute distress, lying
comfortably in bed
HEENT: No conjunctival pallor. No icteric sclerae. MMM. OP
clear.
NECK: Supple, No LAD. no JVD
HEART: regular rhythm, tachycardic, normal S1,S2. No murmurs,
rubs, clicks, or gallops
LUNGS: Absent BS on right except apex with dullness to
percussion. No wheezes, rales, or rhonchi on left.
ABDOMEN: bowel sounds present. Soft, not tender, not distended.
No organomegaly appreciated.
EXT: warm, NO clubbing cyanosis or edema. +2 palpable distal
pulses bilaterally.
NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout the upper extremities. Weak
lower extremities (overall 3+/5) Gait assessment deferred
Discharge:
Objective:
Vitals - vitals not done (CMO)
HEENT: MMM OP is clear
NECK: Supple, No LAD. no JVD
HEART: tachycardic, normal S1,S2. No murmurs, rubs, clicks, or
gallops
LUNGS: decreased BS on right, dressing is clean on right chest
wall.
ABDOMEN: +BS no TTP
EXT: warm, no clubbing cyanosis or edema. +2 palpable distal
pulses bilaterally.
NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation
throughout.
Pertinent Results:
Admission Labs:
[**2121-7-18**] 12:30PM BLOOD WBC-15.6*# RBC-5.98 Hgb-16.1 Hct-51.5
MCV-86 MCH-26.8* MCHC-31.2 RDW-16.1* Plt Ct-227
[**2121-7-18**] 12:30PM BLOOD Neuts-79* Bands-1 Lymphs-8* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-2*
[**2121-7-18**] 12:30PM BLOOD PT-11.9 PTT-33.5 INR(PT)-1.1
[**2121-7-18**] 12:30PM BLOOD Glucose-126* UreaN-35* Creat-1.1 Na-138
K-6.0* Cl-99 HCO3-23 AnGap-22*
[**2121-7-18**] 07:31PM BLOOD CK(CPK)-22*
[**2121-7-18**] 07:31PM BLOOD CK-MB-2 cTropnT-0.02*
[**2121-7-18**] 07:31PM BLOOD Calcium-8.6 Phos-2.3* Mg-2.1
[**2121-7-18**] 12:43PM BLOOD Lactate-4.5* K-6.2*
ECHO [**7-18**]: There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small. Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular free wall
is hypertrophied. The aortic valve is not well seen. The mitral
valve leaflets are not well seen. There is a large pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. No right ventricular
diastolic collapse is seen. There is brief right atrial
diastolic collapse suggestive of elevated intrapericardial
pressure without overt tamponade. Compared with the prior study
(images reviewed) of [**2120-9-13**], pericardail effusion is new.
CXR [**7-18**]: IMPRESSION: Significant interval enlargement of the
right-sided pleural effusion which is now large.
CXR - lateral decub [**7-19**]: FINDINGS: A right pleural effusion is
apparently layering, but given its large size it is difficult to
exclude a loculated component. Lytic skeletal lesion at level
of fourth anterolateral right rib is present and has been more
fully evaluated on prior CT of [**2121-6-9**] which documented
extensive skeletal metastatic disease. Known pulmonary nodules
are also seen to better detail on the CT. Considering the large
size of the effusion and its rapid increase between [**7-1**] and
[**2121-7-18**], hemothorax should be considered in
the appropriate setting.
CXR [**7-19**]: IMPRESSION: 1. Decrease in right pleural effusion
following pigtail pleural catheter placement and development of
a moderate hydropneumothorax. 2. Lytic rib metastases.
CXR [**7-20**]: IMPRESSION: 1. Right basilar pigtail catheter is
seen. There continues to be a lateral and basilar
hydropneumothorax with interval decrease in the apical
component. Patchy opacity at the right lung base reflects
partial atelectasis of the right middle and lower lobes. The
left lung remains clear. There is likely a small residual right
effusion. Several lytic bone lesions are seen involving the
ribs consistent with known metastatic disease. Overall, cardiac
and mediastinal contours are stable. Radiopaque densities
projecting over the left upper quadrant are felt to represent
artifact.
ECHO [**7-22**]: The left ventricular cavity is small. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
a small to moderate sized pericardial effusion subtending the
inferior and posterior wall of the left ventricle and the
inferior (diaphragmatic) wall of the right ventricle. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. The pericardium may be thickened. There
are no echocardiographic signs of tamponade. There is
significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling.
The epicardial surface of the heart appears thickened and
heterogeneous in acoustic texture. This finding, taken together
with the small hyperdynamic configuration of the left ventricle
despite removal of most of the pericardial fluid, raises a
suspicion for the presence of pericardial constriction, possibly
as a result of epicardial metastasis of underlying neoplastic
disease.
CXR [**7-27**]: IMPRESSION:
1) Moderately large right effusion, with underlying collapse
and/or
consolidation.
2) Lateral view shows what is probably a relatively large
loculated
hydropneumothorax in the anterior mediastinum. This appears new
compared with the torso CT from [**2121-6-9**]. A small amount
of streaky pneumomediastinal air is also likely present. In
retrospect both findings were present on the [**2121-7-26**] lateral
radiograph. If clinically indicated, further characterization
with chest CT should be considered, to better assess the
relationship of these findings to the pericardium.
Brief Hospital Course:
50 year old gentleman with metastatic renal cell carcinoma on
chemotherapy, hypertension, Factor V Leiden complicated with PE
on Lovenox at home. Presented with worsening SOB and chest
discomfort, found to have worsening large right pleural effusion
compared to [**2121-7-1**] and worsening large pericardial effusion,
concerning for malignant process.
.
================= ACTVE ISSUES =======================
.
# Dyspnea: multifactorial, most likely secondary to large
pleural effusion that is worse compared to prior ([**2121-7-1**])
leading to partial collapse. Differential for pleural effusion
included malignant process vs parapneumonic effusion. He
received a thoracocentesis on [**7-19**], and a pigtail drain was
placed. Pleural fluid showed Protein 2.9, Glucose 28, LD(LDH):
578, Cholest: 66, Triglyc: 20. This is most consistent with
malignant effusion. Leukocytosis on admission, but cultures
peristantly negative, no improvement on antibiotics (given
vancomycin and cefepime). His large pericardial effusion (see
below) worsened in [**2120**] and was not present in [**2119**]. Pigtail
drain pulled [**7-26**]; patient was initially scheduled for Pleur-X
[**7-28**] which was cancelled given patient and family's evolving
wishes and decision to forgoe invasive interventions.
.
# Pericardial effusion: He had a moderate effusions which may
have been contributing to his symptoms of fatigue and dyspnea,
however he has had slow progression of symptoms over the last 6
months. He did not have pulsus paradoxus or kussmaul's sign on
exam and TTE did not suggest tamponade. He was monitored
hemodynamically and pulsus paradoxus was monitored Q12H.
Cardiology was consulted, and recommended pericardiocentesis. He
underwent pericardial drainage on [**7-21**] with drainage of 350cc
clear fluid. There were no complications, but he was monitored
in the CCU following the procedure. In the CCU patient
continued to have persistent hypotension and tachycardia despite
pericardial effusion drainage. The following day, repeat echo
showed no reaccumulation of fluid and he showed no clinical
signs of tamponade, so the pericardial drain was pulled. However
in the TTE, the epicardial surface of the heart appeared
thickened and heterogeneous which raised suspicion for the
presence of pericardial constriction, possibly as a result of
epicardial metastasis of underlying neoplastic disease. He was
continued on IVF given his preload dependence and was not
symptomatic from his hypotension in the systolic 80s.
# Goals of care: In the CCU and on the floor, patient was seen
by palliative care and his outpatient oncologist who had
prolonged discussions about patient's and his wife's wishes and
goals given his poor prognosis especially with TTE findings of
likely metastasis to his heart. During the discussion patient
was made DNR/DNI, and later CMO. Axitinib was initially
restarted for palliation and later discontinued when patient
made CMO. Patient and his wife confirmed that they would want
to spend whatever time they have left together at home. She
plans to be available to him around the clock and said there are
many family and friends willing to help.
.
# Renal cell carcinona: s/p right nephrectomy, Sutent,
Cyberknife, WB-XRT, was on Axitinib for progression on MRI
(stopped [**2121-7-15**] for possible contribution to his progressive
fatigue). He has known mets to bone, lung, and brain, and he is
no longer undergoing any active treatment. While undergoing work
up of his pericardial effusion, findings on echocardiogram were
suggestive of myocardial/epicardial metastases. This
information was shared with the patient and his wife, and they
subsequently decided to change his code status to DNR/DNI.
.
============= INACTIVE ISSUES ====================
.
# History of PE: Factor V leiden. tumor hypercoagulation state.
He takes lovenox twice daily at home. Last dose AM of [**2121-7-18**].
He was treated with heparin drip while in the hospital for easy
on/off with procedures. Lovenox was discontinued prior to
discharge due to falling platelet counts.
.
# Urine retention: patient reports requiring tamsulosin for good
urine output with history of self catheterization
intermittently. He had a foley in place while in the hospital,
and his tamsulosin was held. Foley as indicated.
.
============== TRANSITIONAL ISSUES ================
- Patient was made CMO during this hospitalization.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Dexamethasone 4 mg PO Q12H
2. Enoxaparin Sodium 80 mg SC Q12H
3. Lorazepam 0.5 mg PO Q4H:PRN anxiety
4. Omeprazole 40 mg PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
7. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
8. Tamsulosin 0.4 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Senna [**12-23**] TAB PO BID
Discharge Medications:
1. Haloperidol 0.5-1 mg PO Q4H:PRN delirium, agitation
RX *haloperidol 0.5 mg [**12-23**] tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*1
2. Morphine Sulfate (Concentrated Oral Soln) 10-20 mg PO Q2H:PRN
dyspnea, pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 10-20 mg by
mouth every 2 hours Disp #*75 Milliliter Refills:*0
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Oxycodone SR (OxyconTIN) 10 mg PO QAM
please hold if sedated or RR <10
RX *OxyContin 10 mg [**12-23**] tablet(s) by mouth twice a day Disp #*50
Tablet Refills:*0
5. Oxycodone SR (OxyconTIN) 20 mg PO QHS
hold for somnolence or RR<12
6. ZOFRAN ODT *NF* (ondansetron) 8 mg Oral every 8 hours nausea
or vomiting
RX *ondansetron 8 mg 1 tablet(s) by mouth every 8 hours Disp
#*28 Tablet Refills:*1
7. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety, nausea
RX *Ativan 0.5 mg [**12-23**] tablet(s) by mouth every 4 hours Disp #*30
Tablet Refills:*0
8. Scopolamine Patch 1 PTCH TP Q72H
as needed for increased respiratory secretions
RX *Transderm-Scop 1.5 mg/72 hour apply one patch to clean dry
skin every 72 hr Disp #*10 Transdermal Patch Refills:*0
9. Prochlorperazine 5-10 mg PO Q6H:PRN nausea or vomiting
RX *prochlorperazine maleate 5 mg [**12-23**] tablet(s) by mouth every 6
hours Disp #*30 Tablet Refills:*1
10. Dexamethasone 4 mg PO QAM
11. Dexamethasone 4 mg PO QPM
12. Docusate Sodium 100 mg PO BID
13. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
Metastatic renal cell carcinoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 88902**], you were admitted to the hospital with fluid
build-up in the linings surrounding your heart and lungs, which
was drained. However, we discovered that your cancer is likely
involving your heart. After numerous meetings between your
oncology team and family, you decided to pursue comfort measures
instead of invasive care and you are being discharged to home
with hospice. It was a pleasure taking care of you, and we wish
you the best.
You have the following medication changes
- please stop axitinib, lovenox, omeprazole, tamsulosin
- please start oral morphine concentrate for pain
- start zofran, compazine, and ativan for nausea
- start ativan for anxiety
- start haloperidol for agitation
- continue OxyContin (long acting), dexamethasone, laxatives as
needed
Followup Instructions:
Call hospice or oncology team as needed
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Completed by:[**2121-7-28**]
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48,292
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6906
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Discharge summary
|
report
|
Admission Date: [**2115-9-22**] Discharge Date: [**2115-10-15**]
Date of Birth: [**2056-11-26**] Sex: M
Service: MEDICINE
Allergies:
Magnevist
Attending:[**First Name3 (LF) 10323**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
Biopsy of fluid collection
History of Present Illness:
58M with hx of metastatic bladder ca s/p XRT completed
carboplatin/gem [**8-27**], prostate cancer s/p brachytherapy, CHF
with LVEF (30%), HTN, DM, CRI, admitted on [**9-19**] to [**Hospital1 **] with
lethargy, hypotension (baseline 90s) with SBPs in the 70s-80s,
and leukocytosis. Transferred to [**Hospital1 18**] from [**Hospital1 **] for further
management.
Patient notes that he was recently discharged from [**Hospital1 18**] for
dyspnea and lightheadedness. Was found to be anemic, likely [**3-7**]
chemotherapy with crit of 23.8. He received 3 units of pRBCs to
symptomatic relief. After being discharged on [**9-8**], patient again
developed lethargy and loss of energy over the subsequent week
and a half. Visiting nurse came to see him for transitional
issues, and patient found he needed help just to get up out of
bed. Diffiulty ambulating unless holding onto something. Felt
similar to s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3454**], [**First Name3 (LF) **] patient.
In addition, patient noted poor appetite and nausea. Also felt
thirsty and dehydrated. In addition, patient noted urinary
incontinence, urinary frequency, but with low urine volumes of
dark yellow color. Felt that the urine smelled "very strong."
Because of these symptoms, went to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Was found to have
UA with 4+ bacteria, leuk esterase positive, 40 WBC. UCx adn
BCx sent. UCx has since grown out 10-50,000 mixed gram positive
flora. Patient also with urinary retention on admission (no
recent problems, per patient) and foley was placed, relieving
patient of blood-tinged urine x600cc. Was also found to have
acute on chronic kidney failure with creatinine of 5.6 although
without hyperkalemia.
CXR was performed which was clear. Labs were notable for anemia
(explained as chronic) with crit in the low 20s and leukocytosis
of 17,000, but without any evidence of ongoing blood loss. For
likely UTI, levofloxacin 250 mg daily was started.
On the floors, patient became hypotensive with SBPs in low 80s,
adn was transferred to ICU. Patient also had RIJ placed and
received total of 5L NS. Neosynephrine was started as well by a
house officer on the night before transfer, and BPs were stable
at > 100 (baseline in 90s). Repeat CXR after fluids did not show
any volume overload. Also noted to have an episode of
bradycardia (known history of tachy/brady). Also reported to
have bouts of nonsustained Vtach and bouts of SVTs during ICU
stay, although also asymptomatic. Creatinine improved with
aggressive hydration. Patient also says that his overall
symptomotology improved whie in the ICU. Finally, on night
before transfer, patient was found to have large quantity of
liquidy brown stool; cdiff was sent, which was negative.
On transfer, VS were:
98.2 100 99/54 29 99%RA
On arrival to the MICU, patient's VS.
98.3 81 109/73 21 100%RA
Past Medical History:
- Metastatic bladder CA, s/p TURBT [**2113-12-8**], high-grade
pT2bNxMx stage II, mets to pelvic nodes, adrenals, lung, s/p
cisplatin/gemcitabine [**2114-2-13**] to [**2114-5-8**] (5 cycles),
carboplatin/gem [**2114-7-31**] to [**2114-9-18**] (3 cycles).
- CAD/CHF w/EF 30%, s/p [**Company 1543**] Virtuoso II DR [**Last Name (STitle) 26019**]
ICD.
- Hx of tachy-brady.
- ICD fired x6 on [**2114-11-4**] related to SVT and NSVT.
- Prostate CA [**2110-10-17**], [**Doctor Last Name **] 3+4=7 in [**2-12**] cores (5% of core)
s/p brachytherapy.
- HTN.
- DM.
- Hyperlipidemia.
- Mild depression.
- Repair ruptured quadriceps tendon.
Social History:
Currently smoking a few cigarettes daily; is in a smoking
cessation program. No alcohol or illicit drugs. Lives at home
alone and working at [**Company 25186**] [**Company 25187**].
Family History:
Both parents died of cancer. Hx of DM in family.
Physical Exam:
Admission PE :
VS: 98.3 81 109/73 21 100%RA
General: Alert, oriented, no acute distress
HEENT: Pale sclera, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Scant bibasilar crackles, otherwise clear to auscultation
bilaterally
Abdomen: Mild tenderness to palpation suprapubic. Soft,
non-distended, bowel sounds present, no organomegaly, no rebound
or guarding . No CVA tendernes.
GU: + foley , blood tinged urine
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PE:
Pertinent Results:
[**2115-9-22**] 10:57PM PT-20.7* PTT-29.5 INR(PT)-2.0*
[**2115-9-22**] 10:57PM PLT COUNT-129*#
[**2115-9-22**] 10:57PM NEUTS-88.1* LYMPHS-5.4* MONOS-6.0 EOS-0.5
BASOS-0.1
[**2115-9-22**] 10:57PM WBC-22.2*# RBC-2.90* HGB-8.7* HCT-26.7*
MCV-92 MCH-30.1 MCHC-32.6 RDW-18.2*
[**2115-9-22**] 10:57PM ALBUMIN-2.6* CALCIUM-8.0* PHOSPHATE-2.2*#
MAGNESIUM-1.4*
[**2115-9-22**] 10:57PM ALT(SGPT)-40 AST(SGOT)-39 ALK PHOS-143* TOT
BILI-0.3
[**2115-9-22**] 10:57PM estGFR-Using this
[**2115-9-22**] 10:57PM GLUCOSE-126* UREA N-35* CREAT-1.6*#
SODIUM-141 POTASSIUM-2.9* CHLORIDE-112* TOTAL CO2-18* ANION
GAP-14
Imaging:
CXR [**9-23**]
FINDINGS: In comparison with study of [**9-5**], the patient has
taken a slightly better inspiration, which may account for the
decrease in transverse diameter of the heart. Dual-channel
pacemaker device remains in good position. No vascular
congestion or pleural effusion or acute pneumonia.
Right IJ catheter has been introduced that extends to at least
the mid portion of the SVC where it is obscured by the pacer
device. This was discussed with the ICU team when they visited
the radiology department this morning.
Echo [**2115-9-26**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is severely depressed (LVEF = 25 %) with regional variation.
Significant contractile dyssynchrony is present, with a typical
left bundle branch block activation sequence. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2114-11-13**], the left ventricular ejection fraction is
slightly further reduced. Significant left ventricular
contractile dyssynchrony is present.
EKG [**2115-9-26**]
Sinus tachycardia with frequent atrial and ventricular ectopy.
Intraventricular conduction delay. Left anterior fascicular
block. Compared to the previous tracing of [**2115-9-5**] the rate has
increased. There is frequent atrial and ventricular ectopy and
continued diffuse low voltage. Otherwise, no diagnostic interim
change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
117 0 122 354/453 0 -65 85
CXR [**2115-9-26**]:
As compared to the previous radiograph, the right internal
jugular
vein catheter has been removed. The right PICC line is in
unchanged position.
Unchanged left pectoral pacemaker. The lung parenchyma shows no
evidence of pneumonia or other pathologic change. No pulmonary
edema. No pleural effusions.
CT Abd/Pelvis [**2115-9-28**]
IMPRESSION:
1. Marked progression of metastatic disease with interval
increase in adrenal
metastases and multiple nodules within the left pelvis as
described above.
Small amount of free fluid in the right paracolic gutter.
2. New wedge-shaped hypodensity within the spleen most likely
an infarct.
3. Collapsed bladder with perivesicular stranding for which the
differential
includes infection, post-treatment changes, or tumor
infiltration.
4. New mild bilateral hydroureteronephrosis.
5. Stable bilateral renal cysts.
6. Osseous metastases as described above with new lesions in
T11 and L3
vertebral bodies.
CT CHEST [**2115-10-2**]
1. New pulmonary nodule located in the right upper lobe,
measuring 7 mm.
2. Relatively stable metastatic disease within the abdomen and
pelvis,
including bilateral adrenal metastasis, retroperitoneal
metastatic lymph nodes and pelvic inguinal chain lymph nodes,
left mesorectal and left adductor node
3. Bladder wall mass, consistent with known bladder carcinoma.
4. Moderate to mild hydroureteronephrosis, not significantly
changed from the prior study. There is no perinephric abscess.
4. No evidence of abdominal or pelvic abscess.
5. There is no intestinal obstruction.
6. Numerous lytic osseous metastases.
RENAL US [**2115-10-8**]
1. Color flow seen in bilateral renal arteries and veins at the
renal hilum. If detailed analysis of the artery and vein is
needed including spectral Doppler and resistive indices, please
reorder the study.
2. Moderate right hydronephrosis. Resolution of left
hydronephrosis.
Multiple bilateral parenchymal renal cysts which were previously
seen on CT.
3. 6.5-cm heterogeneous nodule in the location of the right
adrenal gland which correlates with known adrenal mass.
4. Thickening of the anterior bladder wall consistent with
patient's history of bladder cancer
Discharge Labs:
[**2115-10-11**] 06:50AM BLOOD WBC-18.8* RBC-2.50* Hgb-7.7* Hct-24.0*
MCV-96 MCH-30.8 MCHC-32.2 RDW-16.1* Plt Ct-126*
[**2115-10-11**] 06:50AM BLOOD Glucose-105* UreaN-33* Creat-1.9* Na-138
K-4.2 Cl-102 HCO3-25 AnGap-15
[**2115-10-5**] 06:30AM BLOOD ALT-15 AST-13 LD(LDH)-232 AlkPhos-124
TotBili-0.2
[**2115-10-2**] 06:19AM BLOOD SEROTONIN RELEASE ASSAY- Unfractionated
Heparin Result: Negative
Brief Hospital Course:
Mr. [**Known lastname 26015**] is a 58 yo M with PMHx of prostate CA and metastatic
bladder CA with possible invasion into the R adrenal gland
currently on palliative therapy, ischemic cardiomyoopathy, T2DM
(insulin dependent), and tachy-brady syndrome who presented from
OSH to [**Hospital Unit Name 153**] with sepsis and hypotension secondary to UTI was
managed with IVF and pressors who improved gradually with
antibiotics and was discharged in stable condition to rehab.
# Septic shock/Urosepsis: The patient presented from [**Hospital1 **] with evidence of sepsis from a urinary source requiring
phenylephrine support. He was transferred on levofloxacin.
Weaning the patient from phenylephrine was initially difficult.
Due to his persistent pressor requriement and persistent
leukocytosis, his antibiotics were changed to vancomycin and
cefepime. He was given numerous IVF boluses for blood pressure
support to baseline sbps in 90s, and his phenylephrine dose was
eventually weaned. [**Hospital3 **] blood cultures were negative
and urine culture grew 10-50,000 mixed gram positive flora.
Urine culture at [**Hospital1 18**] grew corynebacterium sp. On the floor,
cefepime was d/c-ed to narrow coverage of cram positive
organisms/corynebacterium. Patient continued to trigger on the
floor primarily for hypotension, and was returned to the ICU
because of this. In the ICU, patient received additional fluid
resuscitation. Given atypical organism causing UTI, ID was
consulted. Cefepime was restarted. CT abdomen/pelvis was also
performed, which showed worsening metastatic disease as well as
bladder wall stranding which could be inflammatory/infectious
process. Patient remained stable and was transferred back from
the ICU. Given thrombocytemia, patient's vancomycin was
discontinued. Patient continued to spike fevers and repeat blood
and urine cultures were sent.
*Blood cultures showed no growth to date with several still
pending on day of discharge.
*Urine cultures originally grew Corynebacteria for which pt took
Cefepime for 10 days, completing a full course. Pt continued to
consistently spike fevers almost daily, up to 101-102F. This
generally would occur aroun 10pm to midnight. UA was sent which
revealed many bacteria many WBCs. There was concern for
recurrent UTI as pt started have symptoms of dilirium and pt was
restarted on antibiotics, Ceftriaxone. ID followed pt and after
two days of Ceftriaxone, antibiotic was discontinued given pt's
rise in creatinine to 2.0 and conern for AIN.
# Acute kidney injury: The patient presented to [**Hospital3 **]
with [**Last Name (un) **] that resolved rapidly with hydration. A renal
ultrasound performed there showed stable mild hydronephrosis. CT
abdomen and pelvis showed bilateral hydroureteronephrosis. Urine
output was maintained. Cr began to trend upwards [**9-29**] and
leveled off at 2.0. Renal was consulted and recommended a renal
ultrasound, Urine eos, and urine electrolytes. Urine
electrolytes showed FENA of 1.5%, indeterminate for intrinsic
process. Given that pt's bump in creatinine occured at the same
time pt was put on Cephalosporins, there was concern for Acute
Interstial Nephritis. Pt's Urine eos were positive therefore
Ceftriaxone for recurrent UTIs was discontinued. On day of
discharge creatinine was 2.1 (baseline 1.2-1.3).
# Metastatic bladder cancer: CT of abdomen and pelvis showed
progression of disease, including increase in size of adrenal
nodules, nodules in pelvis, lytic lesions at L2 (previously
seen) and T11 and L3 (new). Bladder collapsed with surrounding
stranding read as infection vs. tumor infiltration. Patient's
outpatient oncology team (Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 3877**]) aware and
met with patient and his family during admission. Patient and
his daughter understand his poor prognosis from his malignancy
and would like to avoid aggressive treatment and focus on pain
control and symptom management. They agreed to transition to
hospice.
# Dilirium: for several days the week of [**2115-10-7**] pt appeared
somewhat more confused from his baseline. His mental status was
often alert and oriented to person but not place and time
(whereas pt was always AxOx3 prior to this). Pt some mornings
thought he was in a football stadium and that it was Decemeber.
Also pt's daughter reported that he would call her in the middle
of the night sounding confused. This confusion resolved two days
prior to the day of discharge. The differential for his dilirium
includes infection (ie possible given pt's refractory fevers,
leukocytosis, and recurrent UTIs) or overmedication with
narcotics (very possible as well given pt's pain regimen in
hospital was increased). It seems there might be a fine line
between managing pt's pain with narcotics adequately and
allowing him to be mentally alert and oriented x 3. However pt's
mental status improved without any adjustment in pain regimen.
# Thrombocytopenia: Patient with mild thrombocytopenia on
admission (129) likely related to chemotherapy. Counts dropped
during admission, reaching nadir of 54 on [**9-28**]. Differential
included drug effect from vancomycin, so vanc was discontinued.
Heparin dependent antibodies were sent, which returned strongly
positive. Serotonin release assay was negative suggestive that
HIT was not etiology. Platelets returned to baseline prior to
discharge.
# Atrial fibrillation with tachy-brady syndrome: The patient was
maintained on his home digoxin, but his metoprolol was held in
the setting of his hypotension. The patient had occasional
episodes of tachycardia to the 120s. He had no episodes of
bradycardia. When patient returned to ICU, patient's digoxin
dose was increased to 0.25 and he remained hemodynamically
stable. On the floor, patient was persistantly tachy in the
100s-110s, with occasional episodes of tachy to the 120s-140s.
Tele showed frequent PVCs and occasional non-sustained (10 beats
or less) runs of V-tach. Metoprolol was restarted at low dose on
[**9-29**].
# CHF: Because of history of CHF, fluid resuscitation was
performed judiciously. Echo during stay showed EF of 25% and
ventricular dyssynchrony. Patient did not show signs of volume
overload.
# Anemia: The patient's anemia was thought to be related to
chemotherapy. He also had hematuria due to his bladder cancer
throughout his stay. He was occasionally symptomatic, feeling
lethargic. He was transfused 1U PRBCs on two occasions with good
resolution of symptoms and an appropriate increase in HCT.
# Diarrhea: Patient developed loose liquid stools the night
before transfer to [**Hospital1 18**]. Stool studies were sent at [**Hospital1 **] as well as [**Hospital1 18**]. Patient was found to be cdiff
negative without bacterial pathogen, without fecal leukocytes.
Stool guaiac was performed, which was initially positive (when
patient's INR was 2.0); it was subsequently negative. After
negative workup, it was felt that diarrhea was likely secondary
to antibiotic use. Care was taken to make up for insensible
losses with fluid repletion.
# Coagulopathy: Patient presented to [**Hospital1 18**] with INR of 2.0.
Thought to be secondary to antibiotic use compounded by poor PO
intake. Patient received 5 mg vitamin K PO and coagulopathy
resolved. Patient did have one guaiac positive stool which was
thought to be brought on by this transient coagulopathy.
#CODE/ Goals of care: DNR/DNI. Patient and his daughter would
like transition his care to focusing more on comfort and
controlling his symptoms. He should be transitioned to hospice
after acute rehab.
Transitional issues:
- FEVERS: patient continued to have intermittent fevers to 101.5
in the days prior to discharge. No infectious source was
identified. The source of his fevers was thought to be from his
cancer. Patient and his daughter elected not to have further
aggressive treatment or work-up.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientPharmacywebOMR.
1. Digoxin 0.125 mg PO DAILY
2. Eplerenone 25 mg PO DAILY
3. 70/30 14 Units Breakfast
70/30 14 Units Dinner
4. Morphine SR (MS Contin) 30 mg PO Q8H
5. Morphine Sulfate IR 15 mg PO Q4H:PRN pain
6. Phenazopyridine 200 mg PO Q8H:PRN bladder pain Duration: 3
Days
7. Furosemide 20 mg PO DAILY
Continue as you were taking at home, please take daily.
8. Metoprolol Succinate XL 200 mg PO DAILY
9. Prochlorperazine 5-10 mg PO Q6H:PRN nausea
10. Docusate Sodium 100 mg PO BID
hold for loose stools
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
hold for loose stools
3. 70/30 14 Units Breakfast
70/30 14 Units Dinner
4. Morphine SR (MS Contin) 60 mg PO Q8H
hold for oversedation, RR<12
5. Morphine Sulfate IR 15 mg PO Q3H:PRN pain
please hold for RR<12, altered mental status
6. Prochlorperazine 5-10 mg PO Q6H:PRN nausea
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Acetaminophen 650 mg PO TID
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**]
Discharge Diagnosis:
Primary: UTI with sepsis; metastatic bladder cancer; delirium
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 26015**],
You were admitted to the hospital with a low blood pressure and
fatigue, which was severe enough that you needed to go the
intensive care unit for close monitoring. You were found to have
a urinary tract infection and were given IV fluids and
antibiotics. You also had severe back pain, most likely due to
metastatic cancer in your spine, and your pain medications were
adjusted. You also received a single radiation treatment for
your back pain.
You also had frequent fevers throughout your hospitalization. We
evaluated you for a source of infection but no source was
located.
We discussed your goals of care and you would like to focus more
on symptoms and feeling comfortable. You will go to a rehab
facility to get stronger and you can transition to hospice care
when appropriate.
Followup Instructions:
Please keep the following appointments:
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icd9cm
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[
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icd9pcs
|
[
[
[]
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|
10155, 17735
|
282, 311
|
19476, 19476
|
4921, 9715
|
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|
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|
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339, 3262
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|
3284, 3915
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3931, 4117
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,646
| 160,060
|
22362
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 58206**]
Admission Date: [**2151-8-13**]
Discharge Date: [**2151-8-15**]
Date of Birth: [**2073-10-1**]
Sex: F
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: This is a 77 year old woman with
multiple medical problems who was transferred to [**Hospital1 346**] as a trauma transfer. She presented
to an outside hospital status post fall from a three foot
high bar stool directly onto her buttocks and low back. She
had no loss of consciousness at the time, however, she was
found to be diaphoretic at the time of her fall. The EMT
evaluation revealed bradycardia and a systolic blood pressure
in the 70s. She was taken to an outside hospital where she
had recorded systolic blood pressure in the 60s. She was
started on Dopamine, received a left groin Cordis line, four
units of packed red blood cells and five liters of
intravenous fluids. She was seen by cardiology and had an
echocardiogram which was reportedly negative. CT chest,
abdomen and pelvis revealed left pneumothorax resulting from
a T12 burst fracture. The patient was then Med-flighted to
[**Hospital1 69**]. On arrival at our
Emergency Department, the patient was alert with an open
airway and reported no loss of consciousness or head injury.
PAST MEDICAL HISTORY: Hypertension.
Kyphosis.
Left breast cancer.
Angina.
PAST SURGICAL HISTORY: Left mastectomy.
ALLERGIES: Penicillin and Sulfa.
MEDICATIONS ON ADMISSION:
1. Lipitor.
2. Nadolol.
3. Aspirin.
4. Triamterene.
5. Benazepril.
6. Reglan.
PHYSICAL EXAMINATION: On admission, her examination revealed
a temperature of 97.6, heart rate 95, blood pressure 186/85,
respiratory rate 22, oxygen saturation 100 percent on
nonrebreather. She was alert in no acute distress but was
slightly uncomfortable. She had no lacerations or abrasions
of her head. The pupils are equal, round and reactive to
light and accommodation. Extraocular movements are intact.
Tympanic membranes were intact without evidence of [**Male First Name (un) **]. She
did not have a neck collar on. When she arrived in the
Emergency Department, one was placed. At this time, her
trachea was noted to be midline. Her chest had no
deformities. She was regular rate and rhythm, and
tachycardic. She did have some decreased breath sounds at
the bases. Her abdomen was obese, soft, with no tenderness.
She has a transverse right upper quadrant scar and a midline
upper abdominal scar, both surgical in nature. Her pelvis
was stable. She had slightly decreased rectal tone and was
guaiac negative. Her dorsalis pedis pulses were two plus
bilaterally. Neurologically, she was alert and oriented and
followed commands and moved all extremities.
LABORATORY DATA: She had a chest x-ray in the trauma bay
which revealed a large left pleural effusion. A left chest
tube was placed, a 36 French tube, with 1000 cc of
nonclotting old blood draining out upon placement. Her
repeat chest x-ray following placement of the chest tube
revealed the chest tube in good position and pleural effusion
almost completely drained. It should be noted that she had a
CT of her chest, abdomen and pelvis in which the abdomen and
pelvis were negative but the chest revealed a T12 vertebral
fracture and a left hemothorax. At this time, she was taken
to the Intensive Care Unit where orthopedics saw her. They
requested a magnetic resonance imaging which was done that
same night. Based on their findings and evaluation of the
patient, it was determined that they would take her to the
operating room on [**2151-8-15**], for an anterior vertebrectomy
and fusion. She was taken to the operating room. At this
point, the details of the case should be ascertained from the
operative note. The brief story is that she hemorrhaged
during the case uncontrollably despite packed red blood
cells, platelets and fresh frozen plasma. She lost her blood
pressure and cardiopulmonary resuscitation was instituted.
Despite best efforts, she did not regain a heart rate or
blood pressure. She was pronounced dead at 8:40 p.m., on
[**2151-8-15**].
DISCHARGE DIAGNOSES: Death with comorbidities of
hypertension, scoliosis, breast cancer, coronary artery
disease, status post right mastectomy, status post ventral
hernia repair, T12 vertebral fracture, left hemothorax,
status post left chest tube placement, and status post right
groin Cordis line.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Last Name (NamePattern4) 53391**]
MEDQUIST36
D: [**2151-11-15**] 13:18:16
T: [**2151-11-15**] 19:44:31
Job#: [**Job Number 58207**]
|
[
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"805.2"
] |
icd9cm
|
[
[
[]
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[
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|
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|
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|
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201, 1263
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,491
| 149,145
|
25041
|
Discharge summary
|
report
|
Admission Date: [**2195-6-15**] Discharge Date: [**2195-7-10**]
Date of Birth: [**2130-11-8**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Amitriptyline / Adhesive Tape / Flexeril / Carbonic
Anhydrase Inhibitors / Phenergan / Darvocet-N 100 / Propoxyphene
/ Robitussin-Dm / Sulfa (Sulfonamides) / Vicodin
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
altered MS
Major Surgical or Invasive Procedure:
Thoracentesis [**2195-6-15**]
Diagnostic and therapeutic thoracentesis [**2195-6-15**]
History of Present Illness:
This is a 64 yo w/ hep C cirrhosis on transplant list who was at
an OSH since [**2195-5-24**] where she was treated for hepatic
encephalopathy and failure to thrive. She initially presented
w/altered MS x 1wk. Of note, pt had been recently discharged
from [**Hospital1 18**] where she was treated for hydrothorax and
exacerbation of chronic abdominal pain.
.
Briefly, at the OSH, pt was initially taken off of Topamax which
had been started [**4-29**] and though to be worsening MS, Elavil was
also discontinued. LFTs and CBC were near pt's baseline. A GI
consult was obtained, they did not feel at that time that pt was
encephalopathic [**5-25**]. Thoracentesis was performed [**6-10**] for Right
sided pleural effusion. Per report, pt's MS improved [**6-12**]. She
was started on prednisone for a COPD flare and continues on a
taper. Micro data was negative and there was no incident of GIB.
There is no documentation of diagnostic paracentesis/blood cx.
.
Upon transfer, vitals were T 95.9 HR 99 RR 18 BP 128/81 sat
99%2LNC
.
ROS: Currently feels like MS is better but still feels confused.
She denies any pain, feels that chest is "congested" and w/cough
though it has improved. Also notes diffuse swelling which she
does not think is much better.
Past Medical History:
# Hep C cirrhosis, genotype 1, on transplant list
# Chronic abdominal pain.
# Coronary Artery Disease - had PCI w/stenting x 1 in [**2193**] At
[**Hospital 794**] Hospital in [**Hospital1 789**], RI anatomy unknown. No MI per pt
report.
# h/o CCY
# h/o appendectomy
# h/o hysterectomy
# h/o CIN in [**2194**]
# h/o hydrothorax presumed due to liver disease
# Lower extremity edema presumed due to liver disease (ECHO
normal)
# h/o 18-mm hepatic lesion in [**2195**], possibly present on a CT
from 12/[**2192**]. Findings may represent a dysplastic nodule,
however,
hepatoma could not be excluded
# last colonoscopy [**2191**] w/divertiulosis ans small esophgeal
varices
Physical Exam:
vitals T96.1 BP 110/72 HR 92 RR 18 97%2L
Wt: 212.7 (dry weight is reportedly 174)
gen: well appearing, resting comfortably
heent: +sclera icteric, elevated JVP, no lymphadenopathy
cvs: RR s1, s2, no M/G/R
pulm: decreased breath sounds 2/3 up on right w/bronchial BS,
increased tactile fremitus on right, clear on left w/rhonchi at
left base
abd: distended, mild tenderness to palpation in periumbilical
region but soft, w/o rigidity/rebound/guarding; scar noted from
prior cholecystectomy.
ext: 2+ pitting edema BL
neuro: + astrixis
Pertinent Results:
EKG: w/o acute ischemic changes, unchanged from comparison
[**2195-5-2**]
.
Labs:
OSH on discharge: sodium 127 potassium 4.9, chloride 89,
bicarbonate 33, BUN 54, creatinine 1.3, glucose 122, AST 125,
ALT 62, alk phos 123, T bili 5.3, D.bili 2.1
CBC: WBC 10.7, HCT 30.6, platelets 82
INR 2.11
MICRO:
[**5-24**]: u/a (-)
sputum gram stain: mixed flora, C.diff(-), pleural fluid
AFB(-)/cyto (-)
Imaging: OSH
[**5-24**]:CT head: negative for ICH
Brief Hospital Course:
64 yo F with hepatitis C cirrhosis who was admitted to OSH on
[**5-24**] for hepatic encephalopathy and failure to thrive and
transferred here on [**6-15**] to the hepatorenal service for further
mgmt. Pt was noted to have R hydrothorax which was tapped for
1.5 liters. She was also found to have an enterococcal UTI for
which she was treated with ampicillin/vancomycin. She was
starting to develop a hepatorenal picture on her first several
days on the floor, was aggressively diuresed with an increase in
creatinine and oliguria, then became anuric. She was then given
a fluid challenge with albumin and subsequently developed
pulmonary edema on the L side, requiring NRB. She was
transferred to the MICU on [**6-20**] and was intubated and started on
CVVH. Her R pleural effusion was tapped in the MICU; Dr. [**Last Name (STitle) 497**]
did not wish to have a pigtail catheter. She had a total of 72
hrs of CVVH. During CVVH, she was hypotensive, initially felt to
be hypovolemic (intravascularly depleted) and possibly septic
and her abx was broadened from ampicillin to cover enterococci
UTI to vanc/cefepime though all other culture data was negative.
Pt did not have enough ascites to tap. She was then noted to
have failed her [**Last Name (un) 104**] stim (she was previously on prednisone for
copd flare at OSH) and was started on stress dose steroids. This
was tapered to 10 mg po prednisone on [**7-2**]. On She is now
normotensive with sbp in 120s back on her home bisoprolol, which
has been titrated up. UOP has also returned and she was
restarted on lasix/aldactone. She was stable enough to transfer
back to the hepatorenal floor service by [**2195-7-3**] where she was
stable but with guarded status given her hepatorenal syndrome.
Her issues are summarized by issue below:
.
# Hepatorenal syndrome: Pt came in w/Cr of 1.2. and was rapidly
climbing. Urine studies were c/w HRS type/prerenal over ATN. Pt
was anuric after UF on [**6-20**]; UOP has returned. Off CVVH since
Friday [**6-26**], HD line dc'd [**6-12**]. However, the patient's Cr
remained at 1.9 which had been trending upwards. UOP slowing
down on the floor, so on [**2195-7-3**] she was started mitodrine 5mg
TID, octreotide 100mg SC TID. Renal was involved regarding
management of her fluid status as we would prefer to remove
fluid by HD to protect kidneys than give fluid by albumin as pt
had fluid overload, resp distress last time. The family is aware
that her status is guarded and after many discussions, the
decision was made to discharge her to home with hospice.
.
# Hypotension/Sepsis: Initially thought to be likely
multifactorial with the main component being recent
thoracentesis and then HD session with removal of 2L of UF.
There was mild response from SBP of low 80s to high 80s after
500 cc bolus of IVFs and 1 unit of PRBCs. However, MAP began to
drift below 60 in AM of [**6-21**] and pt was started on levophed. BP
also began to fall after intubation, may be due to meds v.
positive pressure ventilation (however, higher PEEP seems to be
improving aeration of R lung). Pt is less likely to be septic
given HR, lack of fever, lack of leukocytosis though pt began to
deteriorate after switching from vanc to amp. The patient's
antibiotic coverage was broadened in the ICU to cefepime/vanc as
pt began to deteriorate after switching from vanc to amp for
enterococcal UTI-treat for a two week course ending on [**7-6**].
Adrenal insufficiency now considered to be primary cause. By the
time she was transferred from the ICU, she was off all pressors,
and antibiotic coverage for sepsis. Her BP ran high so she was
restarted on bisoprolol 10mg daily which was discontinued on
[**2195-7-3**] as her BP was starting to trend downwards. The patient
was also restarted on midodrine and octreotide to maintain her
BP.
.
# s/p Hypoxic respiratory failure in the ICU: This is likely due
to pulm edema after fluid resuscitation in the setting of R
hydrothorax and anuria, also mental status.
Per liver, no pigtail catheter as patient was still being
considered for liver transplant. She was successfully extubated
on [**6-29**], satting well on room air. On the floor after
transfer from the ICU, the patient's respiratory status has been
stable.
.
# Adrenal Insufficiency- The patient had an abnormal [**Last Name (un) 104**] stim
test while septic, so given stress dose steroids and quickly
tapered off steroids by [**2195-7-4**]. Her blood pressure remained
stable off the steroids.
.
#Hypernatremia-likely secondary to intravascular volume
depletion. The patient's tube feeds were adjusted to correct for
hypernatremia.
.
#Hyperglycemia: Likely exacerbated by stress dose steroids and
TPN. The patient's lantus was uptitrated given the patient's
hyperglycemia.
.
# UTI: The patient was initially found to have enterococcal UTI
which was adequately treated with ampicillin and vancomycin. She
continued to grow out yeast in her cultures so was started on
[**2195-7-4**] on a course of fluconazole.
.
# Hepatic encephalopathy: No signs of infection or abnormalities
in portal flow. Pt has only trace ascites, difficult to tap. She
was continued on lactulose and rifaximin titrating up to keep
BM>4/day
.
# Hep C cirrhosis and end stage liver disease: Patient with MELD
of 37 on [**2195-7-8**] and complications including HRS, recurrent
hepatic hydrothorax. Patient was treated for hepatorenal
syndrome as above.
.
# Recurrent R hydrothorax: Patient had been reaccumulating fluid
during her hospital stay given her liver function. She had
multiple thoracenteses on the floor and on the unit.
.
# COPD: Patient was transferred from OSH on steroid taper for
presumed COPD flare. She was continued on albuterol and
ipratroprium nebs prn and her home Advair
(fluticasone/salmeterol) 100/50 1 puff [**Hospital1 **], combivent
(ipratroprium/albuterol) 18 mcg-103 mcg (90 mcg)/Actuation
Aerosol 2 puffs twice a day. No evidence of COPD flare during
this stay.
.
Dispo: Patient was discharged to home with hospice.
.
Medications on Admission:
Meds: per last dc summary in [**2195-4-11**]
Fluticasone-Salmeterol [**Hospital1 **]
Aspirin 81 mg DAILY
Combivent Two puffs Inhalation twice a day.
Lasix 40 mg 2 once a day.
Lactulose 30 ML PO TID
Nexium 40 mg PO once a day.
Spironolactone 100 mg PO DAILY
Bisoprolol 5 mg PO bid
Lidocaine 5 % off for 12 hrs.
Oxycontin 10 mg Q12 hr
Oxycodone 5 mg PO Q8H as needed.
Topiramate 25 mg PO QHS
Singulair 10 mg PO once a day.
Calcium 500 mg PO three times a day.
Vitamin D 400 unit Qdaily
.
Medications on Transfer:
Advair 100/50 1 puff daily
Albuterol nebs Q3h
Albuterol/Ipratropium INH q4h
ASA 81mg daily
Bisoprolol 2.5mg twice daily
Calcium carbonate 600 mg twice daily
Prednisone 2.5 mg(taper)
lasix 40mg twice daily
guaifenasin/dextrometh q4h prn
insulin ss
lactulose 20mg three times a day
milk of mag 30mg QHS prn
omprazole 20mg once daily
oxycodone 5-10mg q4h prn
vitamin K PO 5mg daily
rifaximin 200mg TID
spironolactone 25 once daily
vitamin D 1000unit once daily
Discharge Medications:
1. Ativan 1 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed.
Disp:*30 Tablet(s)* Refills:*2*
2. Morphine Concentrate 20 mg/mL Solution Sig: 2.5-10 mg PO q1h
as needed.
Disp:*30 cc* Refills:*0*
.
Discharge Disposition:
Home With Service
Facility:
Home &Hospice of [**Doctor Last Name **]
Discharge Diagnosis:
Final diagnosis
Hepatorenal syndrome
Recurrent hepatic hydrothorax
Hepatitis C cirrhosis
.
Discharge Condition:
Stable
.
Discharge Instructions:
You were admitted from an outside hospital and found to have a
syndrome called hepatorenal syndrome which means that your liver
function is bad enough that your kidneys start to fail. You also
have known fluid accumulation in your right lung which required
multiple fluid removal procedures. You are now being discharged
home with hospice care to keep you comfortable.
.
Followup Instructions:
.
|
[
"276.1",
"599.0",
"584.9",
"414.01",
"070.54",
"518.81",
"572.2",
"038.0",
"995.92",
"572.4",
"276.0",
"585.9",
"491.21",
"560.1",
"511.9",
"571.5",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"39.95",
"96.6",
"96.72",
"96.04",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10799, 10870
|
3543, 9543
|
446, 534
|
11005, 11015
|
3076, 3162
|
11434, 11439
|
10563, 10776
|
10891, 10984
|
9569, 10055
|
11039, 11411
|
2523, 3057
|
3176, 3493
|
396, 408
|
562, 1815
|
3502, 3520
|
10080, 10540
|
1837, 2508
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,780
| 176,298
|
38896
|
Discharge summary
|
report
|
Admission Date: [**2124-6-14**] Discharge Date: [**2124-6-18**]
Date of Birth: [**2042-4-2**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
- need for drain internalization
Major Surgical or Invasive Procedure:
[**2124-6-14**]: metal stents placed
[**2124-6-15**]: cholangiogram -> metal stents found to be clogged,
ballooned and extended, replaced external drains
[**2124-6-16**]: cholangiogram ->
History of Present Illness:
82 yo F who originally presented to [**Hospital1 18**] [**2124-4-23**] with 2 weeks of
painless jaundice. Her work-up was significant for locally
advanced gallbladder vs. biliary CA and is now s/p palliative
external biliary drain placement and duodenal stenting. She
presented to [**Hospital1 18**] to have her external biliary drain
internalized by interventional radiology on the day of
admission.
Past Medical History:
HTN, hypothyroidism
Social History:
Married, 4 children, from [**Location (un) 3493**], MA. Social alcohol, tobacco
20 pack-years, stopped 7 years ago.
Family History:
Non-contributory.
Physical Exam:
Discharge Physical Exam: AxOx3. NAD. RRR. CTAB. Abd soft, +BS,
NTND, b/l drain sites clean, secure with no erythema, swelling.
Ext WWP.
Pertinent Results:
[**6-18**] Na 128
[**6-16**] T.bil 1.1
Brief Hospital Course:
The patient presented to [**Hospital1 18**] to have her external biliary
drain internalized by interventional radiology.
Post-operatively, upon arrival to PACU, the patient developed
respiratory distress with HTN/tachycardia. She was given lasix
10mg IV and labetalol 10mg IV x2. Placed on BiPAP for 45 minutes
with clinical improvement. Admitted to TSICU on 4LNC,
hemodynamically stable for overnight monitoring of CHF
exacerbation likely in setting of hyperdynamic response post-op.
[**2124-6-14**] & [**2124-6-15**]: Pt's respiratory condition improved after
diuresis in the PACU and SICU. Her oxygen requirements decreased
from BIPAP to NC once lasix was given. Her cardiac markers were
negative and a formal echo done showed mild aortic stenosis. The
cardiology service saw the patient and reported that her
pulmonary
edema may have been due to diastolic dysfunction in the setting
of hypertension and tachycardia. A formal echo done on [**6-15**]
confirmed the presence of mild aortic stenosis. The pt was
transfered from the the ICU to the from on HD 2 and IR attempted
to cap the two externalized biliary drains in the patient.
Fluoroscopic analysis of the pt's two stents revealed that both
stents were clogged. IR placed dilated the two stents and placed
two longer stents over the original stents. These were left
draining on HD 2 with the plan of clamping them for 24 hrs and
if no complications developed sending the pt home on HD 3. The
right drain had moderate output and was clamped on HD 2. The
left drain was not clamped until HD 3 [**1-25**] high ss fluid output.
[**2124-6-16**]: Pt underwent another cholangiogram by IR and it was
then decided to leave both drains clamped
[**2124-6-17**]: LFTs were found to be stable on HD 4 w/ no e/o biliary
obstruction after clamping the tube o/n. Both drains were left
clamped during HD 4 and the patient tolerated a regular diet and
did not develop constitutional sx's. The drains will be left for
7-10 days to ensure patency of her biliary tree and then removed
by IR as an outpatient. Pt was kept in place for 7-10 days to
ensure patency and remove it as an outpatient.
Pt developed hyponatremia on HD4 to 124. She was given salt tabs
and continued her regular diet and by evening her Na had risen
to 128.
[**2124-6-18**]: Pt's Na remained stable on HD5 and she was discharged
to home w/ Na suppl and f/u to PCP in good condition.
Medications on Admission:
Atenolol 50mg daily, dicloxacillin 250 mg Q6H (do not restart),
Levoxyl 75mcg daily, pantoprazole 40mg daily, colace 100 [**Hospital1 **],
valsartan 160mg daily
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Levothyroxine 75 mcg Capsule Sig: One (1) Capsule PO once 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. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day.
6. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO every
eight (8) hours for 2 days: Pls take 3 times per day .
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] vna
Discharge Diagnosis:
unresectable gallbladder vs biliary vs pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistant.
Discharge Instructions:
Resume regular diet.
Please resume all home medications unless specifically asked not
to resume them. Take all new medications as prescribed.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-1**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] in his clinic on [**2124-7-7**]. Please call his
office at [**Telephone/Fax (1) 1231**] to schedule this appointment early next
week.
Completed by:[**2124-6-18**]
|
[
"197.4",
"428.0",
"785.0",
"276.8",
"428.23",
"518.82",
"197.7",
"244.9",
"276.1",
"E878.1",
"156.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.51",
"51.98"
] |
icd9pcs
|
[
[
[]
]
] |
4575, 4626
|
1412, 3814
|
346, 536
|
4727, 4727
|
1349, 1389
|
6506, 6712
|
1159, 1178
|
4026, 4552
|
4647, 4706
|
3840, 4003
|
4881, 6483
|
1193, 1193
|
273, 308
|
564, 966
|
4742, 4857
|
988, 1009
|
1025, 1143
|
1218, 1330
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,412
| 178,656
|
44740
|
Discharge summary
|
report
|
Admission Date: [**2101-1-12**] Discharge Date: [**2101-1-21**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2101-1-14**] Mitral Valve Replacement utilizing a 33 millimeter CE
Perimount Mitral Bioprosthetic Valve
History of Present Illness:
This is an 82 year old male with known mitral regurgitation and
dilated cardiomyopathy. He also suffers from chronic atrial
fibrillation. He complains of worsening fatigue and shortness of
breath. Cardiac catheterization in [**2100-11-21**] confirmed 3+
mitral regurgitation and an LVEF of 35%. Coronary angiography
showed no flow limiting disease. His most recent ECHO was from
[**2100-5-21**] which revealed moderate to severe mitral
regurgitation, 1+ aortic insufficiency, and an LVEF of 45%.
Based on the above results, he was referred for cardiac surgical
intervention. He will be admitted for reversal of Warfarin and
heparinization.
Past Medical History:
Mitral regurgitation, Dilated Cardiomyopathy, Congestive Heart
Failure, History of Myocardial Infarction, Chronic Atrial
Fibrillation, Hyperlipidemia, History of Cerebrovascular
Accident, Trigeminal Neuralgia, Testicular Tumor - s/p
Orchiectomy, s/p Right Shoulder Surgery
Social History:
Lives with wife. Retired chief probation officer. Denies
tobacco. Occasional EtOH - averges out to one drink a day.
Family History:
No premature CAD. Brother and mother died of MI in their 70's.
Physical Exam:
Vitals: T 98.7, BP 139/72, HR 66, RR 16, SAT 100% on room air
General: elderly male in no acute distress
HEENT: oropharynx benign, sclera anicteric, PERRL, EOMI
Neck: supple, no JVD, no carotid bruits
Heart: irregular rate, normal s1s2, systolic murmur noted
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, 1+ edema, chronic venous stasis changes, no
varicosities
Pulses: 1+ distally
Neuro: nonfocal
Pertinent Results:
[**2101-1-12**] 03:04PM BLOOD WBC-6.1 RBC-3.75* Hgb-12.6* Hct-35.4*
MCV-94 MCH-33.6* MCHC-35.6* RDW-13.5 Plt Ct-148*
[**2101-1-12**] 03:04PM BLOOD PT-15.1* PTT-24.6 INR(PT)-1.4*
[**2101-1-12**] 03:04PM BLOOD Glucose-88 UreaN-23* Creat-1.1 Na-142
K-4.2 Cl-107 HCO3-25 AnGap-14
[**2101-1-12**] 03:04PM BLOOD ALT-20 AST-25 AlkPhos-103 Amylase-57
TotBili-0.6
[**2101-1-20**] 06:30AM BLOOD WBC-7.3 RBC-3.10* Hgb-10.0* Hct-30.3*
MCV-98 MCH-32.3* MCHC-33.1 RDW-14.2 Plt Ct-135*
[**2101-1-21**] 09:30AM BLOOD PT-21.1* INR(PT)-2.0*
[**2101-1-21**] 06:35AM BLOOD UreaN-39* Creat-1.7*
[**2101-1-20**] 06:30AM BLOOD Glucose-103 UreaN-39* Creat-1.9* Na-138
K-4.8 Cl-104 HCO3-25 AnGap-14
[**2101-1-19**] 03:23AM BLOOD Glucose-109* UreaN-34* Creat-1.8* Na-135
K-4.2 Cl-103 HCO3-23 AnGap-13
[**2101-1-18**] 04:51AM BLOOD Glucose-108* UreaN-33* Creat-2.0* Na-134
K-4.2 Cl-102 HCO3-24 AnGap-12
Brief Hospital Course:
Mr. [**Known lastname 95715**] was admitted and underwent routine preoperative
evaluation. He was concomitantly heparinized for his chronic
atrial fibrillation. Workup was otherwise unremarkable and he
was cleared for surgery. On [**1-14**], Dr. [**Last Name (STitle) 1290**]
performed a mitral valve replacement utilizing a 33 millimeter
CE perimount mitral bioprosthetic valve. The operation was
uneventful and he transferred to the CSRU in stable condition.
Within 24 hours, he awoke neurologically intact and was
extubated. He initially required atrial pacing for an underlying
junctional rhythm. He otherwise maintained stable hemodynamics
and successfully weaned from inotropic support. Over several
days, his native heart rate improved and low dose beta blockade
was resumed. Given his bradycardia and long standing history of
atrial fibrillation, Amiodarone was not recommended. He was
noted to have a slight decline in renal function but continued
to maintain adequate urine output. His creatinine peaked to 2.0
on postoperative day four. Diuretics were titrated accordingly.
His CSRU course was otherwise uneventful and he transferred to
the SDU on postoperative day five. His renal function continued
to improve. Warfarin was dosed daily for a goal INR between [**12-24**].
He transiently required Heparin for a subtherapeutic prothrombin
time. Over several days, he continued to make clinical
improvements and made steady progress the physical therapy.
He was cleared for discharge to rehab on postoperative day 7.
All surgical wounds were clean without signs of infection. His
creatinine continued to improve, and was 1.7 on the day of
discharge.INR on [**1-21**] was 2.0 after several doses of 5
milligrams.
Medications on Admission:
Lipitor 20 qd, Lasix 20 qd, Warfarin 5 qd, KCL, Aspirin 81 qd,
Toprol XL 12.5 qd
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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Warfarin 5 mg Tablet Sig: Five (5) Tablet PO ONCE (once) for
1 doses: check INR [**2101-1-22**] and prn and redose coumadin, .
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
On [**Location (un) **] - [**Location (un) **]
Discharge Diagnosis:
Mitral regurgitation - s/p MVR, Dilated Cardiomyopathy,
Postoperative Acute Renal Insufficiency, Congestive Heart
Failure, Chronic Atrial Fibrillation, Hyperlipidemia, History of
Cerebrovascular Accident, Trigeminal Neuralgia, Testicular Tumor
- s/p Orchiectomy, s/p Right Shoulder Surgery
Discharge Condition:
Good
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Weigh daily, call with weight gain 2 pounds in one day or five
in one week.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**2-23**] weeks - call for appt.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12646**] in [**12-24**] weeks - call for appt.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**12-24**] weeks - call for appt.
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**2-23**] weeks - call for appt.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12646**] in [**12-24**] weeks - call for appt.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**12-24**] weeks - call for appt.
Completed by:[**2101-1-21**]
|
[
"428.0",
"424.0",
"425.4",
"427.31",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5583, 5656
|
2955, 4678
|
288, 397
|
5990, 6003
|
2054, 2932
|
6667, 7277
|
1513, 1577
|
4809, 5560
|
5677, 5969
|
4704, 4786
|
6027, 6644
|
1592, 2035
|
229, 250
|
425, 1066
|
1088, 1363
|
1379, 1497
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,709
| 169,066
|
37940
|
Discharge summary
|
report
|
Admission Date: [**2110-5-17**] Discharge Date: [**2110-5-24**]
Date of Birth: [**2050-12-18**] Sex: M
Service: SURGERY
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
sigmoid diverticulitis
Major Surgical or Invasive Procedure:
[**2110-5-18**]
Sigmoid resection and end colostomy.
History of Present Illness:
59M with a history of non-Hodgkin's lymphoma on his 4th
cycle of chemotherapy and R RCC s/p nephrectomy [**3-13**] who
presented to OSH with abdominal pain. The pain was sudden onset
in the LLQ and was unlike any pain he had before. The pain was
associated with nausea. He denies fevers, chills, chest pain,
dysuria. He does have SOB at baseline. He had a normal BM today.
CT at the OSH demonstrated sigmoid diverticulitis with free air.
The patient prefered to be transfered to [**Hospital1 18**] since he gets his
care here. He never had a colonoscopy before. He states that he
had diverticulitis in the last 10 years but is unsure how these
episodes were diagnosed
Past Medical History:
[**8-/2108**] Waldenstrom's macroglobulinemia, RCC T3aNxM0,
hypertension, OCD, basal cell carcinoma, linear IgA, ?Lyme
disease, renal insufficiency
PSH: R nephrectomy [**3-13**], R knee surgery '[**66**], ?EVD for
hydrocephalus as neonate '[**50**]
Social History:
He is married, lives in [**State 2748**]. Occasional marijuana
smoker, no tobacco, social ETOH
Family History:
no history of colonCA
Physical Exam:
VS 99.8 113 135/79 20 94% 3L NC
Gen: A and O x 3
Card: tachycardia
Pulm: decreased BS B bases
Abd: obese soft distended TTP throughout especially LLQ with
voluntary guarding. small umbilical hernia
Ext: edema
Pertinent Results:
[**2110-5-17**] 10:10PM WBC-20.2*# RBC-3.98* HGB-13.4* HCT-39.1*
MCV-98 MCH-33.6* MCHC-34.2 RDW-15.6*
[**2110-5-17**] 10:10PM NEUTS-88* BANDS-0 LYMPHS-4* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-1*
[**2110-5-17**] 10:10PM PLT SMR-NORMAL PLT COUNT-160
[**2110-5-17**] 10:10PM PT-14.7* PTT-24.7 INR(PT)-1.3*
[**2110-5-17**] 10:10PM LIPASE-32
[**2110-5-17**] 10:10PM ALT(SGPT)-23 AST(SGOT)-12 ALK PHOS-76 TOT
BILI-1.2
[**2110-5-17**] 10:10PM UREA N-31* CREAT-1.7*
[**2110-5-17**] 10:16PM GLUCOSE-155* LACTATE-2.6* NA+-142 K+-4.0
CL--103 TCO2-26
[**2110-5-17**] 10:10 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ANAEROBIC GRAM NEGATIVE ROD(S). BETA LACTAMASE
POSITIVE.
Anaerobic Bottle Gram Stain (Final [**2110-5-19**]):
GRAM NEGATIVE ROD(S) .
Brief Hospital Course:
On [**5-18**], the patient was taken to the OR for an exploratory
laparotomy and sigmoid colectomy with colostomy/[**Doctor Last Name 3379**]
procedure for perforated diverticulitis and free air. He was
extubated in the SICU on POD 0. On POD 1, heme/onc was called
and they recommended a serum viscosity and possibly starting
IVIG if the patient becomes septic. That evening, his blood
culture was positive for GNR in the anaerobic bottle. He was
started on IVIG on POD 2. He was having issues with hypertension
and tachycardia/tachypnea. IVF were decreased. He also required
a 3 way foley placement for blockage of the foley with sediment.
On POD 3, the patient was doing well. His pain was well
controlled. The NGT was removed and he was transfered to the
floor in good condition.
Following transfer to the surgical floor he was treated with
IVIG a second time based on the heme/onc recommendations but he
required premedication as he developed chills and nausea. The
second administration was successful. He remained afebrile with
a WBC of 5K and subsequent blood cultures from [**5-21**] are
preliminary negative. He will complete a 2 week course of
antibiotics which ends [**2110-6-1**].
He gradually advanced his diet over a 48 hour period and was
able to tolerate a regular diet. His ostomy was active. The
ostomy nurse saw him on a regular basis for teaching and general
care however he will need that re enforced after discharge. On
[**5-23**], he experienced a small amount of drainage from the lower
pole of his incision, which was opened at the bedside and packed
with dry gauze. No pus was expressed, and the remainder of the
wound was clean and dry.
He remained free of any other pulmonary problems and was
maintained on his home bronchodilator as well as using his
incentive spirometer effectively.
He is being discharged home with stable vital signs, laboratory
values within normal limits, and home VNA to perform dressing
changes to the lower pole of his incision. There was no sign of
wound infection at discharge. He was given instructions to
follow up in surgery clinic.
Medications on Admission:
ACYCLOVIR 400"', ALBUTEROL, DAPSONE 50", DILTIAZEM 120,
FOLIC ACID 2, FUROSEMIDE 40, ASA 325, Vit D3
Discharge Medications:
1. dapsone 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) inh Inhalation four times a day as needed for shortness
of breath or wheezing.
4. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 11 days: thru [**2110-6-1**].
Disp:*16 Tablet(s)* Refills:*0*
11. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 11 days: thru [**2110-6-1**].
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Care
Discharge Diagnosis:
Perforated diverticulitis
Post op Respiratory Insufficiency
Gram negative bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-13**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
* The VNA will help you with your ostomy care and re enforce
teaching
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**2-6**] weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
|
[
"041.84",
"569.5",
"273.3",
"401.9",
"189.0",
"790.7",
"562.11",
"202.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.14",
"46.10",
"45.76"
] |
icd9pcs
|
[
[
[]
]
] |
5967, 6031
|
2555, 4659
|
308, 363
|
6160, 6160
|
1732, 2339
|
8251, 8467
|
1463, 1487
|
4811, 5944
|
6052, 6139
|
4685, 4788
|
6311, 7769
|
7785, 8228
|
1502, 1713
|
2383, 2532
|
246, 270
|
391, 1060
|
6175, 6287
|
1082, 1334
|
1350, 1447
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,753
| 143,241
|
49893
|
Discharge summary
|
report
|
Admission Date: [**2180-1-14**] Discharge Date: [**2180-1-26**]
Date of Birth: [**2108-7-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Hypotensive and psychotic
Major Surgical or Invasive Procedure:
Central line placement
EGD
History of Present Illness:
71 yo woman with HTN, b/l hearing loss, and recent admission for
dementia/paranoia presents with paranoia. Was going to be sent
to a psych facility but then had large melenic BM and became
hemodynamically unstable (HR 60s --> 120s and SBP 120s--> 100s).
Pt was overtly psychotic in ED so could not contribute to
history. Psych saw patient and deemed her to not have capacity.
Past Medical History:
HYPERTENSION
HYPERLIPIDEMIA
S/P TAH FOR FIBROIDS
S/P BENIGN BREAST BIOPSY LEFT [**2168**]
ATOPIC DERMATITIS/LICHEN SIMPLEX CHRONICUS ON LEGS
BILAT HEARING LOSS
PPD SCREENING
EPISTAXIS
Social History:
Employment:
Used to work at [**Hospital1 **] Children & Family Services as a home
health
aid, now retired and had increasing
difficulty working due to not being able to hear her clients.
Lives alone. She has four children and two grandchildren.
Her family is very involved in her care.
Grandson: [**Name (NI) **] cp [**Telephone/Fax (1) 104228**]
Daughter: [**Doctor First Name 8982**]- [**Telephone/Fax (1) 104229**] (h), work [**Numeric Identifier 104230**]
-works at [**Hospital6 1708**]
Son: [**Name (NI) **] [**Telephone/Fax (1) 104231**]
Physical Exam:
Temp afebrile
BP 115/82
Pulse 100
Resp 18
O2 sat 96% RA
Gen - Alert, no acute distress, not cooperative with exam
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - no JVD, no cervical lymphadenopathy
Chest - coarse Bs with rhonchi bilaterally
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, ? tender (pt pushing examiner away durign exam),
nondistended, with normoactive bowel sounds
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, 2+ edema to knees, erythema
anteriroly. 2+ DP pulses bilaterally, left upper ext with
nonpitting edema to elbow-stable
Neuro - Alert and oriented x 3, cranial nerves [**3-11**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - No rash
Psych- tangential, at times does not answer questions, paranoid
Pertinent Results:
CXR:
1) Persistent left retrocardiac density.
2) NG tube advanced (tip not on film but beyond duodenal bulb).
LE DUS: 1. No evidence of DVT within the left lower extremity.
2. A 5.7 x 1.9 x 2.0 cm hypoechoic lesion within the left groin
which could represent an abnormal lymph node. Clinical
correlation is suggested to better evaluate this finding.
[**2180-1-18**] 7:00 am SEROLOGY/BLOOD
H-PYLORI,ADDED FROM SPEC#[**Serial Number **]T-[**1-18**].
**FINAL REPORT [**2180-1-19**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2180-1-19**]):
POSITIVE BY EIA.
Reference Range: Negative.
[**2180-1-13**] 11:20AM PLT COUNT-352
[**2180-1-13**] 11:20AM NEUTS-77.4* LYMPHS-16.7* MONOS-4.4 EOS-1.0
BASOS-0.3
[**2180-1-13**] 11:20AM WBC-11.2* RBC-4.12* HGB-12.5 HCT-37.1 MCV-90
MCH-30.3 MCHC-33.6 RDW-12.7
[**2180-1-13**] 11:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2180-1-13**] 04:50PM GLUCOSE-368* UREA N-10 CREAT-0.3* SODIUM-141
POTASSIUM-2.6* CHLORIDE-107 TOTAL CO2-21* ANION GAP-16
[**2180-1-13**] 11:20AM GLUCOSE-59* UREA N-11 CREAT-0.4 SODIUM-142
POTASSIUM-2.6* CHLORIDE-101 TOTAL CO2-19* ANION GAP-25*
[**2180-1-13**] 09:20PM GLUCOSE-83 UREA N-7 CREAT-0.4 SODIUM-144
POTASSIUM-2.7* CHLORIDE-109* TOTAL CO2-20* ANION GAP-18
[**2180-1-14**] 01:36AM K+-3.1*
[**2180-1-14**] 01:36AM COMMENTS-GREEN TOP
[**2180-1-14**] 03:50AM PT-14.4* PTT-26.5 INR(PT)-1.3
[**2180-1-14**] 03:50AM PLT COUNT-387
[**2180-1-14**] 03:50AM NEUTS-65.4 LYMPHS-26.9 MONOS-6.2 EOS-1.1
BASOS-0.3
[**2180-1-14**] 03:50AM WBC-10.4 RBC-3.73* HGB-11.3* HCT-32.6* MCV-87
MCH-30.2 MCHC-34.6 RDW-12.8
[**2180-1-14**] 03:50AM GLUCOSE-123* UREA N-9 CREAT-0.4 SODIUM-144
POTASSIUM-3.4 CHLORIDE-112* TOTAL CO2-19* ANION GAP-16
[**2180-1-14**] 03:51AM HGB-11.1* calcHCT-33
[**2180-1-14**] 03:51AM K+-3.3*
[**2180-1-14**] 03:51AM COMMENTS-GREEN TOP
[**2180-1-14**] 06:10AM HCT-30.6*
[**2180-1-14**] 12:55PM HCT-33.5*
[**2180-1-14**] 12:55PM CALCIUM-7.4* PHOSPHATE-2.4* MAGNESIUM-1.1*
[**2180-1-14**] 12:55PM GLUCOSE-84 UREA N-5* CREAT-0.3* SODIUM-146*
POTASSIUM-2.9* CHLORIDE-119* TOTAL CO2-20* ANION GAP-10
[**2180-1-14**] 01:10PM URINE GR HOLD-HOLD
[**2180-1-14**] 01:10PM URINE UHOLD-HOLD
[**2180-1-14**] 01:10PM URINE HOURS-RANDOM
[**2180-1-14**] 01:10PM URINE HOURS-RANDOM
[**2180-1-14**] 01:10PM URINE HOURS-RANDOM SODIUM-57 CHLORIDE-77 TOTAL
CO2-LESS THAN
[**2180-1-14**] 02:30PM ACETONE-TRACE
[**2180-1-14**] 02:30PM GLUCOSE-82 UREA N-5* CREAT-0.2* SODIUM-148*
POTASSIUM-3.0* CHLORIDE-121* TOTAL CO2-22 ANION GAP-8
[**2180-1-14**] 02:48PM K+-3.0*
[**2180-1-14**] 06:48PM PLT COUNT-291
[**2180-1-14**] 06:48PM WBC-9.3 RBC-3.91* HGB-11.4* HCT-34.6* MCV-89
MCH-29.3 MCHC-33.1 RDW-13.7
[**2180-1-14**] 06:48PM URINE HOURS-RANDOM SODIUM-97 CHLORIDE-172
TOTAL CO2-<5
[**2180-1-14**] 06:48PM ALBUMIN-2.6* CALCIUM-7.7* PHOSPHATE-2.0*
MAGNESIUM-1.0*
[**2180-1-14**] 06:48PM ALT(SGPT)-14 AST(SGOT)-16 LD(LDH)-194 ALK
PHOS-70 TOT BILI-0.8
[**2180-1-14**] 06:48PM GLUCOSE-98 UREA N-4* CREAT-0.2* SODIUM-148*
POTASSIUM-3.3 CHLORIDE-119* TOTAL CO2-22 ANION GAP-10
[**2180-1-14**] 10:30PM HCT-34.3*
Brief Hospital Course:
71F PMH HTN, BL hearing loss, and recent admission for
paranoia--thought to be frontal dementia, who initially
presented for paranoia, but who had a large melanic BM in the ED
and was found to be tachycardic and hypotensive.
MICU course:
*
1. GI bleed: Pt was transferred to the MICU, typed and crossed
for 4 units of PRBCs, NG lavage and EGD attempted, but pt was
combative and were unable to complete. She received 1 unit of
PRBCs in the ED. Pt was electively intubated and EGD performed
which showed esophagitis, small non-bleeding ulcer in the
pyloric channel, diffuse erythema in the stomach (no biopsy
obtained), and evidence of duodenitis. Colonoscopy the following
day revealed grade 1 internal hemorrhoids and multiple
diverticuli of the sigmoid colon. Neither study found stigmata
of recent bleed. The patient was extubated, started on PPI, and
Hct was followed and remained stable throughout the remaining
hospitalization. H.pylori was positive.
*
2. Paranoia: As above, pt initially found to be incompetent for
decision making. Following extubation, she was on PRN haldol.
Over the next few hospital days, her mental status improved and
she was deemed to no longer need inpatient [**Female First Name (un) **]-psych. She is
currently awaiting placement in rehab.
*
3. Abnormal ultrasound: Pt had an ultrasound of the L LE, which
showed no DVT, but a 6x2x2cm hypoechoic lesion concerning for an
abnormal LN. The patient had evidence on physical exam of skin
findings c/w perhaps an attempted femoral line insertion, and
determined that the best course would be to follow this lesion
for resolution, and that the patient should have a repeat U/S in
6 weeks to re-evaluate.
*
4. Abnormal CXR: On transfer from the MICU, she was found to
have a persistent retrocardiac density on CXR, but no clinical
evidence of PNA. She was initially started on levofloxacin,
which was then discontinued in light of the absence of other
findings for PNA. She should have a f/u repeat CXR in 6 weeks.
Floor course:
Pt transferred to the floor and remained stable from a medical
perspective. She refused lab draws on many occasions stating
"they have taken enough blood out of me." In addition, she would
at times refuse to take medications; however, once explained to
her what the medications were for and reassurance she would
comply. She did allow one lab draw3 days prito to discharge.
1. GI Bleed: Stable. Guiac neg stool several times on floor.
Repeat Hct prior to d/c was at baseline. Triple therapy started
with amox/clarithro and should be continued along with protonix
40 mg [**Hospital1 **] x 14 days, then protonxis 40 mg qd.
2. Lower extremity edema: Chronic lower extremity swelling. No
evidence of celullitis. No other sign of failure. Likely venous
stasis. Leg elevation most successful. Tired TEDS which pt will
intermittently wear. States they cut off their circulation. Try
to reassure pt and place TEDS. Monitor exam as outpt.
3. Upper extrmeity edema: Unclear cause. Not IV in in that arm .
No rash or pain. Pt elevates arm with some relief. Monitor.
4. Pscyh: Pt followed by Dr. [**Last Name (STitle) 16293**] from psych. Seroquel used
and dose increased. Haoldol PO if agitated however did not use
this while on the floor. Pt did not want to take seroquel as it
"messes with her mind". It was held day prior to admission. No
aggitation. Encourage pt to take this. She does nto demonstrate
increasing paranoia or dementia. Would cont. seroquel and have
her f/u with her outpt PCP to determine if long term psych f/u
is needed. No actue psych issues at this time.
5. K/Mg depletion: Pt had low K and Mg on the few lab draws done
here. Mg 1.3 on last checka nd K 3.3. Tried medical repletetion
buyt pt refused. Cont to try oral repletionw ith diet. Please
facility manage the repletion.
6. Pt signed HCP form while here. Grandson is HCP.
Pt d/c is stable medical condition.
Medications on Admission:
ketoconazole shampoo, ammonium lactate lotion, hydrophil lotion,
clobetasol cream, asa, atenolol 25 mg qd, lisinopril 20 mg qd,
lipitor 10 mg qd, seroquel 25 mg [**Hospital1 **]
Discharge Medications:
1. Haloperidol 1 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for agitation.
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day: [**Hospital1 **] x 14
days, then qd.
3. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed.
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 14 days.
6. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
7. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
8. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO QPM
(once a day (in the evening)).
9. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once
a day for 3 days.
10. Outpatient Lab Work
please recheck potassium and magnesium in [**4-1**] days and replete
as needed
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center
Discharge Diagnosis:
1. GI bleed
2. Paranoia
3. Dementia
4. Hypercholesterolemia
5. H Pylori positive
6. Lower extremity swelling
7. Left upper extremity swelling
Discharge Condition:
Good. Stable.
Discharge Instructions:
If you have fevers/chills, shortness of breath, blood in stool,
chest pain, please call your PCP or come to the ED.
Please have follow up CXR in 6 weeks.
Please have follow up L groin U/S in 6 weeks.
Follow up with primary care physician [**Last Name (NamePattern4) **] [**1-29**] weeks.
Take prescribed antibiotics for 14 days total.
If you have fevers/chills, shortness of breath, blood in stool,
chest pain, please call your PCP or come to the ED.
Please have follow up CXR in 6 weeks.
Please have follow up L groin U/S in 6 weeks.
Follow up with primary care physician [**Last Name (NamePattern4) **] [**1-29**] weeks.
Take prescribed antibiotics for 14 days total.
Followup Instructions:
Please call your PCP for [**Name Initial (PRE) **]/u in [**1-29**] weeks.
|
[
"275.2",
"578.9",
"276.5",
"295.30",
"401.9",
"455.0",
"535.60",
"782.3",
"285.1",
"276.8",
"459.81",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.93",
"96.04",
"96.71",
"45.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10792, 10852
|
5662, 9567
|
340, 368
|
11038, 11053
|
2429, 5639
|
11773, 11850
|
9795, 10769
|
10873, 11017
|
9593, 9772
|
11077, 11750
|
1561, 2410
|
275, 302
|
396, 774
|
796, 984
|
1000, 1546
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,827
| 189,800
|
15616
|
Discharge summary
|
report
|
Admission Date: [**2105-2-17**] Discharge Date: [**2105-3-5**]
Date of Birth: [**2038-4-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Wound vac placement
History of Present Illness:
Mr. [**Known lastname 45124**] is a 66 yo male with h/p inflammatory spinal disease,
CHF with EF 30%, recurrent UTIs,who presented on [**2-17**] from neuro
clinic for hypotension. He was being seen in clinic for f/u
after recent admission for flaccid paraplegia of unclear
etiology. In clinic, he was hypotensive to 80/50, (baseline BP
is 90-100 with EF of 30%), tachycardic at 110, with a temp of 99
and a productive cough. In the ED, he was noted to be mildly
confused, with some bilateral asterixis.He had a positive UA and
a lactated of 1.7. He was given levaquin and vancomycin. His CXR
was clear and EKG was unremarkable. On the floor he triggered 3
times for hypotension. He as given several boluses for a total
of 3 liters and blood pressure continued to be in the 70s
systolics. His UOP was 800 cc overnight and mental status was
stable. Overnight, he received 3L IVF and SBP remained 80s-100s.
As he was HD stable w/o evidence for sepsis, he was transferred
to medicine the next morning. He was treated with continued IV
ABx (vanc/zosyn). As his paraperesis again became the largest
issue in his care, he was transferred to neurology on [**2-23**]. MRI
demonstrated pan spinal cord inflammation and he was felt to
possibly have a myelitis of inflammatory etiology vs AVM; CT
myelogram, CTA for AVM, and spinal cord biopsy were beign
considered. At midnight, his BP dropped from his recently bl of
90s-100s to 70/58; at 4AM it was 74/52, at 8AM 78/52 and 93/67 @
1600. His creatinine rose from .5 on [**2-24**] to 1.3 to 2 today.
Nephrology was consulted. They evaluated his urine and felt AIN
most likely. At this time, the patient reports that he is
thirsty and has some R shoulder discomfort, but denies chest
pain/tightness, SOB, n/v, diarrhea, BRBPR, melena. On arrival to
floor, I gave the patient a 500cc bolus which rose his pressure
to 100/60. Within 20 minutes, this was down to 80/p so LEJ was
placed, IVF run in, and he was taken to the SICU under the MICU
[**Location (un) 2452**] service. In the MICU, he had a marginal response to a
cosyntropin stim test, so he was started on fludrocortisone for
his hypotension. His antibiotics were stopped, as he had
completed 10 days of antibiotics directed at hospital acquired
PNA.
Past Medical History:
Inflammatory disease of the spinal cord
Right frontal lobe lesion
Abnormal visual evoked potentials
Status post brain biopsy of right frontal lobe lesion
Pulmonary embolus
Status post IVC filter placement
Asthma
Coronary artery disease
Status post liver surgery for liver laceration following stab
wound
Chronic back pain
Vitiligo
Social History:
Patient lives alone and is divorced. Has 3 healthy children.
Retired due to back pain, used to work as [**Doctor Last Name 9808**] driver.
Family History:
No stroke, aneurysm, no seizure, no AAA.
Physical Exam:
98.4/98.2 97/70 96 18 100%OFM
General: elderly man, NAD, A+Ox3, cooperative, pleasant
Neck: supple, no LAD, no JVD
Head: OP clear
Chest: coarse breath sounds diffusely but no w/r/r
Cardiovascular: rrr, no m/g/r
Abdomen: soft, nt, nd, +BS, gtube clean
Extremities: LLE 1+pitting edema, RLE trace edema, both feet in
multipodous boot
Pertinent Results:
[**2105-2-17**] 01:40PM BLOOD WBC-7.6 RBC-4.27* Hgb-13.4* Hct-39.0*
MCV-91 MCH-31.5 MCHC-34.4 RDW-15.4 Plt Ct-422#
[**2105-3-4**] 07:00AM BLOOD WBC-6.3 RBC-3.09* Hgb-9.5* Hct-28.2*
MCV-91 MCH-30.8 MCHC-33.7 RDW-15.4 Plt Ct-258
[**2105-2-17**] 01:40PM BLOOD Neuts-67.9 Lymphs-22.2 Monos-7.6 Eos-1.9
Baso-0.3
[**2105-2-27**] 04:00AM BLOOD Neuts-71.2* Lymphs-18.4 Monos-8.5 Eos-1.4
Baso-0.5
[**2105-2-17**] 01:40PM BLOOD PT-27.8* PTT-31.5 INR(PT)-2.9*
[**2105-2-20**] 03:00PM BLOOD PT-47.5* PTT-36.9* INR(PT)-5.5*
[**2105-3-4**] 07:00AM BLOOD PT-26.2* PTT-63.3* INR(PT)-2.7*
[**2105-2-18**] 01:23PM BLOOD Fibrino-576*#
[**2105-2-18**] 08:52PM BLOOD ESR-70*
[**2105-2-17**] 01:40PM BLOOD Glucose-103 UreaN-13 Creat-0.5 Na-139
K-4.2 Cl-104 HCO3-25 AnGap-14
[**2105-2-26**] 05:24AM BLOOD Glucose-95 UreaN-16 Creat-2.0* Na-138
K-3.6 Cl-105 HCO3-28 AnGap-9
[**2105-3-4**] 07:00AM BLOOD Glucose-119* UreaN-13 Creat-1.6* Na-141
K-3.9 Cl-107 HCO3-27 AnGap-11
[**2105-2-18**] 08:52PM BLOOD ALT-22 AST-13 CK(CPK)-42 AlkPhos-90
TotBili-0.3
[**2105-2-24**] 05:05AM BLOOD ALT-12 AST-10 AlkPhos-88 Amylase-77
TotBili-0.4
[**2105-2-23**] 05:25AM BLOOD Lipase-15
[**2105-2-17**] 01:40PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2105-2-26**] 05:24AM BLOOD CK-MB-2 cTropnT-0.10*
[**2105-2-26**] 05:32PM BLOOD CK-MB-6 cTropnT-0.22*
[**2105-2-27**] 04:00AM BLOOD CK-MB-4 cTropnT-0.07*
[**2105-2-18**] 05:51AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.8
[**2105-2-26**] 05:24AM BLOOD Calcium-8.2* Phos-4.7* Mg-2.1
[**2105-3-4**] 07:00AM BLOOD Calcium-8.1* Phos-4.4 Mg-1.7
[**2105-2-18**] 01:32PM BLOOD Hapto-155
[**2105-2-18**] 05:51AM BLOOD TSH-1.4
[**2105-2-18**] 05:51AM BLOOD Cortsol-9.3
[**2105-2-18**] 05:31PM BLOOD Cortsol-16.7
[**2105-2-18**] 05:58PM BLOOD Cortsol-25.6*
[**2105-2-26**] 05:32PM BLOOD Cortsol-16.2
[**2105-2-26**] 10:40PM BLOOD Cortsol-23.9*
[**2105-2-26**] 11:08PM BLOOD Cortsol-20.0
[**2105-2-27**] 04:24AM BLOOD Vanco-31.7*
[**2105-2-28**] 04:13AM BLOOD Vanco-22.3*
[**2105-2-17**] 01:42PM BLOOD Lactate-1.7
[**2105-2-26**] 08:16PM BLOOD Lactate-1.7
.
[**2105-2-18**] 10:41 am SWAB Source: Sacral ulcer.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2105-2-22**]): NO ANAEROBES ISOLATED.
.
CHEST (PA & LAT) [**2105-2-17**] 2:15 PM
No acute cardiopulmonary disease. Mild hyperinflation suggestive
of COPD.
.
ECG Study Date of [**2105-2-17**] 1:30:52 PM
Resting sinus tachycardia. Prior inferior wall myocardial
infarction. Ppossible prior anterior wall myocardial infarction.
Non-specific ST-T wave changes. Compared to the previous tracing
of [**2104-11-26**], allowing for lead placement variation, no
diagnostic change.
.
MR L SPINE WITH CONTRAST [**2105-2-20**] 3:15 AM
MR [**Name13 (STitle) **] SCAN WITH CONTRAST; MR T SPINE SCAN WITH CONTRAST
1. Since [**2104-11-4**], marked worsening of the expansion and edema of
the thoracic cord now extending from the T2 level down to the
conus with some subtle patchy areas of enhancement at the T9/10
level and at the conus. These findings may represent a primary
tumor of the cord such as an ependymoma, though the relative
lack of enhancement would be atypical, or astrocytoma. Other
possibilities would include a demyelinating/inflammatory process
such as MS or an infectious process such as tropical spastic
paraparesis (HAM/TSP). 2. Multilevel degenerative changes as
described above but without high-grade canal stenosis.
.
CHEST (PORTABLE AP) [**2105-3-2**] 11:42 AM
No acute cardiopulmonary process. No evidence of pneumonia.
.
RENAL U.S. [**2105-2-27**] 2:15 PM
Increased echogenicity of both kidneys, possibly due to acute
renal parenchymal disease. Unchanged left renal cyst.
.
CT CHEST W/O CONTRAST [**2105-3-2**] 4:39 PM
1. Septal thickening at the lung bases and small right pleural
effusion, consistent with hydrostatic pulmonary edema. Dependent
ground glass opacity in right lower lobe is likely due to a
combination of dependent atelectasis and minimal edema. No areas
of consolidation to suggest acute infectious pneumonia. 2. Right
middle lobe nodule is unchanged since [**2104-10-10**] and most
likely benign. However, if there is a concern for metastatic
disease or risk factor for primary lung cancer, then a followup
CT in [**2105-10-10**] may be helpful to ensure stability.
.
ECHO Study Date of [**2105-2-27**]
1.The left atrium is mildly dilated. 2. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is moderate to severe regional left ventricular
systolic dysfunction with XXX. No masses or thrombi are seen in
the left ventricle. 3. Right ventricular chamber size is normal.
4.The aortic root is moderately dilated athe sinus level. The
aortic arch is mildly dilated. 5.The aortic valve leaflets (3)
are mildly thickened. No aortic regurgitation seen. 6.The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. 7.There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2104-11-4**], no significant change. The previous assessment of
LV function was probably an overestimate.
Brief Hospital Course:
66 year old male with hx of inflammatory spinal disease, EF 30%,
recurrent UTIs, presents from neuro clinic for hypotension,
low-grade fever, cough, UTI.
.
# Hypotension/fevers:
Unclear etiology. He was transferred to the MICU twice for
recurrent hypotension, each time responding to IVF boluses.
Differential included hypovolemia (possibly [**3-13**] Hct drop).
Sepsis also possible given pseudomonas UTI during previous
admission, although no leukocytosis, normal differential,
afebrile since admission; alternative source included decub
sacral ulcer which grew MRSA. Cardiogenic shock less likely
given exam findings, no ECG changes, and troponins elevated only
in setting of acute renal failure. Concern for adrenal
insufficiency given history of corticosteroid exposure,
hypotension, low AM cortisol level, and elevated eosinophil
count. Briefly placed on fludricortisone during second MICU
course. Lactate of 1.7 made sepsis less likely and he had been
afebrile since completing 10 day course of vanc/zosyn for ?
HAP/UTI. Midodrine was considered by neurology but never
administered as BP responded to IVF during each hypotensive
episode. Currently hemodynamically stable, continuing to mentate
with good urine output. Outpatient beta blocker and ACEi were
held secondary to hypotension and renal failure and should be
restarted outpatient once BP appears to be stable and renal
function back to baseline normal.
.
# Acute renal failure:
Pt had gradual increase in creatnine from baseline Cr 0.5-0.7 to
peak of 2.0 from [**2-24**] to [**2-26**]. It has been trending down since
then and now remaining stable at 1.6. Urine negative for
eosinophils. Urine lytes consistent with intrinsic failure. UA
showed many wbc with clumps of wbc. In addition he had
peripheral eosinophilia for the past 2 days, likely interstitial
nephritis. Renal ultrasound revealed increased echogenicity of
both kidneys, possibly due to acute renal parenchymal disease
from AIN and WBC's in urine sediment. [**Month (only) 116**] also has a component
of prerenal due to decrease renal perfusion from hypotension and
volume contraction from decreased PO intake and many BM/day.
However, etiology may also be ATN [**3-13**] contrast nephropathy. Now
in polyuric phase with downward trending creatinine, will
continue to follow. Avoid nephrotoxins, renally dose
medications.
.
# CHF:
EF 30%, euvolemic. Unclear why patient not on afterload
reduction. Monitored I/O's for goal of even post fluid
resuscitation. Will continue to hold lopresser.
.
# Cough:
Pt with increased cough over past week, productive with clear
and occasional yellow sputum. Repeat CXR [**2-18**] negative for
infiltrates. Oxygen saturations stable on RA. Symptomatic
treatment with nebs/expectorant/cough suppresant.
.
# Hypoxia:
Baseline asthma, which has been stable throughout this hospital
course. Serial CXR's have been very clear with no evidence of
infiltrate or edema. Lung exam, however, noted to be markedly
worsened on [**3-2**] but again no evidence of infiltrate on CXR. CT
chest scan revealed Septal thickening at the lung bases and
small right pleural effusion, consistent with hydrostatic
pulmonary edema. Dependent ground glass opacity in right lower
lobe is likely due to a combination of dependent atelectasis and
minimal edema. Continue albuterol, advair, nebs, montelukast.
Continue incentive spirometry. Monitor respiratory status
closely.
.
# Hx of UTI:
Patient had a urinary tract infection on [**11-21**] associated with
foley and completed a 7 day course of Ciprofloxacin.
Pansensitive Pseudomonas aeruginosa grew from urine culture. Pt
was unable to perform self-cath due to lack of sensation below
T8. He has remained with indwelling foley. This has contributed
to recurrent UTIs. U/A positive on admission, started on
antibiotics. Switched from cipro to vanco/zosyn post trigger for
low BP, concern for urosepsis.
.
# Constipation:
On aggressive bowel regimen, along with daily lactulose and prn
golytely.
.
# Hx of DVT/PE:
PE and DVT (L superficial femoral) diagnosed in [**10-15**]. Patient
anticoagulated on coumadin, plus IVC filter. Found to have a
large DVT and asymptomatic pulmonary embolus. This was likely
due to immobility and stasis. IVC filter placed under IR on
[**11-24**] for unclear reasons. This was during the same
hospitalization and not clearly secondary to failure through
anticoagulation. INR therapeutic on coumadin increased, likely
from receiving ciprofloxacin on admission. Coumadin was held,
vitamin K was administered, and coumadin was later restarted
with heparin bridge until INR was therapeutic again.
.
# Inflammatory/demyelinating disease:
Pt presented in [**10-15**] with lower extremity weakness which
progressed to paralysis below T8 level during hospital stay. MRI
concerning for demyelinating disease. No improvement with
prolonged steroid course during previous admission. Repeat MRI
during current hospital course revealed expanding inflammatory
cord disease of unknown etiology (? demyelination vs. tumor vs.
AVM). RPR negative, lyme negative, ESR 70/CRP 66.8, [**Doctor First Name **]
negative. ACE wnl and neuromyelitis IgG negative. Ro and La
negative. Further work-up such as biopsy, spinal CTA deferred at
this time due to above acute issues. Appears to be MS variant
based on visual evoked potentials during prior admission,
however, no general consensus on disease process. On tizanidine
4 TID and Neurontin 600 QID. Neurology will followup with
further workup outpatient.
.
# Stage IV sacral decubitus ulcer:
Pt has large decub ulcer measuring 8x10cm in middle of sacrum
extending to bone in some areas. This is concerning for
infection including osteomyeltitis given his presentation with
low BP and fevers. Wound swab culture grew MRSA. Plastics placed
wound vacm, to be changed every 3 days. Recommend WTD dressings
[**Hospital1 **], kinair bed, frequent rotations. On MVI, Zinc, Vit C & tube
feeds for wound healing.
.
# FEN: cardiac diet
Poor PO intake, only taking sips. Continue supplementing diet
with tube feeds via PEG. On aspiration precautions.
.
# Prophylaxis: bowel regimen, ppi
.
# Code: FULL
Revisited during ICU course, Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] with the Palliative
Care service following as needed, patient states "I want to keep
on living."
.
# Communication: PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10145**], [**Telephone/Fax (1) 10573**]
.
# Dispo:
Followup with PCP for further medical management, [**Hospital1 18**] Plastic
Surgery, and [**Hospital1 18**] Neurology. DC to rehab.
Medications on Admission:
1. Montelukast 10 mg QD
2. Atorvastatin 20 mg QD
3. Senna 8.6 mg [**Hospital1 **]
4. Trazodone 50 mg QHS
5. Pantoprazole 40 mg Tablet [**Hospital1 **]
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch QD
7. Simethicone 80 mg TID
8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk [**Hospital1 **]
9. Acetaminophen 325 mg Q4-6H
10. Tizanidine 2 mg TID
11. Albuterol 90 mcg/Actuation 1-2 PUFFS
12. Gabapentin 300 mg TID
13. Insulin Regular Human 100 unit/mL Solution
14. Heparin (Porcine) 5,000 unit/mL SC TID
15. Lactulose 10 g/15 mL TID
16. Docusate Sodium 100 mg QD
17. Bisacodyl 10 mg Suppository [**Hospital1 **]
18. Metoprolol Tartrate 12.5MG QD
19. Miconazole Nitrate 2 % Powder
20. Warfarin 3 mg QHS
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q4H (every 4 hours) as needed for cough.
14. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4-6H (every 4 to 6
hours) as needed.
15. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
18. Hexavitamin Tablet Sig: Five (5) ML PO DAILY (Daily).
19. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
20. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
21. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
22. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
23. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
24. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
Q2H (every 2 hours) as needed for cough.
25. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Paraparesis (unclear etiology)
Autonomic hypotension
Stage IV sacral decubitus ulcer
.
SECONDARY DIAGNOSES:
Right frontal lobe lesion s/p brain biopsy
Abnormal visual evoked potentials
h/p pulmonary embolus s/p IVC filter
Asthma
CAD s/p CABG ([**2100**]; LIMA->LAD, SVG->D1)
CHF (EF 25-30%)
s/p liver surgery for liver laceration following stab wound
Chronic back pain
Vitiligo
Indwelling foley catheter with recurrent UTIs
Decubitus ulcer
Altered mental status
(per OSH note: baseline "alert with periods of confusion")
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted for low blood pressure and suspected
infection. Your low BP responded to fluids after being
transferred to the ICU multiple times, but no definitive soruce
of infection was found. It was thought that your neurological
disorder that resulted in leg paralysis during previous
admission may be contributing to your low blood pressure.
.
Please take all medications as prescribed. Call your PCP or
return to the ED if you experience fevers, chills, shortness of
breath, chest pain, lightheadedness, dizziness, low blood
pressure, nausea, vomiting.
Followup Instructions:
Please have INR level checked regularly to ensure its within
therapeutic range.
.
PLASTIC SURGERY CLINIC
Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2105-3-27**] 1:30
.
Please followup with your PCP [**Last Name (NamePattern4) **] 1 week for further medical
management, call number below to make an appointment:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD @[**Hospital1 18**] Neurology
Phone:[**Telephone/Fax (1) 5434**] Date/Time:[**2105-4-10**] 11:30
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"458.9",
"323.9",
"996.64",
"564.00",
"493.90",
"707.8",
"428.0",
"707.12",
"276.52",
"682.2",
"344.9",
"276.2",
"V12.51",
"707.03",
"V44.1",
"415.19",
"599.0",
"486",
"453.8",
"799.02",
"311",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
18706, 18772
|
9074, 15680
|
324, 346
|
19355, 19365
|
3559, 9051
|
19975, 20709
|
3149, 3191
|
16428, 18683
|
18793, 18899
|
15706, 16405
|
19389, 19952
|
3206, 3540
|
18920, 19334
|
273, 286
|
374, 2621
|
2643, 2976
|
2992, 3133
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,506
| 112,218
|
82+83
|
Discharge summary
|
report+report
|
Admission Date: [**2195-6-6**] Discharge Date: [**2195-6-19**]
Date of Birth: [**2120-5-13**] Sex: F
Service: Cardiothoracic Surgery
CONTINUATION:
DISCHARGE MEDICATIONS:
1. Sertraline 150 mg per jejunostomy tube q.d.
2. Lantus insulin 30 units subcutaneous q.p.m.
3. Prevacid 30 mg elixir via jejunostomy tube q.d.
4. Epogen 10,000 units IV three times weekly with dialysis
treatments.
5. Heparin 5,000 units subcutaneously q. 6 hours.
6. M.V.I. 5 mL via jejunostomy tube q.d.
7. Zinc sulfate 220 mg via jejunostomy tube q.d.
8. Vancomycin 250 mg solution via jejunostomy tube q. 6 hours
for her C. difficile.
9. Amiodarone 200 mg via jejunostomy tube q.d.
10. Flagyl 500 mg IV q. 12 hours also for C. difficile.
11. Vitamin C 500 mg via jejunostomy tube q.d.
12. Reglan 10 mg IV q. 12 hours.
13. Percocet 5/325 one to two tablets via jejunostomy tube q.
4 hours p.r.n.
14. The patient is on vancomycin 1 gram IV to be dosed
according to a level prior to dialysis treatments. The
patient should be dosed with 1 gram IV for a level less than
15.
15. The patient is receiving tobramycin 70 mg IV with
dialysis dosing and should have her tobramycin levels
checked. She should be redosed with tobramycin when her
level falls below 1.5, that is a trough level.
TREATMENT REQUIRED UPON DISCHARGE:
1. The patient receives wet-to-dry normal saline dressings to
her right lower extremity wounds as well as her abdominal
wound t.i.d.
2. The patient has a V.A.C. dressing in her open sternal
wound which should be changed twice weekly. It was most
recently changed on Thursday, [**6-18**].
3. The patient is being tube fed via her jejunostomy tube,
full-strength Impact with fiber at 70 mL per hour.
4. The patient's current ventilator settings are CPAP with
pressure support of 5 and PEEP of 5 and FIO2 of 50%. She may
have a Passey-Muir valve p.r.n. to speak. She should have
assistance from the speech therapy department to assist her
with speaking with her tracheostomy.
CONDITION ON DISCHARGE: Fair.
DISCHARGE DIAGNOSES:
1. Sternal wound infection status post cardiac surgery,
status post limited sternal wound debridements on [**2195-6-9**].
2. End-stage renal disease.
3. Respiratory failure.
4. Clinical depression.
5. Insulin dependent diabetes mellitus.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2195-6-19**] 12:13
T: [**2195-6-19**] 12:33
JOB#: [**Job Number 965**]
Admission Date: [**2195-6-6**] Discharge Date: [**2195-6-22**]
Date of Birth: [**2120-5-13**] Sex: F
Service: Cardiothoracic
HISTORY OF PRESENT ILLNESS: This is a 75-year-old female
patient who had a very prolonged previous hospitalization at
the [**Hospital1 69**] and was ultimately
discharged on [**2195-5-28**]. During her hospitalization,
she underwent coronary artery bypass graft x4 with an aortic
valve replacement. Her postoperative course was complicated
by aspiration, wound infection of her sternal wound as well
as of her saphenectomy, gastrostomy tube placement, followed
by necrosis of the abdominal wall as well as acute renal
failure. Please see discharge summary from that
hospitalization for details of her postoperative course after
her cardiac surgery.
The patient was readmitted to the hospital on [**2195-6-6**]
due to fevers to 103 at the rehabilitation facility despite
being on intravenous antibiotics. In the Emergency
Department, the patient was noted to have a fair amount of
purulent drainage in the open sternal wound. The patient was
admitted to the Surgical Intensive Care Unit at that time.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery bypass
graft as previously noted with an aortic valve replacement
for aortic stenosis.
2. End-stage renal disease. The patient is hemodialysis
dependent.
3. Hypertension.
4. Insulin dependent-diabetes mellitus.
5. Sleep apnea.
6. Vertigo.
7. Osteoarthritis.
8. Skin cancer in the past.
9. Abdominal hernia repair.
10. Uterine cancer status post total abdominal hysterectomy.
11. Obesity.
MEDICATIONS ON ADMISSION TO THE HOSPITAL:
1. Tobramycin.
2. Vancomycin.
3. Reglan.
4. Protonix.
5. Amiodarone.
6. Zoloft.
7. Compazine.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION TO THE HOSPITAL: The
patient was awake and responsive, following commands
appropriately. She was on a ventilator via tracheostomy.
HEENT was unremarkable. Her lungs were clear to auscultation
bilaterally. Patient was tachycardic with a regular, rate,
and rhythm. Her abdomen was soft, obese, nontender, and
nondistended.
LABORATORY VALUES UPON ADMISSION TO THE HOSPITAL: White
blood cell count of 10,000, hematocrit of 32, platelet count
of 201. Sodium of 148, potassium 3.3, chloride 110, CO2 21,
BUN 42, creatinine 3.7, glucose of 277.
Patient initially had an echocardiogram which revealed a left
ventricular ejection fraction of 60% and moderate tricuspid
regurgitation.
Chest x-ray on admission to the hospital revealed a small
left pleural effusion, and questionable congestive heart
failure pattern.
It was noted that the patient's Vancomycin and tobramycin
levels were quite low upon admission to the hospital, and she
was restarted on both of those medications.
On [**6-7**], hospital day two, the patient underwent a
Plastic Surgery consultation due to persistent sternal wound
infection, which had previously been healing now showing
signs of infection. Patient was also noted to have
Clostridium difficile colitis, for which she had been placed
on intravenous Flagyl.
The patient was ultimately taken to the operating room on
[**2195-6-9**] after transesophageal echocardiogram the
previous day ruled out endocarditis. In the operating room
the patient underwent a limited sternal wound debridement and
drainage of some fluids at the inferior portion of her wound.
Postoperatively, the patient returned to the Surgical
Intensive Care Unit, where she has had problems with
intermittent hypotension requiring IV Neo-Synephrine drip.
Patient continued on tube feeds via her jejunostomy tube
which was previously placed during her previous admission,
which she had been tolerating well. She was still on the
ventilator on varying levels of pressure support in the CPAP
mode which she had tolerated well on 50% FIO2.
Patient received a few units of packed red blood cells over
the course of the next few days due to drifting hematocrit.
Patient's sternal wound had remained clean, and ultimately a
VAC dressing was placed in the sternal wound area on [**2195-6-18**]. The patient was maintained on 3x a week hemodialysis
treatments on Monday, Wednesday, Friday, and has been
tolerating those treatments well. Patient's pressure support
was ultimately weaned from 12 to 5, and she has remained on
pressure support of 5 for the past few days with an FIO2 of
50% and a PEEP of 5 as well, and has remained stable on those
ventilator settings.
The patient has had short bouts of trache mask trials, but
does get tachypneic after approximately 30 minutes. Patient
also required bedside repositioning of her jejunostomy tube
which was done in the Intensive Care Unit successful with no
sequelae from that patient. The patient has remained with
stable hemodynamic parameters. Has been tolerating her tube
feeds, has remained on minimal ventilator supports, and she
is ready to be transferred to rehabilitation facility to
progress with Physical [**Hospital 966**] rehabilitation, and ultimate
weaning from a ventilator.
The patient's condition day on [**2195-6-19**] is as follows:
temperature is 99.0, heart rate is 88 in normal sinus rhythm,
respiratory rate varies from 18-24. Her blood pressure is
114/46. On the ventilator, the patient is in a CPAP mode
with 5 of PEEP, 5 of pressure support, and 50% of O2 with a
most recent blood gas being 7.41, 41, 73, 27. Other
laboratory values from today, [**6-19**] are as follows: White
blood cell count 5.6, hematocrit of 35.8, platelet count of
206. PT 13.9, INR 1.3, PTT 29.9, sodium 132, potassium 5.3,
chloride 99, CO2 24, BUN 64, creatinine 3.6, glucose 124.
Patient's most recent chest x-ray was on [**2195-6-8**] which
showed a chronic left pleural effusion.
Most recent cultures include a sputum culture from [**6-8**]
which revealed MRSA, Pseudomonas, as well as Serratia.
Patient is previously cultured MRSA from both her leg wound
and her sternal wound. Stool on [**6-10**] is positive for
Clostridium difficile. Urine on [**6-12**] is positive for
proteus and enterococcus, and her sternal wound swab on [**6-9**] had rare growth of diphtheroids.
Physical examination today: The patient is awake, alert, and
responsive. She has coarse breath sounds bilaterally. Her
chest wound is clean with a VAC dressing in place. Her
abdomen is soft, obese, and nontender. Her extremities are
with 2+ edema bilaterally.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2195-6-19**] 12:04
T: [**2195-6-19**] 12:09
JOB#: [**Job Number 967**]
|
[
"V55.0",
"V10.42",
"707.0",
"008.45",
"403.91",
"998.59",
"518.81",
"V43.3",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.61",
"39.95",
"88.72",
"38.93",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
2046, 2720
|
192, 1300
|
1316, 1993
|
2749, 3728
|
3750, 9298
|
2018, 2025
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,186
| 172,091
|
12445
|
Discharge summary
|
report
|
Admission Date: [**2146-1-24**] Discharge Date: [**2146-1-25**]
Date of Birth: [**2092-1-26**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Aminoglycosides
Attending:[**First Name3 (LF) 1631**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53 yo F with PMH anoxic encephalopathy for years s/p cardiac
arrest, nonverbal at baseline, h/o seizure disorder, hep C
cirrhosis presents with BRBPR and hematemesis at [**Hospital **] rehab. Per
report, pt had been in USOH until today when this occurred. Pt
came into the ED where initial Hct was 35, but BP was in 80-90s.
NG lavage was initially negative. Pt was started on octreotide
gtt and PPI for a presumed variceal upper GI bleed. SBP
subsequently dropped in 60s, when more aggressive blood
transfusions and IVF were started. A femoral cordis was placed.
The NGT was then repositioned and showed profuse dark bloody
output. Pt also began having profuse melena.
.
In [**Name (NI) **], pt was initially triaged to MICU for aggressive treatment
of upper and lower GI bleed. However, after Dr. [**First Name (STitle) **] [**Name (STitle) **]
(the GI fellow on call) and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (senior MICU resident
on call) had a discussion with the pt's mother [**Name (NI) 4134**] [**Name (NI) 363**],
the patient's mother stated that she did not want an EGD
performed and that the patient would not have wanted this
aggressive level of care. She decided that goals of care should
be shifted to comfort only. Currently, pt appears comfortable
after receiving morphine, ativan, and anzemet in ED.
Past Medical History:
1. Seizure disorder.
2. Status post cardiac arrest with anoxic encephalopathy.
3. Sjogren's syndrome.
4. Dysphagia--G-tube dependent.
5. History of alcohol abuse.
6. Cirrhosis.
7. Hep. C positive.
Social History:
The patient's mother is a legal guardian, [**Name (NI) 4134**] [**Name (NI) 363**]
[**Telephone/Fax (1) 38664**]. The patient has history of tobacco and alcohol
abuse. The patient has two kids.
Family History:
noncontributory
Physical Exam:
Tm 98.4 Tc 98.4 BP 60's/P-->115/87 HR 110 RR 12 Sat 100%RA
Gen: awake, alert, somewhat responsive
HENNT: MMM, anicteric, PERRL, EOMI
Neck: LAD, JVD
CV: Regular and tachy, nl S1S2, No M/R/G
Lungs: CTA b/l
Abd: soft, tndr to palpation diffusely, ND, naBS, difficult to
illicit guarding/rebound.
Ext: no edema, ext cold to touch.
Neuro: awake and alert but not verbal or oriented.
Skin: no rash
Pertinent Results:
CXR [**1-25**]:
No acute disease
[**2146-1-24**] 06:25PM BLOOD WBC-20.5*# RBC-4.08* Hgb-12.9 Hct-35.8*
MCV-88 MCH-31.5 MCHC-36.0* RDW-13.4 Plt Ct-316
[**2146-1-24**] 06:25PM BLOOD Neuts-79* Bands-10* Lymphs-5* Monos-2
Eos-2 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2146-1-24**] 06:25PM BLOOD PT-13.3 PTT-28.8 INR(PT)-1.2
[**2146-1-24**] 06:25PM BLOOD Glucose-132* UreaN-30* Creat-0.7 Na-136
K-7.4* Cl-102 HCO3-24 AnGap-17
[**2146-1-24**] 06:25PM BLOOD ALT-75* AST-132* LD(LDH)-819*
CK(CPK)-150* AlkPhos-115 Amylase-103* TotBili-0.5
[**2146-1-24**] 06:25PM BLOOD Lipase-52
[**2146-1-24**] 06:25PM BLOOD CK-MB-3 cTropnT-<0.01
[**2146-1-24**] 09:39PM BLOOD Lactate-3.1*
[**2146-1-24**] 06:30PM BLOOD Hgb-13.0 calcHCT-39
[**2146-1-24**] 09:22PM BLOOD Hgb-8.5* calcHCT-26
Brief Hospital Course:
53 y.o. woman with anoxic brain encephalopathy, Hep C cirrhosis
who presented with coffee-gound emesis and BRBPR from her
nursing home. Initial Hct in ED was 35 but then dropped to 26,
and pt was significantly hypotensive. Initial NG lavage was
negative but after repositioning NGT, it was grossly positive
with dark red blood. Given h/o cirrhosis, esophageal variceal
bleeding was the most likely source of her GI bleed. The
patient's mother and HCP agreed that pt would have wished for
comfort measures. Provided pain relief with morphine, and the
patient expired within 24 hours of admission. Her mother and
attending were notified of her death.
Medications on Admission:
Celexa 10mg qhs
Tylenol
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1636**]
Completed by:[**2146-6-9**]
|
[
"780.39",
"456.20",
"710.2",
"305.00",
"070.70",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4109, 4118
|
3347, 4001
|
292, 298
|
4170, 4180
|
2560, 3324
|
4237, 4397
|
2115, 2132
|
4076, 4086
|
4139, 4149
|
4027, 4053
|
4204, 4214
|
2147, 2541
|
247, 254
|
326, 1666
|
1688, 1887
|
1903, 2099
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,166
| 132,791
|
19978
|
Discharge summary
|
report
|
Admission Date: [**2121-1-17**] Discharge Date: [**2121-1-30**]
Date of Birth: [**2082-10-19**] Sex: M
Service: INT MED
HISTORY OF PRESENT ILLNESS: This is a 38 year old gentleman
with a history of ETOH abuse and esophageal varices who was
transferred to [**Hospital1 69**] on
[**1-18**], to the Medical Intensive Care Unit with
hematemesis, bright red blood per rectum, with a systolic
blood pressure in the 140s and a hematocrit of 30.0. He
arrived intubated for airway protection from the outside
hospital status post transfusion with four units of packed
red blood cells and one fresh frozen plasma. Endoscopy done
at outside hospital showed diffuse gastropathy with oozing.
In the Medical Intensive Care Unit he received q. four hours
hematocrit checks, intravenous octreotide, a hepatic
ultrasound, a diagnostic paracentesis, hepatitis serologies,
AFP check, prophylaxis antibiotics and a repeat
esophagogastroduodenoscopy on [**1-19**].
He was noted to have esophageal Grade 1 varices that were not
bleeding at that time, portal hypertensive gastropathy, and a
nonbleeding moderately sized fundic varix. The hematocrit
remained stable in the Intensive Care Unit with no further
bleeding. He was treated for a likely aspiration pneumonia
with Levofloxacin and clindamycin and was changed to
azithromycin prior to his transfer to the floor.
He was extubated on [**1-23**], changed to nasal cannula
oxygen and transferred to the floor on [**1-24**].
PAST MEDICAL HISTORY:
1. ETOH abuse and history of withdrawal seizures.
2. History of esophageal gastric varices.
3. Hypertension.
4. History of remote right ankle fracture.
ALLERGIES: To Keflex.
FAMILY HISTORY: Family history of hypertension.
SOCIAL HISTORY: Drinking three to four beers a day.
Tobacco, one and a half packs per day.
PHYSICAL EXAMINATION: On initial presentation, vital signs
were a temperature of 99.8 F.; heart rate of 114, blood
pressure of 145/74; saturation of 100%. He arrived
intubated, on CPAP and pressure support of 18 and 8
respectively. He was sedated and ventilated, but responded
to touch. He had moist mucous membranes and clear
oropharynx. Pupils were equal with anicteric sclerae. He
had no jugular venous pressure elevation. Multiple spider
angiomas were noted on his skin. Lungs were clear to
auscultation bilaterally. He had a regular rate but was
noted to be tachycardic. He had a distended abdomen with
positive bowel sounds. Two plus pitting edema was noted
bilaterally.
LABORATORY: On admission, CBC showed a white blood cell
count of 15.0, hematocrit of 28.2, platelet count of 232.
Chem-7 showed a sodium of 144, potassium of 4.4, chloride of
113, carbon dioxide of 22, BUN of 20, creatinine of 0.7,
glucose of 145. He had an ALT of 13, AST of 31, alkaline
phosphatase of 105, direct bilirubin of 1.7, total bilirubin
of 3.4, albumin of 2.7. He had an INR of 1.5 and a PTT of
40.
EKG performed at the time showed no evidence of ischemia.
HOSPITAL COURSE: Intensive Care Unit course preceded as
listed in the HPI. The patient received multiple blood
cultures which were no growth. He had sputum cultures
performed that showed four plus organisms consistent with
oropharyngeal flora as well as beta lactamase negative H. flu
with moderate growth. The peritoneal fluid done on
diagnostic tap showed two plus polys, no organisms and
negative culture.
Initial chest x-ray showed patchy consolidation of the right
lung, aspiration pneumonitis versus pneumonia. Hepatic
ultrasound done on [**1-19**] showed fatty infiltration of
the liver, moderate to large ascites, gallbladder sludging
with no ductal dilation and patent hepatic vasculature.
The patient, on initial transfer to the floor was monitored
with 12 hour hematocrit checks and continued on a proton pump
inhibitor. He had already completed a five day course of
Octreotide by the time he arrived on the floor. He was
followed closely by the Gastrointestinal Service.
His hematocrit remained stable so he was changed to q. 24
hour hematocrits on the 27th. His upper gastrointestinal
bleed remained stable for the rest of his course and he did
not require further transfusion. He had known liver disease
and appeared to have fluctuating mental status changes that
improved with increasing doses of lactulose. He was followed
closely by Liver for this.
2. RESPIRATORY STATUS: The patient was extubated as
previously mentioned on [**1-23**]. He was initially on
Levofloxacin and clindamycin for presumed aspiration
pneumonitis versus pneumonia. He was changed to azithromycin
prior to his transfer to the floor. However, he developed a
fever to 101.0 F., on the [**1-25**]. He was
recultured at that time and it was presumed that azithromycin
was insufficient coverage for his pulmonary infection. He
was restarted on his Intensive Care Unit regimen of
Levofloxacin and clindamycin.
There was a report from one of his nurses that he had had
difficulty with swallowing his water with his morning meal so
he was requested to have a swallow evaluation. His bedside
swallow evaluation was entirely normal so he was put back on
his p.o. diet and had no further difficulties during this
stay.
3. ETOH: The patient was initially maintained on a CIWA
scale but did not require ativan doses while on the floor.
He was seen by Addiction Services in order to assess whether
or not he was ready or wiling to accept help with his current
level of drinking. He admitted to his Care Team as well as
to his family that he intended to continue drinking after
discharge.
Social Work came and talked with the patient as well as with
the family in order to determine the best disposition for the
patient. The patient lived with his parents at home prior to
this admission and they verbalized willingness to take him
back upon discharge. They understand and voiced
understanding of his need for supervision given his hepatic
encephalopathy and level of impulsivity. We discussed with
them the need for the lactulose in order to maintain his
mental status as well as discussed the possibility that he
may have further gastrointestinal bleeds in the future given
his degree of liver disease.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Discharged to home.
DISCHARGE INSTRUCTIONS:
1. The patient is instructed to follow-up with the
[**Hospital 3585**] Clinic within the next several weeks.
2. He is instructed to see his primary care physician within
the next two weeks.
DISCHARGE DIAGNOSES:
1. Gastric bleeding due to liver disease.
2. Alcohol abuse.
3. Hepatic encephalopathy.
4. Alcoholic liver disease.
DISCHARGE MEDICATIONS:
1. Spironolactone 25 mg, two tablets p.o. q. day.
2. Propranolol 60 mg, [**1-31**] capsule q. day.
3. Pantoprazole 40 mg q. day.
4. Lactulose every eight hours, titrated to produce more
than three bowel movements per day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 10454**]
MEDQUIST36
D: [**2121-5-2**] 21:50
T: [**2121-5-2**] 23:09
JOB#: [**Job Number 53857**]
|
[
"518.82",
"303.90",
"507.0",
"285.1",
"578.9",
"789.5",
"291.81",
"428.0",
"572.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"45.13",
"38.91",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
1706, 1739
|
6521, 6641
|
6664, 7139
|
3017, 6212
|
6307, 6500
|
1857, 2998
|
171, 1484
|
1506, 1688
|
1757, 1833
|
6238, 6283
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,164
| 153,745
|
8483
|
Discharge summary
|
report
|
Admission Date: [**2124-4-30**] Discharge Date: [**2124-5-9**]
Date of Birth: [**2060-3-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
SOB/fever/hypotension
Major Surgical or Invasive Procedure:
empyema
s/p R thoracotomy, decortication [**5-3**]
History of Present Illness:
64 yo M w/ hx CLL, HBV, PCP pna, autoimmune hemolytic anemia on
prednisone s/p recent thoracentesis for malignant pleural
effusion, now loculated who presents with fever to 104 and
dyspnea. Pt reports pleuritic CP on R, worse today but present
over several days, persistent dry cough x 4 months (no change
recently) and orthopnea w/ frequent PND. Today he had a fever to
104 and felt SOB, then called EMS. On arrival, he was found to
be wheezing, 93% RA, s/p combivent with symptomatic improvement.
.
In ED patient treated broadly with 1g vancomycin, 2g cefepime,
bactrim IV, 100mg hydrocortisone, toradol and tylenol. An
U/S-guided thoracentesis w/ 300cc of hemorrhagic fluid was
performed without marked improvement in respiratory status. Pt
also received ~ 5L IVNS w/ persistent hypotension SBP's 80-90's
w/ MAPs 55-79. Blood pressure eventually improved after patient
was given steroids for presumed adrenal insufficiency.
Past Medical History:
1. Malignant R multiloculated and trabeculated pleural effusion
s/p 1.5L thoracentesis [**2124-4-18**], planned for decortication in [**5-16**]
for symptomatic relief [**3-15**] loculation
2. CLL dx'ed [**2114**] s/p two cycles of
cytoxan/vincristine/prednisone, rituxan, and one cycle
fludarabine, last in [**10-15**]; CT [**2124-4-18**] documents L hilar,
posterior mediastinal and R lung tumor w/ malignant effusion;
bronchial wall thickening w/ tree in [**Male First Name (un) 239**] in L lung; PET with
solitary area within collapsed right lower lung (underlying
infxn vs. lymphoma), marked HSM with enlarged intraabdominal LN,
nothing is FDG avid
3. Persistent infiltrates, first noted in [**6-14**] with plan for
bronch at [**Hospital3 5097**] but pt could not tolerate, improved with
empiric quinolone therapy, Bronch performed [**10-15**] showed PCP
treated with Bactrim
4. Autoimmune hemolytic anemia on chronic prednisone
5. HBV s/p bld transfusion [**9-14**]
6. Lipomas
7. Splenomegaly on CT
Social History:
Patient is a swimming coach @ [**Last Name (un) 29892**] college. He is married w/
2 adult children. Has 10 pack-yr smoking history. Reports occ
EtOH.
Family History:
Mother died at age 86 of CLL
Father died at age 76
Two brothers alive and well
Physical Exam:
Tm/c 104 PR HR 108 (100-130's) 104/53(MAP 55-70's)[BP in office
105/66 on [**2124-4-18**]] 26 (20-26) 100% (96-100%) on 4L NC
CVP 10-11 SVO2 73%
Gen: thin cauc M lying on stretcher w/ HOB @ 45 deg in NAD
HEENT: PERRL, OP clear, MM dry, anicteric
Lymph: no cervical, submandibular, or axillary LAD
Heart: RRR, S1, S2 no m/r/g
Lungs: R base dull to percussion, no BS and no fremitus; o/w no
wheezing or rales b/l;
Abd: thin S/NT/ND, mild RUQ tenderness w/ palpation
Ext: no edema thin; b/l UE lypomas
Pertinent Results:
LABS: wbc 23 17% PMNs ([**2124-4-18**] prev 26) lact 2.3 creat 0.9 hct
43
mildly elevated ALT/AST
pleural fluid: pending
BCx, UCx, pleural fluid Cx pending
.
RAD:
[**2124-4-30**] CXR reaccumulated R large pleural effusion c/w [**2124-4-14**]
[**2124-4-26**] PET scan pending
[**2124-4-18**] CT chest - hilar, mediastinal tumor, tree in [**Male First Name (un) 239**] of L
lung;
.
EKG: NSR @ 115bpm, c/w baseline [**10/2119**] rate is faster
Brief Hospital Course:
64 yo male w/ hx of CLL, HBV, PCP pna, autoimmune hemolytic
anemiaon pednidone, s/p thoracentesis for malignant pleural
effusion now loculated and presents w/ fever 104 and dyspnea.
In ER ultrasound guided thoracentesis w/ 300cc hemorrhagic fluid
w/ only slight improvement in resp status. Broad spectrum ABX
started. Hypotension treated w/ IVF w/o improvement then given
stress dose steriods w/ improvement.
Admitted to the MICU for observation and thoracic surgery, Dr.
[**Last Name (STitle) **] consulted.
Pt was taken to the OR on [**5-3**] for right VATS , right
thoractomy, with decordication, wedge resection affected right
middle lobe, lymph node excision.
post op course uncomplicated- pt transferred to ICU d/t
intubation post op. Right chest tubes x 3 w/ air leaks and
serosang drainage. Pt remained intubated until POD #2 then
successfully extubated and transferred from ICU. Chest tube
drainage tapered. PCA d/c'd and pt managed on po percocet.
POD#[**4-14**] chest tubes to water seal. Heart rate [**Last Name (un) **] but regular
rhythm -started on low dose lopressor w/ good response. Bilat
LINI's done -no evidence of DVT.
POD#5 apical chest tubes x2 d/c'd. Posterior chest tube remains
to water seal -no air leak. vioding , ambulating and eating
well. pt will remain on po levaquin.
POD#6 Chest tube #3 d/c'd. post pull CXR no PTX. Pt d/c'd to
home. He will cont on po levo for 3 weeks per Dr. [**Last Name (STitle) **]. he
will have f/u with Dr[**Last Name (STitle) **] [**Name (STitle) **] and [**Doctor Last Name **] on [**2124-5-18**] w/ pre
appointment CXR.
Medications on Admission:
Prednisone 5'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: [**2-13**] tablet Tablet PO
BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*1*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 weeks weeks.
Disp:*21 Tablet(s)* Refills:*0*
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic Lyphocytic Leukemia '[**14**] s/p
cytoxan/vincristine/prednisone x2, rituxan, fludarabine x1, last
in [**10-15**]; s/p IVIG [**12-15**] for hypogammaglobulin; Hepatitis B Viral
infection ? blood transfusion [**9-14**] now w/ hepatosplenomegaly;
h/p PCP pneumonia dx by bronchoscopy [**10-15**] tx w/ bactrim.
empyema
s/p R thoracotomy, decortication [**5-3**]
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office ([**Telephone/Fax (1) 170**]) for : Chest pain,
shortness of breath, fever, chills, redness or drainage at
incision site.
You may shower on thursday and remove the bandages on the chest
tube sites and cover with a bandaid if needed.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **]([**Telephone/Fax (1) 170**])
for thursday [**5-18**] 10am [**Location (un) 8661**] building [**Location (un) **]. You will
also see Dr. [**Last Name (STitle) **] at this time. Please arrive 45 minutes
before your appointment for a Chest XRAY -[**Hospital Ward Name 23**] bulding [**Location (un) **].
Completed by:[**2124-5-11**]
|
[
"V64.42",
"038.8",
"482.89",
"283.0",
"255.4",
"204.10",
"790.6",
"V15.82",
"995.91",
"510.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"32.29",
"33.24",
"40.29",
"34.51",
"34.04",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
5944, 5950
|
3642, 5225
|
342, 395
|
6362, 6368
|
3177, 3619
|
6692, 7092
|
2563, 2643
|
5289, 5921
|
5971, 6341
|
5251, 5266
|
6392, 6669
|
2658, 3158
|
281, 304
|
423, 1352
|
1374, 2379
|
2395, 2547
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,856
| 171,201
|
7383
|
Discharge summary
|
report
|
Admission Date: [**2107-5-3**] Discharge Date: [**2107-5-10**]
Date of Birth: [**2044-8-27**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 62-year-old gentleman
whose chief complaint is failing aortobifemoral graft. The
patient is well-known to Dr. [**Last Name (STitle) 1391**]. The patient had a
previous right iliac stenting in [**2105-4-26**] and a fem-fem
bypass in [**2106-7-27**]. He returns now with a failed graft
for elective aortobifemoral bypass.
DRUG ALLERGIES: Bupropion, Zoloft and Celexa cause diarrhea.
MEDICATIONS ON ADMISSION: Albuterol p.r.n., aspirin 325 mg
daily. Fish oil. Flovent p.r.n., lisinopril 20 mg daily,
Lopressor 100 mg b.i.d. Simvastatin 40 mg daily.
PAST MEDICAL HISTORY: Known peripheral vascular disease with
claudication. History of hypertension. History of ischemic
heart disease with a myocardial infarction in [**2096**]. Stress
done on [**2106-6-1**] was without anginal symptoms. He had a
severe fixed inferior wall defect with associated
hypokinesis. The patient also has had an atrial myxoma
resection in [**2104-1-27**]. His echo in [**1-/2106**] showed no
mass or thrombus seen in the left atrium or the atrial
appendage. Ejection fraction was greater than 55%. The aortic
valve was normal. The mitral valve was 1+ MR. There was a
hyperdense mass on the left ventricular side of the posterior
leaflet but not attached to the leaflet. The patient has
history of chronic obstructive disease with asthma, history
of cerebrovascular accident in [**2074**] with a left frontal CVA
and left parietal CVA in [**2092**] and a left middle cerebral
artery stroke in [**2102**] without residual. The patient does have
a history of migraines remote. The patient has a history of
hypercholesteremia, peripheral neuropathy, chronic renal
insufficiency, history of polycythemia [**Doctor First Name **], history of
ventral hernia.
PAST SURGICAL HISTORY: Previous surgeries include a right
iliac stenting in [**2105-4-26**], a left atrial myxoma resection
in [**1-/2104**], a right olecranon process abscess I&D in [**2106-5-27**] and a fem-fem bypass in 08/[**2105**].
SOCIAL HISTORY: The patient is a current smoker within the
last month. He smokes one pack per day for the last 20 years.
Denies alcohol or recreational drug use. Does have a history
of depression.
PHYSICAL EXAM: Patient is in no acute distress. He is alert
and oriented. Heart is a regular rate and rhythm with no
murmur, gallops or rubs. There are no carotid bruits. Lungs
are clear to auscultation. The abdomen was obese, soft,
nontender with a large ventral hernia. Extremities were
without edema. Pulse exam: The left DP and PT were palpable
1+. The right DP and PT were palpable 2+. The toes were pink,
warm with brisk capillary refill.
HOSPITAL COURSE: The patient was admitted over to Balding
area on [**2107-5-3**]. He underwent an aortobifemoral bypass
graft with knitted micro Dacron Velour, an excision of fem-
fem graft. The patient tolerated the procedure well. He was
transferred to the PACU in stable condition. An epidural was
placed intraoperatively. This was utilized for pain
management. Later that same day in the PACU, the patient
developed a cold foot and the patient returned to surgery and
underwent a thrombectomy of the graft limb on the left. The
patient remained intubated and was transferred to the ICU for
continued monitoring and care. Postoperative day 2,
overnight events: The patient had an episode of atrial
flutter which was converted to normal sinus rhythm with
amiodarone drip. There were no other acute events. The
patient remained intubated. The patient's PA numbers showed
vascular spacing. Fluid was held. Lasix was begun. Extubation
and weaning from vent with extubation was begun.
Postoperative day 3, the patient continued with an epidural.
He was extubated. His diet was advanced and ambulation was
begun. The patient was transferred to the VICU for continued
monitoring and care. His epidural was discontinued. He was
begun on oral pain medications for analgesic control.
Postoperatively on postop day 2, the patient's creatinine was
elevated at 1.9. It peaked at 2.9. Renal was consulted on
postoperative day #3. They felt that the ATN was related to
the perioperative hypertension, causing pre renal azotemia
versus ischemic ATN. Lasix was discontinued. The blood
pressure was allowed to normalize at 120. Blood pressure
medicines were held. Urine lytes were sent. All medicines
were renal dosed. By postoperative day number 4, the patient
began to show mild improvement in his creatinine. It went
from 2.9 to 2.7. Diuretics were still held. It was felt
there was no need or indication for dialysis. The patient was
ambulated. His Lopressor was increased. His diet was advanced
to a regular diet by postoperative day 4. By postoperative
day #5, the patient began to pass flatus. His creatinine
continued to show improvement. It was 2.2. Because of weights
up 10 kg, he was given Lasix. The patient did have a small
bowel movement on postoperative day #5. The patient did have
some mild abdominal distention. His diet was placed on hold
and he was allowed sips only. He was given aggressive bowel
regimen with improvement in his abdominal distention and
bowel sounds improved so that he had sounds in all 4
quadrants. His creatinine continued to show improvement by
postoperative day 6. He was begun on sips to clears and on
postoperative day #7, his diet was advanced as tolerated
which he tolerated. Physical therapy saw the patient and felt
he would be able to be discharged to home. He was discharged
home on postoperative day #8 in stable condition with
improving renal function. His creatinine at discharge was
2.2. Diuretics were still held. The patient was instructed to
follow up with his cardiologist regarding management of his
diuresis and to monitor his renal function. His amiodarone
dosing for his atrial flutter was 400 mg b.i.d. for a total
of 3 more days and then starting on [**5-13**], he would be on
Amiodarone 200 mg daily. Thyroid function studies were
ordered. We also ordered C3-C4 amylase and lipase for renal
recommendations. Renal wanted to rule out embolic source for
his renal failure.
At the time of discharge, hematocrit was 30.1, BUN 37,
creatinine 2.2, K 4.1. The patient was discharged to home.
Social service saw the patient prior to discharge for
arrangements regarding home services. We want VNA to come in
to see the patient on discharge to monitor the groin wounds
and pulse rate and blood pressure and weight. The patient has
been instructed to follow up with his cardiologist within a
weeks time. He should take all medications as directed. He
should continue on a stool softener regime since he is on
narcotics. He may ambulate essential distances with
progression but no driving until seen in follow-up. The groin
clips should remain in place and the wounds should be
monitored for any erythema, swelling or drainage. If he
develops a fever greater than 101.5 or changes in his wounds,
he should notify Dr.[**Name (NI) 1392**] office. He should notify his
cardiologist if he develops any weight gain greater than 2
pounds over 24 hours. The patient also should follow up with
his cardiologist regarding his amiodarone dosing monitoring
and thyroid function study monitoring
DISCHARGE DIAGNOSIS:
1. Failed fem-fem bypass graft, status post aortobifemoral
bypass graft for iliac femoral occlusive disease.
2. Peripheral vascular disease.
3. Known coronary artery disease.
4. History of chronic obstructive pulmonary disease.
5. History of hypertension.
6. History of polycythemia [**Doctor First Name **].
7. Postoperative paroxysmal supraventricular tachycardia
converted to normal sinus rhythm.
8. Postoperative hypotension.
9. Acute tubular necrosis (ATN) improving.
10. Postoperative blood loss anemia transfused.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg daily.
2. Simvastatin 40 mg daily.
3. Amiodarone 400 mg b.i.d. for a total of 5 more doses and
then amiodarone 200 mg daily.
4. Colace 100 mg b.i.d.
5. Senna tabs prn.
6. Metoprolol 50 mg b.i.d.
7. Oxycodone/acetaminophen 5/325 tablets one to two q. 4 to
6 hours p.r.n.
8. Amiodarone as indicated.
MAJOR SURGICAL PROCEDURE: Aortobifemoral bypass graft with
re-exploration of the left groin and femoral artery
thrombectomy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2107-5-10**] 14:40:56
T: [**2107-5-11**] 06:14:20
Job#: [**Job Number 27169**]
|
[
"997.1",
"440.21",
"427.0",
"285.1",
"272.0",
"427.32",
"444.0",
"356.9",
"403.90",
"996.1",
"458.29",
"585.9",
"996.74",
"584.5",
"E878.2",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"54.12",
"39.25",
"00.44"
] |
icd9pcs
|
[
[
[]
]
] |
7912, 8643
|
7350, 7889
|
580, 722
|
2811, 7329
|
1928, 2146
|
2361, 2793
|
159, 553
|
745, 1904
|
2163, 2345
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,836
| 191,777
|
41778
|
Discharge summary
|
report
|
Admission Date: [**2184-2-13**] Discharge Date: [**2184-2-17**]
Date of Birth: [**2156-2-6**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Carotid Cavernous Fistula
Major Surgical or Invasive Procedure:
[**2184-2-13**] - Interventional Neuroradiology Angiogram and Coiling CC
fistula
History of Present Illness:
Elective admission for coiling of CC fistula
Past Medical History:
Post C2 body fx, bilat preseptal hemorrhage, small bilateral
PTX, splenic injury s/p splenectomy, L sqaumous temporal bone
fx, bilat anterior acetabular fx, R inferior pubic ramus fx, fx
ant tibial cortex,
Carotid->cav sinus fistula s/p embolization.
Annular tear C2/3 disk, Prevertebral hematoma, skull base -> C4
Social History:
Currently in rehab
Family History:
UK
Physical Exam:
Upon discharge:
A&O x3
PERRL 7-5mm bilaterally, EOMs intact
Face symmetrical
Full motor
Pertinent Results:
Cerebral angiogram [**2184-2-13**]:
Report FINDINGS:
Right internal carotid artery arteriogram demonstrates filling
of the
right internal carotid artery with significant flow into the
carotid cavernous fistula on the right. There is very little
antegrade flow into the intracranial circulation. Most of the
contrast is seen shunting through the right carotid cavernous
fistula with markedly reduced flow of contrast with the anterior
and middle cerebral arteries.
Right internal carotid arteriogram status post coil embolization
demonstrates significant diminution of flow into the right
carotid cavernous fistula with markedly improved antegrade flow
into the anterior and middle cerebral arteries. The right
superior ophthalmic vein continues to remain successfully
occluded.
Brief Hospital Course:
28F elective admission for coiling of the CC fistula on [**2-13**].
Partial coiling was achieved without complication. She was
admitted to the ICU post-angio for monitoring. Her exam remained
stable and she was transferred to the floor on [**2-14**]. Throughout
the weekend, her exam remained unchanged. Current plan is to go
back to angio and place a stent. Patient does not require plavix
before stenting, but if necessary, she was cleared to have
plavix by the ACS team. On [**2-17**], patient remained stable and was
discharged to rehab.
Medications on Admission:
-Bacitracin-polymyxin B 500-10,000 unit/g Ointment Q8H to rigth
eye.
-Timolol maleate 0.5 % One (1) Drop Ophthalmic [**Hospital1 **] to right
eye.
-Nystatin 100,000 unit/mL Five (5) ML PO QID PRN.
-SQ Heparin TID
-Methadone 10 mg [**Hospital1 **] (
-Senna 1 Tablet PO BID
-Docusate sodium 100mg [**Hospital1 **]
-Acetaminophen 650 mg PO Q6H
Dilaudid 2 mg Tablet 1-2 Tablets PO every 3 hours
-Aspirin 325 mg DAILY
-White petrolatum-mineral oil 56.8-42.5 % Ointment One Appl
Ophthalmic Q2H to right eye.
-Lorazepam 0.5 mg PO Q4H
Discharge Medications:
1. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
2. nystatin 100,000 unit/mL Suspension Sig: One (1) ml PO Q8H
(every 8 hours).
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
7. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic Q2H (every 2 hours).
8. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q8H (every 8 hours).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. 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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Cavernous Carotid Fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent 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.
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 call the office of Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 4296**] to make an
appointment to be seen in 4 weeks with an MRI/MRA ([**Doctor Last Name **]
protocol) of the brain to evaluate the coils in your CC fistula.
Completed by:[**2184-2-17**]
|
[
"802.21",
"300.00",
"900.82",
"E812.0",
"V44.0",
"V44.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
4087, 4153
|
1812, 2355
|
331, 414
|
4223, 4223
|
1007, 1789
|
6335, 6606
|
879, 883
|
2935, 4064
|
4174, 4202
|
2381, 2912
|
4374, 5394
|
5420, 6312
|
898, 898
|
266, 293
|
914, 988
|
442, 488
|
4238, 4350
|
510, 827
|
843, 863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,783
| 185,054
|
26571
|
Discharge summary
|
report
|
Admission Date: [**2135-7-19**] Discharge Date: [**2135-7-26**]
Date of Birth: [**2074-6-20**] Sex: M
Service: NEUROLOGY
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Called by Emergency Department to evaluate
ICH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname **] [**Known lastname 13621**] is a 64-year-old man with a history of prior
left sided stroke with residual right hemiparesis who presents
with ICH. He had a headache yesterday. Today, he was noted by
his
nursing home staff to be more confused, seemingly disoriented to
place and slow in his responses; he was also newly incontinent
of
urine today, and required assistance with feeding. This was a
marked change in functional status, so they sent him by EMS to
[**Hospital6 3105**]. There, a CT showed a 4.8 x 3 cm L
frontal intraparenchymal hemorrhage with 7-8 mm of midline
shift.
GCS score there was 14. He was observed to have a 3 minute GTC
seizure while at [**Hospital3 **]. He was given 3 mg IV ativan
and 500 mg IV phenytoin.
He was intubated for airway protection during transport and was
given 10 mg Vec and 100 mg succ at 5 pm, and placed on a
propofol
drip. He was transported by [**Location (un) **] to [**Hospital1 18**].
ROS is not possible.
Past Medical History:
1. Asthma
2. NIDDM
3. HTN
4. Depression
5. Hyperlipidemia
6. Chronic pain
Social History:
Patient is Spanish-speaking from DR. [**Last Name (STitle) 4273**] tobacco use, alcohol
use or any other drug use.
Family History:
NC
Physical Exam:
Vitals: T: 97.8 P: 72 R: 14 BP: 113/64 SaO2: 100% AC
General: Intubated, having just been paralyzed and sedated 90
mins earlier.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: Upper airway sounds
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Eyes closed, unresponsive, having received Vec
10
and Succ 100 90 mins earlier, and been on propofol drip 10 mins
earlier.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupils 2->1 OD and 1.5->1 OS, brisk. No blink to threat.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: No observable doll's eyes.
V: Corneals intact.
VII: No facial droop, facial musculature symmetric.
VIII: No observable doll's eyes
IX, X: +Gag.
[**Doctor First Name 81**]: Not tested.
XII: Not tested.
-Motor: Normal bulk; increased tone on right arm and leg. No
adventitious movements noted. No spontaneous movement, no
movement to pain.
-Sensory: No movement to pain.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 3 3 3 4 3
Plantar response was extensor on right, flexor left.
-Coordination & Gait: Not possible.
Pertinent Results:
[**2135-7-24**] 06:30AM BLOOD WBC-10.1 RBC-3.95* Hgb-11.3* Hct-32.9*
MCV-83 MCH-28.5 MCHC-34.3 RDW-12.4 Plt Ct-265
[**2135-7-24**] 06:30AM BLOOD Plt Ct-265
[**2135-7-24**] 06:30AM BLOOD Glucose-170* UreaN-10 Creat-0.7 Na-141
K-3.9 Cl-104 HCO3-29 AnGap-12
[**2135-7-23**] 04:45AM BLOOD Calcium-9.5 Phos-2.9 Mg-1.8
[**2135-7-25**] 05:45AM BLOOD Phenyto-9.3*
[**2135-7-24**] 06:30AM BLOOD Phenyto-9.5*
NCHCT:
1. Interval evolution of the known large superior left frontal
parenchymal
hemorrhage with increased vasogenic edema without mass effect.
No other
hemorrhagic foci or large vascular territorial infarction is
noted.
2. Apparent vasogenic edema in the right parietal-occipital
region, concrning
for PRES. Recommend MRI for further characterization, as
clinical scenario
dictates.
Brief Hospital Course:
Neurologically: Patient was admitted to the Neuro ICU and had
frequent neuro checks.
Aspirin and Plavix were held. IV fluids were restricted as
possible and he did not require Mannitol. Dilantin had already
been administered at the OSH, and he was given an additional
500mg load on arrival to [**Hospital1 **]. Was also started on Maintenance
200 IV BID, which was increased to 200 AM and 250 PM on [**7-25**] as
Dilantin levels were running just slightly subtherapeutic. Had
no further seizures. Repeat CT showed no increase in size of
bleed. MRI was considered, but deferred as patient was
initially not stable enough and later unable to safely cooperate
for study. Plan is to have repeated in several months time as
out patient. Neurologically he continues to be anteriorly
aphasic but follows some simple commands, but not complex
commands. His dense right hemiparesis is unchanged from
admission.
Cardiovascularly: no events
Resp: no events
GI: was initially NPO, but later able to take soft solids.
Renal: no events
ID: no infectious issues
Endocrine: covered with regular insulin sliding scale QID
during.
Medications on Admission:
ASA 162 mg po daily
Plavix 75 mg po daily
Labetalol 300 mg po bid
Azmacort 2 puffs MDI [**Hospital1 **]
Thiamine 100 mg po daily
Phenytoin 200 mg po bid
Folic acid 1 mg po tid
Norvasc 10 mg po daily
Novolin R
Lantus
Cymbalta 60 mg po daily
Mirtazapine 15 mg po daily
Risperdal 0.25 mg po daily
Zocor 20 mg po daily
Ativan prn
Albuterol prn
Lisinopril 80 mg po daily
Discharge Medications:
1. Senna 8.8 mg/5 mL Syrup Sig: 1-2 Tablets PO BID (2 times a
day) as needed.
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): hold for SBP < 100.
11. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection four times a day: per sliding scale.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed: prn fevers or pain.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
16. Labetalol 200 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day): hold for SBP < 100 or HR < 60
.
17. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO DAILY (Daily): in AM.
18. Phenytoin 50 mg Tablet, Chewable Sig: Five (5) Tablet,
Chewable PO DAILY (Daily): in PM.
19. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours).
20. HydrALAzine 10 mg IV Q6H:PRN SBP>170
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - Colonial Heights - [**Hospital1 487**]
Discharge Diagnosis:
left frontal intraparenchymal hemorrhage
old left sided stroke
Discharge Condition:
Fair. Continues to have dense right hemiparesis. Anteriorly
aphasic but following some simple commands.
Discharge Instructions:
This patient has had an acute left frontal intraparenchymal
hemorrhage. This has caused him to be more confused,
disoriented and less responsive than what was described prior.
It also likely led to the seizure which he had at [**Hospital3 12748**]. The hemorrhage has stabilized and his
deficits appear to be improving. He continues to have language
impairments but follows some simple commands. He still has a
dense right hemiparesis. He will need to follow up as below and
will need to continue taking a medication called Dilantin to
stop him from having further seizures.
Followup Instructions:
Neurologist: [**Name6 (MD) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2135-9-13**] 3:30, [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg [**Location (un) **].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"438.20",
"272.4",
"338.29",
"401.9",
"311",
"493.90",
"432.9",
"780.39",
"250.00",
"788.30",
"V58.66",
"V58.67",
"V85.1",
"784.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7051, 7139
|
3749, 4879
|
334, 341
|
7246, 7354
|
2936, 3726
|
7982, 8303
|
1596, 1600
|
5296, 7028
|
7160, 7225
|
4905, 5273
|
7378, 7959
|
2176, 2917
|
1615, 2019
|
247, 296
|
369, 1350
|
2034, 2159
|
1372, 1447
|
1463, 1580
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,964
| 164,234
|
18609
|
Discharge summary
|
report
|
Admission Date: [**2103-12-8**] Discharge Date: [**2103-12-17**]
Date of Birth: [**2033-8-10**] Sex: F
Service: SURGERY
Allergies:
Plavix / Penicillins / Codeine / Ticlid / Lamictal
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
acute cholesystitis
Major Surgical or Invasive Procedure:
Open Cholecystectomy
History of Present Illness:
This 70-year-old female presented to the [**Hospital3 3583**] ED on
[**2103-12-7**] with the complaint of chest pain which was not resolved
with sublingal nitroglycerine. Pt is s/p known to have severe
coronary artery disease, which is not amenable to stenting and
acute cholecystectomy. Cardiac work-up was negative. She was
found to have a distended gallbladder, thickened gallbladder
wall, edema around the gallbladder, and a dilated comon bile
duct. Her Creatitine was acutely elevated to 2.2. Given her
relatively high risk for surgery she was transfered to [**Hospital1 18**] on
[**2103-12-8**].
Past Medical History:
1. coronary artery disease s/p cardiac cath [**2103-11-29**] (no
intervention)
2. peripheral vascular disease
3. s/p myocardial infarction '[**98**], s/p CABG
4. hypertension
5. macular degeneration
6. h/o C. Diff.
7. dimentia
8. depression
Social History:
Patient is widowed and lives alone. Her daughter
[**Name (NI) 781**] is very involved in her care. [**Doctor First Name 781**] states that her
mother has very poor short term memory and has significant
variations in her ability to understand everything regarding her
medical care.
[**Doctor First Name 781**] is her health care proxy and has power of attorney. She
will accompany her mother to the hospital.
Family History:
Patient has 9 brothers and sisters. One brother
died in his 40's from heart problems. Another brother with
"heart
problems". [**Name2 (NI) **] did not know specifics.
Physical Exam:
On Admission: 100.2, 100 102/60 20 93 RA
AOx3, NAD
RRR, no mumur
CTAB B/L
Abd obese, severely TTP in RUQ c deep palpation. + [**Doctor Last Name 515**].
lowwer abdominal scar from c-sections and appendectomy
ext without c/c/e
Pertinent Results:
On admission:
[**2103-12-9**] 01:17AM BLOOD WBC-9.1# RBC-2.82* Hgb-8.6* Hct-25.6*
MCV-91 MCH-30.5 MCHC-33.6 RDW-14.0 Plt Ct-91*#
[**2103-12-9**] 05:27AM BLOOD Neuts-81* Bands-11* Lymphs-4* Monos-3
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2103-12-9**] 01:17AM BLOOD PT-14.4* PTT-28.7 INR(PT)-1.4
[**2103-12-9**] 01:17AM BLOOD Plt Smr-LOW Plt Ct-91*#
[**2103-12-9**] 01:17AM BLOOD Glucose-118* UreaN-34* Creat-1.6* Na-140
K-3.9 Cl-108 HCO3-22 AnGap-14
[**2103-12-9**] 01:17AM BLOOD ALT-31 AST-22 CK(CPK)-200* AlkPhos-87
Amylase-34 TotBili-0.6
[**2103-12-9**] 01:17AM BLOOD Lipase-15
[**2103-12-9**] 01:17AM BLOOD CK-MB-4 cTropnT-0.01
[**2103-12-9**] 01:17AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.7
Renal:
[**2103-12-9**] 05:27AM BLOOD Glucose-136* UreaN-35* Creat-1.8* Na-138
K-3.9 Cl-110* HCO3-21* AnGap-11
Cardiac:
[**2103-12-9**] 09:21AM BLOOD LD(LDH)-448* CK(CPK)-1054*
[**2103-12-9**] 09:21AM BLOOD CK-MB-35* MB Indx-3.3 cTropnT-0.87*
[**2103-12-9**] 10:59AM BLOOD CK(CPK)-1308*
[**2103-12-9**] 10:59AM BLOOD CK-MB-44* MB Indx-3.4 cTropnT-0.91*
[**2103-12-9**] 06:00PM BLOOD CK(CPK)-2386*
[**2103-12-9**] 06:00PM BLOOD CK-MB-46* MB Indx-1.9 cTropnT-0.73*
[**2103-12-10**] 02:06AM BLOOD CK-MB-20* MB Indx-0.8 cTropnT-0.75*
[**2103-12-10**] 02:06AM BLOOD ALT-133* AST-136* CK(CPK)-2414*
AlkPhos-91 Amylase-34 TotBili-1.0
[**2103-12-10**] 03:20PM BLOOD CK(CPK)-[**2075**]*
[**2103-12-10**] 03:20PM BLOOD CK-MB-13* MB Indx-0.7 cTropnT-0.92*
On discharge:
[**2103-12-13**] 04:02AM BLOOD WBC-5.8 RBC-3.39* Hgb-10.4* Hct-30.0*
MCV-89 MCH-30.8 MCHC-34.8 RDW-14.6 Plt Ct-167
[**2103-12-15**] 06:49AM BLOOD Glucose-95 UreaN-18 Creat-0.9 Na-138
K-3.5 Cl-102 HCO3-28 AnGap-12
[**2103-12-15**] 06:49AM BLOOD Calcium-7.4* Phos-3.1 Mg-2.1
Brief Hospital Course:
# Acute Choleystitis: Upon entering the medical center, she was
actually sent with no laboratories. Repeating her laboratories
to check on evaluation, she became progressively septic. She ahd
an ultrasound, which confirmed small stones and sludge, but a
small gallbladder. Because of her cardiac condition and because
of the impending sepsis, it was thought perhaps percutaneous
cholecystostomy would be appropriate, however, interventional
radiology refused to do that, because of the size of the
gallbladder. Therefore she was brought immediately to surgery
very early on [**2103-12-9**] where we did an open cholecystectomy and
operative cholangiography. The common bile duct was noted to be
enlarged at surgery, however, on doing cholangiograms, she had
free flow of bile into the duodenum. She had multiple small
stones, however, and it is speculated that perhaps one of these
small stones had passed and actually managed to occlude the
common duct. Subsequently, the laboratory came back revealing
that her liver enzymes were all normal preop, but nonetheless,
the common bile duct size was clearly abnormal and therefore the
cholangiograms were necessary. However, the cholangiograms did
show free flow into the duodenum without filling defects.
She was placed on broad spectrum antibiotics. Intra-operative
cultures from the gall bladder later grew pansensitive E. Coli
and she remained on Levoquin. She was to finish a 14-day
course.
# Peri-operative myocardial infarction: Prior to surgery she was
evaluated by cardiology given her significant cardiac history.
She was considered high risk for for a peri-op event, but little
could be done to decrease her risk. Emergent cath was not
recommended given the failed attempt for RCA PCI on [**2103-11-29**].
From the OR the patient remained intubated and was transfered to
the SICU. Post-op the patient cardiac enzymes were noted to be
elevated. Cardiology continue to follow and the patient remained
the in SICU. The acute myocardial infarction was thought to be
demand ischemia. A Swan cathether was placed on [**2103-12-10**] for
improved monitoring especially given her rising cardiac enzymes
and her oliguria. An Echo was obtained on [**2103-12-11**] showing
Overall left ventricular systolic function is mildly depressed.
Per cardiology her home beta blockers were continued. Lipitor
was started and her home ASA resumed.
# Acute Renal Failure: [**2103-12-10**] The patient became oliguric with
an acutely rising creatinine. She was agressively fluid
resucciated. Over the next day the oliguria improved. Her
creatinine returned to baseline by the end of her hospital stay.
.
On [**2103-12-12**] she was transfered to the floor from the SICU. She
was started on clears [**2103-12-14**] which was advanced to regular on
[**2103-12-15**]. Her JP was removed on [**2103-12-15**]. Upon discharge she
was tolerating a regular diet, had good pain control with PO
pain medications, was ambulating with assistance, and her renal
function was normal.
Medications on Admission:
lopressor 37.5mg [**Hospital1 **]
asa 325 mg daily
protonix 40 mg daily
aricept 5 mg daily
paxil 37.5 mg daily
remeron 7.5 qhs prn
nitrotab prn CP
reglan 5 qam
advil prn
nitropatch prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
6. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed. Tablet(s)
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days: continue through doses on [**2103-12-22**].
Total course 14 days.
Disp:*5 Tablet(s)* Refills:*0*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Life Care Center - [**Location (un) 3320**]
Discharge Diagnosis:
acute cholecystitis, intra-operative myocardial infarction,
respiratory failure, acute renal failure, hypokalemia
Discharge Condition:
good
Discharge Instructions:
Restart you home medications as usual. Take your antibiotics as
instructed. Take the new medication (lipitor) as instructed.
Regular diet. You may resume activity as tolerated.
You may shower, then pat-dry incision. Do not rub incision. No
tub baths or swimming for 3-4 weeks.
You may leave the incision uncovered or use a light dressing for
comfort. You will have your staples removed at your follow-up
appointment.
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to eat or drink
* Inability to pass gas or stool
* Redness/swelling/drainage from wound
* Other symptoms concerning to you
Followup Instructions:
1. Call Dr.[**Name (NI) 18535**] office for a follow-up appointment in [**12-17**]
weeks. ([**Telephone/Fax (1) 376**]
|
[
"785.52",
"518.81",
"584.9",
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"369.00",
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"997.1",
"410.71",
"574.81",
"276.8",
"412",
"V45.81",
"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"51.22",
"96.71",
"99.04",
"38.93",
"89.64",
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] |
icd9pcs
|
[
[
[]
]
] |
8246, 8316
|
3875, 6893
|
330, 353
|
8474, 8481
|
2125, 2125
|
9136, 9258
|
1695, 1864
|
7128, 8223
|
8337, 8453
|
6919, 7105
|
8505, 9113
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1879, 1879
|
3578, 3852
|
271, 292
|
381, 988
|
2139, 3563
|
1010, 1252
|
1268, 1679
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,181
| 124,377
|
14556+56554
|
Discharge summary
|
report+addendum
|
Admission Date: [**2148-9-5**] Discharge Date: [**2148-9-26**]
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
man with past medical history significant for idiopathic
tracheobronchomalacia who was admitted with recurrent
productive cough. He recently had tracheal stents placed at
[**Hospital6 256**] in [**2148-8-11**] and
was to return for a follow up subsequently. Since his
discharge, he has had progressively worsening recurrent
cough. He was admitted to an outside hospital in [**Location (un) 7498**] where a chest x-ray showed a pneumonia and his
sputum culture grew Methicillin resistant Staphylococcus
aureus. He was initially treated with levofloxacin and then
switched to ceftriaxone after sensitivity showed resistance
to levofloxacin. He does report a copious thick sputum. On
admission, the patient denied any chest pain, fevers, chills,
or palpitations. He did report dyspnea, but no oxygen
requirement was noted at home as the patient is on home
oxygen. The patient also complained of decreased appetite
and poor peroral intake. The patient did not have any
hemoptysis or hematemesis. The patient was admitted for
further management of his pneumonia and his airway.
PAST MEDICAL HISTORY:
1. Idiopathic tracheobronchomalacia. The patient originally
had stents x2 placed in the left main bronchus and distal
trachea in [**2148-6-10**]. In [**2148-7-11**], the distal
tracheal stent was observed to have migrated to the right
main bronchus and was subsequently removed.
2. Supraglottic edema secondary to cough in [**2148-7-11**] treated with Solu-Medrol.
3. Placement of stent in the trachea in [**2148-8-11**]
4. Deep venous thrombosis of right lower extremity [**2148-8-11**]
5. Asthma
6. Chronic obstructive pulmonary disease with the use of
home oxygen occasionally
7. Possible paroxysmal atrial fibrillation
8. Possible congestive heart failure with history of low
extremity edema with recent ejection fraction of 65%.
9. Mild renal insufficiency with baseline creatinine of 1.4.
10. Hypertension
11. Hemorrhoids
12. History of chronic constipation and painful rectal
spasms.
13. Possible hypoparathyroidism.
14. Seizure disorder
15. Peripheral vascular disease
16. Benign prostatic hypertrophy
17. Migraines
18. Gout
19. Anxiety disorder
20. Possible Parkinson's disease on Mirapex.
PAST SURGICAL HISTORY:
1. Cholecystectomy
2. Appendectomy
3. Hernia repair
4. TURP
ADMISSION MEDICATIONS:
1. Lactulose 30 cc 4x a day
2. Hydralazine 20 mg 4x a day
3. Ativan 1 to 2 mg q 4 to 6 hours prn
4. Robitussin cough syrup prn
5. Colace 100 mg twice a day
6. Mirapex 0.2 mg once a day
7. Allopurinol 100 mg once a day
8. Dulcolax 10 mg po q day
9. Atrovent 4 puffs 4x a day prn
10. Protonix 40 mg once a day
11. Flovent 2 puffs twice a day prn
12. Salmeterol 2 puffs twice a day
13. Theophylline 400 mg once a day
14. Diltiazem 260 mg once a day
15. Flomax 0.4 mg q hs
16. Lovenox 80 mg subcutaneous twice a day
ALLERGIES: PENICILLIN CAUSES RASH.
SOCIAL HISTORY: Lives in an assisted home facility in [**Location (un) 7498**] with occasional alcohol use, but no tobacco use.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2, heart rate 20, blood pressure
146/69, saturation 94% on 3 liters.
GENERAL: Alert and oriented in no apparent distress.
HEAD, EARS, EYES, NOSE AND THROAT: Within normal limits, no
jugular venous distention, no bruits.
PULMONARY: Diffuse rhonchi bilaterally.
CARDIOVASCULAR: Regular rate and rhythm, normal S1 and S2
sounds.
ABDOMEN: Nontender, nondistended, obese with present bowel
sounds and multiple bruises over anterior abdomen.
EXTREMITIES: 1+ pitting edema bilaterally.
NEUROLOGIC: Grossly intact.
ADMISSION LABORATORIES: White blood cell count 6.1,
hematocrit 31, platelets 167. Sodium 142, potassium 3.8,
chloride 102, BUN 12, creatinine 0.9.
SUMMARY OF HOSPITAL COURSE: The patient was originally
admitted to the medicine service. A chest x-ray obtained on
the day of admission showed small pleural effusions, but no
radiographic evidence of pneumonia or congestive heart
failure. On [**2148-9-6**], the patient had his Dumon stent removed
from the left main stem bronchus with rigid forceps without
any complications. In addition, given the diagnosis of
tracheobronchomalacia with bow-string trachea, the patient
underwent right thoracotomy with posterior membranous wall
tracheoplasty with Marlex mesh, tracheostomy tube placement,
flexible bronchoscopy and tracheobronchial aspiration. The
procedure was without any complications. Please see the full
operative report for detail.
The patient was started on intravenous vancomycin. The
aspirate cultures were sent for identification. The tracheal
aspirate grooves Staphylococcus aureus which was coagulase
positive and sensitive to vancomycin, but resistant to
oxacillin (MRSA). Respiratory care specialists were
consulted who administered albuterol and Atrovent treatment
for the patient every six hours in the beginning with good
results. Psychiatry was consulted as well to evaluate for a
possible depression. The patient continued to have the low
grade fever. His white count at the time increased to 13.0,
but subsequently decreased. The patient was maintained on
CPAP. On [**2148-9-12**], the patient's creatinine was noted to be
rising to 2.3 and eventually reached a peak of 6.7 on
[**2148-9-17**].
Renal service was consulted to manage the patient's acute
renal failure. The patient underwent a repeat bronchoscopy
on [**2148-9-9**] which showed edema of the vocal cords as well as
severe malacia in the trachea and main stem bronchi with a
moderate amount of white secretions found diffusely which
were removed with suction. Cardiac surgery was consulted on
[**2148-9-9**] for the evaluation and management of the patient's
tracheomalacia with posterior membranous wall dynamic
collapse. As noted above on [**2148-9-11**], the patient underwent
posterior membranous wall tracheoplasty with Marlex mesh.
The patient tolerated the procedure well. There were no
complications. Please see the full operative note for
detail.
The patient was transferred to the Intensive Care Unit in
stable condition. The patient was noted to have a
temperature of 102??????. Blood cultures were drawn which showed
no growth. The patient continued to receive periodic
bronchoscopies which continued to show secretions which
decreased in amount. The patient was originally hypotensive,
but his blood pressure stabilized while he remained in the
Intensive Care Unit. The patient's renal function gradually
improved with decreasing creatinine. The patient was
hydrated daily. The patient continued to be intubated. The
patient's chest tube was removed on postoperative day 4. The
patient was also started on tube feeds.
Physical therapy was consulted which followed the patient.
The patient appeared to be comfortable on 4 liters nasal
cannula on postoperative day 8 while still in the Intensive
Care Unit. He was continued on intravenous vancomycin, given
MRSA in his sputum. The patient's stay in the Intensive Care
Unit was noted for him pulling out his tracheostomy tube.
The patient remained afebrile during the rest of his
hospitalization. He continued to breathe with less
difficulty. There were no significant secretions towards the
end of the hospitalization. The chest x-ray performed on
[**2148-9-23**] showed improved left lower lobe atelectasis with
worsening right upper lobe and right lower lobe
collapse/consolidation. The waxing and [**Doctor Last Name 688**] nature of
these findings was thought to be consistent with aspiration.
On [**2148-9-24**], the patient's tracheostomy tube was removed.
The patient continued to do well with supplemental oxygen via
nasal cannula. He was able to swallow. However, he still
had relatively poor peroral intake. In addition, a PICC line
was placed for intravenous antibiotic administration. The
patient was discharged to the rehabilitation center in stable
condition.
DISCHARGE CONDITION: Good
DISCHARGE DESTINATION: Rehabilitation facility
DISCHARGE DIAGNOSES:
1. Tracheobronchomalacia status post right thoracotomy with
posterior membranous wall tracheoplasty with Marlex mesh
2. Acute renal failure
3. Clostridium difficile infection
4. Aspiration pneumonia and MRSA bronchitis
5. Asthma/COPD
6. Hypertension
DISCHARGE INSTRUCTIONS:
1. The patient is to follow up with his surgeon, Dr. [**Last Name (STitle) 952**],
in approximately one to two weeks following discharge.
2. The patient is to follow up with his primary care
physician in approximately one to two weeks as instructed.
3. The patient is to continue to receive intravenous
antibiotics.
DISCHARGE MEDICATIONS:
1. Intravenous vancomycin dose to be adjusted based renal
function
2. Lansoprazole 30 mg po q day
3. Multivitamins 1 capsule po q day
4. Colace 100 mg po bid
5. Theophylline 200 mg po bid
6. Flagyl 500 mg po tid x14 days
7. Dilaudid 2 to 4 mg po q 3 to 4 hours prn pain
8. Coumadin 1 mg po hs
9. Plavix 30 mg subcutaneous q 12 hours
10. Flovent 110 mcg 2 to 4 puffs inhaler [**Hospital1 **]
11. Salmeterol 2 to 4 puffs inhaler [**Hospital1 **]
12. Albuterol 6 puffs inhaler qid
13. Ipratropium bromide 6 puffs inhalers qid
14. Ativan 1 mg po q 12 hours prn agitation
15. Mirapex 0.25 mg po q day
16. Allopurinol 100 mg po q day
17. Robitussin cough syrup 15 ml q4h prn
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2148-9-24**] 12:13
T: [**2148-9-24**] 13:11
JOB#: [**Job Number 42958**]
Name: [**Known lastname 7829**], [**Known firstname 7830**] Unit No: [**Numeric Identifier 7831**]
Admission Date: [**2148-9-5**] Discharge Date: [**2148-9-27**]
Date of Birth: [**2067-11-5**] Sex: M
Service:
ADDENDUM: This is an addendum to the previously dictated
Discharge Summary.
DISCHARGE MEDICATIONS:
1. Hydralazine 10 mg p.o. q. six.
2. Lansoprazole 30 mg p.o. q.d.
3. Multivitamins one capsule q.d.
4. Colace 100 mg p.o. b.i.d. p.r.n.
5. Theophylline 200 mg p.o. b.i.d.
6. Flagyl 500 mg p.o. t.i.d. times ten days.
7. Flovent 110 micrograms two to four puffs inhaler b.i.d.
8. Salmeterol two to four puffs inhaler b.i.d.
9. Albuterol six puffs inhaler q.i.d.
10. Allopurinol 100 mg q.d.
11. Mirapex 0.25 mg p.o. q.d.
12. Lactulose 30 mg p.o. q.i.d.
13. Diltiazem 360 mg p.o. q.d.
14. Coumadin 3 mg to be given on [**2148-9-27**]. The
Coumadin dose is to be adjusted by INR levels to the goal
range of 2 to 2.5.
15. Vancomycin IV 1 gram to be dosed for vancomycin level of
less than 15.
DISCHARGE DIAGNOSIS:
1. Idiopathic tracheobronchomalacia, status post stent
removal and posterior membranous wall tracheoplasty.
2. Acute renal failure.
3. Clostridium difficile infection.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 384**] in
approximately three weeks.
2. The patient is to follow-up with his primary
care/cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 7832**], phone number:
[**Telephone/Fax (1) 7833**], in approximately one to two weeks.
3. The patient is to receive 3 mg of Coumadin on [**2148-9-27**]. The Coumadin levels are to be adjusted to the INR goal
of [**1-13**].5 for DVT prophylaxis.
4. The patient is to receive IV vancomycin for a period of
three weeks. The patient is to be given 1 gram of IV
vancomycin for serum vancomycin level of less than 15.
[**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D.
Dictated By:[**Last Name (NamePattern1) 1388**]
MEDQUIST36
D: [**2148-9-28**] 00:51
T: [**2148-9-28**] 06:55
JOB#: [**Job Number 7834**]
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
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"93.90",
"96.05",
"31.79",
"33.23",
"98.15",
"89.64",
"38.93",
"31.1",
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] |
icd9pcs
|
[
[
[]
]
] |
8085, 8140
|
8161, 8418
|
9966, 10664
|
10685, 10857
|
10881, 11790
|
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2406, 2471
|
3928, 8063
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3205, 3899
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136, 1250
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3070, 3183
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,608
| 175,381
|
52960
|
Discharge summary
|
report
|
Admission Date: [**2122-2-27**] Discharge Date: [**2122-3-5**]
Service: MEDICINE
Allergies:
Heparin Sodium / Shellfish
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
Right hip fracture
Major Surgical or Invasive Procedure:
Right hip fracture repair (ORIF)
History of Present Illness:
87M with MMP including DM (last HbA1c 6.7), AFib on coumadin,
CAD s/p CABG/stents, CHF (EF 25-30%), s/p pacemaker/ICD, porcine
AVR/MVR, BPH (chronic foley) presented after mechanical fall
found to have right sub-trochanteric fracture. He was at home,
woke up at 7.25AM and found his foley bag to be full. He tried
to reach the foley bag and accidentally hit the power button of
his nearby motorized wheelchair. He subsequently fell backwards.
He denies having hit anything else except his buttock and right
hip. He specifically did not hit his head. He felt pain ([**11-18**]
in severity) in his right hip and could not move without
excruciating pain. He next called 911 and was brought into the
ED.
.
Patient denies any dizziness or special events preceding the
fall, but he is known to have a very poor sense of balance since
childhood. According to the patient, he has a brain cyst since
birth responsible for his poor balance.
.
ROS: He denies any F/C/N, CP, SOB (beyond his baseline from
COPD), abdominal pain, N/V/D, bloody stools or urine, or urinary
symptoms.
.
ED: In the ED, his VS were stable. He was given Tylenol PO and
morphine 2mg iv x 2 for pain control. Hip films, Head CT and CT
C-spine were performed. They revealed no acute findings except
for a right displaced, subtrochanteric fracture. Ortho evaluated
the patient and decided to operate him in the morning after
medical clearance. His PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2450**], also saw the patient in
the ED and it was decided to admit the patient to the medicine
service for pre-OP clearance given his multiple cardiac risk
factors.
Past Medical History:
1. Atrial fibrillation, on coumadin (INR goal 2.0-2.5 per PCP)
2. s/p pacemaker, AICD
3. CAD s/p CABG, stents (placed 16 yrs ago) - last [**Last Name (STitle) **] [**3-16**]
showing moderate fixed inferior defect
4. CHF - last echo [**12-15**] EF 20-25%
5. COPD / Emphysema (70+ yrs of smoking)
6. Type II diabetes mellitus (last HbA1c 6.7 in [**10/2121**])
7. s/p porcine MVR/AVR in [**2105**]
8. hyperlipidemia
9. BPH - chronic foley (being changed q6weeks)
10. h/o nephrolithiasis
11. CRI - baseline creat 1.1-1.2
12. Chronic anemia (possibly ACD per PCP, [**Name10 (NameIs) **] worked up)
13. Large porencephalic cyst within right parietal/occipital
area (since birth per patient)
14. Hypothyroidism (on replacement therapy)
15. Left inguinal hernia
Social History:
Lives with his wife. Difficult home situation per PCP. [**Name10 (NameIs) **] is
also wheelchair bound. Has meals on wheels, uses a motorized
scooter/walker. Smokes 2-5cigs/day x 70 years. Rare EtOH, no
IVDU.
Family History:
Non-contributory
Physical Exam:
VS: Temp: 97.3, BP: 132/70, HR: 66, RR: 22, O2sats: 95% on RA,
weight: 138.6 lbs
GEN: pleasant, talkative, comfortable, elderly man in NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no upper
teeth
NECK: supple, no LAD, JVP 13cm
RESP: coarse BS, No rhales, rhonchi or wheezes
CV: PMI laterally displaced, RR, S1 and S2 wnl, no m/r/g
ABD: +BS, soft, ND, no masses or hepatosplenomegaly, deep RLQ
palpation causes right hip pain, but no abdominal tenderness
EXT: no c/c/e, wasted muscles, warm legs, 2+ DP/TP pulses, R leg
externally rotated, decreased ROM of R hip [**3-13**] pain, mild
swelling over R hip noted, TTP over R hip and femur
SKIN: no jaundice, old bruise over R forearm (pt hit his arm
accidentally the day prior to his fall)
NEURO: A&O x3, CN II-XII intact, decreased strength of RLE [**3-13**]
hip pain
RECTAL: deferred given immobility of patient
UGT: L groin bulge TTP, approximately egg-sized (known inguinal
hernia), foley in place
Pertinent Results:
[**2122-2-27**] 08:25AM WBC-6.5 RBC-3.65* HGB-11.4* HCT-32.8* MCV-90
MCH-31.2 MCHC-34.8 RDW-13.3
[**2122-2-27**] 08:25AM NEUTS-60.0 LYMPHS-20.5 MONOS-5.7 EOS-12.9*
BASOS-0.9
[**2122-2-27**] 08:25AM PLT COUNT-184
[**2122-2-27**] 08:25AM PT-18.7* PTT-26.7 INR(PT)-1.8*
[**2122-2-27**] 08:25AM GLUCOSE-151* UREA N-32* CREAT-1.0 SODIUM-139
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-24 ANION GAP-12
.
EKG: NSR with LBBB (old), old Q in III, no acute changes
.
[**2-27**] Right hip and knee film:
1. Obliquely oriented fracture of the proximal right femur
extending from the lesser trochanter distally and laterally into
the proximal femoral diaphysis with foreshortening and
displacement.
2. Degenerative changes of the lower lumbar spine.
.
[**2-27**] CT Head: No acute hemorrhage. No shift of midline
structures. Large porencephalic cyst within right
parietal/occiptal area unchanged compared to [**2120-4-12**]. No
hydrocephalus.
.
[**2-27**] CT C-spine: No significant malalignment. No fracture. Mild
retrolisthesis of C4 on C5. Mild- moderate degenerative disease.
.
ECHO [**2121-12-29**]: LA is moderately dilated. Mild symmetric LVH. The
left ventricular cavity size is normal. There is severe global
left ventricular hypokinesis. Overall left ventricular systolic
function is severely depressed (20-25%). The ascending aorta is
mildly dilated. A bioprosthetic aortic valve prosthesis is
present. The transaortic gradient is normal for this prosthesis.
No aortic regurgitation is seen. A bioprosthetic mitral valve
prosthesis is present. The transmitral gradient is normal for
this prosthesis. No mitral regurgitation is seen.
.
CXR AP [**2-27**]: A dual-chamber pacer is present with its leads
overlying the right atrium and ventricle. Median sternotomy
sutures are present. Rightward shift of the trachea which is
likely secondary to atherosclerotic changes and enlargement of
the aortic knob. The lungs are clear. No pleural effusions
present. Mild cardiomegaly is stable. Prosthetic mitral valve in
place.
.
CXR AP [**2-28**]: Increased interstitial markings, which may
represent edema. Change in course of atrial pacer lead. Is there
evidence that this may become dislodged or has it been removed?
.
Hip XR [**2-28**]: Three views. Comparison with the previous study
done [**2122-2-27**]. A comminuted fracture of the proximal femur is
again demonstrated. Major fracture fragments are transfixed by a
screw and intramedullary rod. A small butterfly fragment at the
lateral aspect of the fracture site is displaced laterally.
There is no evidence of dislocation.
.
[**3-3**] Abdomen supine & erect: Mild gaseous distention of the
stomach. Moderate amount of stool within the rectum and colon
without evidence of obstruction.
Brief Hospital Course:
87M with MMP including DM (last HbA1c 6.7), AFib on coumadin,
CAD s/p CABG/stents, CHF (EF 25-30%), s/p pacemaker/ICD, porcine
AVR/MVR, BPH (chronic foley) presented after mechanical fall
found to have right displaced, sub-trochanteric fracture, went
for ORIF, was transiently in MICU for prolonged intubation and
AICD interrogation after tachycardic runs, then stable on floor
again.
.
1. R subtrochanteric fx: Seen by Ortho in ED. Displaced on XR.
ORIF was planned on day of admission but given scheduling
issues, deferred until 7AM the next day. Patient has medium to
high risk for cardiac complications but was overall stable and
cleared for surgery based on clinical exam, stable EKG, CXR, and
labs. Plavix and coumadin were held. Pt was transiently on
Heparin drip prior surgery. Needed 1U pRBC pre-OP for transient
drop in his hematocrit. Operation went without any major
surgical events. However, patient required prolonged intubation
post-OP and thought to have VT run peri-OP. Was briefly in MICU
until extubated. EP interrogated AICD. Runs were likely not VT
but SVT with bundle branch block. Stable since transfer to
floor. Pain control initially with PCA post-OP, then with
Tylenol PO and Morphine IV. Eventually transitioned to PO
oxycodone. Patient only had two transient episodes of Afib with
RPR that postponed discharge by one day. Otherwise, he had an
uneventful hospital course after transfer to the medical floor
except for a small post-Op hematoma around the right waist and
hip. Post-OP Lovenox was discontinued once patient was
therapeutic on coumadin again. Patient needs followup
appointment with Orthopedics four weeks after the operation.
Staples need to be taken out two weeks post-OP ([**2122-3-14**]).
.
2. CAD s/p CABG/stents: Stable throughout most of his hospital
stay. Pt denied any CP or increased SOB on admission. EKG was
without any acute changes. Per PCP, [**Name Initial (NameIs) 109162**]/IIIa inhibitors were
tried in the past, but discontinued due to severe hematuria.
Patient was continued on ASA, statin, betablocker, Nitro SL prn
CP. Plavix was held preoperatively and restarted post-OP at
regular dose.
.
3. Rhythm: Patient has known AFib, is on coumadin and s/p
pacemaker/AICD. Patient was kept on telemetry throughout his
hospital stay. INR goal 2.0-2.5 per PCP. [**Name10 (NameIs) **] coumadin prior
surgery. Was briefly heparinized pre-OP. Received FFPs x2 and
Vit K sc x1 shortly prior surgery. Went for surgery in AM of
[**2-28**]. Had two runs of ?VT peri-OP and AICD did not function. EPS
interrogated AICD and read tachycardic runs as SVT with bundle
branch block as opposed to VT. Patient only had two transient
episodes of Afib with RPR that postponed discharge by one day.
His BB dose was increased to 37.5mg [**Hospital1 **] for better rate control.
Coumadin was restarted post-OP. INR was 1.9 on [**3-3**], and 2.2 on
day of discharge. INR should be checked 2-3 days after discharge
to ensure therapeutic range.
.
4. Systolic CHF: EF 20-25% on last Echo ([**12-15**]). CHF seemed
stable. No LE edema, lungs clear, no increased SOB, no CP. Pt
appeared euvolemic on exam. Patient was continued on his BB and
Nitro SL prn CP. Lasix was restarted upon discharge.
.
5. DMII: Last HbA1c 6.7 in 9/[**2121**]. Glyburide was held during
hospital stay and restarted upon discharge. RISS during peri-op
period.
.
6. COPD: Known emphysema, 70+ years of smoking. Continued home
inhalers (albuterol, ipratroprium prn). Sputum from [**3-1**] grew
only OP flora.
.
7. CRI: Likely [**3-13**] DM. Baseline creat 1.1-1.2. Creat of 1.0 on
admission. Remained stable throughout hospital course.
.
8. Anemia: Hct baseline 27-34. Stable on admission with Hct of
32. Ferritin of 76, iron of 90, folate 17.6, B12 437 in 4/[**2121**].
Unclear etiology but possibly ACD per PCP. [**Name10 (NameIs) **] workup as
outpatient recommended. Hct dropped overnight ([**2-27**]) prior
surgery from 32.8 to 25.6. Stools were guaiac'd and foley
checked for hematuria. Patient received 1U pRBC, Hct came up to
29.4. Pt went to surgery. Post-OP Hct remained stable around
27-29 until discharge.
.
9. BPH: Chronic foley. Being changed q6weeks in urology clinic.
Per PCP, [**Name10 (NameIs) **] to bleed easily from bladder. Ucx from [**2-28**] grew
GNR (10-100K), 2 colonies. No rx.
.
10. Hypothyroidism: continued Levoxyl.
.
11. Hyperlipidemia: continued statin.
.
12. FEN: Diabetic, cardiac diet. Repleted electrolytes as
needed. Patient had poor PO intake post-OP. Supplemented with
Ensure.
.
13. Prophylaxis: Coumadin for Afib. Lovenox post-OP until INR
therapeutic, then stopped given post-OP hematoma around right
waist and hip. Bowel regimen with senna prn and colace standing.
.
14. Code Status: Full
Medications on Admission:
coumadin 1mg M-W-F, 2mg T-T-S
plavix 75mg qday
ASA 352mg qd
metoprolol 25mg po bid
Atorvastatin 10mg qday
Folate 1mg po qday
albuterol inh 1-2 puffs q6 prn
ipratropium inh 1 puff q6h prn
lasix 10mg qday
glyburide 1.25mg qday
Levoxyl 50 mcg qd
Nitro SL 0.4mg prn CP
Discharge Medications:
1. Outpatient Lab Work
Your INR should be checked two to three days after discharge.
Please have have the results faxed to your PCPs office at ([**Telephone/Fax (1) 109163**]. Your coumadin should be adjusted if necessary.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for SOB,
wheezing.
7. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(TU,TH,SA).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for pain.
16. Prochlorperazine 5 mg Tablet Sig: One (1) Tablet PO Q4-6H
PRN () as needed for nausea.
17. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
18. Furosemide 20 mg Tablet Sig: [**2-10**] Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Health and Rehab
Discharge Diagnosis:
Primary Diagnosis:
1. Right subtrochanteric fracture, s/p ORIF
2. AFib with RPR, on coumadin
3. Acute blood loss, requiring blood transfusion
.
Secondary Diagnosis:
1. CAD, s/p CABG, stents
2. Systolic CHF (EF 20-25%)
3. DM type II
4. COPD
5. CRI
6. Chronic anemia
7. Hypothyroidism
8. BPH
Discharge Condition:
Afebrile. Hemodynamically stable. Tolerating PO.
Discharge Instructions:
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, nausea/vomiting,
spontaneous bleeding or any other concerning symptoms.
.
Please take all your medications as directed. Your beta blocker
has been increased to 37.5mg twice daily. Your INR should be
checked two to three days after discharge. Your coumadin should
be adjusted if necessary. Please have have the results faxed to
your PCPs office at ([**Telephone/Fax (1) 109164**].
.
Please keep your follow up appointments as below.
.
You should have your staples removed at the rehabilitation
center on [**2122-3-14**].
Followup Instructions:
Please follow up with your primary care doctor ([**Last Name (LF) **],[**First Name3 (LF) **] T.
[**Telephone/Fax (1) 250**]) in [**2-10**] weeks after rehab. You should have your
staples removed on [**2122-3-14**] at rehab.
.
You have an appointment to see Dr. [**First Name (STitle) **] from Orthopedics on
Tuesday, [**4-7**] at 10:45am on the [**Location (un) 1773**] of the
[**Hospital Ward Name 23**] building on the [**Hospital1 18**] [**Hospital Ward Name **].
.
In addition, please follow up with:
.
Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2122-5-14**] 1:20
Provider: [**Name Initial (NameIs) 10081**]/EXERCISE LAB Phone:[**Telephone/Fax (1) 1566**]
Date/Time:[**2122-6-9**] 10:30
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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|
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|
252, 287
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316, 1952
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4752, 6730
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13751, 13878
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13605, 13730
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1974, 2731
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2747, 2957
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,834
| 198,601
|
3612
|
Discharge summary
|
report
|
Admission Date: [**2183-1-7**] Discharge Date: [**2183-2-14**]
Date of Birth: [**2125-8-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
transfered from OSH for MRSA bacteremia/endocarditis in the
setting of osteomyeltitis
Major Surgical or Invasive Procedure:
MVR (27mm [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 16409**] valve) [**1-24**]
History of Present Illness:
The patient is a 57 y/o male w hx of DM, PVD s/p R TMA [**8-14**], b/l
charcot joints, CKD, HTN, who is tranfered from an OSH after
finding of MRSA bacteremia/endocarditis. The patient has had
multiple b/l foot infections, mostly treated here at the [**Hospital1 18**].
In [**Month (only) 216**], he underwent a R TMA, complicated by persistent wound
infections requring a treatment course of Bactrim for MRSA and a
wound VAC. Healing of the wound has been slow.
The patient presented to [**Hospital3 **] on [**2182-12-23**] w/
complaints of fatigue. He was found to have DKA, leukocytosis
of 28, and ARF on CKD. Further workup revealed a MRSA positive
blood, foot and urine culture. An MRI was obtained, which
showed a suspcion for osteoyeltitis throughout the stumps of the
metatarsal of the right foot. Patient was brought to the OR, and
underwent I+D x 2 and was started on vanc. Because of
persistent fevers and bacteremia, a TEE was ordered and
reportedly showed a soft density on mitral valve and suggestion
of an aortic valve leaflet density consistent with endocarditis.
Patient had a tunneled central venous line under fluroscopic
guidance the day prior to transfer.
The patient additionally presented with a Cr of 3.5 (up from
baseline of 2.0.) The etiology of his renal failure was
believed to be pre-renal in nature, due to dehydration in the
setting of DKA. Patient's renal function improved w/ IVF to
2.5. His DKA was initially treated with an insulin gtt, but
blood sugars were adequatly controlled with NPH and a sliding
scale over the hospitaliztion.
The patient is now transfered to [**Hospital1 18**] for further manegment
and evaluation for the need or cardiac surgery.
Past Medical History:
Multiple lower extremity infections, wounds
Diabetes II - poorly controlled
Peripheral Neuropathy
Hypertention
Chronic Renal Failure (1.8-2.2 Creat)
Left TMA
Right 1st and 4th toe amp
Anemia
Social History:
Non-smoker, NO etoh
[**Company 16410**] Ship Inspector, but not currently working
Family History:
Mother died from alzheimer's, father died from heart attack,
sister has DM and hx of MRSA infection
Physical Exam:
vs: Tc 100.9 BP 136/62 HR 84 O2 95% on RA
Gen: Obese male in NAD, AAOx3
HEENT: PERRL, EOMI, MMM, no LAD, OP w/o exudates or erythema
Chest: CTA b/l, no CVA tenderness, site of tunnel catheter c/d/i
Cardiac: RRR, s1,s2, soft II/VI blowing systolic murmur heard
best at USB
Abd: obese, soft ntnd, no HSM
Extremities: The RLE wound is deep, but dry and w/o drainaige.
No surrounding erythema, necrosis, or edema. Multiple toes
amputated b/l. No splinter hemoarges, jainway spots, or osler
nodes noted.
Pertinent Results:
[**2183-2-13**] 05:37AM BLOOD WBC-9.5 RBC-3.09* Hgb-8.2* Hct-27.3*
MCV-89 MCH-26.7* MCHC-30.1* RDW-18.8* Plt Ct-390
[**2183-2-14**] 03:51AM BLOOD PT-25.1* PTT-98.9* INR(PT)-2.5*
[**2183-2-14**] 03:51AM BLOOD Glucose-99 UreaN-37* Creat-3.2* Na-131*
K-5.2* Cl-100 HCO3-24 AnGap-12
Brief Hospital Course:
A/P Pt is a 57 y/o male w hx of DM, PVD s/p R TMA [**8-14**], b/l
charcot joints, CKD, HTN, who is transferred from an OSH after
finding of MRSA bacteremia/endocarditis in the setting of
osteomyelitis of b/l metatarsals. Foot x-ray here c/w infection.
MRSA+ wound culture at OSH and here. Debrided in OR on [**2182-1-10**].
Path shows osteomyelitis. He also developed acute on chronic
renal failure for which he was followed by renal.
Pt w/persistent MRSA + blood cultures, MRSA+ wound cultures, and
persistent fevers. TEE here shows large MV veg with probable
perf of posterior leaflet and 3+ MR. [**Name13 (STitle) **] has been on
vacomycin since [**2182-12-23**], but has been unable to clear
bacteremia.
He was taken to the operating room on [**2183-1-24**] where he underwent
an MVR. He was transferred to the ICU in stable condition on
amiodarone, vasopressin, milrinone, levophed, neo, propofol and
insulin.
He became oliguric and was started on CVVH. He was extubated on
POD #4. He continued on daptomycin and gentamycin. He was
started on coumadin and heparin IV for his mechanical valves.
Blood cultures continued to remain positive, so he underwent
tagged white blood cell scan which showed uptake increased only
in the right foot. Podiatry continued to follow for his right
foot VAC dressing. His urine output and creatinine improved and
CVVH was discontinued. Bactrim was added, and was then changed
to rifampim given his nausea. He was started on meropenum for
GNR in blood.
Blood cultures from [**1-31**] and after were negative.
Medications on Admission:
Medications on Transfer:
vancomycin 1500mg IV q48 h
ASA 81mg daily
Colace 100mg [**Hospital1 **]
Iron 300mg [**Hospital1 **]
Lisinopril 20mg [**Hospital1 **]
Toprol XL 200mg qam
Senokot [**Hospital1 **]
Lantus 40units qhs
NPH 14 units qam
Regular insuln 7 units qafternoon
regular 14 units qam
ISS
Reglan PRN
Tylenol PRN
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. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
8. Daptomycin 500 mg Recon Soln Sig: Eight Hundred (800) mg
Intravenous Q48H (every 48 hours) for 4 weeks: 4 weeks from
[**1-31**].
9. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q 8H (Every 8
Hours) for 4 weeks: 4 weeks from [**1-31**].
10. Meropenem 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 4 weeks: 4 weeks from
[**2-2**].
11. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous at bedtime.
12. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day.
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
14. Outpatient Lab Work
Needs weekly CBC, LFTs, CK, BUN/Cre faxed to ([**Telephone/Fax (1) 16411**] att
Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **]
15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once)
for 1 doses: titrate dose daily for a goal INR of 2.5 to 3 for a
mechanical mitral valve.
16. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 10
days: reassess fluid level at end of course to guide need to
continue.
17. Wound
Continue wound VAC to foot for one week
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
mitral valve endocarditis now s/p MVR
acute on chronic renal failure
Right foot osteomyelitis s/p debridement and VAC placement
multiple lower extremity infections, DM2, peripheral neuropathy,
HTN, CRI(1.8-2.2), L TMA, R TMA, anemia
Discharge Condition:
Stable
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds for 10 weeks from surgery.
No driving until follow up with surgeon or while taking narcotic
pain medication.
Shower daily, no baths, no lotions, creams or powders to
incisions.
Followup Instructions:
Dr. [**Last Name (STitle) 16412**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks ([**Telephone/Fax (1) 11763**]
Dr. [**Last Name (STitle) 3407**] (vascular) 4 weeks ([**Telephone/Fax (1) 10880**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5866**], MD (Infectious Diseases)
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2183-2-28**] 10:30
Dr. [**Last Name (STitle) **] in 2 weeks. ([**Telephone/Fax (1) 16413**] Continue wound VAC for one
week.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2183-2-14**]
|
[
"038.11",
"421.0",
"997.1",
"V09.0",
"285.9",
"250.00",
"997.62",
"403.90",
"999.31",
"584.9",
"427.31",
"276.1",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"96.6",
"38.95",
"35.24",
"37.22",
"77.69",
"88.56",
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7190, 7263
|
3505, 5053
|
358, 496
|
7540, 7549
|
3202, 3482
|
7922, 8522
|
2566, 2667
|
5424, 7167
|
7284, 7519
|
5079, 5079
|
7573, 7899
|
2682, 3183
|
233, 320
|
524, 2236
|
5104, 5401
|
2258, 2450
|
2466, 2550
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
154
| 102,354
|
7847
|
Discharge summary
|
report
|
Admission Date: [**2127-12-23**] Discharge Date: [**2127-12-26**]
Date of Birth: [**2073-7-26**] Sex: M
Service: MEDICINE
Allergies:
Vicodin / Erythromycin Base
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
chest pain, STEMI
Major Surgical or Invasive Procedure:
left heart catheterization and balloon angioplasty
History of Present Illness:
54yo male with past medical history significant for coronary
artery disease s/p multiple interventions including CABG in
[**2118**], htn, hld who is presenting with STEMI. The patient reports
that he was standing in his kitchen at rest this afternoon
around 4pm and he had sudden onset of chest pressure, which is
how his angina always presents. He took nitroglycerin x4 and the
chest pain did not improve, so he called EMS.
.
Upon arrival of EMS, the patient was given nitro and aspirin. He
was taken to OSH, where EKGs were done and the decision was made
to transfer to [**Hospital1 18**]. On arrival to the cath lab, he reported
his pain as [**4-13**]. In the cath lab, the patient had balloon
angioplasty of the TCA but no placement of stent. There was
thrombosis of the distal RCA that was refractory to balloon
angioplasty, despite IV heparin, IV integrillin and prasugrel.
The final injection showed TIMI 1 flow into the distal vessel
and ST segment elevation consistent with continued inferior wall
STEMI. His CP was [**6-13**].
.
The patient reports that he has been in his baseline state of
health since [**Month (only) 116**], when he was experiencing increasing anginal
symptoms and so he had repeat coronary angiography, done as an
outpatient, where he was found to have severe in stent
restenosis of the RCA and had DES placed. Since that time, he
has had much improved symptoms and has been able to keep up with
his exercise regimen of walking 2miles 5 days a week at a speed
of [**3-7**] miles per hour. On Friday, 4 days prior to presentation,
the patient noted that he was "at the edge of his exertion"
while he was doing his 2 mile walk. By this he means that if he
had increased his speed, he would have had angina, but since he
maintained his speed, he was not having angina. On Sunday, 2
days prior to presentation, the patient had acute onset of chest
pain and realized he had forgotten to take his am meds, so he
took them and he took one nitroglycerin and felt resolution of
the pain.
.
In the CCU, the patient reports 2/10 chest pain, denies dyspnea.
.
On review of systems, he denies any prior history of stroke,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: [**2118-4-6**]: LIMA -> LAD, SVG -> rPDA, SVG -> diagonal, SVG
-> ramus, left radial -> OM
[**2118-9-16**] PTCA and beta-brachytherapy of VG -> PDA
[**2-6**] s/p PTCA/beta-brachytherapy of the SVG->PDA
- PERCUTANEOUS CORONARY INTERVENTIONS:
-[**2117**]: IMI treated with retavase and overlapping proximal RCA
stents and distal RCA stent
-[**6-/2120**] s/p rotational atherectomy of the mid RCA and stenting
with two Taxus DES 3.0 x 12mm in the distal RCA with an
overlapping
3.0 x 24mm Taxus.
- [**5-/2127**] focal severe in-stent restenosis in the right coronary;
Drug-eluting stent (3.5 x 12 mm dilated to 3.75 mm).
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Anxiety/depression
Low back pain (resolved)
Left ankle fracture with surgery
Elbow fracture with surgery
? TIA word finding difficulty, micrographia after receiving
retavase.
Social History:
Divorced, has 3 kids- son, 22 has substance abuse issues;
daughter, 20, is at [**Hospital1 498**] [**Location (un) 5169**]; son, 17 is honors high school
student.
Occupation: Electrical Engineer; went out on disability several
years ago.
Tobacco: Quit [**2100**] (smoked 1-2ppd x7 years)
ETOH: quit 20 yrs
Recreational drug use: denies
Family History:
mother died at age 85 [**2-5**] Parkinson's disease. Dad died in his
40's from liver disease. Brother- died in his 60s from chronic
inflammatory demyelinating polyneuropathy. Sister- breast
cancer, obesity. Sister-depression.
3 children healthy.
Physical Exam:
ADMISSION EXAM:
.
VS: T=AF BP= 92/54 HR=65 RR=14 O2 sat= 98% 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP at clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
.
[**2127-12-23**] 07:50PM BLOOD WBC-8.7# RBC-3.86* Hgb-11.6* Hct-34.3*
MCV-89 MCH-30.0 MCHC-33.8 RDW-12.8 Plt Ct-187
[**2127-12-23**] 07:50PM BLOOD PT-12.3 INR(PT)-1.1
[**2127-12-23**] 07:50PM BLOOD Glucose-107* UreaN-14 Creat-0.9 Na-138
K-4.0 Cl-110* HCO3-21* AnGap-11
.
PERTINENT LABS AND STUDIES:
.
[**2127-12-23**] 07:50PM BLOOD CK(CPK)-84
[**2127-12-24**] 03:07AM BLOOD CK(CPK)-364*
[**2127-12-24**] 04:45PM BLOOD CK(CPK)-1084*
[**2127-12-24**] 03:07AM BLOOD CK-MB-44* MB Indx-12.1* cTropnT-0.27*
[**2127-12-24**] 08:50AM BLOOD CK-MB-90* cTropnT-0.68*
[**2127-12-24**] 04:45PM BLOOD CK-MB-105* MB Indx-9.7* cTropnT-1.28*
.
[**2127-12-24**] ECHOCARDIOGRAM The left atrium is elongated. Left
ventricular wall thickness, cavity size, and global systolic
function are normal. There is mild regional left ventricular
systolic dysfunction with mild hypokinesis of the basal to mid
inferior wall. The remaining segments contract normally (LVEF =
55 %). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
.
IMPRESSION: Mild regional left ventricular systolic function
with preserved left ventricular ejection fraction. Mild mitral
regurgitation. Mild pulmonary hypertension.
Brief Hospital Course:
This is a 53 year-old Male with past medical history significant
for CAD s/p CABG and multiple PCIs, p/w STEMI s/p DES to RCA
with poor flow after stenting ho presented with ST-elevation
myocardial infarction and underwent cardiac catheterization.
.
ACUTE CARE:
.
# CORONARY ARTERY DISEASE - The patient has had multiple PCIs
and is s/p CABG. He had a left heart catheterization with
balloon angioplasty of the RCA at the time of admission without
placement of stent, he was medically managed. He was treated
with Heparin gtt, Integrillin gtt, Pprasugrel and Aspirin. His
integrillin and heparin infusions were discontinued following
his catheterization. A 2D-Echo showed mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
basal to mid inferior wall (LVEF 55%). We did decreased his
Lisinopril from home dose of 40 mg to 10 mg this admission and
stopped his Plavix and decided to utilize Prasugrel.
.
CHRONIC CARE:
.
# HYEPRTENSION - We continued home Lisinopril but at 10 mg daily
and resumed his Metoprolol medication.
.
# HYPERLIPIDEMIA - Continued Atorvastatin 80 mg PO daily.
.
ISSUES OF TRANSITIONS IN CARE:
1. Exchanged Plavix for Prasugrel for anti-platelet therapy.
2. Will follow-up with outpatient Cardiologist and primary care
physician.
3. At the time of discharge, the patient had no pending
radiologic studies, labroatory studies, or microbiologic data.
Medications on Admission:
1. NTG 0.4mg tablet SL prn chest pain
2. aspirin 325mg daily,
3. Plavix 75 mg daily,
4. lisinopril 40 mg daily,
5. Atorvastatin 80mg daily
6. Toprol-XL 200 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. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual as directed as needed for chest pain: Take 1 capsule
x3, separated by 5 minutes.
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1. Acute ST-elevation myocardial infarction
.
Secondary Diagnoses:
1. Hypertension
2. Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 18**] for a heart attack that was caused by
a blockage in your right coronary artery. As you know, you did
not have placement of another stent in your coronary artery but
the artery was opened with a balloon. Your chest pain improved
with medical management and you will continue to follow with
your cardiologist and to take medications for your heart.
Please note the following changes to your medications:
1. STOP taking plavix, take prasugrel instead to prevent
blockages in your heart arteries
2. Decrease lisinopril to 10 mg daily instead of 40 mg.
Please be sure to follow up with your physicians.
Followup Instructions:
.
Department: CARDIAC SERVICES
When: MONDAY [**2128-3-15**] at 10:20 AM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**Last Name (LF) 28295**], [**First Name3 (LF) **] PA.
Location: [**Hospital1 **] PRIMARY CARE
Address: [**Street Address(2) 25171**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 25161**]
When: Tuesday, [**2126-1-6**]:15 AM
*[**Doctor First Name **] is covering for Dr. [**Last Name (STitle) **].
Department: CARDIAC SERVICES
When: MONDAY [**2128-2-9**] at 2:20 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"272.4",
"V45.82",
"V45.81",
"410.81",
"401.9",
"414.01",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9353, 9359
|
7019, 8419
|
308, 361
|
9523, 9523
|
5459, 5459
|
10370, 11313
|
4311, 4559
|
8635, 9330
|
9380, 9380
|
8445, 8612
|
9674, 10120
|
4574, 5440
|
9466, 9502
|
3087, 3735
|
10149, 10347
|
251, 270
|
389, 2979
|
5475, 6996
|
9399, 9445
|
9538, 9650
|
3766, 3942
|
3001, 3067
|
3958, 4295
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,514
| 113,638
|
6672
|
Discharge summary
|
report
|
Admission Date: [**2138-4-10**] Discharge Date: [**2138-5-4**]
Date of Birth: [**2091-2-17**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 47 year old
male, with end stage liver disease secondary to hepatitis C
cirrhosis diagnosed about 5 years prior to admission. The
patient had undergone treatment with interferon and
Ribavirin. He had been admitted to the [**Hospital1 18**] multiple times
early in [**2137**] for management of encephalopathy and ascites.
The patient had been discharged from the [**Hospital1 18**] on [**2138-4-7**],
but was readmitted on [**2138-4-10**] when noted to have worsening
renal function. The patient's serum creatinine on the day of
discharge, on [**2138-4-7**], was 1.9, but was noted to increase to
3.2 on [**2138-4-9**], and was further elevated to 3.6 on [**2138-4-10**].
The patient was admitted with concern for hepatorenal
syndrome.
PAST MEDICAL HISTORY:
1. Hepatitis C cirrhosis for which the patient was on the
liver transplant list.
2. Hypertension.
3. Nephrolithiasis.
4. Hemorrhoids.
5. Knee surgeries.
6. Back surgery.
MEDICATIONS:
1. Miconazole nitrate powder tid prn for groin rash.
2. Protonix 40 mg po bid.
3. Lactulose 30 ml tid (titrated to 4 to 5 bowel movements
qd).
4. Vancomycin 1 gm IV bid.
SOCIAL HISTORY: The patient is married with no children. He
works as a counselor at an alcohol and drug treatment
facility for teenagers. The patient was previously a heavy
alcohol user, but had been sober since [**2120**]. The patient had
also used cocaine in the past, but had also stopped in [**2120**].
HOSPITAL COURSE: (Part of the patient's chart from the
period [**2138-4-10**] to [**2138-4-24**] is currently unavailable, and
this dictation will mainly cover the period from [**2138-4-24**] to
[**2138-5-4**])
As previously mentioned, the patient's creatinine at the time
of admission was up to 3.6 from 1.9 at the time of his
discharge 3 days prior. Over the following 5 days, the
patient's creatinine improved marginally to 2.7.
Optimization of his fluid balance was managed by the medical
service in consultation with hepatology and renal. The
patient's INR on admission was 2.4, with his PT level being
18.9. The patient periodically required transfusions of
fresh frozen plasma, as well as platelets and red cells. The
patient was thrombocytopenic with a platelet count of 49 on
the 23. The patient was continued on vancomycin therapy for
his previously diagnosed Methicillin resistant, coagulase
negative Staph bacteremia. The patient's nutrition was
suboptimal, and the patient was started on tube feeding.
The patient underwent diagnostic and therapeutic paracentesis
on [**2138-4-17**], [**2138-4-22**], and [**2138-4-25**]. He had no evidence of
spontaneous bacterial peritonitis.
On [**2138-4-26**], a liver became available for transplant to the
patient. The patient was taken to the operating room and
underwent an orthotopic liver transplant. In order to aid in
optimization of the patient's fluid status, the patient was
on continuous [**Last Name (un) **] [**Last Name (un) **] dialysis during the procedure. His
estimated blood loss was 2 liters. The patient received 5
liters of crystalloid, 9 units of fresh frozen plasma, 9
units of red cells, 6 units of platelets, as well as 1 liter
of Cell [**Doctor Last Name **]. The procedure proceeded without
complications, and the patient was transferred to the
intensive care unit while still intubated following the
procedure.
The patient underwent an uncomplicated recovery in the
intensive care unit. By postop day 1, the patient was awake,
in no distress, and appeared lucid prior to extubation. The
patient was extubated on postop day 1 without any problems.
The patient was on a Lasix drip to aid in diuresis, and was
ultimately converted to oral Lasix on postop day 1. The
patient's pain control was with morphine. The patient
required 2 units of fresh frozen plasma on the night
following surgery, and 1 unit of platelets on postop day 1,
but otherwise required no blood products following the liver
transplant. The patient was started on sips on postop day 2,
and advanced to clear liquids on postop day 3. He was
advanced to a regular house diet later on postop day 3. The
patient was advanced per protocol to an immunosuppressive
regimen of prednisone, Neoral, and CellCept.
The patient's mental status remained essentially clear
throughout the entire postoperative period. The patient
started ambulating with the assistance of physical therapy
following transfer to the surgical floor. At the time of
discharge, the patient was independent, ambulating, and
functioning well. The patient's appetite improved
significantly, and at the time of discharge the patient was
on a regular diet with no tube feed supplements deemed
necessary. The patient's liver function tests all improved
appropriately by the time of discharge.
The patient's surgical incision was also healing well by the
time of discharge with no evidence of infection. The patient
was ultimately deemed ready for discharge on postoperative
day 8.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Bactrim single strength 1 tablet po qd.
2. Protonix 40 mg po qd.
3. Metoprolol 25 mg po bid.
4. Fluconazole 200 mg po qd.
5. CellCept 1 gm po bid.
6. Prednisone 20 mg po qd.
7. Dilaudid prn.
8. Neoral 500 mg po bid.
9. Valcyte 450 mg po qod.
10.Lasix 40 mg [**Hospital1 **] x 21 days.
11.Colace 100 mg po bid.
FOLLOW UP:
1. The patient was to follow-up with Dr. [**First Name (STitle) **] in the
Transplant Center 3 days following discharge.
2. The patient was to follow-up with Dr. [**Last Name (STitle) 497**] of hepatology
following discharge.
MAJOR SURGICAL PROCEDURES: Liver transplant on [**2138-4-26**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 25452**]
Dictated By:[**Last Name (NamePattern1) 17694**]
MEDQUIST36
D: [**2138-5-7**] 08:29:54
T: [**2138-5-8**] 10:40:21
Job#: [**Job Number 25453**]
|
[
"584.9",
"789.5",
"560.89",
"572.8",
"572.4",
"008.45",
"287.5",
"571.5",
"070.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.00",
"54.91",
"96.6",
"50.59",
"38.95",
"99.04",
"99.05",
"99.07",
"39.95",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
5174, 5183
|
5206, 5520
|
1653, 5152
|
5531, 6098
|
182, 938
|
960, 1323
|
1340, 1635
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,163
| 160,435
|
39018
|
Discharge summary
|
report
|
Admission Date: [**2138-2-8**] Discharge Date: [**2138-2-12**]
Date of Birth: [**2071-6-6**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Hydrochlorothiazide
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 86527**] is a 66M with PMHx significant for HTN, HLD, HD
dependent ESRD one day status post prepyloric polypectomy
([**2138-2-7**]) by ERCP team, 4 cm polyp, 90% removed, and 3 clips
placed, EBL zero. Today, after his dialysis, complains of onset
of black stools, no bright red blood, feeling generally weak and
lightheaded. He has had black stools one time before this, in
[**2134**], at which time EGD revealed an H Plyori related ulcer that
was treated without recurrence. He also had a colonoscopy at
that time that was normal per pt (at [**Hospital1 2025**]). He denies chest pain,
dyspnea, nausea, vomiting, abdominal pain and states that he is
otherwise in his USOH. Pt had usual dialysis today.
.
In the ED, initial VS were: 98.9 80 76/41 16 99% 4L nc. He was
triggered for initial systolic blood pressure in the 70s. he
stated that his SBP is typically in the 90s after HD. He
received a 250cc NS bolus with improvement in his BP to the
100s. He was never tachycardic. Exam was notable for maroon
stool on glove. Labs were notable for hct 32 from baseline low
30s. Coags and plts normal. Was typed and screened and
crossmatched for 2 units pRBCs. 18g and 20g PIVs were placed.
ERCP team was consulted and recommend supportive care,
pantoprazole gtt, if he becomes unstable, will urgently do
endoscopy, otherwise will avoid repeat endoscopy. Recommended
against NG lavage. Given upper GI bleed from large polyp, he was
admitted to the MICU for close monitoring
.
Upon arrival to the MICU, initial VS were: HR 88 BP 88/64 RR 11
O2 Sat 93% RA. In the MICU, they kept him on a PPI drip. He had
no further bowel movements or blood since being in ICU. His diet
was advanced to clears without incidence and he was stable for
transfer to the medicine floor.
Past Medical History:
- DM
- HTN
- Afib
- BPH
- H Pylori s/p treatment
- HD dependent ESRD
- h/o upper GIB requring transfusion [**1-9**] prepyloric ulcer ([**2134**])
Social History:
Divorced, lives alone in [**Hospital1 8**], has children in the area.
Daughter is HCP.
- Tobacco: 25 pack years, quit several years ago
- Alcohol: Occasional
- Illicits: Denies
Family History:
NC
Physical Exam:
Admission Exam:
T 98 BP 101/53 HR 94 RR 12 O2 Sat 95% RA
General: NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1/S2 no S3/S4. II/VI non radiating systolic
murmur heard througout the precordium.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: NTND, NABS, no rigidity, rebound or guarding
Ext: WWP, no c/c/e. 1+ DP pulses bilaterally.
Neuro: A/Ox3, CNII-XII grossly intact, non focal
.
Discharge Exam:
Tc 98.6, Tm 99.1, BP 96/56 (82-115/50-62), P 50s-70s, R 18,
97-100%RA
General: Alert, interactive, NAD
HEENT: Sclera anicteric, EOMI, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: RRR, normal S1/S2 no S3/S4. II/VI non radiating systolic
murmur heard througout the precordium.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: +BS, soft, NT, ND
Ext: WWP, no c/c/e. Left sided fistula.
Neuro: A/Ox3, CNII-XII grossly intact, non focal
Pertinent Results:
Admission Labs:
[**2138-2-8**] 05:50PM BLOOD WBC-9.0 RBC-3.48* Hgb-11.3* Hct-32.0*
MCV-92 MCH-32.6* MCHC-35.4* RDW-14.2 Plt Ct-178
[**2138-2-8**] 05:50PM BLOOD Neuts-80.1* Lymphs-11.6* Monos-7.0
Eos-0.5 Baso-0.8
[**2138-2-8**] 05:50PM BLOOD PT-12.1 PTT-30.1 INR(PT)-1.1
[**2138-2-7**] 01:34PM BLOOD UreaN-40* Creat-8.5* Na-141 K-3.8 Cl-98
HCO3-30 AnGap-17
[**2138-2-8**] 05:50PM BLOOD Calcium-10.0 Phos-2.6* Mg-2.1
.
Discharge Labs:
[**2138-2-12**] 05:25AM BLOOD WBC-4.3 RBC-3.28* Hgb-10.4* Hct-30.6*
MCV-93 MCH-31.8 MCHC-34.1 RDW-14.4 Plt Ct-126*
[**2138-2-12**] 05:25AM BLOOD Glucose-83 UreaN-29* Creat-7.2*# Na-138
K-4.2 Cl-95* HCO3-34* AnGap-13
[**2138-2-12**] 05:25AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.1
.
Micro: none
.
Imaging: none
Brief Hospital Course:
66 year old man with HD dependent ESRD, DM, HTN and atrial
fibrillation who presented with melena after a recent EGD and
biopsy of a large pre-pyloric polyp.
.
# Melena: Likely related to recent pre-pyloric polypectomy
performed the day prior to admission. No other upper source
identified on EGD. Colonoscopy in [**2134**] at [**Hospital1 2025**] was reportedly
normal. The patient was initially treated with a pantoprazole
gtt. He received two blood transfusions ([**2-9**] and [**2-10**]). He
continued to have dark stools but he remained hemodynamically
stable and his HCT remained stable in the high 20s-low 30s. He
was discharged home on pantoprazole 40mg PO BID instead of
omeprazole, and he was informed that he may continue to have
some dark stools for the next few days. He has a PCP f/u
appointment on [**2-19**] and has an appt with GI on [**3-10**].
.
# HTN: Upon discharge the patient was instructed to hold the
metoprolol succinate given recent GI bleed and borderline low
blood pressures. He has a PCP appt on [**2-19**] at which point this
medication may be restarted as indicated.
.
# ESRD: On HD Tu/Th/Sat. We continued sevelamer, cinecalcet, and
nephrocaps.
.
# A-Fib: Currently in NSR on amiodarone. Not on warfarin given
history of bleeding. We continued amiodarone and are holding
metoprolol as noted above.
.
# DM: Continued home regimen.
.
# BPH: Continued tamsulosin.
.
# Chronic Back Pain: Continued Percocet prn.
Medications on Admission:
1. AMIODARONE 200 mg Tablet by mouth once a day
2. CINACALCET [SENSIPAR] 30 mg Tablet by mouth once a day
3. CLONAZEPAM 0.5mg QHS prn
4. FLUTICASONE [FLONASE] 50 mcg Spray 2 sprays ihale twice a day
5. FOLIC ACID-B COMPLEX & C NO.10 [NEPHRONEX] 1 Capsule(s) once
a day
6. INSULIN GLARGINE 15 units QHS
7. LORATADINE 10 mg Tablet by mouth once a day
8. METOPROLOL SUCCINATE 100 mg Tablet by mouth once a day
9. OMEPRAZOLE 20 mg Capsule Delayed Release(E.C.) [**Hospital1 **]
10. OXYCODONE-ACETAMINOPHEN 7.5-325 mg four times daily prn pain
11. PRAVASTATIN 20 mg Tablet by mouth once a day
12. SEVELAMER CARBONATE [RENVELA]
13. TAMSULOSIN [FLOMAX] 0.4 mg Capsule, Ext Release 24 hr daily
14. TIZANIDINE 2 mg Tablet - 2 tablets once a day
15. ASPIRIN [ECOTRIN] 325 mg Tablet by mouth once a day
16. BISACODYL [DULCOLAX]
17. DOCUSATE SODIUM
18. OMEGA-3 FATTY ACIDS
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
4. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
sprays Nasal twice a day.
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime.
7. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. oxycodone-acetaminophen 7.5-325 mg Tablet Sig: One (1) Tablet
PO four times a day as needed for pain.
9. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. sevelamer carbonate 800 mg Tablet Oral
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
12. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
14. bisacodyl Oral
15. docusate sodium Oral
16. omega-3 fatty acids Oral
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Melena following polypectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 86527**],
.
You were admitted to the hospital for black stool after having a
polyp removed by your gasteroenterologist as an outpatient. You
received two blood transfusions, but because your blood counts
did not increase appropriately after the transfusions and you
continued to have black stool, you were monitored closely in the
hospital. Your blood counts stabilized and we started you on a
medication called pantoprazole to help your stomach heal.
.
You should have your blood count (hematocrit) checked at your
dialysis session tomorrow to ensure that it is stable. We have
arranged for a follow up appointment with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) **] (see below for details).
.
The following changes were made to your home medications:
- STOP omeprazole and START pantoprazole 40mg twice daily
- HOLD metoprolol until you see Dr. [**Last Name (STitle) **]
Followup Instructions:
Name: [**Last Name (un) **], SOKHARITH
Location: MARKET SQUARE FAMILY HEALTH
Address: [**Last Name (LF) 86528**], [**First Name3 (LF) **],[**Numeric Identifier 86171**]
Phone: [**Telephone/Fax (1) 46305**]
Appt: [**2-19**] at 11am
.
Department: [**Month (only) 864**]
When: MONDAY [**2138-3-10**] at 5:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], M.D. [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2138-2-13**]
|
[
"458.9",
"250.00",
"458.21",
"998.11",
"285.1",
"578.1",
"403.91",
"E878.8",
"V45.11",
"427.31",
"272.4",
"V15.82",
"600.00",
"585.6",
"V12.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7927, 7933
|
4297, 5739
|
317, 325
|
8006, 8006
|
3534, 3534
|
9109, 9680
|
2517, 2522
|
6650, 7904
|
7954, 7985
|
5765, 6627
|
8157, 8947
|
3967, 4274
|
2537, 3018
|
8965, 9086
|
3034, 3515
|
271, 279
|
353, 2136
|
3550, 3951
|
8021, 8133
|
2158, 2306
|
2322, 2501
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,325
| 148,901
|
35176
|
Discharge summary
|
report
|
Admission Date: [**2109-10-3**] Discharge Date: [**2109-10-10**]
Date of Birth: [**2059-10-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
[**2109-10-7**] Four Vessel Coronary Artery Bypass Grafting(LIMA to LAD,
SVG to OM, SVG to PDA, SVG to PLV)
History of Present Illness:
Mr. [**Known lastname **] is a 49 year old male with known history of coronary
artery disease who had complaints of exertional chest pain for
the last several months. The chest pain radiated to his left arm
with severe exertion and was relieved with rest. Following an
abnormal stress test, he underwent cardiac catheterization at
[**Hospital6 5016**] which revealed severe three vessel coronary
artery disease. LV gram was notable for inferior hypokinesis and
a LVEF of 45%. Based upon the above results, he was transferred
to the [**Hospital1 18**] for further evaluation and treatment.
Past Medical History:
Coronary Artery Disease -
stenting to LAD and Diagonal in [**2087**]
Hypertension
Hyperlipidemia
Chronic Lower Back Pain
Social History:
Employed as a contractor. Denies tobacco. Occasional ETOH, no
history of abuse. Married, lives with wife.
Family History:
Father died of an MI at age 69.
Physical Exam:
Pertinent Results:
[**2109-10-4**] ECHO: 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%). 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 leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
[**2109-10-4**] Carotid Ultrasound: No significant plaque or stenosis
seen bilaterally. Essentially, normal carotid bifurcation exam
for age.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the cardiac surgical service and
underwent routine preoperative evaluation. Workup was
essentially unremarkable and he was cleared for surgery. He
remained pain free on medical therapy. On [**10-7**], Dr.
[**Last Name (STitle) 914**] performed coronary artery bypass grafting surgery. For
surgical details, please see seperate dictated operative note.
Following the operation, he was hemodynamically stable on no
pressors. He was brought to the CVICU for invasive monitoring.
Within 24 hours, he awoke neurologically intact and was
extubated without incident. Low dose beta blockade was resumed.
He maintained good hemodynamics and transferred to the SDU on
postoperative day one. The patient made excellent progress on
the floor. By POD 3 chest tubes and pacing wires h ad been
discontinued, the patient was ambulating freely, the wound was
healing, and pain was controlled by analgesics. He was
discharged to home in good condition on POD **********
Medications on Admission:
Aspirin 81 qd, Lipitor 10 qd, Toprol XL 100 qd, Fish Oil, MV
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease
s/p coronary artery bypass grafts
s/p coronary angioplasty and stenting [**2087**]
Hypertension
Hyperlipidemia
Chronic Lower Back Pain
Discharge Condition:
Good
Discharge Instructions:
Shower daily, no baths or swimming
no ointments, lotions and creams or powders to incisions.
No lifting more than 10 lbs for 10 weeks from the surgical date
No driving for one month from surgical date.
report any fever more than 100.5, or redness or discharge from
wounds
report any weight gain greater than 2 pounds in a day or 5
pounds in a week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in [**4-6**] weeks,([**Telephone/Fax (1) 170**]) call for appointment
Dr. [**Last Name (STitle) **] in [**2-3**] weeks, call for appointment
Dr. [**Last Name (STitle) **] in [**2-3**] weeeks, call for appointment
[**Hospital Ward Name 121**] 6 in 2 weeks for wound check
Completed by:[**2109-10-10**]
|
[
"401.9",
"272.4",
"411.1",
"414.01",
"V45.82",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
4653, 4702
|
2131, 3129
|
344, 453
|
4905, 4912
|
1423, 2108
|
5341, 5677
|
1355, 1388
|
3240, 4630
|
4723, 4884
|
3155, 3217
|
4936, 5318
|
1404, 1404
|
283, 306
|
481, 1071
|
1093, 1216
|
1232, 1339
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,906
| 109,562
|
17934
|
Discharge summary
|
report
|
Admission Date: [**2113-6-16**] Discharge Date: [**2113-7-5**]
Date of Birth: [**2038-5-30**] Sex: F
Service: [**Last Name (un) 7081**]
HISTORY OF PRESENT ILLNESS: The patient is a 74 year old
woman with a history of hypertension, hypercholesterolemia,
and asthma, who developed a vague cough and some right-sided
chest discomfort about a year ago. A chest CT showed a 4.6 x
4.4 cm mass in the posterior segment of the right upper lobe.
It was noted to abut the esophagus and invade the right
paraspinal area. There were 1 cm pretracheal nodes. On
[**2112-12-16**], the patient underwent bronchoscopy that
demonstrated chronic inflammation with focal epithelial
atypia. On [**2113-2-8**], the patient underwent a PET scan that
showed increased activity in the right upper lobe mass, the
right hilar lymph node, and some moderately increased uptake
in the pretracheal lymph nodes. On [**2113-2-16**], the patient
underwent a diagnostic mediastinoscopy. All 35 nodes were
negative. On [**2113-3-10**], the patient underwent a thorascopic
evaluation with biopsy of the right hilar lymph node.
Pathology demonstrated non-small cell lung cancer with
squamous differentiation. At the time of surgery, the right
upper lobe was found to invade along the broad surface into
the vertebral column. It was decided that the patient would
be best served by receiving preoperative chemo-radiation. At
this point, she had experienced a 7 pound weight loss over 3
months and her appetite has been a little lower than usual.
She denied shortness of breath but did have some dyspnea on
exertion after walking up one flight of stairs.
A restaging set of PET and CT scans showed significant
decrease in activity within the right upper lobe mass and
hilar lymph nodes as well as significant reduction in the
overall size on CT scan. There was, however, an area of bony
erosion where the tumor abuts the vertebral column. MRI
showed a more extensive involvement of the vertebral body.
It was decided to have Dr. [**Last Name (STitle) 739**] of neurosurgery to
participate in the resection.
PAST MEDICAL HISTORY: Hypertension.
Hypercholesterolemia.
Asthma.
Sinus surgery in the past.
Hand surgery.
CURRENT MEDICATIONS: Percocet p.r.n.
Hydrochlorothiazide 25 mg q.day.
Tenormin 100 mg p.o. q.day.
Diovan 80 mg p.o. b.i.d.
Lipitor 10 mg p.o. q.day.
PHYSICAL EXAMINATION: General: The patient is a well-
developed elderly female who is active.
Vital Signs: Blood pressure 120/74, pulse 66, temperature
97.1, weight 149, oxygen saturation 97 percent on room air.
HEENT; Sclerae anicteric. Pupils equal, round and reactive.
Chest: Lungs are clear to auscultation and bilaterally
equal. Thorax is symmetrical without masses.
Heart: Regular without murmur.
Abdomen: Benign.
Extremities: No clubbing or edema.
Neurologic: Grossly nonfocal with an intact and appropriate
mental status.
Skin: No lesions.
HOSPITAL COURSE: On [**2113-6-16**], the patient underwent a right
thoracotomy with right upper lobectomy, radical mediastinal
lymph node dissection and an intercostal muscle flap to the
bronchial stump. Dr. [**Last Name (STitle) 739**] of neurosurgery performed
a partial body resection of T4 and T5. At the time of
surgery, the margins were clear. The patient tolerated the
procedure well. Please see dictated Operative Notes for
further details. The patient was kept intubated overnight
and was extubated the following morning without incident.
Over the following three days, the patient experienced some
post-op oliguria which resolved with several fluid boluses.
Lasix was then begun for diuresis. On post-op day two, the
patient was noted to need aggressive chest PT which she did
receive. On post-op day three, the patient's hematocrit had
dropped to 27.2 and she received a unit of packed red blood
cells. This brought her hematocrit up to 32.5.
The patient also underwent a speech and swallowing evaluation
which she failed. Therefore, a feeding tube was placed and
her tube feeds were slowly advanced to goal.
Post-op day four was the first day the patient experienced a
negative fluid balance. This continued through most of her
hospital stay. On post-op day five, the patient continued to
do well and was transferred to the floor. On post-op day
six, the patient was found to be in sinus tachycardia with
wheezing and a chest x-ray showed collapse of the right upper
and right lower lobes. The patient was, therefore,
transferred to the ICU. Over the course of the following
day, the patient underwent two bronchoscopies with suction of
copious amounts of fluid. On post-op day seven, the patient
was noted to have methemoglobinemia, presumably secondary to
benzocaine use. The patient was treated with methylene blue
and improved.
On post-op day eight, a sputum showed gram-negative rods and
the patient was started on levofloxacin. This antibiotic was
continued until post-op day 14. Also on that day, a post-
pyloric feeding tube was placed. The chest x-ray was noted
to be worse on this day and chest PT continued. On post-op
day 11, the patient experienced right arm swelling. The
patient underwent a right upper extremity ultrasound which
showed a right cephalic and right internal jugular deep vein
thrombosis. The patient was begun on a heparin drip and
eventually transitioned to Coumadin with a goal INR of 2 - 3.
The most appropriate Coumadin dose seemed to be 2.5 mg q.day.
Also on post-op day 11, the chest x-ray was noted to be
slightly improved. On post-op 12, a PICC was obtained for
I.V. access.
The patient also underwent a re-evaluation of her swallowing
function and was found to tolerate thin liquids. The post-
pyloric feeding tube was, therefore, removed. On post-op day
14, the patient continued to do well but a chest x-ray showed
a possible right lung collapse. A bronchoscopy revealed a
large amount of mucopurulent secretions in the right middle
and lower lobes. The patient was continued on PT and
diuresis. On post-op day 17, the patient was transfused for
a hematocrit of 24.6, which brought her up to a hematocrit of
33.9. By post-op day 19, the patient was therapeutic on
Coumadin and chest x-ray showed improved aeration of the
right middle and lower lobes. She had experienced no
desaturation episodes over the preceding several days. She
looked well and was discharged to rehab on Coumadin with
aggressive chest PT.
DISPOSITION: To rehab facility.
DISCHARGE DIAGNOSES: In addition to the admitting diagnoses
listed above in the past medical history, the patient has
adenocarcinoma of her right upper lobe, status post right
upper lobectomy, and metastatic carcinoma to her vertebral
soft tissue.
DISCHARGE MEDICATIONS: Warfarin 2.5 mg p.o. q.day.
Ipratropium nebs.
Albuterol nebs.
Metoprolol 37.5 mg p.o. t.i.d.
Lasix 20 mg p.o. b.i.d.
Protonix 40 mg p.o. q.day.
Dextromethorphan/Guaifenesin.
Ibuprofen 400 mg p.o. q.6 hours
Percocet 5/325 p.o. q.4-6 hours p.r.n.
FOLLOW UP PLAN: The patient is to call Dr.[**Name (NI) 1816**] office
to schedule a followup appointment in one to two weeks.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern1) 15517**]
MEDQUIST36
D: [**2113-7-5**] 21:09:44
T: [**2113-7-5**] 23:18:34
Job#: [**Job Number 49665**]
|
[
"196.1",
"198.5",
"997.5",
"507.0",
"162.8",
"512.1",
"453.8",
"518.0",
"934.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"89.64",
"33.24",
"99.04",
"96.56",
"86.74",
"03.4",
"40.59",
"32.4"
] |
icd9pcs
|
[
[
[]
]
] |
6486, 6714
|
6738, 7382
|
2946, 6464
|
2390, 2928
|
2238, 2367
|
186, 2103
|
2126, 2216
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,930
| 153,081
|
8285
|
Discharge summary
|
report
|
Admission Date: [**2144-5-1**] Discharge Date: [**2144-5-25**]
Date of Birth: [**2086-7-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Propranolol / Vancomycin Hcl
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
[**2144-5-1**] Sternal wound debridement
[**2144-5-11**] Pectoral flap closure
History of Present Illness:
57 y/o male s/p CABG X 4 on [**2144-3-26**]. His post-op course
complicated by sternal wound drainage which required local
debridement and intravenous antibiotics. He was ultimately
discharged to home on [**2144-4-16**] with VAC dressings and IV
antibiotics. He was on Linezolid which was discontinued due to
rash. He presented back to the [**Hospital1 18**] with recurrent fevers and
malaise.
Past Medical History:
Coronary Artery Disease s/p Myocardial Infarction [**2132**] and [**2137**],
Hypercholesterolemia, Hypertension, Degenerative Joint Disease,
Osteoarthritis, Sleep Apnea, Depression, Severe stasis
dermatitis, Recurrent Pneumonia, Carpal Tunnel Syndrome s/p
release, s/p Cholecystectomy, s/p Gastric Bypass surery, s/p
Bilat. Knee Replacement
Social History:
Quit smoking 25 yrs ago.
Quit ETOH 27 yrs ago.
Married, lives with spouse currently unemployed
Family History:
Father with MI at age 40 and died age 63.
Physical Exam:
Vitals: BP 125/60, HR 82, RR 14, SAT 95% on room air
General: obese male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: decreased at bases
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Neuro: nonfocal
Incision: clean, dry, one JP in place
Pertinent Results:
[**2144-5-1**] 10:45AM BLOOD WBC-17.7*# RBC-3.90* Hgb-11.4* Hct-35.0*
MCV-90 MCH-29.3 MCHC-32.6 RDW-17.3* Plt Ct-384
[**2144-5-1**] 10:45AM BLOOD Neuts-90* Bands-0 Lymphs-2* Monos-4 Eos-3
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2144-5-1**] 05:11PM BLOOD PT-14.6* PTT-40.0* INR(PT)-1.3*
[**2144-5-1**] 10:45AM BLOOD Glucose-113* UreaN-23* Creat-0.8 Na-133
K-4.7 Cl-100 HCO3-23 AnGap-15
[**2144-5-1**] 10:45AM BLOOD ALT-12 AST-18 LD(LDH)-265* CK(CPK)-27*
AlkPhos-120* Amylase-22 TotBili-0.9
[**2144-5-2**] 02:19AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.1
[**2144-5-24**] 04:16AM BLOOD WBC-18.4* RBC-3.24* Hgb-9.6* Hct-29.3*
MCV-90 MCH-29.5 MCHC-32.8 RDW-18.9* Plt Ct-768*
[**2144-5-25**] 03:01AM BLOOD WBC-17.4* RBC-3.13* Hgb-9.1* Hct-28.3*
MCV-90 MCH-29.1 MCHC-32.2 RDW-18.9* Plt Ct-746*
[**2144-5-23**] 09:57AM BLOOD PT-17.9* PTT->150* INR(PT)-1.7*
[**2144-5-23**] 06:22PM BLOOD PT-15.2* PTT-65.8* INR(PT)-1.4*
[**2144-5-24**] 09:18AM BLOOD PT-15.0* PTT-75.1* INR(PT)-1.4*
[**2144-5-25**] 05:55AM BLOOD PT-17.4* PTT-141.4* INR(PT)-1.6*
[**2144-5-21**] 03:16AM BLOOD Glucose-110* UreaN-48* Creat-1.1 Na-142
K-3.7 Cl-109* HCO3-19* AnGap-18
[**2144-5-22**] 01:58AM BLOOD Glucose-101 UreaN-51* Creat-1.0 Na-142
K-3.3 Cl-108 HCO3-20* AnGap-17
[**2144-5-23**] 01:32AM BLOOD Glucose-263* UreaN-46* Creat-0.9 Na-135
K-3.4 Cl-102 HCO3-18* AnGap-18
[**2144-5-24**] 04:16AM BLOOD Glucose-260* UreaN-52* Creat-1.1 Na-135
K-6.1* Cl-104 HCO3-20* AnGap-17
[**2144-5-25**] 03:01AM BLOOD Glucose-296* UreaN-51* Creat-1.2 Na-131*
K-3.3 Cl-96 HCO3-19* AnGap-19
[**2144-5-14**] 03:54AM BLOOD ALT-52* AST-21 AlkPhos-127* TotBili-0.5
[**2144-5-18**] 04:13AM BLOOD ALT-23 AST-17 AlkPhos-94 TotBili-0.5
[**2144-5-24**] 04:16AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.3
[**2144-5-25**] 03:01AM BLOOD Calcium-8.5 Phos-5.2* Mg-2.1
[**2144-5-20**] Upper Ext Ultrasound: Occlusive clot extends through the
right basilic to right axillary vein continuously. Non-occlusive
clot is seen in the right internal jugular vein as well. There
is additional occlusive clot seen in the distal left cephalic
vein.
[**2144-5-10**] Lower Ext Ultrasound: No evidence of bilateral lower
extremity DVTs.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent urgent sternal debridement.
Infectious Disease and Plastic surgery services were consulted
to assist with medical and operative management. Given the
severity of his sternal wound infection, he was kept intubated
and sedated for a period of time. Given prolonged period of
sedation, TPN was initiated. Intravenous antibiotics were
titrated accordingly, and VAC dressing was applied to his
sternal wound. He also had a left leg wound which required
debridement and VAC dressing changes. Wound and blood cultures
eventually grew out Methicillin sensitive Staph aureus.
On [**5-4**], due to a large left pleural effusion, he required
placement of a chest tube.
On [**5-6**], he returned to the operating room for mediastinal
washout and VAC dressing change.
He experienced periods of hypoxia and intermittent fevers.
Therapeutic and diagnostic bronchoscopy was performed. CT scans
were notable for only atelectasis, there were no findings to
suggest pulmonary embolus.
The ID service continued to adjust his broad spectrum
antibiotics. Despite antibiotics, he continued to have an
elevated white count.
On [**5-11**], he returned to the operating room for additional
debridement and bilateral pectorails flap closure.
His hypoxia gradually improved and he was eventually extubated.
He was eventually started on PO diet.
Given his obesity and prolonged bed rest, he developed partial
thickness ulcers which required local wound care.
His sternal and leg wounds continued to be monitored daily by
the Plastic and Cardiac surgical teams while the ID service
adjusted the antimicrobial therapies.
At one point, neurology was consulted for severe muscle weakness
and mental status changes. This was most likely related to
toxic-metabolic encephalopthy. His mental stauts and muscle
weakness gradually improved throughout his hospital stay. He
required aggressive PT and OT.
Was noted to have upper extremity swelling. Ultrasound revealed
an occlusive thrombus which extended through the right axillary
vein distally to the right basilic vein. There was also
occlusive in the distal left cephalic vein. Given the above
findings, Heparin was started in addition to Warfarin. Warfarin
should be dosed for a goal INR between 2.0 - 3.0.
Eventually cleared for discharge to rehab on [**5-25**]. Patient
will need to follow up with the [**Hospital **] clinic, Plastic surgeon and
cardiac surgeon within one month of discharge to ensure
continued recovery and progress.
Medications on Admission:
Aspirin 81 qd, Simvastatin 40 qd, Flouxetine 20 qd, Metoprolol
25 [**Hospital1 **]
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
2. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO 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. Potassium Chloride 20 mEq Packet Sig: Three (3) Packet PO BID
(2 times a day).
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days: then re-evaluate need for continued diuresis.
10. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
11. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours.
12. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) Grams
Intravenous Q4H (every 4 hours): Continue through [**2144-6-22**]. Grams
13. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: 1800 (1800) Units per hour Intravenous ASDIR (AS DIRECTED):
follow PTT, target 60-80 - please discontinue when INR greater
or equal to 2.0.
14. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every
four (4) hours as needed for pain.
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO qpm: Daily dose
may vary, adjust for INR between 2.0 - 3.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Sternal Infection/Mediastinitis
Leg Infection
Hypertension
Coronary Artery Disease, s/p Coronary Artery Bypass Graft
Obesity
Upper Extremity DVT
Pleural Effusion
Discharge Condition:
Good
Discharge Instructions:
No lifting > 10# for 2 months
No creams, lotions or powders to any incisions
Monitor and record JP drain output daily - do not remove JP
drain
Monitor weekly CBC, LFT's and renal function. Please fax results
to [**Hospital **] Clinic(Attn: Dr. [**Last Name (STitle) 3394**]. FAX [**Telephone/Fax (1) 432**]
Adjust Heparin for goal PTT between 60-80. Please discontinue
Heparin when INR greater or equal to 2.0. Warfarin should be
adjusted for goal INR between 2.0 to 3.0. Before discharge from
rehab, please arrange outpatient Warfarin followup with PCP.
[**Name10 (NameIs) **] Nafcillin through [**2144-6-22**].
Followup Instructions:
1)Dr. [**First Name (STitle) **](Plastic surgery)in approximately 1 week ([**Telephone/Fax (1) 14596**] - call for appt
2)Dr. [**Last Name (STitle) 1270**](PCP) in [**5-7**] weeks, call for appt
3)Dr. [**Last Name (STitle) **](Cardiac surgeon)in [**5-7**] weeks - [**Telephone/Fax (1) 170**],
please call for appt
4)Dr. [**Last Name (STitle) 3394**](Infectious Disease) - appt on [**2144-6-9**] @ 11AM
Completed by:[**2144-5-25**]
|
[
"997.2",
"731.3",
"V45.86",
"E879.8",
"512.1",
"041.11",
"998.31",
"038.11",
"349.82",
"359.81",
"453.8",
"682.6",
"401.9",
"518.82",
"511.9",
"V45.81",
"998.59",
"519.2",
"V43.65",
"278.01",
"995.91",
"730.08",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"38.91",
"99.15",
"88.72",
"83.82",
"33.24",
"38.93",
"77.61",
"77.81",
"86.22",
"34.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8059, 8139
|
3905, 6425
|
300, 381
|
8345, 8352
|
1741, 3882
|
9014, 9448
|
1300, 1343
|
6558, 8036
|
8160, 8324
|
6451, 6535
|
8376, 8991
|
1358, 1722
|
255, 262
|
409, 807
|
829, 1171
|
1187, 1284
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,906
| 181,127
|
31908
|
Discharge summary
|
report
|
Admission Date: [**2188-12-1**] Discharge Date: [**2188-12-9**]
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2188-12-2**] - Redosternotomy, AVR (25mm [**Doctor Last Name **] Pericardial, MV
Repair (28mm [**Doctor Last Name **] Annuloplasty Band)
History of Present Illness:
85 year old gentleman s/p CABG [**2178**] now with worsening dyspnea
on exertion. Work-up revealed severe aortic valve stenosis and
moderate to severe mitral valve regurgitation.
Past Medical History:
CAD s/p CABGx4 [**2178**]
Heart Block
Esophageal stricture s/p schatzki's ring
HTN
Hyperlipidemia
HOH
Social History:
Retired and lives alone. Denies alchol or tobacco use.
Family History:
Multiple brothers with MI at the ages of 50's-70's. Father died
of MI at age 47. Mother died of MI at age 79.
Physical Exam:
96 reg 22 120/80 67" 163lbs
GEN: WDWN elderly male in NAD
HEENT: PERRL, EOMI, NCAT, OP Benign
NECK: Supple, FROM, No JVD
LUNGS: CTA, well healed mid stenal incison
HEART: RRR, IV/VI systolic murmur
ABD: Benign
EXT: Warm, well perfused, no edema. Left GSV harvested. Right
suitable above knee only. Pulses 1+ - 2+ throughout.
NEURO: Nonfocal
Pertinent Results:
[**2188-12-8**] 07:00AM BLOOD WBC-6.4 RBC-3.24* Hgb-9.3* Hct-28.8*
MCV-89 MCH-28.8 MCHC-32.3 RDW-14.5 Plt Ct-175
[**2188-12-1**] 04:55PM BLOOD WBC-5.3 RBC-4.30* Hgb-12.8* Hct-38.3*
MCV-89 MCH-29.7 MCHC-33.4 RDW-14.2 Plt Ct-164
[**2188-12-8**] 07:00AM BLOOD Plt Ct-175
[**2188-12-8**] 07:00AM BLOOD PT-14.2* PTT-26.8 INR(PT)-1.2*
[**2188-12-1**] 04:55PM BLOOD Plt Ct-164
[**2188-12-1**] 04:55PM BLOOD PT-13.8* INR(PT)-1.2*
[**2188-12-8**] 07:00AM BLOOD Glucose-151* UreaN-26* Creat-1.0 Na-141
K-4.4 Cl-103 HCO3-30 AnGap-12
[**2188-12-1**] 04:55PM BLOOD Glucose-122* UreaN-22* Creat-1.0 Na-142
K-4.8 Cl-106 HCO3-27 AnGap-14
[**2188-12-5**] 03:20AM BLOOD ALT-16 AST-43* AlkPhos-54 Amylase-127*
TotBili-0.8
[**2188-12-1**] 04:55PM BLOOD ALT-21 AST-29 AlkPhos-92 Amylase-69
TotBili-0.6
[**2188-12-5**] 03:20AM BLOOD Lipase-15
[**2188-12-1**] 04:55PM BLOOD Lipase-21
[**2188-12-6**] 08:25AM BLOOD Mg-2.1
[**2188-12-1**] 06:15PM BLOOD %HbA1c-6.1*
Probable sinus rhythm with A-V dissocation. Either ventricular
premature beat
or aberrant ventricular conduction. Right bundle-branch block.
Compared
to tracing #1 on [**2188-12-5**] baseline artifact is improved.
TRACING #2
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 0 132 488/491 0 58 36
Sinus rhythm. P-R interval prolongation with one example of Type
I second
degree A-V block. Low limb lead voltage. Left anterior
fascicular block.
Right bundle-branch block. Q-T interval prolonged for rate. No
previous
tracing available for comparison.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
64 0 130 476/483 0 -51 -7
RADIOLOGY Final Report
CHEST (PA & LAT) [**2188-12-6**] 9:54 AM
CHEST (PA & LAT)
Reason: eval pneumo
[**Hospital 93**] MEDICAL CONDITION:
85 year old man s/p avr
REASON FOR THIS EXAMINATION:
eval pneumo
EXAMINATION: Chest x-ray.
CLINICAL INDICATION: 85-year-old man status post AVR, assess for
pneumonia.
FINDINGS: Two views of the chest were obtained and compared to
the prior examination dated [**2188-12-5**] demonstrating no
significant interval change. There is a stable right apical
pneumothorax. No new focal opacities are seen. Again noted is a
vague left retrocardiac opacity, likely reflects an underlying
effusion and atelectasis, difficult to exclude pneumonia. The
cardiac silhouette is within normal limits. A calcified slightly
tortuous aorta is again seen. The patient is status post median
sternotomy and AVR.
DR. [**First Name (STitle) 2353**] [**Doctor Last Name **]
Approved: SAT [**2188-12-6**] 2:17 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 74804**] (Complete) Done
[**2188-12-2**] at 2:05:53 PM 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: [**2103-8-1**]
Age (years): 85 M Hgt (in): 67
BP (mm Hg): 124/67 Wgt (lb): 162
HR (bpm): 56 BSA (m2): 1.85 m2
Indication: Intraoperative TEE for AVR and MVR
ICD-9 Codes: 786.05, 786.51, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2188-12-2**] at 14:05 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW3-: Machine: 3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 50% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Ascending: *4.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *4.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *60 mm Hg < 20 mm Hg
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mildly depressed LVEF. [Intrinsic LV systolic
function likely depressed given the severity of valvular
regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated ascending aorta. Simple atheroma in
ascending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (AoVA <0.8cm2). Mild to moderate ([**1-22**]+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. No MS. [**Name13 (STitle) 15110**] to co-existing
AR, the pressure half-time estimate of mitral valve area may be
an OVERestimation of true area. Moderate to severe (3+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
1.No atrial septal defect is seen by 2D or color Doppler.
2. Overall left ventricular systolic function is mildly
depressed (LVEF 50%). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.]
3.Right ventricular chamber size and free wall motion are
normal.
4.The ascending aorta is moderately dilated. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the descending thoracic aorta.
5.The aortic valve leaflets are severely thickened/deformed.
There is severe aortic valve stenosis (area <0.8cm2). Mild to
moderate ([**1-22**]+) aortic regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. Due to
co-existing aortic regurgitation, the pressure half-time
estimate of mitral valve area may be an OVERestimation of true
mitral valve area. Moderate to severe (3+) mitral regurgitation
is seen.
7.The tricuspid valve leaflets are mildly thickened.
Post Bypass
VERY POOR VIEWS POST BYPASS
1. Patient is being AV paced and receiving an infusion of
epinephrine.
2. LVEF is 35 %. Inferior wall and infero lateral wall are
hypokinetic.
3. Annuloplasty ring seen in the mitral position. It appears
well seated. Mild central mitral regurgitation present.
4. Bioprosthetic valve seen in the aortic postion. Leaflets move
well and appears well seated. No aortic insufficiency.
5. Aorta intact post decannulation.
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) **] [**2188-12-3**] 14:28
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2188-12-1**] for surgical
management of his aortic and mitral valve disease. He was
worked-up in the usual preoperative manner including a CT scan
of his chest. On [**2188-12-2**], Mr. [**Known lastname **] was taken to the operating
room where he underwent a redo sternotomy with repair of his
mitral valve and replacement of his aortic valve. Please see
operative note for details. Postoperatively he was taken to the
cardiac surgical intensive care unit for monitoring. By
postoperative day one, Mr. [**Known lastname **] had awoke neurologically
intact and was extubated. The electrophysiology service was
consulted for a continued second degree AV block type 1
(Wenkebach). A pacemaker was recommended. He had postoperative
confusion and delerium which slowly improved. A 24 hour sitter
was used for safety over several days. He was gently diuresed
towards his properative weight. On postoperative day three, he
was transferred to the step down unit for further recovery. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. As his primary care
provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4541**] is an electrophysiologist, he wanted to
place the pacemaker himself. Thus transfer was arranged to
[**Hospital 107**] Hospital for the procedure. He was transfered to
[**Hospital 107**] Hospital [**2188-12-9**] for further cardiac care.
Medications on Admission:
Meclizine 25mg QD
Lipitor 10mg QD
Lisinopril 10mg QD
Aspirin 81mg QD
Glycolax
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
8. Haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
CAD s/p CABG
AS
MR
Hyperlipidemia
HTN
HOH
Complete heart block/Second degree AV block type 1
Esophageal stricture s/p schatzki's ring
Discharge Condition:
Good
Discharge Instructions:
[**Hospital1 18**] to [**Hospital 107**] Hospital transfer
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.
8) Transfer to [**Hospital 107**] hospital for permanent pacemaker for AV
dissociation
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 62759**] in 2 weeks. [**Telephone/Fax (1) 74805**]
Please follow-up with Dr. [**Last Name (STitle) 4541**] in 1 week or as instructed.
Plan for Pacemaker at [**Hospital **] hospital with Dr [**Last Name (STitle) 4541**] -
hospital to hospital transfer [**2188-12-9**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2188-12-9**]
|
[
"396.2",
"401.9",
"414.01",
"293.9",
"426.0",
"272.4",
"V45.81",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"93.90",
"39.61",
"35.21",
"35.12",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
10625, 10655
|
8338, 9820
|
253, 394
|
10833, 10840
|
1305, 3111
|
11728, 12261
|
816, 927
|
9948, 10602
|
3148, 3172
|
10676, 10812
|
9846, 9925
|
10864, 11705
|
942, 1286
|
194, 215
|
3201, 8315
|
422, 602
|
624, 728
|
744, 800
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,865
| 114,838
|
44345
|
Discharge summary
|
report
|
Admission Date: [**2192-10-20**] Discharge Date: [**2192-10-23**]
Date of Birth: [**2114-7-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Lower back pain, fevers
Major Surgical or Invasive Procedure:
placement of right internal jugular central line
History of Present Illness:
78 y/o with Dementia, urinary incontinence presents with 4 days
of lower back pain, and rigors/fevers. [**Name (NI) **] husband reports
abrupt change in his wife's behavior on Tuesday morning.
Wednesday night she had chills and sweats as well as back ache.
He also notes that she is not walking properly, but is not
focally weak. She has had decreased PO intake during this time
as well. Mild diarrhea during this time. No abd pain. Denies
dysuria or hematuria. Husband reports patient is normally
oriented x 3.
Review of systems: No SOB, cough. No NS. No chest pain, no
palpatations. No abd pain. No N/V. No rash.
In the emergency department VS 99.6, 108/76, 78, 18, 100% RA. In
ED spiked to 103. BP to 69/42. Received 4 L NS. Peripheral
dopamine was started and titrated up to 15 mcg/kg/min. Given
Cipro 400mg IV, Ceftriaxone IV and tylenol 1gm PO x 1. VS prior
to transfer 98.2, 92, [**11/2152**], 14, 100% 4-6L NC. Right IJ placed
in ED. After withdrawing RIJ 2 cm developed transient SOB.
On tranfer to the floor, she had no complaints. She was having
difficulty remembering why she had come into the hospital, but
after reorientation, understood this. She had no chest pain,
shortness of breath, abdominal pain, fevers, chills, night
sweats, nausea, vomting, dysuria, hematuria.
Past Medical History:
Dementia
Chronic constipation
Osteopenia
Spinal stenosis
posterior vitreous attachment right eye
urinary incontinence
s/p hysterectomy [**2153**]
h/o Lyme disease
h/o hepatitis
Social History:
Lives with husband [**Name (NI) 95086**], has son who is involved w/ care
Family History:
Mother died with lymphoma, age 80, [**2173**]
Father died age 67 colon cancer
One brother, 18 months younger, in [**Location (un) **], healthy with some
heavy alcohol use
5 pregnancies, first ended at 7 months with stillbirth of
siamese twins; 3 spontaneous vaginal deliveries of healthy
children all alive and well; one miscarriange
Diabetes: aunt
Physical Exam:
GENERAL: Pleasant, well appearing, in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP not elevated
LUNGS: crackles L base > R, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Appropriate. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. Gait assessed on the day
after transfer to floor and gait was wnl.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2192-10-20**] 11:03AM GLUCOSE-145* UREA N-13 CREAT-1.1 SODIUM-138
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14
[**2192-10-20**] 05:28PM HCT-31.4*
[**2192-10-20**] 04:51AM cTropnT-<0.01
[**2192-10-19**] 06:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2192-10-19**] 06:00PM URINE RBC-[**5-30**]* WBC-[**11-9**]* BACTERIA-MOD
YEAST-NONE EPI-0
[**2192-10-19**] 06:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.002
[**2192-10-19**] 08:23PM ALT(SGPT)-34 AST(SGOT)-45* ALK PHOS-57 TOT
BILI-0.3
CT Abd:
1. Abnormal striated hypoenhancement in the right kidney,
compatible with
infectious process such as pyelonephritis and focal nephronia.
No renal
abscess or perinephric fluid collection.
2. No psoas abscess.
3. 3-cm right adnexal cyst, comparable in size compared to the
prior
ultrasound.
Also:
A 2-mm calcified nodule noted in the
right lower lobe is compatible with a calcified granuloma.
[**10-23**] CXR
Cardiac size is top normal. Small bilateral pleural effusions
are unchanged.
Right lower lobe atelectasis has improved. Left lower lobe
retrocardiac
opacity has also improved, consistent with improved atelectasis.
Mild
degenerative changes in the thoracic spine.
Brief Hospital Course:
Ms. [**Known lastname 27644**] is a 78 year-old lady with Dementia and urinary
incontinence who presented with fevers and back pain, consistent
with urosepsis from pyelonephritis. She was admitted to the ICU
for hypotension requiring pressors in the Emergency Department
and then transferred to the floor on [**2192-10-22**].
1. UROSEPSIS- secondary to pyelonephritis given findings on CT
abdomen, urinalysis and physical exam. She received IV
Ciprofloxacin and Ceftriaxone in the Emergency Department. Due
to persistent hypotension in the ED, she required pressors and
was transferred to the unit. In the ICU, Admission Chest X-rays
were negative for infection and non-focal neuro exam suggested
against meningitis. Dopamine (initial pressor) was changed to
levophed, and mean arterial pressure was titrated to > 65 mmHg.
IV Ceftriaxone was contuned in-house. Patient's urine output
continued to improve during her ICU course and her blood
pressures improved. On [**10-21**], pressors were discontinued and
patient was observed- her blood pressures remained stable over
24 hours off pressors. She was converted to levofloxacin for
HAP (see below) and should continue this for a total of 2 weeks.
On discharge, she was afebrile.
2. Pneumonia - due to presence of increased left lower lobe
opacity and probable evidence for superimposed infection in the
bilateral basis, decision was made to treat with levofloxacin
750mg q48hrs, but repeat CXR showed improvement in bilateral
atelectasis. Given these findings, she did not have pneumonia,
but atelectasis from prolonged bedrest in the ICU.
3. Altered Mental Status: Pt with baseline dementia. Per
husband, she is usually oriented. On admission, she was
disoriented to time and place which could be due to a
combination of her baseline, infection, and delrium. Sedatives
were avoided, and patient was frequently reoriented to her
surroundings. Mental status improved to her baseline during her
ICU stay and per her husband and son, she was at her baseline
prior to transfer to floor and on discharge
4. Acute renal failure - Admission Creatinine was 1.4 which was
likely prerenal given her hypotension. Creatinine trend
continued to improve during her course and was at her baseline
on discharge.
5. Chest pain - Overnight on [**10-20**], the pt had an episode chest
pain overnight with ST depressions laterally in the setting of
urosepsis and infection. She had troponins cycled which were
negative. Repeat EKG on [**10-21**] showed resolution of her EKG
changes. She had no recurrent chest pain and no events on
telemetry. She had lipids checked and revealed LDL of 100 and
triglycerides of 188. She had not recurrence of chest pain
during her hospital stay. She would benefit from an outpatient
stress test given the above history. She was not started on ASA
as this is on her list of allergies. She is already scheduled
for follow up with her primary care on [**11-7**].
Medications on Admission:
Medications (from OMR):
ascorbic acid 500 mg daily
B-complex vitamins
calcium citrate-vitamin d
cyanocobalamin
glucosamine/chondroitin
omega-3
Discharge Medications:
1. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Colace 100 mg Capsule Sig: Two (2) Capsule PO once a day as
needed for constipation.
3. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 11 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Dementia
Urinary urgency
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with fevers, chills and rigors. In the
emergency room, your blood pressure was low and you were given
fluids, antibiotics and were sent to the ICU. Your CT scan
images showed that you had an infection in your kidney. You
also had a chest X ray that was concerning for a pneumonia, but
the repeat imaging does not look like you have this. You were
started on a new medication called levofloxacin for your kidney
infection. You will have to continue this for 2 weeks.
Antacids containing magnesium or aluminum, as well as
sucralfate, metal cations such as iron, and multivitamin
preparations with zinc, should not be taken within 2 hours
before or after LEVAQUIN?????? administration
Please return to the emergency room if you develop persistent
fevers, chills, night sweats, nausea, vomiting, back pain.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7869**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2192-11-22**]
1:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6310**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2192-11-7**]
3:20
|
[
"038.9",
"780.09",
"590.80",
"785.52",
"786.50",
"294.8",
"584.9",
"518.0",
"585.3",
"995.92",
"285.9",
"564.00",
"733.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7896, 7902
|
4455, 6062
|
340, 390
|
7987, 7996
|
3149, 4432
|
8871, 9188
|
2018, 2368
|
7591, 7873
|
7923, 7966
|
7424, 7568
|
8020, 8848
|
2383, 3130
|
952, 1711
|
277, 302
|
418, 933
|
6077, 7398
|
1733, 1911
|
1927, 2002
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,954
| 172,499
|
13931
|
Discharge summary
|
report
|
Admission Date: [**2158-6-22**] Discharge Date: [**2158-8-2**]
Date of Birth: [**2089-3-28**] Sex: F
Service: SURGERY
Allergies:
Maxitrol
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
fevers, chills, nausea, vomitting, diarrhea
Major Surgical or Invasive Procedure:
[**6-23**] pelvic abscess drainage
[**7-24**] exploratory laparotomy with sigmoid resection, colostomy,
[**Doctor Last Name 3379**]
History of Present Illness:
Ms. [**Known lastname 41684**] is a 69 y/o F who was recently hospitalized with a
sigmoid diverticulitis-associated pelvic abscess, and multiple
cardiac issues. She presented at that time with fevers, chills,
nausea, and vomitting, as well as abdominal pain. The abscess
was drained by CT-guidance and grew out amp-resistant
enterococcus. She also underwent cardiac catherization with
stent placement. The abscess drainage catheter was removed
prior to discharge. Approximately two days ago, she again
developed a [**Known lastname **] (up to 102F), and last night began having
nausea and vomitting. She has mild abdominal discomfort, but
denies any chest pain, nausea, vomitting, or SOB.
Past Medical History:
Afib, Asthma, Glaucoma, sleep apnea, RA, fibromyalgia, h/o R
ovarian cyst, CHTN, sigmoid diverticulae, non-ST elevation MI
s/p cath w/o intervention
PSurgHx- LCEA, appy, hysterectomy, NSVDx3
Social History:
NC
Family History:
NC
Physical Exam:
T=101.7 P=80 BP=113/52 RR=20 90%(RA) to 96%(2L)
AAOx3, NAD
Chest: CTA B/L
Abd: soft, non-distended, mildly tender in the lower quadrants,
L>R, but no rebound or guarding. Guaiac+ stool
Ext: warm, dry
On discharge:
same as above except abd wound c/d/i, ostomy bag, 2 JP drains in
place with drain gauze.
Pertinent Results:
[**2158-6-22**] 10:00AM PT-21.4* PTT-29.7 INR(PT)-2.1*
[**2158-6-22**] 10:00AM PLT SMR-NORMAL PLT COUNT-266
[**2158-6-22**] 10:00AM NEUTS-79* BANDS-0 LYMPHS-10* MONOS-6 EOS-5*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2158-6-22**] 10:00AM WBC-11.1* RBC-2.98* HGB-9.6* HCT-28.0* MCV-94
MCH-32.4* MCHC-34.5 RDW-16.6*
[**2158-6-22**] 10:00AM CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-1.7
[**2158-6-22**] 10:00AM LIPASE-39
[**2158-6-22**] 10:00AM ALT(SGPT)-17 AST(SGOT)-18 ALK PHOS-57
AMYLASE-63
[**2158-6-22**] 10:00AM GLUCOSE-100 UREA N-12 CREAT-0.8 SODIUM-136
POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-30 ANION GAP-13
[**2158-6-22**] 10:10AM LACTATE-0.9
[**2158-6-22**] 11:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-8.0 LEUK-NEG
[**2158-6-22**] 11:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2158-6-22**] 11:12PM LACTATE-1.1
[**2158-6-22**] 11:45PM cTropnT-<0.01
[**2158-6-22**] 11:45PM CK(CPK)-37
[**2158-6-22**] 11:45PM GLUCOSE-87 UREA N-7 CREAT-0.7 SODIUM-139
POTASSIUM-2.9* CHLORIDE-104 TOTAL CO2-25 ANION GAP-13
Brief Hospital Course:
The patient was admitted on [**2158-6-22**] for h/o sigmoid
diverticulitis with new onset [**Date Range **], chills, n/v. She was found
to have a pelvic abscess. During the workup, the patient was
noted to have elevated cardiac enzymes and cardiology was
consulted. She was deemed to be unstable for surgery and her
abscess was drained on [**6-23**] and she was treated with
antibiotics. Cardiology recommended to postpone surgery [**3-30**]
weeks to treat her NSTEMI. She was started on plavix. She was
kept as inpatient until her surgery date. On [**7-3**] she was taken
for a cardiac cath, but it was aborted due to inability to reach
distal occlusion. She was started on TPN on [**7-9**] and remained
on it until [**7-31**]. On [**7-10**] she had an abd/pelvis CT that showed
drainage catheter curled within 5cm improving complex pelvic
abscess. On [**7-18**] the plavix was held for surgery per cardiology
recs. On [**7-24**] the patient underwent an ex lap, sigmoid
resection, colostomy and [**Doctor Last Name 3379**]. She had an uncomplicated
perioperative course and was transfered to the SICU postop for
closer monitoring. After surgery her TPN was resumed and she
remained on TPN until POD 6. She stayed in the SICU on POD [**12-26**],
during which time she had a period of low urine output, for
which she was restarted on lasix since she has a history of
being lasix dependant. Her pain was controlled with an
epidural, then transitioned to a PCA, then to PO dilaudid as per
acute pain service recs. On POD6 she complained of back pain as
she was standing up to get out of bed. An MRI showed possible
compression fracture at T11 and degenerative and disc changes.
Acute pain service and ortho spine were consulted and she was
started on conservative pain management per pain service and
both services will see her as an outpatient. PT evaluated the
patient on POD7 and determined that she is able to walk but will
need physical therapy upon discharge.
Medications on Admission:
coumadin, albuterol, ipratropium, timolol, latanoprost, fentanyl
patch, atorvastatin, metoprolol, lasix, prednisone, colace,
amiodarone, plavix
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed for wheezing.
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Atorvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
7. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every
2 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
sigmoid diverticulitis with pelvic abscess
Discharge Condition:
stable
Discharge Instructions:
Please call doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101, nausea/vomiting,
inability to eat, wound redness/warmth/swelling/foul smelling
drainage, abdominal pain not controlled by pain medications or
any other concerns.
Please resume taking all medications as taken prior to this
surgery and pain medications and stool softener as prescribed.
Please follow-up as directed.
No heavy lifting for 4-6 weeks or until directed otherwise. [**Month (only) 116**]
leave wound open to air, please leave steri-strips intact until
they fall off.
Followup Instructions:
Please call Dr.[**Name (NI) 22019**] clinic to schedule a follow up
appointment. The phone number is [**Telephone/Fax (1) 10533**].
Please call orthopedic surgery clinic to schedule an appointment
in [**3-30**] weeks or sooner if any changes in pain or function. The
phone number is [**Telephone/Fax (1) 3573**].
Please call the pain clinic to set up an appointment in the next
7-10 days. The phone number is ([**Telephone/Fax (1) 19931**].
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
Completed by:[**2158-8-2**]
|
[
"493.90",
"403.91",
"414.01",
"585.6",
"428.30",
"569.5",
"365.9",
"410.72",
"714.0",
"428.0",
"562.11",
"447.1",
"427.31",
"V64.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"45.76",
"88.56",
"46.11",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
6343, 6404
|
2900, 4883
|
312, 446
|
6491, 6500
|
1766, 2877
|
7120, 7692
|
1422, 1426
|
5077, 6320
|
6425, 6470
|
4909, 5054
|
6524, 7097
|
1441, 1643
|
1657, 1747
|
229, 274
|
474, 1170
|
1192, 1385
|
1401, 1406
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,552
| 196,064
|
47864+47865
|
Discharge summary
|
report+report
|
Admission Date: [**2150-11-25**] Discharge Date: [**2150-11-26**]
Date of Birth: [**2077-3-23**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name8 (NamePattern2) 812**]
Chief Complaint:
Malaise
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 100984**] is a 73M with ESRD on HD, with progressive NHL,
treated successfully to a PR with Bendamustine and Rituxan, and
type II Diabetes mellitus, discharged yesterday after 1 day
admission for chest pressure p/w weakness and fatigue from
dialysis today.
The patient was admitted 2 days prior for evalution of chest
pressure. He had a nuclear stress test, which showed a moderate
reversible defect in the inferior wall. He was discharged with
instructions to follow up as an outpatient for a cardiac cath.
He presented to dialysis today and felt like a "zombie" -
fatigued and weak 2 hours into dialysis. The dialysis nurse
noted that he looked pale, and the patient was again brought to
the ED.
Initial vitals in the ED: T 97.8 BP 90/50 P 82 RR 18 O2sat
97%RA. He was found to have elevated Trop 0.10. EKG showed NSR @
80bpm, LAD, 1st degree AV block, LBBB morphology, all consistent
with prior EKGs. The patient was given 1L NS, ASA 325mg PO, and
started on a Heparin gtt. Heparin was discontinued after
discussion with the cardiology fellow, given the patient's h/o
platelet defect and elevated troponins in the past. Prior to
transfer, the patient reported feeling improved, back to his
baseline. Vitals prior to transfer: T 99.1 BP 96/51 P 81 RR 16
O2sat 96%Ra.
On arrival to the floor, vitals signs were T 98.6 BP 103/81 P 78
RR 20 O2sat 100%RA. The patient was comfortable and at his
baseline with no complaints. He reports no SOB, CP,
lightheadedness, N/V, F/C, C/D, dysuria, palpitations. No recent
sick contacts. [**Name (NI) **] noted some increasing lymphadenopathy and is
scheduled to follow-up with his oncologist.
Past Medical History:
1. Non-Hodgkin's Lymphoma, slowly progressive (follicular
low-grade B-cell NHL grade I, diagnosed in [**2142**]), on
Bendemustine with partial response, has had recurrence on other
meds, over past month or so palpable lymphadenopathy seems to
have returned
2. Congestive heart failure likely secondary to combination of
moderate aortic stenosis and adriamycin cardiomyopathy EF 30%;
EFs have been improving recently, have been as low as 25% in
past
3. Aortic Stenosis (moderate)
4. End-stage kidney disease on HD MWF (secondary to diabetic
nephropathy; has had trauma to one kidney in childhood)
5. Atrial fibrillation, recently diagnosed
6. Type 2 diabetes mellitus (on glipizide)
7. Gout
8. Meningioma
9. Spinal stenosis- s/p surgery [**51**] yrs ago
10. Osteoarthritis of the hips s/p b/l THR
11. hypogammaglobulinemia (gets monthly IVIG)
Social History:
The patient is married and lives in [**Location 1439**], [**State 350**]. He
has four children. He quit smoking cigarettes 43 years ago after
80 pack yrs. He does not drink alcohol and denies the use of
illicit or illegal drugs. He works as a kosher butcher in
[**Location (un) **].
Family History:
Mother had diabetes mellitus and died at the age of [**Age over 90 **] years.
Father died at the age of [**Age over 90 **] years. He has three brothers and
three sisters who are basically healthy. There is no family
history of sudden death or premature atherosclerotic
cardiovascular disease
Physical Exam:
T 98.6 BP 103/61 P 78 RR 20 O2sat 100%RA
General: Pleasant gentleman, comfortable, NAD
HEENT: No icterus, MMM, NC/AT
Neck: Supple. Cervical and supraclavicular palpable adenopathy
L>R, nontender
Lungs: clear bilaterally, no wheezing/rales
CV: Systolic murmur radiating to carotids, RRR, S1S2
Abdomen: soft, nontender, and nondistended with active bowel
sounds
Ext: no lower extremity edema, +dp pulses
Skin: no rashes
Neuro: A + O X3, no focal neurological deficits
Pertinent Results:
ADMISSION LABS [**2150-11-25**]:
[**2150-11-25**] 12:05PM WBC-3.4* Hgb-11.9* Hct-36.8*
[**2150-11-25**] 12:05PM Neuts-60.3 Lymphs-28.3 Monos-5.2 Eos-5.4*
Baso-0.7
[**2150-11-25**] 12:05PM Glucose-49* UreaN-24* Creat-4.0*# Na-145 K-4.3
Cl-109* HCO3-23 AnGap-17
[**2150-11-25**] 12:05PM cTropnT-0.10*
[**2150-11-25**] 12:05PM CK(CPK)-15*
[**2150-11-25**] 12:18PM Lactate-1.4
CEs:
[**2150-11-25**] 12:05PM CK(CPK)-15*
[**2150-11-25**] 09:10PM CK(CPK)-16*
[**2150-11-26**] 05:20AM CK(CPK)-17*
[**2150-11-25**] 12:05PM cTropnT-0.10*
[**2150-11-25**] 09:10PM CK-MB-NotDone cTropnT-0.11*
[**2150-11-26**] 05:20AM CK-MB-NotDone cTropnT-0.10*
UA: negative
DISCHARGE LABS [**2150-11-26**]:
[**2150-11-26**] 05:20AM WBC-3.3* Hgb-11.2* Hct-36.5* Plt Ct-71*
[**2150-11-26**] 05:20AM Glucose-82 UreaN-41* Creat-5.8*# Na-145 K-4.8
Cl-110* HCO3-22 AnGap-18
[**2150-11-26**] 05:20AM CK(CPK)-17*
[**2150-11-26**] 05:20AM CK-MB-NotDone cTropnT-0.10*
Brief Hospital Course:
Mr. [**Known lastname 100984**] is a 73 yo man with h/o ESRD on HD, progressive
NHL, DM2, discharged the day prior to admission after cardiac
w/u for chest pressure, readmitted after feeling fatigue during
dialysis.
#. Fatigue: Most likely to have been fluid depleted from HD. Pt
returned to baseline after 1L NS given in ED. He was afebrile
and WBC was not elevated. CXR was unremarkable. UA was negative.
The patient had several episodes of hypotension while on the
floor, SBP 80s-90s. He was asymptomatic, and the SBP improved to
mid 90s with 250cc NS bolus.
#. Elevated troponin: The patient had elevated troponins on his
last admission, 0.09, and was readmitted with Trop 0.10. This
was likely because the patient is slow to clear the enzymes [**2-16**]
to ESRD. EKG was unchanged from prior. CEs were cycled x3. The
patient is scheduled for cardiac cath as an outpatient with Dr.
[**First Name (STitle) 437**].
#. ESRD - Pt has 1 kidney, injured the other in childhood. He is
currently on MWF schedule for HD. He was seen by Renal during
his hospitalization. He was continued on Nephrocaps and PhosLo
while in house. He is to attend outpatient dialysis tomorrow.
#. DM2 - The patient is well controlled on oral medications.
Glipizide was held during the hospitalization, and the patient
was kept on ISS.
#. Congestive heart failure: The patient was euvolemic on
presentation to the floor, despite receiving 1L NS in the ED.
His lungs were clear, denied any orthopnea, PND or lower
extremity swelling, and CXR was clear. Digoxin was switched to
every 3 day dosing, as the patient was noted to have elevated
Digoxin level during last hospitalization. He was continued on
Spironolactone and Carvedilol. Lisinopril was held [**2-16**] to
hyperkalemia during last hospitalization and is to be
re-evaluated by the patient's primary care doctor.
Medications on Admission:
1. Carvedilol 6.25 mg [**Hospital1 **]
2. Digoxin 125 mcg tablet daily
3. Spirinolactone 25 mg daily
4. Glipizide 5 mg [**Hospital1 **]
5. PhosLo 667 mg capsule TID with meals
6. ASA 81mg PO daily
8. B Complex-Vitamin C-Folic Acid 1 tab daily
9. Ranitidine 150mg PO daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY 3 DAYS
(Every 3 Days).
8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Hypovolemia
Hypogammaglobulinemia
Secondary Diagnosis
End-stage Renal Disease
Discharge Condition:
Stable, improved, BP 95/68
Discharge Instructions:
You were admitted to the hospital after feeling faint at
dialysis yesterday. You felt better after receiving intravenous
fluids in the emergency department. You had a repeat EKG that
was unchanged from your prior studies. It was likely not a
cardiac event that made you feel faint, but rather that too much
fluid was taken off during dialysis. You also have no evidence
of infection, as your urinalysis and chest xray were normal. You
also had some measurements of low blood pressure while you were
hospitalized, which improved with small amounts of intravenous
fluids.
You received your monthly infusion of IVIg while you were
hospitalized.
The following changes were made to your medications:
Please take your Digoxin every 3 days rather than daily, since
you were found to have an elevated Digoxin level during your
last hospitalization. You can restart your Digoxin tomorrow.
If you feel weakness, fatigue, lightheaded, shortness of breath,
chest pain, fevers, or chills, please call your primary care
doctor or return to the emergency department.
It was a pleasure meeting you and taking part in your care.
Followup Instructions:
Please follow up with your primary care doctor within 1-2 weeks.
Please follow up at these appointments that have already been
scheduled for you:
CARDIOLOGY:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2150-11-30**] 1:30p
ONCOLOGY:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4286**], MD
Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2150-12-29**] 4:00p
[**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]
Admission Date: [**2150-11-27**] Discharge Date: [**2150-12-17**]
Date of Birth: [**2077-3-23**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
Chemotherapy
History of Present Illness:
Pt is a 73 y.o male with h.o NHL, CHF with EF 30%, AS, ESRD on
HD MWF, afib, DM2, hypogammuloglobulinema who presents with
chest pain. Pt states that he developed 8/10 L.sided chest
pressure with radiation to the back at 4pm today. He was given
his brother in law's nitro which he said alleviated his pain
somewhat. He states that pain was gone ~1hr later upon arrival
to [**Hospital **] Hospital. He denies
LH/dizziness/palp/sob/n/v/diaphoresis. He also denies recent
f/c/headache/ST/URI/cough/abdominal
pain/d/c/melena/brbpr/dysuria/leg swelling. Pt states that he's
never had chest pain prior to Monday. Monday at HD, he developed
a generalized feeling of unwell that he cannot describe further
with the same chest pressure. These are the same symptoms that
led to his admission on Wed. Today, similar symptoms present,
but this time he was not undergoing HD.
In the ED initial vitals were: 98.1 72 110/70 15 99%RA. Pt was
given asa and nitro. Pt had 1 reoccurrence of pain in the ED.
He was given nitro and BP went from systolic 114 to 93. Pt
reports normal BP is 90's. EKG reportedly without ischemic
changes. Per discussion with the cards fellow, no heparin given
platelet count.
Of note, pt admitted [**Date range (1) 25029**] and then readmitted [**Date range (1) **].
Pt was admitted after reporting weakness, fatigue, and feeling
like a zombie at HD on the 11th, CE's were cycled and flat, on
heparin gtt briefly. Pt had an episode of hypotension to the
80's that resolved with IVF. The pt had been admitted [**11-23**] for
chest pressure, had a nuclear stress test that showed a moderate
reversible defect in the inferior wall. CE's flat.He was
discharged with instructions to follow up as an outpt for a
cardiac cath.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis (but he reports that he has a clot
in his L.arm related to his old fistula), pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. Non-Hodgkin's Lymphoma, slowly progressive (follicular
low-grade B-cell NHL grade I, diagnosed in [**2142**]), on
Bendemustine with partial response, has had recurrence on other
meds, over past month or so palpable lymphadenopathy seems to
have returned
2. Congestive heart failure likely secondary to combination of
moderate aortic stenosis and adriamycin cardiomyopathy EF 30%;
EFs have been improving recently, have been as low as 25% in
past
3. Aortic Stenosis (moderate)
4. End-stage kidney disease on HD MWF (secondary to diabetic
nephropathy; has had trauma to one kidney in childhood)
5. Atrial fibrillation, recently diagnosed
6. Type 2 diabetes mellitus (on glipizide)
7. Gout
8. Meningioma
9. Spinal stenosis- s/p surgery [**51**] yrs ago
10. Osteoarthritis of the hips s/p b/l THR
11. hypogammaglobulinemia (gets monthly IVIG)
Social History:
The patient is married and lives in [**Location 1439**], [**State 350**]. He
has four children. He quit smoking cigarettes 43 years ago after
80 pack yrs. He does not drink alcohol and denies the use of
illicit or illegal drugs. He works as a kosher butcher in
[**Location (un) **].
Family History:
Mother had diabetes mellitus and died at the age of [**Age over 90 **] years.
Father died at the age of [**Age over 90 **] years. He has three brothers and
three sisters who are basically healthy. There is no family
history of sudden death or premature atherosclerotic
cardiovascular disease
Physical Exam:
VS: T 97.8, BP 112/73, HR 93, RR 20 sat 95% on RA.
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no elevation of JVP, multiple rubbery left
supraclavicular and axillary lymph nodes
CARDIAC: RR, normal S1, S2. [**4-20**] crescendo descrendo systolic
murmur loudest in the aortic area. no r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Scant bibasilar
crackles. Pt with R.sided HD catheter, c/d/i
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
[**2150-11-26**] 05:20AM WBC-3.3* RBC-3.70* HGB-11.2* HCT-36.5*
MCV-99* MCH-30.3 MCHC-30.7* RDW-17.4*
[**2150-11-26**] 05:20AM PLT COUNT-71*
[**2150-11-26**] 05:20AM GLUCOSE-82 UREA N-41* CREAT-5.8*# SODIUM-145
POTASSIUM-4.8 CHLORIDE-110* TOTAL CO2-22 ANION GAP-18
[**2150-11-26**] 05:20AM CALCIUM-8.7 PHOSPHATE-4.2# MAGNESIUM-1.9
[**2150-11-26**] 05:20AM CK-MB-NotDone cTropnT-0.10*
[**2150-11-26**] 05:20AM CK(CPK)-17*
[**2150-11-26**] 09:25PM DIGOXIN-1.4
[**2150-11-29**] 05:15AM BLOOD LD(LDH)-994* CK(CPK)-22*
[**2150-12-2**] 01:05PM BLOOD LD(LDH)-1367*
[**2150-11-30**] 07:10AM BLOOD IgG-659*
[**2150-11-26**] ECG:
Sinus rhythm with first degree A-V block. Left anterior
fascicular block. Non-specific intraventricular conduction
delay of the left bundle-branch block type. Poor R wave
progression could be due to left anterior fascicular block
and/or intraventricular conduction delay. Non-specific ST-T wave
changes.
[**2150-11-26**] Chest Xray:
Stable chest x-ray examination with small-to-moderate sized
right pleural effusion and no superimposed acute process
identified.
[**2150-11-27**] Cardiac Catheterization
1. Selective coronary angiography of this left dominant system
revealed left main plus three vessel coronary artery disease.
The LMCA had an eccentric 60% stenosis with a 20mm Hg gradient.
The LAD was a heavily calcified vessel with a ostial 50%
stenosis, and proximal diffuse
disease to 70-80% involving D1. There was diffuse disease in the
mid-distal LAD to ~50%. The LCX had a modest very high OM1, a
large OM2, an atrial branch, a large branching OM3, and a large
OM4/LPL. The L-PDA was diffusely diseased, with an eccentric
60-70% stenosis proximally,
and provided collaterals to the RV/AM. The RCA was a modest
caliber non-dominant vessel, with a ostial 50% stenosis, and 99%
proximal occlusion with post-stenotic dilatation and faint
filling of the distalsmall AM and tiny AV groove mid RCA. The
conus branch was subtotally
occluded at the origin.
2. Resting hemodynamics revealed elevated right and left sided
filling pressures with a RVEDP of 15 mm Hg and LVEDP of 26 mm
Hg. PA pressures were markedly elevated at 68/37 mm Hg, with an
associated mean wedge pressure of 28 mm Hg. Calculated cardiac
output and index were 5.1 L/minand 2.8 l/min/m2, respectively,
using a measured oxygen consumption of 252 ml O2/min. SVR was
normal at 1161 dyne s/cm5, and PVR was elevated at 314 dyne
s/cm5. Systemic arterial pressures were normal at 120/65 mmHg.
3. There was a mean gradient of 34 mm Hg across the aortic
valve. The calculated valve area was 0.92 cm2.
4. Successful PTCA and stenting of the L-PDA with a 2.5 x 12mm
MicroDriver bare metal stent. Final angiography revealed no
residual stenosis, no angiographically apparent dissection, and
TIMI 3 flow. (see PTCA comments for details)
FINAL DIAGNOSIS:
1. Left main plus three vessel coronary artery disease.
2. Moderate to severe aortic stenosis, with a calculated [**Location (un) 109**] of
0.92cm2.
3. Severe left ventricular diastolic heart failure.
4. Severe pulmonary arterial hypertension.
[**2150-11-30**]: CT Chest/Abdomen/Pelvis
CT CHEST: Airways are patent up to subsegmental level. There are
small bilateral pleural effusions, more on the left, with tiny
bibasilar atelectasis. There is opacity at the left costophrenic
angle, which could be due to atelectasis, (300b:39). Small cyst
seen in the right mid lung, (2:34). There is no pneumothorax.
There is significant interval worsening in the appearance of the
mediastinal lymphadenopathy, with multiple innumerous lymph
nodes seen in the mediastinum, largest one in the aortopulmonary
window, measuring 3.2 x 2.8 cm, (2:22). Scattered prominent
lymph nodes are seen in the hila bilaterally. Small lymph nodes
scattered are seen in the right axilla. In the left axilla,
there is significant interval worsening with massive
lymphadenopathy, and multiple
large lymph nodes seen, the largest one measuring 4.5 x 2.9 cm,
(2:12). these extend along the left lateral chest wall. Multiple
lymph nodes are seen in the supraclavicular station. There are
lymph nodes scattered in the internal mammary region, the pre-
cardiac soft tissue, and retrocrural space, with also scattered
lymph nodes following the descending aorta entering into the
abdomen.
There are hypodensities within the thyroid gland, which could be
evaluated further with thyroid ultrasound. The heart silhouette
is enlarged; however, stable compared to prior study. There is
no pericardial effusion.
There is tunneled catheter in the right IJ, and subclavian
Port-A-Cath, with multiple collaterals at the right shoulder.
CT ABDOMEN: Small hypodensities are seen in the liver, one in
the right liver lobe, (2:56), and one in the left liver lobe,
(2:52), and possible hypodensity at the porta hepatis, (2:57),
too small to characterize. The gallbladder is seen filling with
hyperdense material could be due to the vicarious secretions.
Spleen measures 16 cm, (300b:42). The stomach, loops of large
and small bowel appear normal, with no evidence of bowel
obstruction. Vessels are patent. There is atrophic right kidney,
and similar in size compared to prior study, more are in pelvic
location which is better appreciated on the coronal image
(300b:27). There is heterogeneous enhancement of the right
kidney, new compared to prior contrast-enhanced CT from [**2148**].
The left kidney is absent. Pancreas contains several cystic
lesions, and multiple punctate calcifications, grossly stable
compared to prior study. Adrenal glands appear normal. There is
small amount of free fluid in the abdomen, mostly in perihepatic
and perisplenic distribution, and tracking along the left
paracolic gutter, and mild amount of fluid in the mesentery.
There is evidence of anasarca.
There is massive lymphadenopathy in the mesentery and
retroperitoneum with significant interval worsening compared to
prior scan. There are conglomerates of lymph nodes, the largest
at the paraaortic region measures 6.7 x 4.4 cm, (2:73). There is
a large conglomerate to the right common iliac artery, measuring
4.7 x 4.6 cm, (2:91).
Scattered diverticula seen through the colon with no evidence of
diverticulitis. There is no evidence of bowel obstruction.
CT PELVIS: There is significant streak artifact from bilateral
hip prosthesis, limiting the evaluation of the pelvis; however,
bilateral lymph nodes following at the iliac vessels, more on
the right, with conglomerate of lymph node surrounding the right
iliac artery. The urinary bladder appears
normal. There is no free fluid in the pelvis.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are
seen, with a suboptimal evaluation of the pelvis due to streak
artifact from bilateral hip prosthesis. Multilevel degenerative
changes in the thoracolumbar spine.
IMPRESSION:
1. Significant interval worsening of lymph adenopathy in the
mediastinum, right axilla, supraclavicular region, mesentery,
retroperitoneum and pelvis
2. Splenomegaly.
3. Free fluid in the abdomen.
4. Bilateral small pleural effusion, with minimal bibasilar
atelectasis.
5. Cardiomegaly, stable.
6. Anasarca.
7. Heterogeneous appearance of the right kidney is of uncertain
clinical significance and may reflect diffuse involvement with
lymphoma versus pyelonephritis.
8. Tunneled catheter in the right IJ, and subclavian
Port-A-Cath, with vascular collaterals at the right shoulder.
[**12-7**] Echo
The left atrium is moderately dilated. The right atrium is
moderately dilated. The right atrial pressure is indeterminate.
Left ventricular wall thicknesses and cavity size are normal.
There is moderate regional left ventricular systolic dysfunction
with severe hypokinesis of the inferior and distal half of the
anterior septum and anterior walls. The remaining segments
contract well (LVEF 30-35%). No masses or thrombi are seen in
the left ventricle. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are moderately thickened. There is severe
aortic valve stenosis (AoVA = 0.9cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Suboptimal image quality. Regional left ventricular
systolic dysfunction c/w multivessel CAD. Pulmonary artery
systolic hypertension. Moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2150-8-18**],
regional/global left ventricular systolic function is more
depressed c/w interim ischemia. The severity of aortic valve
stenosis and mitral regurgitation are slightly worse.
Microbiology:
Negative blood and urine cultures
Negative Influenza DFA
Brief Hospital Course:
Mr. [**Known lastname 100984**] is a 73 yo man with history of CHF with EF 35%,
DM2, ESRD on HD, follicular ymphoma, AS, and Afib who presented
with chest pain and fatigue.
#. Lymphoma: He has a prior diagnosis of follicular lymphoma
that had been stable for him over the last several years. He
also had recently had a PET scan in [**10-23**] showing stable
disease. However, on admission, he reported that his lymph
nodes were enlarging rapidly. A CT torso revealed significant
worsening of his lymphadenopathy diffusely and he began to
complain of back pain thought to be related to retroperitoneal
lymphadenopathy. He was started on IV Decadron and transferred
to the oncology service. Lymph node biopsy was not able to be
done prior to his steroid therapy as patient was feeling too
unwell to undergo the procedure. It was later decided not to
pursue biopsy as it would not change his lymphoma management.
Given the rapid interval increase in his lymphadenopathy and
elevated LDH there was concern for high grade transformation.
He received IV dexamethasone, Oncovin ([**12-3**]) and Bendamustine
([**12-3**]), and Rituximab ([**12-4**]). His chemotherapy was
complicated by pancytopenia for which he was started on neupogen
and tumor lysis syndrome for which he received allopurinol and
rasburicase. Patient spiked a fever while neutropenic and
treated empirically with zosyn and vancomycin for febrile
neutropenia. Infectious work up was negative. Patient remained
stable and neutropenia resolved and so antibiotics and neupogen
were stopped.
#. NSTEMI x2: He was admitted with left-sided chest pain and had
had a recent P-MIBI that showed an inferior wall reversible
defect. He was ruled out for MI with cardiac biomarkers and his
ECG showed no changes from previous. His pain was thought to be
consistent with unstable angina and he was taken for cardiac
catheterization. He had a significant stenosis of the LAD and
posterior descending artery and received a bare metal stent to
the PDA, as this corresponded to his perfusion defect on stress
testing. The patient was transfered to the OMED service for
management of his lymphoma. While on OMED, patient suffered
another ischemic event with positive troponins. Cardiology was
consulted who did not feel that the patient was a good candidate
for PCI/CABG. Patient was optimally medically managed. His
carvedilol was switched to metoprolol [**Hospital1 **], and he was started on
captopril. He needs to be on aspirin indefinitely and Plavix
for at least one month.
#. Hypotension: He was admitted overnight to the medical ICU
during his hospitalization after an episode of hypotension with
sytolic blood pressures in the 60's. He also spiked a fever
shortly after this episode and given his low white blood cell
count, he was treated for sepsis and started on Vancomycin and
Zosyn. He has baseline systolic blood pressures in the 80's and
stayed at this level during his ICU stay. Blood cultures were
negative. Ultimately on further review it was felt that the
patient hypotension was chronic, and as he remained asymptomatic
he was closely monitored.
#. Chronic Systolic and Diastolic Heart Failure: His cardiac
catheterization revealed severe left ventricular diastolic
dysfunction as well as moderate to severe aortic stenosis. He
appeared euvolemic on admission and he was continued on his
outpatient regimen. He tolerated low dose beta blocker and
ACE-I.
#. Rhythm: He has a history of atrial fibrillation. He remained
in normal sinus rhythm throughout most of his his
hospitalization and was continued on aspirin and a beta blocker.
He did have one episode tachycardia that the cardiology team
thought was Wenckebach rhythm.
#. ESRD on HD- He was dialyzed three times per week while an
inpatient and followed by the nephrology team. He also was
dialyzed an extra half-session after cardiac catheterization.
#. Type 2 Diabetes Mellitus: He was managed with an insulin
sliding scale and a diabetic diet. He will be discharged back
on his [**Hospital1 **] glipizide.
#. Code Status: He was FULL CODE during this hospitalization
Medications on Admission:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY 3 DAYS
(Every 3 Days).
8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please see your cardiologist within one month and
discuss when to stop this medication. DO NOT STOP before
talking with your cardiologist.
Disp:*30 Tablet(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY 3 DAYS
(Every 3 Days).
7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
11. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
14. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP<100, HR<50.
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) unit
Inhalation Q6H (every 6 hours) as needed for SOB.
17. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for abd discomfort.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) unit Inhalation Q6H (every 6 hours) as
needed for SOB.
19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever: Do not exceed 4 grams daily.
20. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
Primary Diagnoses:
Non ST elevation Myocardial Infarction
End Stage Renal Disease
Congestive Heart Failure
Low grade non Hodgkin lymphoma with possible high grade
transformation
Hypotension
Neutropenic Fever
Secondary Diagnoses:
Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital with chest pain. You underwent
a cardiac catheterization and were found to have a blockage in
two arteries that carry blood to the heart. You received a bare
metal stent to one of those arteries (posterior descending
artery) to open up the blockage. You were also found to have
progressive disease of your follicular lymphoma. We think the
lymphoma became very high grade and so we treated you with
steroids and chemotherapy. After your chemotherapy you had
another heart attack. You also developed a side effect of
chemotherapy called tumor lysis syndrome and we treated you with
rasburicase and allopurinol. You also developed low white blood
cell counts and so we treated you with a medication called
neupogen and antibiotics.
We made the following changes to your medications:
(1) Increase Aspirin to 325mg by mouth daily
(2) Added Plavix 75mg by mouth daily
(3) Added Atorvastatin 80 mg daily
(4) Changed carvedilol to metoprolol
(4) Added MS contin and morphine as needed for pain. This is a
very sedating medication, please take only as indicated. Do not
take this while operating a machinary or motor vehicle.
(5) Added nephrocaps for your kidney disease
(6) Added senna and colace for constipation as needed
(7) Added lisinopril 10mg daily
IT IS VERY IMPORTANT THAT YOU TAKE PLAVIX EVRY DAY. DO NOT STOP
TAKING THIS MEDICATION. PLAVIX WILL PREVENT FURTHER CLOT
FORMATION.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
If you experience chest pain, fevers > 101, chills, shortness of
breath, lightheadedness, or any concerning symptoms please call
your PCP or return to the emergency room.
Followup Instructions:
It is very important that you follow-up with your primary care
doctor, cardiologist, and oncologist. You have the following
appointments scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4286**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2150-12-29**] 4:00
|
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icd9cm
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13557, 13850
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30827, 31037
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27813, 28427
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31252, 32039
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31058, 31086
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31121, 31228
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,905
| 173,520
|
11388+56238
|
Discharge summary
|
report+addendum
|
Admission Date: [**2173-11-17**] Discharge Date: [**2173-11-22**]
Date of Birth: [**2098-4-12**] Sex: F
Service: General Surgery
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 17832**] was seen by
Dr. [**Last Name (STitle) **] regarding a right-sided pheochromocytoma,
status post alpha and beta blockade. The patient denies any
significant family history of this condition.
Mrs. [**Known lastname 17832**] was admitted on [**2173-11-17**] for a right adrenal
mass and had a right adrenalectomy on [**2173-11-17**]. She was
transferred to the Surgical Intensive Care Unit
postoperatively in stable condition due to chest tube
placement with an air leak and a hypotensive episode as the
result of a Dilaudid dose.
PAST MEDICAL HISTORY: Significant for: 1. Arthritis.
2. Status post cholecystectomy. 3. Status post
hysterectomy. 4. Splenic artery aneurysm. 5. Left
shoulder tendinitis. 6. Hypertension. 7. History of
atrial fibrillation, treated by Amiodarone. 8. No history
of coronary artery disease.
MEDICATIONS ON ADMISSION: Univasc 15 mg p.o. q day,
Dibenzyline 10 mg t.i.d. (alpha blocker), Synthroid 100 mcg
p.o. q day, Amiodarone 300 mg p.o. q day, Atenolol, Lanoxin
0.125 mg q day, Dyazide 1 tablet q day, aspirin 325 mg q day,
subcutaneous Heparin 5000 units b.i.d.
SOCIAL HISTORY: Significant for cessation of smoking 30
years ago. No alcohol abuse.
FAMILY HISTORY: Eight children.
PHYSICAL EXAMINATION: On admission to the Intensive Care
Unit, blood pressure was 136/54, heart rate was 64 and in
sinus rhythm with 95% saturation. CVP of 11. She was on a
Neo-Synephrine 1 mcg/kg/minute drip to achieve these blood
pressures. Her lungs showed posterior crackles but no
wheezes. Her right chest tube was in place with a mild air
leak. Her abdomen showed mild distention and was tender to
palpation with her incision clean, dry and intact. She had
pneuma-boots in place.
Her chest x-ray showed a right chest tube to the apex with no
sign of pneumothorax with small right and left effusions.
Her laboratories on admission were a white count of 13.7, a
hematocrit of 30 and platelets of 683,000. Her chem-7 showed
sodium of 135, potassium of 3.5, chloride of 104 and
bicarbonate of 26. Her free ionized calcium was 1.01.
Phosphate was 3.6. Magnesium was 1.6. Her arterial blood
gases showed a pH of 7.45, a pCO2 of 63 and an O2 saturation
of 90.
HOSPITAL COURSE: The patient had a relatively smooth course
in the Surgical Intensive Care Unit. By postoperative day
#1, her blood pressure had stabilized without the need for a
Neo-Synephrine drip. Her postoperative day #1 white count
was up to 23, but her hematocrit was stable at 39. She had
an epidural at that time for pain control, and it was
functioning well according to the Acute Pain Service.
By postoperative day #2, her right-sided chest tube was no
longer leaking, and it was discontinued.
On postoperative day #3, she continued to be stable off of
the Neo-Synephrine with sufficient blood pressures of at
least 110/60 with a stable heart rate of 84. She was
transferred to the floor in stable condition. Her epidural
was capped, and she was getting out of bed with assistance.
By postoperative day #4, we were able to discontinue her
Foley and her PCA and change her over to oral medications.
She was taking solid foods by this time without difficulty.
By postoperative day #5, [**2173-11-22**], she is completely stable.
Her incisions continue to be clean, dry and intact. Her
chest tube site is asymptomatic. She is taking sufficient
food orally and has an excellent urine output. The only
issue is that she continues to complain of weakness and does
not feel that she has sufficient strength. It is being taken
into consideration that she will need to spend a short amount
of time at a rehabilitation facility versus going home.
Physical Therapy will evaluate her today to make this
decision based on her ambulatory status.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home versus to a rehabilitation
center.
DISCHARGE MEDICATIONS: Tylenol Extra Strength 1000 mg p.o.
q6 hours p.r.n., Tylenol with Codeine 1 tablet p.o. q4-6
hours p.r.n., Amiodarone 300 mg p.o. q day, Digoxin 0.125 mg
p.o. q day, Levo-Thyroxine Sodium 100 mcg p.o. q day,
Lorazepam .5 mg p.o. q6 hours p.r.n., Metoprolol 12.5 mg p.o.
b.i.d., Triamterene/Hydrochlorothiazide 1 tablet p.o. q day.
DISCHARGE DIAGNOSIS: Status post right thoraco-abdominal
incision for adrenalectomy.
The pathology results for the surgery are not on line yet for
this patient.
The patient should follow up with Dr. [**Last Name (STitle) **] in
approximately one to two weeks for removal of her staples and
evaluation of her dressing.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 11126**]
Dictated By:[**Last Name (NamePattern1) 9800**]
MEDQUIST36
D: [**2173-11-22**] 09:45
T: [**2173-11-22**] 09:43
JOB#: [**Job Number 36434**]
Name: [**Known lastname 6510**], [**Known firstname 634**] Unit No: [**Numeric Identifier 6511**]
Admission Date: [**2173-11-17**] Discharge Date:
Date of Birth: [**2098-4-12**] Sex: F
Service:
ADDENDUM: The physical therapy evaluation on Ms. [**Known lastname **]
of [**2173-11-22**], indicated that she was too unstable to
manage her daily living activities at home and that she will
need to be discharged to a rehabilitation facility for a
short amount of time in order to regain her strength. She
continues to have excellent recovery from her
thoraco-abdominal incision for her adrenalectomy.
The pathology results on her surgery indicate a
right- sided adrenal neoplasm, identified as a
pheochromocytoma at 5.5-cm size.
Mrs. [**Known lastname **] will be discharged on [**2173-11-23**] to a
rehabilitation facility when a bed is available.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16**], M.D. [**MD Number(1) 17**]
Dictated By:[**Last Name (NamePattern1) 6512**]
MEDQUIST36
D: [**2173-11-23**] 10:50
T: [**2173-11-23**] 11:03
JOB#: [**Job Number 6513**]
|
[
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"996.59"
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icd9cm
|
[
[
[]
]
] |
[
"07.22",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
4033, 4077
|
1428, 1445
|
4101, 4433
|
4455, 6192
|
1075, 1323
|
2436, 3975
|
1468, 2418
|
179, 743
|
766, 1048
|
1340, 1411
|
4000, 4009
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,792
| 132,264
|
42296
|
Discharge summary
|
report
|
Admission Date: [**2137-3-21**] Discharge Date: [**2137-3-22**]
Date of Birth: [**2106-8-4**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
thyroid goiter
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
Ms. [**Known lastname 50762**] is a 30 year old transgender male (preferred name
[**Doctor First Name **], male pronouns) with PMH of bronchial asthma and recently
discovered large thyroid mass who presents to the ED for airway
narrowing secondary to this. Pt has been experiencing
intermittent wheezing and SOB throughout the winter, worse with
URI. He saw his PCP 2 weeks ago, noted to have enlarged thyroid
on exam and was subsequently referred to endocrine.
Endocrinology noted pt to have multinodular goiter on
examination and was clinically euthyroid. Labs were checked and
found to have TSH 0.13 with free T4 of 1.1. Per [**Name (NI) **], pt had no
dysphagia, or respiratory compromise from mass at that time. He
was referred for thyroid ultrasound and CT scan, which were both
done on [**2137-3-20**]. Subsequently his endocrinologist tried to
contact the patient given significant thyroid enlargement with
compression and significant narrowing at the trachea and
esophagus at the level of the thoracic inlet. He was
subsequently referred to the ED.
.
Denies current SOB, dysphagia, CP, n/v, fever. No family hx of
thyroid disorders.
.
In the ED, initial VS were: T 97.5 HR 82 BP 130/78 RR 16. Exam
notable for enlarged thyroid, speaking full sentences, appears
comfortable. Labs showed normal electrolytes and CBC. TSH was
added on and pending at the time of transfer to the ICU. UA
showed 15 WBC's and he was given cipro for presumed UTI. Surgery
was consulted, and recommended monitoring overnight in the ICU
given concern for developing respiratory compromise. For access
he has a 20g PIV. VS prior to transfer 97.7, Pulse: 87, RR: 16,
BP: 127/67, O2Sat: 100, O2Flow.
.
On arrival to the MICU, patient was in no acute distress. He was
monitored overnight and improved clinically so he was called out
to the floor at this time. On arrival to the floor, he feels
well and denies any shortness of breath or throat pain.
Past Medical History:
1. Hormone disorder
2. Bronchial asthma
3. Thyroid mass
4. History of bronchitis
Social History:
He does not smoke, she drinks about 1 beer/week, she works at
[**Company **] and lives with 2 roommates. No radiation to neck.
- Tobacco: denies
- Alcohol: socially
- Illicits: occassional marijuana
Family History:
No family history of thyroid cancer.
Physical Exam:
ADMISSION EXAM:
.
Vitals: T: 98.4 BP: 123/66 P: 83 R: 18 O2: 96%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, EOMI
Neck: supple, JVP not elevated, no LAD, goiter L lobe > R, no
thyroid bruits
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, 2+ reflexes bilaterally,
gait deferred
.
DISCHARGE EXAM:
.
VITALS: 98.4 123/66 83 18 96% RA
GENERAL: Appears in no acute distress. Alert and interactive. No
tripoding and speaking in full sentences.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. No stridor.
NECK: supple without lymphadenopathy. JVD not elevated. Thyroid
palpable diffusely with left greater than right nodularity. No
audible carotid bruits.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally with coarse upper airway
sounds. No wheezing, crackles. Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
Pertinent Results:
ADMISSION LABS:
.
[**2137-3-21**] 08:40PM BLOOD WBC-7.3 RBC-4.30 Hgb-13.8 Hct-39.6 MCV-92
MCH-32.1* MCHC-34.9 RDW-13.4 Plt Ct-203
[**2137-3-21**] 08:40PM BLOOD Neuts-73.1* Lymphs-21.0 Monos-3.2 Eos-1.5
Baso-1.1
[**2137-3-21**] 08:40PM BLOOD Glucose-91 UreaN-18 Creat-0.9 Na-141
K-4.2 Cl-104 HCO3-27 AnGap-14
[**2137-3-21**] 08:40PM BLOOD TSH-0.24*
.
DSICHARGE LABS:
.
[**2137-3-22**] 03:18AM BLOOD WBC-7.0 RBC-4.04* Hgb-12.7 Hct-38.0
MCV-94 MCH-31.4 MCHC-33.4 RDW-12.9 Plt Ct-211
[**2137-3-22**] 03:18AM BLOOD Glucose-86 UreaN-14 Creat-0.7 Na-142
K-3.8 Cl-105 HCO3-30 AnGap-11
[**2137-3-22**] 03:18AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9
.
URINALYSIS: clear, large LE, neg for Nitr, no protein, WBC 15
.
MICROBIOLOGY DATA:
[**2137-3-21**] Urine culture - pending
[**2137-3-21**] MRSA screen - pending
.
IMAGING:
[**2137-3-1**] CHEST (PA & LAT) - No previous images. Cardiac silhouette
is within normal limits. There is no evidence of vascular
congestion, pleural effusion, or acute focal pneumonia.
.
[**2137-3-20**] THYROID U.S. - Multinodular goiter with a large dominant
nodule in the left thyroid lobe measuring 5.8 x 4.7 x 4.6 cm.
Biopsy recommended.
.
[**2137-3-20**] CT CHEST W/O CONTRAST - Significant asymmetric
enlargement of both, though predominantly left thyroid lobe with
compression and significant narrowing of the trachea and likely
esophagus at the level of the thoracic inlet. Mediastinal
lymphadenopathy. Cholelithiasis without evidence of
cholecystitis. Given contracted state of gallbladder cannot
exclude component of gallbladder wall calcifcation. No mass
identified. Recommend right upper quadrant ultrasound to further
assess.
Brief Hospital Course:
IMPRESSION: 30FTM with PMH significant only for mild persistent
asthma who presents with incidental thyroid mass, found to have
evidence of multinodular goiter and a dominant left thyroid
nodule while euthyroid, with imaging findings concerning for
airway encroachment, but with reassuring clinical exam and
stable oxygen saturations.
.
# MULTINODULAR GOITER, LARGE LEFT THYROID NODULE - The patient
presented with a thyroid mass, although nearly euthyroid on TFT
evaluation (TSH 0.24, free T4 1.1) on no thyroid hormone
replacement. Thyroid U/S and CT imaging of the neck demonstrate
a large left thyroid lobe with multinodular goiter - with
significant compression and narrowing of the trachea with
mediastinal LAD. Oxygen saturations have been stable, with
reassuring continuous pulse oximetry. Differential includes
multinodular goiter vs. thyroid adenoma vs. thyroid malignancy
(papillary would be most probable) vs. thymic tissue vs.
vascular anomaly. Biopsy had been recommended following
ultrasound, but was deferred until surgery. The Endocrine
surgery service was consulted and felt the patient was stable
for discharge with an appointment early next week for
pre-operative planning and a plan for thyroidectomy within [**1-28**]
weeks with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The patient's Endocrinologist,
Dr. [**Last Name (STitle) 6092**], and her PCP (Dr. [**Last Name (STitle) 797**] were aware of this plan.
The patient appeared clinically stable without concern for
airway compromise on discharge. Lastly, there have been no
studies or data suggesting an adverse effect on thyroid hormone
and goiter formation in the setting of testosterone replacement,
per our literature review.
.
# ASYMPTOMATIC BACTERIURIA - He presents without symptoms of
dysuria or hematuria. Urinalysis on admission demonstrating WBC,
some leukocyte esterase. He received no antibiotics this
admission. There are no indications for asymptomatic bacteriuria
treatment in this patient and his urine culture was pending at
discharge. Given the plan for future surgical intervention, a
short course of antibiotics may be warranted if the culture is
positive for growth. He had no white count or fevers this
admission.
.
# CHOLELITHIASIS, CONTRACTED GALLBLADDER - Incidental finding on
CT imaging. No jaundice, abdominal pain or nausea, vomiting.
Laboratory studies reassuring. LFTs from [**2136-8-27**] to [**Month (only) 404**]
of [**2137**] remain normal without bilirubinemia or evidence of
obstruction. Will need non-urgent outpatient right upper
quadrant ultrasound.
.
# REACTIVE AIRWAY DISEASE, ASTHMA - Diagnosed after presenting
to [**Hospital1 2025**] in [**2136-12-27**] with concerns of wheezing. In the last
few months, he has developed bronchitis symptoms with nasal
congestion and productive cough, wheezing and shortness of
breath that reportedly resolved with albuterol inhalers and
antibiotics. There is concern that a component of his reactive
airway issues could relate to the mass effect surrounding the
thyroid goiter, but the acuity and resolve of the infectious
symptoms makes that less likely. No history of PFTs or PEF
monitoring. We continued his dosing of Albuterol, Fluticasone
and Zyrtec without issue.
.
TRANSITION OF CARE ISSUES:
1. Will need non-urgent outpatient right upper quadrant
ultrasound given CT chest findings of gallbladder contraction
without infection.
2. Follow-up urine culture - may consider treatment of
asymptomatic bacteruria if culture reveals growth, given
upcoming surgery planning.
3. Will hold testosterone dose this coming Wednesday, [**3-27**], [**2137**] given upcoming surgery planning.
4. Will see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from Endocrine Surgery on
Monday, [**2137-3-25**] at 3:15 PM for surgical planning of
thyroidectomy. Pre-operative evaluation completed this admission
(normal CXR, reassuring EKG and normal coagulation profile).
5. Outpatient PFTs scheduled in [**2137-3-28**] for reactive airway
concerns.
Medications on Admission:
Medications (confirmed with [**Hospital1 778**] records):
1. Zyrtec 10 mg PO daily
2. ProAir albuterol 2 puffs INH Q4-6H PRN wheezing
3. Testosterone 150 mg IM Q2 weeks
4. Fluticasone propionate 110 mcg (2 puffs) INH [**Hospital1 **]
Discharge Medications:
1. cetirizine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation every 4-6 hours as needed for wheezing.
3. testosterone cypionate 100 mg/mL Oil Sig: One [**Age over 90 1230**]y
(150) mg Intramuscular once a week: HOLD injection for this
coming Wednesday, [**2137-3-27**].
4. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Multinodular goiter with compressive features
.
Secondary Diagnoses:
1. Hormone disorder
2. Bronchial asthma
3. History of bronchitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at [**Hospital1 1535**] on CC7 regarding management of
your thyroid goiter and the concern for airway compression from
your thyroid mass. After careful monitoring, your oxygen
saturations remained stable and you had no concerning symptoms.
You were discharged with an appointment Monday to see Dr.
[**Last Name (STitle) **] regarding thyroidectomy and will likely have surgery
in [**1-28**] weeks. You will HOLD your testosterone injection for this
upcoming week prior to surgery.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* You have pain that is not improving within 12 hours or is not
under control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* If you have trouble breathing.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED: NONE
.
* This admission, we CHANGED:
HOLD: Testosterone 150 mg IM injection this coming week prior to
surgery (your Endocrinologist will discuss when it is
appropriate to resume this medication)
.
* The following medications were DISCONTINUED on admission and
you should NOT resume: NONE
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (endocrine-thyroid surgery)
in clinic Monday, [**2137-3-25**] at 3:15 PM. His office
number is [**Telephone/Fax (1) 9**]. He will plan to remove your thyroid in
next 1-2 weeks. Office address: [**Street Address(2) 3375**], [**Location (un) 895**].
.
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2137-4-11**] at 2:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: MEDICAL SPECIALTIES
When: MONDAY [**2137-4-1**] at 3:15 PM
With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2137-3-27**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], 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
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
|
[
"574.20",
"241.1",
"493.90",
"519.19",
"791.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10627, 10633
|
5809, 9851
|
301, 329
|
10833, 10833
|
4135, 4135
|
12999, 14359
|
2627, 2665
|
10136, 10604
|
10654, 10724
|
9877, 10113
|
11016, 12976
|
2680, 3206
|
10745, 10812
|
3222, 4116
|
247, 263
|
357, 2287
|
4151, 5786
|
10848, 10960
|
2309, 2391
|
2407, 2611
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,666
| 192,926
|
381
|
Discharge summary
|
report
|
Admission Date: [**2154-7-16**] Discharge Date: [**2154-7-17**]
Date of Birth: [**2099-4-13**] Sex: M
Service: [**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: Fifty-five year old with male
with end-stage renal disease who is hemodialysis dependent,
who at dialysis session aborted midway on [**Last Name (LF) 2974**], [**2154-7-12**] because he developed chest pain midway through dialysis.
Per his wife, he has had very frequent episodes of chest pain
more than 10 during dialysis since he was started on
hemodialysis in [**2153-8-16**]. He went to a hospital in
[**Hospital1 392**], where he was started on nitrodrip. His chest pain
resolved and has not returned since, and he went home the
next day. His wife noted that the workup for his chest pain
has been negative in the past including a cardiac
catheterization done in [**2153-9-16**] which showed normal
coronary arteries.
Since the night prior to admission, he has had cough. No
fevers, no chills. He missed dialysis today, [**7-15**]
because he was sent to the Emergency Department from home
shortly before he was scheduled for his 5 pm dialysis. He
denies any changes in his diet or noncompliance with dietary
restrictions. He has been unable to lie flat this past day
due to shortness of breath. This is new compared with his
baseline. He does not complain of shortness of breath at
rest currently, and says that he is able to work, but that
his exercise tolerance is markedly decreased compared with
his baseline. In the Emergency Department, his oxygen
saturation on room air is 80%, so he was begun on a
nonrebreather mask.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus for the past 21 years complicated
by retinopathy and nephropathy.
2. Hypertension.
3. End-stage renal disease on hemodialysis since [**2153-6-16**]. The patient has an A-V fistula placed at outside
hospital with subsequent revisions on two occasions. The
patient undergoes dialysis Monday, Wednesday, [**Year (4 digits) 2974**] at South
Suburban in [**Hospital1 392**].
4. History of Clostridium difficile colitis.
5. Diverticulosis.
6. Status post cholecystectomy.
7. Hepatitis C.
8. History of questionable congestive heart failure likely
secondary to volume overload from an infected dialysis.
9. Prior cardiovascular evaluation, echocardiogram in [**2154-1-16**] was a limited study and showed an ejection fraction
of greater than 55%, mild symmetric left ventricular
hypertrophy, no known wall motion abnormalities or valvular
disease.
10. Parathyroid adenoma in the left lower pole of the
thyroid. He is scheduled for surgery on [**2154-8-2**].
11. Status post right great toe amputation [**2154-6-12**].
12. Status post right popliteal to posterior tibial artery
bypass [**2154-5-15**].
13. History of multiple pneumonias and recurrent pneumonia.
14. Patient is scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Vascular
Surgery for a right carotid artery pseudoaneurysm repair.
MEDICATIONS ON ADMISSION:
1. Hydralazine 50 mg qid.
2. Clonidine patch 0.2 mg/hour one patch q Monday.
3. Combivent inhaler two puffs qid.
4. Cozaar 100 mg po q day.
5. Heparin IV with dialysis.
6. Lopressor 150 mg po bid.
7. Multivitamin tablet one tablet po q day.
8. Norvasc 10 mg one tablet po q day.
9. Percocet 1-2 tablets po q4h prn pain.
10. Protonix 40 mg po q day.
11. Zocor 20 mg po bid.
12. Folic acid one tablet po q day.
13. Renagel two tablets po tid with meals.
14. ASA 325 mg po q day.
15. Insulin NPH 7 units subcutaneous q am.
ALLERGIES: Ciprofloxacin causes mouth swelling, but no
difficulty breathing.
FAMILY HISTORY: Mother and father have a history of
diabetes.
SOCIAL HISTORY: Patient used to work for the State Lottery
System, currently is unemployed. Lives in [**Location 38**] with his
wife and two children ages 17 and 20. He has never smoked.
Denies alcohol use.
REVIEW OF SYSTEMS: Patient notes chronic lower extremity
edema right side greater than left side since his surgery,
[**2154-6-12**]. Patient reports that he is reasonably
ambulatory at baseline.
PHYSICAL EXAMINATION: Temperature 96.9, blood pressure
186/67, respiratory rate 28, O2 saturation 94% on
nonrebreather. General: Please middle-aged man appearing
slightly tachypneic in no acute distress. HEENT: Pupils are
equal, round, and reactive to light. Oropharynx with moist
mucosal membranes, no erythema, and no lesions. Neck: 2 cm
pulsatile mobile mass in the right mid cervical area, supple,
no lymphadenopathy. Chest: Breath sounds dull to half-way
up the posterior lung fields bilaterally with crackles at the
top of half-way up the lung fields, also crackles in the
right middle lobe area, upper lobes are clear to
auscultation. Heart: Regular, rate, and rhythm, normal S1,
S2, no murmurs, rubs, or gallops. Abdomen is soft,
nontender, nondistended, positive bowel sounds. Extremities:
2+ pitting edema to the right knee, [**1-17**]+ to the left knee.
The right toes are in wound dressings.
LABORATORIES ON ADMISSION: White count 7.4, 73% neutrophils,
19% lymphocytes, 5% monocytes, 5% eosinophils, hematocrit
34.8, platelet count 229. PT, PTT 12.6 and 26.2
respectively. INR 1.1. Electrolytes: Sodium 142, potassium
5.0, chloride 98, bicarbonate 25, BUN 93, creatinine 8.1,
glucose 130, calcium 11.3, phosphorus 7.5, magnesium 2.0.
CHEST X-RAY: Shows pulmonary edema and bilateral pleural
effusions.
ECHOCARDIOGRAM: Done in [**2154-1-16**], ejection fraction
equals 55%, slightly thickened mitral leaflets, otherwise no
valvular abnormalities.
ASSESSMENT AND PLAN: This is a 55-year-old male with history
of diabetes, hepatitis C, and end-stage renal disease,
hemodialysis dependent, presenting with dyspnea in the
setting of incomplete dialysis three days ago and missed
dialysis today.
HOSPITAL COURSE:
1. Dyspnea: Patient's shortness of breath is most likely
secondary to pulmonary edema, congestive heart failure
secondary to missing hemodialysis on the day of presentation
and having it interrupted on the days prior. His respiratory
status improved after hemodialysis on the night of admission,
[**7-15**], but he is still needed increased oxygen from
baseline.
Patient was continued on his inhalers to improve his
respiratory status. On [**7-17**], he was again taken to
hemodialysis with a new goal dry weight of 65.5 kg.
Following dialysis, the patient's respiratory status had
improved to 97% on 3 liters nasal cannula.
On [**7-17**], he was transferred from the MICU to the General
Medicine floor due to the improvement of his respiratory
status and in preparation for discharge.
2. Renal: Patient underwent hemodialysis on two occasions,
[**7-15**] and [**7-17**] as the patient would not be able to
have dialysis done on the holiday, [**7-18**]. A new goal dry
weight was 65.5 kg. The patient presented with a weight of
76.5 kg. Patient will continue his regular hemodialysis
schedule starting the next week.
3. Noncardiac chest pain: Patient has had unrevealing
extensive workup of his chest pain in the past that has not
been connected with cardiac pathology. No further evaluation
was indicated during this admission. He was continued on his
dosed at 325 mg po q day as well as his other medications for
blood pressure and heart rate control including Lopressor,
hydralazine, Cozaar, and Norvasc.
4. Heme: The patient was continued on Epogen with dialysis
and treatment of his chronic anemia.
5. Endocrine: For the patient's type 2 diabetes mellitus, he
was continued on a regular insulin-sliding scale, and he was
given his regular NPH am dose.
6. Fluids, electrolytes, and nutrition: The patient was
continued on Renagel and renal diet, and vitamin
supplementation.
7. Prophylaxis: Protonix and pneumoboots.
8. Code status: Full code.
9. Vascular: Patient has extensive peripheral vascular
disease, and is also noted to have a pseudoaneurysm on his
carotid on the right side. He is followed by Vascular
Service and has a follow-up appointment on [**7-18**] regarding
these issues.
CONDITION ON DISCHARGE: Stable. The patient has improved
respiratory status post two courses of hemodialysis during
this hospital stay.
DISCHARGE DIAGNOSES:
1. Chronic renal failure.
2. Anemia of chronic renal failure.
3. Hemodialysis.
4. Diabetes mellitus type 2.
5. Hypertension.
6. Hepatitis C.
7. Noncardiogenic chest pain.
8. Peripheral vascular disease status post right toe
amputation, status post right popliteal to posterior tibial
bypass.
DISCHARGE MEDICATIONS:
1. Hydralazine 50 mg po qid.
2. Losartan 50 mg two tablets po q day.
3. Metoprolol 50 mg three tablets po bid.
4. Multivitamins one tablet po q day.
5. Folic acid 1 mg po q day.
6. Amlodipine 5 mg two tablets po q day.
7. Pantoprazole 40 mg po q day.
8. Clonidine 0.1 mg/24h one patch q week.
9. Aspirin 325 mg po q day.
10. Acetaminophen 325 mg 1-2 tablets po q4-6h.
11. Simvastatin 10 mg two tablets po bid.
12. Sevelamer 800 mg two tablets po 3x a day before meals.
13. Insulin NPH 7 units subcutaneous q am.
APPOINTMENTS FOR FOLLOWUP: Please plan to have dialysis done
at your home, Hemodialysis Center following your previous
regimen. Contact your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for
follow-up appointment in the next two weeks. Please keep
your appointment with Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **], [**2154-7-18**] at 12:40.
Patient was advised to keep his appointment on [**7-18**] at 10
am for an ultrasound impression of the pseudoaneurysm of his
right carotid artery. The patient was advised to followup
with Vascular Surgery regarding his wound care and
appropriate dressing changes. The patient was discharged
with VNA services, who will continue dressing changes to the
site of his recent toe amputation as previously prescribed.
The patient was advised to adhere to his renal sodium
restricted diet.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], M.D. [**MD Number(2) 3405**]
Dictated By:[**Last Name (NamePattern1) 1615**]
MEDQUIST36
D: [**2154-8-5**] 12:47
T: [**2154-8-13**] 09:34
JOB#: [**Job Number 3413**]
cc:[**Last Name (NamePattern4) 3414**]
|
[
"250.40",
"070.54",
"250.50",
"443.9",
"285.21",
"428.0",
"362.01",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
3647, 3694
|
8231, 8524
|
8547, 10272
|
3030, 3630
|
5849, 8071
|
4126, 5035
|
3925, 4103
|
181, 1624
|
5050, 5832
|
1646, 3004
|
3711, 3905
|
8096, 8210
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,111
| 113,632
|
31230
|
Discharge summary
|
report
|
Admission Date: [**2190-9-2**] Discharge Date: [**2190-9-7**]
Date of Birth: [**2115-7-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2190-9-2**] Minimally Invasive Off-Pump Coronary Artery Bypass
Graft x 1 (LIMA to LAD)
History of Present Illness:
75 y/o male c/o dyspnea on exertion who had a cardiac CT that
revealed plaque on his LAD. Underwent cardiac cath which
revealed a totally occluded LAD.
Past Medical History:
Coronary Artery Disease, Hypertension, Hyperlipidemia, Aortic
Insufficiency, s/p Appendectomy, s/p Hernia Repair x 2, Benign
Prostatic Hypertrophy
Social History:
Retired. Quit smoking 50 years ago. Drink [**12-1**] glasses
whiskey/night.
Family History:
Non-contributory
Physical Exam:
Admission: VS: 81 16 148/76 5'[**93**]" 170#
Gen: WD/WN male in NAD
Skin: Unremarkable
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM , -JVD
Chest: CTAB
Heart: RRR
Abd: Soft, NT/ND
Ext: -c/c/e, -varicosities
Neuro: A&O x 3, MAE, non-focal
Discharge: VS: T98.4 HR81 BP126/68 RR18 O2sat93%RA
Gen: NAD
Neuro: A&Ox3, nonfocal exam
Pulm: CTA-bilat
CV: Irreg-Irreg, left thoracotomy incision w/steri's CDI
Abdm: soft, NT/ND/NABS
Ext: warm, well perfused. [**12-1**]+pedal edema
Pertinent Results:
[**9-2**] Echo: 1, The left atrium is moderately dilated. No
spontaneous echo contrast is seen in the body of the left
atrium. No thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. 2, Right
ventricular chamber size and free wall motion are normal. Right
ventricular chamber size is normal. 3. There are simple atheroma
in the ascending aorta. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. No masses or vegetations are seen
on the aortic valve. There is no aortic valve stenosis. Moderate
(2+) aortic regurgitation is seen. The aortic regurgitation jet
is eccentric, directed toward the anterior mitral leaflet. There
is no flow reversal in the descending aorta. 4. The mitral valve
appears structurally normal with trivial mitral regurgitation.
Trivial mitral regurgitation is seen. 5, There is a
trivial/physiologic pericardial effusion. 6. LV systolic
function is normal . LVEF= 55%. During occlusion of LAD, there
was akinesis of mid and distal anterior wall with preserved
ejection fraction. Upon release of LAD occlusion, there is
improvement of anterior wall, but some residual anterior
hypokinesis.
[**9-5**] CXR: PA and lateral views of the chest are obtained on
[**2190-9-5**] at 1553 hours and compared with the prior radiograph
performed on [**2190-9-2**]. The patient is status post CABG. He has
been extubated and the Swan-Ganz catheter and pleural tubes have
been removed. Increased density is seen in the right base which
is likely a combination of fluid and atelectasis in the right
lower lobe. Patchy increased density is seen in the retrocardiac
area on the left side consistent with a degree of
atelectasis/airspace disease of the left base. Bilateral small
pleural effusions are present.
[**2190-9-2**] 03:05PM BLOOD WBC-14.6*# RBC-3.01* Hgb-10.1* Hct-28.6*
MCV-95 MCH-33.6* MCHC-35.3* RDW-13.4 Plt Ct-141*
[**2190-9-5**] 02:02AM BLOOD WBC-10.9 RBC-2.90* Hgb-10.1* Hct-28.1*
MCV-97 MCH-34.7* MCHC-35.8* RDW-13.1 Plt Ct-148*
[**2190-9-2**] 03:05PM BLOOD PT-14.5* PTT-31.4 INR(PT)-1.3*
[**2190-9-5**] 02:02AM BLOOD PT-11.8 PTT-27.1 INR(PT)-1.0
[**2190-9-2**] 04:30PM BLOOD UreaN-10 Creat-0.7 Cl-115* HCO3-22
[**2190-9-5**] 02:02AM BLOOD Glucose-113* UreaN-11 Creat-0.8 Na-135
K-4.0 Cl-105 HCO3-24 AnGap-10
[**2190-9-5**] 02:02AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.2
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
07 [**2190-9-5**] 02:02AM 148*
Source: Line-art
[**2190-9-5**] 02:02AM 11.8 27.1 1.0
[**2190-8-30**] 02:02AM 10.9 2.90* 10.1* 28.1* 97 34.7* 35.8* 13.1
148*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2190-9-5**] 02:02AM 113* 11 0.8 135 4.0 105 24 10
Brief Hospital Course:
Mr. [**Known lastname 73692**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On day admission he was
brought to the operating room where he underwent a minimally
invasive off-pump coronary artery bypass graft x 1. Please see
operative report for surgical details. Following surgery he was
transferred to the CVIICU for invasive monitoring in stable
condition. Later on op day he was weaned from sedation, awoke
neurologically intact and extubated. He required Neo-Synephrine
for hemodynamic support until early post-op day three when it
was weaned off. Lasix and beta blockers were initiated and he
was gently diuresed towards his pre-op weight. Chest tubes were
removed on post-op day three and he was transferred to the SDU
for further care. Also on this day his heart rhythm went into
atrial fibrillation and he was started on Amiodarone and
Coumadin. He continued to progress in his activity and on POD 5
it was decided he was ready for discharge home with visiting
nurse visits
Medications on Admission:
Aspirin 81mg qd, Amlodipine 3.75mg qd, Finasteride 5mg qd,
Flomax o.4mg qd, Lasix 20mg qd, Lisinopril 5mg qd, Plavix 75mg
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*1*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): [**Hospital1 **] x 10 days then QD x 14 days.
Disp:*34 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours): [**Hospital1 **]
x 10 days then
QD x 14 days.
Disp:*68 Capsule, Sustained Release(s)* Refills:*0*
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] x 7 days then 400 mg QD x 7 days then 200 mg
QD.
Disp:*60 Tablet(s)* Refills:*2*
12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 3 weeks.
Disp:*65 Tablet(s)* Refills:*0*
13. Warfarin 2 mg Tablet Sig: as directed Tablet PO once a day:
Target INR 1.5-2.0.
Disp:*75 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 1
PMH: Hypertension, Hyperlipidemia, Aortic Insufficiency, s/p
Appendectomy, s/p Hernia Repair x 2, Benign Prostatic
Hypertrophy
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 11493**] in [**1-2**] weeks
Dr. [**Last Name (STitle) 17029**] in [**12-1**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2190-9-7**]
|
[
"401.9",
"600.00",
"272.4",
"427.31",
"424.1",
"413.9",
"458.29",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7248, 7316
|
4268, 5288
|
338, 429
|
7547, 7553
|
1416, 4245
|
7888, 8159
|
889, 907
|
5460, 7225
|
7337, 7526
|
5314, 5437
|
7577, 7865
|
922, 1397
|
279, 300
|
457, 610
|
632, 780
|
796, 873
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,288
| 100,806
|
27971
|
Discharge summary
|
report
|
Admission Date: [**2159-6-8**] Discharge Date: [**2159-6-16**]
Date of Birth: [**2102-11-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
burning sensation in chest/fatigue/lightheadedness that began
[**2159-6-1**]
Major Surgical or Invasive Procedure:
CABGx2(LIMA->LAD, SVG->RCA)/MV repair(28mm band)/PFO closure
[**2159-6-11**]
Extraction of a tooth [**2159-6-10**]
History of Present Illness:
56 yo female transferred in from [**Hospital3 35813**] Center with
burning sensation in chest/nausea/diarrhea/cold sweats 1.5 weeks
ago. On Wed experienced weakness as other sx subsided over 24-48
hours. Five days later she sought medical care when fatigue
continued and diagnosed with MI. Workup revealed 100% LAD, 100%
RCA and MR. Referred for surgical repair. TEE on [**6-8**] showed EF
35%, severe MR, PFO with left to right shunting. Carotid US [**6-5**]
showed [**Doctor First Name 3098**] 40-59%, right ICA less than 40% stenoses. She also
had a + UA and was treated with IV levaquin.
Past Medical History:
PVD with decreased iliac circulation
HTN
elev. chol.
[**2124**] wedge resection of bilat. ovaries/appy
Social History:
works as insurance [**Doctor Last Name 360**]
smokes 1 ppd for 16 years
no ETOH
last dental exam [**2157**]
lives with 2 sons
Family History:
non-contributory
Physical Exam:
HR 66 RR 18 97/66 5'3" 79.7 kg
NAD
skin/HEENT unremarkable
neck supple with full ROM
CTAB
RRR
abd soft, NT, ND, +BS
extrems warm and well-perfused, no edema or varicosities
neuro grossly intact
1+ bilat fem/DP/PTs
2+ radials
Pertinent Results:
[**2159-6-16**] 04:57AM BLOOD WBC-12.2* RBC-3.63* Hgb-10.3* Hct-31.0*
MCV-86 MCH-28.3 MCHC-33.1 RDW-14.6 Plt Ct-489*
[**2159-6-15**] 10:20PM BLOOD Glucose-118* UreaN-22* Creat-0.6 Na-133
K-4.7 Cl-96 HCO3-25 AnGap-17
[**2159-6-8**] 09:26PM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE
[**2159-6-16**] 04:57AM BLOOD Plt Ct-489*
[**2159-6-15**] 10:20PM BLOOD Glucose-118* UreaN-22* Creat-0.6 Na-133
K-4.7 Cl-96 HCO3-25 AnGap-17
[**2159-6-16**] 04:57AM BLOOD UreaN-20 Creat-0.7 K-5.1
[**2159-6-15**] 10:20PM BLOOD Calcium-8.1* Phos-4.8*# Mg-3.6*
[**2159-6-8**] 09:26PM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE
FINAL REPORT
PA AND LATERAL CHEST ON [**2159-6-16**] AT 10:50.
INDICATION: Followup after MVR and CABG.
COMPARISON: [**2159-6-14**].
FINDINGS:
Compared to prior study, the Swan-Ganz catheter has been
removed. There are
diminished interstitial markings consistent with improving fluid
status and
only small posterior effusions were identified on the lateral
view. There is
no PTX. The cardiac silhouette is enlarged but not substantially
different
from prior.
IMPRESSION: Improved chest x-ray with resolving pulmonary edema
and
resolution of previously seen right PTX.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: SAT [**2159-6-16**] 2:44 PM
Procedure Date:[**2159-6-16**]
Brief Hospital Course:
The pt. was admitted on [**6-5**] and underwent a tooth extraction on
[**6-10**] prior to surgery. CABG x2/ MV repair / PFO closure performed
by Dr. [**Last Name (STitle) **] on [**6-11**] and transferred to the CSRU in stable
condition on milrinone, levophed, and propofol drips. Seen by
vascular that evening for decreased pulses in right LE.This
improved the next day. Extubated, and remained on insulin and
milrinone drips on POD #1. Diuresis started, foley and chest
tubes removed on POD #2. Repeat CXR noted small right apical ptx
after chest tubes removed, moderate CHF. Swan removed and
milrinone weaned on POD #3. Transferred to the floor and
restarted on amiodarone for PVCs and transfused one unit PRBCs
on [**6-15**]. Pacing wires removed without incident on POD #4.
Cleared for discharge to home with VNA services on POD #8. Pt to
follow up with Dr. [**Last Name (STitle) **] in 2 weeks as per discharge
instructions.
Medications on Admission:
protonix 40 mg daily
ASA 325 mg daily
lipitor 20 mg daily
RISS
temazepam 15mg
digoxin 0.25 mg daily
lisinopril 2.5 mg daily
lopressor 25 mg TID
heparin drip 1350u/hr
colace 100mg
spironolactone 12.5 mg
paxil 10 mg daily
albuterol
levaquin 500 mg IV
amiodarone 400 mg TID
Discharge Medications:
1. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. 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*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: Decrease dose to 400 mg PO daily for 7 days
after [**Hospital1 **] dose completed, then decrease dose to 200 mg PO daily
after 400 mg daily dose completed.
Disp:*50 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO DAILY (Daily) for 7 days.
Disp:*7 Capsule, Sustained Release(s)* Refills:*0*
14. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
Disp:*1 months supply* Refills:*2*
15. Flovent 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Disp:*1 months supply* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA OF GREATER [**Doctor Last Name **]
Discharge Diagnosis:
Coronary artery disease.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications 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.
Do not use lotions, powders, or creams on wounds.
Call our office for sternal drainage, temp.>101.5
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Make an appointment with Dr. [**Last Name (STitle) 2072**] for 1-2 weeks.
Completed by:[**2159-6-21**]
|
[
"525.50",
"521.00",
"745.5",
"272.0",
"V45.77",
"428.20",
"414.01",
"401.9",
"525.10",
"285.9",
"440.21",
"305.1",
"428.0",
"410.91",
"424.0",
"791.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.64",
"36.11",
"23.09",
"99.07",
"99.04",
"39.61",
"35.33",
"89.68",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6316, 6385
|
3036, 3969
|
354, 471
|
6454, 6462
|
1660, 3013
|
6789, 6962
|
1378, 1396
|
4291, 6293
|
6406, 6433
|
3995, 4268
|
6486, 6766
|
1411, 1641
|
238, 316
|
499, 1092
|
1114, 1219
|
1235, 1362
|
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