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30,650
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Discharge summary
|
report+addendum
|
Admission Date: [**2166-5-28**] Discharge Date: [**2166-6-17**]
Date of Birth: [**2081-11-27**] Sex: M
Service: MEDICINE
Allergies:
Metoprolol
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
malaise, weakness, urinary incontinence
Major Surgical or Invasive Procedure:
Intubation
Hemodialysis
Left Internal Jugular line
Right subclavian HD line
History of Present Illness:
Mr [**Known lastname 33561**] is an Arabic only speaking man with a PMHx of HTN,
dCHF, stage 5 CKD not on HD and history of urosepsis who was
admitted last evening from PCP's office with low grade temps,
leukocytosis. He had presented there with complaints of 2 days
of severe heartburn, minimally responsive to maalox/ranitidine
as well as urinary incontinence, hematuria, polyuria, malaise
and weakness. Per his wife he was "not himself." Per daughter
this was similary to prior presentations where he was admitted
with urosepsis. No recent diarrhea, sick contacts, recent
antibiotics. No known flu exposures. On presentation to the ED
he was afebrile initially at 98.6 with temp increasing to 100.9
HR 106 BP 116/66 RR 22 100% RA. He had blood and urine cultures
taken. His UA had bacteria, blood, tr leuks and some epis. His
CXR did not show any infiltrate, there was a question of a right
pleural effusion. He was given levofloxacin and tylenol in
setting of leukocytosis to 21.5 and low grade fever. His ECG
showed sinus tach with some rate related ST depressions. CEs
flat. He was admitted to the medicine service for further work
up and monitoring; with a plan for continuing the levofloxacin
apparently for a ? + UA and ruling him out.
.
At approximately 4am the evening of admission he was triggered
with temp to 104.2 with rigoring, tachypnea to 38 and
tachycardia in the 130s. He was inially sating in the mid-high
90s on RA but desatted to mid to high 80s, was placed on NC 4L
02. He was given 250cc NS on the floor. The patient's wife was
at bedside, also Arabic only speaking, his daughter was called
and acted as interpreter. [**Name8 (MD) **] RN notes the patient complained
of L breast pain as well as "pins and needles coming and going".
Per phone discussion with daughter as well as patient and wife,
pt who was initially documented as DNR/DNI reversed his code
status to FULL and was agreeable to invasive access and
intubation.
Past Medical History:
* HTN ?????? per previous notes, patient was previously assessed for
HTN ranging from sbp 180-220 in [**8-2**], which has been controlled
with diovan 160 mg qd and metoprolol 25 mg [**Hospital1 **]
* DM2 ?????? controlled with glyburide and lantis, last HbA1c 7.0%
([**2162-8-25**]), 8.6% ([**5-2**])
* Hyperlipidemia ?????? controlled with lipitor
* "Gout" ?????? this has been listed on previous notes, though PCP
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5717**] notes that patient??????s family believes LE edema
is gout
* BPH ?????? controlled with proscar
* CRI ?????? Cr ranged 2.1-2.2 in [**2161**]
* L inguinal hernia
* E. coli urosepsis [**11-30**]
* cataracts
Social History:
patient lives in [**Location 1411**] with wife, has no current occupation
no recent travel abroad
immigrated from [**Country 1684**] and has lived in US for 12 yrs
never tobacco, EtOH
Family History:
patient's wife denies any heart problems in family
Physical Exam:
Vitals: T:103.8 BP:102/57 P:126 R:43 O2:98% 4L
General: Elderly Lebanese man, actively rigoring.
HEENT: Sclera anicteric. MM mildly dry.
Neck: supple, JVP not elevated, no LAD
Lungs: No crackles, shallow rapid breathing, accessory muscle
use. Slight rhonchi that clear with coughing, some diffuse
end-expiratory wheeze.
CV: Tachycardic, regular. Likely systolic murmur, heard best at
axilla, difficult to characterise in setting of tachycardia.
Abdomen: Tense, distended, tympanitic. No BS. No guarding, no
rebound, minimally tender to deep palpation. Active abdominal
breathing.
Ext: No edema. Well perfused.
GU: No external lesions. No prostatic tenderness to palpation.
Dark stool, guaiac negative. Foley in place.
.
Pertinent Results:
ON ADMISSION:
[**2166-5-28**] 02:12PM LACTATE-1.8
[**2166-5-28**] 12:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2166-5-28**] 12:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
[**2166-5-28**] 12:40PM URINE RBC-[**1-30**]* WBC-[**1-30**] BACTERIA-MOD YEAST-NONE
EPI-[**1-30**]
[**2166-5-28**] 12:36PM GLUCOSE-250* K+-4.6
[**2166-5-28**] 12:30PM GLUCOSE-275* UREA N-85* CREAT-3.9*
SODIUM-132* POTASSIUM-4.4 CHLORIDE-94* TOTAL CO2-26 ANION GAP-16
[**2166-5-28**] 12:30PM estGFR-Using this
[**2166-5-28**] 12:30PM ALT(SGPT)-9 AST(SGOT)-12 CK(CPK)-35* ALK
PHOS-120* TOT BILI-0.7
[**2166-5-28**] 12:30PM LIPASE-41
[**2166-5-28**] 12:30PM cTropnT-0.06*
[**2166-5-28**] 12:30PM CK-MB-NotDone
[**2166-5-28**] 12:30PM WBC-21.5*# RBC-4.09*# HGB-10.1*# HCT-34.3*#
MCV-84 MCH-24.8* MCHC-29.5* RDW-16.6*
[**2166-5-28**] 12:30PM NEUTS-90.6* LYMPHS-5.8* MONOS-3.1 EOS-0.5
BASOS-0.1
[**2166-5-28**] 12:30PM PLT COUNT-228
[**2166-5-28**] 12:30PM PT-12.8 PTT-25.9 INR(PT)-1.1
.
ON DISCHARGE: WBC 5.9 HCT 24.5 plt 258
137 | 103 | 44
---------------149
4.7 | 25 | 3
Brief Hospital Course:
84 y/o male with diastolic heart failure, chronic kidney
disease, prior admissions for urosepsis, VRE carrier who was
admitted to the MICU status post septic shock/respiratory
failure for emphysematous gall bladder, presently awaiting
cholecystectomy on IV antibiotics.
# Sepsis/leukocytosis ?????? pt presented with high fevers, rigors,
tachypnea, WBC initially 21, and rising lactate to 4.3.
Abdominal CT showed air in gallbladder wall, bedside
percutaneous gallbladder drain placed by IR [**5-29**]. MRCP showed no
surrounding fluid collection or ductal dilation. Bile output
with various GNR and GNC, also with prevotella bacteremia [**5-29**]
with many negative blood cultures in subsequent days. Initally
started on daptomycin (hx of VRE), cefepime, flagyl, and cipro.
Completed 6 days of daptomycin, cefepime, and flagyl. Biliary
fluid was positive for pan-sensitive Enterococcus. As such, ID
recommended d/c'ing all previous Abx and simply using zosyn. Pt
did also have one positive blood culture for prevotella. He was
transferred to the floor on zosyn. Lactate and t. bili corrected
throughout his stay. Surgery has been following and the overall
plan is for cholecystectomy in several weeks. Abx to continue up
until surgery.
Pt's WBC peaked at 24, but was wnl (5.9) on discharge. A CT of
his abdomen was performed [**2166-6-8**] for concern for increasing
distention. It showed the the cholecystotomy tube was no longer
in the gallbladder. The cholecystotomy tube was replaced and
pt's abdomen became less distended.
# Respiratory Failure - pt was intubated throughout his sepsis.
Was weaned without difficulty and was on minimal NC upon
transfer. On the floor he was weaned from oxygen and currently
has oxygen saturations >92% on room air.
#Altered Mental [**Name (NI) 13115**] Pt found to have waxing and [**Doctor Last Name 688**]
mental status consistent with delerium from his cholecystitis.
Pt was quite somnolent on several occasions. Of note, pt has
unequal pupils at baseline. ABG, blood sugar and vital signs
were all within normal limits while somnolent and pt improved in
the presence of a family members.
# Acute on Chronic Renal Failure - at presentation, pt was stage
IV-V CKD. His Cr stayed near 6.0 throughout his MICU stay. He
was oliguric with a UOP of about 20-30 cc/hr initially, but
responded to lasix gtt and diuril with good diuresis. He
underwent IR guided non-tunneled hemodialysis line on [**2166-6-4**] for
temporary HD. HD was discontinued on [**2166-6-11**] and HD line
discontinued on [**2166-6-17**]. Pt will follow up with Dr [**Last Name (STitle) 4090**]. Pt is
discharged without diovan or phoslo, which may be added back in
follow up.
# ?[**Name (NI) 33562**] Pt developed elevated lipase 1234, without
pain, in the setting of increased inflammation in the
gallbladder/ductal system. Pt's lipase trended down to the 500s
by discharge.
# h/o CHF/CAD - pt was fluid overloaded after tx of sepsis, but
responding well to lasix and diuril therapy at transfer. Upon
transfer to the floor, he had no signs of decompensated heart
failure. Pt was restarted on low dose lasix (40daily) on
discharge. This may require up titration as outpt. Pt was
restarted on his home dose of asa 81mg.
# h/o BPH - Initially, tamsulosin held as pt had foley in place,
continued finasteride. As pt improved tamsulosin was restarted
and foley discontinued.
# DM2 - glyburide was held, and an insulin sliding scale was
continued. He was given 25 units of glargine for basal coverage
in addition to humalog sliding scale as his blood sugars trended
up. Pt is discharged to rehab on insulin, may transition back to
oral hypoglycemics as outpt.
# [**Name (NI) **] pt has anemia at baseline and is on procrit and iron.
Pt's iron was held and not restarted, procrit was restarted.
Iron can be started as an outpt if indicated.
Medications on Admission:
MEDICATIONS AT HOME (per OMR):
Allopurinol - 100 mg Tablet - 1 Tablet(s) by mouth once a day
Lipitor - 20 mg Tablet - 1 Tablet(s) by mouth once
a day
Phoslo - (Prescribed by Other Provider: [**Last Name (NamePattern4) **].[**Last Name (STitle) 4090**]) - 667 mg
Capsule -1 Capsule(s) by mouth three times a day
Epoetin Alfa - (Prescribed by Other Provider: [**Name Initial (NameIs) 4090**]) - Dosage
uncertain
Finasteride - 5 mg Tablet - 1 Tablet(s) by mouth once a day
Lasix - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4090**]
- 40 mg Tablet - 2 Tablet(s) by mouth each morning; 1 tablet by
mouth each afternoon
Glyburide - 5 mg Tablet - [**11-29**] Tablet(s) by mouth twice a day
Flomax - 0.4 mg Capsule, Sust. Release 24 hr - one
Capsule(s) by mouth at bedtime
Verapamil- 120 mg Tablet - 0.5 (One half) Tablet(s) by mouth
once a day
Aspirin 81 mg po daily
Zantac 150 mg po BID
.
Medications - OTC
Ferrous Sulfate - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4090**] -
325 mg (65 mg Iron) Tablet - 1 Tablet(s) by mouth twice a day
MEDICATIONS AT HOME ([**First Name8 (NamePattern2) **] [**Last Name (un) **])
[**First Name8 (NamePattern2) **] [**Last Name (un) **]:
Doxazosin Mesylate 2mg 1 time per day
Prednisone 20mg take 1 (0.5MG/KG) by ORAL route every day
Proscar 5mg take 1 tablet (5MG) by ORAL route every day
Allopurinol 100mg take 1 by Oral route every day
Procrit - Multidose 20000u/ml as directed every 7 days Taking
20,000 sq
Iron 325mg 3 tablets daily
Renagel 800mg three times a day with meals
Diovan 80mg 1 time per day
Glipizide 5mg NOTE TO PHARMACIST: PLEASE SPLIT THE PILL FOR THE
PATIENT
Take [**11-29**] tab in the morning, [**11-29**] tab at dinner
[**Last Name (un) **] Step Monitoring Strips Strips as directed tests once or
twice a day
Phoslo 667mg three times a day with meals
Lasix 40mg twice a day: 2 in am, one in afternoon
Flomax 0.4mg at bedtime
Rocaltrol 0.25mcg UNKNOWN QOD
Lipitor 20mg 1 time per day
Aspirin 81mg 1 time per day
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for BPH.
5. Acetaminophen 650 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO every 6-8 hours as needed for fever
or pain: please do not give more than 4g tylenol in 24h.
6. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for for wheeze.
8. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed for fungal infection.
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
11. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
14. Petrolatum Ointment Sig: One (1) Appl Topical QID (4
times a day) as needed for dry lips.
15. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
16. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
17. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
18. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous at bedtime.
19. insulin, humalog
Please follow the sliding scale as sent along the discharge
paperwork.
20. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
21. Allopurinol 100 mg Tablet Sig: [**11-29**] Tablet PO once a day.
22. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q12H (every 12 hours): Please continue
till Infectious Disease specialist tells you to stop it. Recon
Soln(s)
23. Acyclovir Sodium 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): Please give 350 mg daily.
LAST DOSE IS [**2166-6-19**]! Please d/c on [**6-20**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
1. Emphysematous gall bladder
2. HTN
3. Diastolic CHF (TTE [**2165-3-4**] - LVEF > 65% / Mild symmetric
ventricular hypertrophy)
4. Type 2 DM (last HBA1C 7.0 - [**2162-7-30**])
5 Stage V kidney disease
Secondary:
1. BPH
2. Hypercholesterolemia
3. Recurrent gout
4. L inguinal hernia
5. cataracts
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because of an infection in your gallbladder
you were very sick and it was felt that you were too sick to
have surgery to have your gallbladder taken out so we put a tube
in your gallbladder to drain the infected fluid. Initially you
were not able to breathe on your own but you improved with
antibiotics. You also had worsening of your kidney function
which required that you get a dialysis a few times but your
kidney function seems to be improving now. You are going to go
to a rehabilitation facility where you will continue to get
antibiotics for several weeks. In a few weeks, you will come
back to the hospital in order to get your gallbladder out. After
you get your gallbladder out you will probably be able to stop
taking antibiotics. While at your rehabilitation facility,
please eat your full pureed diet and nutritional supplements
provided.
Followup Instructions:
You have an apt with your kidney doctor [**First Name (Titles) **] [**Last Name (Titles) 4090**] on Mon [**6-23**] at 11:30 am. Phone [**Telephone/Fax (1) 3637**].
You have an apt with Dr [**First Name (STitle) **] from surgery on [**2166-6-25**] at [**Hospital1 18**] in
[**Location (un) 620**] at 2:30pm
You have an apt with your infectious disease doctor: Provider:
[**Name10 (NameIs) 1423**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2166-7-3**]
10:00
You have an apt with your cardiologist: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
[**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2166-7-29**] 10:00
Completed by:[**2166-6-17**] Name: [**Known lastname 5867**],[**Known firstname 5868**] Unit No: [**Numeric Identifier 5869**]
Admission Date: [**2166-5-28**] Discharge Date: [**2166-6-17**]
Date of Birth: [**2081-11-27**] Sex: M
Service: MEDICINE
Allergies:
Metoprolol
Attending:[**First Name3 (LF) 3535**]
Addendum:
#Gout: Pt did not have any flares while in the hospital.
Allopurinol was initially held. Pt was restarted on a lower dose
of allopurinol than his home dose. Dr [**Last Name (STitle) **] will titrate up
prn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Location (un) 50**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3538**] MD [**MD Number(2) 3539**]
Completed by:[**2166-6-20**]
|
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"038.8",
"263.9",
"600.00",
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icd9cm
|
[
[
[]
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[
"96.72",
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"39.95",
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icd9pcs
|
[
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[]
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|
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|
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418, 2381
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|
2403, 3128
|
3144, 3330
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,114
| 190,732
|
52496
|
Discharge summary
|
report
|
Admission Date: [**2178-3-24**] Discharge Date: [**2178-4-3**]
Date of Birth: [**2103-11-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4611**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Chest Tube Placement
History of Present Illness:
Mr. [**Known lastname 108423**] is a 74 year old man with a hx of stage I melanoma
s/p resection, prostate cancer s/p prostatectomy and recently
found to have NSCLC with right sided lung mass, hilar and
mediastinal nodes positive and a right pleural effusion. A PET
scan for staging was to be done today but was not done due to
machine malfunction. He presented to the emergency room with
worsening dyspnea this evening. He was recently admitted from
[**Date range (3) 108425**] with bilateral subsegmental PEs and was put on
Lovenox. During this admission an IVC filter was placed and he
was also treated for an enterobacter UTI, discharged on Cipro
for 2 weeks. A thoracentesis done on [**2178-3-9**] did not show
malignant cells. A CT Torso, bone scan and head MRI showed no
evidence of metastatic disease.
The patients that over the course of the past several days, his
oxygen saturation has gradually decreased by 1-2%. He slowly
became more short of breath with exertion such as walking out of
the house. He denies worsening of his cough but does have a
non-productive cough. He denies fevers or chills. He has felt
progressively weak. He denies headache, nausea, vomiting,
hemoptysis, diarrhea. He has had no bleeding. He has been
slightly constipated due to the codeine cough suppressant.
In the emergency department, initial vitals: 99.1 94 86/57 20
91%. Blood cultures were obtained. CXR showed worsening R
moderate pleural effusion as well as suspected L sided pleural
effusion as well as pulmonary vascular congestion.
Interventional pulmonary was contact and will evaluate the
patient on the floor in the morning.
Review of systems:
(+) Per HPI + constipation, DOE, cough
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea, or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
Diabetes mellitus (last A1c 6.6 in [**1-22**]; diet controlled)
BPPV
Melanoma (Stage I, dx and excised in [**2136**])
Prostate cancer s/p radical prostatectomy and negative LN
dissection ([**12/2172**])
Cataracts
Pulmonary nodules (first noted in [**2171**], s/p biopsy; followed by
Dr. [**Last Name (STitle) 108420**] at [**Hospital1 112**])
Neuropathy
Tremor
Diverticulosis
Colonic polyps (adenomatous in [**2174**])
Celiac artery aneurysm (followed by Dr. [**Last Name (STitle) 17974**] at [**Hospital1 112**])
s/p CCY
s/p inguinal hernia repair
Social History:
Retired. Was a former physicist/electrical engineer. Lives in
[**Location (un) **], MA with his wife.
- Tobacco: Smoked [**1-12**] cigarettes daily for 2 years in his
twenties.
- Alcohol: Rare.
- Illicits: Denies.
Family History:
No family history of clots of bleeding disorders. No h/o CAD,
DM, colon or prostate cancer.
Physical Exam:
Physical Exam on Admission:
VS: T98.3 BP 124/66 HR 94 RR 20 94% on 4L
GENERAL: alert and oriented, breathing comfortably, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: Decreased breath sounds at the bases bilaterally, right
greater than left, with dullness on percussion.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: RLE trace edema, RLE is larger than LLE.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
.
Discharge Physical Exam:
VS: 95.8, 110s-120s/50s-80s, 80s-90s, 20 94% 4LNC, 270cc from
pleurex
GENERAL: alert and oriented, breathing comfortably, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: Decreased breath sounds at the bases bilaterally, right
greater than left, crackles present in bases b/l. Pleurex in
place on R lateral chest
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: RLE trace edema, RLE is larger than LLE.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
Pertinent Results:
Lab Results on Admission:
[**2178-3-24**] 08:00PM BLOOD WBC-9.8 RBC-4.51* Hgb-14.0 Hct-40.3
MCV-89 MCH-31.0 MCHC-34.7 RDW-13.5 Plt Ct-358
[**2178-3-24**] 08:00PM BLOOD Neuts-81.7* Lymphs-12.3* Monos-5.0
Eos-0.4 Baso-0.7
[**2178-3-24**] 08:00PM BLOOD PT-12.2 PTT-32.8 INR(PT)-1.1
[**2178-3-24**] 08:00PM BLOOD Glucose-151* UreaN-25* Creat-1.0 Na-139
K-4.3 Cl-98 HCO3-28 AnGap-17
[**2178-3-24**] 08:18PM BLOOD Lactate-1.7
[**2178-3-24**] 08:00PM BLOOD cTropnT-<0.01
Pertinent Labs:
[**2178-3-28**] 06:55AM BLOOD WBC-14.3* RBC-4.55* Hgb-13.6* Hct-42.5
MCV-93 MCH-29.9 MCHC-32.0 RDW-14.0 Plt Ct-292
[**2178-3-29**] 03:57AM BLOOD WBC-15.0* RBC-4.86 Hgb-14.4 Hct-45.5
MCV-94 MCH-29.5 MCHC-31.6 RDW-13.6 Plt Ct-355
[**2178-3-30**] 04:38AM BLOOD WBC-13.2* RBC-4.47* Hgb-13.2* Hct-41.5
MCV-93 MCH-29.6 MCHC-31.9 RDW-13.4 Plt Ct-334
[**2178-4-2**] 06:40AM BLOOD Glucose-154* UreaN-21* Creat-0.8 Na-139
K-4.1 Cl-103 HCO3-27 AnGap-13
[**2178-4-3**] 06:35AM BLOOD Glucose-158* UreaN-19 Creat-0.7 Na-137
K-4.6 Cl-99 HCO3-30 AnGap-13
[**2178-3-31**] 07:10AM BLOOD ALT-27 AST-28 LD(LDH)-208 AlkPhos-59
TotBili-0.5
[**2178-4-3**] 06:35AM BLOOD Albumin-2.8* Calcium-8.6 Phos-3.8 Mg-2.1
[**2178-3-28**] 07:49PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2178-3-28**] 07:49PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2178-3-24**] 10:22PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.024
[**2178-3-24**] 10:22PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
Micro:
Blood Culture, Routine (Final [**2178-3-30**]): NO GROWTH
URINE CULTURE (Final [**2178-3-26**]): NO GROWTH
Blood Culture, Routine (Final [**2178-3-30**]): NO GROWTH
Blood Culture, Routine (Final [**2178-4-3**]): NO GROWTH
Blood Culture, Routine (Final [**2178-4-3**]): NO GROWTH
MRSA SCREEN (Final [**2178-3-31**]): No MRSA isolated
URINE CULTURE (Final [**2178-3-30**]): NO GROWTH.
**FINAL REPORT [**2178-3-31**]**
GRAM STAIN (Final [**2178-3-29**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2178-3-31**]):
RARE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
Imaging:
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 108426**],[**Known firstname 108427**] [**2103-11-9**] 74 Male [**Numeric Identifier 108428**] [**Numeric Identifier 108429**]
Report to: DR. [**Last Name (STitle) **]. [**Last Name (STitle) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **], La,[**Doctor Last Name **]/mtd
SPECIMEN SUBMITTED: Cell block for Pleural fluid, C12-8988
Procedure date Tissue received Report Date Diagnosed
by
[**2178-3-26**] [**2178-3-30**] [**2178-3-31**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/lo??????
Previous biopsies: [**Numeric Identifier 108430**] Right Pleural Biopsy.
[**Numeric Identifier 108431**] cell block of 4L LN FNA
[**Numeric Identifier 108432**] cell block of LN FNA
[**Pager number 108433**] Cell block from right pleural fluid (C12-6735).
DIAGNOSIS:
Pleural fluid, cell block:
Negative for Malignant Cells.
Reactive mesothelial cells and blood.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 108426**],[**Known firstname 108427**] [**2103-11-9**] 74 Male [**Numeric Identifier 108430**] [**Numeric Identifier 108429**]
Report to: DR. [**Last Name (STitle) **]. [**Last Name (STitle) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 88622**]/mtd
SPECIMEN SUBMITTED: Right Pleural Biopsy.
Procedure date Tissue received Report Date Diagnosed
by
[**2178-3-27**] [**2178-3-27**] [**2178-4-1**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 1431**]/mn????????????
Previous biopsies: [**Numeric Identifier 108431**] cell block of 4L LN FNA
[**Numeric Identifier 108432**] cell block of LN FNA
[**Pager number 108433**] Cell block from right pleural fluid (C12-6735).
DIAGNOSIS:
Pleura, right, biopsy (A-B):
Pleural tissue with reactive mesothelial hyperplasia, see note.
Note: Mesothelial cells are positive for keratin, calretinin
and WT-1 and negative for HMB45, S100 and Mart 1.
Cytology Report PLEURAL FLUID Procedure Date of [**2178-3-27**]
REPORT APPROVED DATE: [**2178-4-1**]
SPECIMEN RECEIVED: [**2178-3-27**] 12-[**Numeric Identifier 108434**] PLEURAL FLUID
SPECIMEN DESCRIPTION: Received 1000 ml gold yellow fluid
Prepared 1 ThinPrep slide
CLINICAL DATA: Airway obstruction. Right pleural effusion.
PREVIOUS SPECIMENS:
[**2178-3-20**] 12-[**Numeric Identifier 108435**] 11R
[**2178-3-20**] 12-[**Numeric Identifier 105246**] 11L
[**2178-3-20**] 12-[**Numeric Identifier 108436**] 7LN
[**2178-3-20**] 12-[**Numeric Identifier 108437**] 4LN
(and more)
REPORT TO: DR. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DIAGNOSIS: Right pleural effusion:
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells and blood, see note.
CHEST (PORTABLE AP) Study Date of [**2178-3-27**] 1:24 PM
IMPRESSION:
1. Interval resolution of right-sided pleural effusion with
placement of new
right chest tube. No pneumothorax.
2. Newly apparent increased diffuse interstitial markings on the
right,
concerning for lymphangitic carcinomatosis.
3. Increased left lower lung consolidation may represent
combination of small
left pleural effusion and atelectasis, though cannot exclude
infectious
process.
CHEST (PORTABLE AP) Study Date of [**2178-3-28**] 1:37 PM
FINDINGS: As compared to the previous radiograph, the two
right-sided chest
tubes are in unchanged position. Bilaterally, the extent of
pleural effusion
has increased and, as a consequence, the lung parenchyma at the
lung bases is
denser than before. There is no evidence of pneumothorax. The
amount of soft
tissue air is smaller than before. A small lucency at the level
of the aortic
arch is no longer visible.
CHEST (PORTABLE AP) Study Date of [**2178-3-29**] 5:21 AM
FINDINGS: As compared to the previous radiograph, there is
minimally improved
ventilation at both lung bases. Otherwise, the radiographic
appearance of the
lungs is unchanged. Unchanged cardiomegaly, unchanged extensive
parenchymal
opacities, right more than left, unchanged position of the right
chest tubes.
The presence of a small left pleural effusion cannot be
excluded.
CHEST (PORTABLE AP) Study Date of [**2178-3-30**] 4:41 AM
IMPRESSION: AP chest compared to [**3-24**] and 16:
Right apical pleural tube still in place. No pneumothorax.
Residual effusion is small and subcutaneous emphysema in the
right chest wall and neck has almost entirely resolved. Moderate
pulmonary edema, has worsened since [**3-27**], and in addition to
the large right hilar or juxtahilar mass, there is suggestion of
new consolidation in both the right suprahilar lung and at the
left lung base medially. How much of that is asymmetric edema,
atelectasis or even fissural pleural fluid is impossible to say,
but raises a real concern for pneumonia. Mild cardiomegaly
stable. No pneumothorax.
Portable TTE (Complete) Done [**2178-3-30**] at 9:59:30 AM FINAL
IMPRESSION: Small to moderate pericardial effusion without overt
tamponade physiology. Abnormal septal motion suggesting
increased inter-ventricular dependence. Normal regional and
global biventricular systolic function.
Portable TTE (Focused views) Done [**2178-3-31**] at 11:32:22 AM
FINAL
IMPRESSION: Limited/focused views. Moderate pericardial effusion
with evidence of impaired ventricular filling. These findings
may represent early tamponade physiology. Clinical correlation
advised.
Portable TTE (Focused views) Done [**2178-4-2**] at 11:21:12 AM
FINAL
IMPRESSION: Small to moderate pericardial effusion without signs
of tamponade.
CHEST (PORTABLE AP) Study Date of [**2178-4-2**] 10:33 AM
There is no evident pneumothorax. Cardiomegaly, widened
mediastinum, right
perihilar mass-like consolidations, and left lower lobe opacity
are unchanged.
The patient has known mediastinal and hilar lymphadenopathy and
multiple lung
nodules, all are better seen in prior CT of [**3-6**]. Left
perihilar
opacities are improved. This could be due to improving
atelectasis and
layering pleural effusion.
CHEST (PORTABLE AP) Study Date of [**2178-4-3**] 8:41 AM
FINDINGS: Bilateral parenchymal opacities are unchanged to
slightly worse.
Superimposed infection cannot be excluded. There is a persistent
small left
pleural effusion and no right pleural effusion. The
cardiomediastinal
silhouette is within normal limits. There is no pneumothorax.
Brief Hospital Course:
Mr. [**Known lastname 108423**] is a 74 year old man with multiple medical problems
including newly diagnosed NSCLC with final pathology pending who
presents to the ER with worsening dyspnea. He was found to have
recurrent pleural effusion, underwent repeat thoracentesis, R
talc pleurodesis with chest tube/pleurex catheter placement.
Hospital course complicated by worsening dyspnea post-procedure
and intermittent runs of SVT.
# Dyspnea: Likely due to re accumulation of pleural fluids.
Also concern for worsening of PE, but patient has been on
Lovenox regularly at 1mg/kg [**Hospital1 **] dosing and also has IVC filter
in place. Lovenox was held for his IP procedures and restarted
after the procedures. His dyspnea initially improved but
worsened again on the medical floor, requiring transfer to the
ICU. Repeat CXR at that time showed re accumulation of pleural
fluid, possibly due to clogged chest tube/pleurex, as his output
had been decreasing. However, in the ICU, his chest tube output
increased again with improvement in his CXR and subjective
dyspnea. He was continued on his Lovenox for anticoagulation
and was also given IV Lasix for gentle diuresis. Given concern
for post-obstructive pneumonia/pneumonitis, especially with
increasing WBC, he was started on Vancomycin and Zosyn for HCAP
coverage. This was stopped once he returned to the floor and he
did not develop worsening SOB or become febrile after
discontinuation. The drainage from his chest tube had decreased
substantially and was removed by IP prior to discharge.
#Pericardial [**Name (NI) 37749**] Pt was found to have a pericardial
effusion on echocardiogram. He did not have any evidence of
volume overload on physical exam and also did not have an
elevated pulsus. Cardiology was consulted and recommended
observation with repeat echocardiogram which were performed. On
subsequent echos the effusion decreased in size. He was
discharged with a follow up appointment with cardiology and
should have another echo in [**1-12**] weeks post discharge.
# Sinus Tachycardia: On transfer to ICU, patient with sinus
tachycardia to 100-120 range. Patient has known history of
pulmonary emboli on anticoagulation with LMWH and no evidence of
prior coronary disease or cardiac history. Per [**Date Range 2287**]
outpatient records, notable history of chronic tachycardia to
the low 110-113 since 2/[**2178**]. Recent 2D-Echo showing mild
concentric LVH with no systolic dysfunction (LVEF 65%). His
cardiac enzymes were negative. He was started on metoprolol and
up titrated to 25mg TID. His HR was much better controlled on
this regimen. We continued anticoagulation with Lovenox for his
known PEs. We controlled his pain with PO Dilaudid. We
discontinued his out pt regimen of propranolol.
# NSCLC: Mr. [**Known lastname 108423**] is a pt of Dr. [**Last Name (STitle) **] who preferred to hold
off starting chemotherapy during this admission. We controlled
his pain with PO Dilaudid. Dr. [**Last Name (STitle) **] visited the pt during this
hospitalization and will discuss further treatment options as an
out patient.
# Pulmonary Emboli: We continued Lovenox 1mg/kg [**Hospital1 **].
# DM: diet controlled as an out patient, he was placed on an
insulin sliding scale during this admission.
#Transitional-
1. Pt has follow up appointments with oncology, cardiology and
interventional pulmonology
Medications on Admission:
zolpidem 10 mg PO qHS PRN insomnia
multivitamin 1 tab PO daily
niacin 500 mg 1 tab PO daily
propranolol 40 mg Tab PO PRN
enoxaparin 100 mg SC BID
ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H for 14
days
[**Hospital1 108422**] AC 10-100 mg/5 mL Liquid Sig: Five (5) mL PO q4H PRN
cough
Discharge Medications:
1. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. niacin 100 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
4. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*60 * Refills:*2*
5. codeine-[**Hospital1 **] 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H
(every 4 hours) as needed for cough.
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
Disp:*30 Powder in Packet(s)* Refills:*2*
10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Metastatic Lung Cancer
Pericardial Effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 108423**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with progressive shortness of
breath. You were found to have fluid in your lungs and a small
amount of fluid around your heart. We feel this is related to
your lung cancer. Interventional pulmonology placed a tube in
your chest to drain the fluid in your lungs. Repeat
echocardiograms showed the fluid around your heart to be stable
in size and not interfering with your heart's ability to pump
blood. It is important that you drain your pleurex catheter
daily to keep fluid out of your lungs.
The following changes have been made to your medications:
STOP:
Propranolol
START:
Metoprolol for blood pressure and heart rate control
Hydromorphone for pain control
Docusate Sodium to soften stool
Polyethylene Glycol to soften stool
Senna for constipation as needed
CHANGE:
Enoxaparin to 80mg injections twice per day
Please see below for follow up appointments made for you.
Followup Instructions:
Interventional Pulmonology will be contacting you on [**Name (NI) 766**] to
schedule a follow up appointment in their clinic in two weeks.
If you do not hear from them please call their office at ([**Telephone/Fax (1) 27079**].
Name: [**First Name8 (NamePattern2) 2563**] [**Last Name (NamePattern1) 2564**], Nurse [**First Name (Titles) **]
[**Last Name (Titles) 4094**]: Cardiology
When: Friday [**4-10**] at 11:50am
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
You will see Dr. [**Last Name (STitle) 108438**] NP for this visit. After this visit
you will see Dr. [**Last Name (STitle) 1923**] in follow up.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2178-4-9**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) 831**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2178-4-9**] at 10:30 AM
With: DR. [**First Name4 (NamePattern1) **] [**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
|
[
"511.81",
"427.89",
"196.1",
"423.9",
"250.00",
"415.19",
"162.9",
"V10.82",
"486",
"V58.61",
"518.81",
"518.0",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.20",
"34.92",
"34.06"
] |
icd9pcs
|
[
[
[]
]
] |
18252, 18301
|
13457, 16844
|
311, 333
|
18388, 18388
|
4473, 4485
|
19550, 20864
|
3178, 3272
|
17192, 18229
|
18322, 18367
|
16870, 17169
|
18538, 19527
|
3287, 3301
|
2025, 2357
|
264, 273
|
361, 2006
|
4500, 4939
|
18403, 18514
|
4955, 13434
|
2379, 2930
|
2946, 3162
|
3865, 4454
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,459
| 143,268
|
49602
|
Discharge summary
|
report
|
Admission Date: [**2197-4-11**] Discharge Date: [**2197-4-17**]
Date of Birth: [**2113-9-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Hydralazine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Aortic stenosis.
Major Surgical or Invasive Procedure:
[**2197-4-11**]
Aortic valve replacement with a 19-mm Magna Ease aortic valve
bioprosthesis.
History of Present Illness:
The patient is an 83-year-old woman with a history of
progressively worsening aortic stenosis. The patient was
referred for aortic valve replacement.
Past Medical History:
-ESRD secondary to Pauci-immune Crescentric Glomerulonephritis
from Hydralazine, on HD since [**Month (only) 205**] (Tu, Th, Sa)
-AFib, not on Coumadin
-Hypertension
-Hyperlipidemia
-Aortic stenosis, severe
-Steal syndrome from her AV fistula (L)
-Gout
-GERD
-Age-related macular degeneration
Social History:
-Lives alone, independent in most ADLs, but daughter assists
with shopping and some meals
-Tobacco: none
-Alcohol: none
-Illicits: none
Family History:
-Father: died at 80 of "[**Last Name **] problem"
-Mother: died at 89 of "something with her heart"
-No history of rheumatologic illness, prostate, breast, ovarian,
or colon cancer.
Physical Exam:
Admission Physical Exam
Pulse:58 Resp:18 O2 sat:98/RA
B/P Right:144/66
Height:5' Weight:128 lbs
General:NAD, alert, cooperative
Skin: Dry [x] intact []multiple bruises, skin thin and fragile
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - II/VI SEM across
precordium
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]well healed midline scar
Extremities: Warm [ ], well-perfused [ ] Edema Varicosities:
None []venous changes ble
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left:+1
DP Right:+2 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right:+2 Left:+2
Carotid Bruit Right/Left:murmur radiates to both carotids
Pertinent Results:
[**2197-4-16**] Hct-31.5*
[**2197-4-15**] WBC-5.8 RBC-3.54* Hgb-10.8* Hct-32.2* MCV-91 MCH-30.3
MCHC-33.4 RDW-17.1* Plt Ct-150
[**2197-4-11**] WBC-12.7*# RBC-3.25* Hgb-9.8* Hct-29.4* MCV-91 MCH-30.1
MCHC-33.2 RDW-18.6* Plt Ct-122*
[**2197-4-16**] Glucose-146* UreaN-43* Creat-2.7* Na-138 K-3.9 Cl-98
HCO3-27
[**2197-4-11**] UreaN-28* Creat-2.4* Na-143 K-3.8 Cl-106 HCO3-30
AnGap-11
[**2197-4-16**] Calcium-8.4 Mg-2.0
[**2197-4-11**] MRSA SCREEN (Final [**2197-4-13**]): No MRSA isolated.
Echocardiogram [**2197-4-12**]
Prebypass
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No spontaneous echo contrast is
seen in the body of the right atrium. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is mildly depressed (LVEF=
45-50%). The right ventricular cavity is mildly dilated with
borderline normal free wall function. There are simple atheroma
in the ascending aorta. There are simple atheroma in the aortic
arch. The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is no pericardial effusion.
Postbypass
The patient is AV paced and is on a phenylephrine infusion.
There is a new bioprosthesis in the aortic position. It is well
seated without evidence of perivalvular leaks. There is no
valvular regurgitation and the peak/mean gradients are 14/6 mmHg
at a CO of 5 L/min. Mitral regurgitation and tricuspid
regurgitation have decreased to mild. The thoracic aorta is
intact post decannulation.
CXR:
[**2197-4-12**]:
There has been interval removal of the right-sided chest tube
with
no evidence for pneumothorax. Hemodialysis catheter and left
internal jugular catheter are in unchanged positions. Persistent
cardiomegaly, interstitial edema and left pleural effusion with
associated atelectasis are seen.
IMPRESSION: Interval removal of right chest tube with no
evidence for
pneumothorax.
[**2197-4-17**] 06:05AM BLOOD Glucose-115* UreaN-54* Creat-2.9* Na-134
K-4.2 Cl-96 HCO3-27 AnGap-15
Brief Hospital Course:
On [**2197-4-11**] Mrs [**Known lastname 1826**] was taken to the operating room and
underwent Aortic valve replacement with a 19-mm Magna Aortic
valve bioprosthesis with Dr.[**Last Name (STitle) 914**]. Cardiopulmonary bypass
time: 86 minutes.Cross clamp time:65 minutes.Please refer to
operative report for further 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. She was extubated, alert, oriented and
breathing comfortably on 4L NC 98%. The patient was
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. On POD#2 the patient was
transferred to the telemetry floor for further recovery. Chest
tubes were discontinued without complication on POD #2.
Respiratory: Successfully extubated POD1. Aggressive pulmonary
toilet, nebs, incentive spirometer and ambulation were
continued. Her oxygen requirements improved to 92% on 2 L via
nasal cannula. She was started on guaifenesin for a persistent
non-productive cough.
Cardiac: pacing wires remained for a junctional rhythm until
[**2197-4-16**] seen by Electrophysiology. They reviewed all her rhythms
which showed her in an escape junctional rhythm for more than a
year without any events. She does have sick sinus syndrome but a
stable escape rhythm. No pacemaker was needed at this time. No
nodal agents were given. Epicardial wires discontinued per EP.
Nutrition: She was seen by Speech for a bedside swallow-exam on
[**2197-4-13**] which she failed. They recommended keeping her NPO.
They re-evaluated her on [**2197-4-14**] and cleared her PO diet, thin
liquids and soft consistency solids. Medications whole with
liquids for which she tolerated.
Renal: She was followed the renal service for HD through Right
Subclavian tunnel catheter. Her last HD was [**2197-4-14**] 2.5L of
fluid were removed. Her next HD on Tues [**4-18**].
Skin: The wound service was consulted for an Area of 11 x 11 cm
ecchymoses on either side of sternal incision and fragile skin.
Recommendations DSD no tape on ecchymotic area.
On POD# 6 she was cleared by Dr.[**Last Name (STitle) 914**] for discharge to rehab.
She was seen by physical and occupational therapy for
evaluation of strength and mobility. She was discharged to [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in [**Location (un) **] [**Telephone/Fax (1) 103747**]. She will follow-up with Dr.
[**Last Name (STitle) 914**], Renal and her PCP as an outpatient. All follow up
appointments were advised.
Medications on Admission:
AMLODIPINE 7.5 mg daily, B COMPLEX-VITAMIN C-FOLIC ACID 1 mg
daily, FUROSEMIDE 40 mg daily, OMEPRAZOLE 40 mg daily,
ONDANSETRON 4 mg by mouth every 8 hours as needed for nausea,
SIMVASTIN 10 mg daily, ASPIRIN 325 mg daily, CALCIUM CARBONATE
260 mg (650 mg) twice a day
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. heparin (porcine) 1,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
9. guaifenesin 600 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day) as needed for
cough.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village
Discharge Diagnosis:
ESRD secondary to Pauci-immune Crescentric Glomerulonephritis
from hydralazine, on HD since [**Month (only) 205**] (Tu, Th, Sa)
Paroxysmal AFib/Aflutter in [**8-6**] during acute renal failure,
loculated pericardial effusion. No Coumadin
Steal Syndrome from AV fistula
Hypertension
Dyslipidemia
GERD
Gout
Age-related Macula Degeneration
Discharge Condition:
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be cleared to drive
No lifting more than 10 pounds for 10 weeks
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2197-5-9**] 1:00 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 10828**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2197-5-16**] 2:00 [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 3971**]
Follow-up with Renal for HD on Tues-[**Last Name (un) **]-Sat.
**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:[**2197-4-17**]
|
[
"427.81",
"427.31",
"997.1",
"424.1",
"272.4",
"V45.11",
"E878.2",
"E849.7",
"582.89",
"585.6",
"403.91",
"362.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8500, 8655
|
4658, 7264
|
329, 424
|
9037, 9240
|
2090, 4635
|
10028, 10729
|
1091, 1274
|
7584, 8477
|
8676, 9016
|
7290, 7561
|
9264, 10005
|
1289, 2071
|
272, 291
|
452, 604
|
626, 921
|
937, 1075
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,603
| 127,274
|
53143
|
Discharge summary
|
report
|
Admission Date: [**2111-6-26**] Discharge Date: [**2111-6-28**]
Date of Birth: [**2053-3-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
"Feeling unwell"
Major Surgical or Invasive Procedure:
--Central venous line placement
History of Present Illness:
Mr. [**Known lastname 96073**] is a 58 year old man with history of end-stage
liver disease status-post liver transplant, with recurrence of
his hepatitis C, who presents today with nausea, vomiting,
diarrhea, and overall feeling unwell.
He reports that for the last 3-4 weeks, he has had on-going
watery diarrhea. He was admitted to [**Hospital1 18**] on the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**]
service from [**6-7**] until the 8th for work-up of the diarrhea. A
discharge summary is not yet available, however he reports that
a CT scan was completed that demonstrated "colitis," for which
he was treated with ciprofloxacin and metronidazole, having
finished a course yesterday. During that admission, stool O&P
was negative, as was c. difficile assay. Of note, around that
time, he had been tapering off methadone and started on
clonidine for his withdrawal symptoms.
He followed up with his liver physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 696**], on [**6-24**],
at which time he reported his symptoms had improved. At that
visit, the plan was to resume ribavirin and interferon for
treatment of his recurrent hepatitis C after transplant; these
had been stopped earlier this year due to concerns over suicide
ideation.
Today he reports that his diarrhea got slightly better at some
points over the last weeks, but has worsened over the last few
days. He is unable to quantify, but states he has had "too many
to count" when asked number of bowel movements. They have been
watery without blood or melena. He has also had emesis
(non-bloody and non-bilious) for the last two days. He reports
poor PO intake and that he vomitted after attempting to eat soup
yesterday. He has been urinating less as well.
He had some lightheadedness and dizziness today that prompted
him to seek medical attention along with feeling overall very
poorly.
In the ED, initial vital signs were: temperature of 98.0, blood
pressure of 71/40, heart rate of 88, respiratory rate of 18, and
oxygen saturation of 99% on room air. During his time in the ED,
he received three liters of normal saline, 1 gram of vancomycin,
and 4.5 grams of zosyn.
During his ED stay, his systolic blood pressure ranged from
74-109. Levophed was written for, but never started given
response of blood pressure to IVF. A chest x-ray was
unremarkable, and an abdominal ultrasound did not demonstrate
any ascites.
Upon arrival to the ICU, he reported that he was very hungry and
wanted to eat. He stated he fele the best he had felt in days.
Past Medical History:
- Status-post OLT liver transplant [**2107**] for HCV cirrhosis and
hepatocellular carcinoma
- Hepatitis C: recurred after transplant
- Hypertension
- Diabetes mellitus
- BPH
- Tobacco use
- Depression
- Back pain
- History of prior IV drug use
- Grade I of esophageal varices
Social History:
Patient lives with his sister. Married, however has complicated
relationship with wife. [**Name (NI) **] daughter in her 20's. History of
prior IV drug use. History of alcohol abuse. Currently on
narcotic contract.
Family History:
Non-contributory
Physical Exam:
Physical Exam (upon admission)
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress, resting comfortably
in bed talking on telephone
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP flat, no LAD, right IJ appears
clean/dry/intact
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CN's sym
Psych: Appropriate
Pertinent Results:
Labs at Admission:
[**2111-6-26**] 11:05AM BLOOD WBC-4.5 RBC-5.00 Hgb-15.2 Hct-47.4 MCV-95
MCH-30.5 MCHC-32.2 RDW-13.5 Plt Ct-259
[**2111-6-26**] 11:05AM BLOOD Neuts-55.7 Lymphs-30.0 Monos-13.2*
Eos-0.6 Baso-0.6
[**2111-6-26**] 11:05AM BLOOD PT-12.0 PTT-24.8 INR(PT)-1.0
[**2111-6-26**] 11:05AM BLOOD Glucose-202* UreaN-36* Creat-2.7*#
Na-131* K-4.7 Cl-98 HCO3-20* AnGap-18
[**2111-6-26**] 11:05AM BLOOD ALT-180* AST-209* AlkPhos-180*
TotBili-0.7
[**2111-6-26**] 11:05AM BLOOD Calcium-10.0 Phos-4.0 Mg-2.2
[**2111-6-26**] 11:21AM BLOOD Lactate-2.6* K-4.6
[**2111-6-26**] 11:21AM BLOOD Hgb-16.5 calcHCT-50
Labs at Discharge:
[**2111-6-28**] 05:25AM BLOOD WBC-2.5* RBC-3.82* Hgb-11.8* Hct-35.9*
MCV-94 MCH-30.8 MCHC-32.7 RDW-13.4 Plt Ct-184
[**2111-6-28**] 05:25AM BLOOD PT-11.7 PTT-29.6 INR(PT)-1.0
[**2111-6-28**] 05:25AM BLOOD Glucose-128* UreaN-29* Creat-1.3* Na-137
K-4.7 Cl-106 HCO3-23 AnGap-13
[**2111-6-28**] 05:25AM BLOOD ALT-98* AST-117* LD(LDH)-145 AlkPhos-120
TotBili-0.6
[**2111-6-28**] 05:25AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.9 Mg-1.7
Microbiology Data:
[**2111-6-27**] Immunology (CMV) CMV Viral Load- pending
[**2111-6-26**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-PENDING; OVA + PARASITES-PENDING; MICROSPORIDIA
STAIN-PENDING; CYCLOSPORA STAIN-PENDING; CLOSTRIDIUM DIFFICILE
TOXIN A & B TEST-FINAL; VIRAL CULTURE-PENDING INPATIENT
[**2111-6-26**] URINE URINE CULTURE- negative
[**2111-6-26**] MRSA SCREEN MRSA SCREEN- pending
[**2111-6-26**] BLOOD CULTURE Blood Culture, Routine-
negative
[**2111-6-26**] BLOOD CULTURE Blood Culture, Routine-
negative
Imaging Studies:
Abdominal ultrasound with doppler ([**6-27**]):
1. Status post liver transplant with patent hepatic vasculature.
2. No definite focal liver lesion seen; however, multi-phase
MRI/CT are more sensitive for focal liver lesions and can be
obtained if clinically warranted.
CXR ([**6-27**]):
Status post right IJ central venous line placement with tip in
the upper SVC. No pneumothorax.
Brief Hospital Course:
1.) Hypotension/Shock
Upon admission to the ICU, the patient had received three liters
of IVF, producing a SBP>100. Given the patient's history and
response to IVF, the cause was most likely hypovolemic shock
given GI losses and poor PO intake. Also considered (given
immunocompromised host) were infections, as well as adrenal
insufficiency and cardiogenic) cuases. Aggressive fluid
resuscitation was continued in the ICU with a goal MAP>65 and
UOP>50cc/hr. Lisinopril, clonidine, terazosin were held.
Patient was continued on vancomycin and zosyn since the ED, with
metronidazole added for empiric coverage of c. difficile and
anaerobic organisms (seems unlikely to need coverage for MSRA
given lack of indwelling lines, no pulmonary/skin symptoms).
Flagyl was removed due to redundant coverage. The patient
remained hypotensive throughout the stay. On [**6-27**] the patient
was transferred to [**Hospital Ward Name 121**] 10. He was observed over night and his
blood pressure ranged from 107-115/69-87. At the time of
discharge his BP was 131/86. He was asymptomatic overnight. His
clonidine was restarted at his home dose. His lisnopril was
held.
2.) Diarrrhea, nausea, vomiting
Patient had long history of nausea, vomiting, and diarrhea (for
about 3-4 weeks prior to admission). Initially felt to possibly
be viral gastroenteritis versus symptoms from methadone
withdrawal. Previous imaging showed evidence of jejunitis.
Patient was started on broad coverage with vanc and zosyn in ED.
Flagyl was added in ICU. C. difficile was negative, so flagyl
was stopped. He did resume interferon/ribavirin recent to
admission, but the symptoms began previous to this. O&P, viral
cultures, and microsporidium/crytposporidium were sent out and
pending upon discharge. Patient was beginning to advance diet
towards a BRAT diet upon discharge. On morning of discharge
patient reported improvement in diarrheal symptoms. While an
infectious cause is possible, the fact that C diff and fecal
culture were negative makes infectious diarrhea less likely. It
is more likely that the syptoms were due to his recent cessation
of methadone. He was discharged home with a script for
loperamide.
3.) Status-post liver transplant with recurrent HCV
Patient was continued on home regimen of immunosuppressives and
prophylaxis. Ribavirin and interferon continued. Liver doppler
was negative for focal lesions. AFP was pending at time of
dischage. Patient is scheduled to follow up with transplant team
in two weeks time.
4.) Depression
HCV therapy was stopped due to suicide ideation, though per last
OMR note, was cleared to resume therapy. Patient continued on
home dose of citalopram throughout stay.
5.) Diabetes Mellitus
Continued on home regimen of insulin.
Medications on Admission:
- Aspirin 81 mg
- Bactrim 400 mg-80 mg daily
- Citalopram 40 mg
- Clonidine 0.1 mg [**Hospital1 **]
- Fish Oil
- Gabapentin 600 mg QHS
- Humalog
- Lisinopril 10 mg
- Multivitain 1 tablet daily
- Oxycodone/Acetaminophen
- Pegasys injection
- Ribavirin 200mg --three capsules BIG
- Terazosin 2 mg QHS
- Viagra 50-100 mg
- Tacrolimus 2.5 mg [**Hospital1 **]
- Mycophenolate Mofetil (CellCept) 250 mg [**Hospital1 **]
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
3. Tacrolimus 1 mg Capsule Sig: 2.5 Capsules PO Q12H (every 12
hours).
4. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. Fish Oil Oral
8. Humalog Mix 75-25 Subcutaneous
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO QHS PRN () as needed for back pain.
11. Ribavirin 200 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
12. Pegasys Subcutaneous
13. Terazosin 2 mg Capsule Sig: One (1) Capsule PO at bedtime.
14. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Viagra Oral
16. Loperamide 2 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for diarrhea.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
--Hypotension secondary to diarrhea
Secondary Diagnoses
--Status-post OLT liver transplant [**2107**] for HCV cirrhosis and
hepatocellular carcinoma
--Hepatitis C: recurred after transplant
--Hypertension
--Diabetes mellitus
--Benign prostatic hypertrophy
--Tobacco use
--Depression
--Back pain
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 for treatment of low blood
pressures and diarrhea. You were treated with intravenous fluid
hydration and intravenous antibiotics and your symptoms
improved. Stool studies did not reveal an infectious cause for
your symptoms. We are therefore stopping antibiotics. Please
take loperamide (Immodium) as needed for diarrhea.
We made the following changes to your medicines:
--we DISCONTINUED the lisinopril. Please restart this medicine
at the discretion of your primary care provider.
[**Name10 (NameIs) **] ADDED Immodium (loperamide) to be taken as needed for
diarrhea.
There were no other changes to your medicines.
Followup Instructions:
--[**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2111-7-1**]
2:20
--[**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3736**] Date/Time:[**2111-7-7**] 10:00
[**Hospital **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2111-7-8**]
8:00
Completed by:[**2111-6-29**]
|
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icd9cm
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3,344
| 162,641
|
12237+56347
|
Discharge summary
|
report+addendum
|
Admission Date: Discharge Date:
Date of Birth: [**2100-6-11**] Sex: M
Service:
AGE: 48.
FULL-ASPIRATION PRECAUTIONS.
DATE OF DISCHARGE: [**Hospital 25403**] rehabilitation bed.
CHIEF COMPLAINT: Fournier gangrene.
HISTORY OF THE PRESENT ILLNESS: The patient is a 48-year-old
male, who was transferred from [**Hospital6 204**]. The
patient has a past medical history of diabetes mellitus and
hypertension. He developed a cyst in his right testicle
three weeks prior to admission, which was treated with
Ciprofloxacin and compresses. Subsequently, he developed
testicular swelling extending into the abdomen. He was then
evaluated at [**Hospital 189**] Hospital, where he was treated with
Imipenem and transferred to the [**Hospital1 188**].
PAST MEDICAL HISTORY:
1. Noninsulin dependent diabetes mellitus.
2. Hypotension.
ALLERGIES: Unknown.
MEDICATIONS PRIOR TO ADMISSION: Glucotrol.
PHYSICAL EXAMINATION: Physical examination on admission
revealed the following: Temperature 100.7, heart rate 120,
blood pressure 108/palpable, respiratory rate 16, saturations
98%. GENERAL: The patient was alert and oriented times
three, mildly diaphoretic. CHEST: Chest was clear to
auscultation bilaterally. HEART: Regular rate and rhythm,
tachycardia. ABDOMEN: Erythema up to mid abdomen with skin
necrosis. Right inguinal area with purulent drainage. Right
testicular swelling with associated necrotic skin. RECTAL:
Guaiac negative.
HOSPITAL COURSE: The patient was admitted under the General
Surgery Service and taken emergently to the operating room,
where he underwent extensive debridement of Fournier gangrene
and of the abdominal wall. Urology consultation was obtained
intraoperatively. They assisted in the scrotal debridement.
The patient was started on IV antibiotics. The patient was
transferred from the operating room to the Intensive Care
Unit intubated and ventilated. In the Intensive Care Unit,
the patient needed to be on Levofloxacin and Pitressin for
maintaining his blood pressure and he required frequent fluid
boluses. Over the next couple of days, more debridement of
the abdominal wound was done at bedside. He continued to
require a vasopressor to maintain his blood pressure.
Infectious Disease consultation was obtained at the time. He
was continued on his antibiotics. He continued to make slow
progress in the Intensive Care Unit. He continued to be
intubated and ventilated. He was weaned off his vasopressors
on the [**1-27**].
On [**2149-2-25**], a post pyloric oral tube was placed and tube
feed was started. He had been receiving total parenteral
nutrition. He continued to have [**Male First Name (un) 3928**] course in the
Intensive Care Unit. He continued to have fever spikes.
On [**2149-3-2**] it was noted that he developed a skin breakdown
in the coccygeal area and the left foot. He needed frequent
bedside debridement.
On [**2149-3-7**] a Biobrain abdominal dressing was sutured to the
wound bed to aid in healing. He has been followed by the
Department of Plastic surgery from the beginning of his stay
in the hospital. He was slowly weaned off the ventilator
over the next few days. He was extubated on [**2149-3-11**]. He
was treated for HSV on his back with acyclovir per Infectious
Disease recommendations. He was also followed by the skin
care specialist.
Abdominal and scrotal wound continued to slowly improve.
On [**2149-3-13**], it was noted that he had signs and symptoms of
dysphagia, which was probably due to deconditioning and
confusion at the time. So, he was continued on his NG tube
feeding and total parenteral nutrition. He has also been
treated for Clostridium difficile with a course of Flagyl.
Podiatry consultation was obtained for necrotic areas on both
feet, which are now stable.
On [**2149-3-17**], swallow study was redone, and he was then
advanced on his oral diet.
On [**2149-3-18**], the patient was transferred to the regular
[**Hospital1 **]. The patient's G-tube feeding was at goal. Currently,
he is now tolerating a regular diet. He self discontinued
his G-tube, which was not replaced because of an adequate
p.o. intake.
Current issues are the following: Abdominal wound, which
requires t.i.d. dressing changes wet-to-dry dressing at the
skin edges with no wet-to-dry dressings on the Biobrain in
the central part of the wound. Activity is as tolerated and
he has been out of bed to chair. The Department of Plastic
Surgery is following him and the plan is for a
split-thickness skin graft at some point in the future. He
is now ready for discharge to a rehabilitation facility.
MEDICATIONS ON DISCHARGE:
1. Flagyl 500 mg p.o.t.i.d. up to [**2149-3-22**].
2. Heparin 5000 units subcutaneously t.i.d.
3. Zantac 150 mg p.o.b.i.d.
4. NPH insulin 7.5 units subcutaneously b.i.d.
5. Regular insulin sliding scale.
6. Clonidine patch .2 mg every week on Sundays.
7. Reglan 10 mg p.o.q.8h. for seven days.
8. Albuterol inhaler 2 puffs q.4h.
9. Nystatin swish and swallow 5 cc q.i.d.
10. Vitamin C 500 mg p.o.b.i.d.
11. Glutamine 5 grams p.o.q.d.
12. Vitamin E 400 units p.o.q.d.
13. ....................220 mg p.o.q.d.
TREATMENT: Abdomen and scrotum wet-to-dry dressing changes
only to the edges of the wound three times a day.
DIET: Soft solids, full liquids, Boost supplement t.i.d.
The patient is to sit upright when taking POs. FULL-
ASPIRATION PRECAUTIONS.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D.
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2149-3-20**] 10:45
T: [**2149-3-20**] 11:34
JOB#: [**Job Number 38244**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 6920**]
Admission Date: [**2149-2-14**] Discharge Date: [**2149-3-21**]
Date of Birth: [**2100-6-11**] Sex: M
Service:
ADDENDUM:
HOSPITAL COURSE: The patient's NG tube was self discontinued
on [**2149-2-20**]. This was not replaced because he is now
tolerating a regular diet. He is on soft solids and full
liquids with Boost supplements tid. He should sit upright
when taking po. He should be on full aspiration precautions.
Regarding wounds, the abdominal wound needs a wet to dry
dressing change only to the edges of the wound tid. His
abdominal wound will be followed by plastic surgery service,
Dr. [**Last Name (STitle) 2023**] with plans for a VAC dressing followed by a skin
graft at some point in the future. He has coccygeal decubiti
which are much improved. He had gluteal fold lacerations
which are much improved now. He also has necrotic ulcers on
both feet, lateral edges, which have been seen by podiatry.
He should have dry, sterile dressings changed to them.
Changes in medications: Insulin 7.5 units subcu [**Hospital1 **].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-164
Dictated By:[**Last Name (NamePattern1) 5028**]
MEDQUIST36
D: [**2149-3-21**] 08:18
T: [**2149-3-21**] 10:19
JOB#: [**Job Number 6921**]
|
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icd9cm
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icd9pcs
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4679, 5964
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922, 934
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957, 1485
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231, 783
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805, 889
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,882
| 115,609
|
8867
|
Discharge summary
|
report
|
Admission Date: [**2147-6-25**] Discharge Date: [**2147-6-29**]
Date of Birth: [**2083-2-4**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
RLQ Abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 634**] is a 64 year old man with a complex medical history
including CHF and COPD, a poor surgical candidate, also with a
history of medically managed appendicitis on 2 prior episodes.
He presents with RLQ pain. In [**4-/2146**], he was admitted to the
West 2A service in for ruptured appendicitis and was treated
with an IR-placed drain. For the current admission, he presented
on [**2147-6-25**] with 2 days of abdominal pain and poor urine output.
He did not complain of nausea, vomiting, changes in bowel
movements, fevers/chills. He was admitted for medical management
for his likely recurrence of appendicitis.
Past Medical History:
Appendiceal abscess in [**2140**] treated with IR drain, recurrent
appendicitis
Insulin-dependent Diabetes Mellitus
COPD
Peripheral vascular disease
Right fem-[**Doctor Last Name **] bypass graft x 2 ([**2115**]'s)
CVA ([**2-/2139**]) - mild dysarthria/mild left facial weakness
Hepatomagaly
Pulmonary hypertension
History of DVT
GERD
Hypercholesterolemia
Hypertension
Obstructive Sleep Apnea
Osteoporosis
Depression
Social History:
-Tobacco history: Former smoker, quit 8-10 years ago.
-ETOH: 2-3 beers/day.
-Illicit drugs: None.
Family History:
Mother with lung carcinoma. No family history of heart disease,
HTN, or DM.
Physical Exam:
VITALS: T 96.9 HR 81 BP 138/92 RR 20 O2sat 99%/1L
GEN: Obese man, sitting comfortably, A&Ox3
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Poor dentition. Neck supple without
lymphadenopathy.
CVS: RRR, no murmurs, rubs or gallops.
RESP: Expiratory wheezing. Labored breathing with increased O2
requirement with ambulation.
ABD: Nontender, soft, obese abdomen. No pain with palpation.
Small reducible umbilical hernia.
EXTR: Warm, dry; small 0.3 cm ulcer on right 1st digit, DP and
PT pulses palpable bilaterally.
Pertinent Results:
[**2147-6-28**] 08:45AM BLOOD WBC-8.7 RBC-3.51* Hgb-11.0* Hct-32.1*
MCV-92 MCH-31.4 MCHC-34.3 RDW-12.6 Plt Ct-335
[**2147-6-29**] 08:00AM BLOOD PT-29.5* INR(PT)-2.9*
[**2147-6-28**] 08:45AM BLOOD Glucose-338* UreaN-23* Creat-1.4* Na-143
K-3.3 Cl-97 HCO3-38* AnGap-11
[**2147-6-28**] 08:45AM BLOOD Calcium-8.5 Phos-1.9* Mg-1.9
[**2147-6-26**] 03:26AM BLOOD ALT-19 AST-18 LD(LDH)-152 AlkPhos-34*
TotBili-0.2
[**2147-6-25**] 10:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006
[**2147-6-25**] 10:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
URINE CULTURE (Final [**2147-6-26**]): <10,000 organisms/ml.
BLOOD CULTURE (taken [**2147-6-25**]): no growth to date
CT ABD & PELVIS W/O CONTRAST Study Date of [**2147-6-25**]
1. Findings consistent with acute appendicitis with no evidence
of abscess or free perforation.
2. A 1.3 cm exophytic liver lesion is stable since [**2140**] and of
doubtful
significance.
CHEST (PA & LAT) Study Date of [**2147-6-25**]
IMPRESSION: Lingular pneumonia.
Brief Hospital Course:
NEURO/PAIN: The patient was maintained on IV Dilaudid upon
admission, and then transitioned to PO Dilaudid PRN on [**2147-6-28**].
The patient remained neurologically intact and without change
from baseline during his stay. The patient remained alert and
oriented to person, location and place.
CARDIOVASCULAR: The patient remained hemodynamically stable. His
vitals signs were closely monitored. He has a history of
congestive heart failure, and was noted to have basilar
crackles, and has been kept on his home doses of furosemide and
metolazone.
RESPIRATORY: The patient was maintained on his home COPD
treatments. A CXR on [**2147-6-25**] demonstrated lingular pneumonia and
he was started on a 10-day coure of azithromycin, and discharged
with this medication. He is on 4L of oxygen at home and he was
continued on this, maintaining adequate oxygenation with no
acute desaturations.
GASTROINTESTINAL: The patient was kept NPO and maintained on IV
fluids for hydration. IV zosyn was used for antibiotic coverage
until [**2147-6-28**]. The patient was transitioned to sips on [**2147-6-27**] and
advanced to a regular diet on [**2147-6-28**]; he tolerated this well. He
did not have any episodes of nausea or emesis. He was
transitioned from iv zosyn to PO cipro/flagyl on [**2147-6-28**], and was
discharged with these medications for a 2-week total course.
GENITOURINARY: The patient presented with an elevated creatinine
of 2.6 and BUN of 72. He was given IV fluids. A Foley catheter
was placed on [**2147-6-26**] to monitor urine output. His creatinine
eventually trended down to 1.4. His foley catheter was removed
on [**2147-6-28**], at which time the patient was able to successfully
void without issue. The patient's intake and output was closely
monitored.
HEME: The patient's hematocrit has been stable at around 32.
The patient has a history of DVT, and takes coumadin, but on
admission his INR was elevated (4.0; goal 2.5-3). His home
coumadin was held until the day of discharge when the INR was
2.9, at which point the coumadin was restarted. He was
instructed to follow up with his coumadin clinic as soon as
possible after discharge.
ID: The patient presented with an elevated WBC of 16.3, which
trended to 8.7 by [**2147-6-28**]. He was treated for appendicitis and
pneumonia with antibiotics as above.
ENDOCRINE: The patient has insulin-dependent diabetes. His blood
glucose was monitored with q6 fingersticks and maintained at a
satisfactory level with insulin sliding scale per protocol.
PROPHYLAXIS: The patient's anticoagulation was held secondary to
supratherapeutic INR. He was encouraged to ambulate as
tolerated. The patient also had sequential compression boot
devices in place during immobilization to promote circulation.
GI prophylaxis was sustained with omeprazole. The patient was
encouraged to utilize incentive spirometry, ambulate, and was
discharged in stable condition.
Medications on Admission:
Albuterol nebulizer 2 Puff Q6H
Alendronate 70 mg PO QWeekly
Budesonide 0.5/2ml [**Hospital1 **]
Citalopram 10mg PO QD
Warfarin 12.5mg PO QD
Furosemide 80mg PO QD
Folic acid 800mcg PO QD
Humalog 100 unit/mL PRN
Humalin 45 units am, 15 units pm
Lipitor 20mg PO QD
Lisinopril 10 mg PO QD
Metolazone 2.5 PO QD
Omeprazole 40 mg PO QD
Prednisone 5mg PO QD
Proventil 2 Puff
O2 4L
Salsalate 750 mg PO BID,
Spiriva inhaler daily
ASA 81mg PO QD
Vit B complex 300mg PO QD
Vit B1 100mg PO QD
Cal/vit D 1200mg PO QD
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
3. budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One
(1) ML Inhalation [**Hospital1 **] (2 times a day).
4. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. warfarin Oral
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Humalog 100 unit/mL Cartridge Sig: sliding scale units
Subcutaneous lunch and dinner.
9. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
45 units Subcutaneous QAM.
10. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. metolazone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. salsalate 750 mg Tablet Sig: One (1) Tablet PO twice a day.
16. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
17. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
18. Vitamin B Complex Oral
19. Vitamin B-1 Oral
20. Calcium 500 + D Oral
21. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for
11 days.
Disp:*22 Tablet(s)* Refills:*0*
22. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 11 days.
Disp:*33 Tablet(s)* Refills:*0*
23. azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
24. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
Fifteen (15) units Subcutaneous QPM.
25. Coumadin 10 mg Tablet Sig: One (1) Tablet PO once a day:
Please fllow up with [**Hospital 197**] clinic on [**2147-7-3**] to check your
INR. Follow [**Hospital 197**] clinic directions.
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent Appendicitis
Lingular pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Discharge Instructions:
Discharge Instructions:
You were admitted to Dr.[**Name (NI) 5067**] surgical service for evaluation
and management of your recurrent appendicitis. You are now being
discharged home. Please follow these instructions to aid in your
recovery:
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.
* Your pain 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.
* You develop any other concerning symptoms.
General Discharge Instructions:
* Please resume all regular home medications, unless
specifically advised not to take a particular medication.
* Please take any new medications as prescribed.
* Please take the prescribed analgesic medications as needed.
You may not drive or operate heavy machinery while taking
narcotic analgesic medications. You may also take acetaminophen
(Tylenol) as directed, but do not exceed 4000 mg in one day.
* Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.
* Avoid strenuous physical activity and refrain from heavy
lifting greater than 10 lbs., until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
* Please also follow-up with your primary care physician.
Please also follow up with your coumadin clinic as soon as
possible following discharge.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2147-8-15**] 9:10
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2147-8-15**] 9:30
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2147-8-15**] 9:30
Provider: [**First Name8 (NamePattern2) 1037**] [**First Name8 (NamePattern2) 3239**] [**Last Name (NamePattern1) 30891**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2147-7-14**] 1:45 [**Hospital Ward Name 23**] 6, [**Hospital Ward Name **]
Please schedule an appointment with PODIATRY service at 1-2
weeks after discharge to continue monitoring your right great
toe ulcer
Please follow up with your coumadin clinic on or before Monday,
[**2147-7-3**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2147-7-28**]
9:00 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **].
You will have an abdominal CT scan prior your appointment with
Dr. [**First Name (STitle) **]. Dr.[**Name (NI) 5067**] office will inform you about time of the
scan. Please arrive in Radiology Department 30 min before the
scan, please do not eat/drink 4 hours before the CT scan.
Completed by:[**2147-6-29**]
|
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"401.9",
"530.81",
"443.9",
"428.0",
"V58.61",
"V12.54",
"540.1",
"496",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8863, 8869
|
3346, 6270
|
321, 328
|
8954, 8954
|
2251, 3323
|
11156, 12584
|
1569, 1647
|
6823, 8840
|
8890, 8933
|
6296, 6800
|
9115, 10248
|
1662, 2232
|
10281, 11133
|
263, 283
|
356, 997
|
8969, 9067
|
1019, 1437
|
1453, 1553
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,634
| 121,263
|
40821
|
Discharge summary
|
report
|
Admission Date: [**2193-5-20**] Discharge Date: [**2193-6-5**]
Date of Birth: [**2131-11-20**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Incarcerated inguinal hernia
Major Surgical or Invasive Procedure:
[**2193-5-20**]
Exploratory laparotomy, lysis of adhesions, small bowel
resection, open abdomen
[**2193-5-21**]
1. Exploratory laparotomy with small-bowel resection times
2 with primary anastomosis.
2. Temporary closure of the abdominal wall.
3. Repair of incarcerated left inguinal hernia
[**2193-5-23**]
Regional abdominal washout with closure of the abdominal wall
with a Vicryl mesh followed by placement of a VAC dressing.
[**2193-5-28**]
Post pyloric feeding tube
[**2193-5-30**]
Left basilic PICC line
History of Present Illness:
61M w/ hx of longstanding dementia and Parkinsonism as well
as a chronically incarcerated L inguinoscrotal hernia presents
today to NEBH after an episode of coffee-ground emesis that
resulted in subsequent desaturation and concern for aspiration
afterward. The patient is apparently nonverbal, holds his tongue
in continuous protrusion, and has had no further emesis. He
presented with a distended abdomen and plain films that were
concerning for a sbo with dilated, ladder-like loops of small
bowel. Based on this presentation a surgeon at the OSH prepared
to take this patient to the operating room, but anesthesia
concern for the patient's airway prompted txfer to [**Hospital1 18**].
Past Medical History:
HTN, NIDDM, depression,asthma, parkinson's disease
Social History:
Lives in a nursing home. Difficult to understand due to
Parkinsons, was able to swallow prior to this admission
Family History:
NC
Physical Exam:
Temp 98.9 HR 75 BP 152/87 RR 22 O2 sat 97% 4L
Flat affect, nonverbal, occasional moans from presumed pain
decreased inspiratory effort bilaterally
CTAB o/W
firmly distended without rigidity, no evidence of rebound, no
evidence of peritonitis, well-healed scars from prior surgeries,
MAE when physically prompted
Pertinent Results:
[**2193-5-20**] 12:06AM WBC-9.8 RBC-4.20* HGB-13.2* HCT-39.4* MCV-94
MCH-31.5 MCHC-33.5 RDW-13.5
[**2193-5-20**] 12:06AM NEUTS-77* BANDS-2 LYMPHS-6* MONOS-12* EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2193-5-20**] 12:06AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+
[**2193-5-20**] 12:06AM PLT COUNT-441*
[**2193-5-20**] 12:06AM GLUCOSE-149* UREA N-47* CREAT-1.2 SODIUM-144
POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-21* ANION GAP-20
[**2193-5-20**] 12:21AM LACTATE-2.4*
[**2193-5-20**] 09:27AM GLUCOSE-154* LACTATE-3.5* NA+-140 K+-4.3
CL--113*
Pathology:
Procedure date Tissue received Report Date Diagnosed
by
[**2193-5-20**] [**2193-5-20**] [**2193-5-21**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl
DIAGNOSIS:
Small bowel, excision:
1. Small intestinal segment with mucosal ischemic change,
submucosal edema, serosal adhesions, and transmural acute
inflammation.
2. Margins of small intestinal segment with focal transmural
acute inflammation, mucosal ischemic change, and serosal
adhesion formation.
Procedure date Tissue received Report Date Diagnosed
by
[**2193-5-21**] [**2193-5-21**] [**2193-5-23**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl
Previous biopsies: [**Numeric Identifier 89187**] Small Bowel.
DIAGNOSIS:
I. Terminal ileum, resection (A-B):
Small intestinal segment with focal transmural necrosis and
diffuse mucosal ischemic change and serosal adhesions; margins
of resection demonstrate mucosal ischemia without transmural
involvement.
II. Soft tissue, left inguinal region (C-D):
Fibroadipose tissue with hemorrhage and reactive mesothelial
lining consistent with hernial sac.
[**2193-5-20**] CT Abd/pelvis :
1. High-grade, likely early small-bowel obstruction appears
secondary to a
bowel-containing left inguinal hernia, as detailed above. There
is also a
bowel-containing right inguinal hernia, which contains
decompressed distal
ileum, and does not appear to represent additional site of
obstruction at this time. There is no evidence of bowel
ischemia.
2. Renal cysts, with additional cortically based hypodensity
likely
representing additional cysts though too small to characterize
on the left.
[**2193-5-20**] 12:26 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2193-5-21**]**
MRSA SCREEN (Final [**2193-5-21**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2193-5-29**] CXR :
The Dobbhoff tube passes below the diaphragm with its tip at
least in the
duodenum. The patient is in interstitial pulmonary edema that
appears to be increased since the prior study. There is also
worsening of the right basal consolidation as well as right
upper lung more rounded opacities that might represent
underlying infectious process. Bilateral pleural effusions are
present, their size is difficult to evaluate on this portable
study. Apices cannot be evaluated since patient's chin is
obscuring lung apices.
[**2193-5-30**] CXR :
1. Satisfactory placement of left upper extremity PICC.
2. Interval resolution of pneumonia and right lower lobe
atelectasis since
[**2193-5-29**].
3. Persistent left lower lobe atelectasis and moderately large
left pleural effusion
Brief Hospital Course:
On the day of admission the patient was taken promptly to the OR
for exlap. Frank stool seen throughout abdomen. There were
multiple areas of microperforation and leaking stool, SB was
resected and he was left in discontinuity with an open abdomen
as he became labile intraoperatively. The following day, he was
taken back to the OR for rising bladder pressures overnight.
Small bowel was resected and reanastamosed. The abdomen was left
open as there was a loss of domain. He tolerated surgery well.
On [**5-22**] he was volume overloaded with low urine outputs so he was
diuresed with good response. His pressor requirement was
decreasing. On [**5-23**] he was taken back to the OR for closure of
the abdominal wall with vicryl mesh and placement of a VAC over
the vicryl mesh. He did have oliguria and was given albumin and
lasix with good response. On [**5-24**], he was extubated. On [**5-25**], the
Parkinson's meds were restarted. Tube feeds were continued. On
[**5-26**], he was given free water flushes for hypernatremia. Also, he
was having persistent elevated tubefeed residuals. He was
manually disimpacted with good effect. On [**5-27**], the VAC was
changed at the bedside. He was transfered to the floor in stable
condition.
Following transfer to the Surgical floor his nasogastric tube
was removed in preparation for a swallow evaluation.
Unfortunately he failed the study with minimal response to food
being placed in his mouth. Subsequently he was taken to
Interventional Radiology for placement of a Dobbhoff feeding
tube. Two other attempts were made at swallow studies as became
more responsive and communicative but he failed all trials. He
remains on full tube feedings with a post pyloric Dobbhoff
feeding tube.
He developed some shortness of breath and increased congestion
on [**2193-5-29**] and a subsequent Chest Xray revealed some CHF with
right upper and right lower lobe consolidations. He improved
with diuresis but due to his Xray appearance he was also placed
on Vancomycin and Cefepime for pneumonia. His Vancomycin trough
was 20 on [**2193-6-5**] which reflected 1 Gm daily. Currently his
Vancomycin is being dosed at 1 Gm. every other day and he will
need a trough on [**2193-6-8**] prior to his dose. From a respiratory
standpoint his oxygen saturations are 95% on room air and his
congestion has resolved. His WBC is 9K and he remains afebrile.
His antibiotics will continue thru [**2193-6-20**].
His abdominal wound is quite extensive but doing well with VAC
therapy. White sponges cover the vicryl mesh followed by black
sponges. The VAC was changed on [**2193-6-5**] and is changed every 3
days. He sometimes requires mild pain medication prior to VAC
changes.
After a long protracted stay he was transferred to rehab on
[**2193-6-5**] to try to increase his mobility, continue enteral
nutrition with the hopes of him eventually swallowing
effectively to tolerate a regular diet.
Medications on Admission:
dep provera 100qwk, trazodone 25', inderal 20'''. fluxoetine
40', remeron 30', sinemet 25-100'''', sinemet 25-100 1/2qpm
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Injection TID (3 times a day).
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
5. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
6. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
7. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for SOB.
9. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
10. propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): Hold for SBP < 100, HR < 60.
11. HYDROmorphone (Dilaudid) 0.25 mg IV Q3H:PRN pain
12. carbidopa-levodopa 25-100 mg Tablet Sig: [**1-20**] Tablet PO HS
(at bedtime).
13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day): to buttocks and both groins.
14. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
17. cefepime 1 gram Recon Soln Sig: One (1) Gm Injection every
eight (8) hours: thru [**2193-6-20**].
18. vancomycin 1,000 mg Recon Soln Sig: One (1) Gm Intravenous
every other day: Next dose [**2193-6-6**]
Treatment thru [**2193-6-20**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
1. Small-bowel obstruction with incarcerated left inguinal
hernia
2. Perforated small bowel
3. Septic shock
4. Ischemic bowel
5. Abdominal compartment syndrome
6. Acute blood loss anemia
7. Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
* You were admitted to the hospital with abdominal pain due to
an incarcerated left inguinal hernia which required an
operation.
* Part of the bowel was necrotic necesitating extensive
resection and your abdomen was left open due to swelling of the
bowel.
* After undergoing 2 additional procedures your abdomen is
closed and a VAC dressing is in place to promote further closing
from the inside out.
* Nutrition is important to heal this wound and unfortunately
you are unable to swallow due to your deconditioned state and
Parkinson's disease. Therefore a feeding tube was necessary as
you are too weak to swallow without aspirating. Hopefully this
will improve as you get stronger.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 1 week.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2193-6-5**]
|
[
"569.83",
"V10.46",
"401.9",
"557.0",
"038.9",
"486",
"995.92",
"331.82",
"550.10",
"266.9",
"294.10",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"54.25",
"53.00",
"54.11",
"96.08",
"54.72",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10239, 10314
|
5405, 8342
|
299, 818
|
10558, 10558
|
2117, 5382
|
11445, 11679
|
1757, 1761
|
8514, 10216
|
10335, 10537
|
8368, 8491
|
10734, 11422
|
1776, 2098
|
231, 261
|
846, 1537
|
10573, 10710
|
1559, 1612
|
1628, 1741
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,252
| 184,146
|
50615
|
Discharge summary
|
report
|
Admission Date: [**2175-8-26**] Discharge Date: [**2175-9-6**]
Date of Birth: [**2129-3-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3233**]
Chief Complaint:
Shortness of breath, orthopnea
Major Surgical or Invasive Procedure:
Medistinoscopy- [**2175-8-27**]
History of Present Illness:
HPI: 46 yo female with no significant medical problems initially
presented to PCP [**Name Initial (PRE) 151**] 2 weeks of dyspnea. She reports two weeks
of incresing shortness of breath. SOB is worse with lying flat
or bending over and better when she lies on her stomach on two
pillows or sits up. She has had minimal dyspnea on exertion, but
otherwise is asymptomatic including no headache, nausea,
vomiting, abdominal pain, weight loss, fevers or pain. Her PCP
at [**Name9 (PRE) **] [**Name9 (PRE) 1459**] ordered a CT that showed a 13x8 cm
medistinal mass with invasion of the pericardium, ? compression
of the SVC and small left pleural effusion. She was sent to
[**Hospital1 18**] for further workup. Family history includes only father
with [**Name2 (NI) 499**] cancer.
.
Pt was initially sent to MICU as there was concern for acute
decompensation given her SVC compression. While in ICU, pt had
no acute symptoms or decompensation and was felt to be stable
for transfer to medicine wards.
Past Medical History:
PMH:
1. Basal cell carcinoma removed many years ago
2. Hypercholesterolemia
3. Endometriosis
Social History:
Lives in [**Location 1456**] with her husband. [**Name (NI) **] 3 children Ages 13,16,19.
Does not smoke, occasional glass of wine, no other drug use.
Family History:
Mother - DM and HTN died age 63 MI. Father died of [**Name (NI) 499**] CA,
Brother with stroke at Age 59. No other malignancies in family.
Physical Exam:
Vitals: T 98.4 HR 99 BP 133/93 RR 25 O2 sats 94 % on RA
General: Middle aged female sitting up in bed breathing
comfortably in NAD
HEENT: MMM, OP clear, no cervical or supraclavicular LAD, no
carotid bruits, no facial erythema or swelling
CV: RR, no m/g/r
Pulm: CTA on right with decreased BS at left base
Abd: NABS, soft, NT/ND
Ext: No edema, no calf tenderness, 2+ DP pulses
Neuro: CN II-XII intact, strength in upper and lower extremities
[**6-2**] and equal bilaterally
Lymph: no axillary or inguinal LAD
Pertinent Results:
[**2175-8-26**] 06:00AM GLUCOSE-94 UREA N-10 CREAT-0.7 SODIUM-141
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-28 ANION GAP-12
[**2175-8-26**] 06:00AM ALT(SGPT)-66* AST(SGOT)-34 ALK PHOS-182* TOT
BILI-0.4
[**2175-8-26**] 06:00AM CALCIUM-9.5 PHOSPHATE-4.0 MAGNESIUM-2.4
[**2175-8-26**] 06:00AM WBC-6.1 RBC-4.45 HGB-13.0 HCT-37.4 MCV-84
MCH-29.1 MCHC-34.7 RDW-13.2
[**2175-8-26**] 06:00AM NEUTS-71.4* LYMPHS-19.3 MONOS-7.3 EOS-1.7
BASOS-0.3
[**2175-8-25**] 08:30PM GLUCOSE-104 UREA N-11 CREAT-0.7 SODIUM-141
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-26 ANION GAP-18
[**2175-8-25**] 08:30PM LD(LDH)-1676*
[**2175-8-25**] 08:30PM ALBUMIN-4.3 CALCIUM-9.9 PHOSPHATE-3.5
MAGNESIUM-2.2 URIC ACID-5.6
[**2175-8-25**] 08:30PM WBC-7.3 RBC-4.68 HGB-14.1 HCT-38.6 MCV-83
MCH-30.3 MCHC-36.7* RDW-13.0
CT Chest: [**2175-8-26**] IMPRESSION:
1. Large heterogeneously enhancing anterior and middle
mediastinal mass which is compressing and nearly occluding the
superior vena cava. The most likely causes are a primary thymic
tumor such as thymic carcinoma or lymphoma. Associated
pericardial and left pleural effusions.
2. No additional masses or adenopathy identified.
.
ECHO: The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptima technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets appear structurally normal with good leaflet excursion.
No aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
a small, anterior pericardial effusion without echocardiographic
signs of tamponade. There is a prominent left pleural effusion.
.
.
LIVER ULTRASOUND: The liver is normal in size and without focal
lesions. The gallbladder is unremarkable without wall thickening
or stones. There is no pericholecystic fluids. The main portal
vein demonstrates normal antegrade flow. While the common bile
duct is not visualized as the patient was unable to roll on to
her sides, there is no intrahepatic biliary ductal dilatation.
IMPRESSION: Common bile duct could not be visualized, however
no evidence for intrahepatic biliary ductal dilatation. No
liver lesions. .
.
BILATERAL LOWER EXTREMITY DVT STUDY: Grayscale and Doppler
son[**Name (NI) 1417**] of the bilateral common femoral, superficial femoral,
and popliteal veins were performed. There is normal flow,
compressibility, and augmentation of these vessels. No
intraluminal thrombus was identified. IMPRESSION: No evidence
of DVT.
Brief Hospital Course:
Ms. [**Known lastname 76215**] is a 46 year old lady who was admitted with
progressive dyspnea. Her work-up revealed a 13x8cm mass in
mediastinum with pericardial infiltration, SVD compression and
bilateral pleural effusion. The patient subsequently underwent
medianoscopy with biopsy of the mass. Pathology established the
diagnosis of primary mediastinal B-Cell lymphoma. Pan-CT studies
and bone marrow biopsy did not show any evidence for other
organ/marrow involvement.
Furthermore, the patient was diagnosed with a left subclavian
thrombosis and was started on a heparin drip. Initially it was
thought that the patient also had lower extremity deep vein
thromboses but multiple subsequent ultrasound studies of the
legs did not show any clots. A CT-angiogram on day of admission
was negative for pulmonary emboli.
After establishing the diagnosis of lymphoma we started therapy
with CHOP (cyclophosphamide, vincristin, doxorubicin,
prednisone, Day 1= [**2175-8-31**]). Due to respiratory status and size
of the mass, initially rituxan was not given. The patient
tolerated the chemotherapy well, never developing signs of tumor
lysis, so we were able to give rituxan on day 5. Ms. [**Name13 (STitle) 105351**]
developed some tachycardia and O2-desaturation to 88% after the
rate of rituxan was increased to 150mg/h, but after reducing the
rate to 100mg/ml and supportive therapy she improved rapidly and
received the whole dose of rituxan (375mg/m2).
The hospital course was complicated by a transaminitis.
Serologies for hepatitis as well as an ultrasound of the liver
were negative. Furthermore, the liver function tests improved
with treatment, so the initial elevation was attributed to
compression of the superior vena cava and congestion of the
liver.
Upon therapy, left pleural effusions as well as left atelectasis
improved on chest Xray.
Two days before discharge the patient complained of pain in her
left gluteal region. Since she had a left femoral line placed,
we performed repeated ultrasound of her legs to rule out deep
vein thrombosis. The studies were negative. Since the site of
the pain also was different from the site of her bone marrow
biopsy and the patient had no redness of the skin, we attributed
the pain to effects of prolonged bedrest and uncomfortable
position due to the femoral line. At discharge the patient was
able to walk and pain was controlled with oxycodon.
On [**2175-9-6**] we pulled the femoral line and switched the heparin
drip to Lovenox (1.5mg/kg per q24h). The patient was discharged
to her home with improved respiratory status and asked to
present to the clinic on [**2175-9-7**] for follow-up.
Medications on Admission:
Lipitor 10 mg Po QD
Calcium
Iron
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*10 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*10 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q 24H
(Every 24 Hours).
Disp:*30 * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Primary mediastinal B-Cell Lymphoma
2) Hypercholesterolemia
3) Psoriais
4) Endometriosis
Discharge Condition:
Afebrile, has some pain in left leg when walking. Has been given
pain medication for pain.
Discharge Instructions:
Please take your medication as described. Please follow your
appointments as noted below.
Please call the BMT doctor on call or go to the emergency
department in case of fevers>101.0, new bleeding, worsening
pain, or new onset of symptoms like diarrhea, urinary burning or
worsening shortness of breath.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3238**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2175-9-7**] 10:30
Provider: [**Name Initial (NameIs) **] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2175-9-7**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2175-9-7**] 11:30
Completed by:[**2175-9-12**]
|
[
"787.02",
"799.02",
"696.1",
"617.9",
"518.82",
"V10.83",
"459.2",
"790.4",
"272.0",
"780.2",
"444.89",
"292.85",
"511.9",
"200.02",
"300.00",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.22",
"04.81",
"99.25",
"41.31",
"34.25"
] |
icd9pcs
|
[
[
[]
]
] |
8322, 8328
|
5055, 7705
|
346, 379
|
8464, 8557
|
2391, 5032
|
8909, 9371
|
1706, 1846
|
7789, 8299
|
8349, 8443
|
7731, 7766
|
8581, 8886
|
1861, 2372
|
275, 308
|
407, 1406
|
1428, 1522
|
1538, 1690
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,219
| 163,067
|
40343
|
Discharge summary
|
report
|
Admission Date: [**2170-9-2**] Discharge Date: [**2170-9-11**]
Date of Birth: [**2089-2-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5134**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 81 year old male who does not recall how he hit his
head and unknown loss of consciousness. He states that he "must
have hit his head somehow". He is unaccompanied by family and
amnestic to the event. He presented to [**Hospital6 2561**] and
had a Head Ct which was consistent with 2 x 2 x 4 cm right
posterior parietal intracerebral hemorrhage compressing the
right lateral ventricle. He was subsequently admitted to
Neurology, but was found to have a RLL PNA. He was noted to be
increasingly tachypnic and a CXR showed the known right sided
infiltrate. ABG showed acute respiratory alkalosis. He was
subsequently transferered to the MICU in setting of tachypnea.
While there, he was never intubed, and was on 2-4LNC+face tent
for a few days. The MICU started him on vanc/zosyn, and had
inititally added Levoflocacin after his urine legionella came
back positive. However, given the patient's IC bleed and risk
for seizure, the patient was switched to vanc/zosyn/azithro. The
patient is on prophylaxis for seizure because of his new head
bleed, but he does not have a history of seizure. His dosing for
vanc/zosyn/azithro x10days, starting on [**9-4**]. Patient was noted
during ICU stay to have decreased urine output in addition to
slight hematuria. Subsequently the Foley was DC'ed and a large
clot was discovered which had been occluding the foley.
Subsequently the patient has been placed on a 3-way foley for
irrigation.
.
The patient's mental status during his hospital stay was notable
for waxing and [**Doctor Last Name 688**] mental status, delirium at night,
hallucinating, though now has drastically improved - improved to
baseline by today.
.
Neuro wants MRI to evaluate for AVM vs amyloid that could make
him more likely to bleed because they feel that the position of
bleed may not be secondary to fall. There is some theory that he
could have had intra-parenchymal bleed first follow by the fall.
His vital signs in the ICU were afebrile since [**9-5**] afternoon,
HR 80s BP 110s-140s O2sat 92-98% on 3L NC.
.
Review of sytems:
(+) Per HPI, endorses some recent loose stool, has a dry cough
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, constipation
or abdominal pain.
Past Medical History:
HTN
Arthritis
BPH
Social History:
PER OMR. Lives at home with his wife. [**Name (NI) **] has one son who lives
in [**Country 14635**]. Denies smoking or alcohol use.
Family History:
NC
Physical Exam:
Exam on admission to MICU:
Vitals: 103 153/53 104 97% on 50% high flow face mask
GEN: thin elderly M in mild respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: tachypneic, lungs with expiratory wheeze and scattered
rhonchi throughout
CV: tachy to low 100's
Abdomen: thin NABS, soft, NTND
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on Admission:
[**2170-9-2**] 09:50PM GLUCOSE-111* UREA N-39* CREAT-1.1 SODIUM-138
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
[**2170-9-2**] 09:50PM CK(CPK)-7811*
[**2170-9-2**] 09:50PM CALCIUM-7.8* PHOSPHATE-2.3* MAGNESIUM-2.1
[**2170-9-2**] 09:50PM CALCIUM-7.8* PHOSPHATE-2.3* MAGNESIUM-2.1
[**2170-9-2**] 09:50PM WBC-12.0* RBC-3.36* HGB-11.3* HCT-31.8*
MCV-95 MCH-33.6* MCHC-35.6* RDW-13.8
[**2170-9-2**] 09:50PM PLT COUNT-113*
[**2170-9-2**] 09:50PM PT-17.0* PTT-30.6 INR(PT)-1.5*
[**2170-9-2**] 11:16AM TYPE-ART PH-7.51* COMMENTS-GREEN TOP
[**2170-9-2**] 11:16AM GLUCOSE-129* LACTATE-2.0 NA+-139 K+-3.7
CL--103 TCO2-24
[**2170-9-2**] 11:16AM HGB-12.9* calcHCT-39
[**2170-9-2**] 11:16AM freeCa-1.02*
[**2170-9-2**] 11:14AM GLUCOSE-130* UREA N-43* CREAT-1.2 SODIUM-140
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
[**2170-9-2**] 11:14AM estGFR-Using this
[**2170-9-2**] 11:14AM ALT(SGPT)-35 AST(SGOT)-138* CK(CPK)-6880* ALK
PHOS-47 TOT BILI-0.9
[**2170-9-2**] 11:14AM LIPASE-24
[**2170-9-2**] 11:14AM cTropnT-0.02*
[**2170-9-2**] 11:14AM ALBUMIN-3.5 CALCIUM-8.2* PHOSPHATE-2.7
MAGNESIUM-2.2
[**2170-9-2**] 11:14AM WBC-11.9* RBC-3.76* HGB-12.3* HCT-35.5*
MCV-94 MCH-32.8* MCHC-34.7 RDW-13.5
[**2170-9-2**] 11:14AM NEUTS-92.6* LYMPHS-5.3* MONOS-1.8* EOS-0
BASOS-0.2
[**2170-9-2**] 11:14AM PLT COUNT-111*
[**2170-9-2**] 11:14AM PT-16.9* PTT-32.8 INR(PT)-1.5*
[**2170-9-2**] 11:00AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.021
[**2170-9-2**] 11:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2170-9-2**] 11:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2 TRANS EPI-0-2
Labs on Discharge:
Imaging:
CT HEAD: CT head performed earlier the same day at [**Hospital3 60734**]
was available for review prior to interpretation.
FINDINGS: Non-contrast head CT was performed. There is a right
temporoparietal intraparenchymal hematoma measuring
approximately 3.6 x 3.0 x 1.7 cm, with minimal surrounding
parenchymal edema. There is moderate amount of subarachnoid
blood seen in the right temporoparietal sulci as well. There is
no subdural or epidural hematoma identified, and no
intraventricular extension. Of note, there is no subarachnoid
blood seen in the basal cisterns or right sylvian fissure.
Elsewhere, the brain appears normal without further foci of
hemorrhage, and without mass effect or parenchymal edema. There
is no CT evidence of acute territorial infarction. There is some
mass effect upon the right lateral ventricle from the
aforementioned hematoma, but there is no significant shift of
midline structures, and the basal cisterns are preserved. There
is no hydrocephalus. There are no calvarial or skull base
fractures identified. There is a mucus retention cyst seen
anteriorly within the right maxillary sinus, with some mild
mucosal thickening circumferentially, but there are no air-fluid
levels to suggest occult fractures. Mucosal thickening is also
seen in the ethmoid air cells. The mastoids are well aerated.
The extracranial soft tissues are notable for
contusion/laceration over the occiput, but otherwise
unremarkable.
IMPRESSION:
1. Right temporoparietal intraparenchymal hemorrhage, with
associated
overlying subarachnoid hemorrhage in the right temporal and
parietal sulci. No subarachnoid hemorrhage is seen in the basal
cisterns or sylvian fissure. Given the history of trauma, this
is most likely post-traumatic.
2. Mild mass effect upon the right lateral ventricle, with no
shift of
midline structures or evidence of herniation.
3. No calvarial or skull base fractures are identified.
[**9-3**] CXR: Patchy consolidation within the right mid and right
lower lung has slightly worsened with less visibility of the
right hemidiaphragm. This may reflect an evolving aspiration
pneumonia considering the provided history of this diagnosis.
Review of recent CT of [**2170-9-2**], confirms extensive
consolidation throughout the right lower lobe. Remainder of
lungs are grossly clear. IMPRESSION: Right lower lobe pneumonia.
CT HEAD W/O CONTRAST Study Date of [**2170-9-3**] 3:31 AM
IMPRESSION:
1. Unchanged right temporoparietal intraparenchymal hemorrhage,
adjacent
subarachnoid and subdural hemorrhage.
2. Bifrontal subdural hemorrhage has decreased in density
compared to the
prior.
3. Unchanged mild effacement of the right lateral ventricle. No
evidence of
herniation.
CHEST (PORTABLE AP) Study Date of [**2170-9-3**] 5:21 AM
IMPRESSION: Right lower lobe pneumonia.
Portable TTE (Complete) Done [**2170-9-4**] at 4:00:00 PM FINAL
The left atrium is normal in size. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen (in suboptimal
views). The pulmonary artery systolic pressure could not be
determined. There is a trivial/physiologic pericardial effusion.
MR HEAD and BRAIN W & W/O CONTRAST Study Date of [**2170-9-8**] 12:00
N
IMPRESSION: Right temporal intraparenchymal hemorrhage with
associated
subarachnoid hemorrhage and small bilateral frontal subdural
hematomas. No
evidence of enhancing lesion seen to indicate underlying
pathology but
followup examination could be helpful. No abnormal vascular
structures are
seen to indicate associated vascular malformation. No acute
infarct.
IMPRESSION: MRA head demonstrates no evidence of vascular
occlusion or
stenosis. Tiny 1-1.5 mm vascular loop or aneurysm seen in the
region of
anterior communicating artery which could be an incidental
finding, but
clinical correlation recommended.
Brief Hospital Course:
Mr. [**Known lastname **] is an 81 year old man, who was admitted s/p fall,
found to have IPH, aspiration PNA.
.
# Intraparenchymal Hemorrhage/Fall:
The etiology of patient's fall was still unclear; initially it
was believed to be mechanical in nature, given the relatively
normal EKG, without evidence of seizure, and without positive
cardiac enzymes. Patient was discovered to have a right
temporoparietal intraparenchymal hemorrhage. Per neurology, it
is possible that the bleed occured first, which may have caused
the fall, because the location of the bleed is such that it is
unlikely to have occured from a fall. Neurology team felt that
given the location, the bleeding was most consistent with
cerebral amyloid angiopathy. The patient's bleed is not in a
typical location for hypertensive bleed. The patient underwent
10 days of seizure prophylaxis with keppra, which he completed
as an inpatient. The MRI showed incidental finding of small 1 mm
ACA aneurysm which could be further evaluated in the future by
an outpatient neurologist. Home does aspirin was stopped in
setting of intraparenchymal bleed and concern for amyloid
angiopathy and should be avoided in the future given this
diagnosis. Staples placed at [**Hospital 8050**] hospital on [**2170-9-2**] for
occipital head laceration were removed on [**2170-9-11**] prior to
discharge.
.
# Pneumonia: In the hospital on the Neurology service, the
patient was noted to be increasingly tachypneic and a CXR showed
the known right sided infiltrate. ABG showed acute respiratory
alkalosis. He was subsequently transferered to the MICU in
setting of tachypnea. While there, he was never intubated, and
was on 2-4LNC+face tent for a few days. In the MICU he was
started on Vanc/Zosyn for presumed HAP/aspiration, and later
Azithromycin secondary to a positive urine legionella assay. By
the time the patient was on the floor, he had received 7 days
treatment with antibiotics to cover CAP, and it was felt that he
would benefit from a continuation of Azithromycin on discharge
for treatment of Legionella pneumonia. The patient received
total course of antibiotics covering community-acquired
pneumonia from [**2170-9-3**] - [**2170-9-10**]; as such, he would have
received a 7 day course for typical CAP organisms. Upon
discharge, he will continue azithromycin for 3 days to finish an
antibiotic course specifically for legionella as well.
.
# Urinary retention: Patient continues to have a foley. Foley
continues to drain darkly colored urine. Patient is noted to
take Terazosin at home, 10 mg Daily, which he had not been
taking during hospitalization. He will be restarted on this
medication upon discharge, to be uptitrated slowly back to his
home dose. He has an appointment with urology for an outpatient
voiding trial in a couple of weeks.
.
#. Abdominal Pain: Patient noted to have lower abdominal
tenderness on examination, but no pain at rest. Abdomen is soft
on examination. This pain may be secondary to antibiotic
associated diarrhea as he had intermittent loose stools. C.
Diff was negative and he was afebrile with a normal WBC count.
.
# Delirium: Pt was noted to have waxing/[**Doctor Last Name 688**] mental status,
also with hallucinations overnight initially in MICU. He was
found to have new pneumonia, for which he was treated. Mental
status improved during the hospitalization, and the pt was alert
and oriented on transfer to the floor.
.
# Code Status: Pt was DNR but OK to Intubate.
Medications on Admission:
Aspirin 81
Discharge Medications:
1. azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day:
**for a total 10 days course from [**2170-9-3**] to [**2170-9-13**]***.
Disp:*3 Tablet(s)* Refills:*0*
2. terazosin 2 mg Capsule Sig: One (1) Capsule PO Per
Instruction: Please take Terazosin according to the following
schedule:
[**2170-9-11**]: 2 mg Terazosin at night
[**2170-9-12**]: 3 mg Terazosin at night
[**2170-9-13**]: 4 mg Terazosin at night
[**2170-9-14**]: 6 mg Terazosin at night
[**2170-9-15**]: 8 mg Terazosin at night--
Continue 10 mg QHS from [**2170-9-16**] onward
may Increase doses as listed above IF TOLERATED by Blood
Pressures.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
- Intracranial Hemorrhage secondary to cerebral amyloid
angiopathy
Secondary Diagnosis:
- Hypertension
- Benign Prostatic Hypertrophy
- Hematuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname **], it was a pleasure taking care of you in the hospital.
You were admitted because you had a fall at home. CT scan of
your head showed some bleeding inside on the right side of your
brain. You were admitted to the neurology service, but started
to become short of breath, for which you were transferred to the
intensive care unit. There, they found that you had pneumonia,
and they began treating you with antibiotics. The neurologists
looked at the images of you brain and believed that it looks
most consistent with cerebral amyloid angiopathy. You have
follow-up with the neurologists in 8 weeks, by which time
hopefully you will have completed your rehabiliation.
When you leave the hospital:
1. START taking Azithromycin 500 mg once a day for 3 (three)
days
2. START to uptitrate your Terazosin using the following
schedule, as long as your blood pressure is still Good with each
increase (will be measured at the Rehab center):
[**2170-9-11**]: 2 mg Terazosin at night
[**2170-9-12**]: 3 mg Terazosin at night
[**2170-9-13**]: 4 mg Terazosin at night
[**2170-9-14**]: 6 mg Terazosin at night
[**2170-9-15**]: 8 mg Terazosin at night
[**2170-9-16**]: 10mg Terazosin at night
Continue to take 10 mg Terazosin as part of your home regimen.
- Please also STOP your aspirin because of the bleeding in your
brain.
Followup Instructions:
Please have your care facility make an appointment with you to
see your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 27106**] by calling
[**Telephone/Fax (1) 34797**].
UROLOGY APPOINTMENT
Location: [**Location (un) 2274**] [**Hospital1 3494**]- Urology
Address: [**Hospital1 76255**], MA
Phone: [**Telephone/Fax (1) 88486**]
Appointment: Thursday [**2170-9-20**] 9:30am
This is for a Spontaneous Voiding Trial.
NEUROLOGY APPOINTMENT
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 7167**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) 2274**] [**Location (un) 2277**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 63931**]
Appointment: Tuesday [**2170-10-30**] 11:20am
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65,074
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Discharge summary
|
report
|
Admission Date: [**2106-5-26**] Discharge Date: [**2106-5-29**]
Date of Birth: [**2035-11-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Latex / Ace Inhibitors / Sulfa
(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
diapheresis, BRBPR
Major Surgical or Invasive Procedure:
Blood transfusion
Endoscopy [**2106-5-27**]
Colonoscopy [**2106-5-28**]
History of Present Illness:
Ms. [**Known lastname 33323**] is a 70 yo woman w/hx of of Afib on
metop/dilt/coumadin and dCHF who presented to the ED with
diapheresis followed by a large bloody bowel movement while in
the ED. In AM on day of admission, she woke up with diapheresis
and felt SOB while taking a shower and exertion prompting her to
initially think that she was having CHF exacerbation. She went
to ED for eval and was placed in observation. At about 10:30am,
she had a bowel movement with frank blood mixed with black blood
insetting of an INR of 4.3. She denies nausea, vomiting,
diarrhea, and abominal pain; she reports never having a bloody
bowel movement prior to this. She had a previous colonscopy
during which a benign polyp was removed but had never been
diagnosed w/ulcers.
.
In the ED, her vitals were T 96.3, HR 82, BP 112/73, RR 16,
saturation 97% RA and was in atrial fibrillation. She recieved
aspirin, vitamin K 5mg iv, vitamin K 5mg po, and a pantoprazole
gtt was initiated. GI was consulted. She was hemodynamically
stable in the ED and did not receive intravenous fluids. An NG
lavage returned 200cc of pink to red fluid with occassional
clots and received ~500cc of NS with the protonix drip in the
ED. She became mildly tachycardic in the early afternoon (hr
101) in the setting of bloody bowel movment (prior HR was in the
60s to 80s range). Pt was admitted to MICU for continued
monitoring at which point she was noted to have a ten point
hematocrit drop but remained asymptomatic w/out any new
complaints.
.
In MICU, pt had EGD which showed ulcers in the antrum; no blood
in the stomach or small bowel; erythema, congestion and
friability in the duodenal bulb compatible with duodenitis but
otherwise normal EGD to third part of the duodenum. While these
were likely to have recently bled, it was felt unlikely that
these were the cause of such a dramatic HCT drop so colonoscopy
was persued. Pt received 4 units of pRBC and HCT improved to
32.7. Pt was felt to be stable and transferred to the floor for
further managment and to await colonscopy.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough or wheezing. Denies chest pain, chest pressure,
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:
# Paroxysmal atrial fibrillation
-- Since [**10-3**], on Coumadin. Status post DCCV [**2105-1-15**].
# Hypertension/LVH -- on Atenolol, Diltiazem, Diovan/HCTZ
# Moderate tricuspid and mitral regurgitation
-- LVEF > 55% on ECHO [**2104-12-24**]
# Hyperlipidemia
# Probable CAD
-- ETT MIBI [**5-1**]: Lateral wall reversible defect
-- TTE [**8-27**]: Regional dysfunction
# H/O moderate-to-large pericardial effusion
# Moderately dilated ascending aorta
# Obesity
# Pulmonary HTN on ECHO [**2104-12-24**]
# Uterine cancer s/p TAH/BSO
Social History:
- Tobacco: distant history
- Alcohol: 6 drinks weekly
- Illicits: none
Patient works as a receptionist in the Prudential building. She
lives alone and is independent of all ADLs. Patient denies use
of tobacco, illicit drugs or herbal medications.
Family History:
Mother died age [**Age over 90 **], had CHF. Father died in 30s with rheumatic
fever. Brother died suddenly in 60s due to sudden cardiac death.
There is no family history of colon or other cancer.
Physical Exam:
DISCHARGE EXAM:
Vitals: T:96.3 BP: 132/78 P:112 R:22 SaO2: 97% RA
I/O: 1000/200+overnight blood BM w/prep
General Appearance: No acute distress, alert pleasant
HEENT: Normocephalic, atraumatic, wearing glasses, PERRL, MMM
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: irregularly irregular, mildly tachy, no murmurs
rubs or gallops appreciated at this time.
Peripheral Vascular: warm lower extremities, radial pulses 2+
bilaterally
Respiratory / Chest: Crackles bilateral bases, more prominent
than reportedly in AM, but now sound improved
Abdominal: Soft, Non-tender, Bowel sounds present, Non-Distended
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace, No Clubbing
Skin: Warm, no lesions
Neurologic: Attentive, Follows simple and complex commands,
moving all extremities, gait not tested at this time
Pertinent Results:
[**2106-5-26**] 07:35AM BLOOD WBC-8.0 RBC-4.08* Hgb-12.1 Hct-37.5
MCV-92 MCH-29.8 Admission Labs:
MCHC-32.4 RDW-15.3 Plt Ct-300
[**2106-5-26**] 04:29PM BLOOD WBC-7.8 RBC-3.04*# Hgb-9.4* Hct-27.6*#
MCV-91 MCH-30.9 MCHC-34.1 RDW-15.4 Plt Ct-223
[**2106-5-26**] 11:50PM BLOOD WBC-8.1 RBC-3.12* Hgb-9.3* Hct-27.2*
MCV-87 MCH-29.8 MCHC-34.2 RDW-16.9* Plt Ct-182
[**2106-5-25**] 08:50AM BLOOD PT-42.7* INR(PT)-4.4*
[**2106-5-26**] 07:35AM BLOOD PT-42.1* PTT-26.3 INR(PT)-4.3*
[**2106-5-26**] 07:35AM BLOOD Plt Ct-300
[**2106-5-27**] 05:38AM BLOOD Fibrino-347
[**2106-5-26**] 07:35AM BLOOD Glucose-187* UreaN-47* Creat-0.8 Na-142
K-4.1 Cl-103 HCO3-23 AnGap-20
[**2106-5-26**] 04:29PM BLOOD Glucose-110* UreaN-54* Creat-0.9 Na-144
K-4.0 Cl-107 HCO3-25 AnGap-16
[**2106-5-27**] 05:38AM BLOOD Glucose-133* UreaN-40* Creat-0.8 Na-144
K-3.9 Cl-109* HCO3-26 AnGap-13
[**2106-5-26**] 04:29PM BLOOD CK(CPK)-44
[**2106-5-26**] 07:35AM BLOOD proBNP-1099*
[**2106-5-26**] 07:35AM BLOOD cTropnT-<0.01
[**2106-5-26**] 04:29PM BLOOD CK-MB-2 cTropnT-<0.01
[**2106-5-26**] 04:29PM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9
[**2106-5-27**] 05:38AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.0
[**2106-5-27**] 02:55PM BLOOD Calcium-8.6 Phos-2.4* Mg-1.9
[**2106-5-27**] 06:11AM BLOOD Type-[**Last Name (un) **] Temp-36.6 pH-7.44
[**2106-5-26**] 01:30PM BLOOD Hgb-11.2* calcHCT-34
[**2106-5-27**] 06:11AM BLOOD freeCa-1.11*
Discharge Labs:
[**2106-5-28**] 01:00PM BLOOD WBC-8.7 RBC-3.71* Hgb-10.8* Hct-33.0*
MCV-89 MCH-29.2 MCHC-32.8 RDW-17.3* Plt Ct-196
[**2106-5-29**] 06:30AM BLOOD WBC-8.2 RBC-3.84* Hgb-11.3* Hct-33.8*
MCV-88 MCH-29.4 MCHC-33.4 RDW-17.4* Plt Ct-212
[**2106-5-28**] 01:00PM BLOOD Plt Ct-196
[**2106-5-29**] 06:30AM BLOOD PT-12.4 PTT-19.8* INR(PT)-1.0
[**2106-5-29**] 06:30AM BLOOD Plt Ct-212
[**2106-5-28**] 06:50AM BLOOD Glucose-109* UreaN-21* Creat-0.8 Na-140
K-3.9 Cl-105 HCO3-24 AnGap-15
[**2106-5-29**] 06:30AM BLOOD Glucose-115* UreaN-17 Creat-0.8 Na-139
K-4.4 Cl-104 HCO3-25 AnGap-14
[**2106-5-28**] 06:50AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.9
[**2106-5-29**] 06:30AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9
.
[**2106-5-27**] 12:55 am URINE Source: CVS.
**FINAL REPORT [**2106-5-29**]**
URINE CULTURE (Final [**2106-5-29**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2106-5-27**] 2:55 pm SEROLOGY/BLOOD
**FINAL REPORT [**2106-5-28**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2106-5-28**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
CHEST (PA & LAT) Study Date of [**2106-5-26**] 8:08 AM
FINDINGS: In comparison with study of [**4-14**], there is little
overall change. Again there is mild enlargement of the cardiac
silhouette without vascular congestion. Continued areas of
opacification at the bases in the region of the costophrenic
angles without evidence of acute focal pneumonia or definite
pulmonary vascular congestion.
EDG [**2106-5-27**]
Findings: Esophagus: Normal esophagus.
Stomach:
Excavated Lesions Two ulcers were found in the antrum. One was
tiny, shallow and clean-based with no stigmata of recent
bleeding. The second ulcer was alrger (2-3mm) with a pigmented
center, possibly reflective of recent bleeding.
Duodenum:
Mucosa: Erythema, congestion and friability of the mucosa with
contact bleeding were noted in the duodenal bulb compatible with
duodenitis.
Other
findings: There was no blood in the stomach or small bowel.
Impression: Ulcers in the antrum
There was no blood in the stomach or small bowel.
Erythema, congestion and friability in the duodenal bulb
compatible with duodenitis
Otherwise normal EGD to third part of the duodenum
Recommendations: Ulcers seen in the stomach, likely with recent
bleeding. This is unlikely to account for degree of hct drop and
BRBPR, so would still pursue colonoscopy in AM. Suggest:
- cont IV PPI [**Hospital1 **] or drip x 72h total, then protonix 40mg [**Hospital1 **]
until repeat EGD. If remains on [**Last Name (LF) **], [**First Name3 (LF) **] need daily PPI
indefinitely thereafter (assuming ulcer healed).
- repeat EGD in [**6-2**] weeks
- check HP serologies and treat if positive
- cont to hold coumadin - d/w cards re need for this medication
- clear diet OK today
Assuming plans to call out of ICU today, anticipate [**Last Name (un) **]
tomorrow:
- MOVIprep this afternoon
- strict NPO after 2AM (inlc no prep) w plan for [**Last Name (un) **] in AM
COLONOSCOPY [**2106-5-28**]
Findings:
Protruding Lesions Medium internal hemorrhoids with stigmata of
recent bleeding were noted.
Impression: Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to terminal ileum
Recommendations: No blood in the colon. Possible hemorrhoidal
bleed in setting of elevated INR.
Brief Hospital Course:
Ms. [**Known lastname 33323**] is a 70 year old female with a history of Afib on
metop/dilt/coumadin and dCHF who presented to the ED with
diapheresis and had a frankly bloody bowel movement while in the
ED. She woke up this morning with diapheresis. She noted to be
more short of breath while taking a shower and doing her morning
activities. She was evaluated in the ED. At about 10:30am, she
had a bowel movement with frank blood mixed with black blood.
She was found to have an INR of 4.3. She denies nausea,
vomiting, diarrhea, and abominal pain.
Gastrointestinal Bleed with acute volume loss anemia: Had EGD
which confirmed 2 gastric ulcers not actively bleeding.
Presumed to be site of GIB. Maintained hemodynamic stability,
however had episodes of tachycardia. Unclear [**Name2 (NI) 33324**] due to
acute volume loss versus uncontrolled atrial fibrillation or a
combination of the two. Initially on protonix drip and
transitoned to po PPI. 3 peripheral lines were established.
Received 4 units PRBCs and 3 units of FFP for stabalization of
hematocrit in the low 30's. Scheduled fo colonoscopy on the
morning of [**2106-5-28**] and having colonic preparation prior from
discharge to the ICU. Before leaving the floor, had large
maroon colored stool with blood clots which was beleived to be
old and b/c of prep. HCT remained stable in the 30s w/out any
significant drop. Pt went to floor and remained stable.
Coloscopy was performed which showed hemorrhoids w/signs of
recent bleeding. GI bleed was thought to possibly be a
combination of ulcer and hemorrohoids in setting of elevated
INR. Follow-up for repeat EGD in 6-8wks to ensure resolution of
ulcer.
Supratherapeutic INR: Unclear etiology. DDx includes infection,
ingestion, dosing. Was reversed with 5mg iv vitamin K, 5mg po
vitamin K, and ffp in setting of GIB. Will need heparin bridge
after procedure to be placed back on coumadin but at a lower
dose w/close follow-up of INR on [**Date Range 766**] of next week.
Atrial Fibrillation: She was currently in atrial fibrillation on
admission to the ICU. Has difficult to control atrial
fibrillation with 200 mg amiodarone, 180 mg diltiaziem, and 300
mg metoprolol daily. Restarted amiodarone at home dose,
restarted diltiazem at 30 mg IV QID, and initially held beta
blocker given concern for repeat bleed. Plan made to resume
atrial fibrillation medications with hemodynamic stability.
Coumadin and [**Date Range **] held as well in presence of GIB. Once
stablized, cards had hoped to cardiovert pt but decision was
made to hold off as placing pt on heparin drip and performing
cardioversion at this time did not seem prudent. Pt had aspirin
held but restarted lower dose of coumadin prior to discharge
after no further evidence of bleeding. Pt remained stable and
was able to be d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] w/ outpt follow-up with cardiology, PCP
and GI planned.
Hypertension: Currently normotensive. Held anti-hypertensives
in ICU.
Hyperlipidemia: continued simvastatin 60mg daily
Dispo: Home. Full code during this admission. Pt remained stable
and was able to be d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] w/ outpt follow-up with cardiology,
PCP and GI planned.
Medications on Admission:
Calcium 600 + D(3) 600 mg (1,500)-200 unit Tab (dose uncertain)
Glucosamine Chondroitin Max Strength 500 mg-400 mg (dose
uncertain)
Fish Oil 1,000 mg Cap (dose uncertain)
Aspirin 81 mg Tab 1 Tablet(s) by mouth once a day
diltiazem CD 180 mg 24 hr Cap 1 Capsule(s) by mouth once a day
furosemide 40 mg Tab 2 Tablet(s) by mouth once a day
Simvastatin 40 mg Tab 1.5 Tablet(s) by mouth once a day
warfarin 5mg qMWF, 7.5mg Qt/th/sa/[**Doctor First Name **]
metoprolol succinate ER 100 mg 24 hr Tab 3 Tablet(s) by mouth
DAILY
***amiodarone 200mg qAM
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: 1.5 Tablets PO QHS (once a day
(at bedtime)): 60mg daily.
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One
(1) Tablet PO once a day.
4. Glucosamine Chondroitin MaxStr 500-400 mg Capsule Sig: One
(1) Capsule PO once a day.
5. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.
6. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
7. furosemide 40 mg Tablet Sig: Two (2) Tablet PO once a day.
8. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO once a day.
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
11. 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*
12. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: GI bleeding in the setting of elevated INR
Secondary: Atrial Fibrillation, Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because you were experiencing sweating
and shortness of breath. You were concerned your symptoms might
be related to a congestive heart failure exacerbation. However,
while in the ED you had a large bloody bowel movement and your
INR was found to be 4.0 (elevated above the therapeutic range).
It was determined that your symptoms where due to
gastrointestinal bleeding and you were transferred to the ICU.
You had a significant drop in your red blood cell count and
required transfusion of blood. An endoscopy was performed which
showed an ulcer which may have bled, and your colonoscopy showed
internal hemorrhoids which also showed signs of recent bleeing
(likely due to the elevated INR). Otherwise these studies where
normal. Your condition improved with blood products and your
bleeding resolved. You were transferred to the regular medicine
floor. Because cardiology hopes to cardiovert you in the near
future because of your atrial fibrillation, the decision was
made to restart you on a lower dose of coumadin but to hold
aspirin after a discussion with cardiology. You continued to
improve and your red blood cell count remained stable without
signs of bleeding. You were discharged home with close follow-up
with your primary care doctor and cardiologist planned. You will
also need to see the gastroenterologist in [**6-2**] weeks for repeat
endoscopy to ensure that your ulcer has resolved. You will also
need to take protonix 40mg twice a day until your repeat
endoscopy, and perhaps longer. If you go back to taking aspirin,
you will need a daily proton pump inhibitor (protonix or
equivalent) indefinitely thereafter (even assuming the ulcer
heals).
We also noticed that you may have a urinary tract infection, and
recommend you take an antibiotic called ciprofloxacin twice
daily for the next 3 days.
The following changes were made you your medications:
- Please START taking Pantoprazole 40 mg every twelve hours.
- Please STOP taking aspirin (please discuss this with your
cardiologist because you may need to restart this medication).
- Please CONTINUE taking coumadin at a lower dose of 4mg.
- Please START taking ciprofloxacin twice daily (antibiotic for
UTI)
- Please continue to take all of your other home medications as
prescribed.
Please go to your usual coumadin clinic to have your INR checked
on [**Date Range 766**] [**2106-5-31**]. Please let them know that you were also
prescribed a 3 day course of antibiotics.
Please be sure to keep all follow-up appointments with your
primary care doctor, gastroenterologist, cardiologist and other
health care providers. You should follow-up with your primary
care doctor early next week; please call their office to make an
appointment on [**Last Name (LF) 766**], [**5-31**]. You will also need to call Dr. [**Name (NI) 33325**] office to schedule a cardiology follow-up appointment
in 4 weeks time. In addition, you will need to schedule a repeat
endoscopy to reevaluate your ulcer within 6 to 8 weeks. Your
primary care doctor can help with making arrangements for this.
It was a pleasure taking care of you and we wish you a speedy
recovery.
Followup Instructions:
Please be sure to keep all follow-up appointments with your
primary care doctor, gastroenterologist, cardiologist and other
health care providers. You should follow-up with your primary
care doctor early next week; please call their office to make an
appointment on [**Last Name (LF) 766**], [**5-31**]. You will also need to call Dr. [**Name (NI) 33325**] office to schedule a cardiology follow-up appointment
in 4 weeks time. In addition, you will need to schedule a repeat
endoscopy to reevaluate your ulcer within 6 to 8 weeks. Your
primary care doctor can help with making arrangements for this.
Dr.[**Name (NI) 14643**] Office Number Phone:([**Telephone/Fax (1) 2037**]
Dr.[**Name (NI) 2056**] Office Number Phone: ([**Telephone/Fax (1) 8683**]
Department: GYN SPECIALTY
When: THURSDAY [**2106-6-3**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 33326**], NP [**Telephone/Fax (1) 5777**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: [**Hospital Ward Name **] [**2106-7-12**] at 8:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: WEDNESDAY [**2106-7-14**] at 7:30 AM
With: RADIOLOGY [**Telephone/Fax (1) 1125**]
Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Completed by:[**2106-5-31**]
|
[
"428.0",
"397.0",
"041.4",
"599.0",
"V58.61",
"428.32",
"531.40",
"401.9",
"790.92",
"416.9",
"427.31",
"V10.42",
"424.0",
"535.60",
"455.2",
"272.4",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
15467, 15473
|
10472, 13731
|
360, 434
|
15626, 15626
|
4839, 4921
|
18953, 20589
|
3751, 3950
|
14327, 15444
|
15494, 15605
|
13757, 14304
|
15777, 18930
|
6234, 10449
|
3965, 3965
|
3981, 4820
|
2539, 2914
|
302, 322
|
462, 2520
|
4937, 6218
|
15641, 15753
|
2936, 3470
|
3486, 3735
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,702
| 151,137
|
37745+58166
|
Discharge summary
|
report+addendum
|
Admission Date: [**2122-11-10**] Discharge Date: [**2122-11-18**]
Date of Birth: [**2039-8-7**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
[**11-10**] Left Craniotomy for SDH
History of Present Illness:
83 y/o women who fell off the side of her bed this morning
reacing for her blancket, She denies head trauma. Taken to
outside facilty where a head Ct was done and reveals a acute on
chronic, mixed density left frontal subdural hematoma with mass
effect on the lateral ventricle.
Past Medical History:
Hypothyroidism
Breast CA, s/p right mastectomy
Social History:
Lives in [**Hospital3 **] with her husband
Remote history of smoking
Family History:
non contributory
Physical Exam:
On Admission:
T: 97.3 BP: 149/70 HR:72 R: 16 O2Sats: 93%
Gen: WD/WN, comfortable, NAD.
HEENT: Normodephalic, Atraumatic. Pupils: 1.5-1.0 EOMs intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 1.5 to 1.0
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-21**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Exam on discharge:
Well healing left frontal cranial incision closed with staples.
Patient awake and cooperative, confused, Oriented to self and
president.
Moves all extremities to command. Antigravity with all four
extremities. Right drift and slight right facial.
Pertinent Results:
[**2122-11-10**] 03:30PM GLUCOSE-108* UREA N-14 CREAT-0.7 SODIUM-139
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14
WBC-7.0 RBC-3.87* HGB-12.1 HCT-35.5* MCV-92 MCH-31.2 MCHC-34.0
RDW-13.6
NEUTS-69.2 LYMPHS-20.8 MONOS-8.4 EOS-0.8 BASOS-0.8
PLT COUNT-202 PT-13.0 PTT-24.6 INR(PT)-1.1
CT head [**11-12**]:
1. Interval decrease in left-sided subdural hematoma. No
evidence of shift
of normally midline structures. External drain is identified
with the tip
within the subdural collection.
2. Post-surgical changes. No new foci of hemorrhage identified.
Chest X-ray [**2122-11-14**]
No active pulmonary disease.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to [**Hospital1 18**] on [**11-10**] after falling out of bed
at her nursing facility. She has a history of falls most
recently in early [**Month (only) **]. Her CT showed
showed a mixed density left frontal SDH. She was admitted to the
neurosurgery service to the ICU. She was pre-op for surgery and
given platelets to reverse the aspirin she was taking. On [**11-11**]
she underwent a left sided craniotomy for evacuation of a
subdural hematoma post operatively she was noted to have some
mild right sided weakness. On the overnight [**11-13**] to [**11-14**] her
O2 saturation dropped but the patient refused CXR. Lasix was
given and a Foley was placed. She had a temp of 101 axillary and
blood and urine cultures were sent. [**11-14**] CXR showed mild left
atelectasis. She had some periods of confusion during her
hospital stay with a stable head CT thought to be realted to
sundowning. Fever work up revealed negative UA and blood
cultures are still pending at this writing. Neurologically she
was awake, alert and orientated X2 with a right drift and right
facial droop. A CT of the head showed a stable subacute left
frontal residual SDH on [**11-18**]. She was found to be a candidate
for rehabiltation.
Medications on Admission:
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day: hold SBP < 100 HR < 60.
2. Furosemide 20 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
9. Levolyl 50 mcg PO Daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Port Rehab & Skilled Nursing - [**Location (un) 5028**]
Discharge Diagnosis:
Left sided subdural hematoma
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Lethargic but arousable
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
Followup Instructions:
Follow up with Dr [**First Name (STitle) **] in 2 weeks with a head CT call
[**Telephone/Fax (1) 4296**] for an appointment
Completed by:[**2122-11-18**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 13418**]
Admission Date: [**2122-11-10**] Discharge Date: [**2122-11-18**]
Date of Birth: [**2039-8-7**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 40**]
Addendum:
Added to follow up care:
Staples need to be removed on [**2122-11-20**], this can be done at the
rehab facility or you may make an appointment at our office for
removal.
Discharge Disposition:
Extended Care
Facility:
Port Rehab & Skilled Nursing - [**Location (un) 6451**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2122-11-18**]
|
[
"426.3",
"244.9",
"E884.4",
"427.31",
"V10.3",
"412",
"852.21",
"401.9",
"V45.71",
"518.0",
"298.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
7713, 7931
|
2929, 4182
|
300, 337
|
6290, 6290
|
2287, 2906
|
6996, 7690
|
820, 838
|
4973, 6112
|
6238, 6269
|
4208, 4950
|
6471, 6973
|
853, 853
|
256, 262
|
365, 646
|
1319, 1999
|
2018, 2268
|
867, 1067
|
6304, 6447
|
668, 717
|
733, 804
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,197
| 102,607
|
43905
|
Discharge summary
|
report
|
Admission Date: [**2197-11-6**] Discharge Date: [**2197-11-24**]
Date of Birth: [**2124-12-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
IR lines
History of Present Illness:
72yo vasculopathic F with ESRD on HD (BL Cr [**4-11**]), bilateral
BKAs, DM2 (HbA1c 5.2), HTN, CHF (EF 50%), hx of MRSA line
infection presents from HD with fever. She completed her HD run
(wts not available in paperwork). There she was HD stable, but
per verbal report 76% RA, Bld cultures were drawn (presumptively
off of the HD line). She was given 750mg of vanco and 60mg of
gentamicin and transferred from [**Hospital1 18**].
.
In the ED, initial vs were 100.8 125 138/70 20 78%RA in triage,
and 102.2 115 94/38 14 99%3L. Patient had more bld cxs drawn.
CXR showed increased opacity on right side (chronic pulmonary
edema +/- mild pleural effusions). Pt was given tylenol and
flagyl (presumptively for asp pna).
.
Per conversation with NH staff Pt had oxygen of 96% thursday and
friday, 93% on monday. They also noted that she has had
decreased appetite, refusing supplements over the last few days,
?right arm swelling, pt had been dening SOB.
.
Of note patient has had mulitple HD lines over the years. Most
recently on [**2197-9-15**] she had an exchange for a non-functioning
HD line.
.
On the floor, she denies pain and is breathing comfortably, but
crying intermittently.
Past Medical History:
1. ESRD on HD since [**2189**]
2. Diabetes mellitus II
3. Orthostatic Hypotension on midodrine
4. Hyperlipidemia: [**4-11**] LDL of 49
5. Peripheral [**Month/Year (2) 1106**] disease
6. Diastolic CHF, LVH, EF 55% in [**7-16**]
7. Chronic upper extremities DVTs
8. CVA x2
9. Seizure d/o s/p CVA
[**99**]. h/o MRSA line sepsis/klebsiella bacteremia, coag neg staph
bacteremia
11. h/o Osteomyletis (L3-L4 vertabrae) '[**92**]
12. h/o Pelvic fx
13. h/o psoas abscess
14. Pericardial tamponade, cardiac perforation post dialysis
catheter change
PAST SURGICAL HISTORY:
1. s/p Right BKA
2. s/p emergent cardiac surgery with sternotomy and drainage in
[**7-16**].
Social History:
Lives at [**Hospital3 **] Home in [**Location (un) 583**], MA. Daughter is
next of [**Doctor First Name **]: [**First Name8 (NamePattern2) **] [**Known lastname **] [**Telephone/Fax (1) 94263**], but friend [**Name (NI) 50269**]
[**Name (NI) **] is HCP. [**Name (NI) **] tobacco, EtOH, drug use.
Family History:
Non-contributory
Physical Exam:
VS: 99.0 114 114/45 11 92%RA, 100%2L
GENERAL: elderly AA female, cachectic, laying in bed, awake,
denies pain and AOx1 (to name, not to date)
SKIN: warm and well perfused, left tunnelled line with tracking
erythema up to above subclavian where line dives deeper, back
with healed sacral decub with very minimal scab.
HEENT: AT/NC, EOMI, pupils sluggish 2 to 1.5mm bilaterally,
anicteric sclera
Neck: Dilated veins throughout neck.
CARDIAC: RRR, S1/S2, 2/6 systolic murmur at USB
LUNG: significant bibasilar crackles, fair air movement, no
wheezes
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, significantly dilated
superficial veins
M/S: R BKA, L AKA, moves upper extremities, hands tightly
clenched
NEURO: A+O x1 (name), rarely makes eye contact, CN [**Name2 (NI) 12428**]
grossly intact, sensation to touch intact, moves all 4, but
hands are held in contracted position (able to move them).
Pertinent Results:
[**2197-11-6**] 05:30PM PT-27.5* PTT-50.5* INR(PT)-2.8*
[**2197-11-6**] 05:30PM PLT COUNT-140* LPLT-1+
[**2197-11-6**] 05:30PM WBC-9.2# RBC-3.05* HGB-10.8* HCT-32.7*
MCV-108* MCH-35.5* MCHC-33.0 RDW-14.7
[**2197-11-6**] 05:36PM LACTATE-1.7
[**2197-11-6**] 06:25PM ALT(SGPT)-63* AST(SGOT)-72* ALK PHOS-279* TOT
BILI-0.6
[**2197-11-6**] 06:25PM GLUCOSE-176* UREA N-20 CREAT-2.3*# SODIUM-143
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-34* ANION GAP-11
.
[**2197-11-24**] 07:58PM BLOOD WBC-6.7 RBC-2.68* Hgb-9.0* Hct-29.0*
MCV-108* MCH-33.6* MCHC-31.0 RDW-15.9* Plt Ct-555*
[**2197-11-24**] 07:58PM BLOOD PT-26.7* PTT-150* INR(PT)-2.7*
[**2197-11-24**] 09:50AM BLOOD PT-17.2* PTT-67.8* INR(PT)-1.6*
[**2197-11-24**] 09:50AM BLOOD Glucose-84 UreaN-22* Creat-3.7*# Na-140
K-3.7 Cl-102 HCO3-29 AnGap-13
[**2197-11-22**] 02:30AM BLOOD ALT-9 AST-17 LD(LDH)-137 AlkPhos-152*
TotBili-0.6
[**2197-11-24**] 09:50AM BLOOD Calcium-8.7 Phos-5.3* Mg-2.1
[**2197-11-24**] 09:31PM BLOOD Type-ART pO2-48* pCO2-46* pH-7.36
calTCO2-27 Base XS-0
[**2197-11-24**] 09:31PM BLOOD Lactate-4.7*
Brief Hospital Course:
A/P: 72yo vasculopathic F with ESRD on HD (BL Cr [**4-11**]), bilateral
BKAs, DM2 (HbA1c 5.2), HTN, CHF (EF 50%), hx of MRSA line
infection admitted for ongoing MRSA bacteremia and recent yeast
fungemia on dapto as well as MS for pain.
.
#. MRSA + yeast line sepsis: Patient with high grade bacteremia
and fungemia persisting on Abx. HD line removed and grew MRSA at
tip. I&D at site of HD line by surgery. On daptomycin from
[**2197-11-18**] onwards with clear cultures since that time. Therefore
new tunnelled line was placed [**2197-11-24**] by IR. Before that pt has
been on multiple abx regimens to treat her perisitent
bacteremia. TTE had been negative, but TEE was not possible in
this pt. Plan was to continue QOD dapto v vanco for 6 weeks from
last confirmed negative culture per endocarditis protocol. If pt
re-infected to consider chronically infected DVTs and move to
CMO.
.
#. Chronic upper extremity DVTs: On coumadin at home. On heparin
drip for line replacement. Concern is that these clots are
infected and serving as source for her ongoing bacteremia. [**Month (only) 116**]
need long term ABx
.
#. Pain: evidently chronic. Reason unclear. Followed closely for
localizing s/s, but nothing ever really localized. On standing
dilaudid plus breakthrough dose as well as standing tylenol per
palliative care with good effect.4
.
#. ESRD: Lytes stable on HD. Cont nephrocaps, cincalcet
.
#. Seizure d/o s/p CVA. Cont keppra.
.
#. Mental status: Per prior housestaff discussion with HCP, pt
has had subacute decline over the last year. Usually oriented to
self. Appears to be at baseline. Moaning in pain but able to
interact.
.
# Elevated LFTs: Abd exam intermittently concerning, but not
clearly [**Last Name 5283**] problem. [**Name (NI) **] of ALT 63* AST 72* AP 279* on [**11-6**].
Resolved spontaneously.
.
#. DM: RISS
.
#. Anemia: Chronic. Baseline around 29-33. Cont Folic acid and
Procrit at HD. Was using 22 as cutoff for xfusion.
.
#. Chronic orthostatic hypotension: Cont Midodrine 10mg TID
.
#. Glaucoma: Cont Timolol gtts, Lumigan gtt
.
#. Healed sacral decubitus ulcer: Chronic, noted at admission.
.
# Course the day of death: Pt had good AM, went to IR for
tunnelled line placement and returned in the evening hypotensive
and tachycardic. TAchycardia had been a problem for the past 48
hours. Was planning pRBC transfusion. Pt ultimately became
diaphoretic and increasingly tachypneic as well as tachycardic.
Trid IVF with little success. After dinner was noted to be
coughing. Sats dropping. CXR looked improved to last check. ABG
was attempted but seems to have been venous blood. Notably,
lactate was 4.7. Concern was for aspiration PNA v fluid overload
v. PE v. DIC/sepsis. Family was contact[**Name (NI) **] and informed of course
and agreed to current plan of DNR DNI. Pt became apneic and
developed PEA. Eventually pass. Family agreed to autopsy.
Medications on Admission:
Medications on Admission:
Insulin Regular Human 100 unit/mL Injection Injection RISS
** NH says Qmonday
Remeron 15 mg Tab Oral QHS
Dilaudid -- 6mg Solution(s) Four times daily 6a,11a,5p,9p
Dilaudid 6mg PRN Q4 hours
Cinacalcet 30 mg Tab Oral Daily
Ranitidine 150 mg Tab Oral Daily
Adult Aspirin 81 mg Chewable Tab Oral Daily
Keppra 500mg QD at 6pm
Coumadin -- 3.5mg Tablet(s) Once Daily
simvastatin 40mg Daily
Timolol gtts 1gtt Ou Daily
Lumigan 1gtt OU QHS
midodrine 10mg TID, hold SBP >130
Nephrocaps Daily
Folic Acid Daily
ducolax PRN
Nitro paste PRN
Albuterol 90 mcg/Actuation Aerosol Inhaler Inhalation
2 Aerosol(s) Every 4 hrs, PRN
Senna plus 2tabs Daily
Lactulose 10 gram/15 mL Oral Soln Oral 1 Solution(s) Twice Daily
tylenol prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
line sepsis
Discharge Condition:
death
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2197-11-27**]
|
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icd9cm
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[
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,697
| 121,105
|
55022
|
Discharge summary
|
report
|
Admission Date: [**2178-9-26**] Discharge Date: [**2178-9-28**]
Date of Birth: [**2155-3-18**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Stab wound to chest
Major Surgical or Invasive Procedure:
[**2178-9-26**] DIAGNOSTIC LAPAROSCOPY
History of Present Illness:
The patient is an otherwise healthy 23 yo male who presents
immediatley status post sustaining a solitary stab wound to his
right lower anterior
medial torso. On examination he had no abdominal tenderness;
however, his lactate level was 8.8 and FAST exam in the
emergency room showed a significant amount of free
intraperitoneal fluid. He was taken to the operating room for
diagnostic laparoscopy.
Past Medical History:
Denies
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
HR: 140 BP: 134/64 Resp: 25 O(2)Sat: 97 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact
Oropharynx within normal limits
Chest: Clear to auscultation, 4cm R anterior chest wound at
T5 level sternal border
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: MAE, intoxicated
Psych: intoxicated
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2178-9-26**] 11:30PM WBC-9.3 RBC-3.11* HGB-9.4* HCT-27.0* MCV-87
MCH-30.3 MCHC-34.9 RDW-13.1
[**2178-9-26**] 11:30PM PLT COUNT-161
[**2178-9-26**] 04:07AM GLUCOSE-100 LACTATE-4.5* NA+-142 K+-3.7
CL--112*
[**2178-9-26**] 02:40AM ASA-NEG ETHANOL-244* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Chest xray:
FINDINGS: The heart size is within normal limits. The
mediastinal width is also within normal limits. The lungs are
clear. There is no pleural effusion or pneumothorax. No
displaced rib fractures are present. No unintended radiopaque
foreign bodies are noted.
IMPRESSION: No evidence of intrathoracic injury.
Brief Hospital Course:
He was admitted to the Acute Care Surgery team and taken to the
operating room immediately for diagnostic laparoscopy. On
laparoscopy, in the upper medial right anterior abdominal wall
there was evidence of an entry stab wound. This was at the
medial aspect of the dome of the liver; the falciform ligament
was then penetrated with an open stab wounds from right to left.
On the left side of the falciform on the surface of the liver
there was a visible approximately 2 cm in length stab wound on
the anterior surface of the liver which was not actively
bleeding. Elevating the liver there was a small half cm stab
wound in the same trajectory visible and it was also not
bleeding. Postoperatively he was taken to the PACU where he was
noted with episodes of tachycardia and elevated blood pressure.
He was given IV Lopressor with improvement in his heart rate and
blood pressure. He was also transfused for a falling hematocrit
felt due to the blood loss associated with his injuries and the
operation. Once hemodynamically stable and was then transferred
to he regular nursing unit where he continued to progress.
He was given a regular diet on the second postoperative day and
was able tot tolerate this without any problems. [**Name (NI) **] was changed
to oral pain medications which were effective in controlling his
pain.
He was seen by Social Work for coping related to his injuries
and also due to the nature of his trauma. A safe discharge plan
was determined to be in place.
He was discharged to home and will follow up in the Acute Care
Surgery Clinic in the next couple of weeks.
Medications on Admission:
Denies
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Ibuprofen 600 mg PO Q8H:PRN pain
Take with food.
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*90 Tablet Refills:*0
5. Milk of Magnesia 30 mL PO Q6H:PRN constipation
6. OxycoDONE (Immediate Release) 5-10 mg PO Q3H:PRN pain
RX *oxycodone 5 mg [**1-19**] tablet(s) by mouth every 4 hours Disp
#*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Stab wound assault
Liver laceration
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a stabbing assault
requiring that exploratory surgery be performed to identify
internal injuires. You were found to have a laceration to your
liver. You were monitoredclosley in the hospital for signs of
infection and bleeding and have remined stable.
You are being discharged home with the following instructions:
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.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**11-2**] 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:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: [**First Name4 (NamePattern1) 5877**] [**Last Name (NamePattern1) 16471**], MD
When: TUESDAY [**2178-10-13**] at 2:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Your insurance records are incomplete- please call our
registration department at ([**Telephone/Fax (1) 22161**] before your first
appointment. We have no address or phone number listed for you
in our system.
|
[
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icd9cm
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[
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[
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icd9pcs
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327, 368
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28,565
| 139,311
|
31547
|
Discharge summary
|
report
|
Admission Date: [**2199-7-24**] Discharge Date: [**2199-7-26**]
Date of Birth: [**2127-7-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Carbapenem
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hypotension s/p cardiac arrest
Major Surgical or Invasive Procedure:
1. Rigid bronchoscopy with argon therapy
2. Endotracheal Intubation
3. Bronchial embolization: A-gram showed patchy blush in the
region of LUL --> embolized with gelfoam.
History of Present Illness:
72 y/o female with h/o NSCLC s/p radiation, PE s/p IVC filter,
DM, htn, COPD admitted to [**Hospital1 18**] [**2199-7-24**] for persistent
hemoptysis. She was initially evaluated at OSH for NSCLC
diagnosed by biopsy. She was also found to have PEs and was
started on anticoagulation. However, then developed hemoptysis
and anticoagulation was stopped which was followed by IVC filter
placement. Patient then transferred to [**Hospital1 18**] for further
evaluation of persistent hemoptysis.
.
Today, patient went to the OR with Interventional Pulmonary for
rigid bronchoscopy. Patient was found to have bleeding in LUL
and L lingula. L lingular bleeding was treated with 3 rounds of
argon laser coagulation which patient tolerated well. OR course
was otherwise uncomplicated except for a brief episode of
hypotension treated with phenylephrine, attributed to propofol.
She was in and out of Afib and sinus on tele. Patient then
received a final round of argon therapy. However, following
final laser treatment, patient lost O2 pleuth and there was
concern for ansent pulses although there is question of whether
she maintained a faint carotid pulse. CPR was initiated and
patient received atropine and epinephrine boluses. A femoral
CVL was placed along with an a-line. Pulses were regained but
pressures remained low. An intraoperative TEE showed air in the
RA, RV, LV, aorta, and RCA. TEE also showed clot in the RA and
severe biventricular systolic dysfunction.
.
Patient was treated with epinephrine gtt and levophed gtt with
improvement in his BPs. She was noted to be in Afib at that
time and was given 150 mg of amiodarone with conversion to sinus
rhythm but also further drop in her blood pressures requiring
increase in her epinephrine gtt. Bleeding continued in the LUL
and her R Mainstem bronchus was selectively intubated (23 at the
lip. at 24, tube occludes RUL. At 22, no longer selective R
bronchus intubation). Following resusitation, TEE showed
resolutiion of air in RCA and improved biventricular function.
She was then transferred to the ICU for further managment.
Past Medical History:
# NSCLC (LUL)
- dx'ed by biopsy
- complicated by hemoptysis
# Type 2 DM
# h/o PE s/p IVC filter
# HTN
# hypercholesteremia
# COPD
# s/p tonsillectomy
# s/p cholecystectomy
.
Social History:
54 pk-yr smoking history. Quit 2 wks ago. No EtOH, drugs. Lives
alone.
Family History:
mother-DM. Father-CAD.
Physical Exam:
T: 95.9, BP: 181/88, HR: 120 , RR: 18, O2: 100% on 1.0 FiO2
Gen: intubated, sedated
HEENT: Pupils fixed and dilated but equal. ET tube in place
NECK: Supple, No LAD. JVP cannot be visualized
CV: Regular. tachycardic. No murmurs appreciated.
LUNGS: Absent breath sounds on L. R lung fields CTA.
ABD: NABS. Soft, NT, ND.
EXT: No edema. 2+ DP on R. Dopplerable only on L.
NEURO: Intubated. Sedated. Face symmetric. Pupils fixed and
dilated.
.
Pertinent Results:
[**2199-7-24**] 09:21PM GLUCOSE-105 UREA N-17 CREAT-0.5 SODIUM-141
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-28 ANION GAP-13
[**2199-7-24**] 09:21PM estGFR-Using this
[**2199-7-24**] 09:21PM CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-2.2
[**2199-7-24**] 09:21PM WBC-11.0 RBC-3.84* HGB-11.2* HCT-34.0* MCV-89
MCH-29.1 MCHC-32.9 RDW-16.6*
[**2199-7-24**] 09:21PM PLT COUNT-428
[**2199-7-24**] 09:21PM PT-10.9 PTT-26.5 INR(PT)-0.9
EKG [**7-25**]: Sinus tach. QWs V1-2. Poor RW progression. ST elevation
in
.
CXR: opacification of the majority of the L lung fields sparing
the superior LUL
.
TEE (intraoperative): large air in aorta seen tracking into
coronary sinuses with severely depressed LV systolic
dysfunction.
.
OP Report: Bronchoscopy [**2199-7-25**]
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 42548**]
ASSISTANT: [**First Name8 (NamePattern2) 74204**] [**Name8 (MD) **], M.D.
PROCEDURE PERFORMED: Rigid and flexible bronchoscopy with
argon plasma coagulation.
INDICATIONS: Ms. [**Known lastname 74205**] has been recently diagnosed with
non-small cell lung cancer s/p X-RT and presents with massive
hemoptysis, worsening over the last 1 day, from an outside
hospital. The
procedure is being performed for airway evaluation and
control of hemoptysis.
PROCEDURE IN DETAIL: Informed consent was obtained from the
patient after explaining the risks and benefits of the
procedure. She was placed supine on the operating table and
general anesthesia was initiated. She was intubated without
difficulty with a 12.2/13.2 rigid bronchoscope. Jet
ventilation was initiated. Initial evaluation revealed frank
blood in the trachea and bilateral mainstem bronchi which was
suctioned clean. Evaluation of the right-sided airways did
not reveal any evidence of active bleeding. Frank bleeding was
seen to originate from the left upper lobe. The rigid
bronchoscope was then advanced into the left mainstem bronchus
to isolate
the lung. Using a flexible bronchoscope, an argon plasma
coagulation probe was advanced into the left upper lobe and
coagulation was performed x3. The patient continued to bleed
. While repeat APC was being performed, the patient developed
acute ST segments on the EKG monitoring and the procedure was
discontinued. She remained intubated with the rigid bronchoscope
while the cardiac status was stabilized. However, she progressed
to PEA/cardiac arrest requiring resuscitation. The rigid
bronchoscope was removed and she was easily intubated over a
Cook
catheter with an endotracheal tube #7. Using the flexible
bronchoscope, the endotracheal tube was advanced into the
right mainstem bronchus to isolate the left lung. The patient
also received epinephrine and norepinephrine for blood
pressure support. CPR was performed for aproximately 1-2min,
until
spontaneous return of circulation. A transesophageal
echocardiogram performed in the operating room [**Hospital1 **]-ventricular
failure, blood clot in RAand PA, gas in aorta and small PFO.
The patient was transferred in a critical condition to the
intensive care unit for further care.
IMPRESSION/COMPLICATIONS:
1. Lung Cancer
2. Massive hemoptysis
3. PEA arrest secondary to Gas embolism/ Pulmonary embolism.
3. Biventricular failure.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 74206**]
I certify that I was present in compliance with HCFA
regulations.
Dictated By: [**First Name8 (NamePattern2) 74204**] [**Name8 (MD) **], M.D.
HEAD CT WITHOUT CONTRAST [**2199-7-26**]
HISTORY: 72-year-old woman status post air embolus in aorta and
status post cardiac arrest, now with decreased mental status.
Assess for CVA.
TECHNIQUE: Contiguous axial images of the head were obtained
without the
administration of IV contrast.
COMPARISON: There were no prior studies for comparison.
FINDINGS: There is marked effacement of the sulci and loss of
[**Doctor Last Name 352**]-white
differentiation. The ventricular system as well as the basal
cisterns are not visualized. There is evidence of a tonsillar
herniation. This is consistent with anoxic brain injury with
diffuse cerebral edema.
There is no definite evidence of hemorrhage.
IMPRESSION:
1. There is diffuse effacement of the sulci and loss of
[**Doctor Last Name 352**]-white matter
differentiation with effacement of the ventricular system and
basal cisterns. There is also evidence of tonsillar herniation.
This is consistent with anoxic brain injury and diffuse cerebral
swelling.
Brief Hospital Course:
A/P: 72 y/o female with h/o NSCLC s/p radiation, PE s/p IVC
filter, DM, htn, COPD admitted to [**Hospital1 18**] [**2199-7-24**] for persistent
hemoptysis now s/p rigid bronchoscopy and argon laser
anticoagulation complicated by air embolus STEMI, and cardiac
arrest.
.
# hypotension: likely cardiogenic shock s/p STEMI secondary to
air embolus. LV function reportedly severely depressed
intraoperatively but with some improvement following
resuscitation and resolution of air on coronaries. Levophed was
being weaned on the night of [**7-25**] with good results. All
hemodynamic parameters as measured by Swanz Ganz were in good
standing. After her IR embolization procedure, Levophed was
weaned off. 30 minutes after total weaning, pt experienced
acute episode of hypotension. PCWP and CVP both dropped so the
patient was given IVF boluses and levophed was increased. She
responded well to these measures. Given drop in PCWP and CVP
with maintained cardiac output, this could be due to septic
shock. broad spectrum antibiotic treatment begun
- Tx with Levo, vanc, flagyl
- treat air embolus with high flow supplemental O2 to maximize
air diffusion through pulmonary vasculature
- Cardiology consulted, no treatment given source of STEMI was
air emoboli. Anticoagulation not indicated, only treatment is
high flow O2.
- minimize PEEP if possible to allow for air diffusion out of
blood
- hold antiplatelet agents and other anticoagulation given
recent hemoptysis and air embolus presumed as etiology
- levophed and fluids for goal CVP 8-12 and SBP > 140.
- Goal Hct>30, transfuse as necessary
.
# STEMI: presumed secondary to air embolus. Fam hx of CAD,
diabetes, smoker, but no known hx of CAD. Doubt plaque rupture
and patient has contraindication to anticoagulation.
- hold anticoagulation as above
- transfuse for goal Hct>30
- hold beta blocker in the setting of hypotension
- Cardiac enzymes elevated but are trending down
- serial EKGs
.
# AMS: Pt with AMS likely [**1-18**] neurological damage during
cardiac arrest vs. air emboli stroke. Pt has a negative doll's
eye maneuver which is likely [**1-18**] brainstem damage.
-- consult Neuro for EEG and/or CT of brain/MRI brain
-- CT Head result: severe diffuse cerebral edema, consistent
with anoxic/low perfusion brain injury
.
# hemoptysis: patient found to have LUL and lingula bleeding on
rigid bronch. Lingula coagulated with argon laser. However, no
intervention on LUL. Due to suspected continued bleeding, R
mainstem selectively intubated. Pt underwent IR embolization
procedure on the night of [**7-25**] for LUL bleeding, pt tolerated
procedure well.
- maintain ET tube at 23 at lip. Further advancement obstructs
RUL, and further removal, no longer selective intubation.
.
# PE: patient w/ h/o PE now s/p IVC filter. Did not tolerated
anticoagulation in past secondary to hemoptysis. Mobile clot
seen in RA on intraoperative TEE. Greatly increases risk of
recurrent large PE.
- hold anticoagulation
- f/u repeat TTE to evaluate for presence of persistent RA
thrombus
.
# post-obstructive pna: presumed given CXR findings on
admission.
- levofloxacin day #[**2201-12-24**] days
- Vanc, flagyl
.
# NSCLC: s/p radiation therapy. Poor prognosis given concurrent
PEs prior to todays events.
.
# DM: type 2. On oral regimen as outpatient.
- oral meds held
- insulin gtt for BGs>150
.
# COPD: currently intubated for respiratory support.
- albuterol and atrovent MDIs
- prednisone burst as written per IP
.
# HTN: BP meds held in the setting of hypotension and pressor
dependence.
.
# Depression: cont Celexa
.
# FEN: NPO.
.
# PPx: PPI. Pneumoboots. IVC filter. Bowel regimen
.
# ACCESS: Radial a-line, Swanz Ganz catheter in Left subclavian
.
# CODE: DNR, comfort measures only
.
# DISPO: After discussing the patient's prognosis and pertinent
test results with the family, the decision was made by the
family to make the patient "comfort measures only" and withdraw
care. The patient expired at 1750 on [**2199-7-26**].
Medications on Admission:
Protonix 40 mg Qday
Celexa 10 mg Qday
Glucotrol XL 10 mg Qday
Colace 100 mg [**Hospital1 **]
Nictotine Patch
Levaquin 750 mg Qday
Lopressor 25 mg [**Hospital1 **]
Vantin 200 mg [**Hospital1 **]
Morphine 1-2 mg prn
Duonebs
Ativan 0.5-1 mg prn
Tylenol prn
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
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81,660
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29537
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Discharge summary
|
report
|
Admission Date: [**2143-12-26**] Discharge Date: [**2144-1-1**]
Date of Birth: [**2093-11-21**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Bilateral nephrostomy tube exchange and right renal biopsy.
Left nephrostomy tube revision
History of Present Illness:
Ms. [**Known lastname 70847**] is a 50 year old woman with h/o rectal adenocarcinoma
(s/p radiation/chemotherapy/surgery), compliacted by lower
extremity paralysis ?[**1-16**] spinal cord radiation injury, HIV on
HAART, LE DVT on Coumadin, radiation-induced b/l ureteral
fibrosis requiring b/l nephrostomy tubes, who was admitted for
observation s/p b/l nephrostomy tube exchange and R renal
biopsy. Pt has her nephrostomy tubes changed every six weeks
due to frequent obstructions, and this was a regularly scheduled
procedure. During transfer between beds in the suite the right
nephrostomy tube became dislodged and pulled out. The
nephrostomy tubes were placed, and in addition a right kidney
biospy was performed. During the biopsy blood was noted from
the needle as it was being withdrawn, notable blood in the
nephrostomy tubes, and since there was concern for continued
bleeding given her INR of 1.5, the patient was admitted to the
medicine service for pain control, and to monitor vital signs
for concern of retroperitoneal bleed.
.
In the PACU, vitals signs were T 98 P 93 BP 123/87 RR 14 O2sat
96%RA.
.
On time of initial examination the patinet is in severe painful
distress and cannot answer questions or confirm the HPI/ROS.
The husband was the primary historian. In addition to the
nephrostomy tube changes, the IR or PACU nurse noted that she
had a malodorous wound on her sacrum. The Wound Care nurse
evaluated the patient and determined that it was Stage IV with
exposed bone, with blanchable erythema and induration. They
cleaned and dressed the wound and left recomendations about
changing it.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBP-ileosotomy, melena,
hematochezia.
Past Medical History:
ONCOLOGIC HISTORY:
1) Rectal cancer:
- late [**2139**]: 6 months of intermittent rectal bleeding, rectal
pressure and a sensation of incomplete emptying.
- [**2141-1-26**]: colonoscopy revealed a polyp in her sigmoid colon and
a 2.5 cm distal rectal mass arising from the anal verge in the
posterior rectum with a large area of induration.
- [**2141-1-31**]: CT torso revealed an exophytic rectal mass measuring
4.8 x 3.8 cm, bulging posteriorly into the presacral space and
anteriorly towards the uterus. There were enlarged lymph nodes
in the perirectal fat adjacent to the mass, a 9-mm enhancing
lymph node in the left pelvic sidewall, and enhancing lymph
nodes in the right external iliac region. There was also a 7-mm
hypodensity in the caudate lobe of the liver. Rectal ultrasound
on [**2141-1-31**] and rectal MRI on [**2141-2-7**] were compatible with T3
disease. There were at least four abnormal perirectal lymph
nodes seen on MRI, in addition to multiple bilateral enlarged
pelvic sidewall lymph nodes, concerning for extensive disease.
- [**2141-2-20**]: began chemoradiation
- [**2141-3-10**]: 5-FU was discontinued due to mucositis, neutropenia,
and abdominal cramping
- [**2141-3-13**]: 5-FU was restarted at a reduced dose
- [**2141-3-22**]: 5-FU was again stopped due to mucositis, perirectal
skin changes, diarrhea, and electrolyte abnormalities.
- [**Date range (3) 70844**]: Radiation was also held
- [**2141-3-27**]: 5-FU was restarted at a further reduced dose
- [**2141-3-31**]: completed radiation
- [**2141-4-3**]: completed chemotherapy
- [**Date range (3) 70845**]: hospitalized for bowel rest and the
initiation of TPN due to presumed radiation enteritis.
- [**2141-5-31**]: found to be HIV positive and began on HAART
- [**Date range (1) 70846**]: required hospitalization for an SBO, underwent
laparotomy, ileocecectomy, end-ileostomy, and placement of [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] tube on [**2141-6-16**]. Pathology from this surgery revealed
severe radiation-induced acute ischemic enteritis. She recovered
from this surgery, but continued to require TPN.
- [**7-/2141**]: Once her CD4 count had recovered, she underwent
laparotomy, lysis of adhesions, ileal resection,
proctosigmoidectomy, colonic jejunal pouch to near-anal
anastomosis with EEA, takedown splenic flexure, resection of
ileostomy and creation of new end-ileostomy. Pathology from the
surgical specimen revealed no residual carcinoma and all 14
lymph nodes sampled were free of disease.
- [**9-/2141**], [**10/2141**]: Subsequent imaging of the abdomen & pelvis
showed no evidence of recurrence.
- [**2142-2-14**]: CT abdomen showed "hyperdense thickening in the lumen
near the anastomatic site, new since the earlier study. Local
recurrence cannot be excluded, although possibly the appearance
is associated with endoluminal debris."
.
OTHER MEDICAL HISTORY:
2) HIV CD4 count 555 on [**5-25**]
3) Short gut syndrome secondary to bowel surgery for CA.
4) Obstructive renal failure from radiation fibrosis, in the
past necessitating b/l nephrostomy tubes which have required
multiple revisions.
5) Lower extremity neuropathy, likely secondary to radiation
fibrosis, uses a wheelchair since 4/[**2141**].
6) Pancreatic insufficiency.
7) Anemia.
8) Chronic pain.
9) DVT in LE X2: requires lifelong coumadin, most recent [**4-24**]
Social History:
Lives with her husband and 4 children in [**Location (un) 17566**], does not
smoke or drink alcohol. On long-term disability. Has [**First Name9 (NamePattern2) 269**]
[**Location (un) 5871**], as well as [**Location (un) 511**] Home Therapy for Port
maintenance.
Family History:
Her father died at 72 of MI. Her mother alive and well. Remote
family history of breast, colon cancer. Her daughter has
ulcerative colitis.
Physical Exam:
Admission physical exam:
VS - Temp 96.9 132/89 p98 r14 100%
GENERAL - woman in severe painful distress, crying, asking for
pain medications.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding. Pink, patent, and productive ileostomy.
BACK - Bilateral nephrostomy tubes in place without local
erythema or ecchymoses or visual deformity, extremely tender to
palpation, R>L, but bilaterally so.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), pale, flacid paralysis of both b/l, cannot cooperate or
cannot move hips, knees, or ankles.
SKIN - stage IV sacral decubitus ulcer with intact dressing in
place.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-18**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
.
Discharge physical exam:
Vitals: Tmax 99.6, Tc 99.6 BP 104-111/58-73 HR 72-88 RR 18 O2
Sat 95-98% RA
General: Tired-appearing patient lying in bed in NAD
HEENT: EOMI. PERRL. MMM. OP without erythema, exudate, and
ulcerations
CV: RRR. No M/R/G
LUNGS: CTAB bilaterally anteriorly. No wheezes or crackles
appreciated. Respirations unlabored. No accessory muscle use.
ABD: NABS+. Soft. NT/ND. Pink ileostomy in the RLQ with stool
present in the ileostomy bag.
EXT: 3+ pitting edema of the dorsum of the feet. 2+ DP pulses
bilaterally. WWP. No erythema or warmth appreciated.
NEURO: Alert and oriented to person, place, and time. CN 2-12
grossly intact.
Pertinent Results:
Admission labs:
[**2143-12-26**] 08:00AM BLOOD WBC-5.1 RBC-3.31* Hgb-9.3* Hct-28.1*
MCV-85 MCH-28.1 MCHC-33.1 RDW-17.1* Plt Ct-265
[**2143-12-26**] 08:00AM BLOOD PT-15.6* INR(PT)-1.5*
[**2143-12-26**] 08:00AM BLOOD Creat-1.1
Discharge labs:
[**2144-1-1**] 05:50AM BLOOD WBC-5.2 RBC-2.70* Hgb-7.5* Hct-22.3*
MCV-83 MCH-27.9 MCHC-33.7 RDW-18.1* Plt Ct-277
[**2144-1-1**] 05:50AM BLOOD PT-22.9* INR(PT)-2.2*
[**2144-1-1**] 05:50AM BLOOD Glucose-79 UreaN-9 Creat-0.9 Na-143 K-4.6
Cl-106 HCO3-27 AnGap-15
Imaging:
[**2143-12-26**] Nephrostomy tube exchange: IMPRESSION: Uncomplicated
exchange of bilateral nephrostomy tubes. The catheters are
connected to external bags for drainage.
[**2143-12-27**] CHEST X-RAY: FINDINGS: A right subclavian infusion port
ends in the mid SVC. Linear opacities at the left base are
stable from prior radiographs and most likely chronic
atelectasis. There is no pleural effusion, edema, or
pneumothorax. The cardiomediastinal silhouette is normal.
IMPRESSION: 1. Chronic left basilar atelectasis. 2. No evidence
of pneumonia.
ABDOMINAL X-RAY: FINDINGS: Bilateral nephrostomy tubes are in
place, with unchanged appearance on the right, but a change in
appearance on the left, with a loss of the previous coiling of
the distal catheter tip and a slightly more lateral position
compared to [**2143-11-15**]. Small bowel distention has decreased in
extent compared to the prior radiograph, and air is also present
within non-distended colon.
CT OF THE ABDOMEN WITHOUT CONTRAST
FINDINGS: The visualized portion of the liver demonstrates
diffuse low
attenuation consistent with fatty deposition. There is no
evidence of focal lesions on this non-contrast study. The spleen
and pancreas are within normal limits. Multiple retroperitoneal
lymph nodes are noted measuring up to 1 cm in short diameter,
similar to the prior study. The adrenals are unremarkable
bilaterally.
Nephrostomy tube is noted in the renal pelvis of the right
kidney entering
through the lower posterior pole. There is no evidence of
hydronephrosis or hydroureter. Small amount of high-density
perinephric dependent fluid is noted consistent with small
hematoma. A number of punctate high-density foci are seen within
the renal pelvis (301B:32 and 301B:36) consistent with small
stones. Of note, the loop of nephrostomy is fully formed.
The left nephrostomy on the first scan demonstrates moderate
hydronephrosis and hydroureter. The nephrostomy is seen entering
from the posterior lower pole and with its unformed loop within
the renal pelvis. Of note, there is also dependent high density
within the collecting system (301B:31).
PROCEDURE: 10 cc of sterile saline were used to flush the
existing left
nephrostomy tube followed by aspiration and then drainage into
the nephrostomy bag. Small amount of punctate particulate
material was aspirated, which was followed by free drainage of
the urine. After flushing, a repeat CT scan demonstrated no
residual hydronephrosis or hydroureter with satisfactory
positioning of left nephrostomy tube within the renal pelvis.
IMPRESSION:
1. Right nephrostomy tube in appropriate position in the right
renal pelvis and no evidence of hydronephrosis or hydroureter.
2. Left nephrostomy tube with unformed pigtail appropriately
positioned
within the renal pelvis. On initial scan, there was moderate
hydronephrosis and hydroureter. After flushing and aspirating,
no residual hydronephrosis or hydroureter were seen.
3. Fatty liver.
4. Multiple retroperitoneal lymph nodes, similar to the prior
study.
Microbiology:
Blood Culture, Routine (Preliminary): NO GROWTH.
Blood Culture, Routine (Pending):
URINE CULTURE (Final [**2143-12-28**]): NO GROWTH.
URINE CULTURE (Final [**2143-12-28**]): NO GROWTH. (right nephrostomy
tube)
URINE CULTURE (Final [**2143-12-28**]): YEAST. 10,000-100,000
ORGANISMS/ML. (left nephrostomy tube)
Brief Hospital Course:
# Bilateral Nephrostomy Tube Replacements: Performed on day of
admission. Patient was going to be observed on the general
medicine floor overnight given elevated INR, but was transferred
to the MICU for unstable vital signs (please see discussion
below). Both tubes were draining urine but with the right
consistently draining more than the left. Patient underwent CT
scan of the abdomen to assess the function fo the left
nephrostomy tube which showed left-sided hydronephrosis.
Interventional radiology aspirated and flushed the patient's
left nephrostomy tube and the hydronephrosis resolved without
having to exchange the tube again. Upon discharge, both
nephrostomy tubes were draining urine well.
.
# Sepsis with SIRS: Upon transfer to the unit, the patient met
sepsis criteria with hypotension, fever, and tachycardia and
probable infectious etiology. Patient was resuscitated with 3L
IVFs and her blood pressure recovered with SBPs at the patient's
baseline 120s. She was initially covered empirically for urinary
and pulmonary sources with linezolid and cefepime. Sepsis
resolved. Upon transfer to the floor, the patient's vitals
remained stable- she has been afebrile, with normal heart rate,
and normotensive. After 48hours of being afebrile, antibiotics
were discontinued given lack of identifiable source and negative
cultures. The cause of the patient's picture was unclear, and
thought to possibly be related to transient bacteremia. The
patient remained afebrile and stable off antibiotics.
.
# Hypoxia: Patient had been coughing and wheezing for 4-5 days
prior to arrival in the MICU. Noted to have a room air sat of
92% by her outpatient provider. [**Name10 (NameIs) **] an outpatient, she was
treated with Augmentin for presumptive pneumonia with albuterol
nebs as an outpatient. ICU team thought that there was likely a
component of obstruction and pulmonary edema after 3L of IVF
given for hypotension. Exam upon transfer notable for diffuse
wheezing and crackles at the bases bilaterally. CXR showing
linear opacities at the bases that are present on previous CXR
that are stable; no other evidence of focal consolidations on
exam. LDH within normal limits, which makes PCP infection less
likely. Patient's oxygen saturations were followed, and the
patient remains with good O2 saturation on RA.
.
# Anemia: Patient initial hematocrit upon admission was 28.
Since being in the ICU, the patient's HCT ranged from 22.6-24.5.
No evidence of bleeding on exam, and her hematocrit was trended
daily through the admission. An active type and screen was
maintained for the patient given her bleeding risk and the
procedure that she had just undergone. Through the admission,
patient's hematocrit remained stable.
.
# Altered mental status: On the night of transfer to the ICU,
the patient was noted to have altered mental status. Patient
alert and interactive upon transfer, answering questions
appropriately. Given her hypotension, her altered mental status
was thought to be due to poor perfusion. Her mental status was
followed while on the floor and remained stable.
.
# Prior LE DVT: Most recent DVT [**4-24**]. Patient requires lifelong
coumadin. Patient's coumadin was restarted [**2143-12-28**]. INR was
monitored through the admission with goal 2.0-3.0. Patient's
home regimen of warfarin was continued through the admission as
her INR appropriately increased. On day of discharge, patient's
INR was 2.2, and she was discharged home on her original
anticoagulation regimen with a repeat INR to be checked [**Month/Day/Year 766**],
Janurary 23, [**2143**].
.
# Stage IV Sacral Decubitus Ulcer: Not actively draining upon
inspection on transfer to the floor. Wound care was consulted.
Their formal recommendations are provided in the page 1 referral
form for the patient's home [**Year (4 digits) 269**] service.
.
# HIV on HAART: CD4 count during this admission was found to be
126. At her last CD4 count in [**Month (only) **] was 550. The patient's home
antiretroviral medications were continued through the admission.
She was not started on Bractrim for PCP prophylaxis as the
patient's CD4 percentage was at goal (greater than 30%), so it
was thought that her low CD4 count represented a transietly low
absolute lymphocyte count. An HIV viral load was sent during
this admission, which was undetectable.
.
# Chronic pain: Home medications were continued.
.
TRANSITIONAL ISSUES:
- Patient needs 2-way valves on nephrostomy tubes and they need
to be flushed [**Hospital1 **] to prevent clogging. Interventional radiology
will contact the patient regarding follow-up of their procedure.
- Follow-up of INR on [**Last Name (LF) 766**], [**2144-1-6**] with the results
faxed to the patient's primary care physician.
Medications on Admission:
Confirmed by Husband on [**2143-12-26**]:
Abacavir 600mg PO daily/Lamivudine 300mg PO daily ([**Date Range 70848**])
Albuterol nebs
Augementin 1tab PO BID (started [**12-23**])
Darunavir 800mg PO daily
Ritonavir 100mg PO daily
Hydromorphone 12mg PO q2h prn pain
Lansoprazole 30mg PO daily
Lorazepam 2mg PO q2h and qhs prn
Methadone 10mg PO BID / 15mg PO BID (12pm and 10pm)
Mirtazapine 15mg PO qhs
Zolpidem 10mg PO qhs prn
Ferrous sulfate 325mg PO BID
Vitamin D 50,000units PO daily
Folic acid 1mg PO daily
Loperamide 4mg PO daily prn
Acetaminophen 500-1000mg PO q6h prn
Cyanocobalamin inj qmonth
Pregabalin 150mg PO TID
Nortriptyline 25mg PO qhs
Warfarin PO daily (4-5mg PO q24)**
Discharge Medications:
1. mirtazapine 15 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO HS (at
bedtime).
2. methadone 10 mg Tablet [**Month/Day (4) **]: 1.5 Tablets PO BID (2 times a
day): Take 1.5 tablets at 12PM and 1.5 tablets at 10PM.
3. methadone 10 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID (2 times a
day): .
4. ferrous sulfate 300 mg (60 mg iron) Tablet [**Month/Day (4) **]: One (1)
Tablet PO BID (2 times a day).
5. folic acid 1 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).
6. pregabalin 75 mg Capsule [**Month/Day (4) **]: Two (2) Capsule PO TID (3 times
a day).
7. [**Month/Day (4) 70848**] 600-300 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day.
8. darunavir 400 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO DAILY (Daily).
9. ritonavir 100 mg Capsule [**Month/Day (4) **]: One (1) Capsule PO DAILY
(Daily).
10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. nortriptyline 25 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO at
bedtime.
12. acetaminophen 500 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every six
(6) hours as needed for pain.
13. lorazepam 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO q2HR as needed
for anxiety.
14. lorazepam 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as
needed for anxiety.
15. zolpidem 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as
needed for insomnia.
16. Vitamin D 50,000 unit Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a
day.
17. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution [**Last Name (STitle) **]: One
(1) injection Injection once a month.
18. loperamide 2 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO once a day
as needed for diarrhea/loose stool.
19. warfarin 2 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAYS
([**Doctor First Name **],TU,WE,FR,SA).
20. warfarin 2 mg Tablet [**Doctor First Name **]: Three (3) Tablet PO DAYS (MO,TH).
21. hydromorphone 1 mg/mL Liquid [**Doctor First Name **]: Twelve (12) mL PO q3hrs as
needed for pain.
22. furosemide 20 mg Tablet [**Doctor First Name **]: One (1) Tablet PO DAILY
(Daily).
23. Outpatient Lab Work
Please have INR checked [**Last Name (LF) 766**], [**2144-1-6**] and the results
faxed to your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 48223**].
(fax) [**Telephone/Fax (1) 18820**]
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Primary Diagnosis:
Sepsis secondary to transient bacteremia
Bilateral nephrostomy tube replacement
Secondary Diagnosis:
HIV
Stage 4 sacral decubitus ulcer
recurrent deep vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 70847**],
It was a pleasure taking care of you during your hospitalization
at [**Hospital1 69**].
You were admitted to the hospitcal because after your
nephrostomy tube exchange you were bleeding, and we wanted to
monitor your blood levels and vital signs to make sure that you
were safe to go home. During your first night here your blood
pressure dropped very low and you were transferred to the
medical intensive care unit. You received IV fluids and your
pressures responded. You remained afebrile with stable vital
signs during the rest of your hospitalization.
The Interventional Radiologists did not feel that your left
nephrostomy tube needed to be revised during this admission
after the original placement. They were able to clear the left
nephrostomy tube with flushing the tube.
Please take all medications as instructed. Note the following
medication changes: NONE
Please have the [**Hospital1 269**] check your INR on [**Last Name (LF) 766**], [**2144-1-6**]
and have them forward the results to your primary care physician
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 48223**].
Please keep all follow-up appointments. They are listed below.
Interventional Radiology will contact you regarding follow-up.
Followup Instructions:
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: TUESDAY [**2144-1-14**] at 11:50 AM
With: [**First Name8 (NamePattern2) 3679**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,722
| 126,759
|
55125
|
Discharge summary
|
report
|
Admission Date: [**2184-9-11**] Discharge Date: [**2184-9-18**]
Date of Birth: [**2128-11-20**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Seizures and AMS
Major Surgical or Invasive Procedure:
PICC line.
History of Present Illness:
55F with history of prior CVA presenting to the ED for
evaluation of altered mental status. Per report, last seen
normal at 830 pm and was found at 11:30pm. The patient was
discovered just prior to coming into the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] slumped over,
unreponsive, no evidence of trauma. Upon EMS arrival patient had
a generalized tonic-clonic seizure which resolved prior to IV
access or medication. Finger stick in the field was 160's.
Patient upon arrival to OSH ED had a second generalized tonic
clonic seizure lasting 50 seconds which subsided prior to ativan
2mg IV administration. Per family, no prior seizure history but
patient has been abusing alcohol (last use 6 weeks ago). No
recent trauma, but the husband says that she was trying to go to
the bathroom late last night but she has fallen 2-3 times
recently. No use of blood thinners. Patient has right sided
deficits from prior stroke. Patient was in her usual state of
health prior to events. Patient empirically given Ativan 2 mg IV
x 1 and loaded with Dilantin 1000mg prior to labs returning. CT
head performed and negative. CXR performed and negative. EKG
normal. Basic labs demonstrated hyponatremic (Na 118),
hypokalemic, hypochloremic metabolic alkalosis. Received 3 ml/kg
of HTS x 1 (150mg total given) for Na of 115, Phenytoin 500mg,
150 of hypertonic saline. 150mg of phenytoin x2, EMS gave 100mg
NS. She was then transferred to [**Hospital1 18**] for ICU admission. Her
vitals on presentation to the ED were 97.6 92 109/71 18 100% 4L
NC. Once admitted to the MICU, the patient opened her eyes to
sternal rub. She could nod her head but not answer questions.
In the MICU, she received NS at 200cc per hour. Nephrology and
neurology were consulted to provide guidance on proper sodium
replacement protocol. The patient was slowly replaced. Her
mental status improved dramatically, and she was transferred to
the floor. On the floor, the patient was alert and responding to
questions. She was familiar with her situation. She denied any
prior history of seizure disorder, and reiterates last drink was
6 weeks ago. She does not complain of pain anywhere. No
f/c/n/v/cp/sob/HA.
Past Medical History:
- hx of CVA
- alcohol abuse
- frequent falls resulting in lacerations
- she is seeing a cardiologist but husband does not know why,
"20% of her heart is working now."
Social History:
Unemployed since [**86**] years ago, she was working at [**Hospital 1263**]
Hospital, in the continuing care dept. PT was coming to the
house, she uses a walker and walks with assistance. Unable to
balance a checkbook.
- Tobacco: 12 cigarettes per day-this represents a decrease
- Alcohol: ongoing alcohol abuse, per husband "she has an
alcohol problem" she has been hiding vodka from him.
- Illicits: unable to obtain.
Family History:
Noncontributory
Physical Exam:
Admission physical exam:
Vitals: T: 98.5 BP: 102/67 P: 87 R: 18 O2: 98%
General: A&Ox0. Opens eyes to sternal rub. No acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL. Cough to
deep suction.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, systolic murmer
heard best at LLLSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: PERRL, coughs in response to gag reflex, opens eyes to
sternal rub, voiced "good," shakes head. She is moving all 4
extremities spontaneously and squeezes hands bilaterally L>R. R
hand with contractures. Did not move toes.
Skin: left fourth digit with ulceration at proximal tarsal joint
with pus and white tendon visualized.
Discharge physical exam:
Vitals: afebrile, normotensive, NSR, satting normally on RA
General: Alert and oriented. No acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no m/g/r
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. significant muscle wasting.
Neuro: CN II-XII intact, reflexes [**2-7**] throughout, strength 5/5,
increased tone in lower extremities.
Skin: left fourth digit with ulceration at proximal tarsal joint
with pus and white tendon visualized.
Pertinent Results:
Admission Labs [**2184-9-11**]:
[**2184-9-11**] 03:05AM BLOOD WBC-7.0 RBC-3.76* Hgb-12.0 Hct-33.6*
MCV-89 MCH-31.9 MCHC-35.8* RDW-12.1 Plt Ct-247
[**2184-9-11**] 03:05AM BLOOD Neuts-71.7* Lymphs-18.3 Monos-9.7 Eos-0.1
Baso-0.2
[**2184-9-12**] 04:00AM BLOOD PT-10.4 PTT-31.4 INR(PT)-1.0
[**2184-9-11**] 03:05AM BLOOD Glucose-93 UreaN-6 Creat-0.5 Na-118*
K-2.3* Cl-62* HCO3-34* AnGap-24*
[**2184-9-11**] 03:05AM BLOOD ALT-34 AST-55* AlkPhos-102 TotBili-1.0
[**2184-9-11**] 03:05AM BLOOD Lipase-22
[**2184-9-11**] 03:05AM BLOOD Albumin-3.7 Calcium-8.5 Phos-2.0* Mg-1.8
[**2184-9-11**] 10:10PM BLOOD VitB12-840 Folate-GREATER TH
[**2184-9-11**] 03:05AM BLOOD Osmolal-250*
[**2184-9-11**] 03:05AM BLOOD TSH-1.4
[**2184-9-11**] 03:05AM BLOOD Cortsol-28.0*
[**2184-9-11**] 11:55PM BLOOD 25VitD-47
[**2184-9-11**] 08:11PM BLOOD Phenyto-21.2*
[**2184-9-11**] 03:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2184-9-11**] 06:19AM BLOOD Type-ART pO2-90 pCO2-42 pH-7.58*
calTCO2-41* Base XS-15 Intubat-NOT INTUBA
[**2184-9-11**] 06:19AM BLOOD Glucose-96 Lactate-1.2 Na-117* K-2.1*
Cl-67*
[**2184-9-11**] 10:48AM BLOOD freeCa-0.98*
[**2184-9-11**] 03:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2184-9-11**] 03:00AM URINE UCG-NEGATIVE Osmolal-356
[**2184-9-12**] 08:24PM URINE Osmolal-321
[**2184-9-11**] 08:40AM URINE Hours-RANDOM UreaN-375 Creat-42 Na-12
K-27 Cl-14
[**2184-9-11**] 08:40AM URINE RBC-0 WBC-5 Bacteri-NONE Yeast-NONE
Epi-<1
[**2184-9-11**] 03:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Labs on transfer to ICU [**2184-9-13**]:
[**2184-9-13**] 04:20AM BLOOD WBC-4.4 RBC-3.41* Hgb-11.3* Hct-31.9*
MCV-94 MCH-33.2* MCHC-35.4* RDW-12.2 Plt Ct-192
[**2184-9-13**] 08:30PM BLOOD Glucose-80 UreaN-1* Creat-0.3* Na-126*
K-4.3 Cl-94* HCO3-25 AnGap-11
[**2184-9-13**] 08:30PM BLOOD Calcium-7.9* Phos-2.7 Mg-1.3*
[**2184-9-11**] 10:30PM BLOOD Osmolal-259*
[**2184-9-13**] 09:18AM BLOOD Phenyto-13.4 Phenyfr-PND
[**2184-9-13**] 08:42PM BLOOD Type-[**Last Name (un) **] pH-7.44
[**2184-9-13**] 04:29AM BLOOD Type-[**Last Name (un) **] pO2-43* pCO2-42 pH-7.41
calTCO2-28 Base XS-1
[**2184-9-13**] 04:29AM BLOOD Lactate-0.5
[**2184-9-13**] 08:42PM BLOOD freeCa-1.00*
Discharge labs:
[**2184-9-18**] 04:40AM BLOOD WBC-5.6 RBC-2.77* Hgb-8.8* Hct-26.5*
MCV-96 MCH-31.8 MCHC-33.3 RDW-12.9 Plt Ct-483*
[**2184-9-18**] 04:40AM BLOOD Glucose-77 UreaN-7 Creat-0.4 Na-134 K-3.9
Cl-100 HCO3-28 AnGap-10
[**2184-9-18**] 04:40AM BLOOD Calcium-8.5 Phos-4.7* Mg-1.6
[**2184-9-15**] 11:39PM BLOOD 25VitD-42
[**2184-9-17**] 06:50PM BLOOD Phenyto-4.1*
[**2184-9-15**] 05:54AM BLOOD pH-7.37 Comment-GREEN TOP
Pertinent Micro/path:
[**2184-9-11**] 3:00 am URINE
**FINAL REPORT [**2184-9-12**]**
URINE CULTURE (Final [**2184-9-12**]): NO GROWTH.
[**2184-9-11**] 5:49 am SWAB Source: L ring finger.
**FINAL REPORT [**2184-9-14**]**
WOUND CULTURE (Final [**2184-9-14**]):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2184-9-12**] 2:00 am SEROLOGY/BLOOD Source: Line-picc.
**FINAL REPORT [**2184-9-13**]**
RAPID PLASMA REAGIN TEST (Final [**2184-9-13**]):
NONREACTIVE.
Reference Range: Non-Reactive.
[**2184-9-13**] 7:21 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2184-9-14**]**
C. difficile DNA amplification assay (Final [**2184-9-14**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Blood cultures:
[**2184-9-12**] 8:40 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2184-9-13**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 1735 [**2184-9-13**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2184-9-14**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Remaining blood cultures pending...
Pertinent Imaging:
[**2184-9-13**] CT Head
There is no acute intracranial hemorrhage, edema, mass effect or
large acute territorial infarction. The ventricles and sulci
are slightly prominent consistent with mild diffuse brain
parenchymal atrophy. There are subtle periventricular and
centrum semiovale confluent hypodensities consistent with
sequela of chronic small vessel disease. There is a hypodense
focus in the pons centrally, which is unchanged since [**9-10**], [**2184**], and might represent a chronic infarct (series 2, image
7 and series 401B, image 40). The paranasal sinuses and mastoid
air cells are clear. There are no suspicious lytic or sclerotic
bony lesions.
IMPRESSION: Hypodense focus in the pons is unchanged since
[**2184-9-10**] and likely represents a chronic infarct. No acute
intracranial process.
[**2184-9-11**] EEG:
MPRESSION: This continuous ICU monitoring study recorded
continuous periodic
lateralized epileptiform discharges in the left posterior
quadrant, and one
brief electrographic seizure over the left posterior region.
These findings
are indicative of a highly epileptogenic region of focal
cerebral dysfunction
in the left posterior quadrant. There is asymmetric background
activity with
continuous slowing on the left hemisphere and PLEDs plus. There
is
intermittent slowing over the right hemisphere as well
indicative of more
diffuse cerebral dysfunction.
[**2184-9-13**] MRI HEAD W/ and W/O Contrast
1. No focal mass or prior infarct in the right occiptal or
parietal lobes.
2. Greater than expected brain volume loss for patient age.
Scattered
punctate and confluent areas of signal hyperintensity on the
FLAIR sequences
within the periventricular subcortical white matter bilaterally,
which are
nonspecific but may reflect sequela of chronic microvascular
disease.
3. Increased FLAIR and T2 signal in the central pons. This may
reflect either
prior infarct or chronic findings of prior central pontine
myelinolysis.
4. Slightly increased T1 signal in the basal ganglia. Correlate
for
hyperalimentation or history of liver disease.
[**2184-9-14**] HAND XRAY
Three views show no convincing evidence of abnormal gas or
opaque
foreign body within the fourth digit. There is soft tissue
swelling in the
region of the PIP joint but no underlying bone abnormality.
[**2184-9-16**] ECHO
Biatrial enlargement. Normal left ventricular cavity size and
wall thickness with borderline hyperdynamic global biventricular
systolic function. No clinically significant valvular
regurgitation or stenosis. Normal pulmonary artery systolic
pressure.
Brief Hospital Course:
Reason for hospitalization:
55yo female with pmhx of CVA and question of heart failure
presenting with altered mental status, seizures, and
hyponatremia.
# Altered Mental Status: Due to electrolyte abnormalities,
resolving postictal state, or possible EtOH intox. Mental status
improved with correction of hyponatremia and treatment of
seizures. The pt did not score on CIWA, however it is not known
whether she could have been intoxicated.
# Hyponatremia: Volume depletion is likely the main contributor
to her hyponatremia given her presentation and physical exam.
History of severely poor oral intake and alcohol abuse, on lasix
for ? CHF (TTE was normal). The time course of her sodium
replacement was calculated carefully by the nephrology team, and
it was found that she was corrected appropriately given her
active seizures. Once her Na reached 128 and her mental status
recovered, she was transferred to the floor. On the floor, she
received q8H electrolyte checks, q4H neuro checks, and q24H
urine lytes. Her Na normalized. Her diet was fluid restricted to
less than 1L free water per day. By discharge, the pt's sodium
had normalized to 134 on a regular diet. Nutrition was consulted
(see below).
# Hypophosphatemia: Likely due to poor PO intake. Nadir at 0.7,
increased with replacement. Concern for rhabdo, but CK and
lactate were stable. This resolved by the time the patient was
transferred to the floor.
# Hypokalemia: Possible over diuresis with home Lasix. Nadir
2.3, no EKG changes, responded to replacement. She continued to
receive K replacement as needed while on the floor.
# Anion Gap Metabolic Acidosis: In the presence of urinary
ketones, the patient's AGMA may be secondary to alcoholic
ketoacidosis. Her albumin is normal, making starvation
ketoacidosis less likely. Anion gap normalized with electrolyte
replacement.
# Hypochloremic Metabolic Alkalosis: Possibly secondary to
overdiuresis with home Lasix. pH 7.58 resolved wtih correction
of the hypokalemia, hypovolemia, hypophosphatemia, and
hypochloremia.
# Seizure: Likely due to hyponatremia, no new seizures after
initial generalized tonic clonic in this ED. Patient received
continuous EEG, neurology reports epileptiform activity from
right side, concerning for structural focus. Repeat head CT
negative for structural disease. A head MRI revealed no
lateralizing lesion or infarct, but rather old punctate lesions
which may represent prior infarct or central pontine
myelinolysis. She was discharged on keppra and dilantin.
# Gram pos bacteremia: only discovered in [**1-8**] bottles. Vanc was
originally started for possible blood stream infection but given
her improved clinical status with correction of Na, it seemed
less likely that infection was causing her AMS. She was afebrile
and no signs of infection. Vanc was stopped once the pt got to
the floor.
# Alcohol Abuse: the patient's husband reports that she has been
hiding her alcohol use from him, and he is unsure how much she
has been drinking. On CIWA, patient did not show signs of
withdrawal. Continued on folate and IV thiamine. She appeared
highly malnourished, with anemia, and various electrolyte
abnormalities which could have been due to lasix use and/or
alcohol abuse. Nutrition was consulted to optimize her caloric
intake, recommended ensure replacement at each meal and calorie
counting (see recs below). Social work was consulted as well.
She was discharged on thiamine and multivitamin.
# Hx of CVA: Repeat head CT showed no evolution of central
pontine lacunar infarct, no new changes. MRI shows possible
multiple punctate infarcts such as lacunar infarct with no
lateralizing lesion.
# Possible history of CHF: Unclear from history, but patient on
lasix, lisinopril, metoprolol, which were all held. These
medications may have been contributing to her electrolyte
abnormalities. Echocardiogram was performed to confirm the
patient's history and rule out CHF as a cause of her
hyponatremia (albeit unlikely given the clinical picture). She
was found to have "biatrial enlargement; Normal left ventricular
cavity size and wall thickness with borderline hyperdynamic
global biventricular systolic function. No clinically
significant valvular regurgitation or stenosis. Normal pulmonary
artery systolic pressure." These findings are consistent with
our clinical assessment that the patient currently does not have
CHF.
# L ring finger lesion: She reports that she obtained the lesion
while "running into things" over the past unknown amount of
time. the patient was followed by hand surgery, who did not feel
that her lesion required surgical repair. It did not appear
infected, so IV abx were stopped. OT was consulted to help with
management. Wound care managed daily dressing changes (see recs
below).
#Frequent falls prior to admission:
Unclear history. Possible diagnoses include intoxication v
muscle wasting v orthostatic hypotension (possibly secondary to
overdiuresis and poor po intake) v CVA v vertigo. The neurology
team did not find the patient to have significant
motor/coordination deficits on exam, although her head CT showed
possible prior lacunar strokes vs CPML, and the pt herself
reports a history of residual deficits from prior stroke. PT was
consulted and felt she could be discharged home with home PT
services.
Transitional Issues:
# F/u with neurology regarding CT/MRI head findings and new
onset seizures.
# F/u with nephrology regarding electrolyte abnormalities
# Wound care recs for finger:
For local wound care - cleanse skin/ulcer with wound cleanser or
NS and pat dry
-apply aloe vesta moisturizer to intact dry skin
-cover wound with piece of moistened aquacel ag sheet/rope
followed by dry gauze
-secure with tape
-change daily
# Nutrition recs:
- Continue with diet as ordered, encourage pos as tolerated
- Oral supplements: chocolate Ensure Plus qd
- Continue daily multivitamin with minerals, thiamine, and folic
acid
- Monitor chem 10, replete lytes prn
- Monitor I/Os, skin, hydration status
# Outpatient OT for finger:
splint to be worn at night and PRN
during day, no ROM to L 4th digit, please keep LUE elevated and
check skin beneath splint 3-4x day
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from OSH
records.
1. Ibuprofen 600 mg PO Q12H:PRN pain
2. Lisinopril 5 mg PO DAILY
hold for SBP < 90
3. Metoprolol Tartrate 150 mg PO TID
hold for SBP < 90, HR < 55
4. Furosemide 20 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Vitamin D 50,000 UNIT PO 1X/WEEK ([**Doctor First Name **])
7. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral [**Hospital1 **]
8. Pyridoxine 50 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
hold for SBP < 90
3. Pyridoxine 50 mg PO DAILY
4. LeVETiracetam Oral Solution 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*1
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*1
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
7. Furosemide 20 mg PO DAILY
**ATTENDING NOTE: THIS MEDICATION IS LISTED IN ERROR. PATIENT
WAS NOT GIVEN FUROSEMIDE DURING THIS HOSPITALIZATION AND SHOULD
NOT TAKE IT AS AN OUTPATIENT. TTE SHOWED NORMAL LVEF.
8. Ibuprofen 600 mg PO Q12H:PRN pain
9. Metoprolol Tartrate 150 mg PO TID
hold for SBP < 90, HR < 55
10. NexIUM *NF* (esomeprazole magnesium) 40 mg ORAL [**Hospital1 **]
11. Vitamin D 50,000 UNIT PO 1X/WEEK ([**Doctor First Name **])
12. Phenytoin Sodium Extended 100 mg PO Q8H
RX *phenytoin sodium extended 100 mg 1 capsule(s) by mouth every
eight (8) hours Disp #*90 Capsule Refills:*1
Discharge Disposition:
Home With Service
Facility:
Steward VNA
Discharge Diagnosis:
Primary diagnoses:
1. Hypovolemic hyponatremia
2. Seizures
3. Anemia of chronic disease
4. Malnutrition
Secondary diagnoses:
1. alcohol abuse
2. hypertension
3. prior CVA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 1726**],
You were admitted to [**Hospital1 18**] for seizures. You were found to have
a very low blood sodium level, which may have been contributing
to your seizures. You received an MRI of the head and EEG to
help investigate your seizures further. While in the hospital
you received sodium replacement in the form of IV saline and
anti-seizure medications. Your sodium level slowly rose to
within normal limits, and your overall status improved. We now
feel it is safe for you to leave the hospital.
We made the following changes to your medications:
1. Start Phenytoin 100mg every 8 hours
2. Start levetiracetam 1000mg twice daily
3. Start Multivitamin daily
4. Start Thiamine 100mg daily
Please be sure to follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], as well as
our nephrology (kidney) and neurology specialists at the
appointment times listed below.
Followup Instructions:
It is very important that you attend the following doctor
appointments listed below:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] Y.
Location: [**Hospital **] MEDICAL GROUP
Address: [**Apartment Address(1) 112458**], [**Location (un) **],[**Numeric Identifier 38978**]
Phone: [**Telephone/Fax (1) 19564**]
Appointment: Tuesday [**2184-9-21**] 10:00am
Department: WEST [**Hospital 2002**] CLINIC- Nephrology
When: THURSDAY [**2184-9-23**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18672**], M.D. [**Telephone/Fax (1) 9420**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROLOGY
When: WEDNESDAY [**2184-10-27**] at 4:00 PM
With: DRS. [**Name5 (PTitle) 540**]/[**Doctor Last Name **] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*The office is working on a getting you a sooner appointment for
follow up of your hospitalization. The office will contact you
at home with information. If you have any questions or concerns
please call the office.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2184-9-22**]
|
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"275.3"
] |
icd9cm
|
[
[
[]
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] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
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12844, 13009
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321, 334
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20913, 20913
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362, 2556
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20928, 21040
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2578, 2747
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|
4159, 4891
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,830
| 199,631
|
53071
|
Discharge summary
|
report
|
Admission Date: [**2123-12-24**] Discharge Date: [**2124-1-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Acute Blood Loss Anemia, GI Bleed, Gastric Ulcers, Ventilator
Associated Pneumonia, Acute Systolic CHF, Diarhea
Major Surgical or Invasive Procedure:
Intubation
Esophageal Gastroduodenoscpy
History of Present Illness:
[**Age over 90 **] year old Female with anemia, Systolic CHF, Atrial
fibrillation previously on coumadin, erosive gastritis, PVD with
recent fall on [**2123-12-14**] with hip fracture s/p left total hip
replacement placed on aspirin/lovenox, who presents with
hematemesis and massive GI bleed. Patient by report developed 24
hours of hematemesis and melena, along with syncope in the
setting of the bleeding. At presentation to the outside hospital
ED, her Hematocrit was 16 from 27 the day prior and NG lavage
was positive, but she was not given blood because she was a
difficult crossmatch. She was transferred to [**Hospital1 18**] for further
management.
In the [**Hospital1 18**] ED, she arrived with SBP in the 50s. Patient was
guaiac positive, NGT putting out blood and small amount of
clots. She received a PPI drip, 4 units PRBCs transfusion, 1
unit FFP (INR 1.3 at OSH, 1.6 here) and 1 bag of platelets with
improvement in her pressures to SBPs 110s. However, she again
became hypotensive and was given a fifth unit of blood.
Initially she was 100% on NRB was and 96% on RA, but she became
markedly hypoxic after the blood transfusions. Given her need
for an endoscopic procedure, her elderly age and frail status,
her LVEF of 30% with demand ischemia on EKG, she was
intubated in the ED.
A surgical consult was obtained and recommended following GI/EGD
results along with serial hematocrits. GI was consulted and
recommended EGD. The patient was sent to the MICU intubated and
sedated. An EGD was performed with results below, which were
injected with epinepharine.
On [**12-26**] she was given one dose of IV lasix and extubated,
however shortly thereafter she developed low grade fever, cough
productive of brown sputum and an infiltrate on chest xray, so
was diagnosed with hospital acquired pneumonia. She was also
noted in florid CHF with a BNP of 45,000. Additional IV diuresis
was performed with improvement. She was transferred to the floor
for further management.
Of note in the MICU, a meeting with the family changed her code
status to DNR/DNI.
On the floor her CHF was treated with continued lasix.
Past Medical History:
1. Systolic heart failure (EF 30-35 [**7-23**])
2. Atrial fibrillation on warfarin
3. Hypertension
4. Dyslipidemia
5. PVD s/p fem [**Doctor Last Name **] bypass
6. Uterine tumor, s/p total hysterectomy > 45yrs ago
7. Cystic Kidneys, with one reportedly "underdeveloped"
8. Esophageal ulcer and gastritis on EGD
9. Normocytic anemia- does not want colonoscopy
10. Bilateral aortoiliac bypass
11. Diverticulitis
12. Depression/anxiety
13. Benign cysts in breast removed X 2
Social History:
The patient lives in a two family house in [**Location (un) 2251**], MA. She was
never married and currently lives in the lower half of the house
with her sister-in-law (another octogenerian). She formerly
worked as a greeting card maker in a factory and retired over 20
years ago. She is still quite independent and can do her own
shopping and meal preparation.
Pt admits to smoking one pack/day for around 25 years and
quitting entirely when she was in her 40's. She drinks wine very
rarely on holidays and denies any history of other drugs.
.
She eats a healthy diet that she prepares at home and tries to
limit her sodium and fluid intake. She tries to exercise by
walking daily, but her walking is limited by leg pain.
Family History:
Mother has h/o of loss of consciousness from "heart problems"
that eventually caused her death. Father died of cirrhosis
(non-alcoholic).
Physical Exam:
Vitals: T: 96.9 BP: 114/75 P: 75, R: 18 O2: 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: bibasilar rales
CV: irregular rate rhythm, normal S1 + S2, 3/6 Systolic Ejection
Murmur
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, 1+ Edema
Pertinent Results:
[**2124-1-3**] 07:45AM BLOOD WBC-9.4 RBC-3.49* Hgb-10.6* Hct-32.1*
MCV-92 MCH-30.5 MCHC-33.2 RDW-16.6* Plt Ct-330
[**2123-12-31**] 08:10AM BLOOD WBC-18.9* RBC-3.59* Hgb-10.5* Hct-32.2*
MCV-90 MCH-29.2 MCHC-32.6 RDW-16.2* Plt Ct-357
[**2123-12-25**] 03:37AM BLOOD Hct-27.7*
[**2123-12-25**] 12:10AM BLOOD WBC-23.3* RBC-3.31* Hgb-10.1* Hct-29.3*
MCV-89 MCH-30.5 MCHC-34.5 RDW-14.3 Plt Ct-295
[**2123-12-24**] 09:45PM BLOOD WBC-21.4* RBC-3.25*# Hgb-9.8*# Hct-28.6*#
MCV-88 MCH-30.2 MCHC-34.3 RDW-14.3 Plt Ct-322
[**2123-12-24**] 06:45PM BLOOD WBC-14.8* RBC-1.82*# Hgb-5.5*# Hct-16.6*#
MCV-91 MCH-30.4 MCHC-33.3 RDW-14.7 Plt Ct-324
[**2123-12-29**] 05:50AM BLOOD Neuts-89* Bands-4 Lymphs-5* Monos-0 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2123-12-24**] 06:45PM BLOOD Neuts-80* Bands-4 Lymphs-10* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-2*
[**2124-1-3**] 07:45AM BLOOD Plt Ct-330
[**2124-1-3**] 07:45AM BLOOD PT-13.2 PTT-26.5 INR(PT)-1.1
[**2124-1-2**] 06:50AM BLOOD Plt Ct-392
[**2124-1-2**] 06:50AM BLOOD PT-13.1 PTT-27.7 INR(PT)-1.1
[**2124-1-1**] 06:30AM BLOOD PT-14.7* PTT-27.7 INR(PT)-1.3*
[**2123-12-31**] 08:10AM BLOOD PT-16.4* PTT-29.6 INR(PT)-1.5*
[**2123-12-30**] 07:50AM BLOOD PT-15.4* PTT-28.5 INR(PT)-1.4*
[**2123-12-29**] 05:50AM BLOOD PT-19.8* PTT-33.8 INR(PT)-1.8*
[**2123-12-28**] 04:15AM BLOOD PT-37.4* PTT-53.1* INR(PT)-3.9*
[**2123-12-27**] 02:52PM BLOOD PT-24.3* PTT-38.3* INR(PT)-2.3*
[**2123-12-27**] 03:51AM BLOOD PT-22.5* PTT-36.0* INR(PT)-2.1*
[**2123-12-26**] 05:30AM BLOOD PT-21.2* PTT-33.3 INR(PT)-2.0*
[**2123-12-25**] 12:10AM BLOOD PT-15.2* PTT-31.5 INR(PT)-1.3*
[**2123-12-24**] 06:45PM BLOOD PT-17.7* PTT-33.4 INR(PT)-1.6*
[**2124-1-3**] 07:45AM BLOOD Glucose-110* UreaN-28* Creat-1.3* Na-140
K-3.5 Cl-108 HCO3-21* AnGap-15
[**2123-12-31**] 12:35PM BLOOD Creat-1.5* K-2.7*
[**2123-12-29**] 05:50AM BLOOD Glucose-107* UreaN-48* Creat-1.6* Na-140
K-2.8* Cl-113* HCO3-16* AnGap-14
[**2123-12-24**] 06:45PM BLOOD Glucose-177* UreaN-83* Creat-1.3* Na-138
K-3.7 Cl-110* HCO3-19* AnGap-13
[**2123-12-24**] 06:45PM BLOOD ALT-20 AST-17 AlkPhos-66 TotBili-0.5
[**2123-12-24**] 06:45PM BLOOD Lipase-29
[**2123-12-27**] 02:52PM BLOOD proBNP-[**Numeric Identifier 109350**]*
[**2124-1-3**] 07:45AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.6
[**2123-12-25**] 12:10AM BLOOD Calcium-6.7* Phos-4.0 Mg-1.5*
[**2123-12-24**] 06:45PM BLOOD Albumin-1.9*
[**2123-12-28**] 04:15AM BLOOD Vanco-3.7*
[**2123-12-25**] 05:51AM BLOOD Type-ART Temp-35.8 PEEP-5 FiO2-50
pO2-159* pCO2-34* pH-7.33* calTCO2-19* Base XS--6
Intubat-INTUBATED
[**2123-12-25**] 12:26AM BLOOD Type-CENTRAL VE pH-7.26*
[**2123-12-24**] 06:55PM BLOOD pH-7.31* Comment-GREEN TOP
[**2123-12-25**] 05:51AM BLOOD Lactate-0.7
[**2123-12-25**] 12:26AM BLOOD Glucose-158* Lactate-1.0
[**2123-12-24**] 06:55PM BLOOD Glucose-164* Lactate-2.4* Na-134* K-3.6
Cl-111 calHCO3-18*
[**2123-12-25**] 12:26AM BLOOD freeCa-1.03*
[**2123-12-24**] 06:55PM BLOOD freeCa-0.95*
[**2123-12-27**] 12:42PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2123-12-27**] 12:42PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2123-12-27**] 12:42PM URINE RBC-1 WBC-6* Bacteri-FEW Yeast-NONE Epi-1
TransE-1
[**2123-12-27**] 12:42PM URINE CastGr-3* CastHy-6*
[**2123-12-25**] 5:35 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2123-12-26**]**
MRSA SCREEN (Final [**2123-12-26**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2123-12-27**] 12:42 pm URINE Source: Catheter.
**FINAL REPORT [**2123-12-28**]**
URINE CULTURE (Final [**2123-12-28**]):
GRAM NEGATIVE ROD(S). ~4000/ML.
[**2123-12-27**] 12:42 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2123-12-28**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2123-12-28**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2123-12-27**] 2:52 pm SEROLOGY/BLOOD Source: Line- Aline.
**FINAL REPORT [**2123-12-29**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2123-12-29**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
[**2123-12-29**] 6:07 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2123-12-29**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2123-12-29**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2123-12-30**] 8:29 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2124-1-1**]**
GRAM STAIN (Final [**2123-12-30**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2124-1-1**]):
MODERATE GROWTH Commensal Respiratory Flora.
ESCHERICHIA COLI. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2123-12-31**] 6:19 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2123-12-31**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2123-12-31**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Endocscopy Report
Date: [**Last Name (LF) 2974**], [**2123-12-24**]
Findings: Esophagus:
Contents: Clotted blood was seen in the esophagus.
Stomach:
Contents: Red blood and clotted blood was seen in the stomach
fundus. The clot was able to be moved by rotating the patient
and there were no additional findings underneath the clot.
Excavated Lesions Multiple ([**3-20**]) superficial non-bleeding
ulcers that had a clean base without a visible vessel, adherent
clot, or oozing, ranging in size from 3 mm to 6 mm, were found
in the antrum. 10 cc of epinephrine 1/[**Numeric Identifier 961**] was injected into
each ulceration with success.
Duodenum:
Mucosa: A small superficial ulcer was seen in the duodenal bulb
that had no stigmata of bleeding, clean based. No therapy was
applied. There was no fresh blood in the duodenum, which was
inspecte to the 2/3rd portion of duodenum. Ampulla visualized
and was unremarkable.
Impression: Blood in the esophagus
Ulcers in the antrum (injection)
Blood in the stomach
Abnormal mucosa in the duodenum
Otherwise normal EGD to second part of the duodenum
Recommendations: Routine post procedure orders
Monitor HCT Q6H.
Repeat INR and maintain <1.5 with FFP.
Continue IV PPI gtt.
Keep intubated until GI team reassesses in a.m. to determine if
repeat scope is indicated.
If worsening hemodynamics overnight or evidence of repeat active
bleeding, please inform GI fellow.
Avoid NSAIDs and anticoagulants.
ECG Study Date of [**2123-12-24**] 7:01:22 PM
Sinus rhythm. Diffuse ST segment depression suggestive of global
myocardial ischemia. Compared to the previous tracing of
[**2123-9-30**] ST segment depression in the anterolateral leads as
well as inferior leads is more prominent. Clinical correlation
is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
93 200 94 324/381 42 46 -146
CTA PELVIS W&W/O C & RECONS Study Date of [**2123-12-24**] 9:50 PM
IMPRESSION:
1. No definite evidence of aortoenteric fistula.
2. Colonic distention, mild wall thickening and mucosal
hyperenhancement
consistent with colitis that may be infectious, inflammatory or
ischemic.
3. Pleural effusions, periportal edema and diffuse subcutaneous
edema.
4. Hiatal hernia, increased in size.
5. Extensive atherosclerotic disease with aortobiiliac graft as
detailed
above.
6. Diverticulosis.
7. Cholelithiasis.
CHEST (PA & LAT) Study Date of [**2123-12-30**] 3:39 PM
Bilateral pleural effusion is moderate, persistent accompanied
by bibasal
atelectasis with some potential progression of the size of the
effusion.
There is slight upper lobe redistribution of the vasculature
which is mildly physiologic due to bibasal large areas of
atelectasis. There is no
pneumothorax. There are no new consolidations. Extensive
calcifications of
the aorta are demonstrated.
Brief Hospital Course:
[**Age over 90 **] yo F s/p fall on [**12-13**] with recent left total hip replacement
on Aspirin and Lovenox with episode of hematemesis and
hematocrit 16 with guaiac positive stool.
1. Acute Blood Loss Anemia due to GI Bleed due to Gastric Ulcers
- Upper GI Bleed: Hct 16.6 down from baseline in low 30s. There
was some initial concern for aorto-enteric fistula but this was
ruled out via CT scan above.
- GI was consulted with urgent EGD performed in the MICU
- Underwent massive transfusion protocol, hct > 25-28
- H. Pylori was negative
- [**Hospital1 **] PPI
- Follow up with GI
- Off anticoagulation
- Transfusion likely cause of CHF exacerbation
2. Ventilator Associated Pneumonia
- Complete course of Vancomycin and Zosyn on [**2124-1-3**] evening
- Will get last dose at [**Hospital1 1501**]
- No further coughing
3. Acute on Chronic Systolic CHF
- Last echocardiogram demonstrated EF 30-35%
- ACEI, diuresis, metablocker
- Almost at baseline at time of discharge, and will likely need
several more days of agressive PO diuresis
# CAD Native Vessle:
- Signs of demand ischemia on EKG on admission, which was
treated with massive transfusion protocol, hct > 21
- Held coumadin and ASA
- Continue ACEI/Beta-blocker
# Atrial fibrillation:
- Currently rate controlled well with metoprolol
- Coumadin held given massive bleeding
# Depression:
- Continued citalopram
# Chronic Kidney Disease Stage III
- Renal Dosing
- Cautious diuresis
- Monitor createnine
# Communication: Patient * [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 109351**]
# Code Status:
- Spoke to nephew, [**Name (NI) **] [**2123-12-26**] 12:30 p.m. (Health Care Proxy).
Confirmed DNR/DNI
Medications on Admission:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: as
indicated by coumadin clinic.
8. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) injection
Injection once a month.
9. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO once
a day.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Vancomycin 1000 mg IV Q 24H hospital aquired pneumonia
stop after [**1-3**] dose
10. Piperacillin-Tazobactam 2.25 g IV Q6H Hospital acquired
pneumonia
stop after [**1-3**] dose
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7806**] Home - [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
1. Upper GI Bleed
2. Gastric Ulcers
3. Ventilator-Associated Pneumonia
4. CHF exacerbation, acute on chronic, systolic
SECONDARY:
1. s/p hip fracture and hip replacement
2. paroxysmal atrial fibrilation
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
It was a pleasure taking care of you during your stay at [**Hospital1 1535**]. You were admitted with a
gastrointestinal bleed which was caused by ulcers in your
stomach. You were treated with blood transfusions as well as
other blood products and a procedure to find the cause of your
bleeding. During this procedure they were able to inject your
ulcers with epinephrine, a drug that can help stop them from
bleeding temporarily. We also stopped your warfarin, which you
were on to thin your blood, since this can contribute to
bleeding.
We have made some changes to your medications. These include the
following:
START taking pantoprazole 40mg twice per day. This is to
protect your stomach from too much acid which can worsen your
ulcers.
STOP taking your digoxin. You can discuss whether or not to
restart this medication with your primary care physician.
[**Name10 (NameIs) **] taking your Warfarin (Coumadin). You can discuss whether
or not to restart this medication in the future with your
primary care physician.
Please follow up with gastroenterology at the appointment listed
below. Please also follow up with your primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **], once you are discharged from your [**Hospital 3058**]
rehabilitation facility. His office can be reached at
[**Telephone/Fax (1) 250**]. Finally, please follow up with your orthopedic
surgeon as previously directed.
Followup Instructions:
GI
MD: Dr. [**First Name4 (NamePattern1) 2795**] [**Last Name (NamePattern1) 908**]
Specialty: Gastroenterology
Date/ Time: Monday, [**1-17**] at 1:30pm
Location: [**Last Name (LF) **], [**First Name3 (LF) 452**] Bldg [**Location (un) **], [**Location (un) 86**] MA
Phone number: [**Telephone/Fax (1) 463**]
Please follow up with your orthopedic surgeon as previously
directed.
|
[
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"276.0",
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"562.10",
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"997.31",
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"599.0",
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"272.4",
"532.90",
"535.40",
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"V43.64",
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"V54.81",
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icd9cm
|
[
[
[]
]
] |
[
"44.43",
"96.71",
"96.04",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
16510, 16585
|
13226, 14939
|
374, 415
|
16842, 16842
|
4436, 13203
|
18475, 18857
|
3829, 3968
|
15657, 16487
|
16606, 16821
|
14965, 15634
|
17019, 18452
|
3983, 4417
|
223, 336
|
443, 2574
|
16856, 16995
|
2596, 3070
|
3086, 3813
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,327
| 124,758
|
6478
|
Discharge summary
|
report
|
Admission Date: [**2163-9-16**] Discharge Date: [**2163-10-11**]
Date of Birth: [**2091-4-26**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 72 year old
woman with a history of HOCM, CHF, diabetes mellitus who had
been complaining of right upper quadrant pain for three
weeks. She went to the emergency department where patient
became acutely short of breath. CT angio shows no signs of
pulmonary embolism. Patient was found to be in pulmonary
edema. Right upper quadrant ultrasound on the 18th showed
echogenic parenchyma suggestive of fatty infiltration of the
liver. No intrahepatic biliary dilatation. Gallbladder
normal without stones or evidence of cholecystitis.
Patient was admitted where she responded to Lasix with
improvement of her respiratory status. Patient normally is
on high doses of Lasix, Aldactone and verapamil. Patient was
started on carvedilol. She had an echo done on [**9-19**] which
showed normal LV systolic function, low peak LV outflow tract
gradient of 14 mm, mild LVH. Her clinical status improved
until the night of [**2163-9-20**] when she was noted to start
getting dizzy. Patient had massive melena and hemoptysis of
600 cc of bright red blood.
Patient was transferred to the MICU where endoscopy was
performed and showed a massive clot in the stomach mucosa
consistent with portal gastropathy. It also showed grade 2
varices in the lower third of the esophagus. Patient had
three endoscopies performed on the 25th. Two bands were
successfully placed on the grade 2 varices in the lower
esophagus. Status post banding of the esophageal varices
patient's hematocrit stabilized. Patient had required
frequent transfusions of packed red blood cells and FFP to
maintain normal INR. Patient's hematocrit had remained
stable and her stools progressively had less melena. She was
continued on PPI.
Hepatic failure. Patient has long standing cryptogenic
cirrhosis leading to portal hypertension. Patient's GI bleed
caused shock liver which led to fulminant hepatic failure.
AST and ALT rose to the thousands. Patient had the ascites
tapped which showed SAAG greater than 1.1 consistent with
portal hypertension. Patient's transaminases resolved in the
ensuing days after her initial hypotensive shock and her
blood pressure was maintained normal. However, she became
encephalopathic. She was started on lactulose for hepatic
encephalopathy and over the ensuing week showed improvement
in her mental status. Patient was also started on nadolol
for portal hypertension.
Patient was electively intubated for airway protection.
However, she became vent dependent secondary to fluid
overload secretions and decreased central draws. Patient
required a vent placed on [**10-7**] and increasingly required
higher PEEP in order to maintain lungs from collapsing in the
setting of increasing intra-abdominal pressure.
Infection. Patient developed staph aureus pneumo and UTI.
She was started on clindamycin and Levaquin of which she
completed a 14 day course.
Patient gradually became hypotensive and her urine output
began to fall. She went into renal failure. She was boluses
normal saline, however, to third space. Swan-Ganz catheter
was placed to assess fluid status and it was found that
patient had good cardiac output and low SVR. Patient was
given packed red blood cells to help improve cardiac
pressure, however, her renal failure continued to worsen. It
was felt that patient likely had hepatorenal syndrome. She
became increasingly fluid loaded up 30 liters from admission.
It was decided that patient should be started on CVVHD to
help with fluid removal. Patient also tolerated Lasix and
Zaroxolyn and was able to remove fluid. She was on CVVHD,
however, her urine output dropped off even further and her
creatinine continued to rise. CVVHD was discontinued.
Thrombocytopenia. Platelets had fallen. Heparin was
discontinued. Heparin antibodies were sent off, however, it
was found that they were negative. It was felt that
thrombocytopenia was likely secondary to hypersplenism.
On [**10-11**] patient's clinical status was discussed with
the family. Her poor prognosis was described. Patient's
family requested withdrawal of care and comfort measures
only. Patient was taken off all medications. She was put on
a morphine drip. Patient was taken off the ventilator at
family's request. Patient expired the evening of [**10-11**]
secondary to cardiac arrest from hypoxia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Doctor Last Name 24874**]
MEDQUIST36
D: [**2163-10-16**] 17:20
T: [**2163-10-17**] 15:49
JOB#: [**Job Number 24875**]
|
[
"535.01",
"482.41",
"571.5",
"584.9",
"276.1",
"456.20",
"428.0",
"572.2",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"45.13",
"54.98",
"96.04",
"54.91",
"31.1",
"38.93",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
163, 4769
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,642
| 133,035
|
31586
|
Discharge summary
|
report
|
Admission Date: [**2136-6-7**] Discharge Date: [**2136-7-10**]
Date of Birth: [**2070-6-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
R leg pain
Major Surgical or Invasive Procedure:
R ileofemoral thrombectomy, aorto pelvic arteriogram, R LE 4
compartment fasciotomy/guillitine AKA [**6-7**]
PEG placement
Trach placement
Central line x 2
PICC line
Femoral art line
History of Present Illness:
65yo with h/o AFib, R MCA stroke, CHF (EF 30% 4/06), dementia,
found down in apartment, screaming with R leg pain. Pt. dyspneic
on arrival to ED, Afib with RVR, ABG 7.14/34/319, lactate 7.8,
CK to [**Numeric Identifier 4756**] and LFTs to >1000, and was intubated and started on
CVVHD. He was found to have a clot partially occluding the right
external iliac artery. Pt. underwent emergent R femoral
thrombectomy initially and four compartment fasciotomy.
Subsequently he underwent the same day a right AKA.
Perioperative TEE showed EF 20-25% with thrombus in L atrial
appendage.
His post-op course has been complicated by MRSA bacteremia,
global hypotension requiring pressors, renal failure requiring
CVVH, and mesenteric ischemia with elevated lactates, hct drop
whenever TFs restarted. A CTA abdomen [**6-13**] was done to assess
these changes and found continued ascending colon edema, a
stable clot in the proximal SMA and a suggestion of new wall
edema involving the distal sigmoid colon as well as small bowel
distension. Surgery consulted and feels pt. is not surgical
candidate currently.
.
Pt. has been weaned off of pressors since [**6-16**], and has been
venting well on PS over the past few days. Last fevers [**6-20**] on
current antibiosis ([**Doctor Last Name **], levo, flagyl). ID, renal, thoracics,
urology consults following.
Past Medical History:
Former PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who retired in [**12-18**]. All care transfer
to Dr. [**Last Name (STitle) 7962**] [**Telephone/Fax (1) 56152**], who has had minimal contact with
patient.
Per Dr.[**Name (NI) 60764**] records:
- R MCA stroke requiring hospitalization/MICU stay at [**Hospital1 112**] in
[**3-16**]. Transient L-sided paralysis which recovered. Episodic A
fib at the time. Pt subsequently at [**Hospital3 **] [**Date range (1) 74256**],
transferred to NH. Pt at NH for 2 days but left AMA. Pt refused
further home rehab services (VNA/PT).
- CHF (EF 30% 4/06)
- non-ischemic [**Date range (1) 7921**]
- dementia (per daughter, pt with memory trouble/difficulty
taking meds at home)
Social History:
(per daughter, [**Name (NI) 74257**], [**Telephone/Fax (1) 74258**]): lives alone in a
government-subsidized apt in [**Location (un) 583**], has never smoked as far
as daughter knows, [**Name2 (NI) **] glass of wine, no illicits
Family History:
Father with "lung disease"
Physical Exam:
Temp 96.7 BP 100/51 Pulse 119 Resp 16
O2 sat 100% on AC 0.35/600/12/5
.
Gen - Alert, no acute distress, intubated
HEENT - icteric, PERRL, EOMI, mucous membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - tachy, irregular rhythm, soft, distant HS. no murmurs noted
Abd - severely hypoactive BS, soft, sl. distended seems to
grimace more to RUQ palpation.
Extr - L AKA under dressing. per nurse [**First Name (Titles) 151**] [**Last Name (Titles) 74259**] drainage,
approximating pretty well. large, fluid filled blisters on R
foot, ecchymotic, gangrenous areas at distal L foot. Warm,
weakly dopplerable pulses.
Neuro - alert, nods head, but not clear if appropriate, does not
follow commands, does not respond to painful stimuli. cranial
nerves III-XII grossly intact, movement in hands and remaining
foot at times
Skin - sl. jaundiced, no rashes noted
Pertinent Results:
[**2136-6-7**] 01:00AM BLOOD WBC-8.1 RBC-4.55* Hgb-14.3 Hct-45.1
MCV-99* MCH-31.5 MCHC-31.7 RDW-13.8 Plt Ct-293
[**2136-7-8**] 04:04AM BLOOD WBC-6.4 RBC-2.39* Hgb-7.3* Hct-21.6*
MCV-91 MCH-30.7 MCHC-33.9 RDW-18.6* Plt Ct-51*
[**2136-6-7**] 01:00AM BLOOD Neuts-65.7 Lymphs-26.1 Monos-6.2 Eos-1.0
Baso-1.0
[**2136-6-26**] 02:54AM BLOOD Neuts-87.1* Lymphs-2.0* Monos-5.0 Eos-0
Baso-3.0* Atyps-2.0* Metas-1.0*
[**2136-6-7**] 01:00AM BLOOD PT-19.2* PTT-38.2* INR(PT)-1.8*
[**2136-7-7**] 04:53AM BLOOD PT-14.9* PTT-43.6* INR(PT)-1.3*
[**2136-7-8**] 04:04AM BLOOD Plt Ct-51*
[**2136-6-7**] 01:00AM BLOOD D-Dimer-4338*
[**2136-6-26**] 05:05PM BLOOD FDP-10-40
[**2136-6-19**] 08:57AM BLOOD Ret Aut-5.6*
[**2136-6-7**] 01:00AM BLOOD Glucose-117* UreaN-25* Creat-1.7* Na-137
K-5.6* Cl-104 HCO3-15* AnGap-24*
[**2136-7-9**] 07:17AM BLOOD Glucose-155* UreaN-142* Creat-2.9* Na-133
K-5.0 Cl-95* HCO3-15* AnGap-28*
[**2136-6-7**] 06:24AM BLOOD ALT-660* AST-871* LD(LDH)-1464*
CK(CPK)-3476* AlkPhos-91 Amylase-234* TotBili-1.9*
[**2136-7-3**] 04:33AM BLOOD ALT-80* AST-125* AlkPhos-481*
TotBili-15.3*
[**2136-6-7**] 06:24AM BLOOD Lipase-25
[**2136-6-7**] 01:00AM BLOOD cTropnT-<0.01
[**2136-6-7**] 06:24AM BLOOD CK-MB-37* MB Indx-1.1 cTropnT-0.01
[**2136-6-7**] 11:14AM BLOOD CK-MB-GREATER TH cTropnT-0.03*
[**2136-6-7**] 07:03PM BLOOD CK-MB-GREATER TH cTropnT-0.07*
[**2136-6-7**] 01:00AM BLOOD Calcium-7.6* Phos-5.6* Mg-2.5
[**2136-6-9**] 08:24PM BLOOD calTIBC-190* TRF-146*
[**2136-6-14**] 02:59AM BLOOD Hapto-52
[**2136-6-27**] 02:52AM BLOOD Triglyc-235*
[**2136-7-3**] 04:33AM BLOOD Triglyc-114
[**2136-6-7**] 11:14AM BLOOD TSH-4.7*
[**2136-6-12**] 04:32AM BLOOD TSH-5.1*
[**2136-6-10**] 10:13AM BLOOD Cortsol-33.5*
[**2136-6-10**] 10:47AM BLOOD Cortsol-32.5*
[**2136-6-10**] 10:47AM BLOOD Cortsol-33.9*
[**2136-6-30**] 06:11AM BLOOD Vanco-14.3
[**2136-6-7**] 01:05AM BLOOD Type-ART Tidal V-520 PEEP-10 pO2-314*
pCO2-34* pH-7.14* calTCO2-12* Base XS--16 Intubat-INTUBATED
Vent-CONTROLLED
[**2136-6-7**] 04:38AM BLOOD Type-ART Rates-16/ Tidal V-500 PEEP-8
FiO2-60 pO2-122* pCO2-25* pH-7.26* calTCO2-12* Base XS--13
-ASSIST/CON Intubat-INTUBATED
[**2136-6-7**] 08:45AM BLOOD Type-ART pO2-120* pCO2-31* pH-7.33*
calTCO2-17* Base XS--8
[**2136-7-4**] 10:12AM BLOOD Type-ART pH-7.35
[**2136-7-4**] 04:07AM BLOOD Lactate-3.0*
[**2136-6-7**] 01:14AM BLOOD Lactate-7.8* K-5.8*
.
[**2136-6-7**] 1:54 am BLOOD CULTURE
AEROBIC BOTTLE (Final [**2136-6-10**]):
ANAEROBIC BOTTLE (Final [**2136-6-11**]):
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
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
AEROBIC BOTTLE (Final [**2136-7-11**]):
REPORTED BY PHONE TO [**Doctor Last Name **] POWER @ 6:08A [**2136-7-7**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. Fluconazole = SENSITIVE.
This test has not been FDA approved but has been
verified
following Clinical and Laboratory Standards Institute
guidelines
by [**Hospital1 69**] Clinical
Microbiology
Laboratory..
[**2136-7-5**] 3:44 pm BLOOD CULTURE BLOOD CULTURE 1 OF 2..
**FINAL REPORT [**2136-7-12**]**
AEROBIC BOTTLE (Final [**2136-7-11**]):
REPORTED BY PHONE TO [**Doctor Last Name **] POWER @ 6:08A [**2136-7-7**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. Fluconazole = SENSITIVE.
This test has not been FDA approved but has been
verified
following Clinical and Laboratory Standards Institute
guidelines
by [**Hospital1 69**] Clinical
Microbiology
Laboratory..
[**2136-7-5**] 5:50 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2136-7-8**]**
GRAM STAIN (Final [**2136-7-5**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): BUDDING YEAST.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2136-7-8**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
YEAST. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- S
VANCOMYCIN------------ <=1 S
[**2136-6-7**] 01:30AM URINE Sperm-MOD
[**2136-6-7**] 01:30AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.026
[**2136-6-7**] 01:30AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2136-6-7**] 01:30AM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
IMAGING:
On Admission:
CT CHEST WITH CONTRAST: The thoracic aorta is of normal caliber,
and there is no evidence of acute aortic pathology. The central
and segmental pulmonary arteries demonstrate no filling defects.
The heart is unremarkable, and there is no evidence of
pericardial effusion. Bilateral right greater than left
small-to-moderate pleural effusions are present with associated
atelectasis. There are no pathologically enlarged axillary lymph
nodes. A precarinal node measures 9 mm in short axis diameter,
which does not meet the CT criteria for pathologic enlargement.
Lung windows reveal perihilar and upper lobe foci of
consolidation bilatterally on a background of ground glass
change. The airways are patent to the level of the segmental
bronchi, bilaterally. An endotracheal tube terminates
approximately 3.7cm above the carina.
CT ABDOMEN WITH CONTRAST: This exam is not tailored to evaluate
abdominal organs and though evaluation of the liver,
gallbladder, spleen, pancreas, and adrenal glands are
unremarkable. A small hypodense 7 mm left midpole renal lesion
is too small to characterize. There is no evidence of
hydronephrosis or hydroureter. The intraabdominal loops of large
and small bowel are unremarkable except for scattered colonic
diverticulosis. There is no free air or pathologically enlarged
mesenteric or retroperitoneal lymph nodes. A trace amount of
free fluid is noted within the right pericolic gutter.
The abdominal aorta is of normal caliber without evidence of
acute pathology. Tight stenosis is seen at the origin of the
superior mesenteric artery with SMA reconstitution and contrast
opacification more distally.
Occlusion of the right common iliac artery is likely nearly
complete and extends into the external iliac artery with partial
opacification of the more distal external iliac and complete
opacification of the right common femoral artery. Poor contrast
opacification of multiple right internal iliac branches is
observed.
CT PELVIS WITH CONTRAST: The rectum, sigmoid colon, and prostate
are unremarkable. A Foley is present within the bladder. No free
fluid or pathologically enlarged pelvic lymph nodes are seen. A
small amount of left inguinal swelling/ hematoma is related to
left femoral line placement.
Bone windows reveal no worrisome lytic or sclerotic lesions.
IMPRESSION:
1. No acute aortic pathology. However, there is near-complete
occlusion of the right common iliac artery extending into that
external iliac artery with poor opacification of internal iliac
artery branches.
2. Small-to-moderate bilateral pleural effusions with perihilar
and upper lobar patchy consolidation and ground-glass change,
concerning for infectious consolidation or aspiration on a
background of volume overload.
3. Partial occlusion of superior mesenteric artery with
opacification of the more distal SMA. Non-contrast evaluation of
bowel is very limited but grossly unremarkable with no finding
to suggest ischemia.
NON-CONTRAST CT HEAD: There is no intracranial hemorrhage, shift
of normally midline structures, or evidence of acute major
vascular territorial infarcts. Encephalomalacic change in the
right frontal lobe is likely the sequela of chronic infarct.
Imaged portions of the paranasal sinuses are well aerated. The
mastoid air cells are poorly pneumatized, bilaterally, and there
is fluid within the left middle ear cavity.
IMPRESSION: 1. No intracranial hemorrhage.
2. Encephalomalacic change in the right frontal lobe is likely
the sequela of chronic infarct.
.
Echocardiogram:
[**2136-6-29**]
TTE:
Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is top
normal/borderline dilated. There is severe global left
ventricular hypokinesis (LVEF = 20-25%). The right ventricular
cavity is mildly dilated.
There is mild global right ventricular free wall hypokinesis.
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. Torn mitral chordae are present.
Trivial mitral regurgitation is seen. The left ventricular
inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial
pressure. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic
pericardial effusion.
IMPRESSION: Borderline-dilated left ventricle with severe global
systolic
dysfunction. Mild right ventricular systolic dysfunction.
Moderate tricuspid regugitation. Moderate pulmonary
hypertension.
[**2136-6-8**]
TEE:
Conclusions:
Moderate spontaneous echo contrast is seen in the body of the
left atrium and left atrial appendage. The left atrial
appendage emptying velocity is depressed (<0.2m/s). A definite
thrombus (1.0 x 1.0 cm) is seen in the left atrial appendage.
Mild spontaneous echo contrast or thrombus is seen in the body
of the right atrium or the right atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Overall left
ventricular systolic function is severely depressed (EF
20-25%). There is global right ventricular free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Impression: Severe biventricular dysfunction. No valvular
vegetations or
paravalvar abcess seen. Definite thrombus in the left atrial
appendage
[**2136-7-2**]:
LIVER/GALLBLADDER SON[**Name (NI) **]
HISTORY: Abnormal LFTs.
COMPARISON: Recent CT [**2136-6-13**].
FINDINGS: Please note that this is a very limited study that was
performed in the MICU. Liver is grossly unremarkable.
Gallbladder demonstrates moderate amount of sludge, with no
definite wall thickening or pericholecystic fluid to suggest
acute cholecystitis. No cholelithiasis is noted. Trace amount of
free fluid is seen. The common bile duct measures 5 mm.
IMPRESSION:
1. Limited liver/gallbladder son[**Name (NI) **] demonstrates sludge within
the gallbladder. However, no evidence for cholecystitis or
cholelithiasis.
2. Trace amount of free fluid.
=
Pathology:
SPECIMEN SUBMITTED: ILIAC CLOT, RIGHT AKA.
Procedure date Tissue received Report Date Diagnosed
by
[**2136-6-7**] [**2136-6-7**] [**2136-6-14**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 2336**]/cma??????
DIAGNOSIS:
1. Blood clot (iliac) (A).
2. Above-the-knee amputation, right (B-L):
A. Subcutaneous hematoma with patchy infarction of skeletal
muscle.
B. Atherosclerosis, multivessel, with thrombosis of posterior
tibial artery.
C. Skin, subcutaneous tissue, bone marrow, and skeletal muscle
at resection margins appear viable.
CXR:
IMPRESSION: AP chest compared to [**6-26**] through 21:
Previous mild pulmonary edema and vascular engorgement in the
mediastinum have cleared since [**6-30**]. Previous left pleural
effusion has not recurred. Volume loss in the left lung,
particularly the left upper lobe has worsened. Dual channel left
supraclavicular central venous line ends in the low SVC.
Tracheostomy tube is in standard placement and nasogastric tube
passes below the diaphragm and out of view.
Brief Hospital Course:
Patient is a 66 yo M with history of CVA and resultant
hemiparesis who was found down and later found to have a
arterial thrombosis. He was evaluated by vascular surgery who
eventually amputated his right lower extremity (AKA). However,
he began to have progressing thromboses and ischemia. It was
thought that he had showering thrombi to his extremities from a
known left atrial thrombus. Patient developed multiorgan
failure.
Respiratory failure: eventually required trach placement and was
unable to be weaned from the vent. Was on trach mask initially,
but had to be replaced on the ventilator after hypercarbia and
increased bloody secretions. Additionally, as renal failure
progressed, he continued to have volume overload and continued
to be anuric.
Cardiac:
CAD: no history of CAD. on admit trops negative. EKG with only
rate related ST changes.
Rhythm: was been difficult to rate control due to rapid afib.
tried dilt drip which was ineffective. esmolol infeffective.
verapamil re-tried and was effective in controlling HR, but pt
developed pauses, and increasing pressor requeremnts. Next step
in HR control is Digoxin. 0.125 q 36hrs. However, Digoxin has a
side effect of bowel ischemia. Metoprolol was also tried with
persistent hypotension following. Anticoagulation was attempted
but had platelet drop with heparin and was ruled out while on
argatroban (though not started on renal dose). However, while
on argatroban patient had supratherapeutic INR with persistent
bleeding. Therefore, no anticoagulation was continued. Patient
remained in AF with RVR and likely had continued poor forward
flow with persistent tachycardia. Additionally there was an
atrial thrombus that was seen on initial echo. Given that the
patient was unable to be adequately anticoaulated, cardioversion
was not an option given that he was at risk for embolism.
Pump: currently massively fluid overloaded. non ischemic [**Last Name (LF) 7921**], [**First Name3 (LF) **]
20-25% on TEE with global hypokinesis. First Swan with CO 2.5,
CI 1.89 on admit to CSRU. Was initially on CVVHD with negative
fluid balance which temporized his disease. However, given that
he had persistent hypotension and was unable to have true HD,
the CVVHD was stopped given that further treatment would be
futile (no signs of improvement of multiorgan failure).
Pressors were restarted in last week without significant
improvement in the patient's overall status.
Hypotension: Persisted without known cause, likely combination
of multiorgan failure, poor systolic function, perhaps with
element of cardiogenic and septic shock. Was initially weaned
off pressors, but did eventually require them again.
Renal failure:
Acute Renal failure [**1-13**] rhabdo +/- ATN. goal to transition to HD
per family. Started on CVVH that was unable to be transitioned
to HD and eventually stopped CVVH as it was medically futile.
This occurred as a result of multiple family meetings and
discussion with the daughter
Vascular disease: patient initially presented with thrombosed
right lower extremity that was eventually amputated. However,
the patient likely had continued thrombi throughout the
hospitalization given that he had areas of necrosis on foot,
face that appeared to be infarcted. However as previously
mentioned, anticoagulation was not possible. Additionally, the
patient continued to have poor wound healing from existing
surgical wound and then of the embolic areas making further
surgical intervention futile. Vascular surgery consulted on
this patient but found no clear options for the patient in terms
of management of vascular complications.
ID: Patient became febrile during acute event in ED. Unclear
precipitating events. being treated for MRSA bacteremia and
possible infected clot. Initially thought to need [**3-16**] wks with
vanc for endovascular infection with clot, however all known
clots(mesenteric, atrial) are arterial so much less likely to be
infected. Has received 20d vanc already. Vancomycin was
discontinued for concern of vanc-induced thrombocytopenia, but
that was negative. Patient was weaned off antibiotics, but then
developed again signs of infection and broad spectrum
antibiotics. Blood cultures eventually grew yeast and since the
patient was not able to have indwelling lines removed, the
treatment was futile and stopped.
# Access: L femoral A-line, RIJ triple lumen, tunneled dialysis
catheter. PICC line
# Code: pt was full code, but after dr. [**Last Name (STitle) **] has had a
discussion with the patient's daughter and established that
resuscitation will be futile and may be harmful for the patient,
status was changed to DNR. If decision to stop cvvhd is made,
family is asking to xfer the patient to [**Hospital1 **] to contiue care. it
seems that the family is stalling for more time, and are happy
with the care at [**Hospital1 18**]. discussion on possibilyt of xfer are
still pending
.
# Comm: daughter, [**Name (NI) 74257**], [**Telephone/Fax (1) 74258**], HCP.
[**Name (NI) **] deceased as a result of multiorgan failure.
Medications on Admission:
at home:
coumadin
lopressor 25 tid
colace
senna
lasix 20 mg daily
zyprexa 2.5 mg [**Hospital1 **]
anusol
Discharge Disposition:
Expired
Discharge Diagnosis:
Multiorgan failure
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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"294.8",
"429.89",
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"728.88",
"428.0",
"287.5",
"518.81",
"607.83",
"444.22",
"038.11",
"255.4",
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icd9cm
|
[
[
[]
]
] |
[
"88.72",
"83.44",
"84.17",
"99.05",
"84.3",
"99.15",
"31.1",
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"96.6",
"96.72",
"96.04",
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icd9pcs
|
[
[
[]
]
] |
22216, 22225
|
16986, 22059
|
332, 516
|
22287, 22297
|
3890, 9461
|
22349, 22492
|
2921, 2949
|
22246, 22266
|
22086, 22193
|
22321, 22326
|
2964, 3871
|
282, 294
|
544, 1893
|
12446, 16963
|
9475, 12437
|
1915, 2659
|
2675, 2905
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,262
| 172,609
|
5067
|
Discharge summary
|
report
|
Admission Date: [**2161-4-22**] Discharge Date: [**2161-4-30**]
Date of Birth: [**2098-6-23**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headaches
Major Surgical or Invasive Procedure:
[**4-22**]: Left occipital craniotomy for resection of metastatic
lesion
History of Present Illness:
62 year old gentleman with past medical history of NHL, Renal
cancer, and metastatic melanoma with know metastasis to the
brain who was admitted to [**Hospital1 18**] after being seen for increasing
bifrontal headaches in the setting of weaning decadron. He had
been weaning the decadron with hopes of starting IL-2. He was
also noted to have some RUE and was admitted to the floor on
[**Hospital Ward Name **] and restarted on Decadron with good results in
decrease of his headache. He underwent a MRI scan of the brain
which showed that there was new hemorrhage in the area of the
lesion when compared to the previous MRI done at the end of
[**Month (only) 956**]. Of note he underwent cyberknife treatment to this
lesion on [**2161-2-27**], which was initially found on MRI in
early [**Month (only) 404**].
The patient requested discharge home for personal reasons at
that time and now presents electively for craniotomy and
resection.
Past Medical History:
NHL, Left nephrectomy [**2154-7-8**] for stage T1a renal cancer,
Melanoma resected from back [**2157**], Right upper lung wedge
resection [**2160-6-11**] revealed metastatic melanoma, BRAF negative.
He
is status post Cyberknife SRS to left occipital met on [**2161-2-27**]
to
1800 cGy., Bipolar disorder, Hypothyroid, Skin cancer as well as
melanoma, Gout, Hypertension,
Social History:
He is divorced and currently disabled. He denies tobacco use. He
occasionally drinks alcohol. He smoked marijuana in the past.
Family History:
non-contributory
Physical Exam:
On Admission:
General:Clearly uncomfortable in wheelchair, unable to sit still
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, dry MM,
CARDIAC: distant heart sounds but RRR, S1/S2, no mrg
LUNG: CTAB, occasional wheeze on right
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
Motor: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: awake, A&O to self, year and date, hosptial. CN II-XII
intact. strength 5/5 in upper and lower extremities.
On Discharge:
AO fully x3, participates in exam at his own discretion
Full strength in all motor groups.
CNII-XII intact
Pertinent Results:
Tissue: occipital metastisis. Study Date of [**2161-4-22**]
Report not finalized.
MR HEAD W/ CONTRAST Study Date of [**2161-4-22**] 8:01 AM
FINDINGS: Again seen is a heterogeneous left occipital lobe
measuring 4.3 cm AP x 3.1 cm TV x 3.3 cm SI. There has been
evolution of blood products in this region, as well as tumor
progression with increased internal solid
components and peripheral enhancement. There is mass effect and
effacement of the left occipital [**Doctor Last Name 534**] and regional sulci.
Linear region of enhancement persists in the left precentral
gyrus (3:21). There has been interval evolution of the 6-mm
hypointense focus at the medial border (2:75), which now appears
more smaller and more well-defined. Finding is not completely
evaluated on this study, but could represent cavitating infarct
or gliomatosis.
Ventricles and sulci are prominent, consistent with age-related
involutional changes. The major intracranial flow voids are
preserved. There is mild mucosal thickening in the right
maxillary and frontoethmoid air cells. Left maxillary sinus is
partially opacified.
IMPRESSION: 1. Interval progression of left occipital
metastasis.
2. Nonspecific enhancement and cystic change in the left frontal
lobe.
3. Paranasal sinus disease.
CT HEAD W/O CONTRAST Study Date of [**2161-4-23**] 7:23 AM
IMPRESSION: Status post excision of left occipital mass with
expected
post-surgical changes of fluid, white matter edema, and small
blood products at the operative site. Bifrontal subdural
nonhemorrhagic fluid collection and pneumocephalus is also seen.
No large infarction is present. Followup should be obtained as
clinically indicated.
MR HEAD W & W/O CONTRAST Study Date of [**2161-4-23**] 8:29 PM
IMPRESSION:
1. Post-surgical changes status post left craniotomy with
expected blood
products and pneumocephalus. No evidence of suspicious
enhancement to suggest residual tumor.
2. Stable small enhancement in the left frontal lobe.
CHEST (PORTABLE AP) Study Date of [**2161-4-26**] 11:50 AM
FINDINGS: The Dobbhoff tube extends to the lower portion of the
esophagus,
then coils on itself so that the tip lies somewhere above the
level of the
thoracic inlet.
[**4-28**] CXR: IMPRESSION: Increased consolidation at the left medial
lower lung, concerning for aspiration.
[**4-29**] CXR: As compared to the previous radiograph, a right-sided
PICC line
projects with its tip at the level of the cavoatrial junction.
[**4-30**]: Bilateral Lower extremity doppler ultrasounds: negative
for DVT
Brief Hospital Course:
On [**4-22**] the patient electively presented and underwent a left
occipital craniotomy and resection of hemorrhagic lesion.
Surgery was without complication and he tolerated it well. He
was extubated and transferred to the ICU. He became increasingly
agitated and did not respond to haldol, ativan or precedex. Due
to this agitation post op imaging was delayed and the patient
required intubation to complete imaging. Head CT was delayed
until [**4-23**] and demonstrated no hemorrhage. MRI was performed
later in the evening on [**4-23**] which showed no residual tumor.
On [**4-24**] patient was successfuly extubated. Psychiatry evaluated
the patient and made recommendations for treatment of his acue
dellerium.
On [**4-25**], the patient continued to be very aggitated. The
Decadron was weaned to decadron 3mg TID. Due to aggitation the
patient required ICU level care.
On [**4-26**], the patient decadron was written to wean to off over
the next 24 hours. Aggitation continued. A CXR was performed
following dophoff placement which was consistent with dobbhoff
tube extends to the lower portion of the esophagus,
then coils on itself so that the tip lies somewhere above the
level of the
thoracic inlet.
On [**4-27**], the patient exam was slightly improved, still confused
and aggitated. The patient was experiencing difficulty with
swallowing and a speech and swallow consultation was placed.On
exam, the patient opened his eyes spontaneously. He was
oriented to self, the month of [**Month (only) **] and for the place states
"[**Hospital3 **]". The patient continued to be impulsive but was
verbal. he exhibited full strength but did not participate in
detailed exam.The last dose of steroids were administered.
Physical therapy worked with the patient. there was a pallative
care meeting in which that patient's primary care Dr [**Last Name (STitle) **] was
present and the patient's partner/significant other but no
changes in current care were made.
On [**4-28**] the patient was neurologically stable. He has one
episode of agitation mid morning but was otherwise doing quite
well.
In the am of [**4-29**] he had a new occurance of Afib with rate of
145. Lopressor was given and his SBP dropped to 90. IL fluid
bolus was given. He was observed in the ICU, managed with PRN
Diltiazem for intermittent rate to 160s. After administration
of diltiazem he remained hemodynamically stable in atrial
flutter. He received a PICC line due to his poor vascular
access which was confirmed by CXR.
On [**4-30**] the patient was more lucid and conversant and he along
with family, HCP and his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], made
the decision to proceed with care plan consistent with comfort
only and arrangements were made for disposition home with
hospice care. Medications were adjusted for more comfort care
measures and he was taken off telemetry. LENIS were negative
for DVTs.
At the time of discharge he is tolerating a regular diet,
ambulating with assistance, afebrile with stable blood pressure
and intermittent tachycardia.
Medications on Admission:
1. Sodium Chloride Nasal [**2-2**] SPRY NU QID:PRN
2. traZODONE 200 mg PO/NG HS
3. Lorazepam 1 mg PO/NG ONCE
4. OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain
5. Ondansetron 4 mg IV Q8H:PRN
6. Acetaminophen 325-650 mg PO/NG Q6H:PRN
7. Divalproex (DELayed Release) 500 mg PO BID
8. MethylPHENIDATE (Ritalin) 20 mg PO/NG [**Hospital1 **]
9. Multivitamins 1 TAB PO/NG DAILY
10. Ranitidine 150 mg PO/NG DAILY
11. Pravastatin 40 mg PO DAILY
12. Levothyroxine Sodium 100 mcg PO/NG DAILY
13. Dexamethasone 4 mg IV Q12H
14. Clonazepam 1 mg PO/NG [**Hospital1 **]:PRN
15. BuPROPion (Sustained Release) 200 mg PO BID
16. Amoxicillin 500 mg PO/NG Q8H
17. Allopurinol 100 mg PO/NG DAILY
18. Docusate Sodium 100 mg PO BID
19. Senna 1 TAB PO/NG [**Hospital1 **]:PRN
20. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
2. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
4. bisacodyl 5 mg Tablet Sig: [**2-2**] Tablet, Delayed Release
(E.C.)s PO DAILY (Daily) as needed for constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
6. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for hiccups.
Disp:*90 Tablet(s)* Refills:*2*
8. divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule,
Sprinkle PO TID (3 times a day).
Disp:*360 Capsule, Sprinkle(s)* Refills:*2*
9. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
10. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO
three times a day.
Disp:*90 Capsule(s)* Refills:*2*
11. haloperidol 5 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
12. sodium chloride 0.9 % 0.9 % Solution Sig: Ten (10) ML
Injection twice a day as needed for line flush.
13. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
Disp:*16 Tablet(s)* Refills:*0*
14. atropine 1 % Drops Sig: Two (2) drop Ophthalmic every four
(4) hours as needed for secretions: 2 drops under the tounge Q4
hours as needed for secretions.
Disp:*15 ml* Refills:*0*
15. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
Five (5) mg PO every four (4) hours as needed for pain or
breathlessness.
Disp:*30 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Eastern MA
Discharge Diagnosis:
Left occipital metastatic lesion
Metastatic Melanoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Dressing may be removed on Day 2 after surgery.
?????? If you have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? If your wound was closed with staples or non-dissolvable
sutures then you must wait until after they are removed to wash
your hair. You may shower before this time using a shower cap to
cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
Followup Instructions:
?????? You have an appointment in the Brain [**Hospital 341**] Clinic on Monday,
[**5-4**] at 11:30 am. The Brain [**Hospital 341**] Clinic is located on the
[**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their
phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change
your appointment, or require additional directions. You will
need a wound check at this time.
Completed by:[**2161-4-30**]
|
[
"296.80",
"V10.52",
"197.0",
"293.0",
"274.9",
"431",
"V15.3",
"V10.82",
"V10.79",
"244.9",
"427.31",
"V66.7",
"401.9",
"197.7",
"198.3",
"V87.41",
"307.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11117, 11165
|
5260, 8374
|
318, 393
|
11261, 11261
|
2711, 5237
|
12813, 13301
|
1918, 1936
|
9231, 11094
|
11186, 11240
|
8400, 9208
|
11445, 12790
|
1951, 1951
|
2584, 2692
|
269, 280
|
421, 1362
|
1965, 2570
|
11276, 11421
|
1384, 1757
|
1773, 1902
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,179
| 178,138
|
47783
|
Discharge summary
|
report
|
[** **] Date: [**2128-5-26**] Discharge Date: [**2128-6-3**]
Date of Birth: [**2056-3-12**] Sex: F
Service: MEDICINE
Allergies:
Sotalol / lisinopril
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
hyponatremia and lethargy
Major Surgical or Invasive Procedure:
[**2128-5-27**] right heart catheterization
History of Present Illness:
Ms. [**Known lastname 100868**] is a 72F with history of end-stage non-ischemic
dilated CMP w/ EF 20%, complete heart block s/p PPM/ICD, and
primary effusion lymphoma s/p chemotherapy ([**2128-4-29**]) who now
presents with hyponatremia to 120 and [**Last Name (un) **] with creatinine to 3.0
from baseline 1.6-1.9. She has been abiding by her fluid
restriction and has been seeing Dr. [**First Name (STitle) 437**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
all of her scheduled appointments. She has not gained very much
weight, (weight was 83.9 lbs on [**5-11**] and today 89 lbs on bed
scale). Her breathing is stable, but her appetite has decreased.
She has been lethargic for about 5-7 days.
Exam in the ED was notable for no JVD, mildly decreased lung
sounds to bases likely representative of bilateral pleural
effusions, [**1-9**]+ LE edema. III/VI systolic murmur with blunted
S2. Quite lethargic, arouses to voice.
Spoke with Dr. [**First Name (STitle) 437**] about her. She has end-stage heart failure
and the family (mainly her son [**Name (NI) **], primary caretaker) has
been somewhat resistant to the idea of how sick she is. She is
not English-speaking and a continuing goals of care discussion
with her and her son will be very important before she gets
sicker. We agreed to try hypertonic saline VERY slowly to try to
avoid volume overload but make her feel better (raise her
sodium). Dr. [**First Name (STitle) 437**] also wants to start tolvaptan to see if this
will work. Patient is confirmed DNR/DNI (per son and HPC
[**Name (NI) **]).
.
In the ED, initial vitals were 98.0, 69, 110/72, 16, 100% RA.
Labs and imaging significant for Na 120, Cr 3.1. Urine lytes
had a Na of less than 10 with an osmolality 320 in the face of
serum osmoles 300 (inappropriate concentration in the face of
hyponatremia and volume overload). Patient given 3% hypertonic
saline in the ED with slight improvement in mental status and
Na increase to 122 over several hours.
.
On arrival to the floor, patient is awake and interactive. She
does not have chest pain, orthopnea, shortness of breath, or
palpitations. She understands what is happening with her heart,
sodium, and kidneys.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, cough, hemoptysis, black stools or red stools.
She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain although she does not walk much
at home. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, orthopnea, palpitations, syncope or
presyncope. She does have ankle edema and PND x1 the day PTA.
Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: Cath in [**2108**] @ [**Hospital1 2025**] with
clean coronaries per report
- PACING/ICD: Dual Chamber [**Company 1543**] Virtuoso DR [**Last Name (STitle) **] in
[**5-/2124**] as replacement of [**Company **] gem for imminent pocket
erosion. PPM placed originally in [**2112**], then repaired in [**2114**]
and [**2115**].
- Nonischemic Dilated Cardiomyopathy, sCHF (LVEF 20% [**2-/2128**])
- Complete heart block s/p ICD
- Severe tricuspid regurgitation
- Pulmonary artery systolic hypertension (TTE [**2-/2128**])
- Atrial fibrillation on warfarin and amiodarone.
- Pericardial effusion [**10/2127**], drained 650cc, atypical cells on
cytology
3. OTHER PAST MEDICAL HISTORY:
- Primary effusion Lymphoma including in the pericardial space
with h/o tamponade s/p rx with velcade x 3 cycles and doxil x 2
cycles
- hypercalcemia
- Osteoporosis
- GERD
- E. Coli cystitis [**11/2127**] treated with 7 days of cipro
- C. diff with PO metronidazole ([**11/2127**]) x14 days
- Chronic kidney disease baseline Cr 1.4-1.6
Social History:
She is originally from Sicily, [**Country 2559**], and immigrated in [**2084**],
Italian speaking, can speak some English. She lives with her
son, [**Name (NI) 100875**]. She previously worked as a factory worker.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Family History:
Her mother and 1 sibling were killed during World War II in a
bombing. She denies any family history of leukemia or lymphoma.
She reports that her father had heart disease. Overall, she had
4 brothers and 4 sisters, none of
which had any malignancy.
Physical Exam:
[**Name (NI) **] PHYSICAL EXAM:
VS: T 97.6, BP 100s/50s, HR 70s, RR 14, O2 sat 94% 2L NC
GENERAL: fraily, ill-appearing F in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Prominent RV heave. RR, normal S1, S2. 4/6 systolic
murmur. 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 but generally decreased breath sounds
bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: 1+ pitting edema bilaterally to mid-shin.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: radial 2+ DP dopplerable
Left: radial 2+ DP dopplerable
DISCHARGE PHYSICAL EXAM
Pertinent Results:
[**Name (NI) **] LABS
[**2128-5-25**] 11:50AM BLOOD WBC-6.3 RBC-4.12* Hgb-12.5 Hct-39.3
MCV-95 MCH-30.4 MCHC-32.0 RDW-16.3* Plt Ct-157#
[**2128-5-26**] 12:33PM BLOOD Neuts-87.7* Lymphs-7.1* Monos-4.5 Eos-0.5
Baso-0.2
[**2128-5-25**] 11:50AM BLOOD PT-15.0* INR(PT)-1.4*
[**2128-5-25**] 11:50AM BLOOD UreaN-115* Creat-3.1* Na-121* K-3.2*
Cl-78* HCO3-29 AnGap-17
[**2128-5-26**] 12:33PM BLOOD ALT-25 AST-47* AlkPhos-257* TotBili-2.2*
[**2128-5-26**] 12:33PM BLOOD Lipase-42
[**2128-5-26**] 12:33PM BLOOD Albumin-3.3*
[**2128-5-27**] 04:03AM BLOOD Calcium-8.8 Phos-4.7*# Mg-2.5
[**2128-5-26**] 12:33PM BLOOD Osmolal-299
[**2128-5-26**] 02:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2128-5-26**] 02:15PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2128-5-26**] 02:15PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
[**2128-5-26**] 02:15PM URINE Hours-RANDOM Creat-38 Na-LESS THAN K-42
Cl-19
[**2128-5-26**] 02:15PM URINE Osmolal-328
SODIUM TREND
[**2128-5-25**] 11:50AM Na-121*
[**2128-5-26**] 10:00AM Na-121*
[**2128-5-26**] 12:33PM Na-120*
[**2128-5-26**] 05:20PM Na-122*
[**2128-5-26**] 08:22PM Na-126*
[**2128-5-26**] 11:53PM Na-124*
[**2128-5-27**] 04:03AM Na-127*
[**2128-5-27**] 08:53AM Na-132*
PERTINENT IMAGING
[**2128-5-27**] TTE:
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is severely depressed
(LVEF= 15-20 %). The right ventricular cavity is moderately
dilated with borderline normal free wall function. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild to moderate ([**12-8**]+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. An eccentric, posteriorly
directed jet of at least moderate (2+) mitral regurgitation is
seen. Severe [4+] tricuspid regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. Significant
pulmonic regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mildly dilated left ventricle with normal wall
thickness and severely depressed global left ventricular
systolic function. Moderately dilated right ventricle with
borderline normal systolic function. Mild to moderate aortic
regurgitation. At least moderate mitral regurgitation. Severe
tricuspid regurgitation. Indeterminate pulmonary artery systolic
pressure.
DISCHARGE LABS:
Brief Hospital Course:
Ms. [**Known lastname 100868**] is a 72 year old female with history of primary
effusion lymphoma (PEL) and non-ischemic dilated cardiomyopathy,
EF 20%, who presented with hyponatremia and acute renal failure
in the setting of volume overload. She was started on milrinone
continuous infusion; CO increased to 3.1 from 2.9, f/u ECHO did
not show significant change but her symptoms improved.
.
# Hyponatremia: Urine osmoles showed inappropriately
concentrated urine in the face of hyponatremia and volume
overload. Likely the inapproriate ADH release was related to
heart failure. This was supported by low urine Na, suggesting
the kidneys were seeing poor forward flow and trying to augment
volume and Na. Got hypertonic saline with good results: Na
increased to 122 --> 126 --> 132 and patient's lethargy
resolved. When hypertonic saline was stopped, Na drifted back
down. Since we felt her hyponatremia was due to heart failure
and poor renal perfusion, she was managed with milrinone as
below as well as salt tabs.
.
# Chronic systolic heart failure (sCHF): Non-ischemic etiology
and symptoms are predominantly right-sided, likely due to wide
open tricuspid regurgitation. Had continued with hypervolemia
symptoms and weight gain despite spironolactone 25 mg daily and
torsemide 80 mg daily at home. She was sent for a right heart
cath which showed improvement in cardiac output with milrinone.
Thus, she was started on milrinone continuous infusion at 0.5
mcg/kg/min. Her echo on this showed "Borderline dilated,
globally hypokinetic left ventricle. Dilated right ventricle
with borderline normal systolic function. Mild to moderate
aortic regurgitation. At least mild to moderate mitral
regurgitation. Severe tricuspid regurgitation. At least moderate
pulmonary artery systolic hypertension. Pulmonary diastolic
hypertension appreciated.
Compared with the prior study (images reviewed) of [**2128-5-27**], at
least moderate pulmonary artery systolic hypertension is now
present; it was previously indeterminate. A slight decrease in
left ventricular cavity size from 5.8 centimeters to 5.6
centimeters is appreciated, but may be due to a
positional/angular change of the transducer used in obtaining
the images, rather than a true decrease in dimension."
As above, her cardiac output improved to 3.1. She was also
continued on torsemide 80mg then 60mg, spironolactone was held
for hyperkalemia. Metoprolol was also held, but then it was
restarted at her home dose before she was discharged. She is no
longer on ACE inhibitors because of her renal function and
because her heart remodeling is considered complete. We
discussed with her and her family that she had end-stage heart
failure and likely around 6 months to live.
# Acute kidney injury ([**Last Name (un) **]): Her [**Last Name (un) **] was likely related to poor
renal perfusion from worsening heart failure as well. With
addition of milrinone, her Cr improved from 3.1 on [**Last Name (un) **] to
2.0
# atrial fibrillation (Afib): Chronic afib status post ICD and
now constantly v-paced. TSH has been normal, most recently in
[**4-17**]. She was continued on metoprolol for rate control and
amiodarone for rhythm control. However, her warfarin was
discontinued because her annual stroke risk is low compared to
life expectancy with a CHADS2 score of 1.
# Somnolence: Initially was lethargic for 1 week prior to
[**Month/Year (2) **] and taking decreased POs. Likely multifactorial with
contributions from hyponatremia as well as uremia. Resolved
with normalization of serum Na.
.
FEN: HH PO, 2 gm Na restriction, 1000 ml fluid restriction
CODE: DNR/DNI confirmed
EMERGENCY CONTACT: [**Name (NI) **] [**Telephone/Fax (1) 100871**] son/HCP
TRANSITIONAL ISSUES:
- Continue discussions with patient and family about her
prognosis from heart failure and PEL. Discussion with
palliative care for hospice care is ongoing.
- VNA for milrinone
Medications on [**Telephone/Fax (1) **]:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Amiodarone 100 mg PO DAILY
2. Spironolactone 25 mg PO DAILY
3. Torsemide 80 mg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Warfarin 2 mg PO DAILY16
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. traZODONE 25 mg PO HS:PRN sleep
8. Ferrous Sulfate 325 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Milrinone 0.5 mcg/kg/min IV INFUSION
RX *milrinone 1 mg/mL 0.5mcg/kg/min continuous Disp #*30 Bag
Refills:*2
2. Outpatient Lab Work
Please check chem-7 on [**First Name9 (NamePattern2) 100885**] [**6-4**] with results to Dr.
[**First Name (STitle) 437**] at Phone: [**Telephone/Fax (1) 62**]
Fax: [**Telephone/Fax (1) 9825**]
3. Amiodarone 100 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Torsemide 60 mg PO DAILY
Please hold for SBP < 90
8. traZODONE 25 mg PO HS:PRN sleep
9. 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.
RX *Heparin Lock 10 unit/mL flush with 2 ml after NS as needed
Disp #*30 Syringe Refills:*2
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS
chronic systolic heart failure--EF 20%, non ischemic
.
Secondary diagnosis:
Complete heart block
Primary effusion lymphoma
Atrial fibrillation
Discharge Condition:
Improved
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 100868**],
You were admitted to the hospital because your sodium was very
low and your kidneys were not working well. We think that both
of these problems were because your heart failure was worsening
and the blood was not circulating well to the kidneys. You
underwent a cardiac catheterization which showed that your heart
pump was weak and improved with a new medication, called
milrinone. You were started on continuous infusion of milrinone
and your kidneys and sodium improved. An ultrasound of your
heart showed that it beat more effectively with milrinone.
However, this medication does not change the overall poor
prognosis of your heart failure.
The following changes were made to your medications:
- START milrinone at 0.5mcg/kg/min, the home infusion company
will help you and your son manage the pump.
- STOP taking warfarin and spironolactone
You should also keep all the follow-up appointments listed
below. It is important to bring your medications to each
appointment so your doctors [**Name5 (PTitle) **] adjust the doses as needed.
Also, weigh yourself every morning, call Dr. [**First Name (STitle) 437**] if weight
goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2128-6-7**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ADULT SPECIALTIES
When: THURSDAY [**2128-6-17**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21927**], MD [**Telephone/Fax (1) 721**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIAC SERVICES
When: THURSDAY [**2128-6-24**] at 11:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: FRIDAY [**2128-6-25**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6887**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: WEDNESDAY [**2128-7-14**] at 10:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6887**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
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"403.90",
"276.1",
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icd9cm
|
[
[
[]
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] |
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,480
| 188,502
|
52770
|
Discharge summary
|
report
|
Admission Date: [**2138-2-20**] Discharge Date: [**2138-3-4**]
Date of Birth: [**2091-4-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
RLE pain, chills
Major Surgical or Invasive Procedure:
Upper Endoscopy
Colonoscopy
Capsule endoscopy
History of Present Illness:
Ms [**Known lastname 449**] is a 46yoF with h/o hx of traumatic brain injury and
developmental delay, Hep C, DM and pseudoseizures, on coumadin
since [**2137-6-3**] for persistant LLE DVT, who presents with pain in
RLE and subjective fever/chills. Care taker found her in a cold
sweat, and less responsive, so called EMS. History limited by pt
being a poor historian. The symptoms began earlier on day of
admission, and associated with general body weakness. She also
complains of feeling SOB and with mild mid-chest pain, pt unable
to further characterize. She denies dysuria or other urinary
changes. She denies any other pain. She denies nausea, vomiting,
diarrhea, cough, or headaches. She had a fall 2 days ago and
broke her left radial head, and per pt did hurt her leg as well.
.
Of note, her prior history is significant for an unprovoked DVT
on [**2137-6-3**] involving the left superficial femoral vein,
nonocclusive. The record notes no recent travel, trauma,
surgeries, OCPs. She has no known malignancy. She has been on
warfarin since that time with INR goal to 2.5-3 range. She had
ongoing symptoms in [**2138-1-2**] and had LENI done at that time
which showed non-occlusive thrombus of the left common femoral
vein is similar in appearance to prior imaging studies. Prior CT
has demonstrated thrombus in the left pelvic vein. She is now on
coumadin indefinitely. She was seen in the ED at that time and
found to have an INR of 1.0. Unclear if she was taking coumadin
but was restarted and given lovenox to bridge.
.
In the ED, initial VS were: T: 99.6, BP: 102/59, P: 127, RR: 20,
O2 Sat: 100% on RA. Her INR was found to be 24, with severely
elevated PT and PTT as well. There was concern for spontaneous
bleed vs compartment syndrome, so ortho was consulted who felt
that this was not compartment syndrome, but instead cellulitis.
She was given vancomycin and unasyn, as well as morphine for
pain and vitamin K 10mg IV x1. An EJ line was placed. Ortho did
feel that she should get Q2H serial compartment checks, with
measurement of compartment pressure if exam changes.
On arrival to the MICU, she is in NAD though complaining of pain
in RLE, mostly in the calf. She also has mild SOB and is mildly
tachypneic, though was 100% on room air.
Past Medical History:
- TBI in childhood after fall from window; had R parietal
craniotomy and subsequent L hemiparesis and cognitivie deficits
- Adult pseuodseizures (with multiple negative EEGs), says last
seizure was over 5 years ago
- Childhood epilepsy
- Hep C
- DM
- Anemia
- Anxiety Disorder
- s/p tubal ligation
Social History:
lives in [**Doctor Last Name **] home, case manager [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 53328**], history of cocaine
use and alcohol, with relapse several years ago, +35 pack year
smoking hx and is still smoking 1ppd; not on OCPs or any
estrogens. Highest level of education 9th grade, does not work,
previous employment hx as guard. Single, not sexually active.
Family History:
denies family history of blood clots. otherwise
non-contributory.
Physical Exam:
Admission exam
Tcurrent: 37.4 ??????C (99.3 ??????F)
HR: 127 (127 - 129) bpm
BP: 96/68(76) {96/60(69) - 105/68(76)} mmHg
RR: 17 (17 - 21) insp/min
SpO2: 94%
General: Alert, oriented though poor historian, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, unable to assess JVP 2/2 strong/fast carotid
pulsations, no LAD
CV: tachycardic, no mrg, normal S1 + S2
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
RLE: Skin clean and intact, +warmth RLE>LLE; Thigh is soft. Leg
compartments firm but compressible, firmer than
contralateral side. No pain w/ passive stretch. 2+ DP pulse. No
obvious erythema. [**2-3**]+ pitting edema up to knee.
LLE: Skin clean and intact, Compartments soft. No pain w/
passive
stretch. 2+ DP pulse
Neuro: CNII-XII intact, LUE: [**5-8**] bicep, [**3-9**] wrist
extension/flexion, intraosseious, RUE: 5/5 strength throughout,
LLE: 4/5 strength throughout; RLE: 5/5 strength; Sensation to LT
intact throughout
5/5 strength upper/lower extremities, grossly normal sensation,
2+ reflexes bilaterally, gait deferred, finger-to-nose intact
..
Discharge PE:
24hr Tmax 99.7 Tc 96.7 HR 80 BP 100/50 RR 18 SaO2 95 on RA
General: Alert, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no JVP, no LAD
CV: tachycardic, no mrg, normal S1 + S2
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
RLE: Skin clean and intact, No pain w/ passive stretch. 2+ DP
pulse. No obvious erythema. trace edema.
Neuro: CNII-XII intact, RUE: [**5-8**] bicep, [**3-9**] wrist
extension/flexion, intraosseious, LUE: 5/5 strength throughout,
RLE: 4/5 strength throughout; LLE: 5/5 strength; Sensation to LT
intact throughout
Pertinent Results:
Admission labs:
[**2138-2-20**] 05:18PM BLOOD WBC-8.9 RBC-2.81*# Hgb-9.2*# Hct-27.0*#
MCV-96 MCH-32.6* MCHC-34.0 RDW-14.2 Plt Ct-229
[**2138-2-20**] 11:27PM BLOOD WBC-7.8 RBC-2.13* Hgb-7.2* Hct-21.2*
MCV-99* MCH-33.8* MCHC-34.0 RDW-14.2 Plt Ct-206
[**2138-2-21**] 04:45AM BLOOD WBC-8.9 RBC-2.27* Hgb-7.3* Hct-21.4*
MCV-95 MCH-32.3* MCHC-34.2 RDW-15.0 Plt Ct-186
[**2138-2-21**] 07:48AM BLOOD WBC-9.0 RBC-2.67* Hgb-8.5* Hct-24.4*
MCV-92 MCH-31.7 MCHC-34.7 RDW-16.2* Plt Ct-171
[**2138-2-20**] 05:18PM BLOOD PT->150 PTT-146.1* INR(PT)-24.0*
[**2138-2-20**] 11:27PM BLOOD PT-25.4* PTT-37.6* INR(PT)-2.4*
[**2138-2-20**] 11:27PM BLOOD Ret Aut-1.4
[**2138-2-25**] 06:01AM BLOOD Ret Aut-2.9
[**2138-2-20**] 05:18PM BLOOD Glucose-216* UreaN-20 Creat-1.3* Na-139
K-4.2 Cl-101 HCO3-25 AnGap-17
[**2138-2-20**] 11:27PM BLOOD Glucose-190* UreaN-17 Creat-1.0 Na-139
K-4.2 Cl-106 HCO3-20* AnGap-17
[**2138-2-21**] 04:45AM BLOOD Glucose-137* UreaN-15 Creat-0.8 Na-141
K-4.2 Cl-110* HCO3-24 AnGap-11
[**2138-2-20**] 05:18PM BLOOD ALT-25 AST-35 AlkPhos-36 TotBili-0.5
[**2138-2-20**] 11:27PM BLOOD ALT-28 AST-54* LD(LDH)-239 AlkPhos-31*
TotBili-0.9
[**2138-2-20**] 05:18PM BLOOD Albumin-3.6
[**2138-2-21**] 04:45AM BLOOD Albumin-2.8* Calcium-7.4* Phos-3.3 Mg-1.9
Iron-128
Iron studies/B12, folate
[**2138-2-21**] 04:45AM BLOOD calTIBC-286 VitB12-404 Folate-11.4
Ferritn-87 TRF-220
[**2138-2-24**] 06:43AM BLOOD TSH-4.0
[**2138-2-24**] 06:43AM BLOOD T4-6.6
[**2138-2-24**] 06:43AM BLOOD Vanco-3.2*
lactate trend:
[**2138-2-20**] 05:21PM BLOOD Lactate-6.6*
[**2138-2-20**] 06:38PM BLOOD Lactate-4.4*
[**2138-2-20**] 09:04PM BLOOD Lactate-3.8*
[**2138-2-21**] 04:59AM BLOOD Lactate-1.4
INR Trend:
[**2138-2-20**] 05:18PM BLOOD PT->150 PTT-146.1* INR(PT)-24.0*
[**2138-2-20**] 11:27PM BLOOD PT-25.4* PTT-37.6* INR(PT)-2.4*
[**2138-2-21**] 04:45AM BLOOD PT-16.6* PTT-34.7 INR(PT)-1.6*
[**2138-2-22**] 03:19AM BLOOD PT-13.1* PTT-38.3* INR(PT)-1.2*
[**2138-2-23**] 06:45AM BLOOD PT-19.8* PTT-40.0* INR(PT)-1.9*
[**2138-2-24**] 06:43AM BLOOD PT-20.3* INR(PT)-1.9*
[**2138-2-25**] 06:01AM BLOOD PT-20.8* INR(PT)-2.0*
[**2138-2-26**] 05:48AM BLOOD PT-23.0* INR(PT)-2.2*
[**2138-2-27**] 05:50AM BLOOD PT-28.9* INR(PT)-2.8*
[**2138-2-28**] 06:55AM BLOOD PT-27.6* INR(PT)-2.7*
[**2138-3-1**] 08:32AM BLOOD PT-24.7* INR(PT)-2.4*
[**2138-3-2**] 07:20AM BLOOD PT-22.4* INR(PT)-2.1*
[**2138-3-3**] 06:00AM BLOOD PT-19.0* INR(PT)-1.8*
[**2138-3-4**] 07:00AM BLOOD PT-20.2* PTT-39.4* INR(PT)-1.9*
Discharge labs:
[**2138-3-4**] 07:00AM BLOOD WBC-7.5 RBC-2.88* Hgb-8.7* Hct-27.6*
MCV-96 MCH-30.1 MCHC-31.4 RDW-15.3 Plt Ct-711*
[**2138-3-4**] 07:00AM BLOOD PT-20.2* PTT-39.4* INR(PT)-1.9*
[**2138-3-3**] 06:00AM BLOOD Glucose-119* UreaN-10 Creat-0.8 Na-142
K-4.6 Cl-105 HCO3-28 AnGap-14
RUQ Ultrasound: [**2138-2-28**]
1. No focal liver lesions identified.
2. Mild gallbladder wall edema is likely related to third
spacing in the
setting of hypoalbuminemia.
3. Small volume perihepatic ascites.
4. Tiny bilateral pleural effusions, as on recent CT from
[**2138-2-21**].
ECHO [**2138-2-27**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
No mass or vegetation is seen on the mitral valve. The pulmonary
artery systolic pressure could not be determined. There is a
very small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
IMPRESSION: No valvular vegetations or abscesses appreciated.
Indeterminate pulmonary artery systolic pressure. Very small,
circumferential pericardial effusion without echocardiographic
evidence of tamponade.
Intestinal Biopsies [**2138-2-25**]
A. Ileocecal valve:
1. Colonic mucosa with no diagnostic abnormalities recognized;
multiple levels examined.
2. Scant adipose tissue is present.
B. 50 cm:
Colonic mucosa with no diagnostic abnormalities recognized;
multiple levels examined.
CTA Chest [**2138-2-22**]
1. There is no evidence of central pulmonary embolism. The
visualization of more peripheral branches is limited due to
patient motion, suboptimal contrast bolus, and contrast flow
artifact; the segmental and subsegmental pulmonary arteries
cannot be reliably assessed for pulmonary embolism.
2. Mild bibasilar atelectasis.
3. New small pleural effusions.
CT Abd/ pelvis: [**2138-2-21**]
1. No retroperitoneal hematoma. No acute intra-abdominal
abnormality on this non-contrast CT.
2. Bibasilar dependent consolidation, probably atelectasis.
CT Lower Extremities: [**2138-2-21**]
1. No acute fracture.
2. No hematoma identified.
3. Slight enlargement of the right lower extremity when compared
to the left. There is subcutaneous swelling and edema most
prominent along the right lateral thigh.
4. Degenerative changes as described above.
Brief Hospital Course:
Ms [**Known lastname 449**] is a 46yoF with h/o hx of traumatic brain injury and
developmental delay, Hep C, DMII and pseudoseizures, on coumadin
since [**2137-6-3**] for persistant LLE DVT, who presents with pain in
RLE and subjective fever/chills, 2 days after a fall.
.
# Tachypnea: On initial presentation to the MICU, the patient
was tachypneic with a [**Doctor Last Name 3012**] score is 6, putting her at high risk
for PE. She was not hypoxic, but given her history of LLE DVT,
as well as her sinus tachycardia, the patient underwent CTA
while on the general medicine floor, which was negative for any
central pulmonary embolus.
.
# RLE pain/erythema: While in the MICU, the patient was started
on Vanc/Unasyn for possible cellulitis. Ortho was also
following her and doing serial compartment checks. She also had
a R LENI, which was negative for any DVTs. The patient also had
a CT pelvis and extremities to evaluate for any RP bleed or
bleeding into thigh that could account for this pain, given her
elevated INR on presentation; both were negative.
.
On transfer to the general medicine floor, it was decided to
stop the vanc/unasyn as there was low clinical suspicion for
cellulitis based on exam. The patient continued to elevated her
RLE. She was initially pain controlled with oxycodone and
tylenold; but because of her increased lethargy on arrival to
the floor, the patient's narcotics were d/ced and her pain was
controlled on tylenol. Upon discharge, her pain was resolved.
She also was seen by PT while in patient.
.
# Supratherapeutic INR: The patient is anticoagulated for her
chronic LLE DVTs. She was found to have an INR of 24 in the ED,
and after getting 10 mg Vitamin K IV in the ED, her repeat INR
was down to 2.4. Possible that this was a spurious result. The
patient was evaluated for evidence of RP bleed, or bleeding into
extremities with CT, which were negative. She was also
initially followed by ortho out of concern for compartment
syndrome. On transfer to the floor, the patient's INR was
subtherapeutic and the patient's coumadin was increased to 4mg
daily. The patient's INR was 1.9 at the time of discharge and
was continued on her coumadin 4mg daily. She will need to
follow up in coumadin clinic for INR monitoring and dose
adjustments after rehab.
.
# Acute kidney injury: The patient has a baseline creat of 0.8,
and on admission, creat found to be 1.3. Likely prerenal and
after fluids, her creat had returned to her baseline.
.
# fever of unclear etiology: After being called out from the
MICU, the patient had fever of unclear etiology, with
temperatures ranging from 100.5 to ~101. She had a negative
infectious work up, including, blood cultures, urine cultures,
ECHO, Cdiff; her PICC line was also pulled. CMV, EBV, and Parvo
virus labs were also were sent, as it was thought that a viral
syndrome could have accounted for her fevers and her anemia (see
below). EBV demonstrated past infection and CMV and parvo were
pending at the time of discharge.
.
Although no source was ever found, the patient remained afebrile
for 96 hours prior to discharge from hospital.
.
# lactic acidosis: The patient was found to have lactate of 6.6
on admission with unclear etiology. Possible that this could
have been do to some underlying infection, but no source of
infection was indentified. More likely, however, is that lactic
acidosis occurred secondary to metformin use in the setting of
acute kidney injury due to dehydration. The patient's metformin
was held while in patient and she was given fluids in the MICU.
Upon transfer to the medicine floor, the patient's lactic
acidosis had resolved. Her metformin was held during the
hospitalization. Upon discharge, the patient's creat had
normalized, and she was discharge on a insulin sliding scale.
Here outpatient primary care provider should determine if she
should be restarted on metformin.
.
# Anemia: The patient has baseline crit in the high 30s, with
most recent crit in our system from [**7-/2137**] at 38.0. On
presentation crit was found to be 27 and downtrended in the MICU
as low as 21, with no active source found. In the setting of her
elevated INR, CT abdomen and extremities were done to rule out
any hematomas, or RP bleed that could account for crit drop.
Iron studies, B12, folate, and hemolysis labs were all normal
although these were obtained after 1 unit of blood was given.
The patient was found to have guaic positive brown stool in the
ED. She was also found to have inappropriately low retic count.
.
On transfer to the floor, the patient had anemia work up that
included EGD, capsule endoscopy, and colonoscopy by GI. The
patient did not have any possible sources of bleeding, as per
GI. The patient had an inappropriately low retic count, and her
peripheral smear was viewed which did not show significant
evidence of schistocytes or teardrop cells. SPEP/UPEP was also
within normal limits.
.
# Left radial head fracture: pt was seen for fall on [**2-18**] and
found to have have Left radial head fracture. As per her [**Hospital 1957**]
clinic appt, no acute intervention was indicated, and her pain
was controlled as above.
.
# epilepsy: The patient follows with Neurology at [**Hospital1 18**]; while
in patient she was continued on her home gabapentin, divalproax,
and lorazepam.
.
# Anxiety/psychotic disorder: The patient's mood has been
stable while in patient; she was continued on risperdal,
amitryptiline, and lorazepam at home doses.
.
#DM last A1c 6.0% in [**2137-8-2**]. On metformin at home, was stop
due to lactic acidosis (see above) and acute illness and put on
HISS.
.
#Hep C - no evidence of decompensation. It is unclear if she
would be a candidate for therapy given possible difficulties
with compliance and psychiatric history. HCV viral load in
[**2137-9-2**] was 31,000 IU/mL.
..
Transitional Issues:
- Liver follow-up: The patient was instructed by her PCP to
follow up in the liver clinic in regards to her Hep C; another
appointment was set up for her to follow with liver as an
outpatient.
- metformin induced lactic acidosis: It is possible that the
patient's initial lactic acidosis was secondary to metformin use
in the setting of acute kidney injury. Her metformin was not
restarted upon discharge.
- Rehab for a less than 30 day stay for evaluation and
treatment.
Medications on Admission:
ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet
- 1 Tablet(s) by mouth q4-6 [**Last Name (un) **] BR6700377
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 1 puff IH q4-6
as needed for wheeze, cough
ALBUTEROL SULFATE - (Prescribed by Other Provider) - Dosage
uncertain
AMITRIPTYLINE - (Prescribed by Other Provider) - 10 mg Tablet -
2 Tablet(s) by mouth at bedtime
CICLOPIROX - 0.77 % Cream - Apply to soles of feet twice a day
as
directed.
COMPRESSION STOCKING - - apply one large compression stocking
to Right Calf Daily With activity
DIVALPROEX - (Prescribed by Other Provider) - 500 mg Tablet
Extended Release 24 hr - 1 Tablet(s) by mouth twice a day
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth Qweekly once a week for 6 weeks
FLUTICASONE - 50 mcg Spray, Suspension - 1 spray IN twice a day
GABAPENTIN - (Prescribed by Other Provider) - 400 mg Capsule -
1
Capsule(s) by mouth twice a day
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth at bedtime at
night
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 1
Tablet(s) by mouth twice a day
RISPERIDONE - (Prescribed by Other Provider) - 4 mg Tablet - 1
Tablet(s) by mouth twice a day
TOLTERODINE [DETROL LA] - 2 mg Capsule, Ext Release 24 hr - 1
Capsule(s) by mouth daily
WARFARIN - 2 mg Tablet - Take up to 3 Tablet(s) by mouth daily
or
as directed by coumadin clinic
ACETAMINOPHEN - 500 mg Tablet - 1 Tablet(s) by mouth every six
(6) hours as needed for pain; Do not exceed [**2126**] mg/day
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - use
to
monitor your blood sugar up to 4 times a day or as directed
BLOOD-GLUCOSE METER [FREESTYLE LITE METER] - Kit - use as
directed to monitor blood glucose twice daily and as needed
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
LANCETS [FREESTYLE LANCETS] - Misc - use as directed to
monitor
your blood sugar up to 4 x per day as directed
SENNOSIDES - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for Constipation
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for SOB or
wheeze.
2. amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. ciclopirox 0.77 % Cream Sig: One (1) Topical twice a day:
apply to soles of feet twice daily.
4. divalproex 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO BID (2 times a day).
5. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Do not exceed 4 gm in 24 hours.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal twice a day.
10. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. risperidone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
13. warfarin 4 mg Tablet Sig: One (1) Tablet PO Tue, Wed, [**Last Name (un) **],
Sat, Sun: adjust for goal INR [**3-7**].
14. warfarin 3 mg Tablet Sig: One (1) Tablet PO Monday, Friday:
adjust for goal INR [**3-7**].
15. insulin lispro 100 unit/mL Solution Sig: One (1) injection w
meals Subcutaneous ASDIR (AS DIRECTED): per sliding scale .
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & [**Hospital **] Care Center - [**Location 1268**]
Discharge Diagnosis:
primary diagnosis:
Metformin induced lactic acidosis
Anemia
Secondary Diagnosis:
Traumatic Brain Injury
Diabetes Type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 449**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because you were
not feeling well at home; in the emergency room, there was
concern you had a leg infection and some of your other blood
markers were elevated. Because of this, you were initially
admitted to the intensive care unit. while you were in the
intensive care unit, you were started on antibiotics. Your
antibiotics were stopped when there was no sign of any infection
in your leg.
You had fevers and we did not determine the cause. Your fevers
resolved on their own and no source of infection was found.
You also had low blood counts. You had no sign of any bleeding
and all your studies were normal.
We made the following changes to your medications:
-Stopped metformin
-Stopped tolterodine
-Started insulin sliding scale
-Started pantoprazole 40 mg by mouth daily
It is VERY important that you follow up with your outpatient
doctors (see below for appointments).
Followup Instructions:
Department: LIVER CENTER
When: THURSDAY [**2138-3-13**] at 3:00 PM
With: [**Name6 (MD) **] [**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: WEDNESDAY [**2138-4-2**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 22337**], 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
Name: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 250**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
|
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7,144
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22347
|
Discharge summary
|
report
|
Admission Date: [**2125-7-22**] Discharge Date: [**2125-7-29**]
Date of Birth: [**2073-8-23**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
upper GI bleed
Major Surgical or Invasive Procedure:
EGD with esophageal banding.
History of Present Illness:
HPI:
51 yo F, hx etoh abuse, who was doing well until about one year
ago when she was diagnosed with cirrhosis. Apparently, the
patient went to her PCP and was sent for an ultrasound. She was
given the dx of cirrhosis at that time. Over the following
year, the patient did not follow up with her physician and she
continued to drink alcohol. In mid-[**Month (only) **] ([**2125-6-28**]), she began
vomiting blood at home. She did not go to the hospital at that
time. The pt continued vomiting and decided to go to OSH ED 3
days later ([**7-1**]). She was admitted at that time with Hct=14
and SBP=80's. During her hospital admission, she had an
EGD/esophageal banding of varicies. She had a few episodes of
melena, but no further hematemesis. She was discharged after 5
days.
After returning home, she did not have any further bleeding and
had abstained from EtOh, without any dk stools, melena, BRBPR,
hematemesis, F/C, nausea, abd pain, no dysuria, + BLE edema.
About 2 weeks later, she was in the car with her sister, and
began vomiting blood/clots again. Her sister brought her to OSH
([**Hospital1 1562**] on [**7-21**]).
Pt admitted to OSH [**7-21**] w/episode of hematemesis of clots, then
500cc BRB en route to OSH. At OSH ED p 114, bp 88/49pt had
massive hemoptysis, intubated for airway protection (ABG
7.43/26/81). They thought that earlier banding 2-3 weeks ago may
have dislodged. Pt tx w/endoscopy, hypertonic saline inj. Tx w/
4U PRBCs, hct 24-23! Given more units PRBCs, hct 31 prior to
transfer, INR 1.9, alb 2.0, tbili 23.6, dbili 15.4. Tx w/vanco
x1, zosyn x1.
Patient was then transferred to [**Hospital1 18**] for further management of
varicies and liver disease. She was admitted to the MICU and
given an aditional PRBCs and had another EGD. Patient was
intubated for airway control. GI performed another esophageal
banding. Pt did not bleed further. She was extubated [**7-24**] and
did well. Only concern was patient's decreased mental status
s/p extubation thought to be related to receiving Ativan. Prior
to admission, she was fully functional, occupied as a teacher.
She was teaching until 3 weeks prior to this admission.
A/P:
51 yo F, hx ETOH abuse, hx recent variceal bleed at OSH [**6-15**] tx
w/banding, now represents after [**2-13**] wks w/recurrent UGIB,
hematemesis, hct 24->29.8 despite 6U PRBCs and hypertonic saline
injection at OSH, hypotensive to 90s, +NGT lavage. Patient now
transferred from ICU with Hct 39 and no active bleeding. Pt
with leukocytosis (25) with CXR LUL infiltrate and mild decrease
in MS.
1) UGIB
-esophageal varices (given acute blood loss, recent hx
w/banding, EGD at OSH); pt s/p transfusion and banding in ICU,
now stable
-NPO, IVF, IV PPI [**Hospital1 **], octreotide gtt (50mcg)
-cont octreotide gtt
-cont. propranolol for variceal bleeding prophylaxis
-maintain 2 large bore IVs
-consider possible TIPS, will follow with GI
2) Cirrhosis: pt w/ h/o cirrhosis (Class C), although no biopsy
proven dx; RUQ u/s w/dopplers w/patent PV, ascites, retrograde R
sided flow, anterograde L sided flow; pt with high INR (1.9 s/p
vit K) and high bili (25). Not transplant candidate.
-follow LFTs, coags, plts, alb, bili: alb still low, tbili
-Liver following with Dr. [**Last Name (STitle) 10285**]
3) Ascites: diagnostic tap in AM [**7-23**]. removed 4.5 liters of
fluid which showed 30 WBC, 95 RBCs with
11poly,32lymphs,25monos,29macs, and total protein less than 0.3
and albumin less than 1.
-prophylactic SBP tx w/ CTX x 5 days ([**Date range (1) **])
-Follow wbc count and temp curve
-Lasix, aldactone and prn paracentesis.
4) Encephalopathy: pt received ativan in ICU, possibly cause of
decresaed MS.
[**Name14 (STitle) **]/c ativan, haldol for agitation
-start lactulose
5) Leukocytosis: pt has wbc=25 but afebrile, s/p tap --> no SBP.
CXR shows ?LUL infiltrate. WBC count rising despite
ceftriaxone. Concerned for hospital acquired/vent associated
vs. aspiration pneumonia.
-will cont ceftriaxone for pneumonia coverage
-will add Clindamycin for better staph/anaerobic coverage
6) Anemia: pt currently not actively bleeding, s/p transfusion,
Hct stable at 39.
-follow Hct
7) ARF: pt initially in prerenal ARF, likely volume depletion,
now resolved. Cr=0.9
-follow Creatine
8) FEN: pt lytes wnl, except low bicarb. will follow
-nutrition via NG tube
9) PROPHYLAXIS
-pneumoboots, PPI IV
10) FULL CODE: discussed with sister, would like full code for
now until quality of life/life expectancy can be discussed with
Liver Team. [**Month (only) 116**] be changed in the near future.
11) DISPO
-will be evaluated later in hosp course; unclear endpoint now.
Past Medical History:
Etoh abuse x 10 yrs, ascites x months; recent hospitalization
[**6-15**] for UGIB w/HCT 15 requiring 5U PRBCs - EGD w/portal
gastropathy and gr [**1-12**] esoph varices s/p banding; gallstones,
rosacea
Social History:
Patient has h/o alcohol abuse, has not had any alcohol for at
least 2 weeks prior to admission. She is a substitue teacher
and often guides tours to Europe.
Family History:
Non-contributory
Physical Exam:
PE:
VS: T=96.9 BP=112/70 HR=75 RR=24 02=94% (5L 50% mask)
GEN: middle aged woman, lying in bed, jaundiced, NAD
HEENT: PERRL OU, EOMI bilaterally, icteric sclera, OP clear, Dry
MM
LYMPH: minimal submandibular LAD, no other LAD
SKIN: + Jaundice, + spider angiomas over chest
CV: Non-displaced PMI, RRR, Normal S1S2, No M/R/G
RESP: No accessory muscle use, minimal rales left middle lung
field, poor air exchange, no wheezes/ronchi
ABD: Normo active BS, non-tender, markedly distended, no masses,
dull to percussion laterally, could not assess shifting
dullness, no organomegaly appreciated
EXT: 2+ edema to knees bilaterally, no cyanosis or clubbing
PULSES: 2+ dp/pt pulses bilaterally
NEURO: CN II-XII intact bilat; sensation and motor exams intact
bilaterally
Pertinent Results:
[**2125-7-22**] 10:44PM ALT(SGPT)-22 AST(SGOT)-127* LD(LDH)-249 ALK
PHOS-82 AMYLASE-65 TOT BILI-17.3*
[**2125-7-22**] 10:44PM LIPASE-19
[**2125-7-22**] 10:44PM ALBUMIN-1.4* CALCIUM-6.4* PHOSPHATE-3.8
MAGNESIUM-1.8
[**2125-7-22**] 10:44PM WBC-19.9* RBC-3.29* HGB-10.2* HCT-29.8*
MCV-91 MCH-30.9 MCHC-34.1 RDW-16.5*
[**2125-7-22**] 10:44PM GLUCOSE-146* UREA N-29* CREAT-1.8* SODIUM-134
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-17* ANION GAP-13
[**2125-7-22**] 10:44PM PT-20.3* PTT-45.9* INR(PT)-2.7
Brief Hospital Course:
MICU COURSE:
At OSH ED p 114, bp 88/49pt had massive hemoptysis, intubated
for airway protection (ABG 7.43/26/81). They thought that
earlier banding 2-3 weeks ago may have dislodged. Pt tx
w/endoscopy, hypertonic saline inj. Tx w/ 4U PRBCs, hct 24-23!
Given more units PRBCs, hct 31 prior to transfer, INR 1.9, alb
2.0, tbili 23.6, dbili 15.4. Tx w/vanco x1, zosyn x1.
EMS: ? given vit K 10mg IM in EMS, dopa gtt transiently then
d/c'ed, fent iv, ativan iv, NS 1000cc.
# UGIB
-ddx: esophageal varices (given acute blood loss, recent hx
w/banding, EGD at OSH), PUD, [**Doctor First Name **]-[**Doctor Last Name **] tear
-NPO, IVF, IV PPI [**Hospital1 **], octreotide gtt (50mcg)
-OGT grossly + for blood clots and some BRB, not clearing
w/almost 1L NS; maintain low intermittent suction
-T&S sent off, xfusing 4U PRBCs o/n (Hct drop 29 to 26 while
here), check HCTs q 4 hrs; stable x 24 hrs, check q 8 hrs; goal
hct <28
-FFP 4U/vit K to reverse INR of 2.7
-GI fellow did endoscopy o/n, s/p banding of 3 varices; follow
closely for evidence of further GIB
-octreotide gtt continue
-[**7-24**]: start propranolol for variceal bleeding prophylaxis
# LIVER DISEASE
-most likely cirrhosis (Class C), although no biopsy proven dx;
RUQ u/s w/dopplers w/patent PV, ascites, retrograde R sided
flow, anterograde L sided flow
-follow LFTs, coags, plts, alb, bili: alb still low, tbili
rising to 23
-prophylactic SBP tx w/ CTX x 5 days ([**Date range (1) **])
-diagnostic tap in AM [**7-23**]. removed 4.5 liters of fluid which
showed 30 WBC, 95 RBCs with 11poly,32lymphs,25monos,29macs, and
total protein less than 0.3 and albumin less than 1.
-encephalopathy: ativan w/caution (liver metabolized, but type
I/II metabolism)
-adding lasix 40/aldactone 100, ? lactulose
# HEMODYNAMICS
-bp 90/50s, dropping to mid-80s requiring NS boluses to maintain
MAPs; xfuse as necessary, IVF NS
-UOP better after bladder pressure [**1-8**] to 18 post
paracentesis; hold on IVF maintenance, bolus as needed only
#LEUKOCYTOSIS
-wbc 19, no fever but ? thick secretions per ETT; check u/a+cx,
sputum GS/cx; blood cx if spikes; already s/p zosyn/vanco at OSH
so decreased yield of micro data
-diagnostic paracentesis in AM as above in #1; on SBP tx w/CTX
(although tap neg, but abx given prior to at OSH)
#ARF
-unclear baseline, CR 1.8, improving to 1.2. Likely [**2-12**]
increased bladder pressure from tense ascities.
-most likely prerenal in setting of hypovolemia, may be related
to liver disease
-follow closely, check urine lytes, cr, fena, urine eos w/recent
abx use.
#RESP FAILURE
-intubated for airway protection, has mild met acid/resp alka;
extubated [**7-24**]
-sedation: ativan iv prn
#ACID-BASE
-likely type I RTA by +urine AG, lowish K and non AG met acid
#LE Edema - bilat LENIs negative [**7-24**]
#ACCESS
3 PIVs (18g) in place, consider cordis for better access
#FEN
-Now extubated, taking po via dop off tube.
# PROPHYLAXIS
-pneumoboots, PPI [**Hospital **]
MEDICAL [**Hospital1 **] COURSE:
Once the patient was transferred to the floor, she remained
stable without further bleeding. Her hematocrit stabilized at
36-39. She continued to be followed by the Liver Team (Dr.
[**Last Name (STitle) 10285**] while on the floor. She remained on tube feeds through
her dobhoff tube. The patient was still full code when she was
transferred from the ICU, but after discussions with the
patient, her health care proxy (sister [**Doctor First Name **], and the Liver
Team, the patient and her health care proxy made the decision to
be DNR/DNI.
Ms. [**Known lastname 38988**] mental status was slightly altered after being
transferred; however, this improved with time. It was thought
that her altered MS could have been related to the Ativan she
received in the ICU vs. hepatic encephalopathy. The Ativan was
held and she was given Lactulose for ?encephalopathy.
Her WBC count remained elevated after being transferred as well.
However, she remained afebrile, and paracentesis in ICU was
negative for SBP, and she remained ceftriaxone for empiric
treatment. Her CXR showed possibilty of LUL pneumonia. In the
setting of recently being on ventilator, her coverage was
broadened to include clindamycin. Her WBC count remained stable
and decreased slightly to 23.
After being transferred to the floor, the patient did not have
adequate access. A femoral line was placed for the evening,
until a PICC line could be placed the following day. The
femoral line was pulled out after about 24 hours.
The patient's creatinine increased (0.9-->1.4-->1.6) while on
the floor. This was likely secondary to prerenal ARF because of
patient's third spacing. She was given IVF hydration.
On [**2125-7-28**], the patient pulled out her dobhoff tube, foley, and
rectal tube. On that day ([**2125-7-28**]), the patient (with her
health care proxy, and family) decided that she did not want to
follow with any more treatment. She decided that she just
wanted to go home and be in peace, with hospice care. Her
sister [**Name (NI) **] made arrangements for her to leave the following
day. The patient was to go home and live with her sister on
[**Hospital3 **], and hospice care would visit her there.
On [**2125-7-29**], the patient and her health care proxy (sister [**Doctor First Name **]
reiterated that she did not want to stay in the hospital, and
did not want any further treatment aside from Hospice Care at
home. The patient's mental status was clear, and she stated
that she understood the consequences of her decision, even the
possiblility of more bleeding, coma, and even death. Dr. [**Last Name (STitle) 10285**]
(Liver Team) also saw Ms. [**Known lastname 31966**] before discharge. He
expressed his concern that she may be making the decision
quickly and suggested that she stay until the following day
(Monday) so that she could have a family meeting along with the
social worker and a psychiatrist. He suggested that this may
allow her and her family to ensure that they were making a sound
decision. The patient refused this suggestion and said that all
she wanted to do was go home. She stated that she has seen many
of her friends die in the past, and she did not want to struggle
like they had. She reiterated the fact that she understood the
possible consequences of her decision: that with treatment she
may have a chance of surviving, and without treatment, she has a
high likelihood of not surviving. The patient was discharged
home with Hospice care and given medications for palliative
treatment.
Medications on Admission:
Minocycline prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed for agitation.
Disp:*60 Tablet(s)* Refills:*0*
3. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Transdermal
Q72H PRN () as needed for secretions.
Disp:*10 * Refills:*0*
4. Prochlorperazine 25 mg Suppository Sig: [**1-12**] Suppositorys
Rectal Q12H (every 12 hours) as needed for nausea/vomiting.
Disp:*30 Suppository(s)* Refills:*0*
5. Heparin Flush (Porcine) in NS 100 unit/mL Kit Sig: One (1)
Intravenous once a day: Please flush PICC line after use.
Disp:*20 * Refills:*2*
6. Roxanol 20 mg/mL Solution Sig: [**1-12**] PO Q2-4H PRN as needed
for pain.
Disp:*30 cc* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital3 **]
Discharge Diagnosis:
Primary: End Stage Liver Disease
Secondary: Cirrhosis, Esophageal varices
Discharge Condition:
Fair
Discharge Instructions:
Please use prescribed medications for palliative/comfort care:
Morphine to control pain; Ativan for anxiety; Scopolamine for
control of secretions; Compazine for control of nausea and
vomiting.
Followup Instructions:
Patient will receive care from [**Hospital3 **] Hospice.
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,655
| 143,283
|
10887+10888
|
Discharge summary
|
report+report
|
Admission Date: [**2196-12-5**] Discharge Date:
Date of Birth: [**2163-8-26**] Sex: F
HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old
woman with a history end-stage renal disease secondary to
lithium toxicity, status post cadaveric renal transplant in
[**2196-6-17**] complicated by post-transplantation
who presented with fever to 102 degrees Fahrenheit, diffuse
abdominal pain times one day, recent discharge on Friday
prior to admission.
She had presented on [**10-17**] with colitis. A biopsy of the
fundus was done via esophagogastroduodenoscopy which showed
post-transplantation lymphoproliferative disorder. Rapamycin
prednisone 40 mg, tapered down to 20. She was readmitted late
[**2196-10-17**]
with fever and abdominal pain similar to this presentation.
Blood cultures were negative. A renal mass lesion biopsy was
consistent
with post-transplantation lymphoproliferative disorder.
Creatinine was increased, and she was diagnosed with acute
rejection. Prednisone was increased to 20 mg after she
received four days of Solu-Medrol 500 mg intravenously q.d.
She was stabilized and sent home three days prior to this
current admission.
On the night prior to admission she spiked a temperature
of 102 and began to have diffuse abdominal pain. She was
sent to an outside hospital ([**Hospital6 33**] Emergency
Department) where her creatinine was found to be 1.8 which
was increased from 1.5 on discharge. Urinalysis was bland
except for trace blood. She was transferred here for further
workup.
She was febrile in the Emergency Room, given p.o. contrast
for abdominal CT. She had emesis times two. Nasogastric
tube was placed. Droperidol was given, and her nausea and
vomiting resolved. An abdominal CT was done which revealed a
small amount of free fluid but was otherwise negative. She
was admitted because of concern for acute rejection versus
infection in an immunocompromised host.
PAST MEDICAL HISTORY:
1. Bipolar disorder.
2. End-stage renal disease secondary to lithium toxicity
in [**2189**]. She had been on hemodialysis times four years.
Status post renal transplant in [**2196-6-17**] complicated by
post-transplantation lymphoproliferative disorder.
3. Hypertension.
4. Hypercholesterolemia.
5. Appendectomy in [**2179**].
6. Post-transplantation lymphoproliferative disorder
diagnosed in [**2196-10-17**].
7. CMV disease diagnosed several weeks prior to PTLD, treated
with prolonged course of IV ganciclovir.
MEDICATIONS ON ADMISSION: Prednisone 20 mg p.o. q.d.,
Depakote 1000 mg p.o. q.a.m. and 500 mg p.o. q.p.m.,
Zoloft 75 mg p.o. q.d., atenolol 25 mg p.o. q.d.,
Norvasc 2.5 mg p.o. q.d., Lamictal 50 mg p.o. q.d.,
Seroquel 25 mg p.o. q.d., valganciclovir 900 mg p.o. q.d.,
Lipitor 20 mg p.o. q.d., Prevacid 30 mg p.o. q.d.,
Bactrim-SS 1 tablet p.o. q.d.
ALLERGIES: She has no known drug allergies.
SOCIAL HISTORY: She lives with her husband. [**Name (NI) **] alcohol,
tobacco, or drug use.
FAMILY HISTORY: A family history of hypertension,
cerebrovascular accident, high cholesterol, and thyroid
disease.
PHYSICAL EXAMINATION ON PRESENTATION: On admission
temperature of 101, blood pressure 144/80, pulse 130,
respirations 24, 93% on room air, 97% on 2 liters. In
general, she was a cushingoid-appearing woman, uncomfortable,
but in no acute distress. Head, ears, nose, eyes and throat
revealed pupils were equal, round, and reactive to light.
Extraocular movements were intact. The oropharynx was clear.
Neck was supple with no jugular venous distention. Pulmonary
was clear to auscultation bilaterally. No wheezes, crackles,
or rales. Heart had a regular rate and rhythm, a 2/6
systolic ejection murmur at the base. The abdomen was soft,
diffusely tender, voluntary guarding. No rebound. Obese
with positive graft tenderness in the right lower quadrant.
Extremities had no cyanosis, clubbing or edema. Dorsalis
pedis and radial pulses 2+ bilaterally. Alert and oriented
times three. Cranial nerves II through XII were intact.
LABORATORY DATA ON PRESENTATION: Laboratories on admission
were notable for a white blood cell count of 3, hematocrit
of 18.3, platelets of 80. Blood urea nitrogen was 25,
creatinine was 1.9. Liver function tests were within normal
range, as were amylase and lipase.
RADIOLOGY/IMAGING: A CT scan revealed stable masses in the
transplant and kidney, consistent with post-transplantation
lymphoproliferative disorder. New free fluid around the
liver, spleen, and slightly increased free fluid in the
pelvis. Stable right upper lobe pulmonary nodule and small
subcapsular hematoma in the transplanted kidney.
HOSPITAL COURSE: Ms. [**Known lastname 35431**] was admitted with a
presumed diagnosis of acute rejection of her cadaveric renal
transplant.
1. RENAL: She was initially given intravenous
Solu-Medrol 500 mg followed by 250 mg intravenously for a
total of three days, and the placed on prednisone 20 mg p.o.
q.d. to counteract acute rejection. A renal biopsy was done
which revealed an ischemic change and mild mesangial
prominence, minimal interstitial fibrosis, tubular atrophy,
diffuse interstitial edema, and a mild diffuse/chronic
inflammatory interstitial infiltrate with very rare foci of
mild tubulitis. Numerous small interstitial eosinophilic
granules were noted which were consistent with apoptotic
debris from the patient's lymphoproliferative disorder.
Several foci of endothelialitis were noted in arterials and
arteries. While there was no overt cellular rejection on the
biopsy specimen, there was interstitial edema and significant
endothelialitis. She continued to receive prednisone;
however, her creatinine decreased until [**12-13**], and it
began to increase. Because of this she was given IVIG. Low dose
rapamycin which she had been started on admission had been
discontinued because of the pancytopenia she had developed.
2. POST-TRANSPLANTATION LYMPHOPROLIFERATIVE DISORDER: The
patient received her second and third doses of rituximab for
this during this hospitalization, and she had a follow-up CT
scan which revealed slight improvement.
3. INFECTIOUS DISEASE: She had low-grade temperatures
during her hospital course, and there was no evidence of
focal infection, however, and the fevers were attributed to
her acute rejection. She was not started on antibiotics.
She received valganciclovir initially, but then that was held
because of possible bone marrow suppression. She had
numerous tests checked for possible viral infection including
cytomegalovirus, [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus, HHB6, and parvovirus B19
PCR.
4. PANCYTOPENIA: This was believed to be secondary to
medication use, but there was also concern about viral
etiology. Because of this her rapamycin was discontinued.
Her valganciclovir was held, and she received Neupogen for
her decreased white blood cell count. She also had
neutropenic precautions, and she received 2 units of packed
red blood cells on the day of admission because her
hematocrit was low in setting of kidney biopsy.
5. NEUROLOGY/PSYCHIATRY: She was followed by the Psychiatry
liaison consultation team because of her bipolar disorder,
and they continued her medication of Lamictal, Depakote,
Zoloft, and Ativan p.r.n.
6. GASTROINTESTINAL: She had episodes of nausea and
vomiting; however, these resolved spontaneously, and no
etiology was found.
Note: This is dictation through [**12-15**].
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**MD Number(1) 3629**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2196-12-15**] 19:33
T: [**2196-12-15**] 19:17
JOB#: [**Job Number 35432**]
(cclist)
Admission Date: [**2196-12-5**] Discharge Date: [**2197-1-27**]
Date of Birth: [**2163-8-26**] Sex: F
CHIEF COMPLAINT: Post-transplant lymphoproliferative
disorder.
HISTORY OF PRESENT ILLNESS: The patient is a 33 year old
[**6-/2195**] at another institution. The patient had no immediate
postoperative transplant complications there, but prior to
admission here, the patient had been diagnosed with PTLD (post-
transplant lymphoproliferative disorder). The patient is
currently off Immuno-suppressant medications except for
Prednisone. Following the cessation of immunosuppressant
medications, the patient developed acute rejection. The
patient's initial fever associated with the rejection subsided
when she received treatments for the acute rejection with Solu-
Medrol 500 times four and then her baseline Prednisone dose
increased to 20 mg per day from 10 mg. The patient was
initially discharged home within a week of this admission and
was doing relatively well.
Just prior to admission, the patient developed abdominal pain
which was predominantly in the lower back and described as
continuous pain in the moderate to severe range. The patient
also had some nausea but denied urinary symptoms or diarrhea.
The patient also complained of chills and rigor.
PAST MEDICAL HISTORY:
1. Bipolar disorder.
2. End-stage renal disease secondary to Lithium toxicity.
3. Increased cholesterol.
4. Post-transplant lymphoproliferative disorder diagnosed in
[**10/2196**] from a biopsy during a colonoscopy. At that
time, the Prograf, Rapamycin was discontinued but the
patient was continued on low dose Prednisone.
PAST SURGICAL HISTORY:
1. Renal transplant 06/[**2196**].
2. Appendectomy.
MEDICATIONS:
1. Prednisone 20 mg p.o. q. day.
2. Depakote 1000/500.
3. Zoloft 75 p.o. q. day.
4. Atenolol 25 p.o. q. day.
5. Norvasc 2.5 p.o. q. day.
6. Lamictal 50 mg p.o. q. day.
7. Seroquel 125 mg p.o. q. day.
8. Lipitor 20 mg p.o. q. day.
9. Prevacid 30 mg p.o. q. day.
10. Bactrim SS, one.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with her husband and
denies the use of alcohol, tobacco or intravenous drug abuse.
PHYSICAL EXAMINATION: Initial physical, blood pressure
150/84; heart rate 114; respiratory rate 24; temperature
maximum 101.6 F. Cardiovascular: Regular rate and rhythm.
Lungs are clear to auscultation. Abdomen: Initially there was
tenderness localized over the kidney allograft . Central nervous
system: No neurological deficits.
LABORATORY: White blood cell count 3,000, hematocrit 18.3
and platelets 80. Blood cultures initially were negative.
Herpes virus 6 antigen was negative. Parva B19 was negative.
EBV PCR was negative and CMV was negative on [**11-7**].
A chest x-ray at that time was negative for pneumonia.
Her initial Chem-7 was 142/4.1, 107/25, 25/1.9, glucose of
164. AST 15, ALT 33, and t-bilirubin 0.2.
HOSPITAL COURSE: The patient was initially started on
Solu-Medrol 500 mg intravenously times three days.
Hematology/Oncology was consulted for the PTLD. The patient
was transfused two units of blood on [**2196-12-6**] for a
hematocrit of 15.4. The patient's initial CMV PCR analysis
was positive for CMV, for which the patient was started on
ganciclovir. On [**12-9**], Psychiatry was consulted due to the
patient's depressed mood and history of psychiatric
disorders. On [**12-12**], the patient continued to have
pancytopenia with a white cell count of 1.2 and a hematocrit
of 21. The patient also continued to show some signs and
symptoms of acute rejection of the graft and on the [**12-12**],
the patient had a BUN of 11 and a creatinine of 1.6.
On the [**12-14**], the patient had the third dose of
the patient's Rituxan therapy which was started previous to
her current admission. During the initial part of the
[**Hospital 228**] hospital stay, she continued to spike intermittent
fevers as high as 103.0 F., on [**12-16**] with the infusion of
intravenous IG therapy.
During the end of [**Month (only) **] and early part of [**Month (only) 1096**], the
patient's BUN and creatinine continued to increase. The
patient's signs and symptoms were consistent with acute renal
failure secondary to rejection. On [**12-20**], it was concluded that
the patient was in acute rejection with renal failure. The
patient was scheduled for a nephrectomy of the allograft on
[**2196-12-23**]. Just prior to scheduling the nephrectomy, the
patient's creatinine and BUN had improved and the nephrectomy
was put on hold by recommendations from the primary Renal
medicine service. On [**12-25**]; however, the patient suffered
severe acute abdominal pain with generalized tenderness and the
patient was brought to the Operating Room. An extensive
discussion was had with the patient's mother, father, and husband
regarding the diagnosis and the necessity for surgery, as well as
the likely need to remove the transplanted kidney. All of the
family's (and patient's) questions were answered and the
patient was taken tho the operating room. Small bowel
perforation was found with frank extravasation of enteric
contents. The patient had an exploratory laparotomy
and resection of the mid-jejunum with primary anastomosis and an
allograft nephrectomy. The patient tolerated the procedure
well and was transported to the PACU in stable condition.
The wound was also left open and packed due to the bowel
perforation. Discussion was then had with the family of the high
likelihood for serious complications including infection
prolonged hospitalization and even death.
On [**12-28**], the patient showed signs of peritonitis and sepsis.
The patient was brought back to the Operating Room with the
initial diagnosis of perforated small bowel and exploratory
laparotomy procedure was performed with primary repair of the
small bowel perforation. The previous repair of the intestine was
completely intact and a new 1 cm small bowel perforation
distal to the previous anastomosis was noted. There was an
abundant enteric content in the abdomen and the small bowel
perforation was repaired. The patient tolerated the procedure
well and was transported to the PACU in stable condition.
Following the surgery, the patient continued on antibiotics
and was treated for her metabolic issues. The patient
continued with low platelets and increased INR. Following
the surgery, the patient continued with hemodialysis on a
regular schedule and her treatments for the post-transplant
lymphoproliferative disorder. The wound continued to heal by
secondary intention with regular dressing changes. The
patient, following the surgery, spent a certain amount of
time in the SICU and was later transferred to the Floor.
The Infectious Disease service continued to follow the patient
and continued with their recommendations of Gentamycin,
Fluconazole. Over that time, the patient continued to spike
intermittently and received multiple blood cultures, urine
cultures, and chest x-rays which could not locate a source for
the infection. Throughout until the end of the time, the patient
continued to spike fevers intermittently for which she continued
to have multiple cultures and scans. The patient also continued
to remain with pancytopenia which was followed by
Hematology/Oncology regarding her diagnosis of lymphoma and the
patient continued on hemodialysis.
The wound continued to granulate and during that time, did
not show signs of infection. There is no gross pus noted on
the examination. During the hospitalization, the patient did
have a wound culture which was positive for VRE and also
urinary cultures which were positive for VRE which were
treated with the appropriate antibiotics. The patient also
had a catheter infection of Methicillin resistant
Staphylococcus aureus which was treated with Vancomycin for
14 days.
In the beginning of [**Month (only) 404**], the patient had a repeat CMV PCR
and [**Doctor Last Name 3271**]-[**Location (un) **] virus PCR to evaluate for possible viral
infections. The CMV PCR was negative and on discharge the
EBV PCR was still pending. The patient, in the beginning of
[**Month (only) 404**], had a CT scan which showed marked improvement of
abscesses in the abdomen.
At that time, the patient continued on antibiotics, the wet
and dry changes, Physical Therapy. On the 5th the patient
continued to spike and at that point had a full work-up for
febrile origins in anticipation of discharging the patient to
Rehabilitation Services. The patient's blood cultures were
negative. The patient's streptococcal antigen was negative.
The patient's urinalysis was negative and urine cultures were
negative. The patient's CMV PCR was negative and the
patient's [**Doctor Last Name 3271**]-[**Location (un) **] virus PCR is pending right now. The
patient's wound was healing nicely with granulation tissue
and no signs of frank pus. The Porta-Cath was also cultured
which was negative. An ultrasound was performed of the
Porta-Cath which showed no abnormalities or fluid
collections.
On [**1-26**], it was decided through the Transplant Service with
the Renal, Hematology/Oncology and Infectious Disease
Services that most likely the cause of the intermittent
temperature spikes were due to resolving lymphoproliferative
disorder. The patient is chronically pancytopenic requiring blood
transfusions. The patient will follow-up with
Hematology/Oncology and will most likely require
transfusions.
On the 10th, Hematology/Oncology stopped by to evaluate the
patient and left several recommendations prior to discharge.
DISCHARGE PHYSICAL EXAMINATION: Included a temperature
maximum of 100.1 F., temperature current of 97.2 F.; pulse of
88; blood pressure 110/70; respiratory rate 20; O2 94%, p.o.
of 600, output bathroom privileges with hemodialysis. In
general, in no acute distress, alert and oriented.
Cardiovascular is regular rate and rhythm. Respiratory:
Clear to auscultation bilaterally. Abdomen soft, nontender,
nondistended, obese, incision healing with secondary
intention; good granulation tissue and no signs of infection.
Extremities: No peripheral edema with mild swelling.
Laboratory values were white cells 3.1, hematocrit 16.8,
platelets 103,000, PT 12.7, PTT 30.9, INR 1.1. Chem-7 is
140/4.2, 104/27, 17/0.6 and a glucose of 81. Vancomycin
level was 21.9, and valproic acid level was 38.
DISCHARGE DIAGNOSES:
1. Status post allograft nephrectomy.
2. Bowel resection for perforation secondary to
lymphoproliferative disorder.
3. Lymphoproliferative disorder.
4. Pancytopenia.
5. Bipolar disorder.
6. End-stage renal disease on hemodialysis.
7. Hypertension.
8. Increased cholesterol.
DISCHARGE MEDICATIONS: Discharge medications include:
1. Protonix 40 mg p.o. q. day.
2. Dulcolax one per rectum q. day.
3. Epogen 10,000 units intravenously at hemodialysis three
times a week.
4. Nephrocaps times one p.o. q. day.
5. Seroquel 25 mg p.o. q. h.s.
6. Depakote 500 mg p.o. twice a day.
7. Heparin 5000 units subcutaneously twice a day.
8. Magnesium oxide 120 mg p.o. q. day.
9. MSO4 1 to 2 mg intramuscularly q. three to four hours
p.r.n.
10. Dilaudid 3 to 4 mg p.o. q. four to six hours p.r.n.
11. Tylenol 650 mg p.o. q. four to six hours p.r.n.
12. Benadryl 25 mg intravenously q. six hours p.r.n.
13. Vancomycin, one gram intravenously times one if the
Vancomycin level falls below 15. The patient is
currently on 12 of 14 doses and will require two more
doses of Vancomycin before discharging.
DISCHARGE DISPOSITION: Stable/good. To Rehabilitation
Services.
DISCHARGE INSTRUCTIONS:
1. The patient will follow-up with Dr. [**Last Name (STitle) **] in roughly one
to two weeks. The patient or Rehabilitation Services
should call the office to schedule an appointment. Dr.
[**Last Name (STitle) 22486**] Clinic can be reached through the main [**Hospital1 18**]
number at [**Telephone/Fax (1) 2756**].
2. The patient should continue on intravenous Vancomycin
which should be renally dosed. The patient should
receive 1 mg intravenously times one if the Vancomycin
level drops below 15.
3. The patient's wound should be changed three times a day
with wet-to-dry's.
4. The patient will require extensive Physical Therapy and
Occupational Therapy.
5. The patient's calorie counts should also be monitored
closely to assure proper nutrition.
6. The patient will also follow-up with Hematology/Oncology
and have a PET scan at the [**Hospital3 328**] Center on [**2-7**],
at 07:30.
7. The patient is also scheduled for an endoscopic
examination with ultrasounds on [**2197-2-10**], at 11 a.m. at
[**Hospital Ward Name 1950**] One. The patient should be NPO from midnight
before the procedure.
8. The patient also should follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
Hematology/Oncology on [**2-17**], which is a Friday, in
the [**Hospital Ward Name 23**] Building on the [**Location (un) 24**].
9. The patient will also require a CT scan of the torso
which should be done with intravenous contrast and
scheduled with Dialysis.
10. The patient should have basic laboratory studies, Chem-7,
CBC, drawn twice a week to monitor the pancytopenia and
chemistries.
11. The patient should also have Vancomycin levels checked
regularly and to have the Vancomycin dosed if the level
falls below 15.
The Hematology/Oncology plans were discussed with the patient
and husband. The discharge plans and prognoses were also
discussed with the patient, husband and father. On [**1-26**], the father agreed with the planned and thought that
Rehabilitation Services was best for Mrs. [**Known lastname 35431**] at
this time.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2197-1-27**] 11:44
T: [**2197-1-27**] 12:04
JOB#: [**Job Number 35433**]
|
[
"584.9",
"998.59",
"567.2",
"996.81",
"078.5",
"569.83",
"038.9",
"997.4",
"238.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"55.53",
"46.73",
"55.23",
"45.62",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
19318, 19361
|
2994, 4646
|
18164, 18451
|
18476, 19294
|
2511, 2881
|
10691, 17356
|
19385, 21823
|
9424, 9822
|
17379, 18143
|
7886, 7933
|
7962, 9037
|
9059, 9401
|
9839, 9941
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,273
| 161,099
|
7830
|
Discharge summary
|
report
|
Admission Date: [**2156-2-13**] Discharge Date: [**2156-2-20**]
Date of Birth: [**2077-10-5**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Heparin Agents
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
Intubation (at OSH)
Extubation
Central Line placement and removal
SVT Ablation
History of Present Illness:
Ms. [**Known lastname 28265**] is a 78 yo female with extensive clot burden
?secondary to HIT (PE, aortic throbus, splenic infarct), SVT on
quinidine/metoprolol, renal stones, here s/p cardiac arrest. She
had reportedly been feeling well until the day before when she
complained of fatigue and was only able to walk 200 ft instead
of her regular 500 ft before feeling fatigued. She was noted on
[**2156-2-11**] at 4AM to be short of breath and then became
unresponsive. Her husband began CPR. EMS was called and
administered shocks and gave epinephrine. Response time is
unknown. He was intubated upon arrival to the [**Location (un) **] [**Location (un) 1459**]
ED. She was found to be in SVT reportedly.
During the hospital stay, she intitially had a chest CTA which
was negative for PE. She was tachycardic and placed on an
amiodarone drip and then needed neo to support her BP. She was
initially covered broadly with vanco/zosyn/azithro without any
clear infectious source, but this was tailored to flagyl/vanco
for C. diff today. Neurology was consulted as her mental status
did not improve without sedation. They felt she opened eyes to
voice, but did not follow commands, found her PERRL, and
withdrawal to noxious stimuli. EEG was performed and showed
encephalopthay. A repeat Head CT today showed SAH so all
anticoagulation was stopped. She was placed on stress dose
steroids.
On the MICU, unable to obtain further history as patient was
intubated.
Of note, patient had recent hospital from [**1-27**] to [**2156-2-5**] where
she presented with nausea/vomiting and became hypoxic &
hypotensive in the ED, requiring pressors and intubation. She
was found to have PE and massive clot burden in body. His
suspician for HIT though negative HIT ab x 2. She has also had
ongoing AVNRT and was intiated on quinidine & lopressor per EP
recommendations.
Review of sytems: unable to obtain as patient is intbutaed
Past Medical History:
Hypertension
SVT
Hyperlipidemia
Extensive clot burden - recent PE, aortic thrombus, splenic
infarct
Nephrolithiasis
Social History:
Married, lives in [**Location 4310**]. Retired, had her own business. Denies
tobacco, alcohol, or drug use.
Family History:
Grandmother with nephrolithiasis. No family history of early
MI.
Physical Exam:
Vitals: BP 108/82, HR 140, RR 19, O2 Sat 100% on AC
General: intubated, not following commands
HEENT: sclera anicteric, PERRL
Neck: RIJ
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, unable to appreciate any murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: cool extremities, no edema
Pertinent Results:
Admission Labs:
[**2156-2-13**] 10:12PM BLOOD WBC-20.8*# RBC-3.90* Hgb-11.6* Hct-33.8*
MCV-87 MCH-29.6 MCHC-34.2 RDW-16.1* Plt Ct-635*
[**2156-2-13**] 10:12PM BLOOD PT-42.8* PTT-51.7* INR(PT)-4.7*
[**2156-2-13**] 10:12PM BLOOD Glucose-130* UreaN-12 Creat-0.9 Na-128*
K-4.1 Cl-98 HCO3-21* AnGap-13
[**2156-2-13**] 10:12PM BLOOD ALT-30 AST-17 LD(LDH)-340* CK(CPK)-33
AlkPhos-54 TotBili-0.8
[**2156-2-13**] 10:12PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2156-2-13**] 10:12PM BLOOD Albumin-2.8* Calcium-7.7* Phos-3.0 Mg-1.8
[**2156-2-13**] 10:51PM BLOOD Type-ART Temp-38.2 Rates-18/0 Tidal V-450
PEEP-5 FiO2-35 pO2-168* pCO2-25* pH-7.51* calTCO2-21 Base XS-0
Intubat-INTUBATED Vent-CONTROLLED
[**2156-2-13**] 10:51PM BLOOD Lactate-2.6*
Interval/Discharge Labs:
[**2156-2-19**] 05:20AM BLOOD WBC-9.0 RBC-3.28* Hgb-9.3* Hct-29.5*
MCV-90 MCH-28.4 MCHC-31.5 RDW-16.2* Plt Ct-378
[**2156-2-19**] 05:20AM BLOOD PT-16.0* PTT-35.0 INR(PT)-1.4*
[**2156-2-19**] 05:20AM BLOOD Glucose-73 UreaN-8 Creat-0.6 Na-136 K-4.2
Cl-101 HCO3-25 AnGap-14
[**2156-2-14**] 03:59AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2156-2-15**] 04:57AM BLOOD Lactate-1.3
[**2156-2-20**] 04:25AM BLOOD WBC-8.8 RBC-3.28* Hgb-9.6* Hct-29.5*
MCV-90 MCH-29.3 MCHC-32.6 RDW-16.3* Plt Ct-348
[**2156-2-20**] 04:25AM BLOOD PT-16.0* PTT-33.5 INR(PT)-1.4*
[**2156-2-20**] 04:25AM BLOOD Glucose-85 UreaN-6 Creat-0.6 Na-139 K-3.4
Cl-99 HCO3-33* AnGap-10
[**2156-2-16**] 04:07AM BLOOD SEROTONIN RELEASE ANTIBODY negative
Micro:
Blood cx: NGTD x1, negative x1
Urine cx: negative
Catheter tip cx: negative
C diff toxin: negative
Studies:
[**2156-2-13**] CXR:
1. Left pleural effusion.
2. Probable persistent atelectasis/consolidation in the left
lower lobe.
[**2156-2-14**] Transthoracic ECHO: The left atrium and right atrium are
normal in cavity size. Left ventricular wall thicknesses and
cavity size are normal. At study initiation (HR 150/min), there
is severe global hypokinesis (LVEF<20%) with relative
preservation of the basl inferolateral wall function.
Subsequently, the heart rate abrupty decreased to 84/;min. There
there was improved function of basal segments, with persistent
[**Last Name (un) **] hypo/near akinesis of the distal hafl of the septum and
anterior wall and apical aneurysm (LAD infarct pattern
distribution with overall LVEF 25-30%). No masses or thrombi are
seen in the left ventricle. Right ventricular chamber size is
normal. with moderate global free wall hypokinesis. 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/myxomatous with suggestion
of systolic prolapse. Moderate to severe (3+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a very small pericardial effusion. There
are bilateral pleural effusions. Compared with the prior study
(images reviewed) of [**2156-1-27**], left ventricular systolic
function has deteriorated and the severity of mitral
regurgitation has increased. Mild aortic regurgitation is now
identified.
[**2156-2-14**] CT HEAD: Linear foci of high attenuation are noted in
the left frontal region (2:16, 17). These may represent small
foci of subarachnoid hemorrhage. Remainder of the brain is
unremarkable.
[**2156-2-15**] CT HEAD: Decreased conspicuity of focus of high
attenuation in the left frontal region which may represent an
evolving very small focus of
subarachnoid hemorrhage. 2. Prominent extra-axial frontal spaces
likely represent a subdural hygroma versus old subdural
hemorrhage.
Brief Hospital Course:
This is a 78 yo female with SVT, extensive clot burden (aortic,
PE, splenic infart), here s/p cardiac arrest and SAH.
1. S/p Cardiac arrest. Unclear precipitant of arrest. Was
reportedly in a shockable rhythmn upon EMS arrival, so possible
torsades, ventricular arrythmia in the setting of being on
quinidine and having a prolonged qtc interval (>650) on one EKG
at OSH. Also possibilitiy of SVT with hypotension given history
of unstable SVT. Cardiac enzymes were not significantly
elevated at OSH so not likely to be acute MI. Echo follow
arrest showed EF fell to 20-25 from 45% two weeks ago. She was
continued on amiodarone and then had successful ablation of
AVNRT on [**2156-2-16**] with subsequent sinus rhythm. Amiodarone was
subsequently discontinued.
2. SVT. Patient has narrow complex tachycardia consistent with
AVNRT. Started on amiodarone and neo, but had been discharged 2
weeks ago with quinidine and metoprolol. Reportly normotensive
when in sinus rhythm. Echo shows reduced EF from prior echo
from 3 weeks ago concerning for ischemia versus tachycardia
induced cardiomyopathy. Quindine was discontinued and amiodarone
was started. Underwent successful ablation of SVT with patient
remaining in normal sinus rhythm for remainder of admission.
Amidodarone discontinued after ablation. Metoprolol IV 5mg q6
was changed to metoprolol 25mg PO BID for improved rate control.
3. Altered mental status. Very poor on admission but improved
prior to discharge. AMS likely multifactorial due to anoxic
brain injury, new findings of SAH, toxic-metabolic in setting of
C. diff infection, and baseline generalized atrophy. Repeat head
CT showed stable SAH. She was treated for C. diff. Once patient
was extubated, she was able to communicate and was AAOx3 but did
have some hoarseness thought secondary to ET tube. She was able
to follow commands and move all 4 extremities upon discharge.
4. Hypotension. Per OSH, when in sinus rhythm not hypotensive,
so hypotension is likely secondary to tachycardia. Also likely
an element of hypovolemia in setting of lasix diuresis at OSH
and ongoing C. diff. Given clot burden, concern for recurrent
PE, though CTA of chest reportedly negative from OSH and was
therapeutic on coumadin on arrival to OSH. In the MICU was
quickly weaned off pressors and with ablation her blood pressure
has been stable and tolerating addition of her beta blocker.
5. Extensive clot burden. Patient has extensive clot burden
likely presumed originally thought [**12-29**] HIT but HITnegative x 2.
Found to have large PE, splenic infarcts, large aortic thrombus.
No history of malignancy but could pursue malignancy workup as
outpatient. SRA checked and negtaive. Heme consult said this was
not HIT and transitioned her from argatroban to lovenox with
bridge to coumadin. Her coumadin dose will need to be adjusted
based on goal INR of [**12-30**]. Her platelets remained stable at time
of discharge on lovenox and coumadin. She will follow up with
heme-onc as outpatient.
6. C. diff. Found to have C. diff positive stool at OSH with
ongoing diarrhea which improved throughout course. She was
initially treated with Vanco and PLagyl then transitioned to PO
vanco for 2 week course (starting [**2-11**]).
7. Hyponatremia. Likely hypovolemic in setting of C. diff and
diuresis at OSH. Improved with hydration.
8.FEN: IVF, replete electrolytes, regular diet. Passed video
swallow but will need calorie count. Able to have regular diet
with thin liquids and ensure supplements.
9.Prophylaxis: lovenox bridge to coumadin, pneumoboots
10. Access: None at discharge
11. Code: FULL
12. Dispo: rehab
Medications on Admission:
Metoprolol 50 mg [**Hospital1 **]
Coumadin 3 mg daily
Quinidine sulfate 600 mg [**Hospital1 **], 300 mg at noon
Aspirin 81 mg daily
Discharge Medications:
1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 8 days: To be complete [**2156-2-26**].
2. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) subcutaneous
Subcutaneous Q12H (every 12 hours): Please discontinue after INR
is therapeutic (between [**12-30**]) for 24 hours.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Please adjust dose for INR [**12-30**].
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Primary:
Cardiac Arrest
Atrial Tachycardia
Subarchanoid Hemorrhage
Clostridium Difficile
Hematuria
.
Secondary:
Pulmonary Embolism
Aortic Thrombus
Splenic Infarct
Hypertension
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted after you had a cardiac arrest which we
believe was because of the medication quinidine you were on. You
were intubated in the setting of the arrest but extubated with
the complication of some vocal cord trauma which should continue
to improve. In addition, we found a small bleed in your head
that we believe is secondary to your anticoagulation with
coumadin. You had a fast heart rate and underwent a procedure
to fix it and have been in normal sinus rhythm since. You were
also found to have an infection called Clostridium difficile
that can cause diarrhea. You are now on antibiotic called
vancomycin to treat this infection.
.
We changed some of your medications:
STOP: quinidine
Change: metoprolol from 50mg by mouth twice a day to 25mg by
mouth twice a day
Change: coumadin from 3mg to 2mg by mouth daily
New: Vancomycin to be completed on [**2156-3-3**].
.
You will need follow up with Dr. [**Last Name (STitle) 28267**] and Dr. [**Last Name (STitle) **] with
cardiology. Their office will call you with your follow up
appointment.
.
Hematology Follow up:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28268**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2156-3-3**] 2:00
Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2156-3-3**] 2:00
.
Once you are discharged from rehab, you should call your primary
care doctor Dr. [**First Name (STitle) 679**] at [**Telephone/Fax (1) 682**] to make an appointment to
see him so he can follow your coumadin levels.
.
If you develop any of the following, chest pain, shortness of
breath, cough, fever, chills, nausea, vomiting, diarrhea,
swelling in your legs, lightheadness, or headache please alert
the doctors at rehab.
Followup Instructions:
You will need follow up with Dr. [**Last Name (STitle) 28267**] and Dr. [**Last Name (STitle) **] with
cardiology. Their office will call you with your follow up
appointment.
.
Hematology Follow up:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28268**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2156-3-3**] 2:00
Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2156-3-3**] 2:00
.
Once you are discharged from rehab, you should call your primary
care doctor Dr. [**First Name (STitle) 679**] at [**Telephone/Fax (1) 682**] to make an appointment to
see him so he can follow your coumadin levels.
|
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
"37.34",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
11126, 11206
|
6726, 10379
|
313, 394
|
11426, 11445
|
3123, 3123
|
13304, 13492
|
2620, 2687
|
10561, 11103
|
11227, 11405
|
10405, 10538
|
11469, 12543
|
3879, 6224
|
2702, 3104
|
13503, 14024
|
255, 275
|
2298, 2340
|
422, 2280
|
6439, 6703
|
3139, 3863
|
2362, 2479
|
2495, 2604
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,551
| 131,207
|
11253+11344
|
Discharge summary
|
report+report
|
Admission Date: [**2122-10-19**] Discharge Date: [**2122-10-28**]
Date of Birth: [**2085-3-9**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 38 year old
woman who was admitted to the Intensive Care Unit for
hypercarbic respiratory arrest. The patient has a past
medical history of bipolar disorder, cocaine abuse and
alcohol abuse, who was transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **]
[**First Name (Titles) **] [**Last Name (Titles) **] for further evaluation of increased confusion.
The patient initially presented to [**Hospital3 5173**] on
[**2122-10-10**], where she was admitted for suicidal
ideation and agitation. Routine laboratory studies were
reportedly normal.
The patient was subsequently transferred to the [**Hospital 36149**]
Hospital for management of increasingly inappropriate
behavior and slurred speech. She was found to be very
combative and was given 5 mg of Haldol and Ativan 1 mg. The
patient slept for 24 hours, until midday on the day of
admission. Upon awakening, she was confused and complaining
of visual hallucinations, and was transferred to [**First Name4 (NamePattern1) 3867**]
[**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for further evaluation.
in the Emergency Room, the patient had increased agitation.
She was given droperidol and 2 mg of Ativan. Multiple
imaging and laboratory studies were done. The patient
ultimately became less responsive and was intubated for a
hypercarbic respiratory arrest with arterial blood gases
showing a pH of 7.32, pCO2 75 and pO2 63.
REVIEW OF SYSTEMS: Unavailable.
PAST MEDICAL HISTORY: 1. Bipolar disorder. 2. Cocaine
abuse. 3. Alcohol abuse. 4. Suicidal ideation. 5.
Cocaine related myocardial infarction times two. 6. Asthma.
7. Hepatitis B with a question of hepatitis C.
ALLERGIES: Penicillin and Toradol.
MEDICATIONS ON ADMISSION: Prozac 20 mg p.o.b.i.d., Seroquel
50 mg p.o.b.i.d. with 100 mg p.o.q.h.s., Elavil 150 mg
p.o.q.h.s., Neurontin 300 mg p.o.t.i.d.
SOCIAL HISTORY: The patient is unmarried and has a 15 year
old son. She has a long history of alcohol and drug abuse
starting at age 12. She was reportedly a nurse but lost her
license secondary to substance abuse. She reports that she
has been sober, using no drugs, for the last year.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On physical examination on admission,
the patient had a temperature of 98.7, heart rate 100 to 110,
blood pressure 100 to 110/30 to 50 on 15 mcg of Dopamine, and
respiratory rate 12. General: The patient was intubated,
lying in bed, sedated. Head, eyes, ears, nose and throat:
Normocephalic, atraumatic, moist mucous membranes.
Cardiovascular: Regular rate and rhythm, normal S1 and S2.
Pulmonary: Diffuse rales without wheezes. Abdomen: Soft,
nontender, nondistended, no rebound or guarding.
Extremities: No cyanosis, clubbing or edema.
LABORATORY DATA: Admission white blood cell count was 18.7
with 88 neutrophils, 8 lymphocytes, 0 bands and 3 monocytes,
hematocrit 41 and platelet count 344,000. Coagulation
studies were within normal limits. Chemistries showed a
sodium of 135, potassium 4.8, chloride 101, bicarbonate 27,
BUN 18, creatinine 0.7 and glucose 100. Urine toxicology
screen was positive for benzodiazepines and methadone. Serum
toxicology screen was positive for benzodiazepines and
tricyclic antidepressants. Lactate was 1.1. Chest x-ray
showed diffuse bilateral infiltrates and right main stem
intubation. CT scan of the head showed no bleed.
Electrocardiogram showed sinus tachycardia with a QTC of 420
milliseconds, QRS 106 milliseconds, no ST changes.
Urinalysis was essentially negative except for 15 ketones.
HOSPITAL COURSE: 1. Pulmonary: The etiology of the
patient's acute respiratory hypercarbic failure was unclear.
The patient appeared to have presumed aspiration pneumonia on
admission. She was treated with a 14 day course of Levaquin
and Flagyl, which is due to end on [**2122-11-1**].
Medications were thought to result in respiratory sedation as
well and the patient was intubated upon admission.
The patient continued to do well and was extubated on [**2122-10-22**], however, the patient became agitated and tachypneic
to the 70s and required elective reintubation. We felt that
the etiology of her failure to be extubated was probably
secondary to benzodiazepine withdrawal. The patient was
reintubated and had a very slow wean of intravenous Ativan
and was again extubated on [**2122-10-25**]. She did well
post extubation, with no signs of having respiratory failure,
and is currently stable upon discharge from a respiratory
standpoint, requiring only Robitussin as needed for
sympathetic cough relief.
2. Cardiovascular: The patient is stable. She required
pressors transiently and, on admission to the Intensive Care
Unit, these were weaned off rapidly. She remained
tachycardiac throughout her hospital course, although her
tachycardia has improved to a rate of 90 to 100 on discharge.
It is unclear of what the etiology of her sinus tachycardia
is at this time.
3. Neurology/psychiatry: The patient has had psychiatry
following her during this admission. Her underlying
diagnosis is bipolar disorder. It is unclear what her
outpatient history is. At the time of discharge, it became
increasingly clear that the patient appeared to be hypomanic
and had no solid living arrangement arranged for discharge.
The patient was discharged to [**Hospital6 22197**] Center. She
is to continue on Seroquel, giving her the lack of mood
stabilizers. She was discontinued off Elavil and Prozac
because this was felt to be potentially exacerbating her
mania.
4. Infectious disease: The patient will continue on
Levaquin and Flagyl for a 14 day course, to end on [**2122-11-1**].
5. Genitourinary: The patient had transient urinary
retention post extubation, which is currently resolved.
6. Physical therapy: The patient underwent a physical
therapy evaluation on [**2122-10-27**]. She was found to have
some mild impairment secondary to her prolonged Medical
Intensive Care Unit course. They felt that she would do well
with one week of continued physical therapy.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
Hypercarbic respiratory failure.
Aspiration pneumonia.
Bipolar disorder.
DISCHARGE MEDICATIONS:
Seroquel 50 mg p.o.q.d., 50 mg in the afternoon and 200 mg in
the evening.
Ativan taper, to end on [**2122-10-28**].
Levaquin 500 mg p.o.q.d., to end on [**2122-11-1**].
Flagyl 500 mg p.o.t.i.d., to end on [**2122-11-1**].
Haldol 2 mg p.o./i.v.q.4h.p.r.n.
Robitussin 10 ml p.o.q.4-6h.p.r.n.
Zantac 150 mg p.o.b.i.d.p.r.n.
Colace 100 mg p.o.b.i.d.p.r.n.
Albuterol and Atrovent meter dose inhaler two puffs q.i.d.
Multivitamins one p.o.q.d.
DISCHARGE PLANNING: The patient is to be discharged to the
Bay State psychiatric inpatient unit. She should continue
with physical therapy for one week as dictated by the
physical therapists here.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Name8 (MD) 21042**]
MEDQUIST36
D: [**2122-10-27**] 17:21
T: [**2122-10-27**] 14:49
JOB#: [**Job Number 32991**]
Admission Date: [**2122-10-19**] Discharge Date: [**2122-10-28**]
Date of Birth: [**2085-3-9**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 38 year old
woman who was admitted to the Intensive Care Unit for
hypercarbic respiratory arrest. The patient has a past
medical history of bipolar disorder, cocaine abuse and
alcohol abuse, who was transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **]
[**First Name (Titles) **] [**Last Name (Titles) **] for further evaluation of increased confusion.
The patient initially presented to [**Hospital3 5173**] on
[**2122-10-10**], where she was admitted for suicidal
ideation and agitation. Routine laboratory studies were
reportedly normal.
The patient was subsequently transferred to the [**Hospital 36149**]
Hospital for management of increasingly inappropriate
behavior and slurred speech. She was found to be very
combative and was given 5 mg of Haldol and Ativan 1 mg. The
patient slept for 24 hours, until midday on the day of
admission. Upon awakening, she was confused and complaining
of visual hallucinations, and was transferred to [**First Name4 (NamePattern1) 3867**]
[**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for further evaluation.
in the Emergency Room, the patient had increased agitation.
She was given droperidol and 2 mg of Ativan. Multiple
imaging and laboratory studies were done. The patient
ultimately became less responsive and was intubated for a
hypercarbic respiratory arrest with arterial blood gases
showing a pH of 7.32, pCO2 75 and pO2 63.
REVIEW OF SYSTEMS: Unavailable.
PAST MEDICAL HISTORY: 1. Bipolar disorder
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D.
[**MD Number(1) 7855**]
Dictated By:[**Name8 (MD) 21042**]
MEDQUIST36
D: [**2122-10-27**] 17:21
T: [**2122-10-27**] 14:49
JOB#: [**Job Number 32991**]
|
[
"E939.4",
"293.0",
"788.29",
"304.70",
"276.5",
"507.0",
"305.00",
"296.7",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.56",
"96.6",
"38.93",
"96.72",
"03.31",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2403, 2421
|
6346, 6420
|
6443, 7479
|
1964, 2094
|
3814, 6012
|
6031, 6301
|
2444, 3796
|
6316, 6325
|
8999, 9013
|
7508, 8979
|
9036, 9313
|
2111, 2386
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,938
| 183,122
|
37850
|
Discharge summary
|
report
|
Admission Date: [**2148-10-15**] Discharge Date: [**2148-10-25**]
Date of Birth: [**2087-4-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
jaw pain and neck pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 14738**] fell 15 feet off a porch while moving a couch when the
railing broke. His GCS at the scene was 3 and he had + LOC and
incontinence. He was transported to [**Hospital1 18**] by Med Flight and his
GCS improved to 14. He had a cervicle collar in place and pan
scanned in the Emergency Room. His injuries included a
fractured right mandible, small SAH, right frontal bone
fracture, right zygomatic arch fracture and C3,4 and 6 lateral
transverse foramen fracture. He was admitted to the Trauma ICU
for further evaluation and management.
Past Medical History:
1. Hypertension
2. Type II Diabetes
3. Hypercholesterolemia
Social History:
Lives with wife, unemployed
[**Name2 (NI) 1139**] : remote
ETOH occassional
Family History:
non contributory
Physical Exam:
O: BP: 151/90 HR:102 RR 24 O2Sats97% Temp 96.2
Gen: WD/WN, comfortable, NAD.
HEENT: Normocephalic, with significant right scalp abrasion,
There is no CSF rhinorrhea or otorrhea. There is however
discrete
hemorrhage from the nares.
Pupils: PERRL EOMs; intact
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-21**] throughout. RUE exam was
deferred for pain. Pronator drift also deferred for RUE pain.
Sensation: Intact to light touch.
Pertinent Results:
[**2148-10-15**] 12:45PM PT-12.4 PTT-25.6 INR(PT)-1.0
[**2148-10-15**] 12:45PM PLT COUNT-314
[**2148-10-15**] 12:45PM WBC-20.3* RBC-4.75 HGB-13.8* HCT-41.0 MCV-86
MCH-29.0 MCHC-33.7 RDW-13.4
[**2148-10-15**] 12:45PM UREA N-16 CREAT-1.0
[**2148-10-15**] 01:01PM GLUCOSE-185* LACTATE-3.3* NA+-140 K+-3.6
CL--101 TCO2-26
[**2148-10-15**] 03:44PM WBC-16.3* RBC-4.79 HGB-13.7* HCT-40.7 MCV-85
MCH-28.7 MCHC-33.7 RDW-13.9
[**2148-10-15**] 03:44PM AMYLASE-166*
[**2148-10-15**] 10:50PM LACTATE-2.6*
[**2148-10-15**] C Spine CT : 1. Right-sided cervical spine fractures
involving the transverse process at
C3, C4, C6, and C7. CTA is recommended to exclude vertebral
artery injury.
2. Linear lucency at the left C6-7 facet, which may represent
a nondisplaced fracture.
3. Right mandibular body fracture. Please note, the mandible
is not fully imaged and therefore a second fracture cannot be
excluded.
[**2148-10-15**] Head CT :
1. Acute subarachnoid hemorrhage in the right inferior frontal
and left
temporal lobes. Possible small acute subdural hematoma along the
right
inferior frontal lobe. No significant mass effect.
2. Acute fractures involving the right zygomatic arch and
right orbital roof. Probable fracture of the right lamina
papyracea with small amount of gas in the right orbit.
[**2148-10-15**] Abd CT :
1. Consolidation in the right lower lobe and left lower lobe
most compatible with aspiration. Gastric distention with fluid
level also noted. Consider NG tube decompression to avoid
further aspiration.
2. Right posterior eleventh rib fracture. Extensive deformity
involving the clavicles and upper rib cage likely related to a
prior episode of trauma.
3. Please refer to CT cervical spine for description of
fractures at the
lower cervical spine, which are better assessed on that study.
4. Metallic foreign body embedded aloing the anterior left
mid-lung resembling a bullet. Please correlate with prior trauma
history as this appears chronic.
5. Dense atherosclerotic calcification along the left coronary
circulation, which clinical correlation is advised.
6. Small fat-containing periumbilical hernia.
7. Prostatic enlargement. Correlate with PSA.
[**2148-10-16**] Head CT :. Right frontal parenchymal hemorrhage and
surrounding mass effect, stable since the most recent study on
[**2148-10-15**].
2. Stable subarachnoid hemorrhage and right frontal subdural
hematoma.
3. Multiple fractures, better demonstrated on the recent
dedicated
maxillofacial CT study.
4. Opacification of all visualized paranasal sinuses, related
to the multiple fractures.
[**2148-10-17**] Cardiac echo : The left atrium is elongated. The
estimated right atrial pressure is 0-10mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). The estimated
cardiac index is high (>4.0L/min/m2). 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 mildly thickened. There is no
mitral valve prolapse. No mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal biventricular regional and global systolic function.
[**2148-10-18**] Head CT : Further slight interval increase in size of
right frontal intraparenchymal hemorrhage, now measuring 3.3 x
3.3 cm, previously 3.2 x 2.9 cm. No change in bilateral
subarachnoid hemorrhage.
[**2148-10-19**] Head CT :
Unchanged right frontal intraparenchymal hemorrhage with mild
perihemorrhagic edema without significant mass effect, shift of
normally
midline structures or herniation. Unchanged multifocal bilateral
subarachnoid
hemorrhage.
Brief Hospital Course:
Mr. [**Known lastname 14738**] was admitted to the Trauma ICU for neuro checks and
evaluation by plastic surgery and maxillofacial surgery for his
multiple facial fractures. He was oriented to person and place
but not time and he was experiencing right back, neck and arm
pain. His pain was relieved with Morphine and he was started on
prophylactic Dilantin. He did not have any seizures. He was
evaluated by the Neurosurgical service for his C spine fractures
and they initially recommended a hard collar for 8 weeks but
this was changed to a soft collar for comfort only as he had no
ligamentous damage. His Dilantin was given for 10 days.
Following transfer to the Trauma floor he continued to make good
progress from a neurologic standpoint. He had serial Head CT's
done to evaluate his right frontal bleed and although he had no
change in his neurologic exam he did have a small increase in
his right frontal bleed but no mass effect or shift. His last
CT scan was on [**2148-10-19**] and was unchanged.
He was seen by the Cardiology service while in the ICU as he had
some tachycardia and ventricular ectopy in the setting of
hypokalemia. Following repletion of his potassium his ectopy
resolved and a cardiac echo was done which revealed a normal EF
and no wall motion abnormalities. Recommendations were to
increase his beta blocker as needed to decrease his heart rate.
Dr. [**Last Name (STitle) 2866**] from OMFS evaluated Mr. [**Known lastname 16184**] mandibular fracture
and opted for conservative treatment for now and a liquid diet.
He will follow up in the out patient clinic next week.
Physical Therapy was involved in his care on a daily basis to
improve his mobility prior to his return home. He was walking
with a cane and required gait training, stair negotiation and
safety awareness. He improved on a daily basis but still
required some cueing. His family will be with him 24 hours a
day and eventually he will follow up with Cognitive Neurology.
Of note he had a routine type and screen done on admission which
showed an anti K antibody. In the future he will need K antigen
negative products. A wallet card and paperwork from the blood
bank will be mailed to his home. he did not receive any blood
products during this admission.
Medications on Admission:
Glucophage 1000 mg PO Daily
Januvia 100 mg PO Daily
Lopressor 50 mg PO BID
Discharge Medications:
1. 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*
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Bacitracin-Polymyxin B Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
7. Listerine Mouthwash Sig: Ten (10) mls Mucous membrane
four times a day: swish and spit.
8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
9. Outpatient Occupational Therapy
10. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. right mandible fracture
2. right frontal bone fracture
3. right zygomatic arch fracture
4. tiny SAH
5. C3,4,6 lateral transverse foramen
6. Anti K antibody
Discharge Condition:
stable
Discharge Instructions:
* Do NOT eat any foods that require chewing
* Drink protein supplements 3-4 times a day ( ie Ensure, Boost
or Glucerna )
* Wear a soft cervicle sollar for comfort
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2359**] for a follow up appointment in 2
weeks
Neurology followup with Dr. [**Last Name (STitle) 84668**] in [**2-21**] weeks, call
[**Telephone/Fax (1) 84669**] to schedule an appointment. Will need a CT
myelogram of R shoulder scheduled prior to the appointment.
Follow-up with Dr. [**Last Name (STitle) **] in 8 weeks (neurosurgery) You needs a
non-contrast head CT and a non-contrast C-spine CT at that time
so let the secretary know when you call.
Call [**Telephone/Fax (1) 1669**] to schedule this appointment.
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 9470**] for a follow up appointment in
[**2-20**]-weeks
Call [**Hospital 34690**] Clinic at [**Telephone/Fax (1) 55393**] for a follow up
appointment [**2148-11-1**]
Call [**Last Name (un) **] [**Doctor Last Name **] from Cognitive Neurology for an appointment
at [**Telephone/Fax (1) 1690**] (call after your health insurance is reinstated)
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2148-10-31**]
|
[
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"293.0",
"250.00",
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"812.20",
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icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9640, 9646
|
6366, 8642
|
338, 345
|
9849, 9858
|
2306, 6343
|
10992, 12114
|
1134, 1152
|
8767, 9617
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9667, 9828
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8668, 8744
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9882, 10969
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1167, 1443
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276, 300
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373, 942
|
1644, 2287
|
1458, 1628
|
964, 1025
|
1041, 1118
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,005
| 180,743
|
54451
|
Discharge summary
|
report
|
Admission Date: [**2160-2-25**] Discharge Date: [**2160-3-4**]
Date of Birth: [**2106-10-26**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
s/p multiple self inflicted stab wounds
Major Surgical or Invasive Procedure:
[**2160-2-25**] EXPLORATORY LAPAROTOMY and REPAIR OF LIVER LACERATION
WITH SUTURE, STERNOTOMY, EXPLORATION OF RIGHT AND LEFT CHEST,
EXPLORATION OF MEDIASTINUM AND HEART, REPAIR OF BILATERAL UPPER
EXTREMITY LACERATIONS AND TENDONS, APPLICATION OF BILATERAL
UPPER EXTREMITY SPLINTS
History of Present Illness:
Mr. [**Known lastname **] is a 53 year old male with a history of depression who
presented by ambulance to the ED with 2 stab wounds to the
chest, 1 to the abdomen and 3 to his wrists and antecubital
fossa. He suffered a left chest sucking chest wound and
underwent placement of a chest tube in the ED. He was taken
immediately to the operating room after assessement of his
abdominal wound verified entry into the abdominal cavity.
Past Medical History:
Depression
Social History:
Lives with his partner and two children. He recently lost his
job and had become increasingly depressed.
Family History:
EtOH in father
Physical Exam:
Upon presentation to [**Hospital1 18**]:
HR:118 BP:120/p Resp:26 O(2)Sat:99% on NRB Normal
Constitutional: ill appearring male in distress; moaning
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Chest: sucking left chest wound; 8 cm; deep into subcut
tissue
Cardiovascular: Regular Rate and Rhythm; tachy; no m/r/g
Abdominal: Soft; nt but epigastic wound when explored
directly into peritoneum
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: right ac and wrist 3.5 cm wounds deep into subcut
tissue; from all digits and hand
Neuro: Speech fluent; GCS 14-15
Psych: moves all 4 extremities
Pertinent Results:
[**2160-2-25**] 11:06AM WBC-18.6* RBC-4.86 HGB-14.4 HCT-40.7 MCV-84
MCH-29.8 MCHC-35.5* RDW-13.0
[**2160-2-25**] 11:06AM PLT COUNT-361
[**2160-2-25**] 11:06AM PT-13.9* PTT-24.1 INR(PT)-1.2*
[**2160-2-25**] 11:06AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2160-2-25**] 11:06AM LIPASE-23
[**2160-2-25**] 05:02PM WBC-14.3* RBC-3.55*# HGB-10.7*# HCT-29.5*#
MCV-83 MCH-30.1 MCHC-36.2* RDW-13.1
[**2160-2-25**] 05:02PM PLT COUNT-266
[**2160-3-2**] 05:05AM BLOOD WBC-5.2 RBC-3.50* Hgb-10.4* Hct-29.2*
MCV-83 MCH-29.9 MCHC-35.8* RDW-14.8 Plt Ct-340
[**2160-3-2**] 05:05AM BLOOD Plt Ct-340
[**2160-3-2**] 05:05AM BLOOD Glucose-115* UreaN-9 Creat-0.5 Na-140
K-3.8 Cl-104 HCO3-28 AnGap-12
[**2160-2-26**] 10:07AM BLOOD ALT-122* AST-174* LD(LDH)-267*
AlkPhos-31* TotBili-0.4
[**2160-2-26**] 03:58PM BLOOD cTropnT-<0.01
[**2160-2-27**] 02:36AM BLOOD freeCa-1.13
Chest - single view xray [**2160-3-2**]
IMPRESSION: Tiny right apical pneumothorax and possible tiny
right pleural
effusion both unchanged since [**3-2**] following removal of the
right pleural drain. Moderate bibasilar atelectasis stable.
Normal cardiomediastinal silhouette.
Brief Hospital Course:
He was admitted to the Acute Care Surgery service:
His hospital course as follows by systems -
Neuro: At presentation in the he was alert and oriented. He
voiced his distress at having failed at his attempt to commit
suicide. His pain was controlled with fentanyl as needed and
the Acute Pain Service was initally consulted for epidural
analgesia. An Epidural was placed during his ICU stay with
adequate pain control. Once he was more awake he was changed to
intravenous narcotics andthe epidural was discontinued. Over the
course of his hospital stay he was eventually transitioned to
oral pain medication. At discharge his pain was under control
with PO Dilaudid prn and Tylenol.
CVS: He was taken to the OR and underwent exploratory
laparotomy. Intraoperatively it was noted that his chest wound
communicated with abdomen as the trajectory of the knife pointed
from the chest, through the pericardium, through the diaphragm
and into the liver. Blood was noted to be coming from the
pericardium through the diaphragmatic defect. The liver
laceration was repaired and then a sternotomy was performed to
assess the heart for injury. The heart was examined both
posteriorly and anteriorly and no injury was seen. The adjacent
lung was also assessed for injury. Bilateral chest tubes and
mediastinal tubes were placed. The mediastinal chest tubes were
removed on POD 4 without complication. he did require initiation
of beta blockade as he was tachycardic during his ICU stay. He
is currently taking Lopressor 25 mg [**Hospital1 **]; this was decreased from
tid. He is in normal sinus rhythm with a heart rate ranging in
the 80's. His blood pressure ranges between 90-110's systolic,
he had not been orthostatic or dizzy with this blood pressure.
His hematocrit is stable at 29.2 with the lowest [**Location (un) 1131**] of 21.5
on [**2-27**]. His surgical wounds are stable and without any evidence
of bleeding. His LFT's were initially elevated felt likely due
to his liver njurym they have since rtrended downward and should
return to normal.
Resp: He had a left sided chest tube placed in the ED under
sterile technique as he presented with a sucking left chest
wound. He was taken to the OR and the pleural space was examined
bilaterally after sternotomy was performed to assess the heart.
Bilaterally chest tubes were placed intraoperatively. The chest
tube placed in the ED remained in place. Two of his chest tubes
were removed on POD 1. He has re accumulation of fluid in his
right pleural cavity, in addition to a small right pneumothorax.
To drain the fluid and re-expand his lung on the right side, a
right sided pigtail catheter was placed on POD6. He tolerated
the procedure well. His left chest tube remained in place until
POD7. His right sided pigtail catheter was removed without
complication on POD8. He has no further oxygen requirements and
his saturations have been in the mid 90's. Because he is a
postoperative patient it is important that he ambulate, cough
and deep breathe frequently.
GI: Exploratory laparotomy revealed two liver lacerations which
were repaired primarily. No bowel or other visceral organ
injury was found. Patient diet was advanced from sips to
regular diet from POD3-4 without issue. He is currently
tolerating a regular diet.
GU/Renal: He continued to have good urine output through his
stay. Initially he had a Foley catheter placed but this was
removed and he is voiding independently without any issues.
MSK: He underwent repair of the stab wounds to his right and
left arms by plastic surgery. His right and left flexor
digitorum superficialis muscle tendinous junction and palmaris
longus muscle were repaired. His left FCR tendon was also
repaired. He also underwent repair of multiple lacerations to
his wrists and antecubital fossa. His splints were adjusted by
occupational therapy and he will follow up in [**12-9**] weeks as an
outpatient with Plastics/Hand Surgery. He was also evaluated by
Physical therapy and is independent with ambulation.
Heme: Intraoperatively patient had a small amount of blood
loss. Post-operatively hematocrit trended very slowly downwards
and he was transfused 2U PRBC on POD2. Following transfusion his
hematocrit remained stable and he required no further
transfusions.
Endocrine: While in the ICU his blood sugars were controlled
with a sliding insulin scale. Upon discharge patient was not
requiring insulin sliding scale and it was discontinued.
ID: Peri-operatively patient was placed on vancomycin to protect
against infection of his sternotomy incision. However, all
antibiotics were discontinued by POD2.
Psych: Psychiatry was consulted and followed along during his
hospital stay. He was placed on 1:1 sitters. His home
psychiatric medications were restarted with some changes made to
the clonazepam at patient request secondary to daytime
drowsiness. It is being recommended that he be discharged to a
psychiatric facility for further treatment after his acute
hospital stay.
Medications on Admission:
Lexapro (unknown dosage), xanax
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
5. risperidone 1 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
6. risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
8. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for Constipation.
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
12. psyllium Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1196**] - [**Location (un) 745**]
Discharge Diagnosis:
s/p Multiple self inflicted stab wounds to chest, abdomen &
upper extremties
Liver laceration
Bilateral wrist lacerations
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after multiple self inflicting
stab wounds to your torso and arms. You sustained multiple
internal organ injuries requiring several operations for repair.
You were also seen by Psychiatry to evaluate and discuss with
you the reasons you harmed yourself. it is being recommended
that you be discharged to an inpatinet psychiatric facility
after your acute issues have been stabilized.
Followup Instructions:
Follow up in [**12-9**] weeks in [**Hospital 2536**] clinic for staple removal and for
evaluation of your wounds; call [**Telephone/Fax (1) 600**] for an appointment.
Follow up in [**12-9**] weeks in Hand clinic, call [**Telephone/Fax (1) 3009**] for an
appointment.
Follow up with your PCP after discharge from inpatient
psychiatric facility. You will need to call for an appointment.
Completed by:[**2160-3-4**]
|
[
"864.15",
"V62.84",
"881.22",
"296.24",
"882.2",
"E849.9",
"280.0",
"881.20",
"860.1",
"862.1",
"E956"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.64",
"34.1",
"86.59",
"50.61",
"82.44",
"34.82",
"34.04",
"54.11",
"34.71",
"77.31",
"86.28"
] |
icd9pcs
|
[
[
[]
]
] |
9431, 9504
|
3211, 8223
|
345, 627
|
9670, 9670
|
2009, 3188
|
10263, 10681
|
1264, 1281
|
8305, 9408
|
9525, 9649
|
8249, 8282
|
9821, 10240
|
1296, 1990
|
266, 307
|
655, 1091
|
9685, 9797
|
1113, 1125
|
1141, 1248
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,873
| 167,518
|
54256
|
Discharge summary
|
report
|
Admission Date: [**2176-11-10**] Discharge Date: [**2176-11-23**]
Date of Birth: [**2134-6-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
found down in street
Major Surgical or Invasive Procedure:
none
History of Present Illness:
42 male found down on [**Location (un) **] St. Found to have pinpoint pupils,
stable vital signs. He was brought to [**Hospital1 18**] ED, and given narcan
with increasing wakefullness. His BS was initially 114. He was
unable to give a history, but admitted to recent use of cocaine
and valium (roughly #20 10mg tabs), as well as confirming that
he is homeless. He complained of some knee pain and foot pain,
presumably from a fall. He started in a methadone clinic last
week, and is scheduled to receive 60mg today.
ED COURSE: He was given 0.4mg narcan, to which he woke up a bit.
He then spiked to 103.1, cultured, and was given IV ceftriaxone
and vancomycin. An LP was performed which showed 3 WBC and 43
RBC and no overt sign of infection. A RUQ ultrasound was
essentially normal. A repeat CXR showed possible infiltrate. He
was then started on flagyl. He was still difficult to arouse,
and was started on a narcan gtt and transferred to [**Hospital Unit Name 153**] for
closer monitoring.
ROS: Once awake, he was able to relate that he has had several
days of productive cough. He denies any SOB. He has not had any
sins congestion, chest pain, otalgia, sore throat, myalgias, or
new rash.
Past Medical History:
Polysubstance abuse
Hepatitis C
Social History:
Homeless, used to work as a roofer. Has a strong history of
substance abuse, including heroin, cocaine. Denies recent
alcohol or tobacco use.
Family History:
non-contributory
Physical Exam:
Vs- 122/80 84 99.3 18 96%2L
Gen- Sleeping in bed, disheveled, arousable (on narcan gtt)
Heent- Anicteric, MMM, white film on tongue, atraumatic, no
sinus tenderness, OP clear
Neck- supple, no LAD, JVP flat
Cv- RRR, soft II/VI SEM along sternal border, nl S1,S2
Chest- Clear to ausculatation bilaterally
Abd- soft, NT, pos BS, no HSM
Ext- no C/C/E
Neuro- AAO x 3, slow speech but coherent, CN intact, pupils 3mm,
reactive to light, normal sensory exam, unable to examine gait
Skin- Multiple tatoos, multiple superficial abrasions
Msk- full ROM with knees and ankles
Pertinent Results:
Laboratory studies on admission
*wbc 15K (87% poly), hct 41, plt 220, chem wnl, ast 76, alt 50,
amylase 36, tbili 0.5, lipase 18
*CSF [**2176-11-10**]: 2 WBC, 43 RBC, Prot 22, Glu 77
*Utox: pos - (benzo, opiate, cocaine, methadone) neg - (babit,
amphet)
*UA: clean, 150 ketones
MICRO~
*CSF gram stain [**2176-11-10**]: pending
*BCx [**2176-11-10**]: pending x 2
STUDIES~
*CT Head [**2176-11-10**]: No evidence of acute intracranial hemorrhage
or mass effect.
*CXR [**2176-11-10**]: There is interval development of a left-sided
pleural
effusion and a possible vague left lower lobe opacity. Right
lung remains clear. Cardiac and mediastinal contours are stable.
There is no evidence of pneumothorax. IMPRESSION: Interval
development of a left-sided effusion and possible vague
left lower lobe opacity.
*CXR [**2176-11-9**]: Cardiac silhouette and mediastinum is normal.
Lungs are clear. Bony structures are within normal limits.
IMPRESSION: No signs for acute cardiopulmonary process.
*RUQ US [**2176-11-10**]: Normal gallbladder. No biliary ductal
dilatation.
*Knee XRay [**2176-11-9**]: There are no signs for acute fractures or
dislocations. Joint spaces are preserved. There is no knee joint
effusion.
*Foot XRay [**2176-11-9**]: No signs of acute bony injury to the right
knee or right foot.
Brief Hospital Course:
42 year old male with a history of hepatitis C and polysubstance
abuse (cocaine, benzodiazepines, heroin) presents with an
opiate/valium overdose.
1) Altered MS / Overdose: He admits to taking methadone at the
clinic as scheduled. He recently had his doctor write a script
for valium, and he took most of the bottle yesterday. He also
took cocaine, but denies heroin since starting methadone. He was
intially placed on a narcan gtt in ED. Upon tranfer to the
floor, narcan gtt was stopped and patient more alert. Repeat
urine tox was still positive for benzos, opioids, methadone, and
cocaine. Of note, per pathology, levaquin can cause false
positives for opioids. The patient was restarted on methadone
(55 mg, confirmed with methadone clinic) and, at time of
discharge, had no evidence of withdrawal. Social work followed
the patient throughout his hospital course. The patient
expressed a desire for drug rehabilitation and, at time of
discharge, he was on several waiting lists.
2) Community acquired pneumonia: The patient completed a 10 day
course of levofloxacin (sputum culture grew MSSA sensitive to
levofloxacin) and, at time of discharge was afebrile with stable
O2 saturation on room air. Additional infectious work-up
included blood, urine, CSF cultures, all of which are negative
to date.
3) Hepatitis C: The patient had mild ALT/AST elevation on
admission, which was normalizing at time of discharge. A right
upper quadrant ultrasound was without evidence of biliary
dilitation. He will follow-up with liver clinic as an
outpatient.
Medications on Admission:
tramadol 50 mg
valium 10 mg prn
neurontin 800 mg tid
methadone 55 mg daily
Discharge Medications:
1. Methadone 10 mg Tablet Sig: Fifty Five (55) mg PO DAILY
(Daily).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
benzodiazapine overdose
opiate overdose
pneumonia
Secondary:
polysubstance abuse
Discharge Condition:
good
Discharge Instructions:
You overdosed on valium and opiates. You received Narcan in the
ED, which helped wake you up. In addition, you have a pneumonia.
You should take a course of antibiotics to treat the pneumonia.
Please continue to go to your methadone clinic. Please take all
medications as prescribed.
Followup Instructions:
1) Please follow-up at your methadone clinic.
2) Please call [**Telephone/Fax (1) 111151**] to schedule an appointment with a
new primary care physician.
3) Given chronic hepatitis C, please call [**Telephone/Fax (1) 2422**] to
schedule an appointment at the liver center ([**Hospital Ward Name **], [**Hospital Unit Name **])
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2176-11-23**]
|
[
"305.91",
"E850.2",
"E853.2",
"965.00",
"482.41",
"292.81",
"285.9",
"969.4",
"791.6",
"719.46",
"070.54",
"V60.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
5582, 5588
|
3750, 5303
|
338, 345
|
5722, 5729
|
2421, 3727
|
6062, 6543
|
1802, 1820
|
5428, 5559
|
5609, 5701
|
5329, 5405
|
5753, 6039
|
1835, 2402
|
278, 300
|
373, 1571
|
1593, 1627
|
1643, 1786
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
726
| 148,109
|
7179
|
Discharge summary
|
report
|
Admission Date: [**2123-7-1**] Discharge Date: [**2123-7-16**]
Date of Birth: [**2046-9-3**] Sex: F
Service: A-Cove
HISTORY OF PRESENT ILLNESS: This is a 77-year-old female
with a past medical history of coronary artery disease,
status post myocardial infarction, chronic obstructive
pulmonary disease (on home oxygen) who presented to the
Emergency Room on [**7-1**] with a chief complaint of increased
cough, decreased oral intake, and weakness for several days.
Her home [**Hospital6 407**] had noted a decreased
blood pressure this same period as well as weakness, and
inability to ambulate, and decreased functional ability. She
was brought to the Emergency Room for evaluation of this.
PAST MEDICAL HISTORY: (Past medical history is notable for)
1. Congestive heart failure (with an ejection fraction
of 25% to 30%).
2. Coronary artery disease; status post coronary artery
bypass graft.
3. Chronic obstructive pulmonary disease (on home oxygen).
4. Hiatal hernia.
5. Osteoarthritis.
ALLERGIES: Allergies include ERYTHROMYCIN and CODEINE.
MEDICATIONS ON ADMISSION: Flovent 110 2 puffs b.i.d.,
isosorbide ointment, Lopressor 50 mg p.o. b.i.d.,
nifedipine-XL 30 mg p.o. q.d., Valsartan 80 mg p.o. q.d.,
Valium 5 mg p.o. q.h.s. as needed, Lasix 40 mg p.o. q.d.,
K-Dur 10 mEq p.o. q.d.
SOCIAL HISTORY: She lives at home with her husband with
[**Hospital6 407**].
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
in the Emergency Room revealed vital signs with a temperature
of 98.9, blood pressure was 110/70, heart rate was 86,
respiratory was 20, oxygen saturation was 90% on 2 liters.
In general, she was in no acute distress. Examination of the
head and neck revealed mucous membranes were dry. No teeth.
No increased jugular venous pressure. Cardiovascular
examination revealed a regular rate and rhythm. No murmurs,
rubs or gallops. Normal first heart sound and second heart
sound. A [**2-24**] murmur in the left lower sternal border. Lungs
revealed diffuse rhonchi, crackles at the bases (left greater
than right). The abdomen was soft, nontender, and
nondistended. No hepatosplenomegaly. Positive bowel sounds.
Extremities revealed no clubbing, cyanosis or edema.
Neurologically, awake and oriented times three. Cranial
nerves II through XII were intact. Motor was grossly
nonfocal.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory
examination revealed white blood cell count was 11,
hematocrit was 37, platelets were 391. PT was 13.2, INR
was 1.2, PTT was 30.9. Chemistry-7 revealed sodium was 144,
potassium was 4.5, chloride was 101, bicarbonate was 28,
blood urea nitrogen was 12, creatinine was 0.8, and blood
glucose was 120. Urinalysis was negative.
RADIOLOGY/IMAGING: A chest x-ray showed bibasilar
infiltrates and a large hiatal hernia.
Electrocardiogram showed a normal sinus rhythm with a rate
of 96; no change from prior baseline.
HOSPITAL COURSE: The patient was admitted to the hospital
for treatment of bibasilar pneumonia. She was treated with
levofloxacin initially.
The patient initially did well on antibiotic therapy;
however, several days into her course she had an episode of
respiratory failure for which she was intubated and
transferred to the Intensive Care Unit.
Antibiotic coverage was broadened at that time. A further
evaluation over the next several days included a CT scan
which revealed a right middle lobe mass, and a bronchoscopy
which diagnosed cancer by cytology. The patient failed to
improve despite maximal medical therapy including mechanical
ventilation, broad spectrum antibiotics, and circulatory
support.
The family was informed of the grave prognosis. On [**7-16**]
life support was withdrawn, and the patient passed. The date
of death was [**7-16**]. The cause of death was pneumonia and
respiratory failure.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1019**]
Dictated By:[**Last Name (NamePattern1) 16123**]
MEDQUIST36
D: [**2123-10-11**] 10:50
T: [**2123-10-16**] 04:29
JOB#: [**Job Number 26650**]
|
[
"493.20",
"276.5",
"482.41",
"507.0",
"584.9",
"428.0",
"518.81",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.27",
"96.72",
"38.93",
"96.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
1415, 2980
|
1100, 1318
|
2999, 4214
|
162, 712
|
735, 1073
|
1335, 1397
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,060
| 156,261
|
23574
|
Discharge summary
|
report
|
Admission Date: [**2177-5-26**] Discharge Date: [**2177-6-6**]
Date of Birth: [**2122-5-26**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain with T10 compression fracture
Major Surgical or Invasive Procedure:
T10 vertebrectomy with cage placement and anterior stabilization
T6-12 posterior fusion
L VATS Washout
History of Present Illness:
55 y/o admitted previously in [**Month (only) 547**] w/ mssa bactermia. Initial
MRI w/o contrast concerning for discitis/osteomyelitis. MRI w/
contrast more compression fx at T10
Past Medical History:
1. Ileocolonic colitis
2. Hypertension
3. Hemachromatosis
4. Hypercholesterolemia
5. S/p arthroscopic knee surgery
6. Recent history of clostridium difficile infection
Social History:
The patient is married and has three adult children, one of whom
has juvenile onset diabetes. Tobacco - former use, 1.5pk/day,
stopped 9 years ago
ETOH - Denies alcohol or illicit drug use
Family History:
His mother is deceased. She had hypertension and myocardial
infarction. His father died at the age of 61 due to colon
cancer. The patient has two male siblings, one of whom has
hepatitis C requiring a transplant and the other is alive and
well.
Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics; sensation
intact in all dermatomes; reflexes intact at biceps, triceps and
brachioradialis
BLE- good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact
distally; reflexes deminished at quads and Achilles
Pertinent Results:
[**2177-6-6**] 08:10AM BLOOD WBC-8.1 RBC-3.10* Hgb-8.9* Hct-27.8*
MCV-90 MCH-28.8 MCHC-32.0 RDW-15.0 Plt Ct-474*
[**2177-6-4**] 09:15AM BLOOD WBC-9.5 RBC-3.39* Hgb-10.0* Hct-29.9*
MCV-88 MCH-29.5 MCHC-33.5 RDW-14.8 Plt Ct-372
[**2177-6-3**] 04:16AM BLOOD WBC-8.9 RBC-3.32* Hgb-10.0* Hct-29.0*
MCV-87 MCH-30.2 MCHC-34.5 RDW-14.9 Plt Ct-294
[**2177-6-2**] 09:48PM BLOOD WBC-7.9 RBC-3.18* Hgb-9.9* Hct-27.7*
MCV-87 MCH-31.2 MCHC-35.9* RDW-14.9 Plt Ct-301
[**2177-5-31**] 09:20AM BLOOD WBC-8.8 RBC-3.48*# Hgb-10.8*# Hct-30.0*#
MCV-86 MCH-31.0 MCHC-35.9* RDW-15.1 Plt Ct-214
[**2177-5-28**] 02:32AM BLOOD WBC-16.6* RBC-3.19* Hgb-9.9* Hct-28.7*
MCV-90 MCH-31.2 MCHC-34.6 RDW-15.3 Plt Ct-182
[**2177-6-6**] 08:10AM BLOOD Glucose-109* UreaN-12 Creat-1.2 Na-137
K-3.7 Cl-102 HCO3-27 AnGap-12
[**2177-6-3**] 04:16AM BLOOD Glucose-110* UreaN-15 Na-138 K-3.0*
Cl-103 HCO3-27 AnGap-11
[**2177-6-2**] 04:15PM BLOOD Glucose-115* UreaN-15 Creat-1.0 Na-138
K-3.6 Cl-102 HCO3-27 AnGap-13
[**2177-6-6**] 08:10AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.9
[**2177-6-2**] 04:15PM BLOOD Calcium-8.4 Phos-3.0 Mg-2.1
[**2177-5-28**] 02:32AM BLOOD Calcium-9.1 Phos-3.4 Mg-3.3*
[**2177-5-27**] 06:35AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.6
Brief Hospital Course:
Mr. [**Known lastname 60353**] was admitted to the Orthopaedic Spine service under
the care of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**]. He was informed and consented for
a T10 corpectomy through a thoracotomy and a posterior fusion
with instrumentation T6-12. He elected to proceed. Between the
first and second procedure he was admitted to the T/SICU for
observation and fluid management. He retuned to the OR for the
posterior procedure. Please see Operative Notes for procedures
in detial.
Post-op he developed a large left sided effusion which the
thoracics service was consulted for. They performed at VATS
washout and serial x-rays showed improvements. He was
hemodynamically stable throughout his hospital course. Drains
and chest tubes were monitored and managed by the Thoracics
service. He was fitted for a TLSO brace and was able to work
with physical therapy.
He will return to clinic in 10 days for repeat radiographs.
He will be discharged on PO levoquin for three months. He is to
follow up with the ID service to determine ultimate length of
treatment.
Medications on Admission:
Aciphex
amlodipine
atenolol
celexa
nafcillin
prednisone
spironolactone
dicyclomine
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
Disp:*120 Capsule(s)* Refills:*2*
6. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: Two (2)
Tablet PO Q6H (every 6 hours) as needed for for diarrhea.
Disp:*100 Tablet(s)* Refills:*0*
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
9. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*180 Tablet Sustained Release 12 hr(s)* Refills:*2*
10. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO QID (4 times a day).
Disp:*240 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO
Q6H (every 6 hours) as needed.
Disp:*100 Capsule(s)* Refills:*0*
13. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
discitis/osteomyelitis T10
L pleural effusion
post-op anemia
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Physical Therapy:
Activity: Ambulate qid
Thoracic lumbar spine: when ambulating
Treatments Frequency:
Please continue to change the dressings with dry sterile gauze.
Followup Instructions:
Please follow up in the Spine Clinic during your previously
scheduled appointments.
Please follow up with the ID service to determine length of
treatment. Call ([**Telephone/Fax (1) 4170**] to schedule an appointment with
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3394**].
Completed by:[**2177-6-6**]
|
[
"511.8",
"998.11",
"E932.0",
"401.9",
"251.8",
"285.9",
"511.9",
"518.0",
"E878.4",
"730.28",
"722.92",
"737.10",
"799.02",
"272.0",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.52",
"34.91",
"34.21",
"81.05",
"81.04",
"77.89",
"34.51",
"81.63",
"84.51",
"33.23",
"77.79",
"80.51"
] |
icd9pcs
|
[
[
[]
]
] |
6009, 6154
|
3063, 4176
|
358, 463
|
6259, 6266
|
1837, 3040
|
6692, 7010
|
1085, 1332
|
4309, 5986
|
6175, 6238
|
4202, 4286
|
6290, 6497
|
1347, 1818
|
6515, 6582
|
6604, 6669
|
279, 320
|
491, 671
|
693, 862
|
878, 1069
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,374
| 133,425
|
28179
|
Discharge summary
|
report
|
Admission Date: [**2119-11-23**] Discharge Date: [**2120-1-5**]
Date of Birth: [**2119-11-23**] Sex: F
Service: Neonatology
ADDENDUM SUMMARY: This is an addendum summary for Baby Girl
[**Known lastname 68473**], to follow the previous surgery done on [**2119-12-7**].
[**Known lastname 68475**] [**Known lastname 68473**] was born at 37 and 2/7 weeks gestation.
Her NICU course since [**2119-12-7**] is as follows:
Respiratory status: On [**2119-12-7**], she had a supraglottoplasty
for her laryngomalacia. She continues to have stridor when
agitated, although she remains well saturated during those
events. At rest, her respirations are comfortable. Lung
sounds are clear and equal. Discharge was planned on [**1-5**] but
she was noted to have bradycardia with spits. Her total fluids
were decreased to 140cc/kg/d, changed to every 3 hours feedings,
and she has remained without any events for more than 48 hours.
Cardiovascular: She has remained normotensive throughout her
NICU stay. She continues to have a 1/6 systolic ejection
murmur, due to a 1 to 2 mm muscular ventricular septal
defect. On examination, her heart rate runs in the 140 to 160
range. Systolic blood pressures run from 83 to 96 and
diastolic blood pressures run 54 to 67.
She will need prophylaxis for subacute bacterial endocarditis for
any surgical procedures.
Fluids, electrolytes and nutrition: At the time of discharge,
her weight is 2390 grams. Her length is 45.5 cm. Head
circumference 30 cm. Her feedings are at 140 ml/kg/day of 30
calorie per ounce of breast milk made with added NeoSure
powder or NeoSure powder concentrated to 27 calories per
ounce and 3 calories per ounce from corn oil.
She takes only a few ml p.o. and the rest is given by
gastrostomy tube with feedings every 3 hours. On [**2120-1-9**], her
electrolytes were: Sodium 137; potassium 4.5; chloride 102;
bicarbonate 27; BUN 10; creatinine 0.5; calcium 10.5.
Gastrointestinal status: A modified barium swallow study
done on [**2119-12-14**] was remarkable for extremely abnormal oral
phase of swallowing with almost no ability to suck. With
squeezing a large amount into the pharynx, there was a
discoordination of swallowing, resulting in nasopharyngeal
reflux. There was no evidence of aspiration.
As a result of this study and her minimal p.o. intake, an
upper gastrointestinal study was done on [**2119-12-26**] which
revealed normal anatomy. On [**2120-1-1**], a PEG gastrostomy tube
was placed. The insertion site is healing well. There is no
erythema or drainage from the site.
Hematology: Hematocrit on [**2120-1-1**] was 31.2. She has received
no blood product transfusions during her NICU stay.
Infectious disease: She did receive intraoperative and
postoperative routine antibiotics but there are no other
active infectious disease issues.
Neurology: A head ultrasound on [**2119-11-24**] was normal.
Sensory: Hearing screen was performed with automated
auditory brain stem responses and the infant referred in both
ears. A follow-up hearing test is scheduled for [**2-1**].
Ophthalmology: The eyes were examined on [**2119-11-24**] and
revealed no coloboma. Normal optic nerve and normal retina.
Follow-up exam is recommended in 6 months.
Psychosocial: The mother has been very involved in the
infant's care throughout her NICU stay. The father has been
able to visit intermittently from [**Known lastname 6687**]. The mother's own
mother has been here with her for a large percentage of the
time. The infant's last name after discharge will be [**Last Name (un) **].
Genetics: [**Known lastname 68475**] has had several genetics tests done due
to her growth restriction and dysmorphic features. She does
have a normal karyotype of 46XX and she had a fish chromosome
study for trisomy 18 and 21 which were both normal. She also
had a fish for 22, Q11, for [**Last Name (un) **] cardiofacial syndrome which
was normal. The most recent genetics recommendation are that
her physical findings are most consistent with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 68476**] syndrome. At this time, the parents have declined
testing for that specific syndrome but are aware of its
features and prognosis.
Her primary pediatric care provider will be Dr. [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **],
telephone number [**Telephone/Fax (1) 38070**].
RECOMMENDATIONS: Feedings of 30 calorie per ounce with calories
to 27 by NeoSure and 3 calories from corn oil at approximately
140 ml per kg per day. Feedings are given every 3 hours. Infant
may attempt oral
feedings but feedings will mostly be given by gastrostomy
tube.
MEDICATIONS: Ferrous sulfate 25 mg per ml, 0.2 ml pg daily.
Goldline baby vitamins, 1 m1 pg daily.
The infant passed a car seat position screening test.
Last newborn screen was sent on [**2119-12-7**] and was within normal
limits.
The infant has received her first hepatitis B vaccine on
[**2119-12-25**].
RECOMMENDED IMMUNIZATIONS: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following three criteria: (1) Born at less than
32 weeks; (2) Born between 32 weeks and 35 weeks with two of
the following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; (3) chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW UP:
1. She will have an audiology test at [**Hospital1 **] Audiology
Department on [**2120-2-1**] at 12:45 p.m.
2. Cape and Island Early Intervention Program, telephone
number [**Telephone/Fax (1) 61720**].
3. [**Hospital3 **] Home Care Visiting Nurse, telephone
number [**Telephone/Fax (1) 49371**].
4. Her supplies for her gastrostomy tube will come from
[**Last Name (un) 6438**], telephone number 1-[**Telephone/Fax (1) 6442**].
5. Gastrointestinal follow-up with Dr. [**Last Name (STitle) 68477**], telephone
number [**Telephone/Fax (1) 46320**]. Appointment is on [**2120-1-12**] at 11:30
a.m.
6. ORL (otorhinolaryngoscopy) Dr. [**Last Name (STitle) 68478**], telephone
number [**Telephone/Fax (1) 42941**]. Appointment is on [**2120-1-12**] at 1:00
p.m.
7. Genetics: Dr. [**Last Name (STitle) **], telephone number [**Telephone/Fax (1) 37200**]. The
parents are to call to plan an appointment 2 to 6 months
after discharge.
8. Cardiology: Cardiology clinic at [**Telephone/Fax (1) 37115**]. Parents
to call to make an appointment 3 months after discharge.
DISCHARGE DIAGNOSES:
1. Term female infant.
2. Status post intrauterine growth restriction.
3. Failure to thrive.
4. Laryngomalacia.
5. Dysfunctional suck/swallow reflex.
6. Rule out genetic syndrome.
7. Status post gastrostomy tube placement.
8. Ventriculoseptal defect (muscular).
9. Anemia.
10. Referred bilateral hearing examination.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2120-1-5**] 05:11:04
T: [**2120-1-5**] 05:57:11
Job#: [**Job Number 68479**]
|
[
"779.3",
"773.2",
"745.4",
"759.89",
"796.1",
"V05.3",
"748.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.55",
"43.11",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6838, 7427
|
5703, 6817
|
5011, 5692
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,904
| 158,577
|
24677
|
Discharge summary
|
report
|
Admission Date: [**2141-12-25**] Discharge Date: [**2142-1-1**]
Date of Birth: [**2075-2-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
cc:[**CC Contact Info 62278**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66 M recently discharged to [**Hospital1 **] from [**Hospital1 **] neurosurg after
being struck by car while on bike and sustaining head trauma
(frontal and parietal contusion, subarachnoid, IVH but no
fracture). Intubated and monitored. Trach'd and PEG'd then d/c
to [**Hospital1 **]. Hosp course complicated by E. coli pneumonia for
which was treated and a R superficial thrombus. Per discussion
with [**Hospital1 **] was discharged only responsive to noxious
stimuli, but ? alert at rehab yesterday. Developed tachy 10
107/tachypnea to 30 yesterday. started on levoquin [**12-22**].
suctioning thick mucus. got hypoxic to low 90's on trach mask
and transferred here to r/o PE.
.
Here unable to obtain access for CTA contrast, but CXR showed
RML infiltrate. Never hypotensive.
Past Medical History:
PMH:
Special needs
Mental retardation high functioning has been holding a job and
taking care of his father [**Name (NI) 62279**] [**Name (NI) 8751**]
[**2141-12-4**] - bike versus car [**Month/Day/Year 8751**] s/p blunt head trauma with
multiple brain contusion and subarachnoid, IVH --> intubated
-- trach and PEG
-- baseline mental status on discharge only responsive to
noxious stimuli
Social History:
Had taken care of father before accident, has special needs,
has been at [**Hospital3 **]
Family History:
NC
Physical Exam:
PE:
vs: Tm 100.6, Tc 98.8, rr 20, 150/87 (130-150), 100% on 50% TM
(7L O2)
gen: no acute resp distress
neuro:
good gag
pupils 3mm --> 2mm, blinks to threat
in c-collar - doll's not tested
unresponsive even to noxious stimuli
withdrawl to deep pain bilateral lower ext, not upper
DTR 2+ biceps/triceps, absent lower
clonus bilat ankles, toes up on R, down on L
upper ext tone normal
heent: mmm, trach nonerythematous, no erosions
lungs: cta b anteriolaterally, good aeration
cv: s1/s2, tachy, no m/r/g
abd: obese, nabs, PEG in place looks good, no grimace with
palpation
ext: ecchymosis LLE, dp 2+ bilat, no edema
access: L PICC brachial vein - no erythema or pus
Pertinent Results:
[**2141-12-24**] 04:37PM BLOOD WBC-12.1* RBC-3.31* Hgb-9.4* Hct-29.4*
MCV-89 MCH-28.4 MCHC-32.0 RDW-15.1 Plt Ct-636*
[**2141-12-24**] 04:37PM BLOOD Neuts-72.5* Lymphs-19.3 Monos-5.8 Eos-1.8
Baso-0.6
[**2141-12-24**] 07:42PM BLOOD PT-16.6* PTT-33.4 INR(PT)-1.9
[**2141-12-24**] 04:37PM BLOOD Glucose-142* UreaN-22* Creat-0.6 Na-143
K-4.2 Cl-107 HCO3-27 AnGap-13
[**2141-12-24**] 04:37PM BLOOD ALT-69* AST-40 AlkPhos-161* TotBili-0.5
[**2141-12-25**] 10:39AM BLOOD Type-ART Temp-38.7 Rates-/40 FiO2-94
pO2-116* pCO2-40 pH-7.47* calHCO3-30 Base XS-4 AADO2-520 REQ
O2-86 Intubat-NOT INTUBA Comment-TRACH MASK
[**2141-12-24**] 04:34PM BLOOD Lactate-1.1
.
Right upper extremity venous ultrasound [**12-24**]: No evidence for
deep vein thrombosis in the right upper extremity.
CXR [**12-28**]: A single semiupright view is compared to previous
examination of [**2141-12-26**]. There is new right basilar
atelectasis. The heart size remains stable. The small focus of
consolidation in the left mid lung has resolved. There is also
better aeration of the left lung base. There is no evidence of
pulmonary edema. Again, note is made of tracheostomy tube and
left subclavian PICC line with the tip in proximal SVC.
.
CXR [**12-24**]:There is a faint airspace opacity in the right middle
lung zone, which is new in comparison to prior study, and may
represent aspiration or pneumonia. There is bibasilar
atelectasis, and small bilateral pleural effusions, greater on
the left. No pneumothorax is seen. A left- sided PICC line is
seen, with the tip in the upper SVC. A tracheostomy tube is seen
with the tip approximately 4 cm above the carina. The pulmonary
vasculature is stable in appearance. Degenerative changes are
seen within the mid thoracic spine. The mediastinal and cardiac
contours are stable in appearance.
IMPRESSION: Faint new airspace opacity within the right mid lung
zone. As this is a new finding in a short time period, this is
concerning for aspiration, though pneumonia should also be
considered. Again seen are small bilateral pleural effusions.
.
head CT [**12-24**]:CT HEAD WITHOUT IV CONTRAST: No new intracranial
hemorrhage, hydrocephalus, shift of normally midline structures,
or mass effect is identified. A small amount of hyperattenuating
fluid consistent with hemorrhage is layering within the
occipital horns of the lateral ventricles bilaterally, unchanged
from the previous exam. Bilateral frontal areas of
hypoattenuation as well as within the splenium of the corpus
callosum consistent with diffuse axonal injury and/or contusions
are unchanged. Partial opacification of the left maxillary,
sphenoid, ethmoid, and frontal air cells is again identified.
IMPRESSION:
1. No acute intracranial hemorrhage or edema.
2. Intraventricular hemorrhage again identified within the
dependent portions of the lateral ventricles bilaterally,
unchanged from the previous exam.
3. Changes from diffuse axonal injury/parenchymal contusions
again seen.
.
Left lower extremity venous ultrasound [**12-24**]: No evidence of
left lower extremity deep vein thrombosis.
Brief Hospital Course:
Upon admission Mr. [**Known lastname 62280**] was started on Ceftaz, Vanco, and
Flagyl for a possible aspiration PNA. Admission CXR showed RML
infiltrate. He had been on levofloxacin since discharge on [**12-22**]
for continued treatment of pansensitive E. Coli bacteremia and
E. Coli and Enterobacter positive sputum, which was d/c'ed on
arrival to the floor. Overnight he required frequent suctioning
of thick mucous and was transferred to the [**Hospital Unit Name 153**] for closer
monitoring.
In the [**Hospital Unit Name 153**], Mr. [**Known lastname 62280**] continued to be tachycardic and have
copious secretions. He was continued on ceftazidime and
vancomycin. Flagyl d/c'ed on [**12-26**]. In efforts to determine the
etiology of his tachycardia (up to 120s), RUE, RLE and LLE U/Ss
were done, which showed no evidence of thrombosis (despite pt's
recent h/o RUE superficial vein thrombosis). PIV was attempted,
but despite several attempts, could not be placed and, thus, CTA
to r/o PE could not be done. Since no DVTs were appreciated,
coumadin was d/c'ed.
A morphine trial was done [**12-27**], which resulted in no slowing of
HR. His HR responded moderately to IVF, but remained somewhat
tachycardic. A similar protocol was carried out on [**12-28**], with
HR to 130s, not responding to morphine or lopressor, but did
decrease to 90s after 500mL NS bolus. Metoprolol was titrated up
to 75mg tid. Tachycardia possibly [**3-8**] autonomic instability as
result of his accident, possibly with mild overlying
hypovolemia.
Due to nonspecific T-wave changes in anterior leads, was ruled
out with negative trops x 3.
Mr. [**Known lastname 62281**] FIO2 was weaned from 0.5 to 0.35 trach mask, and
nursing noted that suctioning was required only intermittently
(approximately 4 times yesterday), with less thick secretions
than at admission. His temperatures, which were initially
elevated, normalized, and he was afebrile by time of discharge.
He was sent out on a somewhat altered regimen, with
significantly increased metoprolol dose (25mg [**Hospital1 **] to 75mg tid).
Coumadin was also d/c'ed, as U/S's showed no evidence of
thrombosis. He was discharged back to [**Hospital **] hospital for
further management.
Medications on Admission:
Rx:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Lansoprazole 30 mg Susp,qd
Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
Miconazole Nitrate 2 % Powder qid prn
Metoprolol Tartrate 25 mg [**Hospital1 **]
Levofloxacin 500 mg po qd (started [**12-22**])
Ipratropium Bromide
Albuterol Sulfate 0.083 %
Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (once) for
1 doses.
was using hydralazine in neuro SICU for BP control, none at
rehab
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Pneumonia
Tachycardia
Discharge Condition:
Stable. Decreased secretions, SaO2 stable on 35% trach mask,
afebrile. On IV antibiotics.
Discharge Instructions:
Please take your medications as prescribed.
.
You should return to the hospital if you develop worsening O2
saturations, weakening cough reflex, significantly increased
secretions, fever, or any other concerning problems.
Followup Instructions:
You will be followed at [**Hospital3 **] facility, where your
care will be further managed.
|
[
"276.3",
"401.9",
"507.0",
"285.9",
"427.89",
"482.41",
"V09.0",
"V44.1",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8692, 8762
|
5502, 7731
|
345, 352
|
8828, 8920
|
2402, 5479
|
9190, 9285
|
1699, 1703
|
8783, 8807
|
7757, 8669
|
8944, 9167
|
1718, 2383
|
275, 307
|
380, 1161
|
1183, 1575
|
1592, 1683
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,700
| 173,032
|
44029
|
Discharge summary
|
report
|
Admission Date: [**2133-11-7**] Discharge Date: [**2133-11-17**]
Date of Birth: [**2100-12-7**] Sex: M
Service: MEDICINE
Allergies:
Dapsone / Bactrim Ds
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pateint is a 32 year old male with PMHx of HIV diagnosed 10
years ago and etoh abuse who presents with reported siezure
witnessed by the patient's mother. [**Name (NI) **] states that he used
to drink [**6-8**] etoh drinks a day and stopped 2 weeks ago (however
when he first came to the ED he was reported as stopping etoh
use 2 days ago). He states that he was in his usual state of
health when he fell from his sofa at 9:30am and was reported as
having a seizure. Patient hit his left shoulder when he fell.
Patient denies any focal deficits before seizure event. He
denies any headache, vision problems, slurred speech, ataxia.
He states that he does not remember the seizure event. He
denies any incontinance. He was brought to the ED by EMS where
he was found to have a temp of 100.6 and tachycardic. Patient
[**Name (NI) 60563**] scale was 18 and was given valium x 3. Patient had head CT
which was negative for any mass lesion and had an LP performed.
CSF was sent out for cell count with diff, gram stain,
cryptococcus antigen. Patient serum toxicology was negative.
Currently patient states that he feels very weak. He states
that his muscles hurt, especially his abdominal muscle. It is
difficult for him to sit up. He denies any numbness. Patient
denies any fever/chills; n/v prior to admission. He states that
he does have diarrhea and has been having diarrhea for 5 years.
Patient states that his left shoulder is very painful. He had
an xray of shoulder done in the ED which was negative for
dislocation or fracture. Patient denies any melena, BRBPR,
hematoemesis.
Patient has been off HAART medication for 6 months. He can't
remember his last viral load and thinks his last CD4 count was <
100 about 6 months ago. He states that he stopped HAART because
he had been on medications for 10 years and just got tired of
taking meds. Patient states that he has PCP x 3 in the past and
has thrush. He denies any rashes or other illnesses related to
his HIV except the diarrhea.
Past Medical History:
HIV 10 years ago
Anxiety
History of seizure in the pst related to etoh use
Social History:
Etoh abuse [**6-8**] drinks per day; states he stopped 2 weeks ago
Denies any illicit drug use
Currently does not have any sexual partners
no smoking history
He lives with his mother and grandmother
Physical Exam:
PE: T 99.9 P 98 BP 131/81 R 19 O2Sat 97%
Gen: [**Last Name (un) **] healthy looking male, who appears to be in mild
discomfort secondary to pain
Heent: PERRLA, EOMI, sclera anicteric, (+)thrush, no exudates
Neck: supple, no LAD
Cardiac: RRR S1/S2 no murmurs
Lungs: CTA B/L
Abd: soft, tender to deep palpation diffuse, no gaurding or
rebound. NABS
Ext: No obvious deformities. Patient unable to lift left
shoulder due to pain. Patient having difficulty lifting legs
secondaryu to pain. No edema, rashes, cuts
Neuro: AAOx3, CN II-XII intact. Exam limited secondary to pain.
Patient with 3/5 MS [**First Name (Titles) **] [**Last Name (Titles) **] and [**3-6**] in LE (however states that he
is weak because of pain). Sensory grossly intact. Patient
unable to perform rapid alternating movements and heel to shin
[**2-2**] pain. Finger to nose test intact.
Pertinent Results:
[**2133-11-7**] 11:10PM GLUCOSE-120* UREA N-7 CREAT-0.7 SODIUM-137
POTASSIUM-3.0* CHLORIDE-101 TOTAL CO2-28 ANION GAP-11
[**2133-11-7**] 05:51PM CEREBROSPINAL FLUID (CSF) PROTEIN-47*
GLUCOSE-74
[**2133-11-7**] 05:51PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* POLYS-0
LYMPHS-98 MONOS-0 MACROPHAG-2
[**2133-11-7**] 04:00PM URINE HOURS-RANDOM
[**2133-11-7**] 04:00PM URINE GR HOLD-HOLD
[**2133-11-7**] 04:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2133-11-7**] 04:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2133-11-7**] 04:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2133-11-7**] 01:15PM GLUCOSE-147* UREA N-9 CREAT-0.7 SODIUM-135
POTASSIUM-2.7* CHLORIDE-93* TOTAL CO2-26 ANION GAP-19
[**2133-11-7**] 01:15PM CALCIUM-9.0 PHOSPHATE-1.1* MAGNESIUM-1.4*
[**2133-11-7**] 01:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2133-11-7**] 01:15PM WBC-2.5*# RBC-4.03* HGB-13.5* HCT-37.0*
MCV-92# MCH-33.6*# MCHC-36.6* RDW-12.8
[**2133-11-7**] 01:15PM NEUTS-50.2 LYMPHS-39.6 MONOS-9.4 EOS-0.5
BASOS-0.2
[**2133-11-7**] 01:15PM PLT SMR-LOW PLT COUNT-99*
[**2133-11-7**] 05:51PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-0
Lymphs-98 Monos-0 Macroph-2
[**2133-11-7**] 05:51PM CEREBROSPINAL FLUID (CSF) TotProt-47*
Glucose-74
Xray Shoulder: LEFT SHOULDER, 3 VIEWS, ON [**2133-11-17**]: Compared to
[**2133-11-7**], there is a nondisplaced fracture through the lesser
tuberosity of the left humeral head, best seen on the axillary
view. No evidence for dislocation.
CT Head: IMPRESSION: No evidence of intracranial hemorrhage or
edema.
[**Month/Day/Year 4338**] Head: There is mild prominence of sulci and ventricles
inappropriate for patient's age. No evidence of midline shift
mass effect or hydrocephalus is seen. There are no focal signal
abnormalities seen. No evidence of acute infarct noted. Mucosal
thickening is seen in the left maxillary and ethmoid sinuses.
Brief Hospital Course:
## Alcohol Withdrawal - Initially the differential diagnosis for
patient's seizure consisted of etoh withdrawal, infection
related to HIV such as toxoplasmosis or PML, or electrolyte
abnormalitiy (very low phosphorus). Patient's phosphorous was
repleated and CSF culture and fungal culture came back negative.
CSF came back negative for cryptococcus. Once patient was sent
to the floor on night of HD #1 he became extremely agitated,
hallucinating with [**Month/Day/Year 60563**] > 38. Patient remained unresponsive to
multiple doses of ativan, valium and haldol. Patient was felt
to be in DTs and sent to the ICU for close monitoring and
aggressive benzodiazapine treatment. In the MICU patient
required > 700mg of Valium. In MICU patient remained somulaent
and psychiatry was consulted to assist with benzo
administration. Psychiatry recommended Valium taper and prn
Haldol for aggitation. PAtient remained in the ICU for 5 days
and when he was transferred back to the floor he was off the
[**Month/Day/Year 60563**] scale and written for prn Haldol for agitation which he did
not require. [**Month/Day/Year 60563**] scale was restarted on the floor for an extra
24 hours to make sure patient truelly recovered from etoh
withdrawal. While on the floor patient remained stable with no
more evidence of etoh withdrawal. Addiction service was
consulted to counsel patient about etoh abuse and setup
outpatient followup if needed.
## HIV - Patient CD4 count came back as 122 and HIV VL was not
processed. Patient was not restarted HAART therapy given
patient's non-compliance and possible resistance. Patient will
follow up outpatient for re-assessment of HAART medications
before restarting. Continued patient on fluconazole for thrush
and restarted patient on Bactrim DS 1 tab daily for PCP
prophylaxis once CD4 count came back as 122. Patient has
history of Bactrim allergy (gets a rash) that he has been
desensitized too. Patient has been off Bactrim for a few months
and some concern if he would now be sensitive to Bactrim.
However after further history taking patient has been on and off
Bactrim for many years without any adverse reactions so it was
felt that it would be okay to restart Bactrim and monitor
closely for allergic reaction.
## Rhabdomyolysis - In the ICU patient also noted with
rhabdomyolysis with CK > [**Numeric Identifier 890**] secondary to alcohol withdrawal.
Patient given aggressive IV hydration to prevent renal failure.
CK, Cre and BUN were monitored daily and continued to trend
down. Patient showed no evidence of renal failure while in
hospital. Patient however remained weak and stiff after
recovering from etoh withdrawal which could be expected given
rhabdomyolysis. Physical therapy was consulted to work with
patient once he was on the floor.
## ID - In the ICU patient was found to have gram postive
urinary tract infection and on HD # 5 was noted to have a temp
of 103.4 (however temp ran elevated as baseline while patient
was in DTs) with cough. Patient had a chest xray done which
suggested a RLL infilatrate and it was felt that patient had
aspiration pneumonia. HE was started on levofloxacin and
flagyl. A repeat chest xray showed no evidence of pneumonia but
patient kept on levofloxacin for UTI. Once on the floor patient
was switched to clindamycin since levofloxacin can lower seizure
threshold. A repeat PA&LA chest xray was done once on the floor
to assess if patient really had a pneumonia. However patient
was kept on 10 day course of clindamycin given his UTI. Patient
remained afebrile on the floor with normal WBC. Once patient
mental status improved it was not felt that he was an aspiration
risk and did well on clear diet so he was advance to a regular
diet.
## Shoulder Fracture - On admission patient had X-ray of
shoulder which was negative for fracture or dislocation, however
the axillary view was not clearly visualized. Patient continued
to have shoulder pain so a repeat x ray was done which showed a
non-displaced fracture of the humeral head of the left shoulder.
Ortho was consulted who recommended that patient keep his arm
in a sling and follow up outpatient with orthopedics. Patient
was setup for outpatient follow up.
Medications on Admission:
none - Patient stopped taking HAART and prophylaxis medication 6
months prior
Discharge Medications:
1. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q8H
(every 8 hours) for 3 days.
Disp:*18 Capsule(s)* Refills:*0*
7. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for insomnia.
Disp:*7 Tablet(s)* Refills:*0*
8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol Withdrawal
Urinary Tract Infection
Rhabdomyolysis
Shoulder Fracture
Discharge Condition:
Stable - Patient finishing course of antibiotics for pneumonia
and will follow up outpatient for shoulder injury.
Discharge Instructions:
Please go to scheduled [**Numeric Identifier 4338**] of shoulder on Tuesday Novemeber 23rd
at 5:45pm on the [**Hospital Ward Name 517**] in the Clinical Center Building in
the Basement.
Please follow up with scheduled appointment with Dr. [**Last Name (STitle) 2719**] on
Tuesday Novemeber 30th at 3:20pm on the [**Hospital Ward Name 516**] in the
[**Hospital Ward Name 23**] Building
Please call Day treatment as soon as you are able, to setup
treatment
Please make sure you follow up with your primary care doctor
outpatient to discuss restarting HAART therapy.
Please continue to take medications as prescribed. You are
being treated for urinary tract infection and pneumonia with
antibiotics, please continue to take antibiotics for full 10 day
course (3 more days).
Followup Instructions:
Please make sure you follow up with your primary care doctor
outpatient to discuss restarting HAART therapy
Please call the Day Treatment Center, number has been provided
Provider: [**Name10 (NameIs) 4338**] Where: CC CLINICAL CENTER [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2133-11-24**] 5:45pm
Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**] ORTHOPEDICS
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2133-12-1**] 3:20pm
|
[
"728.88",
"291.81",
"303.01",
"599.0",
"780.39",
"794.8",
"042"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
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10859, 10865
|
5599, 9832
|
289, 296
|
10985, 11100
|
3544, 5170
|
11923, 12428
|
9960, 10836
|
10886, 10964
|
9858, 9937
|
11124, 11900
|
2663, 3525
|
242, 251
|
324, 2334
|
5179, 5576
|
2356, 2432
|
2448, 2648
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,148
| 197,505
|
31628
|
Discharge summary
|
report
|
Admission Date: [**2180-6-10**] Discharge Date: [**2180-6-14**]
Date of Birth: [**2103-9-28**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Chest pain, anterior ST elevation myocardial infarction
Major Surgical or Invasive Procedure:
Cardiac catherization (Bare Metal Stent x 2 - LAD, LCx)
Swan Ganz catherter placement and subsequent removal
History of Present Illness:
Mr. [**Known lastname **] is a 76 year old man with a past medical history
significant for hypertension who presents as a transfer from
[**Hospital1 18**]-[**Location (un) 620**] with chest pain and concern for anterior STEMI.
The patient woke this morning and, while showering, developed
chest pain which felt like "someone sitting" on his chest; the
pain was initially mild but increased in intensity. He
experienced profuse diaphoresis and increasing shortness of
breath. He initially called his daughter, but as the symptoms
increased, he called EMS and was taken to [**Hospital1 18**]-[**Location (un) 620**]. There,
he received plavix 600 mg X 1, asa 325 mg, lopressor 5 mg,
heparin bolus & drip, nitroglycerin drip, integrillin bolus &
drip, and morphine. EKG showed ST elevations in V1-V5 and I,
hyperacute T waves throughout the precordium, and flipped T in
III, Q waves in V1-3. Initial CK 53. The patient was urgently
transferred to the [**Hospital1 18**] cath lab where angiography showed
subtotal thrombosis of the mid-LAD which was stented with a bare
metal stent; there was also evidence of L circumflex thrombus,
which was also stented with a bare metal stent.
.
On arrival to the floor, the patient denies chest pain. He is
breathing comfortable but requiring non-rebreather to maintain
an oxygen saturation of 96%.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, 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. The patient typically walks
up to [**1-1**] miles several times per week without any chest pain or
dyspnea. He also performs back exercises daily.
Past Medical History:
1) Hypertension
2) Prior esophageal ulcer several years ago (in setting of
taking aspirin for pain, 2 tabs Q4H)
3) Low back pain
4) s/p cholecystectomy complicated by pancreatitis
5) s/p coccyx removal
Social History:
No prior history of tobacco use; he drinks a glass of wine with
dinner several times per week. He is a retired medicinal
chemist.
Family History:
There is no family history of premature coronary artery disease
or sudden death. [**Name (NI) **] mother had rheumatic heart disease.
Physical Exam:
VS: T 96.0, BP 120/70, HR 78, RR 16, O2 89% on 4L NC, 98% on
Non-re-breather
Gen: Well developed and well nourished elderly male in no
distress, speaking in full sentences. Oriented x3. Mood, affect
appropriate. Pleasant.
HEENT: Normal cephalic a-traumatic. Sclera anicteric. PERRL,
EOMI. Mucous membranes moist.
Neck: Supple with JVP of 8 cm.
CV: regular rate, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. L > R crackles
auscultated anteriorly.
Abd: Obese, soft, non-tender and non-distended, No
hepatosplenomegally or tenderness. No abdominial bruits.
Ext: No peripheral edema; femoral sheath in place on the right
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+; 2+ DP
Pertinent Results:
LABORATORY DATA:
From OSH:
WBC 6.1, Hct 42.7, Plt 237
RDW 14.7, MCV 96
Na 135, K 3.5, Cl 101, bicarb 24.1, BUN 15, creatinine 1.2,
glucose 140
calcium 8.4, mg 2
albumin 3.7, bili 0.46, AP 62, ALT 33, AST 17
CK 53 (no MB or troponin)
.
[**Hospital1 18**]:
[**2180-6-11**] WBC-12.4* Hct-43.3 Plt Ct-239
[**2180-6-14**] WBC-8.4 RBC-4.08* Hgb-13.9* Hct-38.4* MCV-94 MCH-34.0*
MCHC-36.1* RDW-14.9 Plt Ct-192
.
[**2180-6-11**] PT-12.2 PTT-62.0* INR(PT)-1.0
[**2180-6-12**] INR(PT)-1.4*
[**2180-6-13**] INR(PT)-1.5*
[**2180-6-14**] PT-22.0* PTT-69.4* INR(PT)-2.2*
.
[**2180-6-11**] CK(CPK)-1700*
[**2180-6-11**] CK(CPK)-2223*
[**2180-6-10**] CK(CPK)-1859*
[**2180-6-11**] CK-MB-126* MB Indx-7.4*
[**2180-6-11**] CK-MB-179* MB Indx-8.1* cTropnT-5.89*
[**2180-6-10**] CK-MB-184* MB Indx-9.9* cTropnT-5.2*\
.
[**2180-6-11**] Glucose-126* UreaN-11 Creat-0.9 Na-130* K-3.8 Cl-98
HCO3-25 AnGap-11
[**2180-6-14**] Glucose-108* UreaN-15 Creat-1.2 Na-136 K-4.1 Cl-101
HCO3-28 AnGap-11
.
[**2180-6-10**] ALT-33 AST-184* AlkPhos-45 TotBili-0.5
.
[**2180-6-11**] Triglyc-112 HDL-57 CHOL/HD-3.2 LDLcalc-102
.
STUDIES:
.
CXR ([**6-10**], from OSH): bilateral blunted costophrenic angles with
hilar fullness
CXR ([**2180-6-13**]): Improving pulmonary edema
.
[**Hospital1 18**] [**Location (un) 620**] ([**6-10**]; 9:30am):
EKG showed ST elevations in V1-V5 and I, hyperacute T waves
throughout the precordium, and flipped T in III, Q waves in V1-3
.
CARDIAC CATH performed on [**2180-6-10**] demonstrated: Right dominant
system wih severe 3VD (60% RCA, 90% mid-LAD, 30% left main, 60%
diags, 60% mid-LCx). Thrombus in the mid-LAD extending into and
past the 2nd diag. Also, hazy filling of mid LCx.
HEMODYNAMICS: central aortic pressure 94/62
.
[**Hospital1 18**] ([**6-10**]) 12pm (after cath):
EKG demonstrated ST elevations in I, V2-V5 (improved from OSH
EKG),Q waves v1-4.
.
[**Hospital1 18**] ([**6-10**]) after cardiac cath:
2D-ECHOCARDIOGRAM: EF 30-35%. Normal L & R atrial size. LV
moderate to severe regional systolic dysfunction. Cannot exclude
LV mass or thrombus. Wall motion abnormalities in LV wall -
midanterior akinetic, midanterior septal akinetic, anterior apex
akinetic, septal apex akinetic, inferior apex hypokinetic,
lateral apex akinetic, apex akinetic. No AS, no AR, no MR. [**First Name (Titles) **] [**Last Name (Titles) 8097**]c pressure indeterminant.
.
[**Hospital1 18**] ([**2180-6-12**])ECHO with definity contrast: Left ventricular
ejection fraction of 35%. Regional left ventricular wall motion
abnormalities (similar to previous study.) Mild left ventricular
hypertrophy. No left ventricular thrombus. Normal left atrial
size. Normal right ventricular size and motion. Nomral right
atrial size. Mildly dilated aortic sinus and ascending aorta.
1+ MR.
Brief Hospital Course:
ASSESSMENT AND PLAN, AS REVIEWED AND DISCUSSED IN MULTI
DISCIPLINARY ROUNDS
Mr. [**Known lastname **] is a 76 year old male with a history of hypertension
who was admitted with an anterior ST elevation myocardial
infarction s/p bare metal stenting to the left anterior
descending artery and left circumflex artery.
.
Anterior STEMI s/p stenting: The patient was taken to the
cardiac catheterization lab and bare metal stents (LAD, LCx)
were placed. Cardiac enzymes were cycled with peak CK of 2223
and a peak CK-MB of 184. Cardiac enzymes began to trend
downward on [**2180-6-11**]. A lipid panel was drawn and found to be
within normal limits. The patient was placed on aspirin 325mg
(this will be lifelong), plavix 75mg (for at least one month, to
be discontinued at the discretion of the patient's primary
cardiologist), a heparin drip, and atorvastatin 80mg. A beta
blocker and captopril were started and titrated to the patient's
blood pressure. On discharge, the patient was on Toprol XL 75mg
PO daily and lisinopril 2.5mg PO Daily. The patient will be
re-evaluated as an outpatient with a repeat ECHO, exercise
stress test, and Holter monitor to better risk stratify his
prognosis. He has follow up set up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] in two
weeks.
.
Congestive Heart Failure s/p anterior STEMI: Left ventricular
ejection fraction on ECHO ([**2180-6-10**]) was 30-35% with
hypokinesis/akinesis of the distal two-thirds of the anterior
septum, anterior wall, distal lateral wall, and apex. Due to
the left ventricular hypokinesis, there was concern for a left
ventricular thrombus. An ECHO with definity contrast was
performed on [**2180-6-12**] and demonstrated no left ventricular
thrombus. However, the risk of future clot formation and
possible stroke was high enough to warrant anticoagulation with
Coumadin. Heparin drip was used to bridge to a therapeutic INR
of [**1-1**]. On discharge, the patient was on Coumadin 2.5mg PO
Daily with an INR of 2.2. The patient will follow up with an
INR drawn by a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 2974**] [**2180-6-16**]. The patient
will then be followed by his PCP's coumadin clinic and he has an
apointment with his PCP on [**Name9 (PRE) 766**] [**2180-6-19**] at 7:45am.
On [**2180-6-11**], the patient was found to be volume overload on exam
with bilateral crackles and increasing oxygen requirement. The
patient was started on Lasix 10mg IV for two days with good
effect and a diuresis of 4.5L. Lasix was then discontinued.
I/O's were monitored. On [**2180-6-12**], the patient was tachycardic
to the 120's. He was given Lopressor 5mg IV. However, he
continued to be tachycardic and his blood pressures dropped to
the 80's/40's. There was concern for possible cardiogenic shock
due to systolic dysfunction and a Swan Ganz catheter was placed.
The pressure values from the Swan Ganz catheter were found to
be within normal limits: central venous pressure 7, mean
pulmonary artery pressure 16, wedge pressure 8, cardiac output
4.8, cardiac index 2.39, and systemic vascular resistance 1050.
The Swan Ganz catheter was removed on [**2180-6-13**]. Finally, it was
also felt that the patient's congestive heart failure would
benefit from the eplerenone. However, the medication was not
started due to the patient's episodes of hypotension. As an
outpatient, once Mr. [**Known lastname 26785**] blood pressures have stabilized,
eplerenone should be considered.
.
Tachycardia: On [**2180-6-11**], the patient started to have episodes
of tachycardia to the 120's with hypotension-80's/40's. At
first, there was concern for possible cardiogenic shock;
however, the pressure values and cardiac output from the Swan
Ganz catheterization made this unlikely. A TSH was check and
found to be 6; however, free T4 was within normal limits. In
the end, it was felt that the tachycardia may be due to his
myocardial infarction/stress response/attempt to mainatin
cardiac output in the setting of low ejection fraction. He will
be discharged on a Toprol XL 75mg PO Daily.
.
Hypertension: The patient has a history of hypertension but on
this hospitalization he was normotensive to hypotensive and his
beta blocker and captopril were titrated to his blood pressures.
.
Abnormal thyroid function studies: The patient should have his
TSH and free T4 rechecked as an outpatient to ensure that TSH
returns to normal. Elevated TSH with normal free T4 in the acute
setting likely represents sick euthyroid syndrome.
.
Prior esophageal ulcer: Potentially could recur in setting of
aspirin, but will maintain patient on pantoprazole 40mg PO
Daily.
.
FEN: Cardiac, low sodium diet. Replete lytes prn.
.
Prophy: The patient received anticoagulants until ambulatory. He
was maintained on a PPI as above as well as bowel medications as
needed.
.
Dispo: Patient was moved from the cardiac care unit to the
floor on [**2180-6-13**]. Physical therapy reported that the patient
was ready to be discharged to home with services (his daughter
will be at home). He will follow up with his PCP [**Last Name (NamePattern4) **] [**2180-6-19**] at
7:45am. He will follow up with Dr. [**Last Name (STitle) 171**], the patient's new
cardiologist, on Please follow up with your cardiologist, Dr.
[**Last Name (STitle) 171**], on [**2180-6-28**] at 2:00pm and [**2180-8-7**] at 1:40pm. You are
also scheduled for an follow up echocardiogram on [**2180-8-4**] at
11:00am. Please call [**Telephone/Fax (1) 128**] for more information.
.
Full code
.
Communication: With patient and his daughter [**Name (NI) **]. ([**Telephone/Fax (1) 74343**].
Medications on Admission:
atenolol 25 mg daily
multivitamin
prilosec 20 mg daily
colace 100 mg prn
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(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 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
please adjust according to your INR.
Disp:*90 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please draw PT/INR on Fri. [**6-16**] and fax results to Dr.
[**Last Name (STitle) **] at # [**Telephone/Fax (1) 36518**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1.) Anterior ST segment Elevation Myocardial Infarction
Discharge Condition:
Stable
Discharge Instructions:
During this hospitalization, you were diagnosed with a
myocardial infarction or a heart attack. You were found to have
a type of myocardial infarction called an anterior ST segment
elevation myocardial infarction and you were treated with a
cardiac catheterization and bare metal stent placement in the
left anterior descending coronary artery and the left circumflex
artery.
.
Be sure to take all of your medications, many of which are new
and are used to treat patients after a heart attack.
This includes plavix and aspirin. Under no circumstance should
you discontinue your aspirim or plavix with out speaking to your
cardiologist.
.
You will also need to take another medicine called Coumadin,
which acts to help prevent clots from forming in your heart.
This medicine requires that you get blood levels (INR) checked
periodically, which can be set up by your primary care provider.
.
Please call your primary care physician or go to the hospital if
you have chest pain, shortness of breath, feel dizzy, have
nausea/vomiting, suddenly become hot and sweaty, or have any
other concerns.
Followup Instructions:
Please follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
within one week of discharge from the hospital. During this
hospitalization you were started on Coumadin to prevent a clot
from forming in your heart. You will need to follow up with a
coumadin clinic, which may be coordinated by your primary care
provider.
.
Please follow up with your cardiologist, Dr. [**Last Name (STitle) 171**]
([**Telephone/Fax (1) 1989**]), on [**2180-6-28**] at 2:00pm and [**2180-8-7**] at 1:40pm.
You are also scheduled for an follow up echocardiogram on [**2180-8-4**]
at 11:00am. Please call [**Telephone/Fax (1) 128**] for more information.
Completed by:[**2180-6-15**]
|
[
"414.01",
"410.11",
"428.0",
"401.9",
"724.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"89.64",
"37.22",
"88.56",
"00.66",
"00.46",
"36.06",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
13541, 13599
|
6690, 12359
|
334, 444
|
13699, 13708
|
3889, 6667
|
14850, 15567
|
2848, 2983
|
12483, 13518
|
13620, 13678
|
12385, 12460
|
13732, 14827
|
2998, 3870
|
239, 296
|
472, 2459
|
2481, 2685
|
2701, 2832
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,790
| 173,681
|
13145
|
Discharge summary
|
report
|
Admission Date: [**2109-5-27**] Discharge Date: [**2109-6-8**]
Date of Birth: [**2044-4-8**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / Ciprofloxacin
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
wound infection with pus, septic [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
operative debridement of infected wound x3
History of Present Illness:
65 yo morbidly obese woman with several potentially
immunocompromising conditions including diabetes, cirrhosis
(attributed to NASH), MGUS, and ulcerative colitis (although
evidently not on any chronically immunosuppressive meds for
this) who fell from standing [**5-11**] and sustained a right femur
fx; this is particularly noteworthy because she has a prior
right hip ORIF as well as bilateral total knee replacements. She
underwent ORIF R femur [**5-13**]; there was extensive hardware
implantation given the extent of the fracture. Course at that
time was complicated by dysuria treated with TMP/SMX DS x3 days
(in addition to peri-op cefazolin); U/A had [**12-9**] WBC and few
bacteria, no accompanying urine culture sent. D/C [**5-20**] to rehab
off antibiotics.
.
By [**5-24**] she was manifesting foul-smelling drainage from the
recent RLE operative site; by [**5-27**] she was hypotensive at rehab
and was sent back to our ED with a BP 80/30 and lactate 4.3.
Code sepsis called, blood culture x1 obtained. Vanc, ceftaz, and
flagyl started. She was found to have fluctuance over her
eythematous right knee that was draining yellow-green pus. She
was taken to the OR [**5-28**] for I&D of skin, subcutaneous tissue
(fat necrosis), and bone, as well as vac placement. Knee
arthrotomy was performed without evidence of a septic joint
clinically.
.
Bld cx (2/2 bottles) from admission with E. coli. All three OR
swabs growing the same E. coli; [**2-22**] growing diphtheroids as
well. Initially treated with vanc, CTX, flagyl post-op, now just
vanc and CTX (day 1 of each is [**5-28**]). Returned to OR [**5-29**] for
second wash-out, likely to return again [**6-2**].
65 yo female s/p ORIF R periprosthetic femur fracture [**5-13**] who
was discharged to rehab on [**2109-5-20**] and presented to [**Hospital1 18**] [**2109-5-28**]
with wound infection and sepsis. She is now s/p 2
debridements/VAC for wound infection. Pt admitted to [**Hospital1 18**] from
rehab out of concern from rehab staff for increasing confusion,
low grade fever, and yellow drainage from right thigh incision
site, as well as concerns for pulmonary edema confirmed by CXR
(pt w/o history of CHF) - they had been escalating her aldactone
dose to attempt to reverse this. On the day af admission at the
rehab she had become hypoxic and tachypnic and was transferred
to [**Hospital1 18**]. In th [**Hospital1 18**] ED Code sepsis called - her BP had
decreased to 79/33, she was given vanco, cefepime, ceftaz as
well as levophed, FFP, and vitamin K (INR was 2.9). On [**5-28**] pt
to OR for deep I and D of right leg w/ vac placed for wound
infection, flagyl added to vanco/ceftaz regimen, transfused 4
units PRBC for hct 20 (hct 29 on [**5-28**]) - second I and D in OR on
[**5-29**], on [**6-2**] closed deep wound and placed superficial vacs. On
[**5-28**] pt extubated, and the [**5-27**] cultures of blood returned with
[**2-21**] ecoli, wound showed ecoli and diptheroids. ID consulted,
suggested ceftriaxone 2 g qd for ecoli(anticipated 6 wk course
given multiple artificial joints), with vanco for diptheroids.
.
Since admission UOP has been trending down to oliguria and
creatinine trending up. Fluid boluses with CVP to 20 without
success. Lasix doses of 20 mg per trial were given w/o
increased output. Aldactone needed to be briefly dc'd given
hyperkalemia. Last CXR [**6-2**] without pulmonary edema, however she
has had increasing o2 requirements since that time. Weight had
increased from baseline with max 7 kgs above baseline but now
back to basline. Volume status has also been complicated by
worsening ascites.
.
On day of transfer to MICU service, transfusion of 2 units
ordered for hct of 23. On exam by primary team it was felt that
MS [**First Name (Titles) **] [**Last Name (Titles) 28495**], possibly from increased dilaudid overnight but
unsure. On transfer medications include ceftriaxone and
vancomycin (per dosing), enoxaparin, and aldactone. All others
ppx medications.
Past Medical History:
NASH cirrhosis, NASH c/b portal HTN w/ gII varices, LGIB [**2-21**]
hemorrhoids, HTN, Diabetes type 2, recent E-coli urosepsis
([**3-24**]), hx of DVT (not in last few months), Ulcerative Colitis,
MGUS, Fibromyalgia, OSA, thrombocytopenia, anx/depression, bl
total knee replacements, MGUS,
BR>1. right hip fracture [**2-23**] s/p ORIF
2. hx. LGIB secondary to hemorrhoids
3. hx of DVT
4. HTN
5. Presumed NASH Cirrhosis with grade II varices on [**9-/2108**]-
followed by Dr. [**Last Name (STitle) 7962**]
6. Ulcerative Colitis
7. Fibromyalgia
8. OSA
9. MGUS
10. thrombocytopenia
11. Restless leg syndrome
12. anxiety and depression
13. Diabetes type 2- hgbA1C = 5.4 in [**1-/2109**]
14. s/p bilateral Total knee replacements
Social History:
no tob/alc, lived in elderly living alone prior to fall (prior
to UTI in [**Month (only) **]). has 2 daughters and son. son=HCP. daughter
has stolen pain meds from her in past.
She lives alone in an apartment complex for the elderly. Elder
services on [**Location (un) 448**] at all time. Housekeeper 3x per week.
Home VNA 1/month since mother was doing well. She has three
adult children. Her son, [**Name (NI) **], is quite responsible and
active in her care. He handles all of her finances since [**Doctor Last Name 1356**]-
daughter stole money from her mother. Receives an allowance and
is able to balance her finances. [**Doctor Last Name 501**] and [**Doctor Last Name **] do the
shopping. Assitance with showering but otherwise able to dress,
clean her appt. Her daughter exhibits drug-seeking behavior,
with a history of stealing mother's pain medications. She has
never smoked, used ETOH or illicit drugs. Her previous work was
in the Cafeteria Department at [**University/College **] [**Location (un) **], as a
"checker." At baseline able to walk w/o walker. No recent
deficits in memory noted.
HCP- [**Name (NI) **] [**Telephone/Fax (1) 40051**]
Family History:
Her mother and father died from MI: at age 70 and 57, resp. No
known cancers.
Physical Exam:
Tc/Tm 98 76(73-83) 100/52 (93-120/52-66) RR 22 100%2L
CVP 17
UOP 277 24 hours
I/O at midnight 6L/4L (drain w/ 1.5 L)
ABG 7.32/38/106
Confused, knows what town she's from
P mildly constricted but reactive and symetric
RIJ ([**6-4**])
unable to determin JVD
Chest RRR nl s1s2, no mrg
Lungs with soft exp wheeze
Abd mildly tender, tense, no g/r, nabs
ext right leg with open wound w/ vac
3+ edema to thighs
L rad a line
Skin without jaundice, marked lymphatic skin loss
Pertinent Results:
Micro:
blood 5/10 neg
blood 5/8 ecoli [**2-21**]
wound [**5-28**] ecoli and dipth
urine [**5-27**] nl
.
Last cxr [**6-2**] atelectasis
Echo [**2106**] nl EF, nl LV size, [**1-21**]+ MR
[**Last Name (Titles) **] .26%
[**2109-5-27**] 03:00PM PT-28.0* PTT-36.3* INR(PT)-2.9*
[**2109-5-27**] 03:00PM PLT SMR-UNABLE TO PLT COUNT-114*
[**2109-5-27**] 03:00PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2109-5-27**] 03:00PM NEUTS-79* BANDS-14* LYMPHS-5* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2109-5-27**] 03:00PM WBC-2.6* RBC-2.86* HGB-9.7* HCT-29.2*
MCV-102* MCH-33.7* MCHC-33.0 RDW-18.5*
[**2109-5-27**] 03:00PM CRP-152.6*
[**2109-5-27**] 03:00PM CORTISOL-44.7*
[**2109-5-27**] 03:00PM CALCIUM-7.9* PHOSPHATE-2.5* MAGNESIUM-1.6
[**2109-5-27**] 03:00PM CK-MB-2 cTropnT-<0.01
[**2109-5-27**] 03:00PM ALT(SGPT)-25 AST(SGOT)-58* CK(CPK)-40 ALK
PHOS-180* AMYLASE-31 TOT BILI-4.4*
[**2109-5-27**] 03:00PM GLUCOSE-140* UREA N-29* CREAT-1.3*
SODIUM-130* POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-22 ANION GAP-15
[**2109-5-27**] 03:26PM LACTATE-4.3* K+-4.6
[**2109-5-27**] 04:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
[**2109-5-27**] 04:25PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2109-5-27**] 05:29PM LACTATE-4.2*
[**2109-5-27**] 06:26PM LACTATE-3.6*
[**2109-5-27**] 08:13PM LACTATE-3.9*
[**2109-5-27**] 08:13PM TYPE-[**Last Name (un) **] PO2-48* PCO2-40 PH-7.36 TOTAL CO2-24
BASE XS--2
[**2109-5-27**] 09:45PM PLT COUNT-149*
[**2109-5-27**] 09:45PM WBC-7.5# RBC-2.53* HGB-8.4* HCT-25.4*
MCV-101* MCH-33.4* MCHC-33.2 RDW-18.6*
[**2109-5-27**] 10:02PM freeCa-1.04*
[**2109-5-27**] 10:02PM HGB-6.5* calcHCT-20 O2 SAT-97
[**2109-5-27**] 10:02PM GLUCOSE-174* LACTATE-4.8* NA+-127* K+-4.5
CL--102
[**2109-5-27**] 10:02PM TYPE-ART PO2-456* PCO2-36 PH-7.41 TOTAL
CO2-24 BASE XS-0 INTUBATED-INTUBATED
[**2109-5-27**] 11:12PM FIBRINOGE-263
[**2109-5-27**] 11:12PM PT-30.9* INR(PT)-3.3*
[**2109-5-27**] 11:12PM PLT COUNT-141*
[**2109-5-27**] 11:12PM WBC-7.1 RBC-3.41*# HGB-11.2*# HCT-32.6*#
MCV-96 MCH-32.8* MCHC-34.4 RDW-19.4*
[**2109-5-27**] 11:12PM CALCIUM-7.9* PHOSPHATE-3.6 MAGNESIUM-1.6
[**2109-5-27**] 11:12PM GLUCOSE-181* UREA N-28* CREAT-1.2*
SODIUM-129* POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-19* ANION
GAP-15
[**2109-5-27**] 11:23PM freeCa-1.16
[**2109-5-27**] 11:23PM LACTATE-4.7*
[**2109-5-27**] 11:23PM TYPE-ART PO2-243* PCO2-43 PH-7.30* TOTAL
CO2-22 BASE XS-
----------
[**6-6**] Echo:
CLINICAL INDICATION: 65-year-old woman with known NASH and
increasing liver function tests.
The liver is small and very coarse in echotexture and is
surrounded by a large volume of ascites. There is also a right
pleural effusion. No focal liver lesions are identified, nor is
there evidence of biliary dilatation. The patient is status post
cholecystectomy.
Color flow and pulse Doppler evaluation of the liver shows
virtually no flow in the left and right portal veins and only
minimal flow in the main portal vein of approximately 5
cm/second. The hepatic veins are all visualized and patent. The
inferior vena cava also is fully patent. Increased arterial flow
is seen throughout the liver.
Both kidneys are seen to be normal in size measuring 10.5 cm in
length on the right and 10.1 cm on the left. There are no signs
of hydronephrosis, renal stones, or masses. The spleen is upper
normal to mildly enlarged measuring approximately 12 cm in
length.
CONCLUSION: Small cirrhotic-appearing liver with marked ascites
and a right pleural effusion noted. Near occlusion of the portal
flow with increased arterial flow, and normal hepatic venous
drainage. There are no focal liver lesions seen.
------------------
[**2109-6-6**] Echo:
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left
ventricular systolic function is normal (LVEF 60-70%). Right
ventricular
chamber size and free wall motion are normal. The number of
aortic valve
leaflets cannot be determined. The aortic valve leaflets are
mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse.
Trivial mitral regurgitation is seen. There is no pericardial
effusion.
Compared with the findings of the prior report (images
unavailable for review)
of [**2106-12-10**], probably no major change.
[**2109-6-8**] EKG
\Sinus rhythm
Modest nonspecific pre-cordial/anterior T wave changes
Prolonged Q-Tc interval - clinical correlation is suggested
Since previous tracing of [**2108-5-27**], no significant change
Brief Hospital Course:
.
-------------
65 F history of dm2, nash cirrhosis, UC, mgus, obesity, p/w
septic [**Date Range **] on [**5-28**] from infected wound after orif [**5-13**] for
femur frx, now s/p debridement x 3, HD stable off pressors,
transferred to MICU from the surgical service with ARF,
confusion and sepsis
.
# Hypotension/[**Name (NI) 21020**] - pt was originally in OR for washout of
right knee w/ debridement. In OR, pt. intubated and was requring
neosynephrine (new for her). Post Op, pt. was extubated
successfuly, but pt. continued to have low blood pressures and
was requiring pressors to maintain MAP goal > 60. On exam, pt.
warm, so distributive [**Name (NI) **] is likely. Possible that pt. has
adrenal insufficiency. Also possible that pt. is becoming septic
- increasing WBC, but afebrile. Patient was transferred to the
MICU with a presumed diagnosis of sepsis on [**2109-6-6**]. Patient
was first bolused to maintain BP (as pt. is losing fluid from
multiple places, including continues oozing of liters of
serosang fluid from multiple places). Due to the patient's body
habitus, it was extremely difficult to obtain accurate BP
measurements, especially once the patient's A-line stopped
functioning correctly. On [**2109-6-8**], patient suddenly dropped her
blood pressure into the systolic of 70s, with worsening of
already poor mental status. Patient was DNR/DNI per family, so
no repeated attempts at intubation were made. No CPR was
performed. The patient's blood pressure continued to drift down
despite use of pressors. Multiple attempts at central line
placement by both MICU and anesthesia staff placement were
attempted, however failed due to the patient's body habitus.
The patient's O2 sats drifted below 70% despite max O2 support
(aside from intubation). The patient lost all brainstem
reflexes. At that point, family was called, the patient was
made CMO, placed on morphine for comfort and expired shortly
thereafter.
.
# Leg excision site wound infection: Pt. s/p washout/debridement
in OR yesterday w/ no overt wound infection. Pt. afebrile, but
w/ increased white count. VAC in place, ortho was following the
wound.
.
# Confusion: likely due to sepsis/hypoxic encephalopathy
sustained during surgery. Overuse of pain medications on the
surgery service might have also contributed. Pain meds were
minimized, and infectious workup was in process. Since patient
also developed renal failure, uremia was contributing to
patient's mental status changes.
.
# ARF: Cr. 1.0 on [**6-3**], trending up gradually to 2.4 on [**6-4**],
[**Month/Year (2) **] (<0.1) on [**6-5**] suggests pre-renal, though hepatorenal in
consideration given cirrhosis. Also c proteinuria prot/cr 1.2,
glomerular process? Not improving with hydration. Renal was
consulted, workup was initiated, renal was planning to start
octreotide/midodrine. On ultrasound, pt. w/ no hydronephrosis
or stones.
.
# NASH cirrhosis: Renal u/s showed a cirrhotic liver w/ portal
vein thrombosis. There was also some ascites noted arond the
liver. GI/Liver was consulted in seeting of increased t. bili
4.2(b/l [**2-22**]) INR 1.6 (b/l 1.5-3) and U/S findings. Hep B/C
negative, AMA ANCA negative, pt has missed several outpt
appointments and has not seen her hepatologist, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **] since the initial visit [**2108-8-24**]. Liver service was
following the patient. Nadolol was held given low BP.
.
Medications on Admission:
Meds at rehab Coumadin dosed by INR (usual 1 mg), Ativan 0.5
[**Hospital1 **], Oxycontin 20 mg po BID, albuterol, vitamin D 400,
colace/senna, protonix 40 qd, aldactone 25 qd, nadolol 20 qd,
fosamax 70 q sunday, Spironolactone 25 mg, Calcium Carbonate 500
mg, Citalopram 60 mg, Nadolol 20 mg, Oxycodone 20 mg Q12H,
Pantoprazole 40 mg, Oxycodone 5-15 mg q4 hours
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Delirium
Multi-system Organ failure
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2109-7-18**]
|
[
"995.92",
"428.0",
"530.81",
"998.59",
"996.42",
"287.5",
"V43.65",
"572.3",
"250.00",
"493.90",
"518.81",
"038.42",
"571.5",
"278.00",
"327.23",
"032.85",
"458.29",
"401.9",
"V12.51",
"285.1",
"584.9",
"729.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.59",
"83.39",
"96.71",
"80.16",
"38.93",
"96.04",
"96.6",
"93.59",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15627, 15636
|
11739, 15214
|
344, 388
|
15722, 15731
|
6933, 11716
|
15783, 15947
|
6352, 6431
|
15657, 15701
|
15240, 15604
|
15755, 15760
|
6446, 6914
|
248, 306
|
416, 4409
|
4432, 5159
|
5175, 6336
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,440
| 151,774
|
49391+59167
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-6-16**] Discharge Date: [**2107-7-20**]
Date of Birth: [**2034-2-15**] Sex: F
Service: SURGERY
Allergies:
Shellfish / Carboplatin
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
weight loss & unable to take POs.
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Biopsy of peritoneal implant.
4. Suture repair of enterotomy (small intestine).
5. Repair of incisional hernia with mesh.
6. Small bowel bypass with (anastomosis x1)
7. PICC line right upper arm [**2107-6-21**]
8. PICC line left upper arm [**2107-6-30**]
7. CT guided drainage of pelvic fluid collection [**2107-7-7**]
8. CT guided drainage of second pelvic fluid collection [**2107-7-13**]
History of Present Illness:
73 y.o. Female w/ stage IIIc papillary serous ovarian cancer s/p
Paclitaxel, 6 cycles of Carboplatin/Gemcitabine, on cycle 6 of
Doxorubicin, h.o. SBO w/ necrotic ileum s/p ileostomy, multiple
abdominal surgery who is being admitted directly from clinic due
to concern about her rapid weight loss and inability to eat.
She had a recent 9 day admission to the hospital starting on
[**2107-5-28**]. Her CT scan at that time showed SBO with a transition
point within the left pelvis, extensive adhesions and decrease
in mesentery deposits compatible with treatment response. She
was treated conservatively with bowel rest. She was seen
received her 6th cycle of doxil on [**2107-6-9**]. She has continued
to have emesis despite restriction to a full liquid diet. She
had a rapid 20 lb weight loss since her previous discharge and
has only been able to tolerate water for the past few days.
.
She reports that she feels nauseated after eating any food or
fluid and generally vomits a half an hour or so after eating.
She denies having any abdominal pain. She reports passing gas
through her ostomy and having some output. She has lost
approximately 15-20 lbs in the past 2 weeks. She was able to
tolerate solids only for 2-3 days after her previous discharge.
She felt lightheaded earlier to day but that improved with IVF
in the clinic.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough, shortness of breath, or wheezes. No recent change in
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rashes.
Past Medical History:
PMH: HTN, depression, basal cell carcinoma, recurrent ovarian
cancer with peritoneal carcinomatosis, h/o TIA, cataracts
PSH: L CEA [**7-/2097**] ([**Doctor Last Name 1476**]); Ex lap, TAH-BSO, lymphadenectomy,
omentectomy, proctosigmoidectomy [**3-6**] ([**Doctor Last Name 2028**]); exploration of
wound dehisence w/ debridement and closure of fascia [**3-6**];
laparoscopic incisional hernia repair w/ mesh [**5-7**] ([**Doctor Last Name **]);
Ex lap, LOA, excision of infected mesh, appendectomy, drainage
of abscess, ileostomy/mucous fistula creation, closure with
vicryl mesh [**6-7**] ([**Doctor Last Name **]); delayed primary closure abdominal
wound [**6-7**] ([**Doctor Last Name **]
Social History:
30 pack-year h/o smoking, quit 9 years ago; social ETOH use;
Lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], 2 children, both live out of state but
very involved
Family History:
FAMILY HISTORY: She denies any family history of cancer.
Physical Exam:
VS: 99.4 144/78 71 18 100% ra.
GEN: AOx3, NAD, pleasant.
HEENT: PERRLA. MMM. no LAD. JVP at 5cm. neck supple.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: high pitched bowel sounds. soft, tender to deep palpation,
ostomy in place, no rebound/guarding. neg HSM. neg [**Doctor Last Name 515**]
sign.
Extremities: wwp, no edema. DPs, PTs 2+ bilat.
Skin: no rashes or bruising
Neuro/Psych: CNs II-XII grossly intact, MAE.
Pertinent Results:
[**2107-6-16**] 11:05AM WBC-4.9 RBC-3.88* HGB-12.0 HCT-35.7* MCV-92
MCH-30.9 MCHC-33.7 RDW-14.3
[**2107-6-16**] 11:05AM PLT COUNT-162
[**2107-6-16**] 11:05AM ALBUMIN-3.9 MAGNESIUM-1.7
[**2107-6-16**] 11:05AM ALT(SGPT)-20 AST(SGOT)-28 ALK PHOS-79 TOT
BILI-0.5
[**2107-6-16**] 11:05AM UREA N-14 CREAT-1.0 SODIUM-136 POTASSIUM-4.3
CHLORIDE-100
[**2107-6-16**] CT Abd/ Pelvis : 1. Dilated small bowel proximally with
a probable transition point in the pelvis and relatively
decompressed distal small bowel and colon, compatible with small
bowel obstruction. No evidence of perforation.
2. New areas of hypodensity in the left hepatic lobe may
represent focal fat deposition, although metastatic disease
cannot be fully excluded. MRI of the liver is recommended for
further evaluation. Otherwise, stable exam.
[**2107-7-5**] Abd CT : 1. Dilated loops of small bowel with air-fluid
levels and distal decompressed loops of small bowel with
transition region noted within the midline pelvis in region of
newly created small bowel anastomosis. This is concerning for
small-bowel obstruction but appears similar to prior exams and
should be correlated with clinical picture.
2. Large thin-rim-enhancing fluid collection within the midline
central
pelvis extending into the lower abdomen near new anastomotic
site. Underlying abscess is not excluded. The more inferior
pelvic component does appear amendable to image-guided
percutaneous drainage as indicated.
3. Interval increase in right pleural effusion with new left
pleural
effusion. Compressive atelectasis of the lower lobes. Small
amount of new
intra-abdominal ascites.
4. Status post repair of ventral hernia. Unchanged ileostomy and
parastomal hernia.
[**2107-7-12**] Abd CT : 1. Overall decrease in size of multiple
loculations of right lower quadrant abdominal fluid collection.
Marked decrease in size in the lowest collection which contains
the drain. An anteriorly located collection is not contiguous
with these loculations and is slightly increased in size.
2. Persistent bilateral pleural effusions, moderate on the
right, small on
the left.
3. Cholelithiasis without evidence of cholecystitis.
4. Small hiatal hernia.
5. Unchanged bilateral adrenal adenomas, as defined by MRI from
[**2104-3-30**].
[**2107-7-19**] Abd CT : 1. Interval decrease in thin rim-enhancing
fluid collection within the midline central pelvis extending
into the lower abdomen near the enteroenteric anastomotic site.
Interval removal of drain within the fluid collection
immediately adjacent to the anastomotic site and superior to the
bladder. Interval placement of new drain within the superior
pelvic component with decrease in size of fluid collection
compared to [**2107-7-12**].
2. Anteriorly located fluid collection does not appear
contiguous with these loculations and is stable in size and
appearance compared to [**2107-7-12**].
3. Dilated loops of proximal small bowel with distal
decompressed loops of
small bowel with transition point noted within the midline
pelvis within the region of the small bowel anastomosis. Oral
contrast is noted within the ileostomy. Findings are concerning
for partial small bowel obstruction, however, appears similar to
prior examinations and may represent chronic dilated small
bowel. Recommend clinical correlation.
4. Interval decrease in right-sided pleural effusion with
resolution of left pleural effusion. Adjacent compressive
atelectasis within the right lung base.
5. Unchanged ileostomy and parastomal hernia.
6. Unchanged bilateral adrenal nodules, previously characterized
as adenomas
Brief Hospital Course:
Ms. [**Known lastname **] is a 73 year ole female with stage IIIc papillary
serous ovarian cancer s/p Paclitaxel, 6 cycles of
Carboplatin/Gemcitabine, on cycle 6 of Doxorubicin; h/o SBO with
necrotic ileum s/p ileostomy, multiple abdominal surgeries who
was admitted for rapid weight loss and inability to eat in the
setting of chronic SBO seen on CT scan one month prior to
admission when the plan was conservative management with slow
advancement of diet.
She was admitted to the hospital on [**2107-6-16**], put on IV fluids
and made NPO. She was then slowly advanced in diet but did not
tolerate it well and on [**2107-6-21**] was remade as NPO, had a PICC
line placed and was started on TPN for improvement of
nutritional status prior to surgery.
She was taken to the operating room on [**2107-6-27**]. An enterotomy
was performed in the distal ileum with a small intestine bypass
to relieve the obstruction. Also, an incisional hernia was
repaired with a veritas bioprosthetic mesh. The operation
proceeded without complication and she was transferred to the
floor after a short stay in the PACU.
She was continued NPO and with TPN post-surgery and observed for
return of bowel function. On POD 4, bowel sounds became more
prominent and she observed gas in the ostomy bag. She was
advanced to a clear liquid diet on POD 5 which she tolerated
well and to a full liquid diet on POD 6 and to a regular diet on
POD 7. She tolerated all advances well.
On POD 4, her right arm was noted to be edematous and there was
increased resistance in flushing the PICC. Right upper
extremity duplex was consistent with thrombotic occlusion of
right brachial vein and right axillary vein. The PICC was
removed and replaced to the left arm. A heparin drip was
started with serial PTTs. Coumadin bridging was started on POD
6 (INR 1.3) and reached therapeutic levels (INR 2.1) on POD 8.
The heparin drip was then stopped.
While Ms. [**Known lastname 103423**] overall status appeared to be improving, she
complained of new lower abdominal pain on POD 8. CT scan showed
a pelvic fluid collection and on POD 9, a pigtail catheter was
placed by IR to drain the fluid yielded 210 cc of brownish,
cream-colored serosanguinous fluid. She was started on
cipro/flagyl therapy, was briefly switched to zosyn for
monotherapy, then switched back to ciprofloxacin after fluid
cultures grew e. coli sensitive to ciprofloxacin. She was kept
NPO after the procedure and another advance of diet attempt was
started on POD 12 with sips to clears then full liquids by POD
15.
On POD 15 a repeat CT scan showed another fluid collection and a
small collection near the midline mesh. A second pigtail
catheter was placed, draining 15 cc of fluid and 25 cc of fluid
was aspirated from the midline mesh area.
Following the procedure, she was advanced again to regular diet
which she tolerated well. PO intake continued to increase
through POD 18, when TPN was cycled with 1/2 the usual volume
over 12 hours and it was discontinued on [**2107-7-16**]. She was
placed on calorie counts, given protein supplements and
continued on a regular diet which she tolerated well in small
amounts.
She had a repeat CT scan on [**2107-7-19**] to assess the fluid
collections which had markedly decreased. There was scant
drainage from the tubes and they were removed on [**2107-7-16**] and
[**2107-7-20**] respectively without difficulty. She will continue on
her course of Ciprofloxicin until [**2107-7-25**].
Mrs.[**Known lastname 103424**] INR has been in the range of 2.3-2.8 on 2 mg
daily. ( 2.8 on [**2107-7-20**] )
Her PICC line was removed on [**2107-7-20**] and she continues to try to
take small frequent meals with Carnation Instant Breakfast in
between. Her ostomy is active and she is comfortable in doing
her ostomy care.
She was discharged to rehab on [**2107-7-20**] with the hopes of
increasing her strength and mobility so that she can return
home. She will follow up with Dr. [**Last Name (STitle) **] in 2 weeks and
Dr.[**Last Name (STitle) **], her Oncologist, after discharge from
rehab.
Medications on Admission:
1. Bupropion HCl 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
2. Citalopram 40 mg Tablet Sig: One (1) Tablet 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Avapro 75mg PO QOD
Discharge Medications:
1. Bupropion HCl 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
6. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO once a
day.
7. Irbesartan 150 mg Tablet Sig: 0.5 Tablet PO QOD ().
8. Irbesartan 150 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day).
9. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
11. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
12. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Ten (10)
ml PO BID (2 times a day).
13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain not controlled by acetaminophen.
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day: thru
[**2107-7-25**].
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): hold sbp < 100 HR < 60
.
17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety, nausea.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
1. Small bowel obstruction.
2. Incisional hernia.
3. Stage IIIc papillary serous ovarian cancer
4. DVT right axillary vein
5. Recurrent pelvic fluid collections
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 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.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**10-14**] 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 Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 3201**]
Date/Time:[**2107-8-5**] 1:45
Call Dr. [**Last Name (STitle) **] for a follow up appointment after
you are discharged from rehab.
Completed by:[**2107-7-20**] Name: [**Known lastname **],[**Known firstname 779**] Unit No: [**Numeric Identifier 16718**]
Admission Date: [**2107-6-16**] Discharge Date: [**2107-7-20**]
Date of Birth: [**2034-2-15**] Sex: F
Service: SURGERY
Allergies:
Shellfish / Carboplatin
Attending:[**First Name3 (LF) 3524**]
Addendum:
Due to an INR of 2.8 on [**2107-7-20**] Mrs. [**Known lastname 10936**] should receive 1 mg
of Coumadin for the next few days so as not to exceed 2.5 INR.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3008**] [**Last Name (NamePattern1) **] - [**Location (un) 164**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**]
Completed by:[**2107-7-20**]
|
[
"996.74",
"998.2",
"553.21",
"998.59",
"783.21",
"V12.54",
"V10.43",
"560.81",
"311",
"783.7",
"453.84",
"453.82",
"V44.2",
"E870.0",
"V10.83",
"401.9",
"567.22",
"568.0",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.79",
"54.91",
"53.61",
"38.93",
"45.91",
"54.59",
"99.15",
"54.23"
] |
icd9pcs
|
[
[
[]
]
] |
16743, 17022
|
7642, 11736
|
319, 765
|
14173, 14173
|
4023, 7619
|
15925, 16720
|
3447, 3490
|
12413, 13823
|
13989, 14152
|
11762, 12390
|
14356, 15556
|
3505, 4004
|
2156, 2488
|
246, 281
|
15568, 15902
|
793, 2137
|
14188, 14332
|
2510, 3204
|
3220, 3414
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,957
| 119,262
|
8833
|
Discharge summary
|
report
|
Admission Date: [**2151-4-18**] Discharge Date: [**2151-4-22**]
Date of Birth: [**2075-9-2**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Hayfever
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Dark stool
Major Surgical or Invasive Procedure:
Enteroscopy
History of Present Illness:
75 year old male with past medical history of clear cell
carcinoma s/p right nephrectomy and adrenectomy with metastasis
to pancreas, duodenal wall and pulmonary (nodules) s/p Whipple
procedure in [**2143**] complicated by injury to hepatic artery. He
had DVT in [**2149**] for which coumadin was started with subsequent
GI bleed requiring 9 units of PRBC thought to be secondary to
jejunal AVM. Repeat endoscopy showed small gastric
angiodysplasia which was treated with BICAP. He was noted to
have increase in jejunal mass on routine surveillance CT scan by
oncology in [**12/2150**] which was decided to be managed
conservative.
.
He reports being in his usual state of health until two days ago
when he noted half a bucket full of bowel movement which was
mahogany colored. He subsequently went to [**Location (un) 8641**] ED where his
HCT was 27.8 from 34 one week prior. He had guiaic positive
stool though no symptoms of chest pain, fatigue,
lightheadedness, shortness of breath, hemoptysis. He was given
one unit of PRBC. EGD which observed esophagus, stomach and
jejunum was normal. He subsequently underwent colonoscopy after
a prep today which was normal except for diverticulosis. He had
500 cc of frank bright red per rectum after the procedure. He
was also noted to have fever (unsure if during or after PrBC).
Blood and urine culture were drawn. He was also noted to have
runs of NSVT for which magnesium and potassium was given. Labs
notable for creatinine of 1.4 which improved to 1.2 with PrBC
and IVF. He was subsequently transferred to [**Hospital1 18**] for further
evaluation and management.
.
On arrival to the MICU, he reports no complaints. While there,
he remained hemodynamically stable and received an additional 2U
PRBCs as his Hct was 19. Hct was monitored closely and
stablized at 25 over the last 2 days. His total bilirubin
transiently rose (? to transfusion) but is now trending down.
Per GI, a CTA was ordered and found increased size of epigastric
mass since [**2151-11-19**], now 3.7 x 3.2 cm (previously 3.3 x 2.8)
in addition to a stable sized enhancing mass protruding into
jejunum. CTA also noted slightly increased intra and extra
hepatic biliary dilation, concerning for mass obstructing the
hepaticojejunostomy. There was no evidence for acute bleeding.
GI performed enteroscopy on [**4-20**], which revealed a clot in
hepatic limb
with no clear source of bleed. Given that he was stable, he was
transferred to the medicine floor for further management.
.
On arrival to the floor, vital signs were T:98.0 BP: 118/64 P:
73 R: 20 O2: 98% on RA. Patient was comfortable with no acute
complaints. His last bowel movement was yesterday and he denies
any dizziness, LH or chest pain.
Past Medical History:
Clear cell carcinoma with metastasis to pancreas, lung and
duodenal wall
HTN
Type 2 DM
DVT in [**2149**]
TKR in [**2149**]
Transamnitis
s/p pacemaker for symptomatic bradycardia
Social History:
- Tobacco: Never
- Alcohol: Sometimes a glass of wine with dinner
- Illicits: No
Family History:
Mom with [**Name2 (NI) 499**] cancer
Physical Exam:
Admission physical exam:
Vitals: T:97.2 BP:89/42 P:95 R:18 O2:99%2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP at 8 cm, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bibasilar crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley. Rectal vault without frank blood. guiaic
positive stool
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation.
Pertinent Results:
[**2151-4-18**] 10:07PM WBC-6.9# RBC-2.45*# HGB-6.4*# HCT-19.8*#
MCV-81* MCH-26.3* MCHC-32.5 RDW-17.0*
[**2151-4-18**] 10:07PM PT-18.4* PTT-33.9 INR(PT)-1.7*
[**2151-4-18**] 10:07PM PLT COUNT-156
[**2151-4-18**] 10:07PM FIBRINOGE-228
[**2151-4-18**] 10:07PM ALBUMIN-1.5* CALCIUM-4.9* PHOSPHATE-1.1*#
MAGNESIUM-1.3*
[**2151-4-18**] 10:07PM CK-MB-1 cTropnT-<0.01
[**2151-4-18**] 10:07PM ALT(SGPT)-37 AST(SGOT)-89* LD(LDH)-120 ALK
PHOS-156* TOT BILI-2.4*
[**2151-4-18**] 10:07PM GLUCOSE-113* UREA N-6 CREAT-0.6 SODIUM-142
POTASSIUM-2.4* CHLORIDE-121* TOTAL CO2-13* ANION GAP-10
[**2151-4-18**] 10:18PM LACTATE-1.6
[**2151-4-19**] 12:24AM BLOOD WBC-6.7 RBC-2.49* Hgb-6.4* Hct-19.9*
MCV-80* MCH-25.8* MCHC-32.3 RDW-16.9* Plt Ct-185
[**2151-4-19**] 01:20AM BLOOD WBC-7.0 RBC-2.63* Hgb-7.0* Hct-21.1*
MCV-80* MCH-26.6* MCHC-33.1 RDW-17.0* Plt Ct-193
[**2151-4-19**] 09:37AM BLOOD Hct-28.4*#
[**2151-4-19**] 01:49PM BLOOD Hct-25.7*
[**2151-4-19**] 08:57PM BLOOD Hct-25.8*
[**2151-4-20**] 03:28AM BLOOD WBC-5.6 RBC-3.14* Hgb-8.6* Hct-24.8*
MCV-79* MCH-27.4 MCHC-34.7 RDW-17.0* Plt Ct-189
[**2151-4-20**] 08:00PM BLOOD Hct-25.1*
[**2151-4-21**] 06:25AM BLOOD WBC-5.1 RBC-3.36* Hgb-9.1* Hct-27.3*
MCV-81* MCH-27.1 MCHC-33.3 RDW-17.8* Plt Ct-212
[**2151-4-21**] 04:15PM BLOOD Hct-29.3*
[**2151-4-22**] 06:32AM BLOOD WBC-4.6 RBC-3.57* Hgb-9.7* Hct-29.8*
MCV-83 MCH-27.0 MCHC-32.5 RDW-17.1* Plt Ct-261
[**2151-4-18**] 10:07PM BLOOD PT-18.4* PTT-33.9 INR(PT)-1.7*
[**2151-4-19**] 12:24AM BLOOD PT-15.8* PTT-31.4 INR(PT)-1.5*
[**2151-4-19**] 01:20AM BLOOD PT-15.3* PTT-30.7 INR(PT)-1.4*
[**2151-4-20**] 03:28AM BLOOD PT-13.4* PTT-32.5 INR(PT)-1.2*
[**2151-4-21**] 06:25AM BLOOD PT-11.5 PTT-32.1 INR(PT)-1.1
[**2151-4-22**] 06:32AM BLOOD PT-11.1 PTT-32.8 INR(PT)-1.0
[**2151-4-18**] 10:07PM BLOOD Fibrino-228
[**2151-4-19**] 01:20AM BLOOD Fibrino-357#
[**2151-4-18**] 10:07PM BLOOD Glucose-113* UreaN-6 Creat-0.6 Na-142
K-2.4* Cl-121* HCO3-13* AnGap-10
[**2151-4-19**] 12:24AM BLOOD Glucose-121* UreaN-7 Creat-1.0 Na-139
K-3.7 Cl-112* HCO3-20* AnGap-11
[**2151-4-19**] 01:20AM BLOOD Glucose-115* UreaN-7 Creat-0.9 Na-137
K-3.8 Cl-111* HCO3-19* AnGap-11
[**2151-4-20**] 03:28AM BLOOD Glucose-86 UreaN-7 Creat-1.0 Na-139 K-3.8
Cl-108 HCO3-22 AnGap-13
[**2151-4-21**] 06:25AM BLOOD Glucose-84 UreaN-7 Creat-1.0 Na-139 K-3.9
Cl-105 HCO3-23 AnGap-15
[**2151-4-22**] 06:32AM BLOOD Glucose-90 UreaN-7 Creat-1.1 Na-141 K-3.7
Cl-108 HCO3-26 AnGap-11
[**2151-4-18**] 10:07PM BLOOD ALT-37 AST-89* LD(LDH)-120 AlkPhos-156*
TotBili-2.4*
[**2151-4-19**] 01:20AM BLOOD ALT-56* AST-132* AlkPhos-207*
TotBili-3.3*
[**2151-4-20**] 03:28AM BLOOD ALT-57* AST-97* AlkPhos-203* TotBili-2.3*
[**2151-4-18**] 10:07PM BLOOD CK-MB-1 cTropnT-<0.01
[**2151-4-19**] 01:20AM BLOOD CK-MB-2 cTropnT-<0.01
[**2151-4-18**] 10:07PM BLOOD Albumin-1.5* Calcium-4.9* Phos-1.1*#
Mg-1.3*
[**2151-4-19**] 12:24AM BLOOD Calcium-7.0* Phos-2.0* Mg-1.9
[**2151-4-19**] 01:20AM BLOOD Calcium-7.1* Phos-2.2* Mg-2.6
[**2151-4-20**] 03:28AM BLOOD Calcium-7.9* Phos-2.3* Mg-1.8
[**2151-4-21**] 06:25AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.8
[**2151-4-22**] 06:32AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.1
[**2151-4-18**] 10:18PM BLOOD Lactate-1.6
CTA abdomen ([**2151-4-19**]):
IMPRESSION:
1. Pancreatic and jejunal masses post-Whipple procedure,
consistent with
known renal cell carcinoma metastases. A fungating mass with
markedly
irregular borders is seen in the jejunal limb at the
pancreaticojejunal
anastomosis. No definite evidence of active extravasation of
contrast
observed, with multiple frond-like enhancing projections felt to
be connected to the lesion itself. However, please note that in
the setting of known GI bleeding, this lesion represents a
likely source of bleeding.
2. Interval enlargement of pancreatic and jejunal masses
consistent with
increase in metastatic disease.
3. New intrahepatic biliary ductal dilation to the level of the
hepaticojejunal anastomosis. Equivocal areas of hypoenhancement
within the
hepatic parenchyma may be perfusional, although metastases
cannot be excluded. Continued attention on followup imaging is
recommended. Correlation with LFTs is suggested as regards
significance of the progressive biliary dilation.
4. Stable right base pulmonary nodule.
5. Equivocal increased thickening of the left adrenal gland
medial limb;
attention on next followup imaging recommended.
6. Fluid or soft tissue nodule in an umbilical fat-containing
hernia, stable to decreased in size.
Enteroscopy ([**2151-4-20**])
Impression:
Esophageal ulcer
Normal mucosa in the stomach
The biliary and enteral limbs were intubated. The biliary limb
contained a couple of small blood clots. There was no other
evidence of recent bleeding or a source of bleeding.
Otherwise normal EGD to enteral and biliary jejunal limbs
Recommendations:
The findings do not account for the symptoms
If rebleeding occurs, would consider a flex sig to ensure no
rectal pathology but most likely bleeding related to mets in the
biliary limb. If rebleeds, would call IR for embolization of
metatatic disease. Would also consider discussion with
outpatient providers to determine plan of care moving forward as
the metastatic disease is likely to process and may well bleed
again.
Brief Hospital Course:
75 year old male with past medical history of clear cell
carcinoma s/p right nephrectomy and adrenectomy with metastasis
to pancreas, duodenal wall and pulmonary (nodules) s/p Whipple
procedure in [**2143**] complicated by injury to hepatic artery and GI
bleed in [**2149**] on anticoaguation from jejunal AVM presents with
mahogany colored stools.
1. GI bleed: Source is thought to be secondary to jejunal AVM
vs erosion from metastatic jejunal mass which has been
increasing in size. As mentioned, OSH EGD negative to jejunum
though AVM are usually difficult to visualize and intermittent.
Colonoscopy only showed diverticulosis. Enteroscopy on [**4-21**]
demonstrated no clear source of the bleed. Hct trended up
during the last three days of admission (25->27->29). Patient
reports one small "black" BM and another "goopy red" BM on [**4-21**]
AM. He was NPO, then advanced slowly to a regular diet, which
he tolerated well. Lengthy discussion between GI, outpatient
oncologist, general surgery, IR and radiation oncology was
conducted via email and it was determined that radiation
oncology would be the best treatment option at this time. The
patient would prefer to receive his daily therapies near his
home, which is only 8 miles from [**Hospital 8641**] Hospital. Radiation
oncology team helped to coordinate care and the patient will
follow-up with them after discharge. The patient will follow-up
with Dr. [**First Name8 (NamePattern2) 1158**]
[**Last Name (NamePattern1) 30813**] (radiation oncologist) near his home. He is aware to
come to the ED if he experiences repeat bleed.
2. Coagulopathy: On admission, INR of 1.7, normal PTT with
albumin of 2.2. Plt of 160 with normal creatinine. Elevated INR
thought to be secondary to malnutrition. He received a single
dose of vitamin K with normalization of INR.
3. Fever likely in setting of blood tranfusion. No source of
infection noted on exam or review of labs and imaging here.
Afebrile during remainder of hospitalization.
4. Type 2 DM- patient on metformin and daily levemer 15U at
home, placed him on insulin sliding scale with glargine 10U qAM
(home levemer not formulary here). On discharge, he was resumed
on home regimen of metformin and levemer.
5. Pancreatic insufficiency: Initially held home creon, ursodiol
and antidiarreals in the setting of GI bleed. Once bleed
resolved, resumed home creon and ursodiol but held
antidiarrheals on discharge.
6. HTN: Held home metoprolol in the setting of GI bleed. BPs
and HR within normal limits without metoprolol while in house so
it was held on discharge. We ask the PCP to please determine
when and if to resume this medication.
# Code: Full (discussed with patient)
Medications on Admission:
Ursodiol 600 mg po BID
Metformin 1000 mg po BID
Protonix 40 mg po qdaily
Metoprolol 50 mg po BID
Creon [**Numeric Identifier **] mg po TID
Levemer 15 units SC qdaily
Lomotil 2 tabs po BID
Tincture opium 1% 0.3 cc qdaily
MVA po qdaily
Iron 325 mg po qdaily
Immodium two tabs po qdaily
Discharge Medications:
1. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO twice a day.
2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. Creon 24,000-76,000 -120,000 unit Capsule, Delayed
Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO
three times a day.
5. Tincture Merthiolate Liquid Miscellaneous
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One
(1) Tablet PO once a day.
8. insulin detemir 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary- GI bleed
Secondary- Renal cell carcinoma with metastasis to pancreas,
lung small bowel
Hypertension
Type II diabetes mellitus
DVT- [**2149**]
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 a GI bleed. An outside
hospital EGD and colonscopy did not demonstrate any acute source
of the bleed and you were transferred to [**Hospital1 18**] for further
management. While here, you underwent a CT scan which
demonstrated enlargement of your small bowel mass, which was the
most likely cause of the bleed. You also underwent an
enteroscopy. While here, you remained hemodynamically stable
and your hematocrits improved by discharge.
The oncology, gastroenterology, general surgery, interventional
radiology and radiation oncology teams discussed your case at
length and determined that radiation therapy would be beneficial
to you. You would like this to be done near your home, which
was arranged prior to discharge. You have an appointment with
Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 30813**] upon discharge and the plan is to begin
radiation therapy as soon as possible.
It was a pleasure taking part in your care, Mr. [**Known lastname 30814**].
The following changes were made to your medications:
1. STOP metoprolol 50mg twice daily
Please continue all other medications as prescribed by your
outpatient providers
Followup Instructions:
Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 30813**] with radiation oncology on [**2151-4-23**]
Department: Primary Care
Name: [**Doctor First Name **] Hseih, Nurse Practitioner for Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Friday [**2151-4-30**] at 10:00 AM
Location: CORE PHYSICIANS-[**Location (un) **] INTERNAL MEDICINE
Address: [**Location (un) 30815**]. BLDG 3A, [**Location (un) **],[**Numeric Identifier 30816**]
Phone: [**Telephone/Fax (1) 30817**]
Department: RADIOLOGY
When: WEDNESDAY [**2151-5-19**] at 1 PM
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
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2151-5-19**] at 2:00 PM
With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**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: WEDNESDAY [**2151-5-19**] at 2:00 PM
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
Completed by:[**2151-4-22**]
|
[
"286.7",
"V10.52",
"530.20",
"197.8",
"401.9",
"263.9",
"197.0",
"578.9",
"V88.12",
"577.8",
"250.00",
"V45.73",
"780.66",
"197.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
13073, 13079
|
9342, 12053
|
288, 301
|
13308, 13308
|
4082, 9319
|
14689, 16164
|
3394, 3433
|
12387, 13050
|
13100, 13287
|
12079, 12364
|
13459, 14666
|
3473, 4063
|
238, 250
|
329, 3074
|
13323, 13435
|
3096, 3276
|
3292, 3378
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,161
| 128,828
|
33469
|
Discharge summary
|
report
|
Admission Date: [**2160-1-29**] Discharge Date: [**2160-2-7**]
Date of Birth: [**2091-12-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Acute Abdomen, hypotensive
Major Surgical or Invasive Procedure:
[**2160-1-29**]: Exploratory laparotomy, Left hemicolectomy with
takedown of splenic flexure, Cholecystectomy.
History of Present Illness:
The patient is a 68-year-old incarcerated male who was found in
his cell hypothermic, hypotensive, and with abdominal pain. The
day before he had reported decreased appetite, N/V, dizziness.
He was noted to be pale but alert and skin was warm and dry. He
was transferred to an OSH where he was placed on peripheral
dopa. CXR and UA were negative. CT scan was done w/o PO contrast
because Cr was 2.0 and showed a 5cm AAA with no stranding. He
was given Zosyn but continued to complain of abdominal pain and
was medflighted to [**Hospital1 18**].
.
Here, he was AOx3 and not hypoxic but hypothermic to 93. He had
severe RLQ pain and diffuse abdominal pain. SBP was 50s-70s on
dopamine. A bedside ultrasound showed a widened abdominal aorta
with clot. He was intubated because of hypotension and concern
for protecting his airway in that setting; etomidate and
vecuronium were used because of a K of 7.0 at the OSH. A RIJ was
placed. CT w/o IV contrast showed a 5cm AAA without stranding
around the aneurysm but stranding around the pancreas. He was
quickly weaned off the peripheral dopamine. He got Vancomycin
and Decadron, and off pressors his BP was in the 160s. Lactate
was 7.8 and decreased to 6.4. WBC was 28.0. CK was 22,927. He
was admitted to the MICU for further management.
.
On arrival to the MICU he was off pressors with SBP in 110s.
However, he began to drop his SBP to the 70s so Levophed was
started.
Past Medical History:
CAD, s/p CABG
DM
HTN
head trauma: lac w/ staples
unsteady gait
+PPD [**2141**]
Social History:
currently incarcerated
Family History:
unknown
Physical Exam:
Vitals: 93.2, 74, 118/66, 22.
General Impression: Intubated, sedated
COR: RRR
LUNGS: CTA bilaterally
ABD: RLQ tenderness, guarding
EXTREMITIES: no sign of infection
Pertinent Results:
On Admission: [**2160-1-29**]
WBC-28.0* RBC-4.91 Hgb-15.2 Hct-42.6 MCV-87 MCH-31.0 MCHC-35.7*
RDW-14.1 Plt Ct-298 Neuts-74* Bands-7* Lymphs-8* Monos-5 Eos-0
Baso-0 Atyps-5* Metas-0 Myelos-1*
PT-19.7* PTT-34.4 INR(PT)-1.8*
Glucose-86 UreaN-95* Creat-3.0* Na-129* K-6.6* Cl-95* HCO3-5*
AnGap-36*
ALT-82* AST-345* CK(CPK)-[**Numeric Identifier 77622**]* CK-MB-155* MB Indx-0.7
AlkPhos-74 Amylase-76 TotBili-0.5 Lipase-98*
Calcium-7.8* Phos-10.5* Mg-3.0*
TSH-0.50
BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
On Discharge: [**2160-2-7**]
WBC-16.2* RBC-3.87* Hgb-11.4* Hct-33.9* MCV-88 MCH-29.5
MCHC-33.7 RDW-14.8 Plt Ct-432
Glucose-98 UreaN-38* Creat-1.0 Na-149* K-3.5 Cl-111* HCO3-32
AnGap-10
ALT-84* AST-124* AlkPhos-80 Amylase-100 TotBili-0.5 Lipase-92*
Brief Hospital Course:
Pt admitted to the MICU and then was noted to have a tender
abdomen. Pt was urgently evaluated by surgery. Serial
abdominal exams were concerning for peritonitis. Pt was taken
urgently to surgery with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and underwent
Exploratory laparotomy, Left hemicolectomy with takedown splenic
flexure and Cholecystectomy. Please see the operative note for
surgical details. In summary; There was no unusual fluid upon
entry into the peritoneal cavity. The small bowel looked
unremarkable but gangrenous colon was identified. A long segment
of gangrenous changes was identified within the sigmoid and
descending colon. This was removed and a colostomy was formed.
In addition the patients gall bladder was found to be necrotic
and this was removed. The patient was transferred to the SICU in
critical but stable condition. Pathology on colon revealed 51 cm
of colon with ischemic injury focally transmural extending to
the proximal and distal resection margins. Gallbladder pathology
showed chronic cholecystitis.
All blood and urine specimens submitted for culture in addition
to VRE and MRSA screens were no growth/negative.
Acute renal failure was attributed to rhabdomyolysis per the
nephrology team. Volume expansion improved this and by the time
of discharge the patients creatinine was 1.0.
A VAC dressing was placed on the abdominal wound on POD 4
He self extubated on POD 5 and in addition pulled out the NGT
through which he was receiving tube feeds. He started on sips
which were tolerated and advanced slowly to regular (diabetic)
diet. He was also written for supplements
He was transferred to the regular surgical floor on POD 8.
VAC was maintained until time of discharge where he will now
have NS wet to dry dressing changes at the rehab facility.
Seen by Ostomy nurse
Medications on Admission:
Insulin
Glucophage 500mg [**Hospital1 **]
ASA 325mg qd
Lopid 600mg po bid
Tylenol 650mg [**Hospital1 **] x 7 days
Pepcid 20mg [**Hospital1 **]
Colace 100mg qd
thiamine 100mg qd
multivit 1 qd
folate 1mg qd
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection twice a day: Until ambulating.
2. Insulin Regular Human 100 unit/mL Solution Sig: per previous
insulin orders at your facility Injection ASDIR (AS DIRECTED).
3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-19**]
Puffs Inhalation Q6H (every 6 hours) as needed.
4. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) Inhalation [**Hospital1 **] (2 times a day).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours).
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
Monitor volume status. Discontinue as indicated for
normalization of fluid volume status .
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Acute abdomen (ischemic colon) now s/p ex lap, cholecystectomy
and colectomy with colostomy placement
Discharge Condition:
Fair, stable
Discharge Instructions:
Please call Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 673**] if the patient
develops fever > 101, chills, nausea, vomiting, diarrhea,
yellowing of skin or eyes, inability to take or keep down
medications.
New colostomy site, monitor stoma
NS wet to dry dressings [**Hospital1 **] to abdominal wound
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD, [**Telephone/Fax (1) 673**] Date/Time: Week of [**2160-2-18**]. PLease call for appointment
Completed by:[**2160-2-7**]
|
[
"568.0",
"401.9",
"038.9",
"584.9",
"781.2",
"557.0",
"276.7",
"441.4",
"414.00",
"276.2",
"V45.81",
"728.88",
"799.02",
"995.92",
"575.11",
"785.52",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.11",
"51.22",
"99.04",
"54.59",
"45.75"
] |
icd9pcs
|
[
[
[]
]
] |
6122, 6137
|
3073, 4918
|
340, 453
|
6283, 6298
|
2267, 2267
|
6696, 6891
|
2058, 2067
|
5174, 6099
|
6158, 6262
|
4944, 5151
|
6322, 6673
|
2082, 2248
|
2815, 3050
|
274, 302
|
481, 1899
|
2281, 2801
|
1921, 2002
|
2018, 2042
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,521
| 126,104
|
431
|
Discharge summary
|
report
|
Admission Date: [**2171-6-4**] Discharge Date: [**2171-6-21**]
Date of Birth: [**2092-5-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Fosamax / Actonel / Iodine / Solu-Cortef / Advair Diskus
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
increasing DOE
Major Surgical or Invasive Procedure:
CABGx1(SVG->OM)/MVR(#25 mm [**Company 1543**] Porcine) [**6-4**]
History of Present Illness:
79 yo F with increasing DOE for several years. Cardiac
catheterization in [**4-13**] showed 3VD and 3+MR and she was
evaluated for surgery.
Past Medical History:
PMH:AS([**Location (un) 109**] 1.4 cm'2),MR, CAD, HTN, Pulm.HTN,
Hypercholesterolemia, DMII, COPD, CRF, OSA-uses CPAP @ home,
Osteoporosis, Chr. LE cellulitis (R>L),
PSH:Parathyroidectomy, CCY, Tonsillectomy, Hysterectomy, Breast
cyst removal
Social History:
Patient denies tobacoo or etoh use or environmental exposures
Family History:
Noncontributory
Physical Exam:
HR 78 RR 20 BP 130/70
Carotids with transmitted murmur bilaterally
Heart RRR, HSM
Lungs CTAB
Abdomen soft/NT/ND
Extrem warm, trace edema
Few bilateral varicosities
Pertinent Results:
[**2171-6-21**] 05:45AM BLOOD WBC-13.3* RBC-3.16* Hgb-9.8* Hct-29.0*
MCV-92 MCH-30.9 MCHC-33.7 RDW-17.8* Plt Ct-260
[**2171-6-21**] 05:45AM BLOOD Plt Ct-260
[**2171-6-21**] 05:45AM BLOOD Glucose-121* UreaN-16 Creat-0.4 Na-137
K-4.0 Cl-104 HCO3-25 AnGap-12
[**2171-6-15**] 03:48AM BLOOD ALT-20 AST-42* LD(LDH)-651* AlkPhos-117
Amylase-280* TotBili-0.7
Brief Hospital Course:
She was taken to the operating room on [**6-4**] where she underwent
a MV replacement and CABG x 1. She was transferred to the ICU in
stable condition, in complete heart block. She was started on
milrinone and epinephroine for a low cardiac index. Her platelet
count dropped, HIT screen was negative. Dobhoff tube was placed
for tube feeds. She was slow to wake up, head CT was negative.
She remained in complete heart block and was seen by
electrophysiology. She developed fevers and was started on ancef
for sternal drainage as well as flagyl for ? of cdiff, and then
cipro for a UTI. She awaited 48 hours fever free prior to
pacemaker placement. She was extubated on POD #9. She was
started on heparin for afib and on [**6-14**] was successfully
cardioverted for afib with hypotension. She continued to require
bipap at night. On [**6-18**],a permenant pacemaker was placed. She
was transferred to the floor [**6-19**]. SHe was seen by speech and
swallow and cleared for nectar thick and pureed consistencies.
She was seen by ENT to assess vocal cord mobility and was found
to have moderate laryngeal edema but no vocal cord immobility or
injury. Recommendations included PPI [**Hospital1 **] as well as zantac and
outpatient f/u with ENT after discharge. Video swallow on [**6-20**]
cleared her for thin liquids and soft solids. stoppped. She was
ready for discharge to rehab on post-operative day 17.
Medications on Admission:
Lisinopril 10(1), Atenolol 50(1), Lescol 80(1),Ecotrin 325(1),
Spiriva (1), Oscal, Didronel,PCN 250(2)
Discharge Medications:
1. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
3. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
MR, CAD s/p CABG, MVR
PMH:AS([**Location (un) 109**] 1.4 cm'2), HTN, Pulm.HTN, Hypercholesterolemia, DMII,
COPD, CRF, OSA-uses CPAP @ home, Osteoporosis, Chr. LE
cellulitis (R>L),
PSH:Parathyroidectomy, CCY, Tonsillectomy, Hysterectomy, Breast
cyst removal
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower daily, no baths, no lotions, creams or powders to
incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon or at least one month.
Followup Instructions:
PCP [**Name9 (PRE) 3657**],[**Name9 (PRE) **] [**Telephone/Fax (1) 3658**] 2 weeks
Cardiologist Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 3659**] in [**3-10**] weeks
Dr.[**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 2232**] (Electrophysiology) 4-6 weeks
call for all above appts.
Dr. [**Last Name (STitle) 1837**](ENT) at ([**Telephone/Fax (1) 3660**].
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2171-6-27**]
11:30
Completed by:[**2171-6-21**]
|
[
"403.90",
"276.0",
"998.89",
"287.5",
"427.32",
"518.5",
"426.0",
"780.6",
"496",
"416.0",
"414.01",
"396.2",
"427.31",
"585.9",
"997.1",
"250.00",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"37.83",
"99.62",
"36.11",
"35.23",
"37.72",
"38.91",
"39.61",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3912, 3991
|
1528, 2937
|
337, 404
|
4292, 4300
|
1153, 1505
|
4641, 5205
|
936, 953
|
3090, 3889
|
4012, 4271
|
2963, 3067
|
4324, 4618
|
968, 1134
|
283, 299
|
432, 573
|
595, 840
|
856, 920
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,214
| 102,348
|
35194
|
Discharge summary
|
report
|
Admission Date: [**2166-10-18**] Discharge Date: [**2166-10-23**]
Date of Birth: [**2126-4-23**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Dizziness; s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
40M w/ no significant past medical history was having "dizzy
spell and palpitations" several times during the week preceding
hospitalization. He reported having an episode of dizziness a
few minutes prior to him falling from a standing postition. Wife
witnessed, no apparent seizures, no slurred speech. Patient
initially AOx1 and responding inappropriately. Mental status
slowly improved with time. Pt presents to [**Hospital1 18**] with short term
memory impairment, dizziness and headache.
Past Medical History:
subjective heart racing
1 kidney (donated kidney to mother}
Social History:
Married, lives with spouse.
[**Name (NI) **] ETOH use, nonsmoker, no ilicit drug use
Family History:
Mother-[**Name (NI) **] disease; Father; Deceased colon CA
Physical Exam:
On Admission:
O: T:97 BP: 136/84 HR:73 R:19 O2Sats:100% 2L N/C
Gen: mild discomfort
HEENT: Pupils: 3->2 B/L EOMI
Neck: Cervical Collar - no tenderness to palpation
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-24**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 3->2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-28**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger.
On Discharge:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Pertinent Results:
Labs on Admission:
[**2166-10-18**] 04:30PM BLOOD WBC-8.1 RBC-5.25 Hgb-16.0 Hct-42.8 MCV-82
MCH-30.6 MCHC-37.5* RDW-13.3 Plt Ct-208
[**2166-10-18**] 04:30PM BLOOD Neuts-59.7 Lymphs-31.6 Monos-2.9 Eos-4.8*
Baso-1.0
[**2166-10-18**] 08:09PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2166-10-18**] 04:30PM BLOOD PT-13.1 PTT-23.5 INR(PT)-1.1
[**2166-10-18**] 04:30PM BLOOD Glucose-135* UreaN-23* Creat-1.2 Na-137
K-3.3 Cl-100 HCO3-27 AnGap-13
[**2166-10-18**] 04:30PM BLOOD Calcium-9.4 Phos-2.5* Mg-1.9
[**2166-10-18**] 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Labs on Discharge:
XXXXXXXXXXX
Imaging:
Head CT [**10-18**]:
IMPRESSION:
1. Multifocal, small regions of right-sided subdural hemorrhage
with adjacent regions of subarachnoid hemorrhage. No significant
midline shift or mass effect.
2. Soft tissue swelling along the left occipital parietal region
with
adjacent linear nondisplaced left occipital fracture extending
towards the
condyle.
C-Spine [**10-18**]:
IMPRESSION: Mild superior endplate deformity with slight loss of
height
involving the anterior portion of C6, likely within normal
limits. Otherwise, no evidence of acute fracture within the
cervical spine. Known left occipital bone fracture as described
in head CT.
MRV [**10-19**]:
IMPRESSION:
1. Asymmetry of the transverse sinuses may be due to anatomic
variation, right dominant transverse sinus.
2. Apparent tubular filling defect in the right jugular vein may
be due to
flow related artifact vs. thrombus.
Head CT [**10-22**]:
Edema of right frontal contusion, similar in appearance since
prior scan with slight decrease in hemorrhage of foci seen.
Brief Hospital Course:
Patient is a 40 year old male with 4mm rt SDH, SAH, fx of left
occipital bone after fall from standing position - felt dizzy
with palpitations and was found to have new onset of Afib.
[**10-19**] Cardiology consulted. ASA 325', atenolol 12.5mg begun.
Pts cervical spine
was also cleared clinically. Pt continued to have non focal
neurologic exam.
Repeat CT of brain done on [**10-20**] showed the frontal blood
collection as slightly increased in size. Neuro exam remaining
unchanged with short term memory
impairment. Pt needing frequent reminders for instructions and
details. MRI/V was completed on [**10-19**] revealing no definite
thrombus. Left transverse sinus is smaller than the right. [**Month (only) 116**]
be anatomic variation. Right jugular with filling defect as
well.
[**10-20**] TTE showing basal wall hypokinesthis. Because of the
hypokinesthis, Cardiology felt it would be better to obtain a
Cardiac MR prior to EPS study which was done on [**2166-10-22**] without
complication. The patient had an implanted cardiac holter
recorder (REVEAL) placed in the cath lab.
Patient reported frontal headache without positional component
on [**10-22**] - repeat CT of head showed stable edema of right
frontal contusion, similar in appearance since prior scan with
slight decrease in hemorrhage of foci seen.
The patient and his wife will be obtaining CD copies of all
images done during his hospitalization at [**Hospital1 18**]. Images will be
for the medical providers who will follow him when he returns to
[**Location 8398**]where he will need neurology follow-up with
continuing Dilantin for at least 3 months plus neuropsych
evaluation before returning to work. Also, needs cardiology
follow-up as well.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please dispense enteric coated tablets.
Disp:*30 Tablet(s)* Refills:*0*
2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 30 days: Discontinue on [**11-18**].
Disp:*90 Capsule(s)* Refills:*0*
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Headache.
Disp:*50 Tablet(s)* Refills:*1*
9. Atenolol 25 mg Tablet Sig: [**12-25**] Tablet PO twice a day: Hold
for HR less than 54 and Systolic Blood pressure <90.
Disp:*30 Tablet(s)* Refills:*2*
10. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID; PRN as
needed for anxiety.
Disp:*42 Tablet(s)* Refills:*0*
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
New Onset Atrial Fibrillation
Traumatic SDH, SAH from fall while standing.
Discharge Condition:
Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed for 30 days. You should have your blood drawn every
three days to ensure an adequate level. This should be monitored
by your PCP [**Name Initial (PRE) **]/or Neurologist.
??????
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
Followup Instructions:
Neurosurgery Follow Up Recommendations:
*You will need to follow up with a neurologist for your head
injury, and Neuro psychiatry testing once back in [**Location (un) 7349**]. You will
need to continue on Dilantin for one month. Dilantin blood
levels must be checked every three days and reported to your PCP
or [**Name9 (PRE) 702**] Neurologist.
*Cardiology follow up also will occur in [**Location (un) 7349**]. You will need an
Electrophysiologic Cardiologist to follow your monitor.
You will be given prescriptions for enough medication to cover
for one month.
Completed by:[**2166-10-23**]
|
[
"801.21",
"780.2",
"427.31",
"E885.9",
"873.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.79",
"37.26",
"89.50"
] |
icd9pcs
|
[
[
[]
]
] |
7087, 7093
|
4246, 5976
|
339, 346
|
7212, 7221
|
2499, 2504
|
8239, 8839
|
1074, 1134
|
6031, 7064
|
7114, 7191
|
6002, 6008
|
7245, 8216
|
1149, 1149
|
2445, 2480
|
280, 301
|
3173, 4223
|
375, 871
|
1723, 2431
|
2518, 3154
|
1445, 1707
|
893, 955
|
971, 1058
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,171
| 158,616
|
841
|
Discharge summary
|
report
|
Admission Date: [**2121-4-5**] Discharge Date: [**2121-5-9**]
Date of Birth: [**2086-12-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Nsaids / Levaquin
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
transfer s/p pericardial window
Major Surgical or Invasive Procedure:
none
History of Present Illness:
In brief, this is a 34 yoF with hypertrophic cardiomyopathy,
multiple atrial arrhythmias including atrial tachycardia, atrial
fibrillation, left atrial tachycardia, and AVNRT s/p recent
pulmonary vein isolation procedure [**2121-3-18**] c/b peristent atrial
tachycardia, respiratory failure and pneumonia who was
readmitted to [**Hospital1 18**] on [**2121-4-5**] with chest pain and shortness of
breath. She initially presented to an OSH w/ intermittent [**11-21**]
chest pain radiating to the arms associated with SOB. CT chest
was negative for PE or dissection. She was found to have a
pericardial effusion with RV compression as well as a
pericardial clot on TTE. She was sent to the OR for pericardial
window on [**2121-4-5**] which showed "fluid under pressure" without
complication. She was extubated on POD 1 without incident. She
had elevated CVPs and was diuresed with improvement in CVPs from
30s->20s. Post-op, also had Atach w/ [**Date Range 5509**] and was loaded with IV
amio. Her home dose verapamil also initiated with improved HR
control. Chest tube was discontinued today, [**2121-4-7**]. Patient
continues to breath comfortably, but with significant O2
requirement.
.
Currently, the patient complains of discomfort at prior chest
tube site as well as very mild SOB but improving. She denies
any other complaints at this time.
Past Medical History:
# Hypertrophic cardiomyopathy.
- Cardiac MR on [**2121-2-28**] with asymmetric LVH with maximal wall
thickness of 19mm at mid septum with focal hyperenhancement
consistent with hypertrophic CM. EF 55%.
# SVT with A fib, left atrial tach and AVNRT s/p pulmonary vein
isolation on [**2121-3-18**].
# Questionable history of WPW
# Tobacco use with bronchitis and associated multifocal a tach.
# Anxiety
# Obesity
# Asthma, ?COPD
.
Cardiac History:
The patient initially presented with syncope at age of l2. At
l3, the patient was seen at [**Hospital3 1810**] for history of
syncope, chest pain and progressive exercise intolerance. She
was found to have hypertrophic cardiomyopathy. She was
subsequently cathed. Left
ventricular end diastolic pressure was found to be 20. She was
then started on chronic Verapamil therapy. At age l6, she
experienced cardiac arrest secondary to complex tachycardia. She
was successfully resuscitated. Repeat catheterization showed
left ventricular end diastolic pressure of 36-40 without outflow
tract obstruction. EP showed inducible atrial flutter with a
rapid ventricular blood pressure. She was felt to have a rapid
antegrade
conduction and possible pre-excitation. She was started on
Norpace. Since then, the patient has been stable on Verapamil
and Norpace with occasional palpitations, chest pain and light
headedness.
.
Social History:
Currently on disability. 40 pack-year smoker (2ppd x20 years)
quit since recent bronchitis. No EtOH. Regular marijuana use.
Family History:
Family history remarkable for hypertrophic cardiomyopathy and
congenital aortic stenosis s/p cardiac surgery during infancy.
No family history of sudden cardiac death or premature CAD.
Physical Exam:
VS 97.2, 97/71, 79, 26, 94% 6LNC
Gen: Obese, pale appearing female in NAD
HEENT: NCAT. MMM. OP clear. EOMI. PERRL.
Neck: Supple. R IJ CVL CDI. Cannot assess JVP.
CV: Sutures at substernal surgical site dressed, CDI. Distant
heart sounds. Irreg irreg. Normal S1 and S2. No M/R/G.
Pulm: Decreased BS at bases w/ faint crackles bilat.
Abd: Obese, Soft, nontender. No organomegaly or masses.
Ext: Trace bilateral lower extremity edema. Cool extremities. 2+
DP pulses bilat.
Neuro: A&Ox3. Moving all extremities.
Pertinent Results:
[**2121-4-5**] 09:15AM BLOOD WBC-17.4*# RBC-3.19* Hgb-9.6* Hct-30.2*
MCV-95 MCH-30.1 MCHC-31.9 RDW-13.5 Plt Ct-696*#
[**2121-4-25**] 05:01AM BLOOD WBC-28.7* RBC-4.27 Hgb-12.4 Hct-40.3
MCV-95 MCH-29.1 MCHC-30.8* RDW-17.1* Plt Ct-403
[**2121-4-26**] 08:09AM BLOOD WBC-32.9* RBC-4.30 Hgb-12.4 Hct-40.3
MCV-94 MCH-28.9 MCHC-30.9* RDW-16.3* Plt Ct-432
[**2121-4-27**] 06:00AM BLOOD WBC-33.0* RBC-4.42 Hgb-12.7 Hct-41.3
MCV-94 MCH-28.8 MCHC-30.8* RDW-16.4* Plt Ct-481*
[**2121-4-27**] 12:07PM BLOOD WBC-38.4* RBC-4.42 Hgb-12.6 Hct-42.9
MCV-97 MCH-28.6 MCHC-29.4* RDW-16.2* Plt Ct-510*
[**2121-4-9**] 02:00AM BLOOD PT-20.0* PTT-29.0 INR(PT)-1.9*
[**2121-4-8**] 02:00AM BLOOD PT-19.5* PTT-26.4 INR(PT)-1.8*
[**2121-4-28**] 02:39AM BLOOD Fibrino-515*# D-Dimer-3283*
[**2121-4-28**] 11:11AM BLOOD FDP-0-10
[**2121-5-3**] 03:10PM BLOOD Glucose-148* UreaN-11 Creat-1.0 Na-130*
K-3.6 Cl-93* HCO3-25 AnGap-16
[**2121-4-30**] 02:20AM BLOOD ALT-25 AST-33 LD(LDH)-457* AlkPhos-102
Amylase-21 TotBili-0.6
[**2121-4-9**] 02:00AM BLOOD ALT-1061* AST-967* LD(LDH)-676*
AlkPhos-98 TotBili-0.7
[**2121-4-27**] 12:07PM BLOOD Lipase-653*
[**2121-4-28**] 05:20AM BLOOD Lipase-245*
[**2121-4-29**] 03:56AM BLOOD Lipase-192*
[**2121-4-30**] 02:20AM BLOOD Lipase-140*
[**2121-4-5**] 09:15AM BLOOD cTropnT-<0.01
[**2121-4-9**] 02:00AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.7
[**2121-4-8**] 02:00AM BLOOD calTIBC-296 VitB12-1702* Folate-19.2
Ferritn-1506* TRF-228
[**2121-4-28**] 05:20AM BLOOD Hapto-195
[**2121-4-27**] 12:07PM BLOOD Triglyc-311*
[**2121-4-20**] 05:41AM BLOOD TSH-2.2
[**2121-4-5**] 05:01PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2121-4-21**] 04:20PM BLOOD Lactate-16.2*
[**2121-4-21**] 10:01PM BLOOD Lactate-5.9*
[**2121-4-22**] 01:56AM BLOOD Lactate-2.3*
[**2121-4-21**] 06:30AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-
TEST
[**2121-4-21**] 06:30AM BLOOD B-GLUCAN-Test
[**2121-5-9**] 05:04AM BLOOD WBC-16.5* RBC-2.74* Hgb-8.0* Hct-26.1*
MCV-95 MCH-29.2 MCHC-30.7* RDW-21.0* Plt Ct-467*
[**2121-4-30**] 02:20AM BLOOD WBC-26.4* RBC-2.73* Hgb-8.0* Hct-25.6*
MCV-94 MCH-29.3 MCHC-31.2 RDW-18.2* Plt Ct-379
[**2121-5-4**] 03:09AM BLOOD WBC-20.8* RBC-3.15* Hgb-9.3* Hct-29.6*
MCV-94 MCH-29.5 MCHC-31.4 RDW-18.5* Plt Ct-447*
[**2121-5-9**] 05:04AM BLOOD PT-21.5* INR(PT)-2.0*
[**2121-5-8**] 04:39AM BLOOD Glucose-99 UreaN-10 Creat-1.0 Na-128*
K-4.4 Cl-93* HCO3-24 AnGap-15
[**2121-5-9**] 05:04AM BLOOD Glucose-106* UreaN-15 Creat-1.1 Na-128*
K-4.6 Cl-94* HCO3-23 AnGap-16
[**2121-4-30**] 02:20AM BLOOD ALT-25 AST-33 LD(LDH)-457* AlkPhos-102
Amylase-21 TotBili-0.6
[**2121-5-8**] 04:39AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.8
TTE [**4-8**]:
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild global left ventricular hypokinesis
(LVEF = 50%). Right ventricular chamber size is normal. with
borderline normal free wall function. There is mild pulmonary
artery systolic hypertension. There is a small pericardial
effusion with an echodense anterior epicardial collection. No
right atrial or right ventricular diastolic collapse is seen.
IMPRESSION: Small pericardial effusion without echo signs of
tamponade. Anterior echodense epicardial collection, likely
representing a thrombus.
Compared with the prior study (images reviewed) of [**2121-3-8**],
the findings are similar.
Cardiac MR:
There was normal epicardial fat distribution. The myocardium
appeared to have homogenous signal intensity without evidence of
myocardial fatty infiltration. The pericardial thickness was
mildly thickened, without CMR evidence of significant
accumulation of thrombus within the pericardial space. There was
a small pericardial effusion and bilateral small to moderate
pleural effusions. There was a moderate degree of epicardial fat
anterior to the right ventricle, which measured up to 16mm in
thickness in the anterior interventricular groove. The origins
of the left main and right coronary arteries were identified in
their customary positions. The indexed diameters of the
ascending and descending thoracic aorta were normal. The main
pulmonary artery diameter index was mildly increased. The left
atrial AP dimension was moderately increased. The right and left
atrial lengths in the 4-chamber view were moderately and
severely increased, bilaterally. The coronary sinus diameter was
normal.
The left ventricular end-diastolic dimension index was normal.
The end- diastolic volume index was normal. The calculated left
ventricular ejection fraction was normal at 67% with normal
regional systolic function. There was no abnormal septal motion
to suggest constriction, although this cannot be excluded. The
anteroseptal wall thickness was mildly thickened and the
inferolateral wall thickness was normal, to a degree which met
criteria for asymmetric left ventricualr hypertrophy (greater
than 1.5:1). The left ventricular mass index was normal. The
right ventricular end-diastolic volume index was normal. The
calculated right ventricular ejection fraction was normal at
64%, with normal free wall motion.
Quantitative Flow
There was no significant intra-cardiac shunt. Aortic flow
demonstrated no significant aortic regurgitation. The calculated
mitral valve regurgitant fraction was consistent with moderate
to severe mitral regurgitation. The resultant effective forward
LVEF was mildly reduced at 46%. The right ventricular stroke
volume and pulmonic flow demonstrated no significant pulmonic
and moderate tricuspid regurgitation.
Myocardial Fibrosis
There was regional hyperenhancement in the anteroseptum and
inferoseptum at the right ventricular insertion site, consistent
with hypertrophic cardiomyopathy. There was no focal
hyperenhancement in the ventricular or atrial free walls to
suggest myocardial injury or perforation.
Pulmonary Vein MR Angiography
Three right-sided pulmonary veins and two left-sided pulmonary
veins were identified, all entering the left atrium and free of
focal stenoses (dimensions listed above). The multiplanar
reconstructions confirmed the above findings. There was a mild
decrease in the cross-sectional area of the left lower pulmonary
vein (28%) without CMR evidence of obstruction.
Additional Findings
Mild hilar lymphadenopathy and a borderline enlarged pretracheal
lymph node measuring 22 x 14 mm were seen.
Impression:
1. Normal left ventricular cavity size with normal regional left
ventricular systolic function. The LVEF was normal at 67%. The
effective forward LVEF was mildly reduced at 46%. No CMR
evidence of prior myocardial scarring/infarction. Late
gadolinium contrast-enhanced CMR images demonstrating areas of
hyperenhancement in the anteroseptum and inferoseptum as
described above.
2. There is no CMR evidence of myocardial rupture or significant
thrombus within the pericardium. The pericardium is mildly
thickened. A small pericardial effusion was seen. There is a
moderate amount of epicardial fat in the anterior
interventricular groove.
3. Normal right ventricular cavity size and systolic function.
The RVEF was normal at 64%.
4. Moderate to severe mitral regurgitation. Moderate tricuspid
regurgitation.
5. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was mildly increased.
6. Moderate right and severe left atrial enlargement.
7. Normal size and orientation of the pulmonary veins without
CMR evidence of pulmonary vein stenosis. There was a mild
decrease in the cross-sectional area of the left lower pulmonary
vein.
8. No evidence of pericardial constriction found.
Compared to the prior study of [**2121-2-28**], the mitral and
tricuspid regurgitation has worsened, and the pericardial
effusion is new.
LENIS:
1. No evidence of DVT in either lower extremity.
CT chest w/contrast [**4-15**]:
. Mild cardiogenic pulmonary edema characterized by the presence
of scattered ground-glass opacities, septal thickening, and
cardiomegaly, particularly the left atrium.
2. Bibasilar atelectasis with adjacent small right more than
left pleural effusion.
3. A right upper lobe consolidation with cavitation worrisome
for pneumonia.
4. A left upper lobe wedge-shaped non-enhancing opacity
worrisome for pulmonary infarct secondary to a coexistent
pulmonary embolism.
Further evaluation to exclude or confirm coexistent pulmonary
embolism is recommended. Information was telephoned to Dr.
[**First Name8 (NamePattern2) 1887**] [**Last Name (NamePattern1) **] at approximately 4:30 p.m.
5.The lymph nodes are rather enlarged for a cardiogenic cause
like heart
failure.Other causes including neoplam should be investigated.
CT abd/pelvis [**4-20**]:
. Consolidation within the right middle lobe has the appearance
of pneumonia. Direct comparison to the prior chest CT is not
possible. There are two non enhancing foci within the
atelectatic changes of the both lower lobes which might
represent foci of infection.
2. Interval increase in moderate right and small left pleural
effusion.
3. Free fluid in the pelvis presacral space possibly due to CHF.
4. No intraabdominal source of infection is identified.
Right heart cath [**4-21**]:
1. In the cath laboratory holding area before the procedure
began Ms.
[**Known lastname **] became hypoxic with pulse oximetery showing saturations
85-95%.
Coincident with the hypoxic she had junctional bradycardia with
a
ventricular rate of approximately 20 bpm. She was given
atropine and
transcutaneous pacing pads were applied. Transcutaneous pacing
was
begun with electrical capture of the ventricle, however she soon
became
pulseless. CPR was promptly begun. She recieved several
epinephrine IV
boluses. Multiple attempts were made for arterial access
without
success. She was intubated without difficultly by Dr. [**Last Name (STitle) 5856**]
from
anesthesia. Compressions were continued throughout this time,
stopping
only to check pulses. An echocardiogram was done that showed no
reaccumulation of pericardial fluid. She regained her pulse
intermittently throughout this period. She was started on
continous
epinephrine, levophed, and neosynepherine infusions. Possible
hyperkalemia was treated with CaCl, insulin, and bicarbonate.
Bilateral
breath sounds were present thoughout the event. Ultrasound was
used to
access the right axiallary vein.
2. The patient was then moved from the holding area into the
catheterization laboratory. Resting hemodynamics revealed an
elevated
mean right atrial pressure of 37 mmHg. There was pulmonary
arterial
hypertension with a pulmonary artery pressure of 72/38
(systolic/diastolic in mmHg). Mean pulmonary capillary wedge
pressure
was markedly elevated at 39 mmHg. Cardiac index was perserved
at 2.6
l/min/m2.
3. Floroscopy was performed to confirm endotrachial tube
position. At
this time there was noted to be a large right pleural fluid
collection
and possible pneumothorax. The pulmonary service promptly
placed a
chest tube.
4. Given the elevated filling pressures and liklihood of
minimal
diuresis given the presumed insult to her kidneys during the
arrest,
renal was called and placed a left femoral hemodyalsis catheter
to be
used upon transfer to the CCU.
5. Before transfer to CCU she had adequate blood pressure and
vasopressors were weened to minimal levels.
6. Drs. [**Last Name (STitle) 911**] and [**Name5 (PTitle) 5857**] present throughout all events above.
Report
given to Drs. [**Last Name (STitle) **], [**Name5 (PTitle) 5858**], and the CCU housestaff who will
continue
care.
RUQ U/S:
Unremarkable study. No cholelithiasis.
Brief Hospital Course:
34 yo F with hypertrophic cardiomyopathy, multifocal atrial
tachycardia, atrial fibrillation, left atrial tachycardia, and
AVNRT, obesity, anxiety s/p recent pulmonary vein isolation
procedure admitted with chest pain and shortness of breath found
to have a pericardial effusion with compression of RV now s/p
pericardial window w/ improved heart rate control but persistent
volume overload.
.
# pericardial effusion: She received a pericardial window on
[**4-5**] with multiple follow up echocardiograms showing no
reacculmulation of the fluid. The fluid was negative for all
infectious and malignant studies.
.
# Rhythm. History of multiple atrial tachyarrhythmias s/p recent
failed ablation. Anticoagulated w/ coumadin as outpt. Patient
was initially controlled with verapamil and was then loaded with
amiodarone. She was initially in normal sinus rhythm but then
converted to atrial fibrillation. He rate control was changed to
metoprolol and titrated up with good effect. She was continued
on a heparin drip during her admission and restarted on her
coumadin. For control of her rate, patient was titrated up to
100mg PO TID of metoprolol, increased to 200mg PO BID of
amiodarone, and started on verapamil 40mg TID. The EP service
was following the patient, and no indication for emergent AV
ablation/pacemaker placement during this hospitalization,
however, may consider this at a later date. Prior to procedure,
R PICC and US evaluation of carotid and subclavian vessels will
need to be done. She was reanticoagulated with heparin bridge
to coumadin and on day of discharge INR was 2.0
.
# Pump
Hypertrophic cardiomyopathy w/o obvious obstruction on ECHO. The
patient appeared to be volume overloaded on presentation to the
CCU and initially responded well to IV lasix. However, she
eventually became more resistant to lasix and started to retain
fluid. However, her fluid status became unclear as her labs
appeared consistent with hypovolemia but her exam was consistent
with hypervolemia. She was sent to the cath lab on [**4-21**] for a PA
line. She was given 1 unit of FFP prior to reverse an elevated
INR. She was found in the holding area pulseless and in
bradycardic PEA arrest. She was actively coded for approximately
1 hour with multiple rounds of epi and atropine. She was
intubated during this time. She regained a perfusing rhythm. A
PCWP taken at that time was 40, confirming her volume overload
status. She was begun on CVVH for aggressive fluid removal.
Approximately 10-12L was removed in this fashion with subsequent
improvement in her hypoxia with weening to room air.
.
# Respiratory failure: The patient was initially hypoxic due to
volume overload and then was intubated during her PEA arrest.
Fluid was removed with CVVH and she was extubated approximately
6 days later. However, 2 days after that, she had what appeared
to be an aspiration event with subsequent hypoxia requiring
reintubation. Intubation was complicated by pneumothorax for
which she had a right chest tube placed on [**2121-4-21**]. She was
treated for an aspiration pneumonia with aztreonam and
clindamycin for a total 10 day course. She again extubated and
did well, eventually weaning to room air.
.
# anterior commisure granuloma
In the setting of her intubations, she developed hoarseness.
ENT was consulted who felt patient had a anterior commissure
granuloma. They recommended PPI therapy and outpatient followup
after discharge to ensure resolution of the granuloma. She
shoul call [**Telephone/Fax (1) 41**] to schedule an appointment
.
# Acute Renal Failure due to acute tubular necrosis: The patient
developed anuric renal failure after her PEA arrest from
hypotension associated ATN. She was initially management with
CVVH with good effect. A right IJ tunnelled triple lumen
catheter was placed. She was eventually transitioned to daily
HD. Her Cr continued to improve 1.1 at time of discharge. Renal
consult team felt that she was unlikely to require dialysis in
the future and R IJ HD line was removed on day of discharge.
She was given 1 unit of FFP prior to removal of this line as her
INR was 2.0.
.
# Leukocytosis and Fever
The patient has had a persistent leukocytosis with intermittent
fevers initially. She was diagnosed with a RML/RLL pneumonia,
likely aspiration based and completed a 10 day course of
aztreonam and clindamycin. However, her leukocytosis persisted.
No positive culture had been obtained at the time of this
writing including multiple sets of blood cultures, urine
cultures, sputum cultures, a BAL, culture of pleural fluid,
b-glucan, galactomannan, urine legionella, c.diff x3, and a
viral DFA. At the time of this writing, the source of her
leukocytosis is unclear. She did exhibit enlarged lymph nodes on
a CT chest, which may be reactive or related to an unclear
malignancy. She should have a follow up chest CT in
approximately 3 months.
.
# Pancreatitis: On [**4-29**], the patient noted new onset abdominal
pain and a CT abdomen noted peripancreatic inflammation,
confirmed by chemical pancreatitis. A RUQ U/S showed no gall
stones or cholecystitis. The pancreatitis was likely drug
related, possibly related to the flagyll that she was given
earlier in her pneumonia course. The flagyl was stopped and the
pancreatitis resolved.
.
# left groin wound
slow healing site of catheterization from PVI but on day of
discharge did not appear infected (nontender, no spreading
erythema, no purulent drainage). Some white granulation tissue
present. Groin wound should be monitored for progression.
.
# Communication: Fiance [**Doctor Last Name **] [**Telephone/Fax (1) 5859**] or uncle [**Name (NI) 122**]
[**Telephone/Fax (1) 5860**]
Medications on Admission:
Montelukast 10 mg Daily
Sertraline 150 mg Daily
Aspirin 325 mg Daily
Bupropion 75 mg Daily
Amiodarone 200 mg 3 times a day
Acetaminophen 160 mg/5 mL PO every 6 hours as needed
Pantoprazole 40 mg Daily
Clonazepam 1 mg 4 times a day
Verapamil 360 mg Daily
Trazodone 200 mg at bedtime as needed
Percocet 5-325 mg 1-2 Tablets twice a day as needed
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day): hold for SBP<85 with symtpoms or HR<60.
14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
17. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours): for use while having back pain.
19. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16): goal INR [**3-16**].
20. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): hold for SBP<85 with symptoms.
21. Loperamide 2 mg Capsule Sig: [**2-12**] Capsules PO QID (4 times a
day) as needed for diarrhea: 4mg for first episode, 2mg for
subsequent episodes.
22. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: 0.5-1 Tablet,
Rapid Dissolve PO four times a day as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Primary:
Pericardial effusion/tamponade
Hypertrophic cardiomyopathy
PEA arrest
Acute tubular necrosis requiring temporary hemodialysis
atrial tachycardia
aspiration pneumonia
acute pancreatitis
surgical wounds in chest (from chest tube) and left groin (from
ablation)
Discharge Condition:
Stable - SBP low 85-95 occassionally symptomatic but improving
with lower dose of verapamil (40mg TID) and metoprolol 100mg
TID.
Discharge Instructions:
You were admitted with chest pain and found to have fluid around
your heart. This was treated with a surgery to drain the fluid.
During your hospital stay you suffered a cardiac arrest. This
had multiple complications but you have recovered very well from
these complications. We are sending you to a rehabillitation
facillity to help you regain your strength.
For your heart failure:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
If you experience chest pain, shortness of breath, fevers,
severe lightheadedness, or any other new or concerning symptoms,
please contact your PCP or come to the emergency room.
Followup Instructions:
Please followup with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5861**] on Tuesday [**5-27**]
at 3pm.
call [**0-0-**] if this is a problem.
.
check BUN/creatinine on monday or tuesday ([**5-12**] or [**5-13**]) - if
greater than 15/1.1 please have patient followup in the
nephrology clinic ([**Telephone/Fax (1) 773**]
.
Please followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**7-26**] at 1:40pm.
Please call ([**Telephone/Fax (1) 5862**] if this is a problem. We will
contact Dr.[**Name2 (NI) 1565**] office to see if you can be seen sooner
by one of his colleagues. Their office will contact you to
reschedule
|
[
"E879.8",
"415.11",
"997.1",
"425.4",
"786.50",
"428.0",
"512.1",
"424.0",
"E849.8",
"790.92",
"507.0",
"429.89",
"584.5",
"427.31",
"518.0",
"E878.8",
"423.3",
"518.81",
"276.6",
"486",
"577.0",
"493.90",
"428.33",
"300.00",
"423.9",
"E931.5",
"427.5",
"E849.7",
"799.02",
"278.00",
"478.79",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"96.72",
"33.24",
"88.72",
"38.95",
"34.04",
"38.93",
"99.60",
"38.91",
"89.64",
"37.12",
"34.91",
"99.04",
"39.95",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
23691, 23772
|
15564, 21249
|
333, 339
|
24084, 24215
|
3994, 15541
|
24932, 25611
|
3261, 3448
|
21643, 23668
|
23793, 24063
|
21275, 21620
|
24239, 24909
|
3463, 3975
|
262, 295
|
367, 1722
|
1744, 3104
|
3120, 3245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,792
| 190,178
|
44491
|
Discharge summary
|
report
|
Admission Date: [**2201-2-3**] Discharge Date: [**2201-2-20**]
Date of Birth: [**2126-8-17**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Pt. found in car with altered mental status and taken to OSH
where he was intubated
Major Surgical or Invasive Procedure:
Tracheostomy
PEG
History of Present Illness:
74M transferred from OSH, no family story obtained from ER
physician. [**Last Name (NamePattern4) **]. found in car with altered mental status and taken
to OSH where he was intubated. this happened around 6pm. He had
a CT scan that showed right parietal hemorhage with small amount
of intraventricular extension and 5mm shift.
Past Medical History:
unable to obtain
Social History:
unable to obtain
Family History:
NC
Physical Exam:
On admit:
O: T:98 BP:133/71 HR:68 R 18 O2Sats 98% on CMV
Gen: Intubated
HEENT: Pupils: 3mm reactive EOMs unable to assess
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated, sedated
Cranial Nerves:
Corneal reflex present
gag reflex present
Moving all extremities when propofol turned off.
Withdrawing from painful stimuli.
Unable to test III - XII because patient is intubated and
sedated
Motor: Normal bulk and tone bilaterally.
Sensation: Withdrawing to pain
Toes downgoing bilaterally
On Discharge:
Exam: General Trach/Vent
Pulm: Lungs sound clear compared to yesterday, minor ronchi at
left frontal field
CV: Distant sounds. RRR
Abd: Soft, Positive bowel sounds
Neuro: Eyes are open not tracking or following objects. right
pupil 2mm Left pupil 3mm reactive. Moving all four extremities
but the left side more then right side. Not following commands.
upgoing toes. Paratonia.
Pertinent Results:
CT:Right parietal bleed. Small extension into ventricles. 5mm
shift
Ammonia: 24
145 105 49 174 AGap=10
5.3 35 1.1
Ca: 10.2 Mg: 2.4 P: 4.5
7.1>11.9<335 --> 8.8>12.3<387
[**2201-2-15**] 9:06 am BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2201-2-18**]**
GRAM STAIN (Final [**2201-2-15**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2201-2-18**]):
Commensal Respiratory Flora Absent.
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
**FINAL REPORT [**2201-2-14**]**
GRAM STAIN (Final [**2201-2-9**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2201-2-14**]):
Commensal Respiratory Flora Absent.
MORAXELLA CATARRHALIS. >100,000 ORGANISMS/ML..
STREPTOCOCCUS PNEUMONIAE. >100,000 ORGANISMS/ML..
Note: For treatment of meningitis, penicillin G MIC
breakpoints
are <=0.06 ug/ml (S) and >=0.12 ug/ml (R).
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints are
<=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R).
For treatment with oral penicillin, the MIC break
points are
<=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R).
Penicillin 1.0MCG/ML Sensitive.
Penicillin Sensitivity testing performed by Etest.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
>100,000 ORGANISMS/ML..
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE----------- 0.5 S
ERYTHROMYCIN----------<=0.25 S
LEVOFLOXACIN---------- <=0.5 S
PENICILLIN G---------- S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
MRSA SCREEN (Final [**2201-2-11**]): No MRSA isolated.
Brief Hospital Course:
Mr [**Known lastname 95346**] was admitted after sustaining an MVA and having a CT
head demonstrate a Right Temp/parietal hemorrhage. He was
admitted to the ICU and intubated. He failed extubation and
received a tracheostomy and PEG.
His course was complicated by a VAP which was treated by broad
spectrum ABX.
His neurologic status did not improve and is characterized by
periods of agitation and being unable to follow even simple
commands. There is no evidence that he is responding in any
meaningful way and required Klonopin and Zyprexa for agitation.
An EEG was performed which demonstrated encephalopathy but no
evidence for seizures.
His blood pressure was controlled after multiple agents were
added.
Neurologic: Patients bleed was stable by serial CT exams. An MRI
of the brain was not completed. He shows no signs of
understanding and an EEG was performed which demonstrated
encephalopathy. It is not known why his structural deficits by
CT head have resulted in his current neurological presentation.
CV: His blood pressure was initially difficult to control. His
current regiment had him well within range. His beta blocker
(labetalol) was titrated down and may be switched to low dose
longer acting medication like metoprolol
Pulm: He was a failed extubation x1. Was emergently re intubated
with some difficulty. He received a tracheostomy and was able to
tolerate Trach mask for a few hours. His lungs by CXR are still
infiltrated. He is on ciprofloxacin for pneumonia (Culture and
sensitivities were performed). He still has a problem with
secretions.
GU: He has irritation at the penile head/meatus.
GI: tolerating PEG tube feeding
RISS: not to goal blood sugars. RISS has been adjusted.
Nephro: no Active issues. BUN and CR still needs to be
monitored.
Medications on Admission:
unable to obtain.
Discharge Medications:
1. HydrALAzine 10 mg IV Q6H:PRN SBP > 160
2. 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.
3. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical
TID (3 times a day).
4. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for wheeze.
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
15. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
16. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
17. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
18. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
19. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for agitation.
20. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
21. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
22. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
23. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
24. insulin glargine Subcutaneous
25. labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
26. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Center-[**Hospital1 8**]
Discharge Diagnosis:
New
- IPH
- Respiratory failure s/p trach
- PEG tube
- VAP
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted after suffering from a intracranial bleed.
Your course was complicated by pneumonia and being unable to
come off a ventilator. You are still on a ventilator. You had a
tracheostomy and a PEG tube placed. Your neurological
examination did not improve much. You had an EEG which did not
provide evidence for seizures. You were discharged to an LTAC
for further care.
Followup Instructions:
Neurology: Dr [**Last Name (STitle) **]. Date/Time. [**4-28**] at 5:30pm. Call ([**Telephone/Fax (1) 19129**] two weeks prior to ensure date and time.
Completed by:[**2201-2-20**]
|
[
"348.5",
"041.3",
"041.85",
"607.2",
"250.00",
"041.00",
"294.8",
"518.81",
"431",
"437.9",
"365.9",
"277.39",
"327.23",
"997.31",
"348.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"43.11",
"96.72",
"96.6",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
8932, 9000
|
4824, 6597
|
396, 415
|
9103, 9103
|
1884, 4801
|
9647, 9830
|
861, 865
|
6666, 8909
|
9021, 9082
|
6623, 6643
|
9239, 9624
|
880, 1127
|
1485, 1865
|
273, 358
|
443, 771
|
1178, 1471
|
9118, 9215
|
793, 811
|
827, 845
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,766
| 119,554
|
17379
|
Discharge summary
|
report
|
Admission Date: [**2108-7-12**] Discharge Date: [**2108-7-14**]
Date of Birth: [**2066-5-8**] Sex: M
Service: MED
Allergies:
Azithromycin / Augmentin / Klonopin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Code red
Major Surgical or Invasive Procedure:
none
History of Present Illness:
42 y/o male with h/o CAD, chronic chest pain, multiple stents,
depression with recent suicide attempt requiring CCU care for
heart block resulting from bblocker and calcium blocker overdose
who presents from community home after intentional benadryl
overdose. Pt known to me from recent ED visit [**7-11**] for an
episode of chest. Returned [**7-12**] after pt ingested 50 tablets of
50mg benadryl 30-45 mins prior to ED presentation. In ED,
patient initially alert and oriented but then level of
consciousness deteriorated with signs of anticholinergic
toxicity of tachycardia, mydriasis, hallucinations. Toxicology
called to bedside. Initial vital signs: BP 143/91 HR 126 RR 17
100% RA. 2mg Physostigmine given with some improvement in
mental status. 30min later another 1.5 mg given without
significant change. OG tube placed and activated charcoal
given. 3 liters NS IVF given in ED (UOP 2 liters) as well.
Pt has not required further doses of physostigmine over last 18
hours. Currently states his chest pain is [**2-25**], burning,
acrossed left and right breast and right axilla. Pain
waxes/wanes, pt thinks the ibuprofen is helping. States his
mood is slightly improved but he still thinks about hurting
himself; however he is adamant that he would not hurt himself
while in the hospital and would alert a staff member if he was
feeling as such.
Past Medical History:
1. CAD- s/p multiple stents with stent to LAD, pRCA, RCA, D1,
mid LCX at various times. Cath [**2108-4-13**] showed no flow limiting
disease with EF=50%. 6 caths since [**11-20**].
2. Hypertension
3. Hyperlipidemia
4. Depression/anxiety
5. Tremor--essential
6. s/p hernia repair
PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Cardiologist is Auerback at [**Hospital1 18**].
PSYCHIATRIC HISTORY: long history of depression. Current treater
is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 48614**] who sees him for psychotherapy and
psychopharmacology.
Reports first being treated for depression 10 years ago after he
was placed on Effexor originally to treat an essential tremor
that is exacerbated by anxiety.
Reports a "suicidal reaction" to Klonopin. Was tried on Klonopin
before being started on Effexor and states that he developed
"violent mood swings", became argumentative and was behaviorally
out of control. He attempted suicide by taking "a bottle full"
of klonopin. He was taken to ED by step-mother who he called to
tell about the overdose. A bed was reportedly not available at
the time and he stayed one night in hospital on medical service
and was followed up by an [**Last Name (NamePattern1) 3782**] psychiatrist shortly thereafter
and started on the Effexor.
SUBSTANCE ABUSE HISTORY: Ethanol dependence, in remission. Pt
attends AA. Sober x 14yrs. No sponsor for last 3 years.
Insterested in getting a new sponsor in area. Pt was sectioned
35 to [**Location (un) 1475**] about 15 years ago (initiated by his father).
He also had one more detox admission after his stay at
[**Location (un) 1475**]. Started drinking as a teenager shortly after his
mother's death from brain cancer. Reports remote MJ use. "Tried"
cocaine "years ago," but did not use habitually. Denies IVDA.
Social History:
Lives with partner, [**Name (NI) **] of 14 years. Close relationship with 5
sisters, father. [**Name2 (NI) 1403**] in the kitchen at [**Hospital1 **]-[**Last Name (un) 4068**]. See 6-page
for more details.
Family History:
Dad: cancer, DM2, mom: lung ca. ; sister= CAD
FAMILY PSYCHIATRIC HISTORY: Father with EtOH dependence. Great
aunt with ?depression, completed suicide.
Brief Hospital Course:
A/P: 42 y/o male with CAD, depression who presents with
anti-cholingergic toxicity [**12-19**] suicide attempt with benadryl
ingestion.
1. Benadryl overdose
-evaluated by toxicology in the ED. 2mg Physostigmine given
with some improvement in mental status. 30min later another 1.5
mg given without significant change. OG tube placed and
activated charcoal given. 3 liters NS IVF given in ED (UOP 2
liters) as well. Patient did not require further doses of
physostigmine. Was monitored in the ICU for ~24 hours and then
transferred to the floor without incident.
2. Suicide attempt/Depression
-patients antidepressants and benzodiazepines were held per
psychiatry's recommendation. He did not exhibit any symptoms of
BZD withdrawal.
-was maintained on 1:1 sitter
-transferred to Deac4 for in-patient psychiatric evaluation and
treatment
-patient is MEDICALLY CLEARED FOR FUTURE [**Month/Day (2) **] TREATMENTS.
3. CAD/Chest pain
-had ST depression v2-v6 on admission ekg which was likely
rate-related; resolved on subsequent ekgs.
-ruled out for MI by serial enzymes; has had recent caths [**3-20**],
[**4-20**] without evidence of flow limiting disease; also with recent
ED evaluation (including CTA, V/Q scans) which ruled out other
serious etiologies of chest pain (ie. PE, aortic dissection)
-cont [**Month/Year (2) **] ([**Hospital1 **]), plavix, bb, statin, norvasc
-current chest pain is NON-CARDIAC; continue ibuprofen 800 tid
4. Leukocytosis
-patient had transient increase in WBC to 12 which resolved
without treatment
-unclear etiology given pt afebrile; no localizing symptoms;
?lab artifact
-had a negative u/a and urine culture
-a cxr showed a ?rml infiltrate but patient with NO clinical
signs of pneumonia, therefore does not need abx. If he were to
become febrile and/or develop a productive cough, would
recommend levofloxacin 500mg po qd x7 days
5. F/E/N
-cardiac diet
6. PPx - SQ Heparin, PPI
7. Dispo - to [**Hospital1 **] 4 for in-patient psych evaluation and
treatment.
Medications on Admission:
Aspirin 325 mg [**Hospital1 **]
Plavix 75 mg qd
Atorvastatin 20mg qd
Pantoprazole 40mg qd
Metoprolol 25 mg [**Hospital1 **]
Effexor 37.5 mg qd
Ativan 0.5mg [**Hospital1 **] prn
Trazadone 50mg qhs
Ibuprofen prn
Discharge Medications:
1. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): please take with food.
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Diphenhydramine overdose
Depression
Coronary artery disease
Gastroesphogeal reflux disease
Discharge Condition:
Medically stable, being transferred to in-patient psychiatry
unit
Discharge Instructions:
Please take all medicines as previously prescribed, with the
exception that you should no longer take your Effexor
Continue to take Ibuprofen 800mg three times/day for your chest
pain. Please be sure to take the medication with food.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] to arrange appropriate follow-up after
discharge.
Follow up with your psychiatrist as instructed by the [**Hospital1 18**]
psychiatry team.
|
[
"V45.82",
"E849.0",
"780.09",
"296.20",
"963.0",
"E950.4",
"413.9",
"414.01",
"288.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6907, 6922
|
4016, 6023
|
298, 305
|
7057, 7124
|
7408, 7594
|
3839, 3993
|
6283, 6884
|
6943, 7036
|
6049, 6260
|
7148, 7385
|
250, 260
|
333, 1702
|
1724, 3600
|
3616, 3823
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,257
| 147,716
|
32141
|
Discharge summary
|
report
|
Admission Date: [**2189-10-31**] Discharge Date: [**2189-11-4**]
Date of Birth: [**2131-2-14**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Tetanus
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
R shoulder pain
Major Surgical or Invasive Procedure:
Reduction of right dislocated shoulder
History of Present Illness:
Mr. [**Name14 (STitle) 75206**] is a 58 y/o male transferred from [**Hospital3 38099**] via [**Location (un) **] s/p motorcycle vs car. Pt awake upon
arrival and was wearing helmet at the time of the accident. ER
head CT revealed right frontal insular intraparenchymal
hemorrhage. Xray of c spine showed no fractures or step offs. R
shoulder was found to be fracture dislocated. Neurosurgery was
consulted by trauma as orthopedic surgery requested our approval
to take patient to OR for reduction of
right shoulder dislocation and fracture.
Past Medical History:
hepatitis C
hypercholesterolemia
clinical depression
Social History:
Lives with roomate, has girlfriend, works as construction worker
Family History:
None
Physical Exam:
On admission:
PHYSICAL EXAM:
O: T: 98.8 BP: 141/78 HR: 88 R 24 O2Sats 98%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3 to 2 bilaterally EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-11**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-13**] throughout; however, could not
test right upper extremity fully due to fracture/dislocation No
pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2189-10-31**] 02:30PM WBC-19.6* RBC-3.94* HGB-13.6* HCT-38.9*
MCV-99* MCH-34.4* MCHC-34.9 RDW-12.6
[**2189-11-1**] 01:12AM BLOOD Glucose-142* UreaN-16 Creat-1.0 Na-143
K-4.1 Cl-109* HCO3-23 AnGap-15
[**2189-10-31**] 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**10-31**] CT head -
Subarachnoid hemorrhage within
the right sylvian fissure and sulci of the right temporal lobe
displays no
interval change. However, there has been new development of a
hyperdense
fluid collection, best appreciated along the left tentorium. No
other new
areas of hemorrhage are identified. [**Doctor Last Name **]-white differentiation
is well
preserved. There is no evidence of ventriculomegaly. Large
right-sided
subgaleal hematoma is stable. Osseous structures and paranasal
sinuses are unremarkable.
[**11-1**] CT shoulder -
Comminuted fracture of the humeral head with multiple intra-
articular fractures with interval relocation of the humeral head
within the glenoid fossa. The high riding position of the
humeral head indicate a probable rotator cuff tear. No evidence
for glenoid fracture. Further
evaluation of the rotator cuff could be obtained with right
shoulder MRI.
[**11-3**] MRI R shoulder -
1. There are fractures involving the greater and
lesser tuberosities.
2. The supraspinatus, infraspinatus, and subscapularis
muscles and tendons are attached to the tuberosity
fracture fragments and displaced medially as described
above.
3. There is dislocation of long head of the biceps
tendon into an intra-articular location.
4. Joint effusion with a prominent amount of soft
tissue swelling.
Brief Hospital Course:
Patient urgently taken to the OR for relocation of R posterior
shoulder dislocation. Post reduction CT showed that shoulder
remained reduced with multiple fracture fragments. Patient was
found to subdural hemorrhage and intraparenchymal hemorrhage.
Neurosurgery was consulted and pt was started on dilantin.
Patient had GCS of 15 throughout hospital course. Dr. [**Last Name (STitle) 2719**]
was consulted due to complex nature of right humeral head
fracture and an MRI was done to ascertain the rotator cuff.
Pain was controlled and tolerated regular diet. Was afebrile
throughout hospitalization. Discharged with instructions to
follow up with Dr. [**Last Name (STitle) 2719**] and Dr. [**Last Name (STitle) **] for orthopedic and
neurosurgical issues respectively.
Medications on Admission:
Xanax
paxil
diaspan
Cialis
Discharge Medications:
Home medications with addition of following
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 6 days.
Disp:*18 Capsule(s)* Refills:*0*
2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
R shoulder posterior dislocation
R comminuted humeral head fracture
Sub arachnoid hemorrhage, Intraparenchymal hemorrhage
Discharge Condition:
stable
Discharge Instructions:
Call or come back in if you experience increase pain, swelling,
shortness of breath, chest pain or any other worrisome symptoms.
Resume home medications. Take pain medications as needed. Take
stool softeners such as docusate to prevent constipation. Take
dilantin (phenytoin) for 6 more days as instructed by
neurosurgery.
Non weight bearing to right upper extremity with no shoulder
mobilization. Keep R arm in sling and swath.
Follow up as directed.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 2719**] in next week. Please call
[**Telephone/Fax (1) 1228**] to schedule an appointment
Follow up with Dr. [**Last Name (STitle) **] in [**5-15**] weeks. Please call
[**Telephone/Fax (1) 1669**] to schedule an appointment. Have an outpatient
head CT without contrast done prior to appointment.
Call Radiology at ([**Telephone/Fax (1) 6713**] to get head CT prior to
neurosurgery appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
|
[
"E812.2",
"870.0",
"070.70",
"852.22",
"305.90",
"812.09",
"305.1",
"840.4",
"852.02",
"272.0",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"08.89",
"79.01",
"87.03"
] |
icd9pcs
|
[
[
[]
]
] |
5679, 5685
|
4291, 5064
|
290, 331
|
5851, 5860
|
2569, 4268
|
6365, 6936
|
1079, 1085
|
5141, 5656
|
5706, 5830
|
5090, 5118
|
5884, 6342
|
1129, 1389
|
235, 252
|
359, 905
|
1682, 2550
|
1114, 1114
|
1404, 1666
|
927, 981
|
997, 1063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,809
| 194,629
|
18356+56944
|
Discharge summary
|
report+addendum
|
Admission Date: [**2173-11-17**] Discharge Date: [**2173-12-3**]
Service:
HISTORY OF PRESENT ILLNESS: This is an 87 year old man with
severe peripheral vascular disease, congestive heart failure
and cardiomyopathy, atrial fibrillation, hypertension,
hypercholesterolemia, chronic renal insufficiency, diabetes,
history of upper gastrointestinal bleed and lower extremity
wound who was recently discharged from [**Hospital6 649**] at the end of [**Month (only) 359**] for Clostridium
difficile colitis and upper gastrointestinal bleed who now
presents with acute and chronic renal failure, hyperkalemia,
worsening lower extremity pain and persistent diarrhea from
[**Hospital **] Rehabilitation. In the Emergency Department, he was
hemodynamically stable. His lower extremity ulcers had a pus
exudate. He had a urinalysis consistent with urinary tract
infection with thick milky colored urine and was found to
have diarrhea. He also had a potassium of 7.3. He was given
D50 plus insulin plus Kayexalate, plus calcium carbonate and
Zosyn times one dose.
Additional history reveals his last admission from [**10-6**]
through [**10-11**], he was positive for Clostridium difficile
on [**10-6**] and had bloody stools, was given intravenous
Levofloxacin and Flagyl and p.o. Vancomycin. He also
underwent esophagogastroduodenoscopy on [**10-7**], which
showed the lower one-third of his esophagus had ulcers plus
duodenitis. He was sent out on p.o. Vancomycin. After
speaking with his daughter the patient has had bloody stools
at [**Hospital1 **], has been receiving increasing doses of Lasix via
phone conversations with primary care doctors. He has a
history of having a colonoscopy in [**2173-4-22**], positive for
only a small benign appearing polyp and reports no fevers,
weight loss, nausea, vomiting, chest pain or shortness of
breath. He is not on home oxygen but is requiring oxygen
upon interviewing. No belly pain. He does have pain in his
lower extremities bilaterally with his wounds. He is not
very ambulatory at [**Hospital1 **].
PAST MEDICAL HISTORY: 1. Peripheral vascular disease,
status post left superficial femoral artery stent; 2.
Congestive heart failure in idiopathic cardiomyopathy with 20
to 30%; 3. History of Clostridium difficile at the end of
[**2173-9-22**] treated for 30 days with p.o. Vancomycin; 4.
History of upper gastrointestinal bleed; 5. Chronic atrial
fibrillation; 6. Chronic renal insufficiency with a baseline
creatinine of 2.0; 7. Diabetes Type 2, diet-controlled; 8.
Hypertension; 9. Hyperlipidemia.
ALLERGIES: Darvocet and Percocet and essentially all
narcotics as they cause altered mental status.
MEDICATIONS: Outpatient Medications include Lipitor 10 mg a
day, Nephrocaps, Plavix 75 mg a day, Allopurinol, Questran,
Digoxin 0.125 three times a week, Flomax, Coumadin,
Rocaltrol, Lopressor 12.5, Aspirin 325, Epogen.
SOCIAL HISTORY: He is a retired dentist, no smoking, alcohol
or drug history. His daughter is intensely involved with his
medical care.
PHYSICAL EXAMINATION: On examination he weighed 85 kg,
temperature 95.3, temperature maximum 97.6, heartrate in the
60s to 70s and atrial fibrillation, blood pressure 113/135/50
to 60s, sating anywhere from 95 to 99% on 2 liters of nasal
cannula, guaiac positive stool. Generally he has a flat,
depressed affect. Neck: No jugulovenous pressure was
appreciated, no nodules or lymphadenopathy. Head, eyes,
ears, nose and throat: Clear oropharynx, moist mucous
membranes, pale conjunctiva, anicteric sclera, small pupils
bilaterally but reactive. Extraocular movements intact.
Chest examination, decreased breathsounds with bibasilar
crackles bilaterally. Cardiovascular, irregular rhythm with
a holosystolic II/VI murmur. Abdomen was soft, positive
bowel sounds, nontender, nondistended. Extremities, erythema
to below the knees with a temperature gradient compared to
the thighs, bandages, foul odor coming from the siege, no
edema. Underneath the bandages find exposed bone and tendon.
Neurological examination, cranial nerves II through XII
appear intact, gross upper extremity strength 5/5 unable to
test lower extremity strength secondary to his chronic ulcers
and pain. Sensation to light touch intact grossly
throughout. Gait not tested. The patient is not ambulatory
with multiple ulcers on bilateral lower extremities.
LABORATORY DATA: Pertinent laboratory data reveals he was
admitted with a white count of 24,000 at maximum which
subsequently dwindled to 8.4 upon discharge. His hematocrit
was metered at 26.0, however, was stable ranging from 30 to
32 upon discharge, platelets stable. Coagulation profile, he
was admitted with an INR of 2.0, held Coumadin secondary to
gastrointestinal bleeding and INR fell to within the normal
range. Chem-7, the potassium was 7.3 upon admission and upon
discharge is within normal range. Sodium initially high at
146 and now within normal limits, BUN initially in the 100s,
104, but within normal limits upon discharge, creatinine
maximum value was 8.6, down to the range of 4 upon discharge.
Calcium, magnesium and phosphorus were followed and were
abnormal. His urinalysis showed more than 50 white blood
cells, moderate leukocyte esterase and liver function test
were within normal limits. Digoxin level was 1.0. Urine
sodium 58, creatinine 58. Culture data, stool negative for
Clostridium difficile on [**11-29**], [**11-19**], [**11-18**]
and stool culture from [**11-17**] was positive for gram
negative rods, this was sent to the state laboratory for
further identification and it is not back yet upon discharge.
No Campylobacter, negative for Clostridium difficile.
Culture data from the urine grew out yeast, otherwise
negative. Culture data from blood showed no growth on
[**11-19**], no fungus or mycobacterium, no growth from
[**11-19**], again and one bottle with Corynebacterium
diphtheroids 1 out of 2 from [**11-17**]. Swab cultures
taken from wounds grew out Pseudomonas and Staphylococcus
aureus coagulase positive, sensitive to Vancomycin and a
Pseudomonas sensitive to Zosyn, multiple cultures were taken.
Studies, renal ultrasound consistent with chronic renal
failure. Chest x-ray, cardiomegaly, left atelectasis and
effusion, pulmonary edema. He had a stress MIBI in [**2171-9-23**], moderate reversible inferior wall defects, no
electrocardiogram changes or symptoms. Ejection fraction was
approximately 30%, diffuse hypokinesis. On [**2173-9-21**], he had a catheterization that showed critical stenosis
of the right superficial femoral artery even after stenting.
HOSPITAL COURSE: 1. Renal failure - Originally it was
suspected that this was a prerenal etiology as the patient
had increased diarrhea and had increasing diuretic regimen
while at [**Hospital1 **]. The patient became anuric. Other causes
of renal failure were investigated including SPEP and UPEP,
which SPEP was consistent with inflammatory response, UPEP
showed no light change. Hepatitic panel was negative with
the exception of the hepatitis B surface antibody, not
indicating disease, indicating immunity. The FENA,
fractional excretion of sodium was 4.6%, urine eosinophils
were positive moderately, renal ultrasound was normal. Renal
Service was consulted and it was decided secondary to the
patient's volume overload and the persistent hyperkalemia
that this patient undergo hemodialysis, thus a right internal
jugular Quinton catheter was placed on [**11-23**] for
hemodialysis and the patient received three episodes of
hemodialysis in a row and then was converted to three times
per week schedule, Saturday, Tuesday and Thursday. There was
a plan for vascular surgeon, Dr. [**First Name (STitle) **] to evaluate the
patient for arteriovenous fistula and graft. Vein mapping was
done on [**11-25**]. A tunneled catheter and PICC line were
placed by Interventional Radiology on [**10-30**]. This
patient was maintained on Calcium Acetate and Nephrocaps and
Epogen and Calcitriol are given at hemodialysis. The patient
has urinary tract infection and was treated with Zosyn
renally. Zosyn was also used to treat the wound cultures as
well. This patient also had a high parathyroid level of 199,
likely secondary to renal pathology.
2. Gastrointestinal bleeding - This patient received five
units of fresh frozen plasma and one unit of red blood cells
in the Intensive Care Unit for gastrointestinal bleeding and
guaiac positive stools following hematocrit. However, after
his stay in the Intensive Care Unit while on the floor he was
stable and had no recurrent episodes of bleeding, his
hematocrit remained stable. Multiple Clostridium difficile
toxins were negative. So, Clostridium difficile toxin B was
sent to an outside laboratory and is currently pending. His
stool culture from [**11-17**] is growing gram negative rods.
This was sent to the state laboratory for infectious disease,
there is question of Shigella possibly. This should be
followed up. He was maintained on a proton pump inhibitor.
Stool osmolality, serum osmolality, sodium and potassium was
obtained. He was found to have a stool osmolar gap of 43
indicating a secretory component to his diarrhea. For the
diarrhea he had a colonoscopy on [**12-1**], which showed no
pseudomembranes and only two benign appearing polyps.
Biopsies were taken, not available at the time of discharge.
Thus, he was treated with Imodium for his chronic diarrhea.
It was felt important to treat this as his nutritional status
is imperative in order to help heal his wound.
3. Peripheral vascular disease - Vascular Surgery was
consulted. This patient has exposed bone and tendon which is
the equivalent of osteomyelitis. He was treated with Zosyn
and Vancomycin. Zosyn was started on [**12-17**] and is
renally dosed. Vancomycin is renally dosed based on a
Vancomycin level which is checked every day. Once the level
dips below 15, the patient receives another dose, 1 gm of
intravenous Vancomycin. Multiple blood cultures taken from
the wounds are positive for pseudomonas and coagulase
positive Staphylococcus aureus sensitive to Zosyn and
Vancomycin respectively. ABI was done and he had an ABI
ratio of 0.61 on the right and 0.83 on the left. Vascular
recommended dry gauze changes with Accuzyme prn and bedside
debridement was performed. Ultimately they recommended
bilateral above-the-knee amputations, however, it was decided
with the primary team that it would be best to try a six week
course of intravenous antibiotics before attempting bilateral
amputations. Amputation would severely limit this patient's
potential ability to ambulate and quality of life.
4. Cardiology - This patient has atrial fibrillation and
congestive heart failure with an ejection fraction of 20 to
30%. His intakes and outputs are monitored and his oxygen
saturations are monitored. His volume overload when he
originally presented with the chest x-ray showed some
pulmonary edema, increased pulmonary vasculature. With
hemodialysis he was able to remove a lot of that fluid and
his saturations became better. He was sating 92 to 93% on
room air upon discharge. His Coumadin for his atrial
fibrillation was held secondary to his gastrointestinal
bleeding. He was continued on his statin, Metoprolol 12.5
b.i.d. Aspirin was held for his colonoscopy but restarted as
baby Aspirin 81 mg.
5. Diabetes - Regular insulin sliding scale, fingersticks
b.i.d., he did not require much insulin at all.
6. Neurological - He was originally given a low dose
Fentanyl patch for his lower extremity pain, however, this
resulted in altered mental status, so this was discontinued.
He was started on Remeron 7.5 mg at night to increase his
appetite, help with depression and sleep. He is sleeping
better and his appetite is up.
7. Fluids, electrolytes and nutrition - Nutrition was
consulted and originally recommended tube feeds since the
patient was not eating, he had a decreased appetite, however,
Nutrition came by later on in his hospitalization and
performed a three day calorie count which found that he was
meeting his caloric needs, thus tube feeds are not needed.
It is thought that the additional of Remeron as well helped
his appetite as well. He was maintained on Folic acid, Zinc,
Ascorbic acid. A speech and swallow evaluation was performed
and this showed no issues with swallowing.
8. Prophylaxis - He was kept on proton pump inhibitor,
subcutaneous heparin and scheduled Tylenol for pain.
CODE STATUS: He is full code, his daughter is his health
care proxy.
DISCHARGE DIAGNOSIS:
1. Renal failure
2. Peripheral vascular disease
3. Atrial fibrillation
4. Hypertension
5. Diabetes Type 2
6. Chronic lower extremity ulceration secondary to
peripheral vascular disease
7. Hypercholesterolemia
The rest of this dictation summary will be dictated at a
later date.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Last Name (NamePattern1) 9789**]
MEDQUIST36
D: [**2173-12-2**] 18:44
T: [**2173-12-2**] 18:25
JOB#: [**Job Number 50559**]
Name: [**Known lastname 9401**], [**Known firstname 77**] Unit No: [**Numeric Identifier 9402**]
Admission Date: [**2173-11-17**] Discharge Date: [**2173-12-9**]
Date of Birth: [**2086-8-5**] Sex: M
Service:
SUMMARY OF HOSPITAL COURSE ADDENDUM: Patient had been
relatively stable on the regular medicine floor, however, he
was noted to have abdominal distention and some abdominal
pain which was worsening daily and on [**12-8**], patient
was noted to be hypotensive and hypoxic with blood pressures
in the 50s and oxygen saturations in the high 80s. He had
refused CT of the abdomen the night prior, but a KUB at that
time showed dilated loops of bowel read by radiologist as
small bowel obstruction.
Patient was immediately seen by Surgery and transferred to
the Cardiac Intensive Care Unit for closer monitoring. In
the Intensive Care Unit, patient was put on pressors and
still had difficulty maintaining his blood pressure. He
appeared lethargic, but still continued to mentate for many
hours.
A CT of the abdomen with contrast was finally obtained which
showed markedly thickened wall in the ileum and ascending
colon. The differential diagnosis included infection,
inflammatory bowel disease, and mesenteric ischemia or
infarcted bowel.
Patient continued on a downhill course in terms of
maintaining his blood pressure and his oxygen saturation, and
with multiple discussions overnight with the attending and
both the patient's daughter and son, it was determined that
patient should be comfort measures only, and he was
pronounced dead at 9:26 a.m. on [**2173-12-9**].
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 285**]
Dictated By:[**Last Name (NamePattern1) 3102**]
MEDQUIST36
D: [**2173-12-29**] 14:37
T: [**2173-12-29**] 14:46
JOB#: [**Job Number 9403**]
|
[
"286.9",
"584.9",
"578.9",
"599.0",
"427.31",
"557.0",
"428.0",
"403.91",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.07",
"86.22",
"86.28",
"38.93",
"45.25",
"38.95",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12595, 14987
|
6626, 12574
|
3062, 6608
|
114, 2067
|
2090, 2900
|
2917, 3039
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,245
| 171,966
|
7988
|
Discharge summary
|
report
|
Admission Date: [**2139-11-16**] Discharge Date: [**2139-11-21**]
Date of Birth: [**2068-2-6**] Sex: M
Service:
CHIEF COMPLAINT: Non-Q wave myocardial infarction.
HISTORY OF THE PRESENT ILLNESS: The patient is a 71-year-old
male with a history of diabetes, hypertension,
hypercholesterolemia, peripheral vascular disease, CHF,
chronic renal insufficiency, and CAD, who was transferred to
the [**Hospital1 18**] from the [**Hospital3 15174**] on [**2139-11-16**] after being ruled in for a non-Q wave MI.
The patient was admitted to the [**Hospital3 15174**] on
the evening of [**2139-11-14**] following the acute onset of
chest pain and shortness of breath while at a church dinner.
He was ruled in for an MI with a troponin peak of 1.07. He
was started on heparin, IV nitroglycerin, and Aggrastat. His
symptoms resolved.
An echocardiogram performed while there showed an ejection
fraction of 30% with basilar inferior hypokinesis and
anterior severe hypokinesis to akinesis. The patient was,
therefore, transferred to the [**Hospital1 18**] for a cardiac
catheterization. The patient had previously had a cardiac
catheterization at [**Hospital1 18**] in [**2139-3-13**], during which the
patient received a stenting of the LAD and PTCA of the
diagonal branch. He was reported to have done well following
the [**Month (only) 958**] procedure, returning to work five days a week and
able to walk several miles without any chest pain or
shortness of breath.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes times 30 years (on insulin for four years).
3. Chronic renal insufficiency.
4. Peripheral vascular disease.
5. Silent MI.
6. Status post right renal artery stenting.
PAST SURGICAL HISTORY:
1. Status post left femoral-popliteal bypass in [**2137**].
2. Status post cholecystectomy in [**2139-5-13**].
3. Status post rotator cuff repair.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Digoxin 0.25 mg p.o. q.d.
3. Lasix 40 mg p.o. q.d. (on hold).
4. Captopril 50 mg p.o. b.i.d. (on hold).
5. Glucophage 850 mg p.o. t.i.d. (on hold).
6. TriCor 160 mg p.o. q.d.
7. Toprol XL 50 mg p.o. b.i.d.
8. Restoril 50 mg p.o. q.h.s.
9. Trazodone 50 mg p.o. q.d.
10. Humalog 75/25 44 units in the a.m., 39 units at
dinnertime.
11. Aggrastat drip.
12. Nitroglycerin drip.
13. Heparin drip.
SOCIAL HISTORY: The patient is a married [**Country 3992**] and Korean
War veteran with possible post-traumatic stress disorder.
The patient works at [**Company 2486**] five mornings a week. The
patient quit smoking 30 years ago after a 40 pack year
history.
PHYSICAL EXAMINATION ON ADMISSION: The patient was a
well-developed, well-nourished male lying on a stretcher in
no apparent distress. Vital signs: 130/53, 82, 99%. Neck:
The patient had no JVD and no bruits. Lungs: The patient
had bibasilar rales, worse on the left. Heart: The patient
had normal S1, S2, with no murmurs. Abdomen: Soft,
nontender, nondistended with positive bowel sounds.
HOSPITAL COURSE: Following cardiac catheterization, the
decision was made to consult Cardiothoracic Surgery given
that the patient's disease was not amenable to medical
therapy. The patient was taken for CABG on [**2139-11-17**]
and the procedure was performed without complications.
The patient was, thereafter, transferred to the CSIU for
continued monitoring. The patient's stay in the CSIU was
only notable for frequent ectopy noted on his rhythm strip.
The ectopy was noted to persist in spite of correction of the
patient's electrolytes. The patient noted that he had a
history of frequent ectopy.
The patient was transferred to the Cardiothoracic Surgery
Floor on postoperative day number two. He continued to
recover uneventfully. The ectopy noted on his rhythm strips
in the CSIU persisted on the floor. His heart rhythm
remained stable in sinus rhythm. His pain was well
controlled.
A postoperative EKG obtained for the patient following
arrival from the floor demonstrated isolated ST segment
elevation in leads V1 through V3. At the time the EKG was
obtained, the patient was complaining of some sharp
needle-like pain on the right side of his chest which was
later deemed noncardiac in origin. Repeat EKGs at eight and
12 hours as well as at the time of discharge demonstrated no
changes from the first postoperative EKG. A series of
cardiac enzymes drawn on the patient were all negative.
The patient was deemed stable for discharge to home on
postoperative day number four.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Percocet.
2. Enteric-coated aspirin 325 mg p.o. q.d.
3. Ranitidine 150 mg p.o. b.i.d.
4. Colace 100 mg p.o. b.i.d.
5. Metoprolol 25 mg p.o. b.i.d.
6. Lasix 20 mg p.o. b.i.d.
7. Potassium chloride 20 mEq p.o. b.i.d.
8. Metformin 500 mg p.o. t.i.d.
9. Fenofibrate 162 mg p.o. q.d.
10. Humalog 75/25 20 units at bedtime and at breakfast.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **]
following discharge. The patient was also to follow with his
primary care physician following discharge.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 28620**]
MEDQUIST36
D: [**2139-11-22**] 15:36
T: [**2139-11-23**] 07:41
JOB#: [**Job Number 28621**]
|
[
"593.9",
"309.81",
"250.00",
"410.71",
"401.9",
"414.01",
"428.0",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"37.23",
"36.12",
"36.15",
"88.56",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4580, 4589
|
4612, 5409
|
3071, 4558
|
1958, 2390
|
1730, 1935
|
146, 1483
|
2688, 3053
|
1505, 1707
|
2407, 2673
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,588
| 164,898
|
41805
|
Discharge summary
|
report
|
Admission Date: [**2177-8-28**] Discharge Date: [**2177-9-5**]
Date of Birth: [**2101-10-22**] Sex: F
Service: NEUROLOGY
Allergies:
Zosyn
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
found down/unresponsive on the floor
Major Surgical or Invasive Procedure:
Ventriculostomy placement
History of Present Illness:
Mrs. [**Known lastname **] is a 75 yo W with h/o HTN, HL, CAD who presents
with IVH.
The patient vomited once the night before admission, but was
otherwise normal. She
was last seen well at 8am before her husband left for work. He
came home at 6pm to find her slumped behind the bedroom door.
She
opened her eyes and knew who he was. EMS arrived. She was
reported to have agonal breathing. She was taken to [**Hospital **]
Hospital where NCHCT showed isolated IVH.
Initial GCS 8. BPs 150/80, 188/98, 184/86. Initial exam revealed
patient unresponsive, pupils pinpoint and nonreactive, withdraws
from pain on L side only. Toes upgoing bilaterally. She was
given
ceftriaxone and azithromycin for possible aspiration.
The family was given a poor prognosis so decided to make her
CMO.
She was admitted to the floor, but she soon began to open her
eyes and speak, she was AOx3, moving all extremities, with a
mild
R hemiparesis.
Because of this improvement, the family wanted to pursue more
aggressive treatment, and patient was transferred to [**Hospital1 18**].
ROS per patient's husband is negative for headaches, fevers,
weakness, speech difficulties, gait difficulties.
Past Medical History:
[] Cardiovascular - HTN, HL, mild CAD
[] Hematologic - essential thrombocythemia (on ASA) by history,
however, this might have progressed over the last years and she
might have developed into a Polycythemia [**Doctor First Name **] (JAK 2 mutation
positive). Her Hematologist is [**First Name8 (NamePattern2) **] [**State 108**] and she has not
established any contact with an hematologist up here.
[] MSK - bilateral total hip replacements, s/p thigh/hip
abscess/infx requiring IV abx ~ 18 months ago
Social History:
lives with husband. Smokes 1 pack/day, no EtOH in several
years.
Family History:
negative for stroke, ICH, aneurysm
Physical Exam:
At admission:
GEN: NAD
HEENT: sclera anicteric, mmm
CV: RRR no m/r/g
PULM: CTAB
AB: ND/NT
EXT: no edema
NEURO:
MSE: Eyes open to voice. Oriented to self, states she is in
rehabilitation hospital (had been told by nurse where she was 2
minutes earlier), doesnt know month or year. Cannot name pen or
glasses. Repetition intact. Comprehension intact. Follows
midline
and appendicular commands (shows 2 fingers on each hand). No
obvious neglect.
CN: PERRL 3 to 2mm and brisk. EOMI intact except for limited
upgaze (poorly following directions). No nystagmus. Face
symmetric. Tongue midline.
MOTOR: normal bulk and tone.
Limited cooperation with testing.
Bilateral delts at least 4.
R tricep 4, finger ext 5-, finger flex 5
L tri, finger ext/flex 5
Bilateral IPs, ham, TA, [**Last Name (un) 938**], gastroc at least 3. There is
asymmetry in withdrawal of RLE to noxious suggestive of
weakness.
DTR: brisk and 2+ in bilateral [**Hospital1 **], tri, brachiorad, patellar,
achilles. Toes upgoing.
___________________________________________________________
At Discharge:
Pertinent Results:
[**2177-8-27**] CT/CTA Head - CT Head: Little change in bihemispheric
subarachonoid hemorrhage and large amount of intraventricular
hemorrhage compared to 9 hours prior. CTA: No large aneurysm,
flow limiting stenosis or other major vasc abnl. Carotid artery
calcification b/l. Final read pending recons.
[**2177-8-28**] CT/CTA Head - IMPRESSION:
1. Unchanged intraventricular hemorrhage in all the ventricles,
predominantly in the frontal [**Doctor Last Name 534**] of left lateral ventricle.
There is associated dilatation of the lateral and third
ventricles. Subarachnoid hemorrhage is noted along cortical
sulci predominantly along the sylvian fissures. The subarachnoid
hemorrhage appears more prominent as compared to the prior CT.
2. No significant abnormality is noted on CTA head. No evidence
of aneurysm.
[**2177-8-28**] CXR - IMPRESSION: Emphysema with concomitant pulmonary
edema and two discrete basal opacities which are suspicious for
aspiration.
[**2177-8-29**] TTE - The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is severe
thickening of the mitral valve chordae. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
vigorous biventricular systolic function. Aortic valve sclerosis
without stenosis. Mild mitral regurgitation. Moderate pulmonary
hypertension.
[**2177-8-29**] NCHCT - 1. Expected short interval evolution in
intraventricular hemorrhage with persistent dilatation of the
lateral and third ventricles.
2. Slight expected interval evolution of bihemispheric
subarachnoid
hemorrhage.
[**2177-8-30**] NCHCT - IMPRESSION: Status post placement of right
frontal ventricular drain with the tip in the region of foramen
of [**Last Name (un) 2044**]. There remains ventriculomegaly with prominence of
temporal horns, not significantly changed from the prior CT.
Previously noted intraventricular and subarachnoid hemorrhage
again noted.
[**2177-8-31**] CTPA - IMPRESSION:
1. No evidence of pulmonary embolus.
2. Generalized volume overload with bilateral effusions and
pulmonary edema. Areas of air space opacity may reflect
superimposed infection.
[**2177-9-3**] MRI/MRA Brain - IMPRESSION:
1. Multiple small acute infarcts as described above. There is no
associated
hemorrhage or mass effect.
2. No interval change regarding the subarachnoid and
intraventricular
hemorrhage.
3. Unchanged diameter of the intraventricular system with
unchanged position
of the right frontal ventriculostomy catheter.
4. No evidence of vessel occlusion or vasospasm.
[**2177-9-4**] EEG - (preliminary) no epileptiform activity, diffuse
theta-delta slowing, severe diffuse encephalopathic pattern
Brief Hospital Course:
75 yo W h/o CAD, HTN, HL, history of essential thrombocythemia
which may have evolved into a Polycythemia [**Doctor First Name **] (JAK2+), tobacco
use p/w up to 10 hours of depressed level of awareness and R
hemiparesis with spontaneous improvement and found to have IVH
and very mild SAH due to hemorrhage leaking out from the foramen
Lushkae into the [**Female First Name (un) **].
[] Intraventricular Hemorrhage - She was found on the ground on
the evening of [**8-27**] by her husband. When she arrived at an
outside hospital, her exam was very poor: she was nonresponsive,
her pupils were described as pinpoint, and she was only
minimally withdrawing on the left side. Based on her poor exam
and large amount of IVH on CT, the OSH physicians predicted a
poor prognosis and the husband decided to change her code status
from DNR to CMO, but her mental status spontaneously improved
without major intervention to the point of her arousing, being
partly oriented, and following commands. Her husband requested
that she be transferred to [**Hospital1 18**] for more aggressive care (if
needed). Her exam since arrival has fluctuated significantly: at
times she was minimally arousable and at other times she
remained awake and followed simple commands with only mild
right-sided upper extremity-predominant weakness, inattention,
and some memory deficits. Neurosurgery was consulted but decided
to hold off on placing a ventriculostomy while her mental status
remained relatively functional. Her exam worsened on [**2177-8-30**]
mainly due to respiratory problems and she was intubated. At
this time, Neurosurgery decided to place a ventriculostomy; the
EVD was placed without complication and with maintenance of
appropriate ICPs with minimal change in neurologic exam. During
her complicated medical course, her neurologic exam has
gradually deteriorated with worsening of her right sided arm and
leg weakness and decreased level of awareness (unable to obtain
attention, no longer following commands reliably). After several
days of delay due to multiple medical complications, she was
stable enough to receive an MRI of the Brain on [**2177-9-3**] which
shows multiple small right-sided ischemic infarcts (DWI bright,
ADC dark), extensive subcortical and periventricular white
matter disease, and persistence (but improvement) in the degree
of intraventricular hemorrhage. The strokes by themselves would
not explain her depressed level of consciousness, and thus an
EEG was performed due to concerns for potential status
epilepticus as she was having rhythmic eyelid contractions and
sporadic eye movements. The EEG was negative for seizure
activity. Given the patient's lack of neurologic improvement and
poor prognosis, the patient's husband opted for comfort care.
She was made CMO overnight on [**7-27**], placed on a morphine
infusion, and she passed away at 0745 on [**2177-9-5**].
[] Thrombocythemia, likely Polycythemia [**Doctor First Name **] - She is noted to
have a history of thrombocythemia per report, and per prior
records from her previous Hematologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 90792**] in
[**State 108**], she has the JAK2 mutation that is strongly suggestive
of Polycythemia [**Doctor First Name **]. We consulted Hematology-Oncology regarding
bleeding risk assessment in case the patient requires further
invasive procedures, for which it appears that her
thrombocytosis would place her at risk for both thrombosis and
hemorrhage (via acquired [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease). Heme-Onc
recommended starting Hydroxyurea to which the patient's cell
counts responded with decreases in all cell lines.
[] Pulmonary Edema, Hemodynamic Instability - On [**2177-8-28**], the
patient became progressively tachycardic, tachypneic, and
hypertensive and required more supplemental O2 to maintain her
SaO2 in the 90s in the setting of a 500cc fluid bolus given for
suspected hypovolemia in the setting of progressive tachycardia.
Her hemodynamic status normalized with metoprolol,
albuterol/ipratropium, oxygen and mild diuresis with furosemide
10 IV. This may have been related to mild volume overload in the
setting of likely COPD or beta blocker withdrawal from having
been off medications during the prehospital obtunded period.
However, her respiratory status continued to be tenuous and she
was intubated for persistent respiratory distress. She
intermittently had episodes of tachynea/tachycardia/hypoxia
without any evident cause (clear lungs to auscultation besides
upper airway sounds and secretions, no infiltrates on CXR, no
cardiac or metabolic causes) which resolved to some degree with
sedation with Propofol.
[] Fever of Unknown Origin - On [**2177-8-30**], the patient became
febrile and had blood, urine, and sputum cultures drawn, all of
which have had no growth to date. On [**9-1**], she had a CSF culture
drawn. She was started on empiric broad-spectrum antibiotics
with Cefepime and Vancomycin; these were stopped when all of her
cultures remained negative. It is possible that her fever was
central in origin and was the result of temperature regulation
dysfunction from the intraventricular hemorrhage.
[] Hypernatremia - The patient was mildly hypernatremic at
admission to the high 140s, thought to be secondary to
hypovolemic hypernatremia. In the setting of large amounts of
IVH and no ventriculostomy for decompression, she was permitted
to have mild hypernatremia to minimize cerebral edema. However,
this progressed during [**Date range (1) 10659**], and the patient was started on
NS, then 1/2NS and Furosemide to address her hypernatremia which
resolved with this treatment. She was kept normovolemic with
tube feeds at goal 100 cc/hr.
Medications on Admission:
Metoprolol succinate 25 daily
Omega 3 fatty acids (1 tablet daily)
Aspirin 81 daily (Ecotrin)
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraventricular hemorrhage, Subarachnoid hemorrhage, Acute
Ischemic Stroke, Polycythemia [**Doctor First Name **], Hypoxic Respiratory Failure
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"414.01",
"430",
"331.4",
"276.0",
"401.9",
"238.4",
"427.31",
"348.5",
"780.60",
"518.81",
"286.9",
"434.91",
"V58.66"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"96.6",
"96.72",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
12480, 12489
|
6537, 12308
|
303, 330
|
12676, 12686
|
3296, 3326
|
12738, 12836
|
2154, 2191
|
12452, 12457
|
12510, 12655
|
12334, 12429
|
12710, 12715
|
2206, 3261
|
3277, 3277
|
227, 265
|
358, 1530
|
3335, 6514
|
1552, 2055
|
2071, 2138
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,432
| 161,373
|
48193
|
Discharge summary
|
report
|
Admission Date: [**2181-6-25**] Discharge Date: [**2181-6-27**]
Date of Birth: [**2110-3-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Admit from ED for respiratory distress in setting of volume
overload
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 yo woman presenting from NH with ESRD due for dialysis today
who had acute onset of SOB at NH with O2 sat 81-89% tachypnic to
30s. She is on home O2 2L. Last HD was Friday. No CP, no back
pain.
.
In the ED, she was Tachypnic to 50s on arrival and started on
Bipap with sats 100%. She had a UTI on U/A treated with
Levoquin, Hyperkalemia to 6.5 was treated with Insulin/D50,
kayexalate. She was given 40mg IV Lasix for volume overload. She
had pulmonary edema on CXR with ? widened mediastinum. She had
Hyperkalemia treated with Insulin and D50. She was also
hypertensive to the 170s and placed on Nitro gtt. Just ptior to
transfer, BP 193/60, slightly tachypnic on bipap sating 100%.
EKG showed q waves in III and AVF. She is being admitted for
dialysis for difinitive treatment in unit.
Past Medical History:
DM II
HTN
ESRD on HD
L Hemiarthroplasty s/p L femoral neck fx
PNA
Pulm Sarcoidosis
AR
Obesity
Vent Hypertrophy
Nontoxic multinodular goiter
LUE AVF
Cystitis
Social History:
Lives at [**Hospital3 537**]. Daughter [**Name (NI) 2659**] is her HCP
Family History:
NC
Physical Exam:
PE: 96.7 64 178/61 --> 130/44 93 20 100% O2 Sats on BIPAP
Gen: AA woman on Bipap mask in NAD in bed
HEENT: Deferred (Bipap)
NECK: Supple, large, No LAD, Cannot assess JVD with Bipap mask
CV: RR, NL rate. NL S1, S2. Loud 3/6 systolic murmurs heard best
at LUSB, radiates to carotids, no rubs or [**Last Name (un) 549**]
LUNGS: Soft BL LL crackles, No W/R
ABD: Soft, NT, ND. NL BS. No HSM
EXT: 1+ edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
PSYCH: Pleasant
Pertinent Results:
[**2181-6-26**] 03:00AM BLOOD WBC-8.2 RBC-4.49 Hgb-11.9* Hct-39.4
MCV-88 MCH-26.6* MCHC-30.3* RDW-17.9* Plt Ct-210
[**2181-6-25**] 04:30AM BLOOD WBC-12.0* RBC-5.45* Hgb-14.3 Hct-49.4*
MCV-91 MCH-26.3* MCHC-29.0* RDW-17.5* Plt Ct-279
[**2181-6-25**] 04:30AM BLOOD Neuts-72.3* Lymphs-18.2 Monos-5.3 Eos-3.4
Baso-0.8
[**2181-6-26**] 03:00AM BLOOD PT-14.3* PTT-32.7 INR(PT)-1.3*
[**2181-6-26**] 03:00AM BLOOD UreaN-34* Creat-7.8*# Na-144 K-5.1 Cl-101
HCO3-29 AnGap-19
[**2181-6-25**] 06:01PM BLOOD K-3.8
[**2181-6-25**] 02:40PM BLOOD Glucose-145* UreaN-49* Creat-9.2* Na-141
K-6.8* Cl-101 HCO3-25 AnGap-22*
[**2181-6-25**] 02:40PM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2181-6-25**] 04:30AM BLOOD cTropnT-0.14*
[**2181-6-26**] 03:00AM BLOOD Calcium-9.7 Phos-5.6* Mg-2.1
[**2181-6-25**] 02:40PM BLOOD Calcium-9.4 Phos-4.7* Mg-2.6
[**2181-6-25**] 04:46AM BLOOD Lactate-3.3* K-5.8*
.
[**6-25**] CT Head: IMPRESSION: 1. No evidence of acute intracranial
hemorrhage or major vascular territorial infarct. If there is
high suspicion, MRI with DWI is more sensitive for acute
ischemia. 2. Complete opacification of the right mastoid sinus
with mild opacification of left mastoid sinus, indicating
probable chronic mastoiditis. No evidence of basilar skull
fracture.
.
[**6-26**] IMPRESSION: 1. Stable or resolving CHF. 2. Persistent
mediastinal widening warrants further evaluation with CTA of the
chest. Given multiple mediastinal calcifications, mediastinal
prominence may be related to underlying lymphadenopathy. 3.
Persistent left lung base consolidation may be related to
asymmetric pulmonary edema or an underlying consolidation. This
may also be further evaluated with CT.
.
CHEST (PA & LAT) [**2181-6-26**] 12:45 AM
CHEST (PA & LAT)
Reason: Please compare to prior film for improvement of edema
and pr
[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with ESRD admitted pre HD with respiratory
distress
REASON FOR THIS EXAMINATION:
Please compare to prior film for improvement of edema and
progression of PNA
INDICATION: 71-year-old female with end-stage renal disease
admitted pre- hemodialysis with respiratory distress.
COMPARISON: AP upright portable chest x-ray dated [**2181-6-25**].
AP SUPINE PORTABLE CHEST X-RAY: Bilateral interstitial edema is
stable or slightly decreased since prior exam. Mediastinal
widening persists, unchanged, and requires further evaluation
with cross-sectional imaging. Punctate calcifications projecting
over bilateral hila are related to prior granulomatous
infection, and could be accounting for the mediastinal widening.
Increased opacification in the left lower lobe may be related to
asymmetric pulmonary edema; however, an underlying consolidation
is not excluded. The surrounding soft tissues are unchanged.
IMPRESSION:
1. Stable or resolving CHF.
2. Persistent mediastinal widening warrants further evaluation
with CTA of the chest. Given multiple mediastinal
calcifications, mediastinal prominence may be related to
underlying lymphadenopathy.
3. Persistent left lung base consolidation may be related to
asymmetric pulmonary edema or an underlying consolidation. This
may also be further evaluated with CT.
.
CT HEAD W/O CONTRAST [**2181-6-25**] 8:58 PM
CT HEAD W/O CONTRAST
Reason: MENTAL STATUS CHANGE
[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with ESRD, sarcoid presented with hypoxia now
with ? mental status change after hypotensive episode during
hemodialysis
REASON FOR THIS EXAMINATION:
Please assess for stroke
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: End-stage renal disease and sarcoid, presenting with
mental status changes and hypotensive episode after
hemodialysis. Assess for stroke.
No prior examinations.
NONCONTRAST HEAD CT: There is no acute intracranial hemorrhage,
shift of normally midline structures, or major vascular
territorial infarct. There are chronic-appearing lacunes in the
basal ganglia, bilaterally. [**Doctor Last Name **]- white matter differentiation
is preserved. Dural calcifications are noted. There is extensive
calcification of the vertebral and cavernous carotid arteries,
related to underlying renal disease. The right mastoid air cells
and middle ear cavity are completely opacified, with a small
amount of fluid in the dorsal aspect of the left mastoid apex
and clear left middle ear; however, there is no evidence of
basilar skull fracture. The visualized paranasal sinuses are
clear.
.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or major
vascular territorial infarct. If there is high suspicion, MRI
with DWI is more sensitive for acute ischemia.
.
2. Complete opacification of the right mastoid process and
middle ear, with small amount of fluid in the left mastoid apex,
indicating probable chronic left otomastoiditis, which should be
correlated clinically.
.
No evidence of basilar skull fracture.
.
Brief Hospital Course:
ASSESSMENT: The patient is a 71 yo woman presenting with ESRD
due for dialysis today who had acute onset of SOB.
.
PLAN:
.
# Respiratory Distress: Was on Bipap on admission in setting of
volume overload. Pt underwent HD and henceforth did not require
non-invasive ventilation and returned to her baseline of 2
liters of oxygen. There was also a suggestion of a left lower
lobe pneumonia on CXR. CT Chest showed a left pleural effusion
and enlarged right mediastinal LAD that was c/w her hx of
pulmonary sarcoidosis. There was no evidence of any aortic
pathology.
A course of Levofloxacin 250 mg PO Q48 was initiated during her
stay. She was to continue to complete a 10 day course.
.
# ESRD: Pt is on q MWF HD schedule with fistula (mature) in L
arm.
- MWF HD - received dialysis (3 kilos off on Monday) and also
underwent HD on day of discharge. Captopril was held on HD days
given propensity for hypotension.
Continued nephrocaps, renagel.
.
# UTI: Found on UA in ED but cultures negative. Will be covered
by Levaquin for CAP as above.
.
# Troponin Leak: Unclear of baseline, probably [**2-16**] ESRD.
- Felt to be secondary to chronic renal insufficiency versus
acute ischemia. They remained flat in the setting of a normal
EKG.
.
# Heart murmur: The patient has moderate AS as well as TR and
mild MR seen on TTE obtained from [**Hospital1 2177**] records.
.
# Thyroid mass: Incidental note was made of a thyroid mass on
his CT scan. Please arrange for outpatient thyroid U/S and f/u.
.
# HTN: To 190s in ED. 200/100 on arrival to ICU and received
Hydral 15mg. Was on Nitro gtt in ED but this was D/C'd as BP
improved to 120s. Home BP meds added on HD#1. On Captopril 100
mg [**Hospital1 **], Norvasc 10 mg PO QD, Lopressor 50 mg PO BID.
- BP remained stable throughout the remainder of her stay.
.
# DM II: Longstanding.
- Cont'd Insulin as Humalog SS and giving home 75/25
.
# FEN: DM/Renal Diet
.
# PPx: SC heparin; PPI
.
# CODE: Presumed full
.
# COMM: With daughter [**Name (NI) 2659**] ([**Telephone/Fax (1) 101578**] who is the HCP.
.
# DISP: to [**Hospital3 537**]
Medications on Admission:
Novolin Insulin SS
Metoprolol 50mg [**Hospital1 **]
Zoloft 75mg Daily
ASA 81mg Daily
Amlodipine 10mg Daily
Captopril 100mg q T, Th, Sat, Sun (non-HD days) [**Hospital1 **]
Lipitor 80mg
Nephrocaps
Protonix 40
Colace
Ibuprofen
Pulmicort 200mcg 2 puffs [**Hospital1 **]
Renagel 800mg 3 tabs TID
Mirtazapine 15mg QHS
Senna 2 tabs QHS
1000ml Fluid restriction
Humalog 75/25 22 U Qam, 10 U qPM
Lactulose 30ml PRN
Tylenol PRN
Oxycodone 5 PRN
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4-6H (every 4 to 6 hours) as needed.
10. Captopril 25 mg Tablet Sig: Four (4) Tablet PO Q T, TH, SAT,
SUN (NON HD DAYS) [**Hospital1 **] ().
11. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
One (1) Inhalation [**Hospital1 **] (2 times a day).
12. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 7 doses.
14. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. Insulin Regular Human Subcutaneous
19. insulin
22 units humalog 75/25 in am, 10 units QHS
20. oxygen
2 liters oxygen by nasal cannula.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Fluid overload
End stage renal disease
Discharge Condition:
Stable. On 2 liters oxygen (baseline).
Discharge Instructions:
Monitor electrolytes with hemodialysis and daily weights. [**Name8 (MD) **]
MD if weight increases by > 2 kgs.
You were admitted with shortness of breath from fluid overload.
You were dialyzed and improved. Please continue to go to your
scheduled hemodialysis sessions.
Followup Instructions:
Please follow up with your nephrologist as scheduled or in 2
weeks.
Please follow up with your primary care doctor in 1 week.
Completed by:[**2181-6-27**]
|
[
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"424.1",
"403.91",
"397.0",
"599.0",
"517.8",
"486",
"135",
"276.7",
"585.6",
"428.0",
"241.1"
] |
icd9cm
|
[
[
[]
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[
"39.95"
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|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,566
| 130,299
|
3659
|
Discharge summary
|
report
|
Admission Date: [**2149-4-4**] Discharge Date: [**2149-4-5**]
Date of Birth: [**2072-3-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
hypotension s/p cardiac cath
Major Surgical or Invasive Procedure:
cardiac cath plus stenting of LAD
History of Present Illness:
77 year old male with h/o HTN, EF 45%, hyperlipidemia, PVD, CVA,
s/p right CEA, STEMI (ST depressions in V2-V6 and 1mm STE in
III, 0.5mm STE in II and avF; [**5-7**]), 3vCAD s/p CAGB x1 (Dr.
[**First Name (STitle) **] [**Name (STitle) **]; SVG-0>OM1; [**5-7**]) who was admitted for CCU
monitoring after cardiac cath with stent placement. The patient
has been symptomatic again with his typical exertional chest
pain for the last few weeks (responsive to Nitro). He was
recently ruled out for an MI during an admission from
[**Date range (1) 16589**] (also found to have ARF which resolved after IVF).
He was scheduled for an outpatient stress test on [**2149-4-3**]. The
exercise stress test was positive (6.75 minutes [**Doctor Last Name 4001**]
protocol, 66% max PHR, stopping due progressive anginal symptoms
with 9/10 arm pain radiating to the chest). The MIBI showed a
reversible defect in the lateral wall and he was sent for
cardiac cath on the day of admission.
.
A cypher stent was placed into LM/LAD. It was attempted to place
also a stent into the mid-distal LAD lesion but failed. During
the catheterization, he developed intermittent CP. His SBP went
up into the 220s and he received IV nitro. Next, the question of
a dissected LAD came up based on the angiographic image of the
wire. He received intracoronary Nitro (200 mcg) to dilate the
vessel and identify any dissection which could not be confirmed.
After this administration, his SBP dropped into the 70s and he
developed a vagal reaction with HR in upper 30s to lower 40s.
This event lasted approx 5 minutes and he responded to IV
atropin, very brief dopamine drip and IVF. There was no LOC but
some associated CP. There were transient ischemic changes during
the procedure (ST depressions in V4-V6). He was exposed to more
than 350cc of dye, about one hour of fluoro and he lost a
significant amount of blood. He received Angiomax in the cath
lab and was started on a bicarb drip. He next was transferred to
the CCU for monitoring after the above mentioned events.
Past Medical History:
Hypertension
Hyperlipidemia
Systolic CHF (EF 45%; [**5-7**])
[**5-7**]: STEMI; 3vCAD with subsequent CABG x 1
[**2138**] CVA
Carotid artery disease, s/p right CEA in [**2144**]
PVD (known bruit over right groin) with claudication
Gout
GERD
Lower back pain s/p L4-5 laminectomy
Nasal fractures, s/p surgical correction
Tonsillectomy
Social History:
100-pack-year history of smoking,and discontinued in [**2136**].
Social beer drinking (about 6 beers 3x/week). Married with four
children.
Family History:
Brother with ??????heart problems??????, died in his 40??????s.
Physical Exam:
VS: T BP 167/59 HR 59 RR 18 O2 100% RA
Gen: WDWN 77 year old male in NAD. Alert & Oriented. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Very dry MM.
Neck: Supple without elevated JVP. Right carotic bruit
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Soft, I/VI systolic murmur at apex, no rub or
gallop. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. Cold feet b/l (chronic per patient). No femoral
bruits (but reportedly known right groin bruit pre-procedure -
not audible currently with gauze/tape covering groin).
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Pre-cath EKG demonstrated normal sinus rhythm at 65 with normal
axis, normal intervals, no ST changes, old Q in III, old TWF in
aVF. Post-cath EKG showed transient ST depressions in V4-V6 (EKG
on next morning back to baseline).
.
2D-ECHOCARDIOGRAM performed on [**2148-5-20**] demonstrated: EF 45%
Pre revascularization:
1.No spontaneous echo contrast or thrombus is seen in the body
of the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. No left ventricular aneurysm
is seen. There is mild regional left ventricular systolic
dysfunction. Resting regional wall motion abnormalities include
mild hypokinesia of the mid and apical portions of the inferior
wall and the inferolateral walls.
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+) to
moderate{ 2+} mitral regurgitation is seen. There is no
pericardial effusion.
.
Post revascularization:
1. Biventricular systolic function remains unchanged.
2. Mild to moderate mitral regurgitation persists.
.
CARDIAC CATH performed on [**2148-5-15**] demonstrated:
1. Selective coronary angiography demonstrated two vessel
coronary artery disease and branch vessel disease in this right
dominant circulation. The LMCA had proximal calcification with a
30% proximal stenosis. The LAD had a 40% proximal stenosis, a
70% D1 stenosis, and 70% origin stenoses in the S1 and S2. The
LCX had a 70% hazy origin stenosis with a 70% stenosis in the
OM2. The RCA was diffusely diseased and tortuous with a 70%
proximal stenosis, and a 95% distal stenosis that involved the
origin of the PDA that was occluded.
2. Right heart catheterization demonstrated normal right and
minimally elevated left sided filling pressures with RVEDP=7
mmHg and mean PCWP=12 mmHg. Pulmonary arterial pressure was
normal. Cardiac
output and index were 7.7 L/min and 3.8 L/min/m2 respectively.
3. Left ventriculogram was not performed to reduce constrast
load.
4. Right femoral Swan Ganz catheter and femoral venous
introducing
sheath were sutured for transport to intenstive care unit.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease with branch vessel
disease.
2. Normal RV diastolic function. Minimal LV diastolic
dysfunction.
.
CARDIAC CATH [**2149-4-4**]:
1. Selective coronary angiography of this right dominant system
demonstrated three vessel CAD. The LMCA had an 80% distal
stenosis. The LAD had an 80% ostial stenosis and 70% mid-distal
tubular lesion at the takeoff of the D1. The D1, S1, and S2 all
had 80% ostial lesions. The LCX ostium was subtotally occluded.
The OM1 filled via the patent SVG and both were free of
obstructive disease. The RCA was a small vessel and had
sequential 90% stenosis at mid and distal segments. The R-PDA
was totally occluded.
2. Conduit arterial angiography revealed patent single graft
(SVG-OM1).
3. Limited hemodynamic assessment demonstrated initial severe
hypertension (up to MAP of 130 mmHg) that was successfully
treated with intravenous nitroglycerine and a brief episode of
hypotension followed by bradycardia following the administration
of 200 mcg of IC nitro. This resolved shortly with treatment.
4. Left ventriculography was deferred.
5. The lesion in the ostial LAD was predilated with a 2.5mm
balloon,
stented with a 3.0 mm Cypher stent and post dilated with a 3.5
mm
balloon with lesion reduction to 0%. The final angiogram showed
TIMI III flow with no residual stenosis, no dissection, no
perforation and no embolisation. The patient left the lab in a
stable condition.
6. The ostium of the D2 was treated with POBA using a 2.5 mm
balloon.
Final angiogarm showed normal flow, minimal residual stenoses,
no
dissection, no perforation and no angiographic evidence of
distal
embolisation. The patient left the lab in a stable condition.
7. The mid LAD lesion was treated with POBA alone using a 2.5 mm
and a 3.0 mm balloon, as no stent could be delivered. The final
angiogram
showed TIMI III flow with <50% residual stenosis, no dissection,
no
perforation and no embolisation. The patient left the lab in a
stable
condition.
.
CXR [**2149-3-21**]: Comparison with [**2148-5-24**]. Slight improvement
in the cardiac shadow size. Left ventricular configuration still
remains. Aortic mural calcifications again noted. Tiny pleural
effusion. Lower lobe atelectasis. No evidence of failure.
Osseous structures unchanged. Changes of CABG.
.
[**2148-12-6**] LE ABI??????s: Right 0.75, left 0.71. Impression: bilateral
tibial disease.
.
Exercise MIBI [**2149-4-3**]:
1. New moderate, reversible defect involving the entire lateral
wall, at the level of exercise achieved. 2. Normal left
ventricular cavity size and function. Calculated EF 49%.
.
LABORATORY DATA (see attached):
normal chem7 (Cr of 1.3 pre-cath came down to 1.0 when arrived
in the CCU). WBC 5.7, Hct 35.8 (baseline 35-40), Plt 190
Brief Hospital Course:
This is a 77 year old male with h/o HTN, hyperlipidemia, PVD,
CVA, s/p right CEA, STEMI ([**5-7**]), 3vCAD s/p CAGB x1 (Dr. [**First Name (STitle) **]
[**Name (STitle) **]; SVG-0>OM1; [**5-7**]) who was admitted for CCU monitoring
after cardiac cath with stent placement into LM/LAD, c/b
hypertensive urgency followed by hypotension and vagal reaction
with HR in high 30s after IV and intracoronary nitro
administration.
.
1) Hypotensive episode: This was likely due to a vagal reaction
after intracoronary nitro administration. Resolved after brief
dopamine drip, IVF and atropine for bradycardia.
.
2) CAD: s/p CABG x1 (Dr. [**First Name (STitle) **] [**Name (STitle) **]; SVG-0>OM1; [**5-7**]), now
s/p cypher stent to LM/LAD and failed attempt to stent
mid-distal LAD. He had intermittent CP during cath with
transient ischemic changes on EKG. A post-cath check at midnight
was without significant hematoma or changes in pulses. Midnight
Hct was stable. Pt was continued on ASA, Plavix. Integrilin drip
for continued for 18 hours after the sheath was pulled. Nitro SL
prn CP was not needed b/o abscence of CP. Cardiac enzymes were
stable. He was monitored for significant blood loss after cath
but his Hct remained stable.
.
3) Rhythm: Bradycardic event resolved after Atropine
administration in cath lab. NSR on EKG.
.
4) Pump: EF of 45% and mild regional LV dysfunction on TTE from
[**5-7**]. Systolic CHF likely secondary to HTN. He will need to
follow up with his primary care physician, [**Name10 (NameIs) **] may need a follow
up TTE as an outpatient. He should follow a salt restricted
diet.
.
5) ARF: Cr of 1.3 prior to arrival in CCU. Recent ARF also
during last admission in [**3-8**] resolving after IVF. Cr was 1.0
when arrived in CCU. Pt received about 400cc of dye load during
cath. Bicarb drip was started in cath lab. He received post-cath
hydration with HCO3 drip for 1.5L at 100cc/h followed by D5
1/2NS at 100cc/h to prevent contrast-induced nephropathy. He
will have outpatient lab work on [**Date Range 766**] to check his creatinine.
.
6) Hyperlipidemia: continue statin
.
7) HTN: Pt was hypertensive during stenting followed by
hypotensive episode after IV and intracoronary nitro
administration. Normotensive when arrived in CCU. On discharge
he was continued on his outpatient blood pressure meds
(lopressor and amlodipine).
.
8) PVD: Known bruit over right groin. S/p right CEA.
Claudication on history but palpable LE pulses. Outpatient
management recommended.
.
9) GERD: cont PPI.
.
10) FEN: Cardiac diet.
.
11) Code: Presumed full
Medications on Admission:
Aspirin 325mg daily every morning
Plavix 75mg daily every morning
Metoprolol 50mg twice a day
Zocor 40mg daily every evening
Prilosec 20mg every morning
Norvasc 5mg daily every morning
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
[**Date Range **]:*30 Tablet(s)* Refills:*3*
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Prilosec 20mg qday
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Outpatient Lab Work
Chem 7 on [**Last Name (LF) 766**], [**2149-4-7**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1. 3 vessel CAD, s/p CAGB and stenting
2. HTN
3. Bradycardic, hypotensive episode responsive to fluids,
dopamine and atropine
.
Secondary diagnosis:
1. s/p CVA
Discharge Condition:
Hemodynamically stable, no chest pain, tolerating POs, no groin
bleeding.
Discharge Instructions:
You have been admitted for a cardiac catheterization. A stent
has been placed in one of your coronary arteries. You have
experienced prolonged radiation from the procedure. If you
experience any skin changes on your back, please go to your PCP
to have them evaluated.
.
Please call your PCP for any chest pain, shortness of breath,
fever, bleeding or any other concerning symptoms.
Followup Instructions:
Please have your kidney function checked by a blood test on
[**Year (4 digits) 766**] at your PCP's office. [**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 250**]
You will also need to see Dr. [**Last Name (STitle) **] within 1-2 weeks for a
full follow up appointment.
Completed by:[**2149-4-5**]
|
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404, 2444
|
12872, 12885
|
12723, 12851
|
2466, 2800
|
2816, 2956
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,700
| 164,511
|
30345
|
Discharge summary
|
report
|
Admission Date: [**2157-5-14**] Discharge Date: [**2157-6-3**]
Date of Birth: [**2116-11-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
s/p drug overdose
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
History taken from family and outside records.
.
Mr. [**Known lastname **] is a 40 year old male who is a [**Country 2451**] war vet with PTSD
who was found by his girlfriend with a needle in his arm,
unconscious in the bathroom surrounded by emesis. EMS came and
brought him to an OSH. EMS also gave him narcan with no effect x
2. At the OSH he was given ativan, versed, and narcan and
intubated for respiratory distress. His ABG at the OSH was
7.13/90/559 on 100%FIO2, AC 500/12. Vital signs: T 98.7, BP
199/110, P 118, RR 32, 74% O2sat. They also gave him vanco,
clinda, ceftriaxone for aspiration pneumonia based on his CXR
with bilateral infiltrates. His tox screen was positive for
opiates and cocaine metabolites. He was transferred to [**Hospital1 18**] for
? ARDS.
.
In our [**Last Name (LF) **], [**First Name3 (LF) **] NGT placed and lavage done. He was given 50g of
activated charcoal in case he had another ingestion which was
unknown. His last ABG in the ED showed pH 7.17 pCO2 85 pO2 65
while on AC FIO2 100%, TV 500 R 30. He was then brought to the
ICU.
.
Upon speaking with his family, he returned from [**Country 2451**] 2 years ago
and has been depressed and obsessive since then. They feel he
has been very angry and [**Doctor Last Name 11506**] as well. 1.5 months ago he
overdosed on heroine in the VA bathroom and spent one month in
the psychiatric unit there. He was just released over 1 week
ago. His family found cocaine in his wallet today in addition to
his heroine use.
Past Medical History:
PTSD
Depression
Polysubstance abuse- heroine/cocaine
Hepatitis C -diagnosed in the early [**2140**]'s. Took interferon for
1 year which ended about 1 year ago. Told he was "in remission."
Chronic ankle pain
Hypercholesterolemia
Hypertension
Social History:
He lives with his girlfriend and is an unemployed painter. He is
a vet who returned from a tour in [**Country 2451**] 2 years ago. He quit
smoking 1.5 months ago but smoked 1.5ppd for 2 years before
that. He drinks alcohol occassionally (not recently), but
according to his family, his drug of choice is heroine. He was
sober for 3 years until a few months ago. Inciting event may
have been conversation with his father who is an addict in the
[**Country 13622**] Republic. Family describes him being obsessive. i.e.
if he starts eating, he eats non-stop. If he starts the heroine,
he does it non-stop.
Family History:
Addiction in several family members. Family denies any heart
disease, stroke, cancers, diabetes.
Physical Exam:
PE:
Vitals: T 102.3 BP 95/41 HR 134 RR 32 O2sat 95% on 100% FIO2.
AC 500, 30
General: sedated and intubated
HEENT: small pupils bilaterally, non-icteric sclera, MMM, no JVP
noted.
CV: tachycardia, no m/r/g appreciated
LUNGS: bilateral rhonchi and wheezing.
ABDOMEN: +BS, distended but soft.
EXT: no e/c/c. multiple erythematous traching marks on left arm.
multiple non-healing wounds on his bilateral lower extremities.
NEURO: sedated and non-responsive to painful stimuli
Pertinent Results:
CXR [**2157-5-14**]
Endotracheal tube at the thoracic inlet and could be advanced 1
to 2 cm for more optimal placement. Bilateral alveolar opacities
consistent with acute pulmonary edema or multifocal aspiration.
Distended air-filled stomach.
.
KUB [**2157-5-16**]
No evidence of obstruction. Ground-glass haziness of the abdomen
suggests ascites.
.
CXR [**2157-5-23**]
Bilateral pulmonary infiltrates and subsegmental atelectasis in
the left mid lung persist
Brief Hospital Course:
40 y/o male with a h/o PTSD, depression, and HTN who initally
presented to an OSH s/p heroin and cocaine overdose. He was
transferred to [**Hospital1 18**] for further evaluation and management of
respiratory failure [**3-11**] to drug overdose. The following issues
were addressed during this hospitalization.
.
# Hypercarbic/hypoxic respiratory failure
The pt was intubated [**3-11**] to both hypercarbic and hypoxic
respiratory failure. The etiology was most likely [**3-11**] to an
opioid overdose causing respiratory depression along with
subsequently diagnosed aspiration PNA. Initially, there was
concern that he may have developed an ARDS pictures and his
ventilatory settings were managed with an ARDS protocol.
However, his clinical picture and CXR were indicative of
aspiration PNA given his overdose and being found down. He was
started on broad spectrum ABx regimen consisting of vancomycin,
cefepime, and flagyl. He was gradually weaned off the ventilator
and subsequently successfully extubated. He completed a course
of vancomycin/cefepime/flagyl for 10 days and then
levofloxacin/flagyl for 4 days for a total of 2 weeks of
antibiotic treatment of his aspiration PNA.
.
# Sepsis/Hypotension/Fevers
The pt was likely septic from aspiration pneumonia. There was a
concern for bacteremia given his IVDU. However, all blood
cultures have been negative and TTE revealed no evidence of
endocarditis. Could also have bacteremia from IVDU. Therefore,
cover for gram positive and negative and anaerobes. Urine,
stool, and sputum cultures were all negative. He was given
hydrocortisone as a form of stress dose steroids empirically
which have been tapered. Hypotension and fevers resolved with
ABx therapy.
.
Prior to discharge, the pt developed fevers daily for 5 days.
Possible sources included resolving aspiration pneumonia off of
prednisone and abx, colitis, pancreatitis, endocarditis, and a
biliary infectious process. ID was consulted. LFTs were wnl, RUQ
u/s wnl, Serial blood/urine cxs all negative. Stool c. diff
negative x2, but diarrhea persists, so CT abd with contrast to
eval for colitis/occult abscess done [**6-1**] was done which was
negative. It also showed concern for septic emboli in the lungs,
but given a negative TEE on [**6-3**], the diagnosis was less likely
in speaking with the radiologist who read the CT scan. In fact,
the consolidations in the chest were improved from prior
imaging. Hep serologies- all negative, including Hep C viral
load and Hep C antibody. TSH, T4 - wnl. WBC trended down from
19.5 to 10.8. Also possible is drug fever from Seroquel, which
was decreased from 25mg to 12.5mg qhs. The patient was afebrile
for 24 hours prior to discharge. For continued diarrhea (mild),
pt was discharged on 7 day course of Flagyl. If he develops
pancreatitis (epigastric/RUQ pain radiating to the pack),
consider d/c'ing Flagyl [**3-11**] drug reaction.
.
# Pancreatitis: 6 days prior to discharge, pt developed RUQ pain
radiating to back as well as elevated amylase/lipase, concerning
for pancreatitis. Pt was made NPO and given heavy IVF, and
pancreatitis resolved within 24 hours. Pt was eating regular
diet at time of discharge. Etiology unclear, most likely
gallstone pancreatitis, but potentially [**3-11**] Flagyl as it was
discontinued at the same time pancreatitis resolved.
.
# Polysubstance abuse
Pt's family described a recent concern for suicidality and
increased recent drug use/abuse. Pt was admitted s/p heroine and
cocaine overdose. Pt had been clean for three years and had only
recently started using drugs for the past 3 days prior to
admission. Given his cocaine use, he completed a ROMI and EKGs
were only significant for Sinus tachy. TTE/TEE was WNL. Social
work and psychiatry both followed the pt.
.
# PTSD/Depression
Pt followed by social work and psychiatry. Pt was re-started on
his home anti-depressant regimen which may need to be adjusted
as outpt.
.
# HTN
Pt has a h/o HTN and was on clonidine as an outpatient. This was
held. BB were avoided given his recent cocaine use.
.
# Hepatitis C
Pt has a h/o known hepatitis C. Unclear if he received treatment
for this in the past. He is also at risk for HIV so HIV testing
was done (negative). Hepatitis serologies were negative,
including Hep C ab and Hep C viral load.
.
Medications on Admission:
Bupropion 100 mg twice a day
MVI
Naproxen 500 mg twice a day
Clonidine 0.1mg at bedtime
Diphenhydramine 50 mg at bedtime for sleep
Paroxetine 30mg in the AM and 40mg in the PM -girlfriend thinks
he's been taking both in the AM
Gabapentin 300mg three times a day- just prescribed and has not
started taking it yet
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
subcutaneous Injection TID (3 times a day).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every 4-6 hours as needed for wheezing.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation every 4-6 hours as needed for wheezing.
4. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Paroxetine HCl 20 mg Tablet Sig: 1.5 Tablets PO QAM (once a
day (in the morning)).
6. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
11. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 7 days.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnoses:
-aspiration pneumonia
-septic shock
Secondary Diagnoses:
-substance dependence
-depression/PTSD
-diarrhea
-pancreatitis
Discharge Condition:
Stable
Discharge Instructions:
You were hospitalized with an aspiration pneumonia after a
heroin overdose. You were initially in the Intensive Care Unit
and then transferred out to the floor and throughout your
hospital course your respiratory status improved. You had
persistent fevers and diarrhea which had mostly resolved before
discharge. You should take the antibiotic "Flagyl" for 7 more
days after discharge. You were discharged to the VA [**Hospital **]
[**Hospital **] Hospital where you will be in an inpatient program for
drug rehab.
.
Return to the ED or call your PCP if you have:
*difficulty breathing, chest pain
*fevers, chills, night sweats
*any new or concerning symptoms
.
Followup Instructions:
You will need to follow-up with your PCP at the VA within one
month of discharge from the VA [**Location (un) **] facility.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2157-6-3**]
|
[
"785.52",
"518.81",
"401.9",
"719.47",
"577.0",
"272.0",
"304.70",
"V62.84",
"584.9",
"560.1",
"309.81",
"787.91",
"311",
"995.92",
"507.0",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.34",
"38.93",
"96.6",
"88.72",
"00.17",
"38.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9599, 9614
|
3876, 8170
|
332, 357
|
9797, 9806
|
3392, 3853
|
10516, 10791
|
2786, 2884
|
8533, 9576
|
9635, 9690
|
8196, 8510
|
9830, 10493
|
2899, 3373
|
9711, 9776
|
275, 294
|
385, 1886
|
1908, 2150
|
2166, 2770
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,961
| 133,559
|
37526
|
Discharge summary
|
report
|
Admission Date: [**2105-10-22**] Discharge Date: [**2105-10-27**]
Date of Birth: [**2042-1-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
cornary artery disease
Major Surgical or Invasive Procedure:
Coronary artery bypass grafts
x4(LIMA-LAD,SVG-Dg,SVG-PDA-PLV)[**2105-10-23**]
History of Present Illness:
This 63 year old white male without significant past medical
history developed chest pain and shortness of breat in [**Month (only) 359**]
when resuming recreational basketball as he does fall and
spring. This resolved quickly with rest. A stress
echocardiogram was positive for posterior ischemia. An elective
catheterization on [**10-23**] revealed significant coronary
disease and he was transferred here for surgery in stable
condition, painfree.
Past Medical History:
Herniorraphy
gastroesophageal reflux
Social History:
Works at a dairy
Nonsmoker
rare ETOH use
lives with his wife
Family History:
Uncle died at age 59 of an infarction
Physical Exam:
Admission:
Pulse:80 Resp:14 O2 sat:
B/P Right:132/80 Left: 130/80
Height: Weight:172lb.
General:WDWN, NAD
Skin: Dry [y] intact [y]
HEENT: PERRLA [y] EOMI [y]
Neck: Supple [y] Full ROM [y]
Chest: Lungs clear bilaterally [y]
Heart: RRR [y] Irregular [] Murmur none
Abdomen: Soft [y] non-distended [y] non-tender [y] bowel sounds
+ [y]
Extremities: Warm [y], well-perfused [y] Edema Varicosities:
None [n]
Neuro: Grossly intact
Pulses:
Femoral Right:3 Left:3
DP Right:3 Left:3
PT [**Name (NI) 167**]:3 Left:3
Radial Right:3 Left:3
Carotid Bruit Right: N Left:N
Pertinent Results:
[**2105-10-26**] 07:00AM BLOOD WBC-8.7 RBC-3.11* Hgb-9.5* Hct-27.9*
MCV-90 MCH-30.7 MCHC-34.2 RDW-15.6* Plt Ct-171
[**2105-10-25**] 03:28AM BLOOD WBC-9.2 RBC-3.34* Hgb-10.3* Hct-29.4*
MCV-88 MCH-30.7 MCHC-34.9 RDW-15.8* Plt Ct-162
[**2105-10-26**] 07:00AM BLOOD Glucose-122* UreaN-31* Creat-0.8 Na-140
K-3.8 Cl-101 HCO3-34* AnGap-9
[**2105-10-25**] 03:28AM BLOOD Glucose-142* UreaN-21* Creat-0.8 Na-137
K-4.0 Cl-103 HCO3-30 AnGap-8
[**2105-10-26**] 07:00AM BLOOD Mg-2.6
[**2105-10-22**] 06:50PM BLOOD %HbA1c-5.7
[**2105-10-24**] 09:45AM BLOOD Type-ART Temp-38.2 PEEP-5 FiO2-40 pO2-104
pCO2-47* pH-7.35 calTCO2-27 Base XS-0 Intubat-INTUBATED
Vent-SPONTANEOU
Brief Hospital Course:
Following admission he remained stable. The usual preoperative
labs and CXR were done. On [**10-24**] he went to the Operating Room
where revascularization was performed uneventfully. He weaned
from bypass on insulin, Propofol and Phenylephrine infusions.
He remained stable form a cardiovascular standpoint but had
significant CT drainage with normal coagulation labs. Platelet
transfusion, Protamine and FFP were given, drainage slowed and
stopped. he did not require reoperation. He was kept sedated
overnight.
On POD 1 his sedation was stopped, the ventilator was weaned and
he was extubated. A CXR was clear, there was minimal CT
drainage and CTs were removed. He was begun on beta blockers,
his statin was resumed and diuresis begun.
He had a brief episode of rapid atrial fibrillation on POD 2
which resolved with a small dose of IV Lopressor. His temporary
pacing wires were removed on POD 3 and ambulation progressed.
Physical Therapy worked with him for mobility and strength.
His wounds were clean and healing well, he was tolerating a diet
and he was ready for discharge on POD 4. Instructions,
precautions, medications and follow up were discussed with him
prior to discharge.
Medications on Admission:
omeprazole 20mg daily
New at transfer:
ASA 81 mg daily
Simvastatin 40mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily) for 4 weeks.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Personal Touch
Discharge Diagnosis:
coronary artery disease
gastroesophageal reflux
s/p inguinal herniorraphy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]): Tuesday, [**2105-11-24**]
at 1:30 PM
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks ([**Telephone/Fax (1) **]) Your nurse will
make an appointment
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 76130**] in 2 weeks ([**Telephone/Fax (1) 84264**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39975**] in [**12-23**] weeks ([**Telephone/Fax (1) 66607**])
please call for appointments
Completed by:[**2105-10-27**]
|
[
"790.01",
"530.81",
"414.01",
"411.1",
"E878.2",
"998.11",
"276.8",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
4676, 4721
|
2442, 3645
|
345, 425
|
4838, 4934
|
1761, 2419
|
5475, 6012
|
1062, 1101
|
3774, 4653
|
4742, 4817
|
3671, 3751
|
4958, 5452
|
1116, 1742
|
283, 307
|
453, 908
|
930, 968
|
984, 1046
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,030
| 107,207
|
16226
|
Discharge summary
|
report
|
Admission Date: [**2133-9-16**] Discharge Date: [**2133-10-5**]
Date of Birth: [**2067-3-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Pt has a persistant and slight growth increase in a spiculated
nodule in the right upper lobe. This was PET positive, with no
evidence for
distant metastatic disease.
He was admitted for bronch, med and right upper lobectomy via
right thoracotomy.
Major Surgical or Invasive Procedure:
right upper lobe lobectomy, chest tube placement, doxycycline
pleurodesis
History of Present Illness:
Mr. [**Known lastname 9464**] is a 66-year-old gentleman with
multiple medical problems including coronary artery disease,
dysrhythmias, and a mixed obstructive and restrictive lung
process. He was seen earlier this summer with an infiltrative
nodule in the right upper lobe, associated with infectious
symptomatology. He was treated aggressively and an interval
followup showed resolution of the pneumonitis, but
persistence and slight growth in a spiculated nodule in the
right upper lobe. This was PET positive, with no evidence for
distant metastatic disease.
Past Medical History:
PMH: CLL dx [**2131**]
Renal Cell carcinoma, followed by serial CT scans, next [**Month (only) **]
[**2132**]
COPD
CAD s/p MIx2, stent
Chronic back pain
Vision impairment
Postoperative neuralgia, responsive to nortriptyline
Bell's palsy giving L facial droop.
Social History:
Lives in [**Location 1456**], MA with girlfriend. Retired police officer,
worked in security / alarm company. Currently retired.
Significant tobacco history, now quit. Rare social alcohol.
Sedentary lifestyle.
Family History:
Brother and sister with lung CA, mother CAD
Physical Exam:
General; well appearing 66 yr old male in NAD.
HEENT: non-focal
COR: RRR S1S2
Lungs: CTA bilat
abd: soft, NT, ND, +BS
Extrem: no c/c/e
Neuro: A+OX3- no focal findings.
Pertinent Results:
[**2133-9-16**] 02:55PM GLUCOSE-125* UREA N-19 CREAT-1.0 SODIUM-141
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14
[**2133-9-16**] 02:55PM CALCIUM-8.2* PHOSPHATE-4.3 MAGNESIUM-1.6
[**2133-9-16**] 02:55PM WBC-22.4*# RBC-4.91 HGB-15.2 HCT-45.3 MCV-92
MCH-30.9 MCHC-33.5 RDW-13.6
CHEST (PA & LAT) [**2133-10-2**] 10:58 AM
CHEST (PA & LAT)
Reason: interval chnage in PTX
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with s/p thorocotomy, 2 right CT's-posterior
tube clamped/ anterior tube to water seal.
REASON FOR THIS EXAMINATION:
interval chnage in PTX
HISTORY: Chest tubes clamped and/or to water seal.
Lateral and two frontal chest radiographs. Since examination 24
hours earlier on previous day, the more posterior of the two
right chest tubes has been removed. The large right pneumothorax
is unchanged in size and appearance with no focal mass and
probably no consolidation in secondarily collapsed lung. Heart
is normal in size with tortuous aorta. Clear left lung without
vascular congestion. No effusions identified. Right subcutaneous
emphysema.
IMPRESSION: Removal right chest tube with otherwise no change.
Specifically, the large right PTX is unchanged.
cardiac echo;
Conclusions:
The left atrium is elongated. Left ventricular wall thicknesses
are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic
function is mildly depressed. Resting regional wall motion
abnormalities
include inferolateral akinesis/hypokinesis (the apex is not
fully visualized).
Right ventricular chamber size and free wall motion are normal.
The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation
is seen. The estimated pulmonary artery systolic pressure is
normal. There is
no pericardial effusion.
Compared with the report of the prior study (tape unavailable
for review) of
[**2133-4-7**], regional wall motion is probably similar.
Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD on [**2133-9-24**] 17:49.
Brief Hospital Course:
Pt was admitted on [**2133-9-16**] for bronch, med and right upper
obectomy via right thoracotomy.
Operative course was notable for raw parenchyma along the
sharply developed right minor fissure was oversewn with 2
layers of Prolene. 2 right chest tubes were placed and connected
to sxn with continuous air leaks d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] parenchyma.
Post operative course was complicated by persistant air leaks,
secretions requiring serial bronchs, and afib. These air leaks
were prolonged and pt was unable to tolerate water seal. Chest
tubes were doxycyclined x 3. After approx 2 weeks, pt was able
to [**Last Name (un) 1815**] clamping of one chest tube which was removed and the
remaining chest tube was placed to a hemlick valve with a
continued but slow leak upon discharge.
Pt initially required serial bronch's to clear secretions and
was started on augmentin for PNA.
AFIB: post operative afib was managed with amiodarone and
lopressor. Pt was subsequently admitted to the CCU for severe
bradycardia. Pt's amiodarone and lopressor were d/c'd. His heart
rate stabilized and his afib remained rate controlled without
beta blocker. He was started on anticoagulation -lovenox with
bridge to coumadin. His INR on d/c was 2.1. His primary care,
Dr. [**Last Name (STitle) 7790**] will follow his INR. His lisinopril was resumed as
prior to admission for BP control.
Pain: was initially controlled w/ epidural, transitioned o PCA
then to po percocet w/ good relief.
He was [**Last Name (un) 1815**] reg diet, ambulating w/ walker and remained O2
dependent.
He was d/c'd to home w/ VNA follow up.
Medications on Admission:
xanax, ASa, combivent, lipitor, lisinopril, nortriptyline
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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 puffer* Refills:*2*
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*5 Patch 24HR(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed for chest tube prophylaxis.
Disp:*30 Capsule(s)* Refills:*0*
12. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
right upper lobe lobectomy for lung cancer, persistent air leak,
atrial fibrillation.
Discharge Condition:
stable
right chest tube to hemlick valve
Discharge Instructions:
please resume all your preoperative medications. You can return
to your regular diet. You may shower.
Call Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 46290**] if you have fever, chills, sweats,
nausea, vomiting, shortness of breath, wound redness or drainage
or if your chest tube or valve are no longer functioning. DO NOT
OCCLUDE THE VALVE AT THE END OF THE CHEST TUBE.
Your primary care doctor will monitor your anticoagulation. You
must have your blood drawn on [**10-6**] by the visiting nurse. If
you experience a headache, change in vision or a trauma to your
head you must present to the emergency room immediately. Please
be careful to not injury yourself because you are at high risk
of bleeding due to the anticoagulation.
Followup Instructions:
please follow up with Dr. [**Last Name (STitle) **] on tuesday [**10-13**] at 3:30pm
in the [**Hospital Ward Name 23**] clinical center. Please arrive 45 minutes prior
to your appointment and report to [**Hospital Ward Name 23**] clinical center [**Location (un) **] radiology for a Chest XRAY. Please follow up with your
primary care physician to have your INR checked. The VNa will
check your INR on tuesday [**10-6**].
Completed by:[**2133-10-6**]
|
[
"512.1",
"482.30",
"997.3",
"427.32",
"162.3",
"997.1",
"451.84",
"427.31",
"999.2",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.4",
"34.92",
"32.29",
"96.05",
"34.22",
"40.11"
] |
icd9pcs
|
[
[
[]
]
] |
7637, 7686
|
4160, 5799
|
569, 645
|
7816, 7859
|
2019, 2404
|
8650, 9104
|
1771, 1816
|
5907, 7614
|
2441, 2545
|
7707, 7795
|
5825, 5884
|
7883, 8627
|
1831, 2000
|
282, 531
|
2574, 4137
|
673, 1238
|
1260, 1523
|
1539, 1755
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,152
| 172,615
|
50220
|
Discharge summary
|
report
|
Admission Date: [**2148-12-6**] Discharge Date: [**2148-12-9**]
Date of Birth: [**2073-4-5**] Sex: M
Service: MEDICINE
Allergies:
Indocin
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
colonoscopy and EGD on [**2148-12-7**]
History of Present Illness:
Mr. [**Known lastname 104752**] is a 75 y/o M w/ a PMH that includes UGI bleed in
[**2141**], GI bleed in [**2145**], HTN, hyperlipidemia, diverticulosis,
chronic renal insufficiency (baseline 1.7-2.1), who presented to
the ED on [**2148-12-6**] with BRBPR. The patient first noted bleeding
the day of admission. His first bowel movement filled the toilet
with blood. He then had one further bloody bowel movement and in
the evening diarrhea with more blood and decided to come to the
ER. No melena. No abdominal pain or cramps. No nausea or
vomiting. Patient of noted had a UGI bleed in [**2141**] secondary to
a gastric ulcer while on indomethacin for gout. He was also
admitted with melanotic stools in [**2145**], but his EGD did not show
any evidence for UGI bleed and his colonoscopy at that showed
only diverticulosis.
Currently the patient is not using any NSAIDS but was on a baby
aspirin prior to admission.
In ED, the patient's NG lavage was negative, he was
hemodynamically stable and was admitted to the floor with a
hematocrit of 36. While on the floor he had a large maroon stool
with orthostatic hypotension, he was transferred to the [**Hospital Unit Name 153**]. A
tagged red cell scan was negative. His hematocrit iniitally went
from 36-->31-->30 but dropped to 25.1 after bowel prep for
colonoscopy and he received 1 U PRBCs. On [**12-7**], his EGD showed
only polyp in the fundas and some erythema in the antrum and
stomach body, his colonoscopy showed a sessile polyp and
multiple diverticuli in the sigmoid and descending colon, no
blood in colon or terminal ileum. The patient's hematocrit has
remained stable since the one unit of blood and he has had no
further bleeding. He has not had another bowel movement since
the prep. He denies any current abdominal pain, chest pain,
shortness of breath. He does feel somewhat anxious.
Past Medical History:
1. HTN
2. H/o gastric ulcer and UGI bleed in [**2141**] while on NSAIDS
3. GI bleed in [**2145**], possibly secondary to diverticulosis
4. depression
5. hyperlipidemia
6. gout
7. glaucoma
8. squamous cell skin ca removed from ear and leg
9. h/o thrombocytopenia
Social History:
Lives in [**Location 2624**] with his wife. Is a retired vending machine
business owner. Has two sons. Quit cigarettes 20 years ago.
Drinks one beer per day.
Family History:
Son has diverticulosis.
Mother had type 2 diabetes mellitus.
Father had MI in his 60s.
Aunt had type 2 diabetes mellitus.
No colon cancer, IBD.
Physical Exam:
PE: (on transfer from [**Hospital Unit Name 153**] to floor)
VS: T AF HR 55 BP 127/64 RR 17 98% RA
GEN: thin male, NAD, pleasant
HEENT: mmm, PERRL
NECK: supple, JVP flat
CV: RRR S1S2 no mrg
LUNG: CTA b/l
ABD: soft, nt,nd, bs+
EXT: no edema, DPs 1+ b/l, warm and well perfused, no edema
Pertinent Results:
Hematocrit:
[**12-6**]: 36-->31-->30-->30
[**12-7**]: 25-->25-->24-->29-->29-->28 (received 1 U PRBC on this
day)
[**12-8**]: 26.7--> 29.3
INR 1.1
Na 140 L 3.3 Cl 112 CO2 25 BUN 13 Cr 1.9 Glu 132
Ca 7.8 Mg 1.5 Phos 2.2
[**12-7**] EGD: polyp in fundus, no evidence bleeding, erythema in
the antrum and stomach body
[**12-7**] colonsocopy: no blood in colon or terminal ileum,
diverticulosis of the sigmoid colon and ascending colon, polyp
at 45 cm in the descending colon
Tagged cell scan [**12-7**]: IMPRESSION: Delayed static views of the
pelvis suggestive of a possible source of gastrointestinal
bleeding within the rectum, and clinical correlation with direct
visualization of this area is recommended.
Brief Hospital Course:
GI bleed: This GI bleed was thought to be secondary to
diverticulosis. The patient was admitted to the floor initially
but then had a large bloody bowel movement and was
orthostatically hypotensive and was therefore transferred to the
[**Hospital Unit Name 153**]. There he was monitored. He was never really
hemodynamically unstable. His hct eventually dropped to 25 and
he received 1 U PRBCs. He underwent a tagged RBC scan which was
negative though there was a question of bleeding in the rectum.
He underwent colonoscopy which showed a sessile polyp that was
not biopsied and diverticulosis, no blood. His EGD showed
erythema in the stomach. He had no further GI bleeding and his
hematocrit remained stable at 30. He was advanced to a regular
diet without problems. [**Name (NI) **] was transferred to the floor and
monitored overnight. Plan is for f/u c-scope in [**3-20**] weeks to
biopsy the sessile polyp. He is also to start fiber at home. He
will have a repeat hematocrit next week with his PCP. [**Name10 (NameIs) **] ASA
will be held on discharge as well.
.
2. CRI: This is presumably from hypertension. His baseline
creatinine is 1.7-2.0 and her remained within this range during
this admission
.
3. HTN: His Norvasc was held during this admission, restarted on
d/c.
.
4. Thrombocytopenia: Patient reports this is chronic and that
his PCP has not been concerned about it. Plts were initially 113
but then dropped to the 70s after his bleeding episodes, and
this was likely related to the bleeding itself. Heparin products
were held. WEre again in the 100s on last day of discharge. GI
recommended that he get a RUQ ultrasound to look at spleen and
liver as an outpatient.
5. Depression: He was continued on lexapro and klonopin.
.
6. He was full code.
Medications on Admission:
Lexapro
Klonopin
ASA 81 mg
Norvasc
Prilosec
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic QD ().
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Outpatient Lab Work
Please have hematocrit and platelets drawn on [**12-11**] or [**2148-12-12**]
at your PCP's office.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
GI Bleed
Secondary:
Thrombocytopenia
Discharge Condition:
Good
Discharge Instructions:
1. Continue on your home medications but do not restart your
aspirin.
2. Restart fiber -- you can take metamucil or Fibercon (a pill)
once daily.
3. Get your hematocrit checked next week (by Thursday) at your
PCPs to ensure stability.
.
If you experience recurrent bloody or black stools, abdominal
pain, chest pain, or other concern
Followup Instructions:
You have the following appointment scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Date/Time:[**2149-4-8**] 3:15
You should also call Dr.[**Name (NI) 13540**] office ([**Telephone/Fax (1) 4971**] to
schedule a colonoscopy in [**3-20**] weeks.
You should f/u with your PCP this week for a hematocrit check.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"401.9",
"287.5",
"276.50",
"211.1",
"585.9",
"211.3",
"274.9",
"V10.83",
"562.12",
"285.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.23",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6342, 6348
|
3876, 5644
|
272, 312
|
6438, 6445
|
3140, 3853
|
6827, 7283
|
2673, 2818
|
5738, 6319
|
6369, 6417
|
5670, 5715
|
6469, 6804
|
2833, 3121
|
227, 234
|
340, 2197
|
2219, 2482
|
2498, 2657
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,315
| 179,847
|
53576
|
Discharge summary
|
report
|
Admission Date: [**2160-8-30**] Discharge Date: [**2160-9-9**]
Date of Birth: [**2090-9-12**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Codeine / Demerol
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic appendectomy
History of Present Illness:
69 year old female, presenting with 24-hr history of RLQ
abdominal pain, constant, slowly progressive up to [**2158-9-19**] in
the ED. Denies any nausea/vomiting, but refers some subjective
fevers and chills. Her last bowel movement was last night and
normal. Has been passing flatus/BMs without problems.
Past Medical History:
migraines, HTN, hypercholesterolemia,
depression, osteoporosis, PICA aneurysm, cholelithiasis,
bleeding
ulcer, h/o SBO & distal SB wall thickening, diverticulosis
Past Surgical History: MVR [**2158**] (porcine), BTL
Social History:
lives alone, retired, denies Tob, +EtoH (wine with dinner once a
week)
Family History:
NC
Physical Exam:
On admission:
Temp: 98.7 HR: 74 BP: 122/67 Resp: 18 O(2)Sat: 100 Normal
Constitutional: Comfortable
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, significant tenderness to palpation in the
right lower quadrant, positive Rovsing's, no rebound or
guarding, not rigid
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mentation
On discharge:
Vitals: 97.9 po, HR 106, BP 114/64, RR 18, 96% on room air.
Neuro: AAO x 3. NAD. Pleasant.
Card: S1, S2. No m/r/g. Intermittent irregular beats.
Pulm: Clear bilaterally in full lung fields (anteriorly).
GI: Active BS. Abdomen softly distended, non-tender.
GU: Voiding frequently. Low post-void residuals [**Name8 (MD) **] RN. UA
clean. No subjective feelings of dysuria, burning.
Extrem: Warm, dry, well-perfused.
Pertinent Results:
[**2160-8-30**] 01:15PM BLOOD WBC-17.3*# RBC-4.82 Hgb-14.7 Hct-43.9
MCV-91 MCH-30.6 MCHC-33.5 RDW-12.4 Plt Ct-242
[**2160-8-31**] 06:05AM BLOOD WBC-5.0# RBC-4.11* Hgb-12.5 Hct-37.9
MCV-92 MCH-30.4 MCHC-33.0 RDW-12.6 Plt Ct-164
[**2160-9-8**] 01:29AM BLOOD WBC-11.0 RBC-3.71* Hgb-11.1* Hct-34.3*
MCV-93 MCH-29.9 MCHC-32.3 RDW-13.1 Plt Ct-356
[**2160-8-30**] 01:15PM BLOOD Neuts-85.2* Lymphs-9.9* Monos-4.5 Eos-0.1
Baso-0.3
[**2160-9-4**] 03:49AM BLOOD Neuts-81.9* Lymphs-11.9* Monos-4.1
Eos-1.8 Baso-0.3
[**2160-8-30**] 01:15PM BLOOD Glucose-118* UreaN-10 Creat-0.8 Na-136
K-3.7 Cl-99 HCO3-24 AnGap-17
[**2160-8-31**] 06:05AM BLOOD Glucose-172* UreaN-8 Creat-0.7 Na-137
K-3.7 Cl-106 HCO3-21* AnGap-14
[**2160-9-8**] 01:29AM BLOOD Glucose-97 UreaN-8 Creat-0.5 Na-137 K-3.6
Cl-104 HCO3-23 AnGap-14
CT abd/pelv [**2160-9-6**]: 1. Prior appendectomy for perforated
appendicitis with presence of multiple rim enhancing collections
within the abdomen as above. Right lower quadrant abscess which
is adjacent to the suture line demonstrates internal locules of
gas and is amenable to percutaneous drainage. 2. Imaging
findings consistent with diffuse peritonitis. 3. There is no
pneumoperitoneum. 4. Mildly dilated loops of small bowel
without transition point. There is no pneumatosis or portal
vein gas.
Brief Hospital Course:
Ms. [**Known lastname 110096**] was initially admitted to the floor for management
of her abdominal pain and concern for ileus vs obstruction. She
was then transferred to the ICU when she went into afib w/ RVR
and became unstable on the floor. She had progressive abdominal
pain, guarding, and tachycardia to 140s in afib. She was given
diltiazem and metoprolol on the floor with minimal reponsive.
She was transferred to the SICU. She responded to diltiazem 25
mg total and her heart rate decreased from 140s to 90s. However,
her tachycardia persisted and she was placed on neo early
morning [**9-1**]. She was cardioverted with amiodarone. She did well
and was transitioned to intermittent IV lopressor on [**2160-9-2**].
She stayed in sinus rhythm throughout the day on IV lopressor
and was transferred to the floor on the evening of [**9-2**].
Overnight, however, she again went into afib with RVR; she was
given additional doses of lopressor without success. On the
morning of [**9-3**] she was transferred back to the ICU. She was
cardioverted again and started on an amiodarone drip. This
effectively rate controlled her; she was then transitioned to a
diltiazem drip with PO amiodarone doses. On [**9-4**] she began
passing flatus and tolerated sips of liquids with her
medications. On [**9-5**] she spontaneously converted to sinus and
was weaned off the diltiazem drip. Her heart rate remained in
sinus rhythm in the 70's-80's on oral amiodarone and oral
diltiazem. She continued to pass flatus and was advanced to
clear liquids, which she tolerated well. She had a CT scan on
[**9-6**] that showed multiple pelvic collections. IR placed a drain.
She was advanced to a regular diet and tolerated that well. She
worked with physical therapy.
Medications on Admission:
METOPROLOL TARTRATE 50', NITROGLYCERIN 0.4mg prn, OMEPRAZOLE
20mg'', SIMVASTATIN 20, ASA 325, CALCIUM CARBONATE-VITAMIN D3
600 mg (1,500 mg)-200 unit daily, multivitamin daily, Topamax
25mg two tabs qhs
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
perforated appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Discharge Instructions:
ACTIVITY:
- Do not drive until you have stopped taking narcotic pain
medicine and feel you could respond in an emergency.
- [**Male First Name (un) **]??????t lift more than [**11-24**] pounds for 6 weeks.
- You may start some light exercise when you feel comfortable.
- You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
YOUR INCISION:
- Your incision may be slightly red around the stitches or
staples. This is normal.
- You may gently wash away dried material around your incision.
- Do not remove steri-strips for 2 weeks.
- It is normal to feel a firm ridge along the incision. This
will go away.
- You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
- Over the next 6-12 months, your incision will fade and become
less prominent.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as ??????soreness.??????
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your [**Name2 (NI) 5059**].
- It is important you take your pain medicine as directed. Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
- Your pain medicine will work better if you take it before your
pain gets too severe.
- If you are experiencing no pain, it is OK to skip a dose of
pain medicine.
- To reduce pain, remember to exhale with any exertion or when
you change positions.
DRAIN CARE:
You should continue to keep your drain in place until follow-up.
Please record the output of the drain each day. You can flush
the drain with 5cc of normal saline once a day so that the drain
does not get clogged. Bring the output records to your next
clinic appointment.
Followup Instructions:
Please follow-up with [**Hospital 2536**] clinic 1-2 weeks after your discharge.
Call to make an appointment: [**Telephone/Fax (1) 600**]
Completed by:[**2160-9-9**]
|
[
"346.90",
"560.1",
"E878.6",
"V42.2",
"540.0",
"997.1",
"272.0",
"427.31",
"997.49",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"47.01",
"38.91",
"54.91",
"99.61",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
5372, 5469
|
3366, 5119
|
305, 332
|
5537, 5537
|
2035, 3343
|
7610, 7778
|
1014, 1018
|
5490, 5516
|
5145, 5349
|
5688, 5688
|
877, 909
|
1033, 1033
|
1586, 2016
|
5721, 7587
|
251, 267
|
360, 668
|
1048, 1571
|
5552, 5664
|
690, 854
|
925, 998
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,874
| 139,353
|
9233
|
Discharge summary
|
report
|
Admission Date: [**2111-5-9**] Discharge Date: [**2111-5-10**]
Date of Birth: [**2082-6-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 31710**] is a 28 year old female with type I DM who presents
to MICU for diabetic ketoacidosis.
Her history of type I DM dates back to when she was 3 years old;
at 18 years of age she started using an insulin pump for Humalog
administration. She has micro-retinopathy but no other
complications of diabetes. Her only hospitalization was several
years ago for cellulitis. She has never previously had diabetic
ketoacidosis. She is followed at [**Last Name (un) **].
Other past medical history includes hypothyroidism, diagnosed at
age 6, and depression.
One night prior to admission, she went out to eat with her
friends to celebrate finishing her [**Name (NI) **]. She had not eaten all
day and that evening she had a lot of appetizers and several
shots of vodka. Returning home, she checked her blood sugar
which was near 400. She gave herself humalog through her
insulin pump at a level slightly below what it recommended
because she knew alcohol tends to induce hypoglycemia. However,
in the morning, she awoke with vomiting and a blood sugar near
400. Between this morning and 2 PM today she had several
episodes of emesis with [**Name (NI) 6801**] ranging from 300 to >400. She
was unable to tolerate POs. Her parents brought her to the ED.
In the ED, she had repeated emesis but denied abdominal pain or
diarrhea. Her serum glucose was 500, pH was 7.15, lactate was
5, and WBC count was 19. Urine ketones were found. Her anion
gap was 32. She had a good mental status and was not
hypotensive. She received 10 units regular insulin, was started
on an insulin drip at a rate of 5 cc/hr and received a 2 L fluid
bolus. Potassium was 4.6 and she was supplemented with 40 mEq.
She complained of chest pain which resolved in 30 min; EKG
revealed mild ST depressions in infero-lateral leads. Insulin
pump was turned off.
She denied any recent infections. Chest x-ray revealed no acute
pulmonary process and urine was bland. No urine pregnancy test
was performed. Review of systems only positive for nausea and
emesis.
Past Medical History:
1. type I DM with no complications and no prior DKA history
2. hypothyroidism
3. depression
Social History:
Lives in [**Location **], recently completed her [**Location **] at BC. No
smoking history, occasional social alcohol use 2X / wk.
Family History:
No history of type I DM in her family
Physical Exam:
VS: HR 120, temp 98, RR 12, 118/66, 98% RA
Gen: Caucasian female in no apparent distress
Cardiac: Nl s1/s2 RRR no murmurs appreciable
Pulm: clear to auscultation bilaterally
Abd: soft, nontender, nondistended with normoactive bowel sounds
Ext: no edema noted
Pertinent Results:
CBC:
[**2111-5-9**] 02:50PM BLOOD WBC-15.0*# RBC-5.20 Hgb-15.8 Hct-52.2*
MCV-100*# MCH-30.3 MCHC-30.2* RDW-13.1 Plt Ct-410
[**2111-5-9**] 06:00PM BLOOD WBC-19.4* RBC-4.79 Hgb-14.6 Hct-49.5*
MCV-104* MCH-30.4 MCHC-29.4* RDW-13.0 Plt Ct-287
[**2111-5-10**] 08:07AM BLOOD WBC-15.0* RBC-4.44 Hgb-13.5 Hct-42.8
MCV-96# MCH-30.4 MCHC-31.5 RDW-13.3 Plt Ct-323
[**2111-5-9**] 02:50PM BLOOD Neuts-87.3* Lymphs-10.7* Monos-1.5* Eos-0
Baso-0.5
Electrolytes:
[**2111-5-9**] 02:50PM BLOOD Glucose-503* UreaN-25* Creat-1.3* Na-140
K-4.6 Cl-95* HCO3-13* AnGap-37*
[**2111-5-9**] 08:00PM BLOOD Glucose-160* UreaN-17 Creat-1.0 Na-142
K-4.8 Cl-110* HCO3-16* AnGap-21*
[**2111-5-10**] 08:07AM BLOOD Glucose-141* UreaN-10 Creat-0.8 Na-137
K-3.9 Cl-110* HCO3-20* AnGap-11
[**2111-5-10**] 03:32PM BLOOD Glucose-256* UreaN-9 Creat-0.8 Na-138
K-3.9 Cl-105 HCO3-21* AnGap-16
[**2111-5-9**] 08:00PM BLOOD Calcium-8.1* Phos-2.2* Mg-1.8
[**2111-5-10**] 03:32PM BLOOD Calcium-8.4 Phos-1.3* Mg-1.8
VBG:
[**2111-5-9**] 03:02PM BLOOD Type-[**Last Name (un) **] pO2-59* pCO2-36 pH-7.15*
calTCO2-13* Base XS--15 Comment-GREEN TOP
[**2111-5-9**] 09:10PM BLOOD Type-[**Last Name (un) **] pO2-84* pCO2-27* pH-7.32*
calTCO2-15* Base XS--10
[**2111-5-10**] 03:13AM BLOOD Type-[**Last Name (un) **] pO2-52* pCO2-35 pH-7.34*
calTCO2-20* Base XS--5
Lactate:
[**2111-5-9**] 03:02PM BLOOD Lactate-5.0*
[**2111-5-9**] 09:10PM BLOOD Lactate-1.1
[**2111-5-10**] 03:13AM BLOOD Lactate-1.2
Hemoglobin A1c:
[**2111-5-9**] 07:44PM BLOOD %HbA1c-PND
Urine:
[**2111-5-9**] 02:50PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.019
[**2111-5-9**] 02:50PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2111-5-9**] 02:50PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
[**2111-5-10**] 12:57AM URINE UCG-NEG
CXR [**2111-5-9**]:
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
28 year old female with type I DM who presents to MICU for
diabetic ketoacidosis
# Diabetic Ketoacidosis: Pt presented with hyperglycemia,
acidosis with anion gap, and ketones in urine consistent with
diabetic ketoacidosis. This was likely triggered by dietary
indiscretions on night prior to admission coupled with
underdosing of insulin with her insulin pump. There were no
ostensible sources of infection. U/A did not show evidence of
infection and CXR did not show pneumonia. She was placed on
insulin drip and given IV fluid hydration. Hyperglycemia
resolved and anion gap closed. Electrolytes were repleted as
needed. She was seen by [**Last Name (un) **] consult. She was continued on
insulin pump and was tolerating po's. Blood [**Last Name (un) 6801**] were in 200s
by time of discharge. She was advised to follow up with her
[**Last Name (un) **] doctor [**First Name (Titles) **] [**Last Name (Titles) 6801**] continued to be elevated. Hemoglobin
A1c was pending by time of discharge
.
# Leukocytosis: WBC was 15-19. Per above, there were no
ostensible sources of infection. She remained afebrile.
Elevated WBC was likely in setting of DKA.
.
# Hypothyroidism - She was continued on home dose levothyroxine
.
# Depression - She was continued on home dose sertraline
Medications on Admission:
1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. insulin lispro 100 unit/mL Cartridge Sig: insulin pump
Subcutaneous QIDACHS.
Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. insulin lispro 100 unit/mL Cartridge Sig: insulin pump
Subcutaneous QIDACHS.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diabetic Ketoacidosis
Secondary:
Diabetes mellitus type 1
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted with high [**Last Name (Titles) 6801**] and electrolyte abnormalities, a
condition called diabetic ketoacidosis. You were placed on an
IV insulin drip and seen by a diabetes specialist. Your [**Last Name (Titles) 6801**]
decreased on the insulin and you were transitioned to your
insulin pump. Your [**Last Name (Titles) 6801**] continued to improve and you were
felt to be safe for discharge home. Please call your [**Last Name (un) **]
doctor if your [**Last Name (un) 6801**] remain high at home.
There were no changes made to your medications.
Followup Instructions:
Please call your primary care doctor as well as your [**Last Name (un) **]
doctor to arrange follow-up appointments with them within one
week of discharge from the hospital.
Completed by:[**2111-5-10**]
|
[
"584.9",
"786.50",
"250.53",
"V58.67",
"535.30",
"250.13",
"305.00",
"244.9",
"288.60",
"362.01",
"311",
"V45.85"
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6716, 6722
|
4916, 6208
|
275, 281
|
6834, 6834
|
2992, 4893
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6743, 6813
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6234, 6452
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6985, 7612
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2712, 2973
|
232, 237
|
309, 2375
|
6849, 6961
|
2397, 2491
|
2507, 2641
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,590
| 164,624
|
41385
|
Discharge summary
|
report
|
Admission Date: [**2116-4-25**] Discharge Date: [**2116-4-29**]
Date of Birth: [**2034-10-8**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Headache followed by left sided weakness, then obtundation.
Major Surgical or Invasive Procedure:
Endotracheal intubation at [**Hospital3 **].
History of Present Illness:
This is an 81 year-old man with a history of dementia, extensive
subcortical white matter vascular injury, and hypertension who
was transferred from [**Hospital3 **] following severe headache,
left sided weakness, then stupor.
He woke as usual at around 6:30 and had a low-grade headache,
his usual. At 8:30 he complained of acute onset of severe L.
sided headache and the sensation of pressure. He laid down for
30 minutes and felt that the headache improved. He tried to eat
breakfast but found that he could not keep food or liquids in
his mouth. His wife then noted prominent L. lower facial
weakness and brought him to the local ER.
At LGH he was noted to have a GCS of 14, slurred speech, and
diminished movement in his L. face and arm. CT revealed an 8.3
x 3.8cm intraparenchymal hemorrhage with subarachnoid and
subdural components and 6mm midline shift. This prompted
transfer to [**Hospital1 18**] for neurosurgical evaluation. Neurosurgery
was consulted upon arrival. They felt that he would not benefit
from surgical
intervention.
He required intubation for agitation, inability to tolerate CT.
He received Etomidate, succinylcholine, and propofol.
ROS: Longstanding and progressive dementia. Intermittent
agitation, helped by zyprexa. Chronic daily headaches, stable
until the severe exacerbation this morning. There have been no
recognized and recent changes in vision or hearing, neck pain,
tinnitus, vertigo, weakness, numbness, difficulty with
comprehension, speaking, language, swallowing, eating, balance
or gait. General review of systems was negative for fevers,
chills, rashes, change in weight, energy level or appetite,
chest pain, palpitations, shortness of breath, cough, abdominal
pain, nausea, or vomiting.
Past Medical History:
- HTN
- Dementia. Mrs. [**Known lastname **] does not know the etiology, but MRI from
[**Hospital1 487**] demonstrating chronic microvascular white matter injury
is suggestive of vascular dementia / cerebral amyloid
angiopathy.
- Amputation of his L. leg at the upper thigh secondary to
trauma in the [**Country 13622**] Republic in [**2092**]. He ambulates
independently with crutches at baseline.
- Chronic daily headache for several years, generally responsive
to [**Hospital1 **] naproxen.
Social History:
Social History:
The patient lives with his wife of many years, is originally
from the [**Country 13622**] Republic, speaks only Spanish, and is
dependent on his wife for many ADLs secondary to his dementia
and amputation of his L. leg.
Physical Exam:
VS: Tm 96.7 BP 184/87 HR 59 RR 22 OS 100%, Intubated
General:
Appearance: Appears younger than stated age. Intubated, sedated
and paralyzed. No response to stimuli.
Skin: No rashes or bruising.
HEENT: NCAT, bleeding from unseen oral injury (intubation, no
visible tongue bites. MMM.
Neck: Supple, No Thyromegaly, No LAD
Ext: High femoral amputation of the L. leg, secondary to trauma.
R. leg is nearly hairless and with extensive signs of peripheral
vascular disease. Severe onychomycosis.
MS:
Gen: 45 minutes after etomidate and succinylcholine for
intubation, he withdraws his R. foot and hand purposefully with
nailbed pressure. No response in the L. hand. Occasional
bursts
of agitating grasping of the R. hand, not accompanied by
arousal.
Does not follow commands in English or Spanish. Does not open
eyes to sternal rub or supraorbital pressure.
CN:
I: Not tested.
II: No blink to threat. Very minimal movement with
occulocephalics. Minimal blink to corneal stimulation. PERRL
2.5mm to 2mm. No RAPD.
III,IV,VI: Does not track my face, minimal eye movements (but
conjugate) on occulocephalic testing.
V: Unable to assess.
VII: Diminished L. nasolabial fold.
VIII: No response to loud voice.
IX,X: Gag is present but weak per RT.
[**Doctor First Name 81**]: SCM and trapezii full.
XII: Unable to assess - intubated.
Motor: No volitional movements. Withdraws hand and foot
purposefully with noxious stim - not purely reflexive.
Withdrawal of both hand and foot is at least a [**4-21**]. No movement
of the L. hand or L. thigh stump with pinch.
Reflex: With reflex testing of the R. arm, near continuous
movement - difficult to assess reflexes.
[**Hospital1 **] Tri Bra Pat [**Doctor First Name **] Toes
C6 C7 C6 L4 S1
R 1 1 1 2 2 down
L 2 1+ 1+ absent absent absent
[**Last Name (un) **]: Withdraws to nailbed in the R. foot and hand, not in the
L. hand.
Pertinent Results:
[**2116-4-28**] 01:19AM BLOOD WBC-11.9* RBC-4.27* Hgb-12.9* Hct-38.6*
MCV-90 MCH-30.2 MCHC-33.4 RDW-13.4 Plt Ct-252
[**2116-4-25**] 02:30PM BLOOD Neuts-61.8 Lymphs-31.1 Monos-4.4 Eos-2.2
Baso-0.5
[**2116-4-28**] 01:19AM BLOOD PT-11.9 PTT-23.1 INR(PT)-1.0
[**2116-4-28**] 01:19AM BLOOD Glucose-150* UreaN-11 Creat-0.7 Na-140
K-4.0 Cl-111* HCO3-21* AnGap-12
[**2116-4-28**] 01:19AM BLOOD Calcium-9.0 Phos-1.8* Mg-2.0
[**2116-4-25**] 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
NCHCT [**2116-4-26**]
FINDINGS: Again noted is a large parenchymal hemorrhage within
the right temporal lobe measuring approximately 7.5 x 2.8 cm.
There is surrounding edema which is slightly increased compared
to the most recent prior examination. There is mass effect on
the right lateral ventricle with unchanged slight shift of the
uncus medially, but without evidence of extensive uncal
herniation. A 4-mm leftward shift of normally midline structures
is again noted, previously 5 mm. There is also subarachnoid
hemorrhage, best visualized at the vertex. A small right-sided
subdural hematoma with a maximum width of approximately 5 mm is
once again noted with adjacent mass effect. There are also
bilateral subdural hematomas along the tentorium.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted after several hours of progressively
worsening headache, followed by left-sided weakness, then marked
stupor. Consistent with this history and the above examination,
a large intraparenchymal hemorrhage was noted on non-contrast
head CT. Given his poor functional status prior to the
hemorrhage and the likelihood of further disability, he was made
comfort measures only, after extensive discussion with his
extended family. He passed away the following day.
Medications on Admission:
- Zyprexa 2.5mg at Noon, 5mg qHS, 2.5mg prn for agitation
- Naproxen 500mg [**Hospital1 **]
- Metoprolol 500mg qDay. I presume this is extended release,
but not noted on pill bottle.
- Donepezil 5mg qHS
Discharge Medications:
Not applicable.
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracerebral hemorrhage.
Discharge Condition:
Expired.
Discharge Instructions:
Not applicable.
Followup Instructions:
Not applicable.
|
[
"V49.86",
"294.8",
"342.80",
"V49.76",
"V66.7",
"432.1",
"401.9",
"348.5",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6989, 6998
|
6196, 6694
|
365, 411
|
7067, 7077
|
4905, 6173
|
7141, 7159
|
6949, 6966
|
7019, 7046
|
6720, 6926
|
7101, 7118
|
2978, 4886
|
266, 327
|
439, 2191
|
2213, 2710
|
2742, 2963
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,313
| 169,885
|
12428
|
Discharge summary
|
report
|
Admission Date: [**2101-7-19**] Discharge Date: [**2101-7-27**]
Date of Birth: [**2030-2-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
carotid stenosis
Major Surgical or Invasive Procedure:
[**2101-7-19**] Left carotid endarterectomy
[**2101-7-20**] Cardiac catheterization
[**2101-7-22**] Balloon pump
[**2101-7-22**] Tandem heart+ECMO and high risk PCI with 2DES to the LAD
and 1 to the Lcx.
History of Present Illness:
71 year old female with PMH COPD on home oxygen, HTN, PVD s/p
b/l Fem-[**Doctor Last Name **] bipass who is pod #1 from Lt CEA. Immediately post
operatively she was hypotensive requiring neosynephrine ggt for
several hours and received ~5L IVF. She was very transiently
weaned of the neosynephrine to bp's in the high 90's but then
decompensated again in the early am hours requiring retransfer
to the PACU and reinitiation of neosynephrine. CXR performed
showed pulmonary edema and she received 20IV Lasix with some
good relief.
.
On initial evaluation, she was feeling somewhat better. She only
complained of some shortness of breath. She didn't have any
chest
pain or pressure. We did a trial of BIPAP which she didn't
tolerate, and on re-evaluation ~1-2 hours later she began
feeling
nausea with chest burning and worsening dyspnea. ECHO was
performed which showed, "severe regional left ventricular
systolic dysfunction with severe hypokinesis of the setpum,
inferior, inferolateral, distal 2/3rds of the anterior and the
apical walls." Given changes on ECHO patient was taken to the
cardiac cath lab for evaluation for ACS versus demand ischemia.
.
In the Cath lab, he was noted to have elevated filling pressures
with PA pressures of 48/29 and mean wedge of 32 and diffuse two
vessel disease with 90% LAD, 80% proximal Lcx and occluded
distal and 30% Left main prox with nondominant RCA. She was
given IV lasix 120 x 1 with UOP of 600 cc. She was also noted
to have subclavian stenosis with 10-20 mm Hg gradient. Swan was
left in place to measure PA presures. No intervention was done
and she was tranferred to CCU for monitoring and CT surgery
evaluation for CABG.
.
On cardiac review of symptoms, prior to arrival to the hospital
she denies any chest pain, sob, orthopnea, doe. She does use
home oxygen. She isn't very active due to hip pain. All other
ROS
negative.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
PAST MEDICAL HISTORY:
?Coronary artery disease
COPD on home oxygen on 2L at night
peripheral vascular disease s/p fem/[**Doctor Last Name **] bipass (?bilaterally),
4-cm thoracicaneurysm
history of AAA abdominal repair
chronic hyponatremia, right
hip fracture repair in [**2090**].
.
PAST SURGICAL HISTORY:
AAA s/p repair
.
Social History:
Significant for tobacco use. She has roughly an 80 pack-year
history of tobacco abuse. She admits to drinking alcoholic
beverages 4-5 days a week.
Family History:
Father MI in his 40's
Physical Exam:
Physical exam on transfer:
99.3 87 109/59 18 100 FI02 0.35 FM
Gen - thin diaphoretic female in mild respiratory distress
HEENT - CN 2-12 intact, strength, sensation intact, incision w/
dressing, dressing CDI
Pulm - crackles throughout b/l
CV - RRR, Echo showing global ventricular dysfunction, EF 25%
abd - soft NTND
Extrem - warm, palp fem/[**Doctor Last Name **]/dop DP/PT b/l
Pt deceased on [**2101-7-27**]
Pertinent Results:
[**2101-7-19**] WBC-12.1* Hct-29.7* Plt Ct-250
[**2101-7-20**] WBC-12.9* Hct-25.9* Plt Ct-196
[**2101-7-20**] WBC-21.0* Hct-34.3* Plt Ct-233
[**2101-7-20**] PT-12.5 PTT-29.3 INR(PT)-1.1
[**2101-7-19**] Glucose-109* UreaN-11 Creat-0.6 Na-133 K-4.0 Cl-100
HCO3-24 [**2101-7-20**] Glucose-112* UreaN-11 Creat-0.5 Na-131* K-3.7
Cl-103 HCO3-20
[**2101-7-20**] CK-MB-9 cTropnT-0.20*
[**2101-7-20**] CK-MB-41* cTropnT-0.60* proBNP-3200*
[**2101-7-20**] CK-MB-99* MB Indx-8.4* cTropnT-1.18*
[**2101-7-20**] CK-MB-109* MB Indx-7.9* cTropnT-1.99*
[**2101-7-20**] Echo: Global ventricular dysfunction, EF 25%
[**2101-7-27**] 04:04AM BLOOD WBC-19.3* RBC-3.84* Hgb-11.5* Hct-33.8*
MCV-88 MCH-30.0 MCHC-34.0 RDW-16.8* Plt Ct-66*#
[**2101-7-27**] 04:04AM BLOOD PT-20.8* PTT-150* INR(PT)-1.9*
[**2101-7-27**] 04:04AM BLOOD Glucose-91 UreaN-45* Creat-3.3* Na-135
K-4.8 Cl-100 HCO3-16* AnGap-24*
[**2101-7-25**] 09:39AM BLOOD ALT-2065* AST-1419* LD(LDH)-1296*
CK(CPK)-4089* AlkPhos-333* TotBili-2.1*
[**2101-7-25**] 09:39AM BLOOD CK-MB-22* MB Indx-0.5 cTropnT-7.80*
[**2101-7-27**] 04:04AM BLOOD Calcium-8.6 Phos-5.1* Mg-1.9
[**2101-7-26**] 06:13AM BLOOD Vanco-6.7*
[**2101-7-27**] 06:53AM BLOOD Type-ART Temp-36.5 Rates-25/ Tidal V-535
PEEP-8 FiO2-50 pO2-457* pCO2-34* pH-7.22* calTCO2-15* Base
XS--12 Intubat-INTUBATED
[**2101-7-27**] 06:53AM BLOOD Lactate-6.6*
[**2101-7-24**] 12:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- neg
[**7-25**] ECHO The left ventricular cavity is dilated. There is
severe global left ventricular hypokinesis (LVEF = 20-25%), with
some regional variation, most consistent with multivessel CAD.
There is focal hypokinesis of the apical free wall. There is a
trivial circumferential pericardial effusion, outside of a
rather large anterior fat pad. There are no echocardiographic
signs of tamponade.
.
[**7-22**] TTE: Normal left ventricular cavity size with severe
systolic dysfunction c/w multivessel CAD or other diffuse
process. Mild mitral regurgitation. Pulmonary artery systolic
hypertension.
Compared with the prior study (images reviewed) of [**2101-7-20**],
the severity of mitral regurgitation is slightly reduced.
.
[**7-24**] CXR: FINDINGS: In comparison with the study of [**7-24**], the
monitoring and support devices remain in place. The degree of
pulmonary vascular congestion has decreased, especially on the
right. The central pulmonary vessels and hila are also much less
prominent.
.
Micro:
[**2101-7-20**] 9:18 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2101-7-27**]**
GRAM STAIN (Final [**2101-7-20**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
CONSISTENT WITH HAEMOPHILUS
SPECIES.
RESPIRATORY CULTURE (Final [**2101-7-22**]):
SPARSE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.
MODERATE GROWTH.
BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.
LEGIONELLA CULTURE (Final [**2101-7-27**]): NO LEGIONELLA
ISOLATED.
Brief Hospital Course:
71F with PVD (fem-[**Doctor Last Name **] bypass and AAA repair) post-op from CEA
who suffered NSTEMI complicated by acute systolic heart failure
and flash pulmonary edema requiring emergent balloon pump
followed by tandem heart and high risk PCI [**7-22**] ultimately made
CMO after failure to wean from cardiopulmonary support.
Vascular Surgery Course:
The patient was admitted to the vascular surgery service under
the care of Dr [**Last Name (STitle) **]. She underwent an uncomplicated left
carotid endarterectomy. In the PACU on POD 0 she became
hypotensive and required starting a neo ggt as well as
resuscitation w 5 L of crystal. She then became acutely hypoxic
and was administered IV lasix after a CXR demonstrated pulmonary
edema. A stat cardiac consult was done and an Echo obtained. The
echo showed diffuse ventricular disfunction. The patient was
intubated in the PACU and taken ungently to the cath lab. The
cath showed multivessel dx and the patient was transfered to the
cardiac ICU for further work up and treatment.
.
CCU Course
#. Acute systolic heart failure: After post CEA hypotension, pt
was cathed and found to have diffuse two vessel disease with
nondominant RCA. 90% LAD, 80% proximal Lcx and occluded distal
and 30% Left main prox. She was continued on aspirin,
atorvastatin 80 mg po qdaily and IV heparin gtt. She was
extubated and while she was awaiting CT surgery evaluation, she
had episode of flash pulmonary edema requiring reintubation.
She was deemed too sick to be a candidate for CABG. She
underwent intraortic ballon pump placement with
revascularization with DES to LAD and LCx. She required further
augmentation of her cardiac output so IABP was replaced with
tandem heart in right atrium with oxygenator. She additionally
required pressor support with multiple inotropes, with
decreasing effect over time, and complications including atrial
fibrillation requiring electrical cardioversion. She was not
able to wean off tandem heart and her course was complicated by
anuric acute kidney injury, ischemic limbs and metabolic
acidosis. Goals of care were discussed with family and the
decision was made to cease pressor and mechanical support. Pt
was unable to maintain sufficient cardiac output to sustain
life.
#. Hypoxemic respiratory failure: Likely due to flash pulmonary
edema and subsequent volume overload [**3-9**] anuric [**Last Name (un) **]. She was
placed on tandem heart with oxygenator. She was unable to be
weaned off respiratory support. She was continued on
versed/fentanyl for sedation/compliance and VAP precautions,
however sedation was weaned without evidence of neurologic
response.
.
# PVD: Vascular consulted for R leg ischemia in setting of
tandem heart. She underwent tandem flow to profunda with some
improvement.
.
# Hypoglycemia: Likely in setting of critical illness. D5/bicarb
gtt and closely monitor
.
# [**Last Name (un) **]: Pt with increase of cr from 0.8 - 3.3. Likely ATN [**3-9**]
cardiogenic shock. Pt became grossly volume overloaded. Renal
was consulted however felt that CVVH unlikely to improve
clinical status as lytes stable and pt continued to receive
fluid boluses for pressure support.
.
# HIB on sputum sample. Pt initially started on cefepime then
with persistent fevers and hypotension was broadened to
meropenem/vancomycin. Blood cultures remained negative.
.
# Thrombocytopenia: Initial concern for HIT, heparin gtt was
stopped and pt maitained on bivalrudin. When Ab returned
negative pt was restarted on heparin gtt. Thrombocytopenia more
likely related to critical illness and tandemheart
.
#. Left CEA POD#7. Surgical site stable.
.
# Goals of care: Clinical status worsened despite maximum
support, without evidence of neurologic dysfunction despite
weaning sedation. In discussion with the pt's cousin the
decision was made to transition to CMO. Pressor support and
tandem heart were decreased. Morphine gtt was started. Vent was
dced. Pt passed comfortably.
Medications on Admission:
ProAir HFA 90 mcg 2 puff QID, amlodipine 7.5', Plavix 75',
Advair Diskus 500 mcg-50 mcg 1 puff [**Hospital1 **], Isosorbide mononitrate
ER
30', metoprolol 100', Singulair 10', Simvastatin 40', Tiotropium
Bromide 18 mcg 1 puff Daily, ASA 325', Vit D3 400', propylene
glycol 400 0.03-0.04% 1-2 drops per eye daily PRN
Discharge Medications:
pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
myocardial infarction
heart failure
hypoxemic respiratory failure
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
"428.0",
"584.5",
"410.71",
"E878.8",
"496",
"447.1",
"998.12",
"416.8",
"440.20",
"441.2",
"276.2",
"785.51",
"518.81",
"287.5",
"433.10",
"414.01",
"997.1",
"428.21",
"305.1",
"427.31",
"276.1",
"424.0",
"305.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"99.61",
"96.72",
"99.15",
"37.23",
"00.41",
"88.56",
"00.40",
"37.68",
"38.12",
"37.61",
"39.65",
"00.47",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
11263, 11272
|
6894, 10861
|
322, 528
|
11381, 11391
|
3798, 6871
|
11448, 11459
|
3330, 3353
|
11228, 11240
|
11293, 11360
|
10887, 11205
|
11415, 11425
|
3129, 3147
|
3368, 3779
|
266, 284
|
556, 2800
|
2844, 3106
|
3163, 3314
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,677
| 104,441
|
13780
|
Discharge summary
|
report
|
Admission Date: [**2118-8-7**] Discharge Date: [**2118-8-17**]
Service:
Patient was originally admitted to the Urology service.
HISTORY OF PRESENT ILLNESS: Patient is an 81-year-old male
with multiple medical problems including end-stage renal
disease on hemodialysis, who was admitted on [**2118-8-7**]
preoperatively for left nephrectomy for a left renal mass
found incidentally on arterial study for vascular disease.
No specifics available regarding studies at this time. No
associated symptoms were noted. No flank or abdominal pain.
No hematuria. No dysuria. No fever or chills. Patient also
has necrotic right fourth finger.
PAST MEDICAL HISTORY:
1. AFib.
2. End-stage renal disease on hemodialysis.
3. Insulin dependent-diabetes mellitus.
4. Nephrolithiasis.
5. Prostate cancer.
6. Peripheral vascular disease.
7. Hypertension.
8. Anemia.
9. History of CVA.
10. History of diaphragmatic hernia.
PAST SURGICAL HISTORY:
1. Significant for bilateral peripheral revascularizations,
question of a femoral distal bypass.
2. Bilateral peripheral angioplasties approximately 5-6 years
ago.
3. Left third toe amputation.
4. Right flap over DP wound.
5. Right upper extremity A-V fistula.
6. Question of bypass of that right A-V fistula.
7. Prostatectomy in [**2112-8-31**].
8. Bilateral nephrolithotomy about 15 years ago.
9. Bilateral cataract surgery three years ago.
MEDICATIONS ON ADMISSION:
1. Actos 15 mg q.d.
2. Colace 100 mg b.i.d.
3. Epogen 7200 units q week.
4. Hytrin 10 mg q.d.
5. Lasix 80 mg q.d.
6. Lipitor 20 mg q.d.
7. Lopressor 50 mg b.i.d.
8. Nepro vitamins one q.d.
9. Novolin NPH 5 units b.i.d.
10. Phenergan 12.5 mg q.6h. prn.
11. Protonix 40 mg p.o. q.d.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: Patient was afebrile and vital signs
stable. Clear to auscultation bilaterally. Regular, rate,
and rhythm, no murmurs. Abdomen is soft, nontender,
nondistended. Pulses were palpable distally bilaterally.
Patient had positive thrill over right arm fistula.
Well-healed incision over the left lower extremity surgically
absent to the left third toe. Flap over the right medial
malleolus, which was well healed. Right second toe somewhat
edematous and ecchymotic, and a little bit macerated at the
tip.
EKG showed AFib at a rate of 94.
Patient was made NPO after midnight with IV fluids and
preoped for a left nephrectomy by the Urology service. Was
taken on [**2118-8-8**] for left nephrectomy. Please see operative
report for detailed account of happenings. Subsequent to
patient's left nephrectomy, patient was assessed for right
arteriovenous steel syndrome, which had resulted in ischemic
right hand and a necrotic gangrenous right fourth digit.
Patient was discharged postoperatively to the ICU on [**Hospital1 1444**] [**Hospital Ward Name 516**]
On postoperative day #2 from patient's left nephrectomy, the
patient was taken by the Transplant Surgery Service to the OR
for repair of a right arm fistula which seemed to be
responsible for his right ischemic hand as well as a right
fourth digit amputation. Patient received right A-V fistula
patch angioplasty as well as a fourth digit amputation with
simple closure. For detailed account, please see operative
report.
The patient was then transferred to the Transplant Service on
the [**Hospital Ward Name 517**] to facilitate patient's frequent need for
hemodialysis. Patient did well postoperatively with no
complications. PT/OT saw patient and recommended a rehab
facility. Patient was resistant to this idea, and instead
opted to go home with VNA and with home PT. Patient was
stable on discharge.
DISCHARGE STATUS: Discharged to home with VNA and home PT.
DISCHARGE DIAGNOSES:
1. Renal cell carcinoma.
2. Status post left nephrectomy.
3. Arteriovenous steel syndrome.
4. Ischemic right hand.
5. Gangrenous fourth digit on the right hand.
6. End-stage renal disease.
7. Diabetes mellitus.
8. Status post cerebrovascular accident.
DISCHARGE MEDICATIONS:
1. Lipitor 20 mg p.o. q.d.
2. Terazosin 10 mg p.o. q.h.s.
3. Folic acid and vitamin B complex 1 mg p.o. q.d.
4. Colace 100 mg p.o. b.i.d.
5. Collagenase one application topical q.d.
6. Calcium carbonate 500 mg p.o. t.i.d.
7. Metoprolol 50 mg p.o. t.i.d.
8. Famotidine 20 mg p.o. b.i.d.
9. Lasix 80 mg p.o. b.i.d.
10. Pioglitazone 15 mg q.d.
FOLLOW-UP PLANS: Follow up with Dr. [**Last Name (STitle) 365**] in the [**Hospital 159**]
Clinic, call [**Telephone/Fax (1) 2756**] for appointment in one week and
with Dr. [**First Name (STitle) **] in the Transplant Center. Clinic will call
patient to inform of appointment. Dr. [**Last Name (STitle) 365**] will arrange any
Oncology followup that will be necessary.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2118-8-21**] 00:01
T: [**2118-8-24**] 08:05
JOB#: [**Job Number 41438**]
|
[
"427.31",
"443.9",
"996.73",
"285.9",
"V10.46",
"V12.59",
"189.0",
"785.4",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.01",
"39.49",
"55.51",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
3733, 3986
|
4009, 4351
|
1414, 1750
|
944, 1388
|
1773, 3712
|
4369, 4982
|
167, 649
|
671, 921
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,622
| 157,538
|
26613
|
Discharge summary
|
report
|
Admission Date: [**2158-7-3**] Discharge Date: [**2158-7-20**]
Date of Birth: [**2088-2-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
Exploratory lap
Repair of inguinal hernia
CVL
History of Present Illness:
HPI: 70 year old male who complains of N/V x2days. Living at
[**Hospital 100**] rehab most recently. No c/o abdominal pain. Has known
scrotinguinal hernia for ~ 10 years and had been refusing
surgical repair.
ROS:
(+) per HPI
(-) Denies pain, fevers, chills, night sweats, unexplained
weight loss, fatigue/malaise/lethargy, changes in appetite,
trouble with sleep; pruritis, jaundice, rashes; bleeding, easy
brusing; headache, dizziness, vertigo, syncope, weakness,
paresthesias; hematemesis, bloating, cramping, melena, BRBPR,
dysphagia; chest pain, shortness of breath, cough, edema;
urinary frequency, urgency
Past Medical History:
Past Medical History:
schizophrenia, prostate Ca (on lupron since [**2154**]), anemia of
chronic disease with macrocytosis, cryptogenic cirrhosis, COPD,
compression fracture, large inguinoscrotal hernia (has thus far
deferred surgery), pyruvate kinase deficiency, splenomegaly
Past Surgical History: CCY, vertebroplasty
Social History:
Lives at a group home for his schizophrenia ([**Street Address(1) 65648**])
which has help daily, but not at night. Ex-wife [**Name (NI) **] [**Name (NI) 65646**]
cell [**Telephone/Fax (1) 65650**], pager [**Telephone/Fax (1) 65653**]
Smokes 1 PPD for "a long time", approximately 20 years. Reports
prior history of etoh abuse, approximately 10 beers per day for
about 20 years. Denies IVDU.
Family History:
He has 4 sisters that he does not keep in regular contact with.
Unsure of what his parents died from.
Physical Exam:
Physical Exam:
97.6 96 108/53 16 97
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, nontender, no rebound or guarding,
normoactive bowel sounds, large scrotal/inguinal hernia with
significant bowel contents contained within. No skin changes, no
tenderness, not reducible
DRE: normal tone, no gross or occult blood
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2158-7-20**] 06:22AM BLOOD WBC-3.2* RBC-3.04* Hgb-9.5* Hct-28.1*
MCV-93 MCH-31.1 MCHC-33.6 RDW-15.7* Plt Ct-222
[**2158-7-15**] 02:28AM BLOOD PT-13.6* PTT-32.4 INR(PT)-1.2*
[**2158-7-14**] 02:20AM BLOOD ALT-26 AST-32 AlkPhos-304* TotBili-1.6*
[**2158-7-19**] 05:44AM BLOOD Calcium-6.9* Phos-2.6* Mg-1.4*
Brief Hospital Course:
70M with nausea and vomiting with acute on chronic incarcerated
massive scrotoinguinal hernia. He was admitted to Dr.[**Name (NI) 670**]
surgical service on [**2158-7-3**]. A nasogastric tube placed and
patient resuscitated. Nasogastric output ~ 2L/day with feculent
material. Patient continue to deny surgery. Health care proxy,
psychiatry, and legals were involved in his care as he was
deemed incapable of making any decisions. Finally, with all
groups in consent and patient's agreement and lack of clinical
progress, he was taken to the operating room on [**2158-7-7**] for an
exploratory laparotomy and hernia repair. A triple lumen CVL was
placed.
Postop, taken to the intensive care unit for monitoring and was
extubated on postop day 1, but required aggressive pulmonary
toilet. CXR demonstrated lower lobe collapse. He was hypotensive
(sbp in 80s)and required neo. PRBC were given for a low hct of
23. Albumin was given, but he required Levophed as well.
Tachycardia was noted with a drop in hct. More PRBC were
administered. Hct stablized. EKG was normal. Pressors were
weaned. Sinus tach with frequent PAC was treated with iv
metoprolol. Non invasive ventilation was required for
respiratory status. NG was draining bilious fluid. Vancomycin
was given postop x2 for coverage due to hernia repair with mesh.
This was stopped.
He was transferred out of the SICU once improved. The NG was
removed on [**7-12**] after clamping trials were tolerated. Diet was
slowly advanced and poorly tolerated. Intake was fair and
supplements were ordered. A dobhoff was placed, but the patient
self removed. TPN was started. He was passing stool via a
Flexiceal. On [**7-14**], he experienced a vasovagal episode during a
BM. No further events or treatments were required.
Flexiceal was removed on [**7-6**]. Foley catheter was removed on [**7-19**]
without incident. Vital signs were stable. He did continue to
require oxygen as he would desat to 87% on room air. Abdominal
incision was intact with staples. The lower portion of the
incision had small amounts of tannish drainage, but no redness.
The surrounding areas lateral to the incision initially had a
mottled appearance that evolved to ecchymosis. These areas
lightened up. The JP was left in place as outputs were initially
high. Outputs decreased, but were still ~ 110ml/day as of [**7-20**].
Fluid was sero-sanguinous. He received minimal pain medication.
His affect was calm and cooperative. TPN was stopped and the CVL
was removed on [**7-20**].
PT evaluated him and recommended rehab. A bed was available at
[**Hospital 100**] Rehab.
Contacts: Outpatient [**Hospital **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22020**] MA Mental Health
Center, beeper [**Telephone/Fax (1) 14428**].
Medications on Admission:
Advair, tiotropium Bromide 18 mcg 1 puff daily,
Calcium [**Hospital1 **], MVI, Ativan 1 mg [**Hospital1 **] PRN anxiety, insomnia 0.5 mg
qam and 1 mg qhs, thiamine 100 mg daily, Albuterol Neb Solution
PRN, Benztropine 1 mg daily, Fosamax 70 mg q week, Colace 100 mg
[**Hospital1 **], Folic Acid 1 mg daily, Lactulose 10 gram/15 mL Daily ,
Levofloxacin 250 mg Daily, MVI Daily, Omeprazole 20 mg Tab(E.C)
Daily, Risperidone 1 mg qhs, Senna [**Hospital1 **], Bisacodyl 10 mg Tab
Daily, Ondansetron 4 mg Tab prn, Polyethylene Glycol PRN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection [**Hospital1 **] (2 times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection ASDIR (AS DIRECTED).
3. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Risperidone Microspheres 37.5 mg/2 mL Syringe Sig: One (1)
Syringe Intramuscular Q2W (TH): next dose due [**7-27**] .
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Benztropine 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): hold for sbp <110 or HR <60.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
16. Lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection [**Hospital1 **] PRN
() as needed for anxiety.
17. Hydromorphone (PF) 1 mg/mL Syringe Sig: 0.25 mg Injection
Q4H (every 4 hours) as needed for breakthrough pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
incarcerated scrotal/inguinal hernia
Small bowel obstruction
Schizophrenia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
please call Dr. [**First Name8 (NamePattern2) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 65654**] [**Telephone/Fax (1) 673**] if you
experience any of the warning signs listed below.
You will be discharged to [**Hospital 100**] Rehab today
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2158-9-12**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2158-7-27**] 2:00
Completed by:[**2158-7-20**]
|
[
"276.1",
"568.0",
"282.3",
"518.0",
"295.62",
"571.5",
"550.11",
"496",
"185",
"305.1",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"99.15",
"54.59",
"38.93",
"53.03"
] |
icd9pcs
|
[
[
[]
]
] |
7757, 7823
|
2730, 5505
|
332, 379
|
7942, 7942
|
2399, 2707
|
8411, 8747
|
1797, 1900
|
6090, 7734
|
7844, 7921
|
5531, 6067
|
8127, 8388
|
1349, 1371
|
1931, 2380
|
273, 294
|
407, 1025
|
7957, 8103
|
1069, 1325
|
1387, 1781
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,219
| 110,512
|
35388
|
Discharge summary
|
report
|
Admission Date: [**2183-9-3**] Discharge Date: [**2183-9-19**]
Date of Birth: [**2125-7-5**] Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending:[**First Name3 (LF) 4057**]
Chief Complaint:
odynophagia
Major Surgical or Invasive Procedure:
flex and rigid bronchoscopy x 2
radiation therapy to esophagus
lumbar puncture
EEG
History of Present Illness:
.
58F with a history of metastatic RCC complicated by extensive
mediastinal mets requiring placement of bronchial stent who was
recently admitted for near syncope where she had a work up
including head CT, which was without changes, a CTA of the
chest which was negative for PE and showed stable masses and an
Echo which showed mild hypokinesis and an 40-45%.
She noted yesterday she had a low grade temp 100.4 that she
states went up to 102 so she contact[**Name (NI) **] her oncologists Dr [**Name (NI) **]
and Dr [**First Name (STitle) **] who told her to come to the hospital if it
continued above 100.4. She has also been experiencing a
significant amount of throat pain from her esphagitis and was
encouraged to use lidocaine/ benedryl for this. She has been
unable to swallow and her PO intake is down. She has also noted
flu like symptoms over the past few days such as myalgias cough
with yello sputum, body aches. She just recieved radiation
therapy yesterday.
She was started on palliative chest XRT ([**2183-8-19**]) and
chemotherapy with sunitinib.
In the ED she was tachycardiac on presentation to 123 and
improved with fluids. She had a T Max of 101.4 for which she was
given rectal tylenol. She had nausea and was give 8mg Zofran.
Blood and urine cultures were drawn, she was flu swabbed and she
was started on Levofloxasin. Her WCC was 1.4 and ANC 1275.
lactate 1.1
Past Medical History:
PAST ONCOLOGIC HISTORY:
The patient was in USOH until winter of [**2181**] when she developed
cold symptoms which did not clear with antibiotics. She
developed hemoptysis, which was evaluated in [**2182-2-9**] with
x-rays of the chest. Lung mediastinal mass was detected on CXR,
which was followed by a CT scan, which confirmed a mass in the
mediastinum. Scanning also indicated a mass in the left kidney.
This was further evaluated with imaging studies of the abdomen,
which showed a large left renal mass measuring 15 x 11 cm. Lytic
lesion was also detected in the right acetabulum. She was
further evaluated with MRI which showed a left renal mass with
no evidence of involvement of the left renal vein. MRI scan
showed a mass in the vertex of the skull measuring 5 cm in
greatest dimension. She underwent a bronchoscopy to evaluate the
hemoptysis symptoms and biopsy the lung mass. However, pathology
from this study was inconclusive. She underwent a biopsy of the
left kidney mass, which showed renal cell carcinoma [**Last Name (un) 19076**]
nuclear grade 1. These slides have been reviewed and showed
renal cell carcinoma, clear cell type, and nuclear grade 1. With
these findings, she underwent radiation therapy to the right hip
and leg receiving 10 treatments at the [**Hospital6 5016**].
Following these treatments, she was evaluated by the Biologics
group and the Urology group for definitive treatment of renal
cell carcinoma. Recommendation was for dendritic cell vaccine
therapy. For this therapy, she will require a tumor sample. She
is now s/p left debulking nephrectomy [**2183-4-11**].
======================
PAST MEDICAL HISTORY:
- Renal CA metastatic to skull, R hip, lungs, medistiastinum as
above
- Airway compression, s/p y-stent
- sciatica
====================
Social History:
Married. Occ Etoh, 30-40pkyr Hx of smoking, no illicits
Family History:
Non-contributing oncologic history
Physical Exam:
Vitals: stable HR 100 BP 121/65 O2 98% 2L T 98.1
GENERAL: Laying on the bed with discomfort in her neck
[**Name (NI) 4459**] Pt not allowing palpation of neck due to pain
CVD tachy
Lungs: scattered rhonchi all lung fields
Abdomen soft non distended diffuse tenderness
Ext WWP
Back No CVA tenderness
LN No axillary or femoral LN palpated
Exam on discharge:
97.6 110/70 100 18 96% RA
590+2260/3750
GENERAL: Laying on the bed, NAD, communicative, A and O x 3 and
appropriate
[**Name (NI) 4459**]- PERRLa, EOMi, clear oropharynx
CV- regular rhythm, tachycardic, no m, r, g
Lungs: left lung has improved breath sounds s/p bronchoscopy,
clear on right
Abdomen soft, non distended, non-tender to palpation, no
guarding/rebound, active BS
Ext WWP
No CVA tenderness
LN No axillary or femoral LN palpated
Pertinent Results:
TTE:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is severe global left
ventricular hypokinesis (LVEF = 20 %). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. with normal free wall contractility. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Tricuspid
regurgitation is present but cannot be quantified. The pulmonary
artery systolic pressure could not be determined. There is a
small pericardial effusion. There are no echocardiographic signs
of tamponade.
.
Compared with the prior study (images reviewed) of [**2183-8-28**],
the LVEF has significantly decreased. There is now a small
pericardial effusion.
.
CT abdomen/pelvis
1. Distended gallbladder, with no definite CT evidence of
cholecystitis. If clinical concern, this can be further
evaluated with HIDA scan.
2. Interval free fluid in the abdomen, mostly at the perihepatic
and
perisplenic distribution and tracking along the right paracolic
gutter into the pelvis. Bilateral pleural effusions.
3. Questionable wall thickenning of the colon at the splenic
flexture, could be due to collapsed colon; however this finding
can be seen in colitis, if there is clinical concern.
4. Stable right acetabular lesion with pathologic fracture at
the right
inferior acetabulum, unchanged. Multiple lesions within the
spine consistent with metastatic disease, with possible
hemangioma at L1.
5. Status post left nephrectomy with no definite evidence of
recurrence at
the surgical bed.
.
EEG [**9-15**]: This is a normal video EEG study. Interictal
background activity was normal. There were no epileptiform
discharges or electrographic seizures. Compared to recording
from 24 hours prior, this study contains fewer electrographic
seizures
.
EEG [**9-13**]
This is an abnormal portable EEG due to continuous generalized
rhythmic spike and slow wave activity at a frequency of 2.5 Hz
for the first half of this record consistent with non-convulsive
status epilepticus. EEG markedly improved after administration
of I.V. Ativan with resolution of non-convulsive status and only
brief short bursts of generalized spike slow wave discharges in
the latter half of the study. No focal lateralizing features
were noted. An irregularly irregular rhythm was seen on cardiac
monitor. Based on these findings, we would recommend long-term
monitoring for this patient
.
MR head:
Compared to the previous MRI from [**2183-2-18**], the soft tissue
component
associated with the vertex frontal bone calvarial lesion has
markedly
decreased in size likely reflecting interval treatment. The bony
component
appears relatively stable. This may represent treated neoplasm
in bone.
.
Left frontal scalp lesion is unchanged compared to the most
recent study.
.
There is no evidence for intracranial metastatic disease.
.
There is diffuse pachymeningeal enhancement, which may be
related to prior
radiation/LP or infectious/inflammatory sequela. Appearance is
not suggestive of dural mets. There is a tiny 5- mm left frontal
subdural focal thickening or collection which does not cause
mass effect.
.
[**9-19**] CXR (post-bronch): Atelectasis in the left base has
minimally improved. Cardiomediastinal contours are unchanged.
Patient has known mediastinal and hilar lymphadenopathy and
right rib metastatic lesion. There is no evident pneumothorax or
enlarging pleural effusion. The left hemidiaphragm is elevated.
Stent is seen in the left main bronchus
.
[**9-15**] CXR: Complete white out of the left hemithorax and
shifting of the
cardiomediastinum towards the left is unchanged due to collapse
of the left lung. Assessment of the left pleural effusion is
limited. The right lung is grossly clear. Destructive lesion in
the lateral aspect of right mid rib is again noted.
.
Labs on discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
1.6* 2.90* 8.5* 24.6* 85 29.2 34.3 21.3* 200
.
Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos
68 2 14* 14* 0 0 0 2* 0
.
PT 11.5 PTT 26.4 INR 1.0
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
108* 17 0.6 136 4.4 101 25 14
.
ALT AST AlkPhos TotBili
11 15 78 0.2
.
Calcium Phos Mg
8.7 3.4 2.2
Brief Hospital Course:
58 year old female with metastatic renal cell carcinoma to
skull, mediastinum, lungs, s/p Y stent placement presented with
an episode of fever, nausea and worsening dysphagia/odynophagia.
.
# Fever/odynophagia/dysphagia- Initial differential diagnosis of
this constellation of symptoms included esophagitis from
radiation, thrush, or mucositis. Flu swab was negative. The
patient was initially given levofloxacin in the ED, but this was
discontinued. The patient also received supportive care,
including magic mouthwash, sucralfate, PPI, H2 blocker,
morphine, and reglan. Fluconazole was given for oral/esophageal
candidiasis.
.
# Renal cell carcinoma- Patient recently completed course of
radiation therapy to skull and espophagus. Sutent had been
started and was initially continued upon admission with good
response. Sutent was then discontinued in the setting of
developing pancytopenia, which improved following cessation of
the drug.
.
# Mental status- The patient had an episode of altered mental
status on [**2183-9-7**] that was attribued to hyponatremia. She
required a brief course in the ICU, received IVF and hypertonic
saline with improvment in both her mental status and
hyponatremia (thought to be due to mild hypovolemia and SIADH).
The patient was hypotensive thought to be due to hypovolemia,
which improved with IVF. An echocardiogram was obtained, and
her LVEF was depressed at 20%. The patient did not have any
other signs or symptoms of CHF, and was started on metoprolol
and lisinopril. Her depressed EF was non-ischemic in etiology
and was thought to be due to either radiation or sutent.
.
The patient then developed second episode of AMS on [**2183-9-12**]-
patient was non-verbal/non-communicative, not somlonent. An LP
was performed, which showed a normal opening pressure, with no
evidence of infection. The patient received empiric
ceftriaxone, vancomycin, and acyclovir which were all
discontinued after cultures were negative. An EEG on [**2183-9-13**]
showed that the patient was in non-convulsive status
epilepticus. She was loaded with ativen and fosphenytoin with
near-immediate improvement in her mental status. She again
required a brief stay in the ICU to monitor her airway after
receiving anti-epileptic therapy. Her airway was never
compromised. She initially received phenytoin, but developed a
leukopenia thought to be secondary to phenytoin. She is now
being bridged to keppra and doing well. She will continue
taking phenytoin 100 mg TID for six days. She will continue
taking keppra 500 mg [**Hospital1 **] for three days, then keppra 750 mg [**Hospital1 **]
for three days, then keppra 1000 mg [**Hospital1 **] ongoing.
.
# Bronchial stents- The patient underwent a flex bronchoscopy on
[**2183-9-11**] which showed increasing tumor burden in the left main
stem bronchus. Post-bronchoscopy, the patient was noted to have
decreased breath sounds on the left, and a chest film showed a
white out of her left lung. The patient never dveloped an
oxygen requirement. A scheduled rigid bronchoscopy on [**2183-9-18**]
was performed which showed an occluded left main stem with
granulation tissue, dilation was performed and a stent was
replaced in the left main stem with good effect and significant
improvement in her chest film. The patient has scheduled follow
up with her outpatient pulmonologist on [**2183-10-6**].
.
#
PROPHY: mobilization (patient will need continued physical
therapy, ppi, bowel regimen)
Nutrition: the patient was tolerating some PO intake at
discharge, and was also receiving PPN. please cont transition
to full regular diet
ACCESS: PIV
CODE: FULL
Medications on Admission:
Docusate Sodium 100 mg Capsule PO BID
Folic Acid 1 mg Tablet PO DAILY
Senna 8.6 mg Tablet Sig: One Tablet PO BID
Morphine 30 mg Tablet Sustained Release i tab PO q12
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H
Tessalon Perle 100 mg Capsule Sig: One Capsule PO TID prn
Levalbuterol HCl 0.63 mg/3 mL 1 neb q4 hours prn
Ipratropium Bromide 0.02 % Solution One (1) neb q6h prn
Lactulose(30) ML PO Q8H as needed for constipation.
Reglan 10 mg One (1) Tablet PO every 6-8 hours prn nausea
Ferrous Sulfate 325 mgOne (1) Tablet PO once a day.
Ativan
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 3 days.
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 6 days.
6. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 days.
7. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. Maalox 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO every
six (6) hours as needed for pain with swallowing.
9. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Neb Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
10. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for pain.
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
16. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety/seizure.
17. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gm PO DAILY (Daily) as needed for constipation.
19. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) Neb
Miscellaneous TID PRN () as needed for wheezing/cough.
20. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
21. Guaifenesin AC 10-100 mg/5 mL Syrup Sig: [**4-20**] ml PO four
times a day as needed for cough.
22. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1)
Tab, Multiphasic Release 12 hr PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary Diagnosis:
renal cell cancer with mediastinal/bronchial metastases
Secondary Diagnoses:
systolic CHF
sciatica
Chronic sinusitis
benign breast cyst
C-section
seasonal allergies
Discharge Condition:
stable and improved
Discharge Instructions:
You were admitted to the hospital with difficulty swallowing and
fever. You finished radiation to your esophagus, and your
discomfort was thought to be due to a possible infection in your
esophagus or from the radiation itself. You then developed some
confusion, which was thought to be due to a low sodium level.
You improved somewhat after your sodium was increased and you
received IVF. However, you developed increased confusion and an
inability to speak, which was due to a seizure. This improved
dramatically after you received treatment for your seizure. You
will need to continue taking a medication to prevent future
seizures. You also had an ultrasound of your heart which showed
decreased function (EF of 20%), but luckily you did not have
symptoms from this. You also had 2 bronchoscopies to help clean
out your airways. You will need rehabilitation.
.
Medications:
Most of your medications have changed. Please see the list
provided to your rehabilitation center.
- You will be transitioned from phenytoin to Keppra as indicated
on your medication list and on the discharge summary.
.
Please call your doctor or return to the ER if you have
increasing pain, confusion, fevers/chills, nausea/vomiting,
diarrhea, chest pain or other concerns.
Followup Instructions:
You should call the neurology clinic ([**Telephone/Fax (1) 2528**] for an
appoinment in the next 2-4 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2183-9-30**]
2:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 4322**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2183-9-30**] 2:00
[**First Name8 (NamePattern2) 828**] [**Name8 (MD) 829**], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2183-10-6**] 10:00
|
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icd9cm
|
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[
[]
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40,183
| 122,960
|
35205
|
Discharge summary
|
report
|
Admission Date: [**2143-11-18**] Discharge Date: [**2143-12-6**]
Date of Birth: [**2091-3-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Zetia / Simvastatin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
[**11-18**] External Ventricular Drain placement, [**11-20**] Left
Craniotomy cauterization of AVM, post-op angiogram, [**11-26**]
Ventriculo Peritoneal Shunt placement, Cyberknife therapy
[**2143-12-5**] for mirror AVM on L
History of Present Illness:
HPI: 52M transferred from an OSH with a L ICH. Pt reportedly
presented to OSH due to headache in setting of recent URI
empirically treated with amoxicillin. A CT scan discovered a L
ICH and was transferred to [**Hospital1 18**]. On initial presentation, pt's
exam was remarkable for encephalopathy and nuchal rigidity. He
also has some difficulty with visual tracking (saccadic
intrusions with upgaze). His labs showed a leukocytosis. Pt was
reportedly GCS13-14, somewhat confused on arrival and mental
status has been progressively declining to GCS9 in matter of
2-3hours.
Past Medical History:
PMHx: anxiety, HLD, glucose intolerance, colonic polys removed,
R
ankle surgery, L knee surgery, appy?
Social History:
Social Hx:-denies EtOH, tobacco, drugs
-divorced, 2 children
-works at the post office
Family History:
Family Hx:-mother: stroke, emphysema
Physical Exam:
PHYSICAL EXAM:
O: T:100.5 BP: 176/74 HR:50 R:18 O2Sats:98%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3mm fixed b/l EOM unable to assess
Neck: unable to assess
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Opens eyes to noxious stimuli, inconsistently
gives "thumbs up", inconsistently localize to pain in left
extremity, withdrawals to pain in all extremities
Orientation: unable to assess.
Recall: unable to assess.
Language: makes incomprehensible sounds.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils 4mm to 3mm bilaterally.
III, IV, VI: intact
V, VII:intact
VIII: Hearing intact to voice.
IX, X: +gag reflex.
[**Doctor First Name 81**]: intact
XII: intact
Motor: moves all extremities to command
Sensation: grossly intact
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
On discharge pt is neurologically intact without deficits.
Pertinent Results:
CT HEAD [**2143-11-18**]
IMPRESSION: Left frontal lobe parenchymal hemorrhage with
ventricular extension as above, associated with moderate
hydrocephalus, concerning for obstruction at the level of the
aqueduct.
CTA HEAD W&W/O C & RECONS [**2143-11-18**]
IMPRESSION: AVM seen in the right frontal lobe adjacent to the
midline at the vertex. Interval decrease in ventriculomegaly
status post external ventricular drainage. Questionable aneurysm
is seen in the area of the left MCA.
Dopplers:
INDICATION: 52-year-old man with left calf tenderness in
prolonged bed rest.
Evaluate for DVT.
COMPARISON: No previous exam for comparison.
FINDINGS: Grayscale, color and Doppler son[**Name (NI) 1417**] of the left
common femoral,
superficial femoral, popliteal and tibial veins were performed.
There is
normal flow, compression and augmentation seen in all of the
vessels.
IMPRESSION: No evidence of deep vein thrombosis in the left leg.
The study and the report were reviewed by the staff radiologist.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20982**], RDMS
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
CT head [**11-24**]
CT HEAD WITHOUT IV CONTRAST: Appearance of the ventricular
system is
unchanged from 10 hours prior, again measuring 13 mm in maximal
width the
right lateral ventricle. Right intraventricular catheter again
terminates
near the midline from a right frontal approach. The patient is
also status
post left pterional craniotomy. Appearance of left frontal
parenchymal
hematoma is again mildly decreased, likely due to continued
evolution,
currently measuring 4.1 x 2.4 cm. Left temporal extra-axial
hematoma again
measures up to 8 mm in thickness. 5-mm rightward shift of
normally midline
structures is unchanged. Mild mass effect on the left uncus is
similar in
appearance compared to the prior study. There may be subtle
increase in
sulcal effacement along the right cerebral hemisphere.
Layering hematoma in the right occipital [**Doctor Last Name 534**] is less
conspicuous although a
small amount of hematoma is again seen layering in the left
occipital [**Doctor Last Name 534**]. In
addition, blood clot remains within the left frontal [**Doctor Last Name 534**]. Small
amount of
pneumocephalus remains. Appearance of subcutaneous gas and
subgaleal hematoma
along the left is similar to the prior study. Mucosal thickening
is unchanged
in the left sphenoid and maxillary sinuses. Partial
opacification of the left
mastoid air cells is again noted.
IMPRESSION: Overall exam is little changed compared to 10 hours
prior, with
stable appearance to the ventricular system after placement of
right
intraventricular catheter. Left extra-axial hematoma and left
frontal
parenchymal hematoma are similar in appearance. Rightward shift
of normally
midline structures and mild mass effect on the left uncus are
similar to
prior. There may be subtle increase in sulcal effacement along
the right
cerebral hemisphere. Left subgaleal hematoma not increased.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: MON [**2143-11-25**] 1:59 PM
Brief Hospital Course:
Pt was admitted on [**2143-11-18**] with ICH with hydrocephalus seen on
CT from OSH. His mental status declined rapidly and EVD
placed.[**11-19**]: Neuro intact. follows commands x4extremities with
sedation off. EVD @15cm;open. EEG done which did not show
seizure activity. [**11-19**]: Aneuyrsm Coiling not done, therefore on
[**11-20**] pt went to O.R. for an open Left craniotomy for venous
aneurysm/AVM cauterization. [**11-21**]: extubated.
possibly secondary to getting Dilaudid prior to exam. On [**11-23**]:
CSF [**First Name9 (NamePattern2) 80329**] [**Last Name (un) 26734**] 500 WBC with fever; trial of EVD clamped
failed. [**11-24**] Spiked fever to 101.8 Repeat CSF sent which
resulted negatively. [**11-25**] failed clamp again, Urine culture neg.
[**11-26**]: VPShunt placed. Pt also developed generalized rash,
Dilantin D/c'ed Keppra started. [**11-27**]: EEG No epileptiform
foci,Widespread encephlopathy. Left focal slowing. Diet resumed.
Na 131 - fluid restriction 1500cc [**11-28**]: A+O [**2-24**]., head sutures
d/c'ed. [**11-29**]: A+O x3. VSS. Following commands, PT/OT oob to
chair. feeding self. To stepdown vs floor which ever bed avail.
[**12-6**]: pt. transfered to [**Hospital Ward Name **] at [**Hospital1 18**] for the afternoon
for cyberknife treatment of Left sided AVM, no complications
noted, procedure tolerated well. Was started on Lopressor for HR
100-110. Today HR 70's. Please follow.
Medications on Admission:
None
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-23**]
Drops Ophthalmic PRN (as needed).
8. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for fever or pain. Tablet(s)
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed: To affected areas.
11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-23**]
Drops Ophthalmic PRN (as needed).
12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for Headache.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
15. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Please hld for SBP <100 and HR <60.
17. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Left intracranial hemorrhage, left venous AVM, right anterior
artery AVM
Discharge Condition:
Neurosurgically stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection such as redness, drainage or swelling.
?????? Take your pain medicine as prescribed. If you are taking a
narcotic such as Percocet or Dilaudid you should not drive while
taking this medication. [**Month (only) 116**] cause drowsiness and impair your
ability to drive a car.
?????? Exercise should be limited to walking; no lifting >10lbs which
is approx. a gallon of milk. No straining or holding breath such
as when moving your bowels or coughing. No excessive bending.
?????? You may wash your hair only after sutures and staples have
been removed. You should use a mild shampoo such as [**Location (un) **] and
[**Location (un) **] baby shampoo initially.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
?????? 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
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in one month.
??????You will need imaging of your brain, A CT, without contrast,
That will be arranged by the office for you.
Completed by:[**2143-12-6**]
|
[
"430",
"747.81",
"253.6",
"693.0",
"998.81",
"E878.8",
"E947.8",
"E849.7",
"451.9",
"331.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.34",
"93.59",
"38.91",
"92.39",
"96.04",
"38.93",
"96.71",
"02.2",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
8951, 9025
|
5826, 7257
|
308, 535
|
9142, 9167
|
2459, 5803
|
11120, 11434
|
1387, 1426
|
7312, 8928
|
9046, 9121
|
7283, 7289
|
9191, 11097
|
1456, 1721
|
243, 270
|
563, 1139
|
2057, 2440
|
1736, 2041
|
1161, 1266
|
1282, 1371
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,123
| 185,864
|
30694
|
Discharge summary
|
report
|
Admission Date: [**2187-7-14**] Discharge Date: [**2187-7-28**]
Date of Birth: [**2126-5-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 16983**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
paracentesis
History of Present Illness:
HPI:
.
The patient is a 61 year old male with a history of a recently
diagnosed by CT scan of the chest on [**2187-5-15**] RCC measuring 15
x 4 x 13.8 cm with extensive metastatic disease including
extensive retroperitoneal lymphadenopathy, multiple pulmonary
nodules, bone mets, ascites, and soft tissue attenuation within
the region of the greater omentum suspicious for peritoneal
carcinomatosis on Sutent chemotherapy who presented to the ER on
[**2187-7-14**] with the chief complaint of lightheadedness, dizziness
and increased shortness of breath.
.
The patient has had a chronic cough since [**11-27**] but over the
past 5 weeks has noted increased shortness of breath which he
dismissed as he felt better on Sutent (Tyrosine Kinase
Inhibitor) for his RCC. However, he noted the day prior to
admission, while walking to his attorney's office, that he could
not walk 350 feet approximately without having to stop twice for
shortness of breath. This is a clear change from his baseline
which is unlimited. He denies any chest pain, no radiation to
his left arm, back or jaw. No diaphoresis. He denies any weight
gain or lower extremity edema. No calf pain. However, he does
report increased orthopnea within the past few weeks. He does
admit to having blood-tinged sputum. The patient states that in
the ER, he had approximately a table-spoon of hemoptysis.
.
Also, the patient reports a 3 week history of yellow colored
"diarrhea" with poor PO intake and fatigue. His definition of
diarrhea is [**1-23**] small bowel movements ranging from loose to
watery in nature that began when he started antibiotics in [**Month (only) 547**]
for a presumed pneumonia. The day prior to presentation, he had
non-bilious emesis x 3 which he felt was secondary to the
chemotherapy.
.
He also reports lightheadedness, dizziness, no syncope or
presyncope. As his breathing was worse and he felt lightheaded,
he called his oncologist who referred him to the ED. Of note,
the patient takes atenolol, lisinopril and triamterene/HCTZ at
baseline and was taking these until 2 days ago as he felt his BP
might be low.
.
In the ER, the patient's lactate was found to be 3.8 and 3.9 in
the setting of known malignancy which oncology felt was not
necessarily indicative of infection. His SBP on presentation 70
systolic. The patient had 2 18 gauge peripheral IVs placed and
was given a total of 3 liters of IVF with a systolic blood
pressure in the low 100s.
.
The patient was also found to have acute renal failure with a Cr
of 3.9 (baseline Cr 1.6-1.9) and BUN of 59. Na 132. CK 130, MB
10, MBI 7.7, troponin 0.10. His Hct was 40 (baseline 36-43) and
on rectal had gross blood around the rectum with a history of
internal/external hemorrhoids.
.
In addition to IVF, the patient was given vanc/levo/flagyl
empirically for ?sepsis with no clear source on CXR although
there was a suspicion for ?RLL infiltrate on CXR by the ED.
.
Cardiology was consulted in the ED for a stat echo to assess for
RV strain with concern for PE in the setting of dyspnea but it
was unclear at the time if it was necessary.
.
His EKG showed:
.
NSR at 83 bpm. NL axis. Low voltage. QTC 412 ms. [**First Name (Titles) **] [**Last Name (Titles) **] in I, Q
in lead III. TW flattening II, III, AVF, I, AVL, V4-V6. No
baseline for comparison.
.
Given his acute renal failure, the patient was unable to obtain
a CT-A and given his metastatic disease, a VQ scan was felt to
be unhelpful as well. Oncology requested that if his BP resolved
with IVF, that heparin not be initiated unless clearly
indicated. However, the patient did have bilateral lower
extremity dopplers which showed:
.
1. Acute thrombus within the left common femoral vein which is
nonocclusive.
2. No evidence of DVT within the right lower extremity.
3. Evidence of ascites.
.
On arrival to the MICU, the patient's SBP was 89/65 systolic. He
was sat'ing 97% on 3 liters NC with no apparent respiratory
distress.
.
ROS:
.
16 pound weight loss over past year with increased abdominal
girth. No fevers/chills. No headaches but change in vision over
past few weeks. The patient had been hospitalized at [**Hospital 42317**]
Hospital in [**4-28**] for ?pneumonia for which he was treated with
levaquin and had a chest CT which diagnosed the RCC with mets.
Positive burning with urination. Bright red blood per rectum
only with wiping. No history of bloody stools.
.
Past Medical History:
PMH:
.
HTN
internal/external hemorrhoids
Metastatic renal cell carcinoma - diagnosed in [**4-28**] on chest CT
for workup of chronic cough, ? pneumonia
Prior right medial cerebellar infarct (asymptomatic, seen on
brain MRI)
H/o ETOH abuse requiring hospitalization 28 years ago, no
history of DTs
.
Past Surgical History:
.
Bronch [**2187-5-25**] with biopsy: poorly differentiated carcinoma
Social History:
Social History:
.
The patient lives with his wife and children in
[**Location 72727**] [**State 350**]. He smoked one pack per week for 30
years but quit 10 years ago. He formerly drank about [**4-26**]
brandies every evening 28 years ago. Last drink 6 months ago -
claims to drink on occasion at present. He lives close to New
[**Location (un) 8957**], [**State 350**]. He has three sons, ages 35, 28, and
18, respectively. The 35 and 18-year-old live at home. Retired
employement officer. Nephew is [**Name (NI) **] attending at [**Hospital1 18**].
.
Family History:
Family History:
.
Significant for maternal grandfather with rectal
cancer. Sister with breast cancer. No CAD, DMII.
Physical Exam:
Tc = 98.5 P = 88 BP = 89/65 RR = 20 97% on 3 liters O2 sat
.
Gen - NAD, no accessory respiratory muscles, speaks full
sentences
HEENT - 8 cm external JVD, PERLA, pale lips
Heart - RRR, grade II/VI holosystolic murmur at LLSB
Lungs - Diffuse expiratory wheezes bilaterally, no crackles
Abdomen - Distended, active bowel sounds, + fluid [**Hospital1 **], NT
Ext - No C/C/E, no calf tenderness bilaterally
Back - No CVAT
Skin - Spiculated, melanotic appearing nevi on back -> need
outpatient follow up
Neuro - CN II-XII intact, negative Babinski's bilaterally
Rectal (in ER) - gross blood around rectum
.
Pertinent Results:
EKG [**2187-7-14**]:
NSR at 83 bpm. NL axis. Low voltage. QTC 412 ms. [**First Name (Titles) **] [**Last Name (Titles) **] in I, Q
in lead III. TW flattening II, III, AVF, I, AVL, V4-V6. No
baseline for comparison.
.
CXR [**2187-7-14**]:
Probable diffuse metastatic disease including mediastinal and
hilar lymphadenopathy, as well as pulmonary edema. No
significant pleural effusions.
.
U/S LE Bilateral [**2187-7-14**]:
1. Acute thrombus within the left common femoral vein which is
nonocclusive.
2. No evidence of DVT within the right lower extremity.
3. Evidence of ascites.
.
Head CT [**2187-7-14**]:
.
1. No intracranial abnormality is detected.
2. Mucosal sinus thickening and aerosolized secretions within
the right maxillary sinus which may be consistent with acute
sinusitis.
.
CXR. [**2187-7-17**].
Stable interstitial edema and nodular pulmonary opacities.
Stable small left pleural effusion. Unchanged rectangular right
perihilar opacity which again could represent atelectasis,
pneumonia, or fissural fluid.
.
Renal Ultrasound: [**2187-7-16**].
1. No right-sided hydronephrosis. Large left renal mass
partially imaged.
2. Moderate ascites.
3. Right pleural effusion partially imaged.
.
Echo [**2187-7-14**]. Dilated right ventricle with moderate RV systolic
dysfunction. Preserved left ventricular global and regional
systolic function. Moderate tricuspid regurgitation. Mild aortic
regurgitation. Small pericardial effusion without tamponade.
Brief Hospital Course:
MR. [**Known lastname 3748**] is a 61 yo male with recently diagnosed metastatic
RCC on Sutent who was admitted for presumed PE s/p IVC filter
because unable to be anticoagulated because of active
hemoptysis.
.
1. Presumed PE. Patient has dypnea because of a presumed PE in
addition to extensive metastases to the lung. A DVT was
confirmed on LE doppler and echo showed RV systolic dysfunction.
A CTA could not be done because patient had ARF. Because he is
not a candidate for anticoagulation given his extensive lung
mets with hemoptysis, an IVC filter was placed. Oxygen
saturation improved over course of stay. On discharge, he was
requiring on ly 2LNC of oxygen.
.
2. ARF. Patient developed pre-renal ARF during
hospitalization, which improved over hospital stay.
.
3. Urinary retention. Patient reports that he has been told he
has a large prostate, although he does not carry the diagosis of
BPH. Patient failed a voiding trail after removal of foley, so
started on lasix and aldosterone to improve UOP and to treat
abdominal ascites. Was voiding without problems on discharge.
.
3. Ascites. Pt. has significant ascites likely from the
cancer. Paracentesis was performed on [**2187-7-22**]. Was sent home on
aldactone and lasix to improve abdominal ascites and UOP.
.
4. Metastatic RCC. He has RCC with bone, lung, and peritoneal
metastases. He was recently treated with one month of Sutent.
Management of cancer by Dr. [**Last Name (STitle) **].
.
Full code.
Medications on Admission:
Medications:
Lisinopril 40 mg p.o. daily
Atenolol 50 mg p.o. daily
Triamterene/hydrochlorothiazide 37.5/12.5 mg p.o. daily
Recently on Sutent chemotherapy - last dose last Sunday
Discharge Medications:
1. Oxygen
Home oxygen delivered at 3L by nasal canula.
2. hospital bed
Hospital bed
3. Commode
Commode
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
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. 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*
8. Oxycodone 5 mg/5 mL Solution Sig: One (1) 5 ml Solution PO
Q3-4HRS () as needed for pain.
Disp:*100 5 ml Solution* Refills:*0*
9. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home Care Services
Discharge Diagnosis:
Pulmonary embolism
Renal cell carcinoma
urinary retention
hemorroids
Discharge Condition:
fair.
Discharge Instructions:
You were admitted to the hosptial for a pulmonary embolism.
.
Please note that your lisinopril and atenolol have been stopped.
Please discuss restarting these medications with your Primary
Physicians as an outpatient.
.
You were started on two new medications to reduce the swelling
in your abdomen and to aid in urination, called aldactone and
lasix. These medications will replace triamterene and
hydrochlorothizide.
You have also been given fentanyl patch and oxycodone to be
taken as needed for pain.
Please call your doctor or return to the hospital for worsening
shortness of breath, chest pain, fevers, chills, or any other
concerns.
Followup Instructions:
Please see Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] on [**2187-7-30**] at 2:30.
Phone:[**Telephone/Fax (1) 22**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16984**] MD, [**MD Number(3) 16985**]
|
[
"788.20",
"584.9",
"198.5",
"415.19",
"486",
"197.6",
"455.2",
"197.0",
"605",
"196.1",
"189.0",
"453.41",
"455.5",
"196.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"54.91",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
10922, 10992
|
8016, 9503
|
328, 343
|
11105, 11113
|
6522, 7993
|
11805, 12114
|
5780, 5882
|
9733, 10899
|
11013, 11084
|
9529, 9710
|
11137, 11782
|
5101, 5173
|
5897, 6503
|
277, 290
|
371, 4757
|
4779, 5078
|
5205, 5748
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,973
| 177,593
|
3380
|
Discharge summary
|
report
|
Admission Date: [**2175-7-14**] Discharge Date: [**2175-7-17**]
Date of Birth: [**2095-12-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Rectal bleeding [**1-25**] prostate biopsy.
Major Surgical or Invasive Procedure:
Colonoscopy.
Tagged RBC scan.
History of Present Illness:
79 yo AAM w/PMH sx for CAD s/p CABGx2 and PCI, ventricular
pacer, DM2, and BPH s/p recent biopsy for elevated PSA who was
at home sitting at his computer when he felt the urge to
defecate. He notes that he delayed going to the bathroom for a
while, then noted increasing urgency to move his bowels, and on
the way to the bathroom, he passed a large amount of bright red
blood per rectum, with associated lighthesadness. No SOB, chest
pain, nausea or vomiting, or SOB. At the time, he called EMS and
was transported to the ED, where he continued to pass multiple
clots of BRB. He was transferred emergently to the MICU for
stabilization.
Past Medical History:
CAD s/p CABG X 2 and PCI, Pacer
DM-2 on insulin
PVD.
BPH
Chronic anemia
Chronic thrombocytopenia
Prostate Cancer - diagnosed today - had biopsy one week ago
today, but did not have any bleeding afterwards at that time.
Social History:
Retired [**University/College **] Biochemistry Professor. Quit tobacco in [**2154**]
Occasional ETOH - one glass of wine per day. Lives at home with
his wife. Children in the area.
Family History:
DM-2
Physical Exam:
Tm 98.8 BP 140/57 HR 64 O2 sat: 93% 2L
Gen: well appearing. alert and oriented. hard of hearing.
conversing comfortably.
HEENT: PERRL. EOMI. MMM. JVD to 12 cm.
Lungs: Inspiratory bibasilar crackles. Poor inspiratory effort.
No rales or rhonchi.
Hrt: Irreg irreg. No MRG.
Abd: S/NT. Mildly distended. +BS. Fem art sheath in place. No
bleeding or tenderness at site.
Ext: 2+ pitting edema in BLE. 2+carotid, radial, DP pulses.
Purplish discoloration of BLE. No rash or tenderness.
Neuro: 5/5 mm strength bilaterally. Intention tremor. Negative
FTN.
Pertinent Results:
[**2175-7-14**]
Hct 27.7 --> 33.8
CEx3 negative.
[**2175-7-14**]
PT: 13.5 PTT: 27.1 INR: 1.2
137 101 65 / 246 AGap=16
-------------
4.6 25 1.9
7.4 \ 9.6 / 127
------
27.7
N:69.5 L:20.4 M:6.4 E:3.3 Bas:0.4
PT: 13.9 PTT: 27.5 INR: 1.3
UA Lg nitrites. >50 WBC. 0-2 bact. Neg LE.
EKG: V-paced. Unchanged from prior.
GI Bleeding study:
INTERPRETATION: Following intravenous injection of autologous
red blood cells
label with technetium-[**Age over 90 **]m, blood flow and delayed images of the
abdomen were
obtained for 90 minutes.
Blood-flow images do not show any abnormal trace of activity.
Delayed blood-flow images show increased trace of activity in
the area behind
the urinary bladder. This area is somewhat obscured by the
activity in the
urinary bladder and the penile contamination. Increased trace of
activity is
also seen in the sheets adjacent to the patient's buttock, who
was having bright
red blood per rectum during the time of this study.
IMPRESSION: Findings are consistent with active bleeding in the
rectosigmoid
area.
IR Embolization:
No active extravasation of contrast. No evidence of
angiodysplasia,
arteriovenous malformation or aneurysm involving the bowel
vascular tree. No
finding is present for which intervention could be directed.
Local anesthesia in the right inguinal region with 5 cc of 1%
lidocaine.
A total of 44 cc of Optiray radiograph contrast was utilized.
No immediate complications.
IMPRESSION: No angiographic finding that could warrant
intervention.
Follow-up with endoscopy may be of use, if indicated.
On discussion with the intensive care unit the right common
femoral 5-French
vascular sheath was left in situ postprocedure. All other
equipment was
removed. The sheath was fixed in place with a single 0 silk
suture and a
Tegaderm dressing.
Sigmoidoscopy:
A single diverticulum was seen in the splenic, however, the
presence of more diverticula can not be excluded due to the poor
prep.
Colonoscopy:
Impression: 1. An adherent clot at 8 cm from the anal verge and
localized to the left lobe of prostate gland by simultaneous
palpation and endoscopy. Source of GI bleeding is due to
post-prostate biopsy bleed. Two endoclips placed for hemostasis.
2. Angioectasia in the mid-ascending colon
3. Polyp in the sigmoid colon
4. Diverticulosis of the sigmoid colon
Brief Hospital Course:
IMPRESSION: 79 year old man with hx CAD and MI s/p PTCA on
Plavix and ASA, ventricular pacer, DM2, and prostate cancer
presents with BRBPR [**1-25**] prostate biopsy performed several days
prior.
1. BRBPR: On admission to the MICU, patient was initially
stable, and in the early morning, he became tachycardic, and
dropped his blood pressure into the 60s/30s, and received 4u
pRBCs and 2L NS for resuscitation. On evaluation by GI, patient
was felt to need a tagged RBC scan by IR, which showed bleeding
at the rectal sigmoid junction, with continued BRBPR. An
embolization was attempted in IR, but it was felt that they were
unable to localize the bleeding and the embolization was
unsuccessful. A femoral sheath was left in place at the time. A
sigmoidoscopy was attempted as well, but also did not localize
site of bleeding due to incomplete bowel prep. Patient was then
prepped for colonscopy in AM to attempt to further localize the
site of bleeding. Colonoscopy was performed, and showed an
adherent clot at left lobe of the prostate gland, with endoclips
applied for hemostatis, as well as angioectasia, polyps, and
diverticuli. It was felt that the source of GI bleeding was due
to post-prostate biopsy bleeding.
After hemostasis was achieved during colonoscopy, patient
remained stable with no further decrease in hematocrit. His
platelet count decreased to 75 throughout admission; a HIT panel
was sent and pending at the time of discharge. Patient was
placed on IV protonix, and his plavix and aspirin were held. Two
large bore peripheral IVs were placed, and patient was
transitioned to po Protonix. Patient's hematocrit was monitored
closely. On admission, hematocrit was originally 27.7, which
dropped to 23, and after transfusion of 7u pRBC, his hematocrit
stabilized at 35. On discharge, his hematocrit was
He had trace OB+ stools on discharge, felt to be residual from
his large volume LGIB two days prior.
2. CAD. Patient had three sets of negative cardiac enzymes and
no changes on EKG, as well as no complaints of chest pain. He
was restarted on his blood pressure medications when he was
transferred out of the MICU; however, he had an asymptomatic
hypotensive episode of SBP in the 90s, and patient's lisinopril
and Imdur were both discontinued, and he was discharged only on
metoprolol 50 mg po qd. He was also restarted on his
atorvastatin 10 mg po qd.
3. DM2, on insulin. Patient was placed on a diabetic diet, with
FSQID and SSI per his [**Last Name (un) **] sliding scale with NPH 18 qam and
17 qpm.
4. Prostate cancer. Patient's prostate cancer was diagnosed on
the day of the prostate biopsy. Stage is unknown.
5. FEN. His electrolytes were stable throughout admission. He
was able to take full diet. His I/Os and daily weights were
monitored.
6. Rehabilitation. Patient was seen by physical therapy during
his admission.
7. Access - Patient had two large-bore peripheral IV's placed.
8. Code - DNR/DNI.
9. Disposition - Patient was discharged to home.
Medications on Admission:
Isosorbide
Lasix
Flomax
Toprol
Lipitor
Plavix
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO HS (at bedtime).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
take 40 mg 5 days a week and 20 mg 2 days per week.
4. Insulin 70/30 70-30 unit/mL Suspension Sig: 18 u Qam, 17 u
QPM as directed Subcutaneous twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Rectal Bleed
Discharge Condition:
good
Discharge Instructions:
Please do not take your Aspirin, Plavix, Toprol, Lisinopril and
Isosorbide until you follow up with Dr. [**First Name (STitle) **] in the [**Hospital 191**]
clinic.
Return to the ED or call your doctor if you have any episodes of
rectal bleeding, lightheadedness, dizziness, shortness of
breath, chest pain or if your symptoms worsen.
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **] or one of his colleagues at the [**Hospital 191**]
clinic in 1 week. Call [**Telephone/Fax (1) 1247**] to make an appointment. He
will take your blood pressure and talk to you about restarting
your blood pressure medications as well as your aspirin and
plavix.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"185",
"569.3",
"E878.8",
"998.11",
"V58.67",
"584.9",
"285.1",
"250.00",
"600.00",
"V45.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"45.43",
"45.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7997, 8003
|
4477, 7470
|
367, 399
|
8060, 8066
|
2110, 4454
|
8450, 8896
|
1522, 1528
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7566, 7974
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8024, 8039
|
7496, 7543
|
8090, 8427
|
1543, 2091
|
284, 329
|
427, 1065
|
1087, 1307
|
1323, 1506
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,186
| 177,474
|
1285
|
Discharge summary
|
report
|
Admission Date: [**2146-5-16**] Discharge Date: [**2146-6-28**]
Date of Birth: [**2079-5-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / latex
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
- Central Line Placement and Removal
History of Present Illness:
Ms. [**Known lastname **] is a 67 year old woman with a history of prior CVA's.
She has left sided hemiparesis at baseline and speaks only a few
words. She lives at a nursing facility. Her daughter visited her
on her birthday ([**5-11**]). She reports that the patient was
less responsive and kept her mouth open during the whole visit.
It is unclear if she improved back to her baseline. This AM she
was reportedly less responsive than normal per the staff at the
nursing facility. She was also diaphoretic. An ambulance was
called and she was brought to the [**Hospital1 18**] ED. Her blood glucose en
route was 117.
.
In the ED, initial vital signs were 84/60 116 99% on room air.
She spiked a temp to 102 while in the ED. Labs were significant
for sodium of 173, creatinine of 2.7, troponin of 0.14, and
lactate of 1.3 (after fluid). Urinalysis showed large leuk
esterase. She received 4.5 L of normal saline. Her chest xray
was clear. There was no evidence of new stroke on CT. Her BP's
continued to drop in the ED. A central line was placed and she
was started on levophed.
.
On arrival to the MICU, patient did not respond to questions or
movement.
Past Medical History:
- s/p thromboembolic CVA w L hemiplegia, nonverbal
- Atrial fibrillation on coumadin
- Hyperlipidemia
- Hypertension
- Seizures
Social History:
Patient lived at a nursing facility. She was a phlebotomist at
[**Hospital1 18**].
Family History:
Unable to obtain
Physical Exam:
ADMISSION EXAM:
Vitals: T:99.0 BP:112/63 P:91 RR:17 O2:98% on RA
General: Awke, nonverbal, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI grossly
intact but unable to follow commands to track finder, PERRL
Neck: JVP not elevated
CV: Tachycardic and irregular, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally on the anterior, no
wheezes, rales, rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact grossly, able to move RUE, did not see
patient move LUE/LLE or RLE.
.
DISCHARGE EXAM:
Physical Exam:
Is/Os: incontinent of urine, In was about 1600cc
Vitals: T97.1, BP 136/58, HR 61, RR 17, O2Sat 100% RA
General: asleep, sometimes opens eyes to voice, nonverbal,
unable to follow commands, no acute distress, comfortable
appearing
CV: RRR, irregular, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally on anterior exam, no
wheezes/rales/rhonchi
Abdomen: soft, non-distended, bowel sounds present, feeding tube
in place in epigastric region with clean dry bandage
GU: no Foley, diaper, healing stage 1 ulcer with clean dry
bandage
Ext: RLE and LLE warm, well-perfused, 1+ DP pulses bilaterally,
2+ popliteal pulses bilaterally. Slow capillary refill
bilaterally
Neuro: deferred
Pertinent Results:
Blood Counts
[**2146-5-16**] 12:20PM BLOOD WBC-11.6* RBC-4.83 Hgb-13.8 Hct-45.2
MCV-94 MCH-28.6 MCHC-30.6* RDW-14.4 Plt Ct-190
[**2146-5-17**] 05:03AM BLOOD WBC-14.8* RBC-4.00* Hgb-11.5* Hct-38.5
MCV-96 MCH-28.9 MCHC-29.9* RDW-14.2 Plt Ct-194
[**2146-6-1**] 07:30PM BLOOD WBC-4.1 RBC-3.62* Hgb-10.4* Hct-32.5*
MCV-90 MCH-28.8 MCHC-32.2 RDW-15.5 Plt Ct-132*
[**2146-6-3**] 08:35AM BLOOD WBC-3.2* RBC-3.49* Hgb-10.1* Hct-31.2*
MCV-89 MCH-29.0 MCHC-32.5 RDW-15.5 Plt Ct-144*
[**2146-6-5**] 07:15AM BLOOD WBC-2.5* RBC-3.37* Hgb-9.6* Hct-30.0*
MCV-89 MCH-28.5 MCHC-32.0 RDW-15.1 Plt Ct-148*
[**2146-6-24**] 07:25AM BLOOD WBC-2.9* RBC-4.09* Hgb-11.6* Hct-36.4
MCV-89 MCH-28.3 MCHC-31.8 RDW-14.9 Plt Ct-194
[**2146-6-24**] 07:25AM BLOOD Neuts-41.2* Lymphs-44.8* Monos-11.3*
Eos-2.4 Baso-0.4
.
Coagulation Panel
[**2146-5-16**] 03:05PM BLOOD PT-56.0* PTT-43.9* INR(PT)-5.6*
[**2146-6-3**] 08:35AM BLOOD PT-21.2* PTT-36.0 INR(PT)-2.0*
[**2146-6-23**] 07:45AM BLOOD PT-24.7* PTT-45.2* INR(PT)-2.4*
.
Chemistries
[**2146-5-16**] 12:20PM BLOOD Glucose-144* UreaN-73* Creat-2.7* Na-173*
K-4.6 Cl-140* HCO3-23 AnGap-15
[**2146-5-18**] 09:56AM BLOOD UreaN-26* Creat-1.2* Na-151* K-3.2*
Cl-124*
[**2146-5-21**] 09:54AM BLOOD Glucose-106* UreaN-20 Creat-1.0 Na-143
K-3.6 Cl-110* HCO3-26 AnGap-11
[**2146-6-3**] 08:35AM BLOOD Glucose-109* UreaN-17 Creat-0.8 Na-141
K-4.0 Cl-106 HCO3-29 AnGap-10
[**2146-6-23**] 07:45AM BLOOD Glucose-94 UreaN-17 Creat-0.8 Na-142
K-3.8 Cl-106 HCO3-27 AnGap-13
[**2146-6-23**] 07:45AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0
.
Microbiology
URINE CULTURE (Final [**2146-5-18**]):
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
IMAGING:
[**2146-5-16**] CXR: No acute cardiopulmonary process.
.
[**2146-5-16**] Head CT: Encephalomalacia, no evidence of acute
hemorrhage, several chronic changes.
.
[**2146-5-19**] TTE
Biatrial enlargement. Moderate symmetric left ventricular
hypertrophy with normal cavity size and preserved global and
regional biventricular systolic function. Increased left
ventricular filling pressure. No valvular vegetations or
abscesses appreciated. Indeterminate pulmonary artery systolic
pressure.
.
[**2146-6-2**] R Lower Extremity Arterial Duplex
No evidence of fixed arterial obstruction. Mild atherosclerotic
disease with biphasic waveforms.
.
[**2146-6-2**] R Arterial Doppler Study
Mild right lower extremity peripheral vascular disease based on
ABIs and Doppler waveforms. No significant left-sided arterial
vascular
disease. PVRs seem discordant and are likely artifactually low.
Brief Hospital Course:
This is a 67yo F PMhx Afib w prior thromboembolic CVAs w
resulting nonverbal state and L hemiparesis who presented with
hypotension, hypernatremia to 160, found to have a urinary tract
infection, treated with antibiotics and fluids, course
complicated by seizure, now with lab values returning to
baseline
ACTIVE ISSUES
# Septicemia / UTI / Hypovolemia: Patient was admitted w
hypotension, fever, positive UA, requiring 2d of vasopressors
and aggressive fluid resuscitation. She was initially covered
with cefepime, which was narrowed to ciprofloxacin once Ucx grew
Proteus. Additionally, she had coag negative staph grow from 2
blood cultures, thought to be contaminant, but for which she
received 4d of vancomycin. She completed a 7-day course of
Cipro (completed on [**2146-5-23**]).
# Hypernatremia: The was admitted with Na 173, thought to be
secondary to a free water deficit (estimated at 5 liters). She
was volume resuscitated and given free water to correct her
sodium over 3 days. Subsequently, the patient received
increased free water flushes for treatment of her hypernatremia
and serum Na remained stable in the low 140s.
# Metabolic Encephalopathy: On admission, patient was
unresponsive to voice or light touch. With correction of her
hypotension and UTI, her mental status improved to baseline
level of alertness: responsive to voice and touch, making vocal
sounds (though not speaking words), not following verbal
commands.
# Seizures: The patient's MICU course was c/p seizures, thought
to be secondary to her metabolic abnormalities. EEG showed
diffuse slowing, worse in the left temporal region, with
frequent spikes which can be seen in the post-ictal state. A CT
head showed evidence of her prior strokes but no acute process.
Neurology was consulted and patient was treated with Keppra for
seizure prophylaxis. The patient developed leukopenia to 2.5
after starting Keppra so the patient was transitioned to Vimpat
with which the WBC count has been stable at ~2.9-3.5.
# Acute Renal Failure: Admission creatinine was 2.7 (baseline is
~1.4 per the [**Hospital 228**] nursing home). This was likely pre-renal
and improved to her baseline with fluids. Cre at discharge was
0.8.
# Atrial fibrillation: Patient with a history of thromboembolic
CVA [**12-30**] afib; patient's coumadin was uptitrated during a
subtherapeutic episode. Given her history of prior CVA's she
will need to be bridged with enoxaparin for future INR<2.0. The
patient was also started on metoprolol for rate control.
# Peripheral Vascular Disease: Patient was noted to have
decreased pulses in R lower extremity on exam. Initially given
history of afib and a subtherapeutic INR there was concern for
arterial thromboembolism, however, pulses remained dopplerable
and arterial ultrasound did not demonstrate any fixed
obstruction. Mild peripheral vascular disease was noted. As
patient was already optimized from a cardiovascular perspective
(atorvastatin, metoprolol, ezetimibe, coumadin) no additional
medications were initiated.
# CAD - Continued atorvastatin, ezetimibe. Started metoprolol
for improved rate control.
# Hypertension - Patient was previously on amlodipine and
ramipril. These medications were held in the MICU. Amlodipine 5
mg was restarted. She was started lisinopril 10 mg daily
(therapeutic interchange while in hospital, given ramipril was
non-formulary).
# Leukopenia. Mild. Thought to be [**12-30**] drugs, such as Kappra.
She had recurrence of very mild leukopenia (2.9) and ranitidine
was held on [**2146-6-26**]. She will need to have repeat lab on
[**2146-7-1**] to check CBC.
INACTIVE ISSUES
# GERD. Patient was continued on ranitidine until [**2146-6-26**]
given mild leukopenia. She is on a ranitidine free trial to see
if the leukopenia is from medication.
.
TRANSITIONAL
1 - Full code
2 - Patient should be bridged with enoxaparin for INR < 2.0
3 - Given seizures during this visit, patient was scheduled for
follow-up with neurology
4 - Repeat CBC on [**2146-7-1**] to monitor for leukopenia
5 - Repeat INR, PT, PTT on [**2146-7-1**] to monitor warfarin therapy
Medications on Admission:
1. potassium daily 20 mEq
2. metoclopramide 10 mg q8 hours
3. jevity 1.2 50 cc/hr, 30 cc flush q8 hours, 200 cc flushes TID
4. lipitor 80 mg
5. ramipril 10 mg [**Hospital1 **]
6. amlodipine 5 mg
7. ranitidine 150 mg [**Hospital1 **]
8. ezetimibe 10 mg
9. warfarin 3 mg daily
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
2. Ezetimibe 10 mg PO DAILY
3. Lacosamide 100 mg PO BID
4. Warfarin 4 mg PO DAYS (MO,WE,FR)
M,W,F. Second order for Saturday.
5. Warfarin 5 mg PO DAYS (TU,TH)
Tues, Thurs. second order for Sunday
6. Amlodipine 5 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO TID
hold for HR<60, SBP<90
8. Ramipril 10 mg PO BID
9. Outpatient Lab Work
Please draw CBC, INR, PT, PTT on [**2146-7-1**]. This is for
leukopenia and atrial fibrillation on warfarin. Please fax the
result to the rehab center.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2251**] Nursing and Rehabilitation - [**Location (un) 2251**]
Discharge Diagnosis:
PRIMARY
- Septicemia with Urinary Tract Infection
- Metabolic Encephalopathy
- Seizure
SECONDARY
- s/p thromboembolic CVA w L hemiplegia, nonverbal
- Atrial fibrillation on coumadin
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to [**Hospital1 69**]
because you had a urinary tract infection and dehydration.
Your sodium level was also very high, causing you to have a
seizure. You were treated with course of antibiotics and you
received fluids. Your sodium improved. You were started on a
medication called Vimpat to prevent seizures. You were also
started on a medication called metoprolol because of your fast
heart rate, and you are now ready for discharge. We
discontinued your ranitidine because you have a very mild low
white blood cell count, and you will need to have repeat lab on
[**2146-7-1**]. This can be monitored in the rehab setting.
Thank you for allowing us to participate in your care. All best
wishes in your recovery.
Followup Instructions:
Department: NEUROLOGY
When: THURSDAY [**2146-6-23**] at 4:00 PM
With: DRS. [**Name5 (PTitle) 540**]/[**Last Name (un) 7745**] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2146-6-28**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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11423, 11528
|
6436, 10555
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302, 341
|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,742
| 185,325
|
4418
|
Discharge summary
|
report
|
Admission Date: [**2144-2-1**] Discharge Date: [**2144-2-3**]
Date of Birth: [**2071-1-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4373**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Central line placement and removal
History of Present Illness:
73 y/o female with breast cancer metastatic to the
liver/lung/bones/CNS s/p whole brain XRT in [**6-29**] who presented
to the ED with weakness and lightheadedness. Of note, her last
chemo was on [**2144-1-29**] and had one shot of Neupogen on [**2144-1-30**] and
she was to return for 2 more doses of Neupogen but she did not
make it ([**2144-1-31**], [**2144-2-1**]). On the day of presentation to the ED,
she was walking to the bathroom using her walker and felt weak
and lightheaded. She then had a LOC and episode of syncope
(witnessed by husband) for approximately 4 minutes. No
incontinence. No evidence of seizure activity per husband. She
regained consciouness and felt fine afterwards. She decided to
come to the ED for further evaluation. She also has a known RLE
DVT and is on Coumadin.
In the ED, initial vitals were T 97.3 HR 73 BP 110/50 RR 18
O2sat 100% 4L NC. She was found to be hypotensive transiently to
90/40 which improved with 250 bolus of NS. She was also given
Zofran for nausea x 1, dilaudid for pain, and
vancomycin/levofloxacin/flagyl for a presumed infection. Bedside
TTE revealed no evidence of pericardial effusion. A right IJ CVL
was placed for central access. She had a CTA which was negative
for PE. She was c/o right LE pain and she had a CT which was
negative. CXR was negative. CT abdomen was negative. RLE U/S
revealed her known DVT.
Upon arrival to the ICU, she was normotensive and had an episode
of nausea and vomiting, 300 mL of undigested food.
ROS: Denies F/C. Positive for N/V x 1 episode after arrival to
the ICU. No diarrhea. No CP or SOB. No rash. No urinary or bowel
complaints. No palpitations. No orthopnea or PND. No LE edema.
Past Medical History:
Prior Onc Hx:
In [**2133**] pt had a mass noted in her R breast and she underwent
mastectomy. She had 2 positive LN. She was diagnosed with
inflammatory breast CA, estrogen receptor positive. SHe received
cyclophosphamide, adriamycin, 5 FU, and chest XRT. She then took
Tamoxifen for 2 years; then changed to Arimidex. In [**7-28**] she
developed metastatic disease with rising tumor markers. She was
taken off Arimidex and placed on Taxol/Avastin. She has
bone/liver mets and mediastinal adenopathy (bone mets to T12,
iliac crest, L2/L3. In [**1-29**] CT head showed multiple areas of
cerebral calcifications--however pt . In [**2-27**] repeat CT of torso
showed regression of all of her mets and she had decreased tumor
markers. She is now receiving weekly Taxol which was restarted
in [**3-29**] after Taxol/Avastin had been held for fatigue and CHF.
Additionally, is s/p brain irradiation.
PMH:
1. cardiomyopathy from Adriamycin. TTE [**2142-2-16**]: There is severe
global left ventricular hypokinesis. Overall left ventricular
systolic function is severely depressed. EF 25-30%.
2. bilateral knee replacements, one in [**2134**]
and another in [**2136**].
3. osteoarthritis
4. lymphedema right arm
Social History:
No tobacco or illicit drug use. Drinks a glass of wine a day.
Lives with her husband and has visiting PT.
Family History:
Father died of rectal cancer.
Physical Exam:
Tmax: 35.2 ??????C (95.4 ??????F)
Tcurrent: 35.2 ??????C (95.4 ??????F)
HR: 77 (77 - 83) bpm
BP: 106/81(87){103/54(66) - 106/81(87)} mmHg
RR: 19 (18 - 19) insp/min
SpO2: 97%
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal),
(Murmur: Systolic), RUSB
Peripheral Vascular: (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right: Trace, Left: Trace
Neurologic: Attentive, Follows simple commands, Oriented (to):
person, place, and time, Tone: Normal, [**3-28**] RUE, [**4-27**] left
Pertinent Results:
CXR [**2144-1-31**]
No acute cardiopulmonary disease.
RLE U/S
Extensive deep vein thrombus within the right lower extremity as
detailed above. Intraluminal thrombus starting from the distal
common femoral vein extending throughout the superficial femoral
vein and into the popliteal vein.
Right hip films
No acute pathology, prelim read.
CT Abdomen and Pelvis
No evidence of pulmonary embolism. Stable pulmonary nodules.
Improving left lingular opacity representing either infectious
or
inflammatory etiology. Non-visualized liver lesions, likely due
to differences in phase of contrast.
EKG: NSR at 71, LAD, LBBB, no acute ST changes.
TTE (Complete) Done [**2144-2-3**] at 3:30:00 PM
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with hypokinesis of the
basal to mid inferior septum, inferior wall and inferolateral
wall. There is no ventricular septal defect. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction.
No pathologic valvular abnormality or significant outflow tract
gradient seen. Mild pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2143-6-4**],
the overall ejection fraction is probably similar. The prior
echo reported global mild hypokinesis, however the inferior and
inferolateral segments appeared to have worse function at that
time also.
Brief Hospital Course:
A/P: 73 y/o female with metastatic breast ca (bone, liver,
lungs, CNS) who p/w weakness and was found to have transient
hypotension, initally admitted to the ICU for further evaluation
of hypotension, then transferred to the Oncology service for
further monitoring.
# Hypotension - Transient and resolved prior to admission to
ICU. Fluid responsive. Denies poor po intake. Other
considerations included infection (though no symptoms & no data
while inpatient) or cardiac source. Ruled-out for myocardial
infarction. No arrhythmia on telemetry. Normotensive throughout
stay after minimal fluid supplementation. TTE was additionally
obtained given her history of known cardiomyopathy and low EF.
ECHO results where similar to those of last study. Thus, she
was discharged to home with resolution of problem.
# Leukocytosis - No signs or symptoms of infection during stay.
Patient received Neupogen in the week prior to admission which
would explain leukocytosis. Blood/urine cultures obtained and
negative. CXR without evidence of infection. Thus, likely
secondary to Neupogen.
# Syncope - Upon transfer to the Oncology service had
effectively been ruled-out for PE, infection and MI. [**Month (only) 116**] have
had mild dehydration though she denies decreased po intake prior
to event. Seizure unlikely though no EEG performed. No new
neurological deficits concerning for TIA. Arrhythmia possible,
but none seen while on telemetry in ICU. ECHO nondiagnostic for
new abnormaliity. Given history and other negative work-up, her
syncope is most consistent with a vasovagal response.
# Metastatic breast CA - Currently being treated with Dr.
[**Last Name (STitle) **]. Last treatment was [**1-29**] and also recieving Neupogen.
Resultant leukocytosis as above. Deferred to outpatient
follow-up. Continued Megace on d/c per outpatient regimen.
# Cardiomyopathy [**1-25**] adriamycin toxicity - Continued outpatient
blood pressure medications and statin while inpatient. Including
Coreg 3.125 mg PO daily, Lisinopril 5 mg PO daily, Lipitor 20 mg
PO daily and ASA 81mg daily.
# Anemia - Chronic, likely [**1-25**] anemia of chronic disease. Last
work-up in [**2143-7-24**] was notable for Iron 28ug/dL, TIBC
170ug/dL, Vitamin B12 311pg/mL, Folate 15.1ng/mL, Ferritin [**2106**]
ng/mL, Transferrin 131mg/dL. Continued on folic acid daily.
# RLE DVT - On Coumadin as an outpatient. Intermittently
subtherapeutic as an outpatient. Supratherapeutic on admission,
therapeutic upon transfer to Oncology. Continued coumadin as
outpatient.
# Code: Full (confirmed on admission)
# Communication: Husband [**Name (NI) **] is HCP, [**Telephone/Fax (1) 19003**].
Medications on Admission:
Percocet 1-2 tabs Q4-6H PRN
Coreg 3.125 mg PO daily
Lasix 40 mg PO daily (d/c'd on [**2143-7-17**])
Lisinopril 5 mg PO daily
Albuterol PRN
Folic acid 1 mg PO daily
Hydroxyzine PRN
Lipitor 20 mg PO daily
Megestrol 40 mg PO QID
Mycostatin topical
Nystatin
Warfarin 2.5 mg PO daily
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for Pain.
3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Albuterol Inhalation
6. Hydroxyzine HCl Oral
7. Megace Oral Oral
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: to
start on [**2144-2-4**].
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: please
do not take if you feel dizzy.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension NOS
Metastatic breast cancer
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with hypotension. A full workup has been
performed, and no clear source for your low blood pressure was
discovered.
If you develop dizziness, weakness, fainting, fever, chills,
shortness of breath, or chest pain, please seek medical
attention immediately.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2144-2-17**]
10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4286**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2144-2-26**] 10:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4285**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2144-2-26**] 10:40
|
[
"198.5",
"V12.51",
"V58.61",
"197.0",
"E933.1",
"V10.3",
"425.9",
"285.22",
"198.3",
"276.52",
"197.7",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9684, 9690
|
6111, 8772
|
321, 358
|
9775, 9784
|
4321, 6088
|
10107, 10583
|
3436, 3468
|
9101, 9661
|
9711, 9754
|
8798, 9078
|
9808, 10084
|
3483, 4302
|
274, 283
|
386, 2069
|
2091, 3297
|
3313, 3420
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,981
| 172,886
|
13782
|
Discharge summary
|
report
|
Admission Date: [**2138-5-7**] Discharge Date: [**2138-5-14**]
Date of Birth: [**2096-6-26**] Sex: M
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: This is a 41-year-old male with
human immunodeficiency virus and progressive multifocal
leukoencephalopathy who was admitted to an outside hospital
for new onset of tonic-clonic seizures. He was reportedly
found by his mother. The symptoms lasted 20 minutes,
followed by postictal confusion, bowel and urinary
incontinence.
The patient was taken to [**Hospital3 3583**] intubated for airway
protection, treated with Dilantin and transferred to the [**Hospital1 1444**] Medical Intensive Care Unit
for further management.
In the Medical Intensive Care Unit, he was successfully
extubated and treated for aspiration pneumonia with
clindamycin. He was seizure free during his stay in the
Medical Intensive Care Unit. His course in the Medical
Intensive Care Unit was complicated by a fall which led to
L1-L3 superior endplate compression fracture. Neurosurgery
was consulted at that point. The patient was scheduled for a
lumbar spine magnetic resonance imaging. The patient was
also seen by Neurology. Dilantin was continued, per their
recommendations.
Electroencephalogram showed changes consistent with
encephalopathy; however, no seizure foci were found. Head
magnetic resonance imaging showed no acute dural infarcts.
There were some foci of dysplastic areas involving the right
parietal lobe with thinning of adjacent gyrus. The patient
was subsequently transferred to the [**Hospital6 733**]
Firm for further management and care.
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus and acquired
immunodeficiency syndrome; CD4 count of 129.
2. Progressive multifocal leukoencephalopathy.
3. Blindness.
4. Bipolar disorder.
5. Increased urinary frequency and nocturia.
MEDICATIONS ON ADMISSION: Medications on initial admission
to the Medical Intensive Care Unit included Zerit, Ziagen,
Epivir, risperidone, lithium.
MEDICATIONS ON TRANSFER: Medications on transfer from the
Medical Intensive Care Unit to the floor included Percocet,
Dilantin 300 mg p.o. q.h.s., Protonix, subcutaneous heparin,
clindamycin 600 mg intravenously q.8h.
ALLERGIES: FLAGYL.
FAMILY HISTORY: Family medical history was noncontributory.
SOCIAL HISTORY: The patient lives at home with mother who
takes care of him. No tobacco, alcohol, or drug use.
PHYSICAL EXAMINATION ON TRANSFER: Temperature of 97.2, pulse
of 96, blood pressure of 160/104, respiratory rate of 29,
oxygen saturation of 97% on room air. In general, alert and
oriented times three. Head, eyes, ears, nose, and throat
revealed bilateral parotid enlargement which is chronic.
Mucous membranes were moist. The oropharynx was clear.
Cardiovascular revealed first heart sound and second heart
sound, a regular rate and rhythm. Pulmonary was clear to
auscultation bilaterally. The abdomen was nontender and
nondistended. Extremities revealed no cyanosis, erythema, or
edema.
PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell
count of 8.1, hematocrit of 35.6, platelets of 247. Sodium
of 140, potassium of 3.7, chloride of 105, bicarbonate of 23,
blood urea nitrogen of 6, creatinine of 0.7.
HOSPITAL COURSE BY SYSTEM:
1. MUSCULOSKELETAL: Magnetic resonance imaging of the
lumbar spine showed L2-L3 compression fractures; however,
they were thought to be chronic. Additional lesion on L5-S1
area could be a fragment of a disk. The Neurosurgery team
recommended magnetic resonance imaging with gadolinium to
rule out epidural abscess in light of the patient's
underlying diagnosis of human immunodeficiency virus.
The magnetic resonance imaging of the lumbar spine showed
disk herniation, and therefore the Neurosurgery team
recommended conservative management with nonsteroidal
antiinflammatory drugs.
2. INFECTIOUS DISEASE: The patient remained afebrile
throughout the course of his stay in the hospital. After a
discussion with the patient's outpatient infectious disease
specialist, the patient was resumed on his highly active
antiretroviral therapy.
3. NEUROLOGY: The patient was continued on Dilantin for his
seizures. However, in light of increased liver function
tests, the patient's Dilantin was discontinued, and he was
switched to Keppra. The patient remained seizure-free
throughout the course of his stay on the [**Hospital6 2399**] Firm.
4. NEUROPSYCHIATRY: The patient was restarted on his
lithium and risperidone while on the [**Hospital6 733**]
Firm. The patient's mood and affect remained appropriate
throughout the course of his stay in the hospital.
5. CARDIOVASCULAR: Given the patient's increased high blood
pressure, he was restarted on his outpatient dose of
atenolol.
DISCHARGE DIAGNOSES:
1. Human immunodeficiency virus with progressive multifocal
leukoencephalopathy and seizure disorder.
2. Bipolar disorder.
3. Status post lumbar spine disk herniation.
MEDICATIONS ON DISCHARGE:
1. Zerit 40 mg p.o. q.d.
2. Epivir 150 mg p.o. b.i.d.
3. Ziagen 300 mg p.o. b.i.d.
4. Lithobid 600 mg p.o. q.a.m. and 300 mg p.o. at noon
and 600 mg p.o. q.p.m.
5. Risperidone 3 mg p.o. b.i.d.
6. Motrin 600 mg p.o. t.i.d.
7. OxyContin 20 mg p.o. b.i.d.
8. Oxycodone 5 mg p.o. q.6-8h. p.r.n. for breakthrough
pain.
9. Peri-Colace.
10. Keppra 250 mg p.o. b.i.d. times two days; then
250 mg p.o. q.a.m. and 500 mg p.o. q.a.m. times three days;
and then 500 mg p.o. b.i.d.
11. Atenolol 25 mg p.o. q.d.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharged to home with home physical
therapy.
DISCHARGE FOLLOWUP: The patient was to follow up with his
primary care physician next week to check liver function
tests. The patient was to follow up with Dr. [**Last Name (STitle) 41445**], the
patient's infectious disease specialist, next week.
Additionally, the patient was to follow up in the [**Hospital 878**]
Clinic on [**6-25**] with Dr. [**Last Name (STitle) 2340**].
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2138-6-3**] 15:18
T: [**2138-6-4**] 10:15
JOB#: [**Job Number 41446**]
|
[
"780.39",
"276.2",
"046.3",
"042",
"518.81",
"507.0",
"369.00",
"722.10",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2276, 2321
|
4805, 4977
|
5004, 5532
|
1894, 2017
|
3288, 4784
|
5547, 5650
|
5672, 6281
|
174, 1622
|
2043, 2258
|
1644, 1867
|
2338, 3260
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,016
| 136,048
|
33146
|
Discharge summary
|
report
|
Admission Date: [**2159-2-12**] Discharge Date: [**2159-2-15**]
Date of Birth: [**2100-3-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Hypercarbic Respiratory Failure
Major Surgical or Invasive Procedure:
Rigid bronchoscopy
Intubation
Central line placement
History of Present Illness:
58 y/o woman w/ SCLC, metastatic, s/p XRT, CHEMO with recent
non-response to chemotherapy admitted to [**Location (un) **] with
dyspnea. She was found to have a right upper lobe collapse, and
a pleural effusion. A pleurex catheter was placed. She was
transfered to [**Hospital1 18**] for IP evaluation and possible tracheal
stenting. Bronchoscopy however, demonstrated extensive
involvement of the right mainstem, right upper lobe, right
middle lobe, and right lower lobe with tumor. She is not a
candidate for a stent given distal airway disease. After the
procedue she developed hypercarbic respiratory failure. They
attempted Non-invasive ventilation but she failed this with
continued hypercapnea. She was intubated with initial vent
settings of pressure support 22/5 PEEP, 50% fi02. Her RR was
30-40. She was tachycardic and an attempt was made to obtain a
CTA of her chest. She was hypotensive to the 50s sytolic during
the study and was returned to the TSCIU. She was then transfered
to the MICU.
.
When in the MICU, she was transitioned to volume control
ventilation with Tv 350/RR 20/100% Fi02 and 10 peep. Her ABGs
improved on these settings. Given her underlyign COPD, her
minute ventilation was approx [**6-30**] with a prolonged expiratory
time and ap[prox 6mmH20 auto-peep.
.
A CTA was performed of chest/brain to eval for PE and brain
metastasis. No PE was seen, but several large brain lesions were
seen including a cerebellar mass with tonsilar herniation. The
patient's husband was [**Name (NI) 653**] about the findings which was new
to him. She was last seen by her oncologist in [**Month (only) **]. He
expressed that she would not want aggresive measures taken and
that surgery was not in line with her goals of care.
.
Neurosurgery was [**Month (only) 653**] prior to speaking with his husband
who [**Name2 (NI) 77048**] IV decadron. Manitol coudl not be used
secondary to pressor dependance and hyperventialtion also coudl
not be performed due to her unerlying lung disease.
Past Medical History:
Small Cell Lung Cancer - treated @ [**Hospital 1559**] Medical Center. Had
chemotherapy last summer.
COPD - unknown pulmonary function.
Hyperlipidemia
Psoriasis
Social History:
to be obtained
Family History:
deferred
Physical Exam:
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: course breath soudns bilaterally, moves air bilateraly,
moreon left than right. She has end expiratory wheezing on left.
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
NEURO: intubated and sedated. Pupils were equal and responsive
with corneal refelxes.
Pertinent Results:
[**2159-2-12**] 04:50PM PT-13.1 PTT-22.1 INR(PT)-1.1
[**2159-2-12**] 04:50PM PLT COUNT-210
[**2159-2-12**] 04:50PM WBC-8.6 RBC-3.26* HGB-10.1* HCT-29.9* MCV-92
MCH-30.9 MCHC-33.6 RDW-15.6*
[**2159-2-12**] 04:50PM CALCIUM-9.2 PHOSPHATE-3.8 MAGNESIUM-2.2
[**2159-2-12**] 04:50PM estGFR-Using this
[**2159-2-12**] 04:50PM GLUCOSE-146* UREA N-25* CREAT-0.9 SODIUM-140
POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-35* ANION GAP-9
.
CXR [**2-13**] Line Placement: In comparison with earlier study of
this date, the right subclavian catheter extends to the mid
portion of the SVC. There is even further diffuse opacification
involving the right hemithorax with congestion in the left lung.
The possibility of a left lower lung pneumonia can certainly not
be excluded.
.
CXR [**2-13**]: No previous images. There is extensive opacification
of the right hemithorax consistent with some combination of
pleural effusion, atelectasis, and pneumonia. The mediastinal
structures appear to be within the midline. The left lung is
clear.
.
CT Head [**2-13**]: Enhancing mass lesions centered within the left
thalamus, right pons and left cerebellar hemisphere, concerning
for metastatic disease. There is mass effect with downward
displacement of the left cerebellar tonsil and compression of
the third and fourth ventricles with asymmetric dilatation of
the posterior left ventricular [**Doctor Last Name 534**]. If clinically indicated,
further characterization could be performed with
contrast-enhanced MRI to assess for small lesions not seen on
CT.
.
CXR [**2-14**]: Little overall change except for placement of
nasogastric tube.
.
CTA Chest [**2-14**]: 1. No evidence of pulmonary embolus. 2. Known
mass replacing the majority of the right lung and significantly
compressing both the pulmonary arterial and bronchial trees.
There is extensive associated thoracic adenopathy. 3. Patchy
left lung opacity has an appearance more suggestive of an
infectious or inflammatory process.
Brief Hospital Course:
Ms. [**Known lastname 8049**] is a 58 y/o female with SCLC admitted with hypercarbic
respiratory failure, found to have several large brain
metastases with tonsillar herniation on head CT.
.
#) Hypercarbic Respiratory Failure. Unclear etiology/inciting
event. She did receive sedation, but she had a bronchoscopy the
day prior with sedation and no subsequent respiratory failure.
Brain lesions may be contributing, but no acute herniation event
(pupils still reactive). No PE seen on CTA. Mechanical
ventilation continued. Nebulizers, steroids, and empiric
levofloxacin/metronidazole were started. After a discussion with
the family, a mutual goal of weaning the ventilatory was
established so that the patient could communicate and interact
with her family. She was discharged to [**Hospital 16843**] Hospital on
AC 330x30, 80%, 10.
.
# Brain Metastasis. Found on head CT, large and multiple. Had
received previous whole brain prophylactic radiation 2 years
ago. Neurosurgery was consulted and recommended steroids IV as
well as mannitol. Given the size of the masses, they could be
removed prior to any pallitive radiation, but in her current
decompensated respiratory state, is unlikely to offer benefit,
even short term. If we are able to get her off the ventilator,
woudl be reasonable to discuss possible intervention. However,
the family believes that she would not want surgery, so the
goals of care shifted more towards palliation, with goals to
wean the ventilator.
.
# Post-Obstructive Pneumonia. Seen on bronchoscopy, with
elevated WBC and fevers to 102. Empiric treatment with
levofloxacin/metronidazole.
.
# Hypotension: Concerning for both hypovolemia and sepsis. Other
etiologies could be sedation related. Central compression also
possible. Blood, urine, and sputum cultures sent. Pressors
given as needed (phenylephrine).
.
# SCLC: As above, metastatic. Further treatment discussions
largely dependent on if it is possible to wean her from
ventilator.
.
# CAD: continue statin, hold aspirin/metoprolol given brain
metastases and hypotension, respectively.
.
# Depression: continued citalopram.
Medications on Admission:
methotrexate 10qFri
metoprolol 50'
celexa 20'
zocor 20'
prednisone 60'
asa 81
albuterol
atrovent
mg oxide
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Methotrexate Sodium 2.5 mg Tablet Sig: Four (4) Tablet PO
QFRI (every Friday).
6. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
9. Midazolam 5 mg/mL Solution Sig: One (1) IV drip Injection
TITRATE TO (titrate to desired clinical effect (please
specify)).
10. Fentanyl Citrate (PF) 50 mcg/mL Solution Sig: One (1) IV
drip Injection INFUSION (continuous infusion).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours).
12. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
13. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
15. Insulin Lispro 100 unit/mL Solution Sig: One (1) insulin
sliding scale Subcutaneous ASDIR (AS DIRECTED).
16. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
17. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven
[**Age over 90 1230**]y (750) mg Intravenous DAILY (Daily) for 7 days.
18. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 7
days.
19. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Four
(4) mg Injection Q6H (every 6 hours).
20. Mannitol 20 % 20 % Parenteral Solution Sig: 12.5 gm
Intravenous Q8H (every 8 hours).
21. Levophed 1 mg/mL Solution Sig: 1.5 mg/kg/min Intravenous
continuous: titrate to MAP < 60.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Small cell lung cancer with brain metastases
Right lower lobe collapse
Hypoxic and hypercarbic respiratory failure
COPD
Discharge Condition:
Stable for transfer: AC 330cc x 30 breath/min, 80% FiO2, 10 PEEP
Discharge Instructions:
You were admitted for rigid bronchoscopy and evaluation of the
right lung. Unfortunately, no stenting could be performed due to
the extensive involvement of tumor in the right lung. You
developed respiratory failure after the procedure, and you were
intubated; CT head revealed brain metastases, likely from your
primary lung cancer. You are being discharged to [**Hospital 16843**]
Hospital to be closer to your family.
.
Please take all your medications as prescribed. If you develop
any concerning symptoms, please speak to the medical personnel
at [**Hospital 16843**] Hospital.
Followup Instructions:
None
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2159-2-15**]
|
[
"348.4",
"518.5",
"198.3",
"162.8",
"458.29",
"401.9",
"997.3",
"696.1",
"414.00",
"272.4",
"E879.9",
"278.00",
"486",
"311",
"496",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.23",
"96.71",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9345, 9360
|
5108, 7223
|
346, 400
|
9524, 9591
|
3110, 5085
|
10222, 10370
|
2663, 2673
|
7380, 9322
|
9381, 9503
|
7249, 7357
|
9615, 10199
|
2688, 3091
|
275, 308
|
428, 2431
|
2453, 2615
|
2631, 2647
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,251
| 107,993
|
38820+38821
|
Discharge summary
|
report+report
|
Admission Date: [**2111-2-1**] Discharge Date: [**2111-2-4**]
Date of Birth: [**2049-3-16**] Sex: F
Service: MEDICINE
Allergies:
Reglan
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
61F with chronic headaches and symptoms of hypopituitarism since
[**10-20**], s/p multiple evaluations, recently discharged from [**Hospital1 18**]
[**2111-1-23**] for symptoms of severe headache, nausea, and vomitting,
at which time she underwent largely unremarkable LP, and was
evaluated by neurosurgery and neuro-oncology who recommended
discharge home with plan for outpatient biopsy of her mass.
.
Since her discharge, the patient describes feeling quite well,
with good control of her headaches with tylenol and prn
fioricet. She has ongoing symptoms of nausea, but notes no
vomitting. She otherwise denied any fevers, abdominal pain.
.
She did note 2-3 episodes of "feeling wobbly" when looking to
the left only, which she attributed to her celexa, though she is
certain she has not missed any dosages. These symptoms have
resolved completely at present.
.
She also describes an episode of syncope ~2 weeks PTA. She rose
from her bed, and while walking to the kitchen, "saw black
spots" and found herself on the floor. Her husband witnessed
the fall, notes LOC lasting <1-2 seconds, no head trauma.
.
She was doing well until 1d PTA, when she awoke in her USOH,
then developed gradually worsening HA over the course of the
evening, starting between her eyes, then spreading to behind
both eyes, sharp, stabbing pain, eventually spreading over the
top of her head, and into the upper neck. She notes a 3-4min
period of a "film over my right eye" but otherwise denies other
visual or auditory changes (has chronic ringing in her ears).
She also notes intermittent episodes of dizziness when looking
towards the left.
.
Over the course of the night she took tylenol x 2, then fioricet
x 2, then dilaudid 2mg po x 1, then fioricet, without releif.
Her headache was worse with vagal maneuvers. She presented to
the ED in the morning, having been unable to sleep.
.
In ED VS= 98.1 133/86 933 20 95%RA. She received 1L IVF,
reglan 10mg iv, benadryl 25mg iv x 1, ativan 0.5mg x 1, with
some improvement of her pain from [**9-20**] to ~[**7-21**]. She is
admitted to the medical service for pain control.
During her most recent admission, which tme MRI of the head
demonstrated a 9x10mm pituitary mass.
Past Medical History:
Past Medical History:
- restless leg syndrome
- breast CA s/p R mastectomy with reconstruction, s/p chemo, has
had normal mammograms annually since
- hypercholesterolemia
- pituitary mass
.
Past Surgical History:
- R mastectomy with reconstruction
- hip surgery
- R knee surgery
- s/p appendectomy
- s/p tonsillectomy
Pituitary mass
R breast ca (s/p breast reconstruction) 15 years ago
Microscopic Colitis with intermittent diarrhea
Hyperlipidemia
Depression
Restless legs syndrome
hip and knee surgeries in the past
tonsillectomy during childhood
Family History:
Mother had breast cancer, father had [**Name (NI) 2481**] disease.
Physical Exam:
VS: 98.7 160/92 100 18 99%RA
GEN: initially uncomfortable, after receiving dilaudid/ativan,
sleepy.
HEENT: PERRL (3->2mm bilaterally), no overt papilledema (exam
limited by pt participation). no cervical LAD.
CV: RR, no murmurs, rubs, [**Last Name (un) 549**].
PUL: CTA bilaterally, no rales, ronchi, wheezing.
ABD: soft, non-tender, nondistended, normal bowel sounds.
EXT: no edema.
SKIN: no rash.
NEURO: A&Ox3. CN 2-12 intact. pupils 4-2mm bilaterally. no
gross horizontal nystagmus. 5/5 strength at biceps, triceps,
delts, wrist extension, hip flexion, dorsoflexion,
plantarflexion. visual [**Last Name (un) 18100**] grossly intact. normal finger to
nose coordination. gait not assessed [**1-13**] just receiving
dilaudid. visual [**Last Name (un) 18100**] grossly intact.
Pertinent Results:
[**2111-2-1**] 07:55AM BLOOD WBC-13.8* RBC-4.72 Hgb-14.1 Hct-42.8
MCV-91 MCH-29.9 MCHC-32.9 RDW-14.7 Plt Ct-500*#
[**2111-2-1**] 07:55AM BLOOD Neuts-55.6 Lymphs-36.7 Monos-5.0 Eos-1.4
Baso-1.4
[**2111-2-1**] 07:55AM BLOOD Plt Ct-500*#
[**2111-2-1**] 07:55AM BLOOD PT-12.0 PTT-24.6 INR(PT)-1.0
[**2111-2-1**] 07:55AM BLOOD ESR-40*
[**2111-2-1**] 07:55AM BLOOD Glucose-85 UreaN-12 Creat-0.9 Na-139
K-5.9* Cl-100 HCO3-28 AnGap-17
[**2111-2-1**] 07:55AM BLOOD CRP-7.2*
[**2111-2-1**] 11:00AM BLOOD Glucose-93 K-4.4
[**2111-2-1**] 08:03AM BLOOD Lactate-1.5
[**2111-2-1**] 11:00AM BLOOD Hgb-14.0 calcHCT-42
Brief Hospital Course:
This is a 61 year-old woman with known pituitary hypofunction
and inflammation of unknown etiology who represented with severe
headache, nausea, and vomiting. The etiology of headache was not
entirely clear but could be secondary to the undiagnosed
pituitary process as the symptoms of panhypopituitarism
(fatigue, polyuria, polydipsia, etc) were coincident with
headache onset. There was no evidence of intracranial hemorrhage
or increased intracranial pressure. She had no visual changes to
suggest temporal arteritis and a biopsy in the past month was
negative. In regards to the etiology of the pituitary
inflammation, she was seen by endocrine and neurosurgery during
last admission. The DDX was wide and included inflammatory or
granulomatous process, or metastasis (h/o breast cancer). During
that admission, she had LP with CSF findings of elevated protein
with negative protein electrophoresis (no oligoclonal banding)
and negative flow cytometry for malignant cells. She also had
negative beta-2-microglobulin, CEA, LDH, ACE, routine culture,
AFB stain, gram stain, cryptococcal antigen, and HSV. The CSF
VDRL was still pending. The patient will have transsphenoidal
pituitary surgery for definite diagnosis this Friday. During
this admissiom, she had conservative management with pain
control with Dilaudid and Tylenol and anti-emetics with Zofran
and Compazine.
Medications on Admission:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Pramipexole 0.25 mg Tablet Sig: Two (2) Tablet PO daily ().
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ketoconazole 2 % Cream Sig: One (1) application Topical [**Hospital1 **]
(2 times a day).
5. Desonide 0.05 % Cream Sig: One (1) application Topical [**Hospital1 **] (2
times a day).
6. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): This medicine is for nausea, you may take around the
clock to prevent nausea.
Disp:*75 Tablet(s)* Refills:*0*
8. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for severe
nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
9. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-13**]
Tablets PO Q6H (every 6 hours) as needed for head ache.
Disp:*60 Tablet(s)* Refills:*0*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for pain: This is only for severe headaches
that are not responsive to fiorcet.
Disp:*10 Tablet(s)* Refills:*0*
11. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
12. Lorazepam 0.5 mg Tablet Sig: [**12-13**] Tablet PO BID (2 times a
day): you may take 1 extra dose per day as you need for nausea.
Disp:*30 Tablet(s)* Refills:*2*
13. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for diarrhea.
Disp:*30 Tablet(s)* Refills:*0*
14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
4. Desonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
10. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for headache/neck pain.
11. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO QDAILY ().
12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for headache.
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Severe headache
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You had headache that was treated conservatively with
medications hoping that a trans-sphenoidal biopsy (brain biopsy)
will reveal the etiology for the inflammation in the pituitary
region. Please do not take aspirin or NSAIDS (like Ibuprofen)
for headache until after your surgery.
Followup Instructions:
Please see your Neurosurgeon on Friday for the brain biopsy
Admission Date: [**2111-2-6**] Discharge Date: [**2111-2-13**]
Date of Birth: [**2049-3-16**] Sex: F
Service: NEUROSURGERY
Allergies:
Reglan
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Headaches
Major Surgical or Invasive Procedure:
[**2111-2-6**] s/p transphenoidal resection of abcess
History of Present Illness:
[**Known firstname **] [**Known lastname 86162**] is a 61 year old woman who presented with
headaches since [**2110-9-11**]. She also had reported increase
thirst and had been drinking [**1-14**] gallons of water per day. As
part of the evaluation, she underwent an MRI which revealed a
9mm x 10mm pituitary lesion. She underwent endocrine hormonal
work-up which was notable for low gonadotropins, low-normal T4
levels, morning
cortisol of 3.3 and 6.6 with a 60 minute value of 21.6. She had
recently been started on prednisone for adrenal insufficiency,
Synthroid for hypothyroidism, and DDAVP for diabetes insipidus.
[**2111-2-6**] she underwent an elective resection of the mass. This
revealed yellow turbid fluid which are consistent with an
abscess.
Past Medical History:
Past Medical History:
- restless leg syndrome
- breast CA s/p R mastectomy with reconstruction, s/p chemo, has
had normal mammograms annually since
- hypercholesterolemia
- pituitary mass
Past Surgical History:
- R mastectomy with reconstruction
- hip surgery
- R knee surgery
- s/p appendectomy
- s/p tonsillectomy
Pituitary mass
R breast ca (s/p breast reconstruction) 15 years ago
Microscopic Colitis with intermittent diarrhea
Hyperlipidemia
Depression
Restless legs syndrome
hip and knee surgeries in the past
tonsillectomy during childhood
Social History:
Lives with husband. Nonsmoker. [**Name2 (NI) **] ETOH.
Family History:
Mother had breast cancer, father had [**Name (NI) 2481**] disease.
Physical Exam:
Pre-op Exam:
O: T: 97.6 BP:116/65 HR: 73 R 16 O2Sats 98%
Gen: WD/WN, comfortable, sitting in the dark
HEENT: Pupils: equal/reactive EOMs intact, visual fields
intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-15**] throughout.
Sensation: Intact to light touch, proprioception.
Toes downgoing bilaterally
Exam on Discharge:
Same as above
Pertinent Results:
Labs on admission:
[**2111-2-7**] 02:14AM BLOOD WBC-23.7*# RBC-3.72* Hgb-10.2* Hct-33.2*
MCV-89 MCH-27.4# MCHC-30.7* RDW-14.5 Plt Ct-414
[**2111-2-7**] 02:14AM BLOOD PT-12.8 PTT-27.1 INR(PT)-1.1
[**2111-2-6**] 09:33PM BLOOD Glucose-272* Na-145
[**2111-2-7**] 02:14AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.8
[**2111-2-6**] 04:13PM BLOOD Osmolal-322*
Labs on Discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2111-2-12**] 05:50AM 11.6* 3.63* 10.9* 33.5* 92 30.0 32.5
15.2 356
BASIC COAGULATION (PT, PTT, PLT, INR)
[**2111-2-12**] 05:50AM 13.4 32.6 1.1
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2111-2-13**] 12:43AM 133
ANTIBIOTICS Vanco
[**2111-2-13**] 12:43AM 25.7*
Vancomycin @ @ 1:30 (Trough)
MRI [**2-6**]:
IMPRESSION:
Post-surgical changes with a residual 5 x 3 mm hypointense
lesion with rim
enhancement present in the posterior most aspect of the
pituitary gland on the right.
ECHO [**2-11**]:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is no pericardial
effusion.
No vegetation seen.
Brief Hospital Course:
Patient is a 61F electively admitted for transpheoidal pituitary
mass. Intraoperative findings were consistent with a pituitary
abscess. Post-evacuation, the patient was kept in the ICU to
monitor signs of sepsis and diabetes insipidus. Endocrinology
and Infectious disease were consulted. She was started on broad
spectrum antibiotic coverage while cultures were growing. She
had several titrations of her DDAVP dose to address her DI.
Neurologically she remained intact. On [**2-9**], she was transferred
to the NSURG stepdown unit for further monitoring. Once her DI
was adequately controlled with DDAVP and steroid taper, she was
transferred to floor status on [**2-11**].
She received a PICC line on [**2-12**] in anticipation of going home
iwth IV abx. She was discharged to home with the PICC line and
services from home Solutions, with Abx dose of Vancomycin 1GM
BIM IV, and Moxifloxicin 400mg PO Daily. She was put on a strict
2.0 fluid restriction daily. She was given detailed instructions
on her numerous discharge appointments and instructions.
Medications on Admission:
Levothyroxine 75 mcg PO Q day
DDAVP 0.1 mg PO Q day
Simvastatin 20 mg PO Q day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pramipexole 0.25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Desmopressin 0.1 mg Tablet Sig: [**12-13**] Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
12. Moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO Daily ().
Disp:*60 Tablet(s)* Refills:*0*
13. Picc Line Flush
PICC lince flush per Home Solutions Protocol
14. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
once a day.
Disp:*1 .* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Home Solutions Infusion Therapy
Discharge Diagnosis:
Pituitary Abcess
Diabetes Insipidus
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Continue Sinus Precautions for an additional two weeks. This
means, no use of straws, forceful blowing of your nose, or use
of your incentive spirometer.
?????? You have been discharged on Prednisone, take it daily as
prescribed. If on any day, you are ill, take the prednisone as
you have been instructed by the endocrine team.
?????? You are required to take Prednisone, an oral steroid, make
sure you are taking a medication to protect your stomach
(Prilosec, Protonix, or Pepcid), as this medication can cause
stomach irritation. Prednisone should also be taken with a
glass of milk or with a meal.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 9403**] to schedule an appointment with your
surgeon, Dr. [**First Name (STitle) **], to be seen in 4 weeks.
??????Please call ([**Telephone/Fax (1) 9072**] to schedule an appointment with your
endocrinologist to be seen next week. You should have your
sodium checked on Monday. Your endocrinologist should fax the
following labs to the [**Hospital **] clinic every week: CBC with diff, Bun,
CR, LFTs, and a vancomycin Trough. Fax the results to
([**Telephone/Fax (1) 4591**]
You should remain on a strict 2.0 L fluid restriction until
follow up (including the fluid you get from your IV Vancomycin)
??????Please call ([**Telephone/Fax (1) 5120**] to schedule Formal Visual Field
Testing to be done before you are seen in follow-up with your
surgeon. The Ophthalmology department is located on the [**Hospital Ward Name **] in the [**Hospital Ward Name 23**] building, [**Location (un) 442**].
You must make an appointment to see your Dentist NEXT WEEK. He
should have a copy of your Panorex films. He will evaluate if
you need to have your tooth extracted.
Also, make sure that your endocrinologist gives you a stress
dose of steroids prior to having your tooth extracted.
[**Doctor Last Name **] on [**3-6**] at 0930 at [**Hospital1 18**]
Completed by:[**2111-2-13**]
|
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"333.94",
"253.8",
"782.1",
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icd9cm
|
[
[
[]
]
] |
[
"07.72",
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icd9pcs
|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,638
| 103,816
|
36635
|
Discharge summary
|
report
|
Admission Date: [**2145-8-17**] Discharge Date: [**2145-8-19**]
Date of Birth: [**2099-9-7**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2145-8-18**], placement of 2 drug-eluting
stents to LAD, and 1 drug-eluting stent to the RCA.
History of Present Illness:
Mr. [**Known lastname 6164**] is a 45 yo male w/o known CAD with an aspirin allergy
who presented to his PCP yesterday for 2 weeks of intermittent
chest pain. His PCP did an ECG that showed ST depressions in
V1-V5 and he was sent to the ED at [**Hospital3 **]. By time he arrived
at the ED, his pain had resolved. No medications were given at
that time. He had one episode of chest pain overnight which
also resolved without treatment. He was transferred to [**Hospital1 18**]
for aspirin desensitization and cardiac catheterization.
He describes his chest pain as a pressure in the upper chest
("like someone is standing on me") that lasts about 3-5 minutes
and resolves on its own. His initial episode was two weeks ago
during light activity (walking around). His next episode was a
few days later and he began having chest pain episodes more
often (up to about 3 per day) and having pain at rest. He
states that during one episode a few days ago, he had a cough
that was productive for slightly blood-tinged saliva. Yesterday
morning he went to work and his friends convinced him to call
his PCP.
At [**Hospital3 **] Hospital, he was given 5000 units SC heparin, 70mg
SC Lovenox, and Plavix 300mg po. 1st set of enzymes was CPK
236, CKMB 3.2, Troponin I 0.06 (indeterminate per their lab).
2nd set CPK 200, CKMB 2.8, Troponin I 0.08 (also indeterminate).
Third set 180, 2.5, and 0.04 (also indeterminate). He also had
a normal CXR and CT that showed emphysematous changes but no
evidence of PE.
He has a very strong family history for premature CAD with his
sister having a MI at age 42 and his father having multiple [**Name (NI) 5290**]
beginning in his 50's.
On review of systems, he denies any fever, chills, headaches,
weakness, numbness, nausea, vomiting, diarrhea, constipation, or
hematuria. He endorses one episode of left side pain at the OSH
due to "sitting in one place too long" that resolved with 2mg IV
morphine. All of the other review of systems were negative.
Past Medical History:
Herniated disc in back
Emphysema - diagnosed after he had an episode of pneumonia,
reports his exercise tolerance is high and he can "walk forever
and run with my kids"
Social History:
Lives in [**Location 2498**], MA with his wife and son (age 13). Previously
smoked cigarettes extensively (2-3ppd for 30 years), quit 1.5
years ago, now continues to smoke some cigars (states he will
completely quit after this hospitalization). Denies EtOH or
illicit drug use. Works as an iron worker.
Family History:
He has a very strong family history for premature CAD with his
sister having a MI at age 42 and his father having multiple [**Name (NI) 5290**]
beginning in his 50's.
Physical Exam:
VS: T=98.3 BP=143/79 HR=65 RR=14 O2 sat=97% RA
GENERAL: Well-appearing male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma. No LAD,
no thyromegaly
NECK: Supple with no JVD.
CARDIAC: PMI located in 5th intercostal space at midclavicular
line. RRR, 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. BS+
EXTREMITIES: No clubbing/cyanosis/edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
15.9
11.8>---<304
47.5
141 107 13
-----------< 92
4.1 24 0.8
PT 12.2 PTT 53.1 INR 1.0
CK 125
CK-MB 3
Trop T <0.01
Notable OSH labs: WBC 13.5 with normal diff, Cr 1.0, BUN 11
Tot Chol 180 LDL 116 HDL 47 Trig 85, Normal LFT's
EKG:
[**8-16**] at OSH: NSR, very slight ST elevations in V1-V2, T wave
inversions in V4-V5, ST depression V4-V5
[**8-17**] at OSH: NSR, T waves slightly normalized in V4-V5,
continued ST depression in V4-V5
[**8-17**]: NSR, no ST elevations but T wave inversion V4
[**8-18**] 4:45am: NSR, Marked ST elevation in leads V1-V4
[**8-18**] 4:55am: NSR, Resolution of ST elevations, T wave inversions
V1-V4
[**8-19**]: NSR, Continued T wave inversions in precordial leads c/w
[**Last Name (un) 46104**] T waves
CT Chest at OSH: No CT evidence of pulmonary thromboembolism.
Emphysematous changes.
Cardiac cath [**2145-8-18**]:
Coronary angiography in this right dominant system demonstrates
two vessel disease. The LMCA had no angiographically apparent
disease. The LAD had an 80% stenosis in the mid-portion of the
vessel. The D1 had a 70% stenosis at the origin. The Cx had
minor luminal irregularities on angiography. The RCA had a 70%
stenosis in the mid portion of the vessel. Patient received two
Endeavor 3.0 drug-eluting stents to the LAD and an Endeavor 3.5
drug-eluting stent to the RCA.
TTE [**2145-8-18**]: The left atrium and right atrium are normal in
cavity size. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
INPATIENT LABS:
[**2145-8-19**] 04:25AM BLOOD WBC-14.1* RBC-4.84 Hgb-15.7 Hct-45.8
MCV-95 MCH-32.4* MCHC-34.3 RDW-13.0 Plt Ct-285
[**2145-8-19**] 04:25AM BLOOD PT-11.5 PTT-36.0* INR(PT)-1.0
[**2145-8-19**] 04:25AM BLOOD Glucose-112* UreaN-12 Creat-0.9 Na-137
K-4.8 Cl-104 HCO3-23 AnGap-15
[**2145-8-18**] 01:55AM BLOOD CK(CPK)-104
[**2145-8-18**] 05:00PM BLOOD CK(CPK)-76
[**2145-8-18**] 01:55AM BLOOD CK-MB-3 cTropnT-<0.01
[**2145-8-19**] 04:25AM BLOOD CK(CPK)-66
[**2145-8-18**] 01:55AM BLOOD PT-12.4 PTT-125.3* INR(PT)-1.0
[**2145-8-19**] 04:25AM BLOOD PT-11.5 PTT-36.0* INR(PT)-1.0
Brief Hospital Course:
# CORONARY ARTERY DISEASE: Patient was admitted for two weeks
of intermittent escalating chest pain. On admission, he was
chest pain free and had ECG changes concerning for ACS (T waves
inversions and ST depressions in precordial leads). It was felt
that his symptoms were consistent with unstable angina and he
was scheduled for cardiac catheterization the next morning. He
was started on a heparin gtt, metoprolol 12.5mg po bid,
atorvastatin 80mg po daily. His PTT was at goal approximately 8
hours after initiating heparin.
Early the morning after admission, the patient experienced
an episode of chest pain. An ECG was obtained which showed ST
elevation in leads V1-V4. His pain resolved with administration
of SL nitro x 3 and morphine. He was then started on
integrillin gtt, nitro gtt, and given Plavix 75mg. Later that
morning, he was taken for cardiac catheterization and found to
have 70% stenosis of the LAD and 80% stenosis of the RCA. He
received 2 DES to the LAD and 1 DES to the RCA. He had no
complications during the procedure. After the procedure, he was
chest pain free and remained chest pain free throughout his
admission. A follow-up TTE showed normal heart function.
His cardiac markers remained negative throughout his
admission, and his chest pain and ST elevations had resolved
quickly with SL nitro and morphine. Therefore, it was felt that
the patient's chest pain was best attributable to coronary
vasospasm. Therefore, his medications were switched to
isosorbide mononitrate 30mg po daily and amlodipine 5mg po daily
to prevent coronary vasospasm. His metoprolol was discontinued,
and atorvastatin 80mg was changed to simvastatin 20mg po daily.
Since he received 3 drug-eluting stents, he will need to
continue Plavix 75mg po daily for at least one year, and aspirin
indefinitely.
# ASPIRIN DESENSITIZATION: Patient had an allergy to aspirin on
admission, and had previously had angioedema and hives with
aspirin therapy. Therefore, an aspirin desensitization protocol
was instituted and the patient was desensitized without
complications.
# BACK PAIN: Patient has a history of herniated disc in his
back, and complained of some back pain during admission. He was
managed with prn oxycodone-acetaminophen for the back pain as an
inpatient, but takes Darvocet and Soma at home. He was
discharged with PCP [**Name9 (PRE) 702**] for further prescriptions of pain
medication.
Patient requested he be a FULL CODE during his admission.
Medications on Admission:
Carisoprodol 350 mg Tablet One Tablet(s) po daily prn for back
pain
Propoxyphene N-Acetaminophen [Darvocet-N 100] 100 mg-650 mg
Tablet [**2-5**] Tablet(s) by mouth three times a day prn for back
pain
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual As directed: Take one tablet if you develop chest
pressure. If pain fails to resolve completely, may repeat every
5 minutes, maximum 3 doses. If you take this medication, call
your physician [**Name Initial (PRE) 2227**].
Disp:*10 tablets* Refills:*2*
7. Carisoprodol 350 mg Tablet One Tablet(s) po daily prn for
back pain
8. Propoxyphene N-Acetaminophen [Darvocet-N 100] 100 mg-650 mg
Tablet [**2-5**] Tablet(s) by mouth three times a day prn for back
pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Coronary artery disease, coronary artery vasospasm,
status-post stenting to coronary arteries
Secondary: Chronic back pain, emphysema
Discharge Condition:
Hemodynamically stable, afebrile and without chest discomfort.
Discharge Instructions:
You were admitted with chest pain that had begun about 2 weeks
prior. You also had an aspirin allergy. You were evaluated and
found to have narrowing in the arteries that supply your heart.
These were treated with stents to keep them open. You also
underwent aspirin desensitization. You have been started on
several new medications. You MUST take these medications every
day to keep your heart healthy, your stents open and to prevent
new development of aspirin allergy. You especially need to take
your Plavix and Aspirin every day for one year, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s.
Please take all medications as prescribed.
- Start Clopidogrel 75 mg daily
- Start Simvastatin 20 mg daily
- Start Aspirin 325 mg daily
- Start Isosorbide Mononitrate 30 mg daily
- Start Amlodipine 5 mg daily
You need to have repeat lab tests in 6 weeks. These labs should
include liver function tests and a cholesterol panel.
Please keep all outpatient appointments.
Given your recent procedure, you must not lift objects greater
than 10 pounds (lbs) for the next 7 days. No driving for 2 days
after discharge.
Seek medical advice immediately if you notice recurrent chest
pain, chest pressure, shortness of breath out of proportion to
exercise, difficulty breathing at rest, lower extremity
swelling, fever, chills, recurrent bleeding or pain from your
groin or any other symptom that is concerning to you.
Followup Instructions:
You have follow-up scheduled with your primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 17918**] on Monday, [**2145-8-23**] at 3:45 pm.
Cardiology: Wednesday [**9-15**] at 11:30am. Address: 15 [**Doctor Last Name **]
Bros Way and [**Street Address(2) 82898**], [**Location **]. Phone:
[**Telephone/Fax (1) 8725**]
You need to have repeat lab tests in 6 weeks. These labs should
include liver function tests and a cholesterol panel. Please
discuss these lab tests and all your new medications with Dr.
[**Last Name (STitle) 17918**] at this appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"722.2",
"V17.3",
"413.1",
"492.8",
"V14.6",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.47",
"99.20",
"37.22",
"88.56",
"00.41",
"88.53",
"36.07",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
10563, 10569
|
6695, 9187
|
278, 400
|
10757, 10821
|
4067, 4067
|
12317, 13036
|
2959, 3127
|
9439, 10540
|
10590, 10736
|
9213, 9416
|
10845, 12294
|
3142, 4048
|
228, 240
|
428, 2428
|
4088, 6672
|
2450, 2620
|
2636, 2943
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,593
| 185,057
|
48651
|
Discharge summary
|
report
|
Admission Date: [**2151-6-11**] Discharge Date: [**2151-6-25**]
Date of Birth: [**2085-6-12**] Sex: M
Service: SURGERY
Allergies:
Iodine / Peanut
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
2.8 cm HCC in the left lateral
segment associated with 2 closely aligned satellite nodules.
Major Surgical or Invasive Procedure:
[**2151-6-11**] resection of hepatic segment 3
History of Present Illness:
65-year-
old male, with a history of chronic HCV infection and
cirrhosis, who has developed a 2.8 cm HCC in the left lateral
segment associated with 2 closely aligned satellite nodules.
He is not a transplant candidate at this time because of
continued alcohol use. He is therefore brought back to the
operating room after informed consent was obtained for
segment III resection.
Past Medical History:
HCV cirrhosis
Hepatocellular CA
peripheral neuropathy
obesity
osteoarthritis
COPD
Social History:
Habits: former smokere (tobacco free b/w 1 month and 12 years)
Physical Exam:
preop: Hr 91 BP 158/99 O2 98%
chronically ill appearing
alert, depressed affect
rrr
lungs mild weheezing
[**6-25**]
a&o
rrr
lungs diminished in bases with crackles. rr 18-22. +sob with
exertion
abd obese, +bs
Pertinent Results:
[**2151-6-11**] 10:32AM BLOOD WBC-8.9# RBC-4.04* Hgb-13.1* Hct-38.6*
MCV-96 MCH-32.5* MCHC-34.1 RDW-14.2 Plt Ct-108*
[**2151-6-25**] 06:00AM BLOOD WBC-14.0* RBC-3.42* Hgb-10.8* Hct-32.8*
MCV-96 MCH-31.5 MCHC-32.9 RDW-14.0 Plt Ct-168
[**2151-6-19**] 05:30AM BLOOD PT-19.6* PTT-39.2* INR(PT)-1.8*
[**2151-6-25**] 06:00AM BLOOD Glucose-80 UreaN-22* Creat-1.1 Na-135
K-4.4 Cl-99 HCO3-26 AnGap-14
[**2151-6-11**] 10:32AM BLOOD ALT-48* AST-73* AlkPhos-96 TotBili-2.9*
[**2151-6-23**] 08:10AM BLOOD ALT-32 AST-33 AlkPhos-67 TotBili-2.6*
[**2151-6-20**] 05:00AM BLOOD Lipase-41
[**2151-6-21**] 05:00AM BLOOD Calcium-7.9* Phos-3.9 Mg-1.8
[**2151-6-23**] 08:10AM BLOOD Albumin-2.4*
Brief Hospital Course:
On [**2151-6-11**] he underwent Segment III mass resection and
intraoperative ultrasound for hepatocellular carcinoma and
hepatitis C virus infection and cirrhosis. Surgeon was Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. A macronodular cirrhotic liver was noted.
There was a 2.8 cm lesionalong the edge of the left lateral
segment in segment III as seen on the preoperative CT scan.
Intraoperative ultrasound demonstrated no other lesions in the
liver. He had mild portal hypertension.the mass was removed with
a
margin of [**12-17**].9 cm in all directions. EBL was 1500ml. He
received 5 liters of crystalloid. Please refer to operative note
for further details. In PACU, he was hypoensive and required
re-intubation for hypercarbia.
Postop, he was transferred to the SICU for hypotension and
oliguria management. WBC was elevated at 22.7 and respiratory
distress. IV lasix drip was used for overload and dobutapmine
was given for hypotension. He improved and sedation was weaned
allowing for BIPAP for increasing O2 needs. CXR showed increased
pulmonary edema. Lasix was continued with improvement. O2 was
changed to nasal cannula. Respiratory status continued to
improve with intermittent iv lasix. On [**6-13**], a TEE was done
noting the following: The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). The estimated cardiac index is high (>4.0L/min/m2).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. There is a
small pericardial effusion.
On [**6-17**], he was transferred out of the SICU. Lasix was stopped as
urine output dropped. He appeared too dried out and IV fluid was
given with improved urine output. Nephrology was consulted for
elevated creartinine (up to 1.7 from baseline 0.7). Creatinine
slowly trended back down to baseline. Repeat CXRs demonstrated
improved effusions and elevated right hemidiaphragm. Low dose
lasix was resumed for noted edema and bibasilar crackles.
Spironolactone was added. O2 was removed with room air sats of
96%.
On [**6-/2129**] he was noted to have low grade temperature of 100.6. WBC
was 7.6. This increased to 17.1 on [**6-23**]. Urine culture was
negative. The central line was removed with the tip cultured.
This was negative. The incision was cultured growing Staph coag
+/ CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH.
An abdominal CT scan was performed on [**6-24**] noting
small-to-moderate ascites with no evidence for loculated
intra-abdominal fluid collection to suggest abscess formation.
Evaluation is limited by lack of intravenous contrast. Two
nonobstructing stones in the lower pole of the left kidney.
Diffuse superficial soft tissue stranding without evidence for
drainable fluid collection and degenerative changes of the
thoracolumbar spine as described above. He experienced multiple
BMs after the scan. WBC increased to 20.2 on [**6-25**], but decreased
to 14 on [**6-26**]. He remained afebrile.
The abdomenal incision was noted to have drainage mid incision
requiring dry gauze dressings. This drainage was felt to
represent fat necrosis.
LFTs increased intially, but slowly trended down.Diet was
advanced and tolerated. Incision pain was managed with po
dilaudid, but he was somnolent. Smaller intermittent doses of
dilauaid were given with less sedation and improved mental
status.
PT evaluated and recommended rehab. He was ambulatory. [**Hospital **] Hospital ([**Telephone/Fax (1) 49137**]accepted him and he was
transferred there on [**6-26**] in stable condition.
Pathology report was as follows:
Liver, segment 3, resection:
A. Hepatocellular carcinoma, moderately differentiated. See
synoptic report.
B. Non-neoplastic hepatic parenchyma with:
1. Cirrhosis, confirmed on Trichrome stain (Stage 4).
2. Moderate portal, septal and mild periseptal/lobular
mononuclear inflammation, consistent with chronic viral
hepatitis C (Grade 2).
3. Focal, mild mixed droplet steatosis with rare balloon
degeneration involving <10% of the parenchyma; no definite
associated hyalin seen.
4. Mild iron deposition, predominantly in periseptal
hepatocytes and Kupffer cells, seen on iron stain.
Medications on Admission:
inhalers, percocet, valium
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-18**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Dilaudid 2 mg Tablet Sig: 0.5 Tablet PO prn: [**Hospital1 **] for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
HCV cirrhosis
HCC
h/o etoh abuse
obesity
copd
ARF, resolved
fluid overload
Discharge Condition:
stable
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, increased abdominal pain, incision has
redness, increased drainage
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2151-7-1**]
8:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2151-6-25**]
|
[
"572.3",
"458.29",
"584.9",
"070.54",
"356.9",
"155.0",
"571.5",
"303.91",
"997.5",
"786.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.22"
] |
icd9pcs
|
[
[
[]
]
] |
7433, 7505
|
1954, 6313
|
367, 416
|
7624, 7633
|
1258, 1931
|
7856, 8166
|
6390, 7410
|
7526, 7603
|
6339, 6367
|
7657, 7833
|
1026, 1239
|
235, 329
|
444, 826
|
848, 931
|
947, 1011
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,043
| 114,564
|
1716
|
Discharge summary
|
report
|
Admission Date: [**2156-4-1**] Discharge Date: [**2156-4-2**]
Date of Birth: [**2091-4-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Admitted for right heart catheterization and evaluation for
weaning off milrinone therapy
Major Surgical or Invasive Procedure:
cardiac catheterization and Swan Ganz catheter placement
History of Present Illness:
Patient is a 64 year old man with a history of end stage
ischemic cardiomyopathy s/p CABG in [**2135**] now with improved EF to
35-40% on Milrinone at 0.6mcg/kg/min since [**2151**]. At that time,
he was not a heart transplant candidate due to irreversible
pulmonary hypertension. Over the years he has been doing
extremely well without significant heart failure. He has not
been on diuretics in years. Last echo from [**2154**]: LVEF 35-40%. He
was admitted for RHC and hemodynamics on and off milrinone to
assess for possible weaning off of milrinone. Right heart
catheterization was performed, and he tolerated the procedure
well. PA pressures 35/15, PCWP 22, CO 3.47 and CI 1.97 on
milrinone .6 mcg.kg/min.
.
Patient reports he has been feeling quite well. Denies any
increasing SOB, CP, palpitations, dizziness, lightheadedness,
fevers. He does report a dry cough that is occasionally
productive of small amounts of white sputum. He has been taking
sugar free robitussin as home. Two of his daughters at home
currently have colds. He has had the flu shot.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, 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, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
.
Past Medical History:
1) Ischemic Cardiomyopathy (EF15-20% at worst and started on
milrinone in [**2151**], last echo in [**2154**] with EF35-40%) s/p [**Hospital1 **]-V
Pacer/ICD ([**11-12**])
2) CAD/CABG [**2135**] (SVG-LAD-s/p stent in [**2148**], SVG-LCX(known
occlusion), LIMA to diag, SVG to RCA-known occlusion, stent to
LM into LCX)
3) DMII
4) CRI (Cr 1.3-1.8)
5) Anemia of Chronic Disease
6) HTN
7) Lichen Simplex Chronicus
8) h/o left subclavian vein occlusion
9) Hernia repair [**2151**]
.
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
.
Cardiac History: CABG, in [**2145**] anatomy as above
.
Percutaneous coronary intervention, as above
.
Pacemaker/ICD placed in [**2151**]
.
Social History:
Lives with wife and daughters. [**Name (NI) **] five children and two
grandchildren. Born in [**Country 9819**] - has lived in USA for ten
years. Previous leather goods importer/exporter. Never smoked
cigs, drank ETOH or used recreational drugs.
.
Family History:
Brother had MI at 48. Mother had DM, CHF and MI and unknown age.
Father had CAD, but no MI.
.
Physical Exam:
VS: T 97.3, BP 116/76 , HR 75 , RR 17 , O2 100% on RA
Gen: Eldery male in NAD, resp or otherwise. Oriented x3. Mood,
affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple could not assess JVP as lying flat after cetherter
placement.
CV: RR, normal S1, S2. II/VI SEM at LLSB
Chest: Resp were unlabored, no accessory muscle use. No
crackles, wheeze, rhonchi anteriorly.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Well-healed midline scar
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; 2+ DP, PA catheter in place
without ooze
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
.
Pertinent Results:
MEDICAL DECISION MAKING
.
EKG demonstrated V pacing, rate 72
.
2D-ECHOCARDIOGRAM performed on [**9-15**] demonstrated: The left
atrium is mildly dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is mildly dilated with
mild-moderate global hypokinesis (EF 35-40%) and septal near
akinesis. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
HEMODYNAMICS: RA 8, RV 40/4, PCWP 22, PA 35/15
.
LABORATORY DATA:
[**2156-4-1**] 01:11PM WBC-3.9* RBC-4.08* HGB-12.6* HCT-36.8*
MCV-90# MCH-31.0 MCHC-34.4 RDW-14.4
[**2156-4-1**] 01:11PM PLT COUNT-161
[**2156-4-1**] 01:11PM PT-12.5 PTT-48.3* INR(PT)-1.1
[**2156-4-1**] 01:11PM GLUCOSE-73 UREA N-22* CREAT-1.2 SODIUM-144
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-25 ANION GAP-12
[**2156-4-1**] 01:11PM CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-2.2
.
.
.
.
.
Cardiac catheterization ([**2156-4-1**]) -
1. Resting hemodynamics revealed high-normal right-sided
filling
pressures with RVEDP 9 mmHg. Mild elevation of pulmonary
arterial
systolic pressures with PASP 35 mmHg. Elevated mean wedge of 22
mmHg.
Depressed cardiac output with CI 2.0 L/min/m2.
FINAL DIAGNOSIS:
1. Mild elevation of filling pressures on chronic milrinone.
2. Transfer to CCU for milrinone wean with swan in place.
.
.
Trans-Thoracic Echocardiogram ([**2156-4-1**]) -
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears moderately-to-severely
depressed (ejection fraction 30 percent) secondary to akinesis
of the septum and hypokinesis of the rest of the left ventricle.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. There are focal calcifications in the aortic arch. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2154-9-24**], the left ventricular ejection fraction is
somewhat reduced.
.
.
Trans-Thoracic Echocardiogram ([**2156-4-2**]) -
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is moderate to severe
global left ventricular hypokinesis (LVEF = 30 %). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The supporting structures
of the tricuspid valve are thickened/fibrotic. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2156-4-1**], the findings are similar.
.
.
Brief Hospital Course:
ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN
MULTIDISCIPLINARY ROUNDS:
#. Ischemic cardiomyopathy - The patient has a known history of
ischemic cardiomyopathy with an EF of 15-20% in [**2151**] and has
been on milrinone since then. Repeat TTE in [**9-/2154**] revealed
improvement in his EF to 35-40%. He had not been requiring
standing diuretics, and has been doing quite well at home. He
underwent cardiac catheterization that showed mildly elevated
filling pressures, and Swan-Ganz catheter placement in the cath
lab showed a Cardiac Index of 1.97 on milrinone. He had a TTE
that showed moderately-to-severely depressed LV systolic
function (EF 30%) secondary to akinesis of the septum and
hypokinesis of the rest of the left ventricle. He was weaned off
the milrinone with a stable Cardiac Index of 1.94 off milrinone.
Repeat TTE after weaning off milrinone was similar to that done
while he was on milrinone. He was able to be discharged home off
of milrinone. He was otherwise continued on his home
medications, and discharged on these without any changes.
.
Medications on Admission:
milrinone via a continuous infusion at 0.6 mcg/kg/minute
Aspirin 325 mg daily
Lipitor 20 mg daily,
Bumex 0.5 mg only as needed - has not taken in 3 months
Coreg 12.5 mg twice a day
Plavix 75 mg daily
digoxin 0.125 mg a half a tablet daily
Imdur 30 mg a half a tablet at bedtime
lisinopril 5 mg daily
multivitamin daily
Glipizide 4 mg QAM and 2 mg QPM
.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO QHS (once a day (at
bedtime)).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Amaryl 2 mg Tablet Sig: Two (2) Tablet PO qam.
10. Amaryl 2 mg Tablet Sig: One (1) Tablet PO qpm.
11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) mL Intravenous once a day: 2 mL of 100 Units/mL heparin (200
units heparin) each lumen Daily. Inspect site every shift.
Disp:*120 ml* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
physicians' home care-[**Hospital1 **]
Discharge Diagnosis:
Primary:
1. acute on chronic systolic heart failure
Secondary:
1. coronary artery disease
2. diabetes mellitus
3. chronic renal insufficiency
4. hypertension
5. hyperlipidemia
Discharge Condition:
Ambulatory. O2 sats in 90s on room air. BP and HR stable.
Discharge Instructions:
You were admitted to the hospital for evaluation of your heart
failure. Your medication milrinone was stopped.
increases by > 3 lbs. Please adhere to a 2 gm sodium diet.
Please restrict fluid intake to 2 liters per day.
Avoid heavy lifting (>10 lbs) for the next week to rest your
groin after the catheterization.
Please follow up with Dr. [**Last Name (STitle) 1968**] and Dr. [**First Name (STitle) 437**] as below.
Please call your doctor or return to the hospital if you
experience worsening shortness of breath, chest pain,
lightheadedness, palpitations, or any other concerns.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2156-4-7**] 9:50
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Phone: [**Telephone/Fax (1) 3512**] Date/Time:
[**2156-4-19**] 1:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2156-6-1**]
1:30
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2156-6-1**] 2:00
|
[
"428.0",
"414.8",
"428.23",
"285.21",
"585.9",
"250.00",
"403.90",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"89.64",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
10249, 10318
|
7841, 8915
|
411, 470
|
10539, 10600
|
3969, 5534
|
11236, 11826
|
3045, 3141
|
9319, 10226
|
10339, 10518
|
8941, 9296
|
5551, 7818
|
10624, 11213
|
3156, 3950
|
282, 373
|
498, 2060
|
2082, 2764
|
2780, 3029
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,823
| 153,858
|
4997
|
Discharge summary
|
report
|
Admission Date: [**2172-6-13**] Discharge Date: [**2172-6-22**]
Date of Birth: [**2099-5-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
diarrhea/hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 73 yo female with MMP including CRI, DM, HTN, CHF
requiring admissions, and a recent admission for cellulitis who
presents with seven days of diarrhea and found to be
hypotensive, meeting code sepsis criteria. Pt was recently
admitted to [**Hospital1 **] from [**Date range (3) 20690**] with a left lower extremity
cellulitis treated with unasyn transitioned to augmentin as an
outpt. She took the augmentin for 11 days post-discharge with
last being ~[**2172-6-9**]. Pt says that for the last seven days she
has had profuse diarrhea (two days per husband), last today with
3 episodes. No blood or melena noted. She denies any
lightheadedness/ fever/ chills/ nausea/ vomiting or chest pain.
She has had decreased PO intake for many days (could not
quantify).
In the ED, VS on admission were: T: 99.6; HR: 112; BP
88/42-->70/20; RR: 22; O2: 93% RA. An abdominal CT was done
which showed mild diffuse colonic wall thickening without
distention. She was given levaquin 500 mg IV and flagyl 500 mg
IV x 1. She was also started on norepinephrine gtt prior to
transport via ambulance
Past Medical History:
1) Chronic renal insufficiency baseline Cr 2.6 on [**8-4**]
2) Restrictive lung disease presumed to be secondary to obesity
with PFTS in [**2165**]
3) Hyperlipidemia
4) NIDDM x 10 years
5) Obesity
6) HTN
7) CHF, EF >55% with an echo in [**9-2**]
8) Moderate AS (10'[**69**] echo) with AV gradient of 64
9) Chronic atrial fibrillation on coumadin and amiodarone
10) Hypothyroidism TSH 6.7 in [**6-3**]
11) Iron deficiency anemia Hct 34 at baseline 0n [**2171-6-7**] with
gastritis and ectasias on recent EGD/colonoscopy
12) B12 deficiency on supplements
13) Venous insufficiency
14) h/o Left lower extremity cellulitis treated with full course
of Augmentin in [**2171**]
15) Glaucoma; s/p surgery in [**11-3**]
16) h/o left hand cellulitis/gout flare [**10-4**]
Social History:
Lives with her husband in [**Name (NI) 583**]. She denies any smoking or
alcohol use.
Family History:
NC
Physical Exam:
VS: T: 99.5;HR: 75; BP: 103/61; RR: 21; O2: 95 7L; CVP:3
Gen: Speaking in full sentences in mild distress
HEENT: PERRL; EOMI; sclera anicteric; OP clear
Neck: JVD difficult to see [**1-2**] neck girth
CV: RRR S1S2 III/VI crescendo-descrendo murmur at RUSB with
radiation to carotids.
Lungs: scattered crackles 1/3 up without wheezes.
Abd: NABS. Soft, obese, NT, ND
Back: unable to assess
Ext: Brown venous stasis changes ankle--> below knee b/l, L>R.
No open sores, erthema, or warmth. DP 1+. 2+ edema, non-pitting.
Neuro: A&O x 3. MS [**First Name (Titles) 20691**] [**Last Name (Titles) 5235**].
Pertinent Results:
Labs on Admission:
CBC ([**2172-6-13**] 12:10A) WBC-31.6*# RBC-3.88* HGB-11.9* HCT-35.1*
MCV-91 MCH-30.7 MCHC-33.9 RDW-16.4*
NEUTS-88* BANDS-5 LYMPHS-2* MONOS-4 EOS-0 BASOS-0 ATYPS-1*
METAS-0 MYELOS-0
Chemistires ([**2172-6-13**] 12:10AM) GLUCOSE-189* UREA N-94*
CREAT-4.4*# SODIUM-128* POTASSIUM-5.3* CHLORIDE-93* TOTAL
CO2-19* ANION GAP-21*
MAGNESIUM-2.0
Coags: ([**2172-6-13**] 12:56AM) PT-37.0* PTT-33.6 INR(PT)-4.1*
Lactate: ([**2172-6-13**] 12:57AM) LACTATE-3.5*
UA: ([**2172-6-13**] 03:40AM) URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]-1.012
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
VBG ([**2172-6-13**] 01:14PM) TYPE-MIX TEMP-37.8 PO2-53* PCO2-47*
PH-7.22* TOTAL CO2-20* BASE XS--8 INTUBATED-NOT INTUBA
[**Last Name (un) **] Stim:
[**2172-6-13**] 01:37PM CORTISOL-33.4*
[**2172-6-13**] 02:46PM CORTISOL-46.8*
[**2172-6-13**] 03:25PM CORTISOL-52.1*
Imaging:
CHEST (PORTABLE AP) [**2172-6-13**] 2:04 PM
IMPRESSION:
Compared with earlier the same day, the right IJ central line
has been retracted. The tip now overlies the SVC/RA junction.
There has been interval progression of left lower lobe collapse
and/or consolidation with interval obscuration of left
hemidiaphragm. A small left and also a small right pleural
effusion cannot be excluded. No pneumothorax is detected.
RADIOLOGY Final Report
CT ABDOMEN W/O CONTRAST [**2172-6-13**] 5:29 AM
IMPRESSION:
1. There is colonic wall thickening extending along the entire
course of the colon, with associated pericolonic inflammatory
stranding. This appearance is consistent with mild pancolitis,
of inflammatory or infectious etiologies. No pericolonic fluid
collections or free intraperitoneal air or fluid is identified.
2. Cholelithiasis without evidence of acute cholecystitis.
EKG ([**2172-6-13**])
Sinus rhythm; Borderline first degree A-V block; Left bundle
branch block
Lateral ST-T changes may be due to myocardial ischemia;
Generalized low QRS voltages
No change from previous
Echo ([**2172-6-15**])
IMPRESSION: Suboptimal study. At least moderate (may be severe)
calcific
aortic stenosis. LVH. Normal LVEF. If clincally indicated, a
repeat study with definity contrast may improve spectral doppler
fidelity to assess morte accurately the aortic valve
gradients/area. Compared to the prior report dated [**2170-9-20**], an
aortic valve area change cannot be excluded on the basis of the
current study. LVEF is probably similar.
Brief Hospital Course:
Pt is a 73 yo Ukranian female with MMP who presents with
hypotension, despite fluid resuscitation, and with diarrhea.
She initially required pressors (epinephrine). After more
aggressive IVF use, she was able to be weaned off pressors.
During this time, she was also changed from flagyl to PO
vancomycin (for positive c. diff colitis), given her initial
lack of progress. During this time, her SBPs were in the 90s,
often dropping to the 70s systolic. Her initial acute on
chronic renal failure improved over the first few days. After
this initial improvement, her course began to worsen again. Her
blood pressures again required pressor support (despite IVF),
her WBC began to increase (with 14% bands) and her blood gas
showed a worsening acidemia. Her urine culture grew
enterococcus. Treatment with vanc and flagyl for c. diff and
gent/cefepine for UTI were begun. Despite this, she required
more pressor support and her respirations became less strong.
She expired at 5:59 pm on [**2172-6-22**].
Medications on Admission:
Albuterol prn
Allopurinol 200 mg [**Hospital1 **]
Amiodarone 200 mg qday
Bisacodyl 5 mg qday
Colace 100 mg [**Hospital1 **]
Colchicine 0.6 mg po qod
Glipizide SR 2.5 mg qday
Ipratropium 2 puffs QID
ferrous sulfate 325 one po tid
Levothyroxine 125 mcg qday
Atorvastatin 20 mg qday
Lisinopril 5 mg qday
Pantoprazole 40 mg qday
Cyanocobalamin 1000 mg qday
Furosemide 40 mg po bid
Toprol XL 25 mg qday
Warfarin 1 mg po qhs
Epoetin 6000 units [**Hospital1 **]
Amoxicillin-Claulanate 500-125 mg q12--ENDED [**2172-6-9**]
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Sepsis
C. Diff Colitis
UTI
Cardiopulmonary arrest
Secondary:
Diabetes Mellitus
CHF
CRI
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"424.1",
"266.2",
"427.31",
"038.9",
"244.9",
"584.9",
"496",
"008.45",
"276.52",
"250.00",
"995.92",
"V58.61",
"585.9",
"428.0",
"459.81",
"276.2",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7144, 7153
|
5537, 6549
|
335, 341
|
7294, 7304
|
3005, 3010
|
7357, 7365
|
2366, 2370
|
7115, 7121
|
7174, 7273
|
6575, 7092
|
7328, 7334
|
2385, 2986
|
275, 297
|
369, 1458
|
3025, 5514
|
1480, 2245
|
2261, 2350
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,248
| 158,080
|
34946
|
Discharge summary
|
report
|
Admission Date: [**2104-8-19**] Discharge Date: [**2104-8-25**]
Date of Birth: [**2041-12-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Angina & SOB
Major Surgical or Invasive Procedure:
[**2104-7-31**] Coronary artery bypass grafts x 4 (LIMA to LAD, SVG to
Diag, SVG to OM, SVG to PDA)
History of Present Illness:
This 62 year old male has a 5+ year history of exertional chest
tightness and dyspnea. This initially occurred while running as
a soccer referee. In [**Month (only) **] of this year while traveling he had
worsening symptoms, occurring after walking up [**Doctor Last Name **] [**Date range (1) 61126**]
mile. He had to rest for 5-10 minutes before continuing.
A stress test recently done, was stopped after 6 minutes due to
dyspnea. He was referred for cardiac catheterization which was
done today at [**Hospital1 **].
Catheterization showed preserved LV function(60%) with distal
ulceration of and 80% left main disease, occluded circumflex and
80% osteal right lesion. He remained stable and painfree and was
transferred for urgent revascularization.
Past Medical History:
Hypertension
Hypercholesterolemia
obesity
Social History:
retired electronics technician
lives with his wife
drinks 2 glasses of wine a day- rarely more
Never smoked
Family History:
Father had and MI at an older age
Brother died of throat cancer
Physical Exam:
Alert and oriented
Gen: WDWN NAD
Skin: Unremarkable
Chest: clear
Heart: SR at 82, 134/72, 1-2/6 SEM
Abd: Soft, NT/ND +BS, Obese
Ext: Warm, well-perfused, trace LE edema
Pertinent Results:
[**8-19**] CNIS: 1. No significant ICA stenosis on either side. 2.
Antegrade low in both vertebral arteries.
[**8-20**] Echo: PRE CPB No spontaneous echo contrast is seen in the
body of the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results in the
operating room at the time of the procedure. POST CPB The
patient is being atrially paced. There is normal biventricular
systolic function. The thoracic aorta appears intact. No
significant changes from the pre bypass study.
[**2104-8-25**] 05:35AM BLOOD WBC-11.4* RBC-3.21* Hgb-9.9* Hct-28.8*
MCV-90 MCH-30.9 MCHC-34.5 RDW-12.7 Plt Ct-413
[**2104-8-25**] 05:35AM BLOOD Plt Ct-413
[**2104-8-25**] 05:35AM BLOOD Glucose-106* UreaN-20 Creat-0.9 Na-138
K-3.9 Cl-102 HCO3-29 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname **] was transferred from OSH for surgical intervention.
He underwent usual pre-operative work-up upon admission. On [**8-20**]
he was brought to the operating room where he underwent a
coronary artery bypass graft x 4. Please see operative report
for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition, requiring no pressors. On the
day of surgery he was weaned from sedation, awoke neurologically
intact and extubated. On post-op day one he was started on beta
blockers and diuretics and gently diuresis. He was transferred
to the telemetry floor for further care.
He was febrile to 100.5 and was cultured. He defervesced and
cultures were negative. He was ambulatory and his exam was
benign. At discharge he [**Last Name (un) **] still above his preoperative
weight and had trace edema of the legs and was, therfore, sent
home on a short course of diuretics.
He was instructed as to discharge instructions and medications
prior to discharge and medications are as listed.
Medications on Admission:
Lisinopril 10 mg/D
Lopressor 50mg [**Hospital1 **]
Gemfibrazil 600mg/D
ASA 325mg [**8-19**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*1*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
5. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 7 days.
Disp:*14 Tablet Sustained Release(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 40 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 with left main stenosis
s/p Coronary Artery Bypass Graft x 4
Hypertension
Hypercholesterolemia
Discharge Condition:
good
Discharge Instructions:
no lifting more than 10 pounds for 10 weeks
no driving for 4 weeks and off all narcotics
shower daily, no baths or swimming
no lotions, creams or lotions to incisions
report any drainage or redness of incisions
report any temperature greater than 100.5
take all medications as prescribed
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 32255**] in [**12-30**] weeks
Dr. [**Last Name (STitle) **] in [**11-28**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2104-8-25**]
|
[
"401.1",
"413.9",
"782.3",
"272.0",
"414.01",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.72",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
5362, 5411
|
3139, 4205
|
333, 434
|
5574, 5580
|
1695, 3116
|
5916, 6216
|
1425, 1490
|
4347, 5339
|
5432, 5553
|
4231, 4324
|
5604, 5893
|
1505, 1676
|
281, 295
|
462, 1219
|
1241, 1284
|
1300, 1409
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,192
| 145,075
|
29052
|
Discharge summary
|
report
|
Admission Date: [**2172-9-29**] Discharge Date: [**2172-10-9**]
Date of Birth: [**2093-7-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
lethargy, fevers.
Major Surgical or Invasive Procedure:
NG tube placement
Central line placement
History of Present Illness:
Briefly, 79 yo M NH resident, h/o dementia, remote h/o saddle
PE, MRSA, Afib not on coumadin presumable due to temporal lobe
hemorrhage, urinary retention with recurrent UTIs who presents
with urosepsis. Patient presented to [**Hospital1 **] [**Location (un) 620**] with lethargy,
fevers to 102, HR 180s Afib, BP 100/90s. Treated with Zosyn, 2L
IVF, and transferred to [**Hospital1 18**] for further management on [**2172-9-29**].
On arrival to [**Hospital1 18**] [**Name (NI) **], pt was rigoring and minimally
interactive, VS 100.2, 80, 132/74, 38, 94% NRB and then became
hypotensive to 70s. He was rescusitated with 6L IVF w/o
improvement in BP. Neosynephrine was started after a R IJ was
placed. Levophed was started due to persistent hypotension.
In the MICU, patient treated with Zosyn ([**10-2**]), growing proteus
in urine resistant to amp and fluoroquinolones and piperacillin
based on culture data from [**Location (un) 620**], here sensitive to Zosyn and
clinically improved. Blood culture growing [**2-23**] coag neg
staph--sensitivities pending. Also started to have loose stool,
C.Diff positive- started flagyl on [**10-4**]. NG tube placed for
feeding. Pt developed ARF with Cr to 2.8 now resolved. Patient
now back on diltiazem for HR control and SBP stable. Upon
transfer to the floor, patient resting comfortably, denies pain,
oriented to self and place. VSS.
Past Medical History:
1) Bilateral Saddle Pulmonary Emboli s/p IVC filter
2) Delirium
3) Alcohol Withdrawal
4) Dementia
5) Urinary retention
6) Complicated urinary tract infection
7) Thrombocytopenia NOS
8) Large Inguinal hernia
9) Macrocytic anemia
10) History of alcoholism
11) Hypertension
12) Lung nodules NOS
13) Schizotypal personality disorder with paranoid ideation
14) Does NOT report appendectomy
Social History:
Graduated HS, taught machine shop, [**University/College 23925**] and [**University/College 5130**]
[**Location (un) **], rec'd Bachelor's of Science. Was most recently
teaching at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 69987**] Occupational Center in [**Location (un) 669**] but
quit in [**2153**] b/c "had enough money".
Family History:
No h/o psychiatric illness per pt. Mom died of GI cancer, dad
died of heart failure
Physical Exam:
VS 97.1 122/62 90 24 96% RA
Gen: cachectic male, NAD, lying flat in bed
HEENT: OP clear, dry, anicteric
Neck: supple, RIJ in place, C/c/i
CV: nl s1/s2, irregularly irreg
Lungs: CTA anteriorly
Abd: soft, NT
Ext: 2+ edema throughout. Large scrotal edema
Neuro: oriented to self and place, follows simple commands,
diminished strength throughout.
Pertinent Results:
Admission Labs:
[**2172-9-29**] 11:08PM BLOOD WBC-4.7# RBC-2.59* Hgb-8.3* Hct-24.9*
MCV-96 MCH-32.0 MCHC-33.3 RDW-15.2 Plt Ct-101*
[**2172-9-29**] 07:30PM BLOOD WBC-1.3*# RBC-2.97* Hgb-9.7* Hct-29.9*
MCV-101*# MCH-32.8* MCHC-32.5 RDW-15.0 Plt Ct-134*
[**2172-9-29**] 11:08PM BLOOD Neuts-73* Bands-22* Lymphs-3* Monos-0
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2172-9-29**] 11:08PM BLOOD PT-16.2* PTT-42.9* INR(PT)-1.5*
[**2172-9-29**] 11:08PM BLOOD Glucose-75 UreaN-71* Creat-2.4* Na-140
K-3.9 Cl-115* HCO3-13* AnGap-16
[**2172-9-29**] 11:08PM BLOOD ALT-95* AST-167* LD(LDH)-264* CK(CPK)-131
AlkPhos-202* Amylase-52 TotBili-2.2*
[**2172-9-29**] 11:08PM BLOOD Albumin-2.0* Calcium-6.2* Phos-3.5#
Mg-1.5* UricAcd-6.7
[**2172-9-29**] 07:45PM BLOOD Lactate-8.8*
Discharge labs:
[**2172-10-8**] 09:00AM BLOOD WBC-9.3 RBC-3.44* Hgb-10.9* Hct-33.4*
MCV-97 MCH-31.6 MCHC-32.6 RDW-16.1* Plt Ct-182
[**2172-10-8**] 09:00AM BLOOD Plt Ct-182
[**2172-10-8**] 09:00AM BLOOD Glucose-68* UreaN-27* Creat-0.8 Na-136
K-4.4 Cl-106 HCO3-23 AnGap-11
[**2172-10-8**] 09:00AM BLOOD Calcium-7.6* Phos-2.4* Mg-1.8
Imaging:
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2172-9-29**] 7:54 PM
CHEST (PORTABLE AP)
Reason: eval for pna, IJ placement
[**Hospital 93**] MEDICAL CONDITION:
79 year old man with sepsis, right IJ
REASON FOR THIS EXAMINATION:
eval for pna, IJ placement
INDICATION: Sepsis, right IJ placement.
COMPARISON: [**2172-6-27**].
SINGLE VIEW CHEST, AP: There has been interval placement of a
right IJ CVL with the tip within the mid SVC. No pneumothorax is
identified. The pulmonary vasculature is within normal limits
allowing for the supine technique of the exam. The cardiac and
mediastinal contours are stable with unfolding of the aorta and
wall calcifications.
IMPRESSION: Right IJ CVL tip within the mid SVC. No evidence of
pneumothorax.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Approved: TUE [**2172-9-29**] 9:05 PM
RADIOLOGY Final Report
ABDOMEN U.S. (COMPLETE STUDY) [**2172-9-30**] 9:14 AM
ABDOMEN U.S. (COMPLETE STUDY)
Reason: EVAL FOR BILIARY DISEASSE/EVAL FOR HYDRO
[**Hospital 93**] MEDICAL CONDITION:
79 year old man with mild transaminitis
REASON FOR THIS EXAMINATION:
Eval for biliary disease
LIVER ULTRASOUND ON [**2172-9-30**]
CLINICAL HISTORY: Elevated LFTs. Low albumin.
FINDINGS: Grayscale and color ultrasound of the abdomen was
performed without priors available for comparison. The liver
remains normal in size and echotexture. Spleen remains normal in
size. The splenic vein is prominent at the level of the
spleno-portal confluence, which can be an early indicator of
portal hypertension. Gallbladder wall is markedly thickened with
a small gallbladder lumen. No cholelithiasis or biliary
dilatation is seen, and this likely is a manifestation of third
spacing/hypoproteinemia. No focal hepatic lesions. Portal vein
remains patent, and flows in the proper direction.
The kidneys remain normal in size and echotexture without
hydronephrosis.
IMPRESSION:
1. Marked gallbladder wall edema, without biliary dilatation or
cholelithiasis, likely due to third spacing.
2. Mild distention of the splenic vein, which may indicate early
portal hypertension. Continued surveillance advised.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2172-10-1**] 10:22 AM
RADIOLOGY Final Report
SCROTAL U.S. [**2172-10-1**] 3:21 PM
SCROTAL U.S.
Reason: Eval for bowel loop strangulation or other mass.
[**Hospital 93**] MEDICAL CONDITION:
79 year old man with known inguinal hernia with scrotal edema
and now with ecchymosis.
REASON FOR THIS EXAMINATION:
Eval for bowel loop strangulation or other mass.
SCROTAL ULTRASOUND.
CLINICAL INDICATION: 79-year-old male with known large inguinal
hernia and scrotal edema and ecchymosis. To evaluate for bowel
loop strangulation or other mass.
COMPARISON STUDY: CT scan, [**2172-5-11**], which demonstrated a very
large right inguinal scrotal hernia containing both right colon
and cecum as well as multiple small bowel loops.
Scans over the swollen ecchymotic scrotum were performed using
deep abdominal and high-resolution linear probes. The left
testis is small and high in position almost within the left
inguinal canal, but is otherwise unremarkable. The right testis
and epididymis are also small and similar in appearance to the
left and are displaced medially by the large inguinal scrotal
hernia sac. The free fluid within the hernia sac is clear,
showing no signs of exudative characteristics. Within the sac
are multiple bowel loops, none of which shows active peristaltic
activity. Some of the small bowel loops have normal mucosal fold
architecture, while other loops are more distended with
effacement of the mucosal folds. Some of the loops are
fluid-filled and others are air-filled, but the walls of the
various small bowel loops show no evidence of edema or air
contained within the walls. Neither is there evidence of free
air within the sac.
Color flow and Doppler assessment of the testes and epididymides
show normal to perhaps slightly increased vascularity in both
testes in a symmetrical distribution with normal pulsed Doppler
waveforms. Color flow assessment of the bowel walls within the
scrotal hernia also show vascular flow in all of the
interrogated bowel loops.
CONCLUSION: Large right inguinal scrotal hernia containing both
large and small bowel. While the bowel is dilated and flaccid,
there are no specific signs of ischemia or necrosis, and
specifically there is no evidence of air within the bowel wall,
edema within the bowel wall or lack of vascularity.
However, since no contrast is available for use in ultrasound,
the assessment for bowel wall ischemia is incomplete on this
study and consideration of contrast-enhanced CT scan is
recommended. These findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1887**]
at 4:40 p.m. by telephone.
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2172-10-1**] 8:02 PM
Atrial fibrillation with rapid ventricular response. Probable
left
anterior fascicular block. Poor R wave progression. Consider
prior
anterior myocardial infarction. Since prior tracing of [**2172-6-28**]
voltage in
leads V1-V3 is decreased on the current study and the rate has
increased.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] D.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
175 0 88 278/479 0 -43 -160
Brief Hospital Course:
Briefly, 79 yo M NH resident, h/o dementia, remote h/o saddle
PE, MRSA, Afib not on coumadin presumable due to temporal lobe
hemorrhage, urinary retention with recurrent UTIs who presents
with urosepsis. Patient presented to [**Hospital1 **] [**Location (un) 620**] with lethargy,
fevers to 102, HR 180s Afib, BP 100/90s. Treated with Zosyn, 2L
IVF, and transferred to [**Hospital1 18**] for further management on [**2172-9-29**].
On arrival to [**Hospital1 18**] [**Name (NI) **], pt was rigoring and minimally
interactive, VS 100.2, 80, 132/74, 38, 94% NRB and then became
hypotensive to 70s. He was rescusitated with 6L IVF w/o
improvement in BP. Neosynephrine was started after a R IJ was
placed. Levophed was started due to persistent hypotension.
In the MICU, patient treated with Zosyn ([**10-2**]), growing proteus
in urine resistant to amp and fluoroquinolones and piperacillin
based on culture data from [**Location (un) 620**], here sensitive to Zosyn and
clinically improved. Blood culture growing [**2-23**] coag neg
staph--sensitivities pending. Also started to have loose stool,
C.Diff positive- started flagyl on [**10-4**]. NG tube placed for
feeding. Pt developed ARF with Cr to 2.8 now resolved. Patient
now back on diltiazem for HR control and SBP stable. Upon
transfer to the floor, patient resting comfortably, denies pain,
oriented to self and place. VSS.
Through the course on the floor, the patient's central line was
removed. He received a speech and swallow eval finding that he
could tolerate nectar thick liquids but did not swallow purees
without coaxing. Zosyn was changed to oral Cefpodoxime on [**10-6**]
and given in nectar thick liquid. He continued to receive
flagyl for C diff and diltiazem for Afib. Patients vitals
continued to be stable and he continued to improve clinically.
He had no delerium episodes, however, he removed his NG tube on
[**10-7**]. A repeat speech and swallow eval on [**10-8**] indicated that
patient could tolerate purees. Patient is now medically stable
and optimized on therapy to return to NH.
Medications on Admission:
Cholecalciferol (Vit D3) 400mg po daily
Hexavitamin daily
Thiamine HCl 100mg PO daily
Folic acid 1mg po daily
Acetominophen 325mg prn
Haloperidol 1mg PO BID
Quetiapine 25mg two tabs po BID
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Metronidazole 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3
times a day) for 16 days.
3. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: One (1) PO BID (2
times a day).
4. Diltiazem HCl 60 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO QID (4
times a day).
5. Miconazole Nitrate 2 % Powder [**Month/Year (2) **]: One (1) Appl Topical QID
(4 times a day) as needed for rash.
Disp:*1 qs* Refills:*0*
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily) as needed for
prophylax.
7. Cefpodoxime 100 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q12H (every
12 hours) as needed for UTI for 6 days.
8. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Urosepsis
Afib
Dementia
Acute Renal Failure resolved
Failure to thrive
Anemia
Discharge Condition:
Stable
Discharge Instructions:
You were treated in the hospital for a urinary tract infection
that progressed to sepsis. You improved on antibiotics and you
are being discharged back to your nursing home. Please take
your medicines as directed and keep follow up appointments.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2172-11-5**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2172-10-30**] 9:30
Also recommend outpatient neurology appointment
[**Hospital 878**] Clinic
Phone [**Telephone/Fax (1) 44**]
Location [**Hospital Ward Name 23**] 8
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"301.22",
"550.90",
"038.11",
"263.0",
"401.9",
"785.52",
"788.20",
"285.9",
"584.9",
"996.64",
"995.92",
"041.6",
"287.5",
"294.8",
"332.0",
"008.45",
"599.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13216, 13293
|
9866, 11948
|
332, 375
|
13415, 13424
|
3056, 3056
|
13720, 14333
|
2585, 2671
|
12188, 13193
|
6808, 6895
|
13314, 13394
|
11974, 12165
|
13448, 13697
|
3834, 4287
|
2686, 3037
|
275, 294
|
6924, 9843
|
403, 1797
|
3073, 3818
|
1819, 2206
|
2222, 2569
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,616
| 104,736
|
14126+14202
|
Discharge summary
|
report+report
|
Admission Date: [**2171-4-3**] Discharge Date: [**2171-4-25**]
Date of Birth: [**2106-1-18**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 65-year-old woman
with a complicated medical history who was admitted to [**Hospital3 15516**] Hospital on [**2171-3-3**] for small-bowel obstruction,
status post laparotomy and lysis of adhesions, who
postoperatively, was found to have line sepsis with MRSA. She
then was found to have abscessed. This was percutaneously
drained on [**2171-3-26**] and she was found to have
vertebral osteomyelitis/diskitis at the level T4-T5, T11-T12,
and L2-L3. She was seen by the Department of Neurosurgery at
[**Hospital3 **] Hospital where the decision was made for long-term
antibiotic treatment with Vancomycin and Rifampin. No
surgery was planned at that time. Apparently, the patient
was going to be discharged to rehabilitation on the day of
admission to [**Hospital1 69**] on [**4-3**],
when the patient became lethargic and had a temperature to
103.8. She was transferred to [**Hospital6 2910**]
briefly, where her initial blood pressure was in the 90s. The
patient was very lethargic there and ABG showed a blood gas
with pH of 7.39, carbon dioxide 39.6, and oxygen 79. Chest
x-ray showed a right left lower lobe infiltrate. She was
started on Ceftriaxone and Flagyl and given hydrocortisone
200 mg since the patient is on chronic steroids. Also, of
note, the patient had been given Levaquin and Diflucan at
[**Hospital3 **] Hospital for pneumonia and [**Female First Name (un) 564**] in the urine.
The patient was then transferred from [**Hospital6 1322**] to [**Hospital1 69**] for a
possible ICU bed. Upon arrival to the emergency room, the
vital signs were blood pressure 148/56; heart rate 80;
temperature 98.6; respiratory rate 16; oxygen saturation 98%
on four liters. The patient was alert and oriented. She was
seemed stable from the Medicine Floor. Repeat ABG there
showed a pH of 7.35, pO2 149, pCO2 40, on four liters by
nasal cannula. The patient, on initial labs, was seen to
have a hematocrit of 25, decreased from 30, two days
previously.
REVIEW OF SYSTEMS: On review of systems, the patient denied
headache, back pain, chest pain, shortness of breath, cough,
abdominal pain, nausea, vomiting, diarrhea, dysuria,
hematemesis, melena, or bright red blood per rectum. She was
alert and oriented and conversant and stated that she felt
fine on admission.
Per medical history, osteomyelitis of the vertebral bodies of
L2 and L3, growing MRSA in blood cultures, diskitis at three
sites including T4 to T5, T11 to T12, and L2 to L3; psoas
abscess status post percutaneous drainage; polymyalgia
rheumatica on steroids chronically; hypertension;
rectovaginal fistula; parotid tumor status post right parotid
gland resection; bladder spasms and incontinence; macular
degeneration; depression/panic disorder, status post sigmoid
colectomy for diverticulitis; status post herniorrhaphy;
status post hysterectomy.
ALLERGIES: The patient is allergic to PENICILLIN, SULFA, AND
PERCOCET.
SOCIAL HISTORY: Her son is [**Name (NI) 892**] [**Name (NI) 42086**] at [**Telephone/Fax (1) 42087**].
She also has as sister who lives in [**State 2748**] and a
granddaughter.
PHYSICAL EXAMINATION: On examination, temperature was 98.0,
blood pressure 117/38, heart rate 76, respirations 14, oxygen
saturation 98% on four liters by nasal cannula. GENERAL:
The patient was alert and conversant, frequently inattentive,
no acute distress, speaking full sentences. HEENT: Oral
thrush present, dry mucous membranes. Pupils 0.5-mm, hard to
assess if reactive, constricted. Extraocular muscles are
intact. NECK: No lymphadenopathy. CHEST: Decreased breath
sounds at the right base with egophony at the right base. No
wheezes, no rales, [**Last Name (un) **] catheter site at the right chest,
no erythema, nontender. CARDIOVASCULAR: Regular rate and
rhythm, normal S1 and S2. No murmur. ABDOMEN: Soft, with
right lower quadrant tenderness, no guarding, no rebound, no
mass, no hepatosplenomegaly, no psoas sign present. No
[**Doctor Last Name **]-[**Doctor Last Name **] sign. BACK: Diffuse thoracic and lumbar spine
tenderness. EXTREMITIES: No edema. SKIN: Maculopapular
rash over chest, neck, back, and posterior thigh. There was
no sacral decubitus ulcer present. NEUROLOGICAL: The
patient was alert and oriented to person and date, knew
[**Location (un) 86**], but could not name the hospital. Cranial nerves II
through XII intact. EXTREMITIES: Lower extremity: Motor:
Hip flexion strength 3/5, dorsiflexion [**4-7**], plantar flexion
[**4-7**], hyperreflexic patellar reflexes, 3+ and symmetrical,
unable to elicit ankle jerks, toes downgoing and withdraws.
RECTAL: Examination revealed guaiac negative with brown
stool.
LABORATORY DATA: Laboratory data revealed the following:
White count 5.5, hematocrit 25.5, platelet count 257,000.
Chem 7 remarkable for creatinine of 2.2, magnesium 1.1, AST
81, ALT 23, alkaline phosphatase 119, albumin 2.1, INR 1.6,
PTT 40.8, D-dimer greater than 1.0. Urinalysis: Positive
nitrites, 3+ blood, no leukocyte esterase, 2 to 5 red blood
cells, 5 to 10 white blood cells, no bacteria.
Culture data: The patient had multiple negative blood
cultures dating from [**4-4**] through [**4-20**], which showed
no growth, regular cultures and microcytic cultures. Urine
cultures were negative from [**4-4**] to [**4-11**] and then
positive for Pseudomonas greater than 100,000 from urine
cultures [**4-16**] and [**4-18**]. Stool cultures were negative
for C. difficile times four. Tissue culture from the L2-L3
disk on [**4-15**], showed no growth. Tissue culture L2-L3
bone on [**4-15**] grew MRSA. Genital swab on [**4-15**], grew
MRSA. Abscess from the psoas abscess site on [**4-12**] grew
Enterococcus. CSF from the lumbar puncture on [**4-10**] was
negative.
Radiology: Multiple chest x-rays done between [**4-4**] and
[**4-20**], initially showed a right lower lobe atelectasis and
left lower lobe consolidation consistent with pneumonia,
which improved over time and chronic mild CHF.
CT scan of the abdomen and pelvis on [**4-4**], showed no
retroperitoneal bleed and atelectasis of bilateral lungs.
Repeat abdominal CT on [**4-22**] showed no evidence of
intraabdominal abscess, thickened wall of the sigmoid
consistent with circular muscle hypertrophy. No CT evidence
for diverticulitis. MRI of the spine on [**4-8**], showed
diskitis and osteomyelitis of T4-T5 and T11-T12 and L2-L3.
On [**4-8**], MR of the head showed old ischemic disease in the
brain stem with a tiny lesion present advanced
periventricular microvascular ischemic changes, left-sided
mastoiditis of uncertain age and generalized atrophy. On [**4-19**], repeat MR of the spine and head showed no change from
the initial studies. Echocardiogram on [**4-10**],
transesophageal echocardiogram showed no thrombus; no atrial
septal defect; mild LVH with LV function ejection fraction
greater than 55%, normal RV with mild aortic regurgitation,
tricuspid regurgitation and significant pulmonary
regurgitation. Perforation was seen at the base of the
posterior mitral leaflet consistent with endocarditis of the
mitral and aortic valves.
HOSPITAL COURSE: (by system)
INFECTIOUS DISEASE: The patient initially came in on
Vancomycin, Levofloxacin, Ceftriaxone, Aztreonam, Rifampin,
and Fluconazole for treatment of her psoas abscess and
vertebral osteomyelitis. This was trimmed down to only
Vancomycin on admission. She then developed a severe rash on
[**4-9**], approximately six days after admission. It was not
clear to which drug this rash developed, but it was thought
most likely due to Ceftriaxone or Lasix. Vancomycin was also
considered possibly, although remotely likely cause and this
was discontinued and the patient was started on Linezolid.
Transesophageal echocardiogram done [**4-10**] showed a probable
mitral valve perforation consistent with endocarditis, no
vegetations seen. The patient had a lumbar puncture on the
8th. CSF from this puncture was culture negative and had no
organisms on gram stain, 1+ PMN. The psoas abscess was
drained by Interventional Radiology [**4-12**]. Culture of the
abscess subsequently grew enterococcus. The patient was
continued on Linezolid for the enterococcus, as well as the
MRSA, which had grown at [**Hospital **] [**Hospital **] Hospital from both
blood cultures.
The patient continued with fevers and the rash gradually
developed bullae and also started to exfoliate. On
[**2171-4-12**], the Vancomycin was discontinued and the
patient was started on Linezolid. On [**4-15**], the L2-L3
disk was debrided by the Neurosurgical Team as this was
thought to be a possible nidus of infection. Linezolid was
then continued for a 28-day course, dating from the time of
the surgery [**4-15**]. Urine culture subcutaneously grew
Pseudomonas and the patient was started on Tobramycin on [**4-20**] for a seven-day course. Stool was sent for C. difficile
as the patient briefly developed some diarrhea. This was
negative times four. The patient will be continued for a
full seven-day course of tobramycin for her Pseudomonas in
the urine, as well as the full 28-day course of Linezolid.
The patient developed some irritation of the bladder and
Foley site on [**2171-4-24**]. Urine was sent for urinalysis
and culture. Urinalysis was consistent with a UTI with
nitrite, leukocyte esterase, and white blood cells with many
bacteria. The culture was pending at the time of this
dictation. Because the patient is already on Linezolid and
Tobramycin, we will followup culture results and treat
accordingly. Foley was removed.
CARDIOVASCULAR: The patient does not have a significant
cardiac history aside from hypertension on admission.
However, she developed refractory atrial fibrillation on [**4-9**]. She was transferred to the ICU for atrial fibrillation
and hypotension. She was started on an Amiodarone drip as
per the electrophysiology and cardiology fellow
recommendations. The was eventually switched to p.o.
Amiodarone initially at 400 mg p.o. b.i.d. and then 400 mg
p.o.q.d. for a month and then ongoing at 200 mg p.o.q.d. She
had no further episodes of atrial fibrillation.
Transthoracic echocardiogram was done [**4-9**] and
Transesophageal echocardiogram was done on [**4-10**], which
showed probable endocarditis involving the mitral valve. CT
surgery was consulted, who did not recommend surgery at this
time because the patient had no evidence of ventricular
failure and recommended ongoing medical therapy. The patient
has a history of hypertension. She was started on Lopressor
and Hydralazine during her hospital stay to control her blood
pressure.
DERMATOLOGY: The Dermatology Service was consulted on [**4-10**] to evaluate the rash, which was thought most like to
Cephalosporins or Lasix as the patient has a Sulfa allergy,
more remotely Vancomycin was a possibility. The patient was
initially treated with Fexofenadine, which was discontinued
on [**4-18**], Synalar and hydrated petroleum and Aveeno baths,
the rash gradually improved and by the time of discharge it
was almost completely resolved except for some light flaking
of the skin mostly of the lower extremities.
PULMONARY: The patient had failure in the setting of atrial
fibrillation in early [**Month (only) 116**]. This then resolved. She had no
further pulmonary issues and she had good oxygen saturations
on room air.
ENDOCRINE: The patient's TSH was checked and elevated at 22.
The Levoxyl dose was then increased to 100 mcg p.o.q.d.
RHEUMATOLOGY: The patient has polymyalgia rheumatica and is
chronically on steroids. She was gradually weaned from
high-dose steroids used during her initial days of
hospitalization down to Prednisone 15 mg p.o.q.d. This
should be weaned further as tolerated by the patient.
HEMATOLOGY: The patient is anemic with hematocrit stable,
but running in the low 20s throughout the hospital course.
She was guaiac negative. She had two CT scans, which showed
that she did not have any retroperitoneal bleed. Anemia labs
were sent, which were normal. She had a good reticulocyte
count. It is most likely that she had suppression due to her
infection, which will recover as the patient clinically
improves. The patient received a total of four units of
packed red blood cells throughout her hospital stay.
NEUROLOGICAL: The patient was slightly confused and
lethargic on admission. The mental status gradually improved
throughout the hospital stay, although there were periods of
worsening. She did not have any evidence for meningitis by
lumbar puncture and intracranial abscess or hemorrhage was
ruled out by head MRI.
The patient was followed by the Neurosurgical team, who
debrided the L2-L3 disk on [**4-15**]. This wound filled well
with no complications. The patient's mental status was
markedly improving during the last days of her admission
prior to transfer. The patient was oriented to place and
date, time of discharge, as well as to person.
RENAL: The patient's creatinine was initially increased to
2.2 on admission from the baseline of 0.8. This gradually
improved with hydration and thought to be prerenal in
etiology. It came down to her baseline and it was stable at
the time of discharge.
FLUIDS, ELECTROLYTES, AND NUTRITION: This patient was
started on TPN on [**2171-4-11**] and on tube feeds [**4-18**].
She tolerated this well. She was gradually taken off TPN on
[**4-24**], when she was at goal with her tube feeds. She was
then started on a clear diet with the intention of
transitioning her from tube feeds to a regular p.o. diet.
The NG tube will likely be removed before discharge.
GASTROINTESTINAL: The patient had a small bowel obstruction
at the outside hospital and had a laparotomy and lysis of
adhesions there. She continued with abdominal pain during
her hospital stay here and she was treated with Tramadol and
Neurontin. She had slightly worsened abdominal pain [**4-20**]
to [**4-22**], but repeat abdominal CT on [**4-22**] showed no
intra-abdominal pathology. She did have some constipation,
which was relieved with a bowel regimen. She then had some
diarrhea. This was sent for C. difficile times four, which
was negative.
PAIN CONTROL: The patient's pain was controlled with
Tramadol, Neurontin, and for a while she received some
morphine, however, this seemed to exacerbate her altered
mental status. Mental status cleared once this was
discontinued.
DISCHARGE STATUS: The patient is discharged to
rehabilitation.
CONDITION ON DISCHARGE: Improved.
DISCHARGE DIAGNOSES: Endocarditis with MRSA and
Enterococcus. Vertebral osteomyelitis. Psoas abscess.
MEDICATIONS ON DISCHARGE:
1. Heparin 5000 units subcutaneously b.i.d. to be continued
until the patient is ambulating well.
2. Prevacid suspension 30 mg per G-tube q.day. This should
be changed to Protonix 40 mg p.o.q.d, once she is taking
adequate POs.
3. Amiodarone 400 mg p.o.q.d.
4. Lopressor 50 mg p.o.b.i.d.
5. Miconazole powder applied to groin p.r.n.q.i.d.
6. Tylenol 650 mg p.o.q.4h. to 6h.p.r.n.
7. Dulcolax 15 mg p.o./pr/prn.
8. Hydralazine 50 mg p.o.q.i.d. hold for systolic blood
pressure less than 100.
9. Tobramycin 100 mg IV q.12h.
10. Levoxyl 100 mcg p.o.q.d.
12. Tramadol 50 mg p.o.q.i.d.p.r.n.
13. Aveeno bath two to three times a day p.r.n.
14. Prednisone 15 mg p.o.q.d.
15. Fluocinolone 0.025% cream one application to body b.i.d.
16. Nystatin oral suspension 5 ml p.o.q.i.d.
17. Regular insulin sliding scale.
18. Colace 100 mg p.o.b.i.d.
19. Senokot two tabs p.o.q.d.
20. Linezolid 600 mg IV q.12h.
[**Doctor Last Name **] M.[**Name8 (MD) **] M.D.12-735
Dictated By:[**Last Name (NamePattern1) 7896**]
MEDQUIST36
D: [**2171-4-24**] 15:15
T: [**2171-4-24**] 15:39
JOB#: [**Job Number **]
Admission Date: [**2171-4-3**] Discharge Date: [**2171-4-27**]
Date of Birth: [**2106-1-18**] Sex: F
Service:
This is a discharge summary addendum covering the dates [**4-25**] through [**2171-4-27**].
The patient continued to improve clinically during the last
two days of her hospital course. However, she did develop
some erythema and tenderness at the site of her PICC line on
the right arm. This was evaluated by a right upper extremity
ultrasound which showed thrombophlebitis of the right
cephalic vein surrounding the catheter, with no evidence for
deep venous thrombosis. It was recommended that the PICC
line be changed. In addition, because thrombus had developed
at the site of the PICC line, we started the patient on
Lovenox 30 mg subcutaneously twice a day, and discontinued
her heparin 5000 units subcutaneously twice a day to prevent
further clot formation at the site of the new line. The new
line was placed by the Interventional Radiology service. It
is a midline suitable for use with linezolid and tobramycin,
however, the patient should not receive other antibiotics or
medications through this line without first checking with
Pharmacy to see if this line is appropriate.
The patient will have a follow-up MRI on [**2171-5-15**], at
10:15 A.M. at the fourth floor of the [**Hospital Ward Name 23**] Center for
follow up. The Infectious Disease service will follow up
with her in clinic as well.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 7896**]
MEDQUIST36
D: [**2171-4-26**] 22:10
T: [**2171-4-27**] 00:12
JOB#: [**Job Number 42247**]
|
[
"725",
"730.08",
"427.31",
"421.0",
"451.82",
"693.0",
"038.11",
"486",
"728.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"77.49",
"99.15",
"80.51",
"88.72",
"38.93",
"83.95",
"96.6",
"99.69"
] |
icd9pcs
|
[
[
[]
]
] |
14693, 14777
|
14803, 17651
|
7291, 14635
|
3282, 7273
|
2160, 3080
|
3097, 3259
|
14660, 14671
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,330
| 125,187
|
1209
|
Discharge summary
|
report
|
Admission Date: [**2153-1-27**] Discharge Date: [**2153-1-29**]
Date of Birth: [**2084-8-9**] Sex: M
Service: SURGERY
Allergies:
Augmentin / Cefuroxime / Tape [**12-3**]"X10YD / Ceftin / Iodine-Iodine
Containing
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Acute onset bilateral thigh pain
Major Surgical or Invasive Procedure:
OPERATIONS:
1. Ultrasound-guided puncture of bilateral common femoral
arteries.
2. Ultrasound-guided puncture of right common femoral vein.
3. Advancement of catheters bilaterally into infrarenal
abdominal aorta.
4. Stent placement at infrarenal abdominal aorta.
5. Bilateral stent placement at common iliac arteries.
History of Present Illness:
68M with severe PVD who is s/p b/l CIA stents, Right CFA->BK
[**Doctor Last Name **] with LGSV in [**2142**] and L AK-BK [**Doctor Last Name **] with NRSVG in [**2150**], on
Coumadin for a-fib. Pt reports acute onset of bilateral thigh
pain starting at 0330 this morning when he attempted to get out
of bed to go to the bathroom. Pt states he ambulates with a cane
at baseline. Pain has improved with IV narcotics this morning
but
has not completely resolved. Pt transferred from OSH ED to [**Hospital1 18**]
ED due to complex nature of his multiple medical problems.
Past Medical History:
1.Coronary artery disease, CABG [**2139**] and PCI
2.Congestive Heart Failure-EF 48% by P-MIBI, last TTE in [**2147**] w
LVH, mild systolic LV dysfunction, mild MR
3.CKD s/p transplants in [**2135**] and [**2139**]. Baseline Cr 1.5-1.7
4.Hypertension
5.Hyperlipidemia
6.Atrial fibrillation
7.PVD-[**3-/2143**]- Right femoral below-knee popliteal bypass graft
[**9-/2143**]- Right heel ulcer s/p skin grafting
8.GERD
9.Bladder neoplasm
Social History:
Married with 3 adult children. He is retired.
Prior to retiring he worked as a supervisor for the [**Company 2318**]. He
quit smoking 30 years ago. Prior to quitting he smoked 1ppd for
approximately 14 year. He denies the use of recreational drugs.
He drinks an occasional cocktail with dinner
Family History:
Father had CAD requiring a CABG at the age of 74 and is alive
and well at the age of 86.
Physical Exam:
on admissio:
Exam
Temp 97.3, HR 79 (A-fib), 178/60, RR 14, O2 Sat 90% on RA
Gen: mildly agitated but conversive, intermittently confused,
oriented x3
CV: Irreg/Irreg, No R/G/M
Resp: Decreased breath sounds at bases b/l
Abd: Protuberant, soft, nt, RLQ renal transplant incision well
healed
Ext: HD fistula in LUE forearm with strong palpable thrill,
lower
extremities cool bilaterally with delayed cap refill >2 sec but
no mottling. No dopplerable signals in either LE graft or in
either PT or DP. Very weakly dopplerable bilateral femoral
signals. [**1-4**]+ edema BLE worse on the right.
Pertinent Results:
[**2153-1-29**] 05:05PM BLOOD
WBC-7.4 RBC-2.90* Hgb-8.6* Hct-27.0* MCV-93.1 MCH-29.2 MCHC-31.7
RDW-16.0* Plt Ct-90*
[**2153-1-29**] 05:05PM BLOOD
PT-25.3* PTT-41.6* INR(PT)-2.4*
[**2153-1-29**] 05:05PM BLOOD
Glucose-294* UreaN-30* Creat-2.4* Na-134 K-5.2* Cl-100 HCO3-14*
AnGap-25*
[**2153-1-29**] 05:05PM BLOOD
ALT-227* AST-791* LD(LDH)-3785* CK(CPK)-[**Numeric Identifier 7641**]* AlkPhos-145*
Amylase-234* TotBili-2.0*
[**2153-1-29**] 01:07PM BLOOD
CK(CPK)-[**Numeric Identifier 7642**]*
[**2153-1-29**] 11:06AM BLOOD
CK(CPK)-[**Numeric Identifier 7643**]*
[**2153-1-29**] 05:29AM BLOOD
CK-MB-52* MB Indx-0.1 cTropnT-0.41*
[**2153-1-29**] 05:05PM BLOOD
Albumin-2.4* Calcium-7.8* Phos-6.5*# Mg-2.5
[**2153-1-29**] 06:47PM BLOOD
Type-ART pO2-232* pCO2-42 pH-7.07* calTCO2-13* Base XS--17
[**2153-1-29**] 06:47PM BLOOD
Glucose-263* Lactate-14.5*
CHEST: The right subclavian central venous catheter terminates
appropriately in the mid SVC. The left internal jugular catheter
is malpositioned terminating in the left superior intercostal
vein. ET tube is appropriately positioned and terminates in the
mid trachea. The NG tube extends below the level of the
hemidiaphragms and is post-pyloric in positioning.
The visualized thyroid gland is unremarkable. The heart is
enlarged, without pericardial effusion. Dense coronary artery
calcifications. Aortic and mitral valve calcifications are
unchanged. Borderline in size mediastinal lymph nodes are seen,
specifically in the paratracheal position measuring up to 1 cm
in short axis. Although this study is not designed to evaluate
the pulmonary arteries, no filling defect is seen to suggest
pulmonary embolus. The thoracic aorta is normally opacified with
dense arteriosclerosis. The ascending aorta is mildly ectatic
measuring up to 3.7 cm. Descending thorasic aorta is normal
caliber. Bilateral pleural effusions are layering and have
slightly increased in size. Associated bibasilar atelectasis.
Concomitant consolidation with preserved air bronchograms cannot
be excluded. Additional multifocal patchy airspace opacities are
seen throughout both lungs. This may represent volume overload
and/or an evolving infectious/inflammatory pneumonitis. There is
confluent consolidation also seen in a patchy distribution in
the posterior aspects of both upper lobes. No airway lesion
is identified.
ABDOMEN AND PELVIS: The liver appears unremarkable on this
single phase of
imaging. Reflux of intravenous contrast into the hepatic veins
suggests right
heart strain. Cholelithiasis. Vicarious accumulation of contrast
into the
gallbladder lumen. The pancreas is near completely replaced by
fat. The
spleen is unremarkable. The stomach is appropriately
decompressed by NG tube,
which terminates in the post-pyloric region. The native kidneys
are
bilaterally significantly atrophic, without hydronephrosis or
hydroureter.
Stable bilateral perinephric stranding. Adrenal glands are
unremarkable
bilaterally. Visualized non-opacified small bowel loops are
normal in caliber.
Mild thickening of portions of the colon may be a result of
underdistension
rather than thickening related to a mild colitis.
Trace free fluid is now seen within the abdomen, particularly in
the paracolic
gutters and in the presacral region. Patient is status post
bilateral lower
quadrant renal transplants. The right lower quadrant renal
transplant is
markedly atrophic. Left renal transplant appears unchanged
without
hydronephrosis. There is no significant enhancement. There is
trace fluid
surrounding the left renal transplant, similar to previous exam.
Scattered
diverticula of the colon. Remaining pelvic loops of bowel,
distal ureters,
prostate and seminal vesicles are unremarkable. The urinary
bladder is
partially decompressed but appears to have associated
inflammatory changes, a concomitant cystitis cannot be excluded.
No significant new pelvic or inguinal adenopathy.
Post-procedural stranding and fluid are seen in both inguinal
regions, likely related to recent intervention. No discrete
collection is seen. Worsening anasarca of the surrounding
subcutaneous fat.
CTA OF THE ABDOMEN AND PELVIS: The abdominal aorta is normal in
caliber with dense calcific atherosclerosis along its length.
There is extensive calcific atherosclerotic disease involving
the celiac artery and its branches, superior mesenteric artery,
inferior mesenteric artery, and bilateral native renal arteries.
The celiac axis again demonstrates moderate stenosis due to
calcific atherosclerosis. The SMA is patent without significant
stenosis. The [**Female First Name (un) 899**] origin again demonstrates patchy multifocal
areas of moderate-to-severe stenosis and appears increasingly
opacified distally beyond its origin. Both native renal arteries
have a severe degree of stenoses and calcification. There
appears to be restenting of the distal aorta extending into both
common iliac arteries. There is now opacification in the distal
aorta extending into the common iliac arteries. Preserved
opacification of both external and internal iliac arteries is
now visualized. Extensive calcified atherosclerotic disease is
present within the common, internal, and external iliac arteries
bilaterally. There is flow demonstrated in the renal artery
supplying the left iliac fossa renal transplant, a significant
improvement from prior study. Partially visualized right
femoropopliteal bypass graft is opacified. The right obturator
internus muscle appears asymmetrically larger and may be a
result of intramuscular hematoma. No active extravasation is
seen on this phase of imaging.
BONE WINDOWS: No suspicious lytic or sclerotic osseous
abnormalities are
seen.
IMPRESSION: Status post restenting of the distal aorta extending
into both
common iliac arteries. Patency of the distal aorta and bilateral
common iliac arteries, external/internal iliac arteries is now
appreciated.
Improved arterial opacification supplying the left lower
quadrant renal
transplant, in comparison to previous exam.
Worsening moderate-sized layering bilateral pleural effusions
with associated bibasilar atelectasis and/or consolidation.
Patchy multifocal ground-glass opacities and areas of patchy
posterior confluence have progressed. Multifocal pneumonia and
superimposed volume overload are likely contributors.
Left internal jugular central venous catheter is malpositioned
and terminates in the left superior intercostal vein.
Asymmetric thickening and enlargement of the right obturator
internus muscle may represent intramuscular hematoma related to
recent procedure. No active extravasation is seen on this exam.
Brief Hospital Course:
Pt transfered from [**Hospital 7644**] hospital for total aortic occlusion.
Lehriche syndrome.
pre-opd and consented for the procedure
Emergently take to the OR:
OPERATIONS:
1. Ultrasound-guided puncture of bilateral common femoral
arteries.
2. Ultrasound-guided puncture of right common femoral vein.
3. Advancement of catheters bilaterally into infrarenal
abdominal aorta.
4. Stent placement at infrarenal abdominal aorta.
5. Bilateral stent placement at common iliac arteries.
PT transfered to the CVICU in critical condiotion.
Pt intubated for duration.
Pt went into muliti factoral organ failure.
Post op course significant for severe hyperkalemia, and
acidemia.
CRRT for severe electrolyte/metabolic disarrangement, equivalent
home immunosuppressant regimen, bicarb to protect the kidneys,
pt aneuric post op
Pt was on heperin drip.
CTA was obtained:
Status post restenting of the distal aorta extending into both
common iliac arteries. Patency of the distal aorta and bilateral
common iliac
arteries, external/internal iliac arteries is now appreciated.
Improved arterial opacification supplying the left lower
quadrant renal
transplant, in comparison to previous exam.
Worsening moderate-sized layering bilateral pleural effusions
with associated
bibasilar atelectasis and/or consolidation. Patchy multifocal
ground-glass
opacities and areas of patchy posterior confluence have
progressed. Multifocal
pneumonia and superimposed volume overload are likely
contributors.
Left internal jugular central venous catheter is malpositioned
and terminates
in the left superior intercostal vein.
Asymmetric thickening and enlargement of the right obturator
internus muscle
may represent intramuscular hematoma related to recent
procedure. No active
extravasation is seen on this exam.
Transplant and nephrology consulted.
PT required pressors for BP control
Family notified of grave circumstances
Pt made DNR / DNI
pt extubated
Expired shortly after
Medications on Admission:
Prograf 1", prednisone 5', metoprolol 12.5", Tricor 145', ASA
81', Bactrim ss', Cozaar 25', Pravachol 80', Zetia 10', Plavix
75', warfarin 2mg, Lasix 40'
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
MULTI ORGAN FAILURE
OCCLUDED AORTA
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
Completed by:[**2153-3-15**]
|
[
"440.20",
"276.7",
"427.31",
"996.74",
"530.81",
"428.0",
"V58.67",
"584.5",
"428.22",
"V45.82",
"588.89",
"V58.61",
"250.60",
"433.10",
"433.30",
"996.81",
"V10.51",
"414.01",
"272.4",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.44",
"88.48",
"00.42",
"39.50",
"39.90",
"88.42",
"00.47"
] |
icd9pcs
|
[
[
[]
]
] |
11679, 11688
|
9462, 11443
|
375, 703
|
11766, 11775
|
2806, 9439
|
11831, 11869
|
2089, 2180
|
11647, 11656
|
11709, 11745
|
11469, 11624
|
11799, 11808
|
2195, 2787
|
302, 337
|
731, 1301
|
1323, 1760
|
1776, 2073
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,849
| 171,588
|
49465
|
Discharge summary
|
report
|
Admission Date: [**2121-6-25**] Discharge Date: [**2121-7-2**]
Date of Birth: [**2052-8-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Central line placement
Angiogram of the abdomen with coil placement in SMA
EGD
Arthrocentesis
History of Present Illness:
Mr. [**Known lastname **] 68M with hx of HTN, hyperlipidemia, who presented to
the ED after 2 large episodes of bright red blood per rectum.
He reported a left sided crampy abdominal pain around 10am,
which did not bother him much, but afterwards he experienced a
brown bowel movement mixed with bright red blood associated. At
about 2pm, he reports an episode of lightheadedness and
diaphoresis after bending over. At that time, he went to the
bathroom, passed large clots of bright red blood with small
amount of brown stool afterwards.
He has been taking occasional naproxen for back pain in the last
week, and he is on a baby aspirin at home. Denies nausea,
vomiting, shortness of breath, chest pain, cough, fevers,
chills, dysuria.
In the ED, patient's initial VS were as follow: 96.9 109 109/70
16 100% Non-Rebreather. He triggered for hypotension to
systolic 85 shortly after arrival with blood pressures
intermittently improved. He was not having any abdominal pain
or tenderness on exam but was noted to have external hemorrhoids
which were non-bleeding; he did have gross red blood in rectal
vault with small amount of brown stool. He had no further bowel
movements or bleeding in the ED. He declined NG lavage in the
ED. He was given a total of 3L of IVFs and was typed and
screened. Patient was started on a pantoprazole bolus plus
drip. He has 2 peripheral IVs. GI was consulted in the ED.
Patient was admitted to ICU for further monitoring with vitals
in ED prior to transfer as follows: afebrile 98 105/59 22 98%
RA.
On the floor, patient was feeling well. He had no
lightheadedness. He does complain of left mid back pain for the
last week. He lifts his girlfriend up from the tub several
times per week. Was started on naproxen and cyclobenzaprine
last week. Pain was worsened in the ED after lying in bed,
improved somewhat now.
Last colonoscopy [**3-/2121**] showed diverticulosis of the sigmoid
colon, descending colon and ascending colon. No pior GI bleed
history, though he has had heme positive stools, per OMR.
Past Medical History:
Hypertension
Hyperlipidemia
ETOH
Gout
Social History:
Lives with girlfriend, considers her to be common law wife who
has sarcoidosis. He has a son that lives out of town.
Tobacco: quit in [**2069**], smoked about 1/2ppd x5 yrs
ETOH: shares [**12-8**] pint brandy with another person every friday,
saturday, and sunday (each day) ; no history of ETOH withdrawal
Illicits: occasional marijuana at younger age
Family History:
- Mother - bipolar on Lithium, breast cancer, HTN, anemia,
deceased at 86
- Father - deceased at 75, throat cancer
- Brother - deceased
- 2 other brothers healthy
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 97.4 BP: 129/70 P: 70 R: 26 O2: 100%RA
General: Alert, oriented, pleasant male, appears younger than
stated age, in no acute distress
HEENT: Sclera anicteric, mildly dry mucous membranes, oropharynx
clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate, normal rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding
Back: left paraspinal muscle tightness, felt better on palpation
Ext: warm, well perfused, good DP pulses, no clubbing, cyanosis
or edema
ON DISCHARGE:
GEN: NAD
KNEE: Right knee with mild effusion, no erythema, mild
tenderness
Pertinent Results:
[**2121-6-25**] 04:10PM BLOOD WBC-12.2* RBC-3.74* Hgb-11.3* Hct-33.4*
MCV-89 MCH-30.3 MCHC-33.9 RDW-14.6 Plt Ct-250#
[**2121-6-25**] 04:10PM BLOOD Neuts-66.4 Lymphs-29.3 Monos-2.5 Eos-0.9
Baso-0.8
[**2121-6-25**] 04:10PM BLOOD PT-12.6 PTT-24.8 INR(PT)-1.1
[**2121-6-25**] 04:10PM BLOOD Glucose-167* UreaN-24* Creat-1.6* Na-140
K-4.1 Cl-105 HCO3-24 AnGap-15
[**2121-7-1**] 01:20PM BLOOD Glucose-197* UreaN-10 Creat-1.1 Na-136
K-4.0 Cl-100 HCO3-27 AnGap-13
[**2121-7-2**] 08:00AM BLOOD Hct-31.2*
[**2121-7-1**] 04:14PM JOINT FLUID WBC-5715* RBC-460* Polys-93*
Lymphs-0 Monos-7
[**2121-7-1**] 04:14PM JOINT FLUID Crystal-FEW Shape-ROD Locatio-I/E
Birefri-NEG Comment-c/w monoso
[**2121-6-26**] CT pelvis IMPRESSION: Area of active bleeding within the
rectum
EGD [**2121-7-1**] Impression: Polyps in the stomach body
Gastric nodule
Erythema in the antrum
Biopsies were not attained give recent history of GI bleeding.
Otherwise normal EGD to third part of the duodenum
Recommendations: No source of GI bleeding was identified.
Follow-up with inpatient hospital and GI consulting team for
further treatment of GI bleeding.
Follow-up with gastroenterology as an outpatient for further
evaluation of submucosal lesion and consideration of EUS
Brief Hospital Course:
68 year-old man presented with massive lower GI bleed and
admitted to the ICU. He was given 11 units PRBC, 2 units FFP, 1
pack of platelets. He underwent IR embolization of bleeding
vessel on [**2121-6-26**] successfully. Post-procedure, he had
occasional small blood in stool and occasional dark maroon
stools, but HCT mostly stable (Over 5 days, HCT 32/33-->31). On
day prior to discharge, patient developed acute right knee pain.
Joint fluid analysis revealed negative Gram stain and presence
of urate crystals. Prednisone started for Acute Gout.
BY PROBLEM LIST:
# GI Bleed: The patient's history is consistent with lower GI
bleed, most likely secondary to diverticular bleed given
diverticulosis shown in colonoscopy in [**2121-3-7**]. Hemorrhoids
were non-bleeding on exam. Upper GI bleed less likely, as large
amounts of bright red blood from upper source would be more
likely to cause more hemodynamic instability and NG lavage done
in the unit was negative for blood. Patient declined NG lavage
in the ED. The patient was scheduled for colonoscopy for the day
after admission, but he continued passing a large amount of
blood per rectum and Hct was trending down with transfusions. He
developed signs of hemodynamic instability with tachycardia,
orthostatic pressure, and BP drop. He urgently underwent CTA
which showed an area of active bleeding in the rectum. The IR
attempted angiogram and found a bleeding site in an SMA
territoy. The bleeding site was ambolized. During the procedure,
he received 11u pRBC, 2u FFP, and 1 bag of platelet. Since
embolization, he has not had active bleeding. Pt went to floor,
was monitored with stable Hcts for several days around 34. Pt
did continue to have dark melanotic stools and per pts report
with some bright red blood. Pt went for EGD which showed gastric
nodule but no acute bleeding. Nodule will have to be biopsied in
the future, biopsies not obtained due to recent history of
bleed.
# Acute Renal Insufficiency: He had an elevated Cr and most
likely from prerenal etiology in setting of GI bleed. He
received 3L IVFs in the ED and transfusions in the unit. His Cr
is trending down.
# Right Mid Back Pain : The patient reported pain in left mid
back since last week. It appeared to be related to repeated
stress to the back from lifting his wife out of the bathtub,
roughly every other day. Naproxen was held in setting of GI
bleed.
# Hypertension: His antihypertensive meds (lisinopril and
amlodipine) were held post bleed but restarted just before
discharge.
# Gout History: He was countinued on allopurinol at renal
dosing.
Pt developed right knee effusion on [**2121-7-1**]. We tapped the
joint, aspirated 10cc of yellow nonpurulent fluid, cell counts
revealed a mild inflammatory arthritis. due to gout history we
started pt on a 4 day course of steroids.
TRANSITIONAL CARE:
1. F/u [**Hospital 3390**] clinic within in [**2-10**] days to have HCT rechecked.
2. F/u GI for LGIB and gastric nodule; will likely need repeat
EGD for biopsies
3. [**Month (only) 116**] need uptitration of allopurinol once gout flare resolves.
Medications on Admission:
- allopurinol 100 mg Tablet daily
- amlodipine [Norvasc] 10 mg Tablet daily
- cyclobenzaprine 5 mg Tablet at bedtime
- lisinopril 20 mg Tablet daily
- naproxen 500 mg Tablet 1 Tablet(s) by mouth twice a day as
needed for with food 5-7 days
- omeprazole [Prilosec] 20 mg Capsule, Delayed Release(E.C.)
1 Capsule(s) by mouth [**Hospital1 **] PRN
- sildenafil [Viagra] 100 mg Tablet - 0.5 (One half) Tablet(s)
by mouth once a day
- aspirin 81 mg Tablet daily
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. cyclobenzaprine 5 mg Tablet Sig: One (1) Tablet PO at
bedtime.
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*40 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. Viagra 50 mg Tablet Sig: One (1) Tablet PO once a day.
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
8. prednisone 30mg x2days then 20mg x2 days
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleed
Gout flare
Gastric nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure taking care of you during your recent
hospitalization. You came in with a large bleed in your
gastrointestinal tract. Interventional radiology coiled (cut off
blood flow to) one of the arteries that was bleeding. You
received a blood transfusion. We performed an
esophagogastroduodenoscopy (camera looking at the upper GI
tract) which showed no evidence of persistent bleeding. We
monitored your blood counts for several days to make sure you
were not still losing blood. Finally we advanced your diet to
regular foods and restarted your home blood pressure
medications.
WE MADE THE FOLLOWING CHANGES TO YOUR MEDICATIONS:
We STOPPED your aspirin and naproxen. These medications could
make your GI tract bleed more easily.
we STARTED omeprazole 20mg twice a day. this medication protects
your intestinal lining from acid and lowers risk of bleeding.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2121-7-4**] at 11:30 AM
With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up.
Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD
Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 682**]
Appointment: Monday [**2121-7-14**] 3:30pm
Department: [**Hospital3 249**]
When: MONDAY [**2121-7-14**] at 1:40 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"562.12",
"584.9",
"724.5",
"401.9",
"272.4",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"39.79",
"88.49",
"81.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9434, 9440
|
5146, 5705
|
331, 426
|
9532, 9532
|
3883, 5123
|
10601, 11825
|
2956, 3120
|
8752, 9411
|
9461, 9511
|
8271, 8729
|
9682, 10321
|
3135, 3774
|
3788, 3864
|
10350, 10578
|
264, 293
|
454, 2508
|
5719, 8245
|
9547, 9658
|
2530, 2569
|
2585, 2940
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,763
| 171,192
|
36893
|
Discharge summary
|
report
|
Admission Date: [**2133-10-22**] Discharge Date: [**2133-11-1**]
Date of Birth: [**2076-8-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2133-10-23**] - Cardiac Catheterization
[**2133-10-29**] - Coronary artery bypass grafting to four vessels (Left
internal mammary->left anterior descending artery, saphenous
vein graft(SVG)->Diagonal artery, SVG->First obtuse marginal
artery, SVG->Second obtuse marginal artery).
History of Present Illness:
57 yo Spanish speaking Cuban male with history of CAD s/p stent
[**34**] yrs ago, HTN, family history of CAD, and tobacco use who
presented to PCP with CP. Instructed to go to ED after
concerning EKG. Pt ruled in for NSTEMI and was referred for
cardiac cath. Now asked to evaluate for CABG.
Past Medical History:
Past Medical History
htn
Hyperlipidemia
MI [**2122**]
Diabetes
CAD s/p stent
Past Surgical History
s/p hernia repair x3
Coronary stent [**2122**]
Social History:
Race:Hispanic
Last Dental Exam:years
Lives with:alone
Occupation:nigh club promoter
Tobacco:1ppd x30 yrs
ETOH:4 beers/week
Illicit drugs: occasional use; last one month ago
Family History:
Mother died age 67 of MI, father died of MI age 80
Physical Exam:
Pulse:75 Resp:20 O2 sat: 96% RA
B/P Right:116/82 Left: 108/86
Height:5'7 Weight:170 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Discharge
T 98.2 HR: 80-90 SR BP: 90-100/60 Sats: 96% RA
General: sitting in chair in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple
Card: RRR normal S1,S2 no murmur
Resp: clear breath sounds bilateral
GI: benign
Extr: warm no edema
Incision: sternal and LLE clean dry intact
Neuro: non-focal
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2133-10-23**] Cardiac Catheterization
1. Coronary angiography of this right dominant system revealed
three
vessel coronary artery disease. The LMCA was heavily calcified
with a
distal eccentric 40% stenosis. The LAD had focal moderate
calcification
and was diffusely diseased. There was a proximal 30% stenosis
and 50-60%
stenosis in the mid vessel, and sent apical and septal
collaterals to
the RPL and RPDA. The LCx was diffusely diseased with total
occlusion
after OM2 with late filling of the LPL via left to left
collaterals. The
OM2 had a moderate 40-50% stenosis. The RCA had a proximal 40%
stenosis
followed by total occlusion in the proximal stent. All the
coronaries
were small caliber.
2. Limited resting hemodynamics demonstrated normal systemic
arterial
blood pressure (SBP 115 mm Hg). The left ventricular filling
pressure
was mildly elevated (LVEDP 17 mm Hg). There was no gradient upon
pullback of the catheter from the LV into the aorta.
3. Left ventriculography revealed mild anterior wall hypokinesis
and
severe hypokinesis of the inferolateral and inferior walls, with
an EF
of 36%. The degree of mitral regurgitation was unable to be
assessed
given ventricular ectopy.
[**2133-10-28**] ECHO\
PRE-BYPASS: The left atrium is normal in size. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. Left ventricular wall thicknesses and cavity
size are normal. There is moderate to severe regional left
ventricular systolic dysfunction with akinetic apex, severely
hypokinetic mid-basal anterior, antero-septal and lateral wall.
The remaining left ventricular segments are hypokinetic. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the abdominal aorta. There are three
aortic valve leaflets. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Mild to moderate ([**1-16**]+) mitral regurgitation is seen.
There is no pericardial effusion.
POST CPB:
1. Improved global and focal systolic function (Epinephrine
infusion). Pesrsistent wall motion abnormalities
2. Preserved right ventyricular systolci function.
3. Mitral regurgitation is now mild.
4. Intact aorta
10/17/0 WBC-11.3* RBC-3.64* Hgb-10.7* Hct-31.3* Plt Ct-196#
[**2133-10-30**] WBC-12.0* RBC-3.52* Hgb-10.5* Hct-30.1* Plt Ct-111*
[**2133-10-22**] WBC-7.7 RBC-5.13 Hgb-15.1 Hct-44.7 Plt Ct-315
[**2133-11-1**] UreaN-12 Creat-0.9 Na-137 K-3.9 Cl-100 HCO3-25 Mg-2.1
[**2133-10-25**] ALT-42* AST-25 AlkPhos-103
CXR: [**2133-10-31**] Bilateral atelectasis, left greater than right,
have improved. There is less mediastinal widening. There is
better aeration of the lungs. Sternal wires are aligned. There
is no pneumothorax or pleural effusion. Cardiac size is top
normal.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2133-10-22**] for further
management of his myocardial infarction. Plavix, aspirin,
heparin and a statin were started. A cardiac catheterization was
performed which revealed severe three vessel disease. Given the
severity of his disease, the cardiac surgical service was
consulted for surgical revascularization. Mr. [**Known lastname **] was owrked-up
in the usual preoperative manner. Plavix was allowed to clear
from his system. On [**2133-10-28**], Mr. [**Known lastname **] was taken to the
operating room where he underwent coronary artery bypass
grafting to four vessels. Postoperatively he was taken to the
intensive care unit for monitoring. Over the next 24 hours, Mr.
[**Known lastname **] awoke neurologically intact and was extubated. Beta
blockade, aspirin and a statin were resumed. He transferred to
the floor POD1, chest tubes and pacing wires were removed per
protocol. He remained in sinus rhythm and hemodynamically
stable. He autodiuresed, electrolytes repleted. He tolerated a
regular diet. He was seen by physical therapy and was discharged
to home on POD4.
Medications on Admission:
Atenolol 50 mg /D,Lipitor 40mg /D,ASA 325 mg/D,Temazepam 30mg/D
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
1:Heart Attack
2:CAD s/p coronary artery bypass grafting to 4 vessels
Secondary:
1:High cholesterol
2:Tendonitis of the left arm
Discharge Condition:
In stable condition.
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please Follow up with Dr. [**Last Name (STitle) 914**] at [**Telephone/Fax (1) 62**] in 1 month.
Please follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8878**] in [**2-17**] weeks. [**Telephone/Fax (1) 83300**]
Completed by:[**2133-11-1**]
|
[
"410.71",
"272.4",
"401.9",
"428.0",
"250.00",
"726.90",
"412",
"300.00",
"414.01",
"428.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"39.61",
"88.53",
"88.56",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
6535, 6592
|
5268, 6421
|
295, 580
|
6775, 6798
|
2316, 4451
|
7597, 7868
|
1277, 1330
|
6613, 6754
|
6447, 6512
|
6822, 7574
|
1345, 2297
|
245, 257
|
608, 901
|
923, 1070
|
1086, 1261
|
4461, 5245
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,138
| 100,654
|
10664+10665
|
Discharge summary
|
report+report
|
Admission Date: [**2138-10-3**] Discharge Date: [**2138-10-14**]
Date of Birth: [**2086-2-26**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: Briefly, the patient is a
52-year-old gentleman with a past medical history of alcohol
abuse who was diagnosed with alcoholic cirrhosis on this
admission. He was admitted on [**10-3**] with eight episodes
of hematochezia and melena and one episode of hematemesis on
the day of admission.
The patient called the Emergency Medical Service. His blood
pressure was found to be 80/palp with a heart rate in the
130s. He was transferred to the Emergency Department.
Hemodynamically, the patient was stabilized.
In the Emergency Department, the patient's hematocrit was
found to be 16.9. The patient was transfused 4 units of
packed red blood cells, 4 units of fresh frozen plasma, and
intravenous proton pump inhibitor. He was started on an
octreotide drip and intravenous erythromycin. The patient
had an nasogastric tube lavage which was positive for bright
red blood. The Gastrointestinal Service was consulted for an
emergent esophagogastroduodenoscopy.
PAST MEDICAL HISTORY:
1. Alcohol abuse.
2. Question diabetes mellitus.
MEDICATIONS ON ADMISSION:
1. Multivitamin.
2. Vitamin A.
3. Vitamin B.
4. Vitamin C.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives with his partner. [**Name (NI) **]
drinks a 6-pack of alcohol and half a pint of gin every
evening for the past several years. He quit tobacco 10 years
ago. He has no history of intravenous drug use or illicit
drug use.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission to the Medicine Service revealed the patient's
blood pressure was 131/78, his heart rate was 70, his
respiratory rate was 16, and his oxygen saturation was 96% on
room air. In general, the patient was a pleasant
African-American gentleman in no apparent distress. Head,
eyes, ears, nose, and throat examination revealed he did have
scleral icterus. The oropharynx was clear. The mucous
membranes were moist. Cardiovascular examination revealed a
regular rate and rhythm. Respiratory examination revealed
the patient's lungs were clear to auscultation bilaterally
with decreased breath sounds at the bases and crackles at the
left base. The abdomen was soft, distended, and nontender.
He had tympanitic bowel sounds throughout. There was no
hepatosplenomegaly. Extremity examination revealed he had 1+
edema to the his knees. His pulses were 2+.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on admission to the Medicine Service revealed the patient's
hematocrit was 30.3. His Chemistry-7 was within normal
limits. His INR was 1.8. His hepatology series was positive
for HBAB antibody. At this point, all cultures were negative
to date.
BRIEF SUMMARY OF INTENSIVE CARE UNIT COURSE: At this point,
the patient was intubated for airway protection. The
esophagogastroduodenoscopy showed active bleeding from the
gastric varix. The patient had 2+ bleeding varus in the
esophagus. The bleeding site was injected with epinephrine
and morrhuate sodium to sclerose the varix; however, the
bleeding did not subside. He was then treated with
intravenous vasopressin and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube was placed. The
[**Last Name (un) **] tube remained in place until [**10-4**]. He had no
more episodes of bleeding. The Pitressin was discontinued;
however, the patient remained to be hypertensive. A sepsis
workup ensued, and he was started on Levophed as his
hypertension did not respond to fluid boluses.
On [**10-5**], the patient had a right upper quadrant
ultrasound to see if there was enough ascites to tap.
Minimal fluid was tapped. At this point, the patient became
febrile. An echocardiogram was done which showed that he had
no vegetations, but there was possibly a left lower lobe
pneumonia. Therefore, the patient was started intravenous
antibiotics.
On [**10-6**], the [**Last Name (un) **] tube was removed. During his
Intensive Care Unit course, the patient was weaned off
pressors. He was dependent on fresh frozen plasma during his
hospital course due to his coagulopathy secondary to his
liver disease.
On the evening of [**10-7**], the patient was extubated. He
tolerated this well. His vital signs were stable. His
hematocrit had been stable in the 30s for over 24 hours, so
the patient was called out to the Medicine floor for further
treatment.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. GASTROINTESTINAL/VARICEAL BLEED ISSUES: The patient was
followed by the Liver Service throughout his hospital course.
His hematocrit levels had remained stable. He was maintained
on twice per day Protonix.
He had a repeat endoscopy on [**10-9**] which showed that he
had varices or cardia at the gastroesophageal junction and at
the lower one-third of the esophagus. This varix was banded
successfully. He also had an ulcer in the gastroesophageal
junction and cardia and blood in the body and antrum of his
stomach.
The patient was started on carafate 1 g four times per day.
He was continued on Protonix twice per day, and he was
started on nadolol and titrated up as tolerated. However,
during his hospital course the nadolol had to be discontinued
given that he had worsening renal function. In order to
maximize renal perfusion, the nadolol was discontinued.
Per the patient's computed tomography, it appeared that the
patient had chronic pancreatitis. He did have significant
steatorrhea during his hospital stay; however, he was
asymptomatic.
2. INFECTIOUS DISEASE ISSUES: The patient had spiked a
fever on [**2138-10-6**] and was continued on ceftriaxone
and vancomycin in the Intensive Care Unit. As his cultures
had been negative for any suspicious organisms, his
vancomycin was discontinued, and he was continued on
ceftriaxone during his hospital course.
He had a repeat paracentesis done on [**10-11**] which showed
no evidence of spontaneous bacterial peritonitis. He
remained afebrile and was completing the course for his left
lower lobe pneumonia.
The patient had been on stress-dose steroids in the Intensive
Care Unit. On [**10-10**], as it appeared that the patient
had not been septic and remained afebrile, his stress-dose
steroids were discontinued.
3. PULMONARY ISSUES: The patient was extubated on [**10-7**]. He had no respiratory issues during his Medicine Service
stay.
4. ENDOCRINE ISSUES: For the patient's diabetes mellitus ?
secondary to steroid use ? previous to his admission, he
remained on fingersticks four times per day and an insulin
sliding-scale as needed.
5. RENAL ISSUES: During the [**Hospital 228**] hospital course, he
had acute renal failure which started on [**10-9**]. His
creatinine increased to 1.1. The source of his renal failure
was unclear. Initially, this was thought to be an acute
tubular necrosis secondary to his hypotension while in the
Intensive Care Unit; however, it persisted so it was likely
secondary to hepatorenal syndrome.
The patient's diuretics were discontinued. he was started on
intravenous albumin infusions daily. He was continued on his
octreotide in order to maximize renal perfusion.
During his hospital course, upon until [**10-12**], the
patient's creatinine continued to rise. Therefore, on
[**10-12**], the nadolol was discontinued and he was started
on Trental 400 mg by mouth three times per day and midodrine
75 mg by mouth three times per day.
6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient
remained nothing by mouth during his hospital stay in the
Intensive Care Unit. His diet was advanced on [**10-11**],
and the patient tolerated this well.
The Medicine Service tried to optimize his nutritional status
with additional Boost supplements and Mighty shakes.
7. HEMATOLOGIC/COAGULOPATHY ISSUES: The patient was
admitted with an INR of 2.6, and it appeared that he was
dependent on fresh frozen plasma in order to reverse his
coagulopathy; however, during his hospital course an empiric
trial of vitamin K was started on [**10-9**].
8. CONSULTATION ISSUES: The Addiction Service and Social
Work were consulted, and the patient will likely continue
with an outpatient detoxification treatment.
DISCHARGE DIAGNOSES:
1. Alcoholic cirrhosis.
2. Ascites.
3. Alcohol abuse; continuous.
4. Acute renal failure secondary to hepatorenal syndrome.
5. Coagulopathy.
6. Esophagitis.
7. Hypoalbuminemia.
8. Esophageal varices with bleed.
9. Hypophosphatemia; repleted.
10. Hypokalemia; repleted.
NOTE: The patient was to be discharged at a later date, and
someone else will complete the Discharge Summary at that
time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 34978**], M.D. [**MD Number(1) 24755**]
Dictated By:[**Name8 (MD) 8736**]
MEDQUIST36
D: [**2138-10-14**] 14:45
T: [**2138-10-14**] 19:26
JOB#: [**Job Number 34979**]
Admission Date: [**2138-10-3**] Discharge Date: [**2138-10-17**]
Date of Birth: [**2086-2-26**] Sex: M
Service:
CONTINUATION: Previous discharge summary dictated by Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **].
HOSPITAL COURSE: From [**2138-10-14**], to [**2138-10-17**].
1. Gastrointestinal bleed - The patient remained stable in
terms of the gastrointestinal bleeding. He had no further
bleeding episodes. The patient was continued on Octreotide
and Midodrine until [**2138-10-15**]. The Midridogin and the
Octreotide were then discontinued. The patient was continued
on Trental as well as Sucralfate and Protonix. The patient
was later started on Nadolol the day prior to discharge for
prophylaxis against further gastrointestinal bleeding
episodes from severe varices. The patient tolerated the
Nadolol with blood pressure remaining around 100/60,
asymptomatic with changes of position.
2. Infectious disease - The patient continued to have low
grade temperatures in the 99.0 to 100.0 range. There was no
obvious source of infection. The patient had blood cultures
and urine cultures which were negative for infection. The
patient had Clostridium difficile toxin assays done on his
stool which did not document any Clostridium difficile. The
patient was continued on Ceftriaxone for a full ten day
course.
3. Pulmonary - There were no active pulmonary issues during
the remainder of his hospital stay. The patient did have
stable pleural effusions which should be followed up with
chest x-ray as an outpatient.
4. Endocrine - The patient was noted to have high blood
sugar consistent with diabetes mellitus during his
hospitalization. It was felt that the elevated blood sugar
may be related to acute illness. The blood sugar did trend
down throughout the hospital stay. Therefore, insulin was
discontinued on discharge. The patient was discharged home,
however, with a glucometer to do fingerstick four times a day
with each meal and at bedtime. The patient agreed to keep a
record of his blood sugar which he will bring to his primary
care physician appointment with Dr. [**Last Name (STitle) 818**] on Tuesday,
[**2138-10-21**]. It is felt that at that time he might consider
starting Glipizide at a low dose. Given that he has
hepatorenal syndrome, we are hesitant upon starting an oral
hypoglycemic on discharge unless he definitely needed to be
started on an oral [**Doctor Last Name 360**]. The patient was advised that if
his blood sugar was over 300 that he should call the clinic
or present to the Emergency Department for therapy.
5. Renal - The patient had renal failure consistent with
hepatorenal syndrome. His creatinine remained stable at
around 1.4 for three days prior to discharge. The patient
was maintaining good urine output throughout the remainder of
the hospitalization. As stated previously by Dr. [**Last Name (STitle) **], the
patient's Nadolol was initially held secondary to what was
thought to be poor renal perfusion. His creatinine did
improve somewhat and Nadolol was restarted prior to discharge
for prophylaxis of further vascular bleeding.
6. Hematology - The patient had significant coagulopathies
related to his hepatic failure. The patient's INR remained
in the 2.3 to 2.4 range despite treatment with Vitamin K and
therefore on discharge, the Vitamin K was not continued. The
patient was told to monitor for signs of bleeding and, if he
needs follow-up with any further gastrointestinal bleeding,
especially blood in his vomit or his stool, he was instructed
to return to the Emergency Department immediately. The
patient will be followed up by hepatology in clinic.
7. FEN - The patient was followed by nutrition for calorie
counts prior to discharge. The patient did show improvement
in meeting his goals, however, he was below goal caloric
intake of greater than [**2134**]. On discharge, the patient was
encouraged to drink supplements which he agreed to do and he
was discharged home with a prescription for Nepro supplements
and instructed to drink them four times a day. The patient
stated that he felt he would be eating better at home.
8. Hepatic failure - As stated above, the patient had
significant coagulopathies from his hepatic failure. The
patient's hepatic enzymes improved dramatically during
hospitalization. His total bilirubin appeared to be
decreasing by discharge with a peak at 7.4. The patient
likely had hepatitis secondary to alcohol with significant
sources given his variceal bleeding. The patient was
continued on Ursodiol on discharge. He was encouraged to
remain abstinent from alcohol. The patient will follow-up
with AA after discharge. The patient did have significant
ascites which he was asymptomatic from. The patient was
informed that if he began having abdominal pain from tense
ascites that he should call his primary care physician or the
gastroenterology doctors that are following him for a
possible therapeutic tap.
DISCHARGE DIAGNOSES:
1. Renal genitourinary failure.
2. Ascites.
3. Alcoholic cirrhosis.
4. Esophagitis.
5. Hepatopathy anemia.
6. Esophageal varices with bleed.
7. Alcohol abuse.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with services.
MEDICATIONS ON DISCHARGE:
1. Thiamine 100 mg p.o. once daily.
2. Folate 1 mg p.o. once daily.
3. Multivitamin generic one capsule p.o. once daily.
4. Pantoprazole 40 mg p.o. twice a day.
5. Ursodiol 300 mg p.o. three times a day.
6. Nadolol 10 mg p.o. once daily.
7. Sucralfate one gram p.o. four times a day.
8. Pentoxifylline 400 mg SR p.o. three times a day.
9. Nepro Liquid one to two p.o. four times a day.
10. Glucometer - please check blood sugar with each meal and
at bedtime.
11. Test strips.
12. Lasix.
FOLLOW-UP: The patient is to follow-up with gastroenterology
on Tuesday, [**2138-10-21**], for repeat endoscopy to further
evaluate varices and possible repeat banding. The patient is
also advised to follow-up with a new primary care physician
which will be Dr. [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 818**] on Tuesday, [**2138-10-21**], at
1:30 p.m. The patient was encouraged to attend AA meetings
across the street. The patient was advised that if he noted
any further blood in his vomit or in his stool or black tarry
stools that he was to return to the Emergency Department
immediately. The patient was also encouraged to drink
nutritional supplements throughout the day.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2138-10-17**] 16:34
T: [**2138-10-18**] 11:34
JOB#: [**Job Number 34980**]
|
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"571.2",
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] |
icd9cm
|
[
[
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[
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"42.33",
"45.13",
"38.93",
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icd9pcs
|
[
[
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|
14301, 15777
|
1228, 1346
|
9282, 14010
|
4576, 8317
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166, 1128
|
1150, 1202
|
1363, 4542
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14223, 14275
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,006
| 106,686
|
17968+56904
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-3-2**] Discharge Date: [**2112-3-11**]
Date of Birth: [**2047-11-5**] Sex: F
Service: [**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: The patient is a 64 year-old
female with end stage renal disease on hemodialysis secondary
to diabetes mellitus, status post right femoral AV graft with
stable hematoma, who was noted to have a temperature of 100.2
associated with rigors at hemodialysis on day of admission.
The patient was sent to the [**Hospital1 188**] Emergency Department. Upon arrival she was noted to
have a temperature of 101.8 and her blood pressure was
stable. In addition, the patient complained of back pain,
fever, nausea and vomiting. The patient denied loss of bowel
and bladder function or lower extremity weakness and abscess.
In addition, the patient also denied any headaches, chest
pain, shortness of breath or diarrhea. The patient had
previously been at home until two weeks to admission when she
was transferred to a rehabilitation for wound care in the
setting of a right groin hematoma.
In the Emergency Department the patient was assessed by the
transplant surgery team and it was noted that the patient had
a right groin abscess at the site of her AV graft. The
patient then underwent removal of the AV graft and evacuation
of the infected hematoma. Prior to procedure the patient was
given 2 units of fresh frozen platelets and was given a dose
of Vancomycin and Gentamycin. The patient's oral
anticoagulation was also discontinued at this time.
On hospital day number two the patient was transferred to the
Medicine Service for further evaluation.
PAST MEDICAL HISTORY:
1. End stage renal disease secondary to diabetes mellitus.
2. Insulin dependent diabetes mellitus.
3. Status post right AK in [**2111-7-26**].
4. Hypertension.
5. Right femoral AV graft.
6. Colectomy in [**2110**].
MEDICATIONS ON ADMISSION:
1. Insulin of unspecified dose.
2. Nephrocaps one tab po q.d.
3. Renagel.
4. Coumadin 1.5 mg tabs po q.d.
5. Phos-Lo.
6. Lopressor 50 mg po at hemodialysis.
7. Prevacid q.d.
8. Lisinopril 40 mg po on nonhemodialysis days.
9. Zoloft 100 mg po q.d.
ALLERGIES: Penicillin, Kefzol.
SOCIAL HISTORY: The patient has been residing for two weeks
at St. [**Hospital 11042**] nursing home. The patient denies any tobacco
history.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 101.8. Heart
rate 97. Blood pressure 147/37. Respiratory rate 26. The
patient was sating at 92% on a nonrebreather face mask. In
general, the patient was noted to be lethargic, though
arousable and alert and oriented times three. HEENT was
within normal limits except for palpable right parotid gland.
Neck examination was unable to assess JVP secondary to body
habits. Cardiac examination revealed S1 and S2, regular rate
and rhythm. There were no murmurs, rubs or gallops
appreciated. Chest examination was notable for bibasilar
crackles. Abdomen obese, soft, nontender, nondistended.
Rectal examination was noted to have good rectal tone in the
Emergency Department. Extremities, the patient had a right
above the knee amputation and was noted to have a firm right
groin mass that was warm with 3 cm eschar and murky fluid
that was leaking from around eschar. There was a palpable
thrill at the right groin area. No clubbing, cyanosis or
edema noted on other extremities.
LABORATORY DATA ON ADMISSION: White blood cell count of
11.6, hematocrit 35.7, platelets 324. Chem 7 revealed a
sodium of 140, potassium 4.4, chloride 95, bicarb 29, BUN 20,
creatinine 3.6, glucose 171, calcium 10, magnesium 2.1,
phosphate 2.9. An ALT of 18, AST of 19, amylase of 83, total
bilirubin of .4. Arterial blood gas on admission was 7.51,
PCO2 44, PO2 of 357. Electrocardiogram was noted to be in
sinus tachycardia with normal axis and normal intervals and
left atrial enlargement. There was no Q wave noted, early R
wave progression, there is no significant ST or T wave
changes compared with patient's baseline. Chest x-ray was
negative for any acute cardiopulmonary process.
ASSESSMENT: The patient is a 64 year-old female with a
history of insulin dependent diabetes mellitus, end stage
renal disease who was initially managed by the transplant
surgery service for evacuation of an infected right
hematoma. Status post procedure the patient was transferred
to the [**Location (un) **] Medicine Service for further evaluation and
management. Upon transfer the patient the patient continued
to have a decreased mental status, though remained afebrile.
Prior to transfer the patient's initial blood cultures
returned 4 out of 4 positive for gram positive coxae.
HOSPITAL COURSE: 1. Infectious disease: The patient
presented with right femoral AV graft abscess and status post
evacuation of this infected right hematoma. The patient was
continued on a Vancomycin that was dosed at hemodialysis for
levels less then 15. At this time the patient remained
afebrile and hemodynamically stable. CAT scan of the spine
ordered by the transplant service was negative for any
evidence of overt infection, soft tissue swelling or abscess.
CAT scan was notable for diffuse osteophytes throughout
several levels of the spine. The patient also underwent a
TTE given bacteremia. The patient's TTE was negative
function and any thyroid vegetations. The cultures on [**2112-3-4**] were 1 out of 2 positive for gram positive coxae.
The remaining blood cultures drawn on [**2112-3-6**] revealed
no growth to date at the time of discharge. Throughout this
hospital stay the patient defervesced and had a decreasing
white count and remains hemodynamically stable. Given the
small piece of graft that remains at the AV fistula site, the
patient will be continued on a course of Vancomycin for a six
week course of treatment. The patient is to be dosed at
hemodialysis for levels less then 15.
On hospital day number four the patient also underwent
further surgical debridement of the right AV femoral fistula
site. V.A.C. was placed at this time. The patient was
followed by the transplant surgical service throughout the
remainder of her hospital stay. The V.A.C. was removed on
date of discharge. The patient is to follow up with vascular
surgery for further management of the right AV femoral site.
2. End stage renal disease: The patient with a history of
end stage renal disease requiring hemodialysis three times a
week secondary to diabetes mellitus. Upon removal of her
right femoral AV site, the patient underwent a temporary
Quinton catheter placement by the IR Service. However, it
was noted during hemodialysis this Quinton had poor flow.
Given this in the setting of repeat positive surveillance
blood culture the patient was again taken to the Operating
Room for placement of a temporary tunneled catheter. On the
day prior to discharge the patient had the new tunnel
dialysis catheter placed. On the day of discharge [**2112-3-11**] the patient received hemodialysis achieving good flow
through this new line. The patient was also continued on
calcium acetate throughout this admission. This was titrated
up accordingly. The patient's Renagel was discontinued. The
patient is to follow up with outpatient hemodialysis on
Mondays, Wednesdays and Fridays as per prior regimen.
Further permanent access in the left femoral site will be
determined as status post antibiotic therapy by the
transplant surgery service.
3. Change in mental status: Upon admission the patient was
noted to have a decreased mental status. This was likely
secondary to patient's bacteremia as well as the narcotic
pain medications the patient received on admission.
Throughout the hospital course the patient was titrated off
of her narcotic pain medication and had continued improvement
in her mental status.
4. Cardiovascular: The patient with no known history of
coronary artery disease on admission. However, given her
risk factors of diabetes mellitus it was felt by the medicine
team that the patient should be continued on an aspirin for
primary preventive therapy. However, during this admission
the patient continued on high doses of non-steroidal
anti-inflammatory medications since aspirin therapy was held
given the increased risk of gastrointestinal bleeding. An
echocardiogram performed during this admission revealed an
ejection fraction of 70%, with no wall motion abnormalities.
The patient had been on an ace inhibitor as well as a beta
blocker as an outpatient. Upon admission the patient's ace
inhibitor was discontinued by the transplant surgery service
who noted low blood pressures. This ace inhibitor was held
throughout the remainder of her hospital stay. The patient
then continued on a dose of Metoprolol 25 mg po b.i.d.
However, given persistent low blood pressures the beta
blocker was discontinued during this admission. However, the
patient should be reinitiated on her beta blocker therapy for
noted persistent hypertension as an outpatient.
5. Endocrine: The patient has a history of insulin
dependent diabetes mellitus. She was continued on a regular
insulin sliding scale throughout this admission. The patient
was noted to have good glycemic control throughout this
admission. The patient will be discontinued on a regular
insulin sliding scale and should have insulin therapy as
needed.
6. Hematology: Upon admission the patient was receiving
oral anticoagulation therapy as a preventive measure for
graft thrombosis. Coumadin was discontinued upon admission.
The patient was given one dose of vitamin K for reversal of
coagulation procedure in the setting of multiple procedures.
The patient had a quick reversal of her INR therapy. There
is no indication for reinitiation or anticoagulation at the
time of discharge. The patient had a fluctuating hematocrit
throughout this admission. The patient had no evidence of
any bleeding. Iron studies were checked and confirmed the
patient's history of chronic anemia and the patient was
continued on Epogen at hemodialysis throughout this hospital
stay. On the day of discharge given the patient's hematocrit
of 23.8, she was given 1 unit of packed red blood cells. The
patient had no known evidence of bleeding at this time. The
patient is to have stools guaiaced prior to discharge.
7. Psychiatric: The patient was continued on Sertraline for
major depressive disorders throughout this admission. The
patient remained stable.
8. Pain: Throughout this admission the patient continued to
complain of right sided lower back pain. CAT scan on
admission was negative for any frank abscess or underlying
musculoskeletal disease. The patient was continued on
Oxycodone, which was titrated to off throughout this
admission and non-steroidal anti-inflammatory medication.
The patient did continue to complain of this low back pain
throughout the majority of her hospital stay. On the day
prior to discharge the patient underwent an MRI to look for
an underlying soft tissue or occult infectious process. The
final report of this study remains pending prior to
discharge, however, will be reviewed by the medicine team
pending discharge. The patient should be continued on
Ibuprofen 800 mg po t.i.d. with meals prn for pain. On the
date of discharge the patient notes marked improvement of her
pain.
9. Fluids, electrolytes and nutrition: The patient was
continued on a diabetic diet, which was tolerated well
throughout this hospital stay. The patient's fluid balance
appeared euvolemic throughout this hospital stay and was
titrated accordingly at hemodialysis.
10. Prophylaxis: The patient was continued on Lansoprazole
given the high dose of non-steroidal anti-inflammatory
medications that were given. The patient was also continued
on Pneumatic boots secondary to deep venous thrombosis
prophylaxis particularly given the patient's refusal to
participate in physical therapy secondary to pain.
11. Access: The patient had peripheral intravenous access
and had a placement of the Quinton and temporary catheter
throughout this admission. There were no complications
DISCHARGE STATUS: To St. [**Hospital 11042**] nursing home.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Femoral AV graft abscess.
2. MRSA bacteremia.
3. End stage renal disease.
4. Hypertension.
5. Diabetes mellitus.
6. Lower back pain.
7. Anemia of chronic disease.
8. Depression.
DISCHARGE MEDICATIONS:
1. Sertraline 100 mg po q.d.
2. Phos-Lo two tabs q.d with meals.
3. Nephrocaps one tab po q.d.
4. Lansoprazole.
5. Regular insulin sliding scale.
6. Ibuprofen 800 mg po t.i.d. prn.
7. Vancomycin 1 gram to be dosed at hemodialysis for a level
less then 15.
DISCHARGE INSTRUCTIONS:
1. The patient is to undergo hemodialysis as previously
scheduled as her outpatient regimen.
2. The patient is to follow up with transplant surgery on
Thursday [**3-17**] at 1:00 p.m. for further evaluation and
management of right femoral AV graft abscess.
[**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 4626**]
MEDQUIST36
D: [**2112-3-11**] 10:55
T: [**2112-3-11**] 12:11
JOB#: [**Job Number **]
Name: [**Known lastname 9214**], [**Known firstname **] Unit No: [**Numeric Identifier 9215**]
Admission Date: [**2112-3-2**] Discharge Date: [**2112-3-17**]
Date of Birth: [**2047-11-5**] Sex: F
Service: [**Location (un) 571**]
HOSPITAL COURSE:
1. Infectious disease. Since previously dictated discharge
summary, patient continued to remain afebrile with negative
blood cultures. Patient continued on vancomycin and was
dosed q.Wednesday for a level less than 15. On the day of
discharge patient's VAC was removed by the transplant surgery
service. The underlying wound was noted to be granulating
well. Patient is to have wet to dry dressings b.i.d. with
saline for further continuation of wound care.
2. End stage renal disease. The patient was continued on
thrice weekly hemodialysis via the temporarily placed left
subclavian catheter. Patient was continued on PhosLo and
Nephrocaps.
3. Change in mental status. Please see previous discharge
summary.
4. Cardiovascular. Please see previous discharge summary.
5. Endocrine. The patient continued to have good glycemic
control throughout this hospital admission.
6. Hematology. The patient has an underlying history of
chronic anemia. During this admission patient had a down
trending hematocrit two days prior to discharge and received
one unit of packed red blood cells on this admission.
Patient evidenced no further signs of bleeding and was
discharged to rehab with a stable hematocrit. Patient is to
continue to have hematocrit levels checked at hemodialysis.
Patient is to continue to receive epo at hemodialysis.
7. Pain. The patient complained of iliosacral pain
throughout this admission. Patient underwent an MRI to
evaluate for the possibility of an abscess in this area on
[**2112-3-10**]. MRI was negative for abscess with the pelvis
or lower lumbar region. Given these findings, the medicine
team felt that patient's continued ongoing pain was secondary
to a musculoskeletal process. Patient's pain medications
were adjusted as necessary and patient remarked about
improvement with the initiation of tramadol for therapy.
Patient was titrated up on tramadol during this hospital
stay. Patient is to follow up with orthopaedic surgery as an
outpatient.
8. Access. The patient is status post placement of a
Quinton catheter that was discontinued secondary to poor
flow. Patient then had a temporary catheter placed by IR
during this hospital admission. On [**2112-3-15**], patient
was noted to have bleeding from the area of insertion of the
tunneled catheter. Patient was taken to interventional
radiology for further exploration of this catheter. Further
investigation was notable for both ports being patent, but
catheter tip was found to be in the azygos vein. As a
result, the tube was repositioned and advanced until it
reached the right ATM/lower SVC region. There was also noted
to be a clot around the external portion of the catheter and
a Sybek patch was applied. After this procedure, there was
no further leakage at the site and the catheter itself
remained well functioning at hemodialysis.
DISCHARGE STATUS: To [**Hospital 9216**] Nursing Home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Femoral AV graft abscess.
2. MRSA bacteremia.
3. End stage renal disease.
4. Hypertension.
5. Diabetes mellitus.
6. Lower back pain.
7. Anemia of chronic disease.
8. Depression.
DISCHARGE MEDICATIONS: Please see page 1.
DISCHARGE INSTRUCTIONS: The patient is to undergo
hemodialysis as previously scheduled as per her outpatient
regimen. Patient is to follow up with transplant surgery on
[**2112-3-24**], at 11:20 a.m., telephone number [**Telephone/Fax (1) 242**], at
[**Last Name (NamePattern1) 9217**]on the seventh floor. Patient is to
follow up with orthopaedic surgery (musculoskeletal clinic)
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9218**], on [**2112-3-24**], at 1:00 p.m. at [**Hospital1 1294**] [**Hospital Ward Name **] Building, telephone
[**Telephone/Fax (1) 9219**]. For wound care patient is to have wet to dry
dressing changes b.i.d. with saline. Dressings are to be
packed underneath the skin to bridge the wound. Patient is
to receive vancomycin 1 gm IV q.Wednesday in hemodialysis
until [**4-8**].
[**First Name11 (Name Pattern1) 5084**] [**Last Name (NamePattern4) 9220**], M.D. [**MD Number(1) 9221**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2112-3-17**] 14:30
T: [**2112-3-17**] 15:29
JOB#: [**Job Number 9222**]
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76,182
| 117,068
|
35366
|
Discharge summary
|
report
|
Admission Date: [**2164-1-28**] Discharge Date: [**2164-2-12**]
Date of Birth: [**2095-1-22**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Theophylline
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
Transjugular liver biopsy
Nasogastric tube placement
PICC line placement
History of Present Illness:
The pt is a 69 year old woman w/ PMHx of poly-substance abuse
including EtOH and oxycodone, breast cancer s/p mastectomy,
diverticulitis s/p resection, and DVTs, now presenting with
jaundice. The jaundice started approx 6 weeks ago, with
associated weakness, lightheadedness, chalky stools, and dark
urine. She has also noted increasing diffuse abdominal pain,
nausea, gassiness, and diarrhea, but no vomiting. She has had
chills x1 day, but no fevers or sweats. Her abdominal pain is
diffuse and worse with certain movements, [**6-15**], without
radiation. She does note new low back pain, but thinks this is
different from her abdominal pain. She denies any hematemesis,
melena, hematochezia, or pruritus. Her symptoms have been
progressively getting worse, so she presented to [**Hospital 73458**] Hospital today, where she was found to have elevated
LFTs and reportedly a negative RUQ U/S but a contrast abdominal
CT that showed findings c/w pancreatitis. She was transferred
given concern for her elevated LFTs and the potential for
developing fulminant liver failure.
Of note, she was recently moved here from [**State 108**] by her family,
to undergo rehabilitation at [**Hospital1 882**]. She completed this approx
2 mo ago, at which point she stopped drink EtOH and was started
on naltrexone (last drink [**2163-11-7**]). She first noted her symptoms
approx 1 week later. She was seen as an outpatient approx [**6-15**]
days ago for her jaundice, which was thought to be [**1-9**]
naltrexone, so this medication was stopped, but her symptoms
have continued to worsen.
ROS: See HPI and below. Otherwise reviewed in complete detail
and negative.
(+) palpitations: for approximately 1 year, with some left-sided
chest and neck pain and shortness of breath; these symptoms may
have been increasing in frequency over the last few weeks; they
are quickly relieved with rest
(+) urinary frequency and nocturia: approximately every 2 hours;
no hematuria or dysuria
(+) bilateral upper arm pain: chronic, positional
(+) recent cough and nasal congestion
Past Medical History:
- h/o Poly-substance abuse, including EtOH, oxycodone, and Xanax
- DVTs: one in setting of abdominal surgery and other in setting
of long flight
- Factor V Leiden deficiency, not currently anti-coagulated
- Breast cancer s/p left mastectomy [**2153**]
- h/o Diverticulitis s/p resection
Social History:
Pt's family moved her here from [**State 108**] in [**Month (only) 1096**] for rehab at
[**Hospital1 882**]. She has 3 children: 2 sons and 1 daughter. She has a
distant h/o smoking, but heavy alcohol abuse as well as
oxycodone and Xanax. She has been drinking [**6-13**] drinks of rum
daily x30 years.
Family History:
Mother died of cancer (type unknown, possibly CRC). Father died
of colon disease. No family history of liver disease.
Physical Exam:
VS: Temp 98.9F, BP 152/72, HR 85, R 18, SaO2 96% RA; Wt 117lbs.
GEN: Thin middle-aged woman in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRL/EOMI, +icteric sclera, dry MM, OP clear.
NECK: Supple, no LAD or JVD.
CV: RRR, nl S1-S2, no MRG.
CHEST: CTAB, no crackles, wheezes or rhonchi.
ABD: NABS, soft/ND; +hepatomegaly w/ liver edge [**2-8**] finger
breadths below RCM, +TTP over liver edge; no splenomegaly, no
rebound/guarding. +Right CVA tenderness.
RECTAL: light brown stool, Guaiac negative, ? posterior internal
hemorrhoid.
EXT: WWP, no c/c/e.
SKIN: +jaundice, +spider angioma on chest but no other stigmata
of chronic liver disease.
NEURO: A&Ox3, Able to relate history without difficulty, CNs
[**1-19**] intact, strength 4/5 throughout, sensation intact; No
nystagmus, dysarthria, intention or action tremor; No asterixis.
Pertinent Results:
ADMISSION LABS:
CBC:
[**2164-1-29**] 02:20AM BLOOD WBC-8.8 RBC-3.87* Hgb-12.4 Hct-36.0
MCV-93 MCH-32.1* MCHC-34.5 RDW-16.5* Plt Ct-130*
[**2164-1-29**] 02:20AM BLOOD Neuts-82.6* Lymphs-8.9* Monos-5.7 Eos-2.1
Baso-0.7
COAGS:
[**2164-1-29**] 02:20AM BLOOD PT-23.4* PTT-46.8* INR(PT)-2.3*
CHEMISTRIES:
[**2164-1-29**] 02:20AM BLOOD Glucose-96 UreaN-9 Creat-0.9 Na-140 K-4.3
Cl-107 HCO3-26 AnGap-11
LFTs:
[**2164-1-29**] 02:20AM BLOOD ALT-302* AST-287* LD(LDH)-292*
AlkPhos-116 Amylase-27 TotBili-26.0* DirBili-17.0* IndBili-9.0
[**2164-1-29**] 02:20AM BLOOD Lipase-23 GGT-61*
[**2164-1-29**] 02:20AM BLOOD TotProt-6.1* Albumin-3.0* Globuln-3.1
Calcium-9.0 Phos-2.3* Mg-2.1 Iron-150
[**2164-1-29**] 02:20AM BLOOD calTIBC-159* Hapto-<20* Ferritn-937*
TRF-122*
[**2164-1-29**] 02:20AM BLOOD CEA-2.6 AFP-25.9*
[**2164-1-29**] 02:20AM BLOOD PEP-PND IgG-2405* IgA-616* IgM-65
[**2164-1-29**] 02:20AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2164-1-29**] 02:20AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 [**Last Name (un) **]
[**2164-1-29**] 02:20AM BLOOD PEP-POLYCLONAL IgG-2405* IgA-616* IgM-65
IFE-NO MONOCLO
[**2164-1-29**] 02:20AM BLOOD HCV Ab-NEGATIVE
[**2164-1-29**] 02:20AM BLOOD CERULOPLASMIN-Negative
[**2164-1-29**] 02:20AM BLOOD CA [**73**]-9 - Negative
Liver, transjugular biopsy:
1. Established cirrhosis (confirmed by trichrome stain) with
focal sinusoidal fibrosis and associated cholangiolar
proliferation; mild cholestasis is present.
2. Mild to moderate portal/septal, mild periportal and lobular
mixed inflammation consisting of lymphocytes, focally prominent
plasma cells, neutrophils and eosinophils. Foci of piecemeal
necrosis are identified; no definite collapse is seen on
reticulin stain.
3. Mixed micro-macrovesicular steatosis involving approximately
30% of the non-fibrotic hepatic parenchyma. Rare balloon
degeneration present; no intracytoplasmic hyalin seen.
4. Iron stain shows minimal iron deposition in rare periportal
hepatocytes.
Note: The steatosis, rare balloon degeneration and sinusoidal
fibrosis are suggestive of a toxic/metabolic injury.
Additionally, however, the focally prominent plasmacytic
inflammation and piecemeal necrosis raise the possibility of a
concomitant chronic active hepatitis, such as due to an
autoimmune, drug or viral etiology. Further correlation with
clinical and serological findings is required. The findings were
discussed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 696**] on [**2164-2-2**]. Dr. [**Last Name (STitle) **] . [**Doctor Last Name 10165**]
reviewed the case and concurs.
Brief Hospital Course:
A 68-yo woman with long history of ETOH abuse, illicit substance
abuse, breast cancer s/p mastecomy and nephrectomy,
diverticulitis s/p resection, multiple DVTs who recently stopped
drinking ETOH and presented to an OSH with jaundice and
abdominal pain found to have elevated bilirubin.
# Acute Hepatitis: Initially she was felt to have an acute on
chronic alcoholic hepatitis and she was initiated on a course of
pentoxyfilline 400 mg TID that was stopped after 5 days given
uncertainty about whether this actually was acute on chronic
hepatitis since time between patient's last alcoholic drink and
onset of symptoms was nearly one month. The following were
negative: Hepatitis panel, AMA, ceruloplasmin, CA [**73**]-9, SPEP,
CMV Abs, EBV panel. [**Doctor First Name **] was weakly positive. The IgG was >[**2154**]
on two occasions. A transjugular liver biopsy showed cirrhosis,
mixed micro-macrovesicular steatosis, and inflammation
containing lymphocytes and plasma cells. This histologic picture
suggested both toxic/metabolic injury and concomitant chronic
active hepatitis, possibly due to virus or autoimmune condition.
As a result of these findings she was started on prednisone, the
thinking being that her hepatitis was autoimmune in nature.
Steroid therapy was initiated after treatment of her urinary
tract infection, as below. After the initiation of steroids, her
bilirubin started to improve, and symptomatically she began to
gain strength and her appetite increased. However, on the
morning of [**2-12**], she was found to have rapidly declining mental
status and confusion progressing to non-responsiveness. She was
observed to cough up several hundred ML of coffee-ground emesis.
As her code status was DNR/DNI, no resuscitation efforts were
attempted. It is unclear what the source of her bleed was, but
likely causes include gastritis, peptic ulcer, or variceal
bleed.
# Atrial Fibrillation: She was observed to go into atrial
fibrillation with rapid ventricular response. She required
transfer to the ICU and brief treatment with a diltiazem drip
after which she converted back to sinus rhythm. She was started
on oral diltiazem 60 mg four times daily and was able to be
transferred back to the medicine floor. After transfer, she
remained well-controlled, in normal sinus rhythm, on diltiazem.
# Urinary Tract Infection: A urine culture grew out proteus
vulgaris and enterococcus. She was treated with ciprofloxacin
250 mg twice a day for a total of seven days and her foley
catheter removed. Unfortunatly, due to her high post-void
residuals and suprapubic pain, we had to reinsert the foley
catheter. Surveillance cultures grew out yeast, for which we
gave one dose of fluconazole but then stopped due to concern of
liver toxicity.
# Leukocytosis: She developed a mild leukocytosis with a
neutrophilic predominance prior to initiation of steroid
therapy. We took cultures of the blood and urine, and measured
the stool for C dif toxin. With the exception of the UTI above,
which was treated, all cultures and micro data were negative. In
addition, a CXR was negative for infiltrate. Abdominal
ultrasound showed no ascites at admission, so SBP was felt to be
unlikely. She remained afebrile with no localizing symptoms.
Thus we initiated steroid therapy due to her worsening
hepatitis. Once on prednisone, her white count continued to
rise. This was likely due to the hepatitis (possibly with a
component of EtOH hepatitis) and demargination of white cells on
steroid therapy.
# Hypertension: Her blood pressure was well controlled.
Lisinopril was held given concern that medications could be
playing a role in acute hepatitis.
# Depression: Given that Paxil was started prior to her
developing acute hepatitis this medication was held during
admission.
# Nutrition: Calorie count revealed poor caloric intake. An NG
tube was placed and tube feeds were initiated.
She was DNR/DNI during this admission.
Medications on Admission:
- Aspirin 81mg PO daily
- Paxil 10mg daily
- Trazodone 2tabs QHS --> has not been working
- Lisinopril 10mg PO daily
Discharge Medications:
Deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Acute hepatitis, autoimmune or alcohol-related
Secondary: Cirrhosis, Hypertension, Atrial fibrillation,
Depression
Discharge Condition:
Deceased.
Discharge Instructions:
Deceased.
Followup Instructions:
Deceased.
Completed by:[**2164-2-25**]
|
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"V45.71",
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"288.60",
"427.31",
"599.0",
"584.9",
"276.1",
"571.5",
"571.42",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.13",
"38.93",
"96.6",
"96.08"
] |
icd9pcs
|
[
[
[]
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|
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|
2500, 2790
|
2806, 3110
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,089
| 125,160
|
28015
|
Discharge summary
|
report
|
Admission Date: [**2173-11-22**] Discharge Date: [**2173-12-4**]
Date of Birth: [**2095-7-14**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Abdominal pain, nausea, and vomiting
Major Surgical or Invasive Procedure:
[**11-26**] Exploratory laparotomy
PICC line placement
History of Present Illness:
Mr. [**Known lastname 11674**] is a 78 year old male with a history of colon and
esophageal cancer, s/p surgical resection [**9-5**], who presented to
an OSH on [**11-21**] with complaints of abdominal pain, nausea, and
vomiting. An x-ray confirmed a small bowel obstruction, a
nasogastric tube was placed. He is one week post 5FU infusion.
He was transferred to [**Hospital1 18**]-ED on [**11-21**] via ambulance for
further treatment and admitted to the surgical service. An
abdominal x-ray repeated upon admission to [**Hospital1 18**] confirmed small
bowel obstruction with possible mesenteric ischemia. He was
tachycardic and hypotensive, a central venous catheter was
placed, he received fluid resuscitation, and was transferred to
the surgical intensive care unit for further management.
Past Medical History:
Past Medical History:
Esophageal cancer
Colon cancer
Atrial fibrillation
Hypertension
Glaucoma
Benign prostatic hypertrophy
Past Surgical History:
[**9-14**] Laparoscopic right hemicolectomy, placement of feeding
jejunostomy, and venous access device
B/L cataract surgery
Left inguinal hernia repair
Repair of deviated septum
Social History:
He admits to drinking one glass a wine daily
30 pack year of smoking, he quit 30 years ago
Family History:
His father had renal cell cancer in his late 80's, died at age
[**Age over 90 **]
His mother had coronary artery disease and died in her 70's
Physical Exam:
Upon admission by surgical service:
101.4 120's 170's/110's
Abd: Distended, non-tender, hypoactive bowel sounds
Rectal: Heme + stool
J tube with coffee ground bloody output
Pertinent Results:
Admission:
[**2173-11-22**] 12:40AM BLOOD WBC-17.5* RBC-4.31* Hgb-12.3* Hct-34.5*
MCV-80* MCH-28.6 MCHC-35.7* RDW-14.5 Plt Ct-337
[**2173-11-22**] 12:40AM BLOOD Neuts-66 Bands-2 Lymphs-12* Monos-16*
Eos-0 Baso-0 Atyps-3* Metas-1* Myelos-0
[**2173-11-22**] 12:40AM BLOOD PT-14.8* PTT-26.8 INR(PT)-1.3*
[**2173-11-22**] 12:40AM BLOOD Glucose-140* UreaN-70* Creat-1.3* Na-133
K-3.2* Cl-99 HCO3-21* AnGap-16
[**2173-11-22**] 12:40AM BLOOD ALT-35 AST-27 AlkPhos-105 Amylase-13
TotBili-0.4
[**2173-11-22**] 12:40AM BLOOD Lipase-12
[**2173-11-22**] 04:37PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2173-11-22**] 12:40AM BLOOD Albumin-2.8* Calcium-7.7* Phos-4.2
Mg-2.8*
[**2173-11-24**] 12:41PM BLOOD Triglyc-77
[**2173-11-22**] 01:02AM BLOOD Lactate-2.4*
[**2173-11-22**] 02:38AM BLOOD freeCa-1.07*
Discharge:
[**2173-11-30**] 04:42AM BLOOD WBC-23.2* RBC-3.26* Hgb-9.6* Hct-26.1*
MCV-80* MCH-29.4 MCHC-36.7* RDW-15.9* Plt Ct-234
[**2173-12-3**] 04:27AM BLOOD PT-19.8* PTT-60.8* INR(PT)-1.9*
[**2173-12-2**] 06:29AM BLOOD Glucose-101 UreaN-23* Creat-0.7 Na-132*
K-4.1 Cl-101 HCO3-24 AnGap-11
[**2173-12-2**] 06:29AM BLOOD Calcium-7.8* Phos-4.1 Mg-2.3
[**2173-11-22**] 12:40 am BLOOD CULTURE
**FINAL REPORT [**2173-11-28**]**
AEROBIC BOTTLE (Final [**2173-11-28**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2173-11-28**]): NO GROWTH.
[**2173-11-23**] 6:12 pm MRSA SCREEN Site: RECTAL
Source: Rectal swab.
**FINAL REPORT [**2173-11-25**]**
MRSA SCREEN (Final [**2173-11-25**]): NO STAPHYLOCOCCUS AUREUS
ISOLATED.
[**2173-11-23**] 6:12 pm SWAB Source: Rectal swab.
**FINAL REPORT [**2173-11-26**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2173-11-26**]):
No VRE isolated.
[**2173-11-27**] 5:10 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2173-11-28**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2173-11-28**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2173-12-1**] 4:34 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2173-12-2**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2173-12-2**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
RADIOLOGY Final Report
ABDOMEN (SUPINE & ERECT) [**2173-11-21**] 11:58
ABDOMEN (SUPINE & ERECT)
Reason: please do KUB to eval for SBO, please do upright to eval
for
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with ? SBO
REASON FOR THIS EXAMINATION:
please do KUB to eval for SBO, please do upright to eval for
perf
INDICATION: Evaluate for possible perforation.
No comparison studies.
TWO VIEWS OF THE ABDOMEN AND PELVIS, SUPINE AND UPRIGHT:
There are markedly distended loops of small bowel and air-filled
colon. Multiple air-fluid levels are seen within the small
bowel. Nasogastric tube is present with tip in the gastric
fundus. There is no definite evidence of free air; however, the
diaphragms are well visualized. On prior chest radiograph which
was done in the upright position, there was no definite evidence
of free air. There is a small amount of air seen within the
rectum. There is no evidence of pneumatosis. Surrounding soft
tissue and osseous structures are unremarkable.
IMPRESSION:
Marked distention of the small bowel diffusely. Air is present
within the rectum. These findings concerning for small bowel
obstruction, ischemic bowel, or most likely ileus. Recommend CT
for further investigation.
RADIOLOGY Final Report
CHEST PORT. LINE PLACEMENT [**2173-11-22**] 3:22 AM
CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN
Reason: TLC placement r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with portal venous air
REASON FOR THIS EXAMINATION:
TLC placement r/o ptx
AP CHEST, 3:29 a.m. [**11-22**]
HISTORY: Portal venous air. Line placement.
IMPRESSION: AP chest compared to [**9-15**] and [**11-22**] at
12:13 a.m.
Severe generalized intestinal distention is seen in the upper
abdomen. No pneumoperitoneum is evident, but free
subdiaphragmatic gas might not be detected on this supine view.
Lungs are low in volume but clear and there is no pneumothorax.
Pleural effusion, if any, is minimal, on the left. Heart is
mildly enlarged. Mediastinum midline. Bilateral subclavian line
tips project over the SVC. Nasogastric tube is looped in the
stomach.
RADIOLOGY Final Report
CT PELVIS W/O CONTRAST [**2173-11-22**] 12:52 AM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: ABD.PAIN.DISTENTION.COLON/ESOPH.CA.R/O SBO
Field of view: 40
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with colon/esophageal cancer with belly pain
REASON FOR THIS EXAMINATION:
With PO contrast only to eval for sbo, perf
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 78-year-old male with colon and esophageal cancer
with pelvic pain. Evaluate for intra-abdominal pathology.
COMPARISON: [**2173-8-12**] CT PET.
TECHNIQUE: MDCT-acquired axial images of the abdomen and pelvis
were performed without IV contrast. Patient's creatinine was
1.6. Multiplanar reformations were performed.
CT ABDOMEN WITHOUT IV CONTRAST: The lung bases contain no focal
areas of consolidation. There is mild bilateral dependent
atelectasis. Within the left lobe of the liver, there are
multiple branching air-filled spaces consistent with portal
venous gas. The pancreas, spleen, adrenal glands, and kidneys
are unremarkable. Oral contrast is seen layering within the
stomach and not advancing into the duodenum. There are markedly
distended loops of small bowel with air-fluid levels with a
small amount of pneumotosis in the mid -distal small bowel. Per
history provided patient is status post right hemicolectomy. The
remaining portion of the transverse and descending and sigmoid
colon contain a moderate amount of air. Air and stool are seen
extending all the way down into the rectum. Mesenteric and
mesocolic fluid are present. There is a small amount of
perisplenic fluid. No definite small bowel or large bowel wall
thickening is identified. There is no evidence of pneumatosis.
There are multiple lymph nodes within the mesentery and
retroperitoneum, none of which appear pathologically enlarged.
Of note, patient is status post J- tube placement percutaneously
which has now been removed. A residual soft tissue strand is
seen extending from the skin through the subcutaneous tissue
into the jejunum which appears stitched to the peritoneum along
the lateral left anterior abdominal wall. A nasogastric tube is
also seen with the tip terminating in the gastric fundus. There
are moderate amount of aortic calcifications and minimal aortic
calcifications seen within the celiac artery and SMA.
CT PELVIS WITH IV CONTRAST: There is a fluid-filled left
inguinal hernia with no evidence of soft tissue or bowel
present. There is no free fluid in the pelvis. The rectum,
sigmoid colon contain air and bowel as mentioned above. The
prostate is unremarkable. The urinary bladder is catheterized.
BONE WINDOWS: No suspicious lytic or sclerotic bony lesions.
IMPRESSION:
1. Portal venous gas with markedly distended loops of small
bowel and mesenteric fluid and pneumotosis. These findings are
consistent with ischemic bowel. Given diffuse distribution of
bowel wall distention it is difficult to pinpoint specific
distribution of ischemia.
2. There is no evidence of small or large bowel obstruction.
3. Fluid-containing left inguinal hernia.
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2173-11-22**] 12:52 AM
CT HEAD W/O CONTRAST
Reason: MS CHANGES.COLON/ESOPH CA.?BLEED
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with colon/esophageal cancer w/ ms changes
REASON FOR THIS EXAMINATION:
please eval for bleed/mass
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 78-year-old man with colon and esophageal cancer
with mental status changes. Evaluate for bleed or mass.
No comparison studies.
TECHNIQUE: Non-contrast CT of the head.
FINDINGS: There is no evidence of intracranial hemorrhage, mass
effect, or shift of normally midline structures. [**Doctor Last Name **]-white
matter differentiation is preserved. There is no evidence of
acute major vascular territorial infarction, with chronic
micro-ischemic change in periventricular white matter, and
chronic lacune in the anterior limb of the left internal
capsule. The ventricles are somewhat enlarged, but are
proportionate to deepened sulci, diffusely, consistent with
global atrophy. The visualized paranasal sinuses and mastoid air
cells are clear. The surrounding osseous and soft tissue
structures are unremarkable.
IMPRESSION:
1. No evidence of intracranial hemorrhage or acute infarct.
2. No specific evidence of intracranial metastasis; enhanced MRI
would, of course, be more sensitive.
The study and the report were reviewed by the staff radiologist.
RADIOLOGY Final Report (Revised)
ABDOMEN (SUPINE & ERECT) PORT [**2173-11-23**] 12:46 PM
ABDOMEN (SUPINE & ERECT) PORT
Reason: remaining contrast in abdomen
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with question of retained contrast from prior CT
REASON FOR THIS EXAMINATION:
remaining contrast in abdomen
INDICATION: 78-year-old man with question of retained contrast
from prior CT. Question remaining contrast in abdomen.
COMPARISON: CT abdomen and pelvis [**2173-11-22**].
FINDINGS: Three supine and erect plain radiographs of the
abdomen and pelvis were obtained. An NG tube appears coiled
within the stomach with its tip located within the fundus.
Persistent dilatation of air-filled small bowel is identified, a
nonspecific finding. There is no evidence of free
intraperitoneal air. Contrast is not definitively seen within
the bowel.
IMPRESSION: No evidence of contrast within bowel. Persistence of
dilated small bowel, nonspecific finding.
RADIOLOGY Final Report
CT ABDOMEN W/CONTRAST [**2173-11-25**] 11:00 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: COLON/ESOPHAGEAL CA, ABD DISTENSION.
Field of view: 48 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with colon/esophageal cancer with belly pain,
h/o portavenous air on admission scan and now increasing WBC and
abd distension
REASON FOR THIS EXAMINATION:
r/o bowel ischemia vs perforation - please give both IV and PO
contrast & PLEASE PAGE [**Numeric Identifier 68201**] with read
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Colon and esophageal cancer, abdominal distention,
history of portal venous air.
COMPARISON: [**2173-11-22**].
TECHNIQUE: Axial contrast-enhanced images through the abdomen
and pelvis with multiplanar reformats.
CT OF THE ABDOMEN WITH CONTRAST: There are small bilateral
pleural effusions and bibasilar atelectasis. There is a small
pericardial effusion. There are mitral annular calcifications as
well as coronary artery calcifications. The feeding tube is
within the stomach. There is circumferential wall thickening of
the mid to distal esophagus. There are multiple enlarged
gastrohepatic ligament lymph nodes measuring approximately 1 cm.
There is a 1.8 x 1.5 cm epicardial lymph node. There is interval
increase in the ascites, but the portal venous air and
pneumatosis has resolved. The liver, spleen, gallbladder,
adrenal glands, pancreas, kidneys and ureters are unremarkable.
There are multiple 1-cm paraaortic lymph nodes. There are also
multiple subcentimeter mesenteric and aortocaval lymph nodes.
There is a new G-tube. Within the mid to distal jejunum, there
is bowel wall thickening. The celiac axis, superior mesenteric
artery, and inferior mesenteric arteries, including the duodenal
branches are all patent. There is atherosclerotic calcification
of the descending artery and its branches. There is stranding
and small amount of fluid within the mesentery. The patient is
status post right colectomy.
CT OF THE PELVIS WITH CONTRAST: There is a catheter within the
bladder and rectum, which are otherwise unremarkable. There is
free fluid within the pelvis. There is a left hydrocele. There
is no inguinal or pelvic lymphadenopathy meeting CT criteria.
REFORMATTED IMAGES: Degenerative changes within the spine but no
suspicious lesions.
IMPRESSION:
1. Resolved portal venous air and pneumatosis. New jejunal wall
thickening is concerning for ischemia, given the patient's
history. Less likely on the differential includes infection and
inflammatory etiologies.
2. Circumferential thickening of the esophagus consistent with
the known carcinoma. Gastrohepatic, epicardial, and
retroperitoneal lymphadenopathy.
3. Increased ascites.
4. Bilateral pleural effusions.
Cardiology Report ECHO Study Date of [**2173-11-25**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. /Evaluate for atrial
clot/thrombus/PAF.
Height: (in) 66
Weight (lb): 211
BSA (m2): 2.05 m2
BP (mm Hg): 145/88
HR (bpm): 90
Status: Inpatient
Date/Time: [**2173-11-25**] at 11:30
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W047-0:42
Test Location: West SICU/CTIC/VICU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.4 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *7.6 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.3 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.8 cm
Left Ventricle - Fractional Shortening: 0.47 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aorta - Arch: *3.2 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - E Wave Deceleration Time: 114 msec
TR Gradient (+ RA = PASP): 25 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement. Elongated LA. Thrombus in the
body of the
LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%). Normal regional LV systolic function. No
resting LVOT
gradient.
RIGHT VENTRICLE: RV not well seen.
AORTA: Normal aortic root diameter. Mildly dilated ascending
aorta. Mildly
dilated aortic arch.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral
annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA
systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
The rhythm
appears to be atrial fibrillation. Echocardiographic results
were reviewed by
telephone with the houseofficer caring for the patient.
Conclusions:
The left atrium is mildly dilated and elongated. A 2.8 x 6.1-cm
echodensity is
seen attached to the posterior wall of the left atrium,
consistent with
thrombus. The right atrium is moderately dilated. There is mild
symmetric left
ventricular hypertrophy with normal cavity size and systolic
function
(LVEF>55%). Regional left ventricular wall motion is normal. The
ascending
aorta and the aortic arch is mildly dilated. The aortic valve
leaflets (3) are
mildly thickened but aortic stenosis is not present. There is no
aortic
regurgitation. 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.
IMPRESSION: Large left atrial thrombus. Mild symmetric left
ventricular
hypertrophy with preserved global and regional systolic
function.
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] F.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on MON [**2173-11-29**]
9:47 AM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 68202**]
Service: [**Last Name (un) **] Date: [**2173-11-26**]
Date of Birth: [**2095-7-14**] Sex: M
Surgeon: [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], MD 2205
PREOPERATIVE DIAGNOSIS: Rule out ischemic intestine.
POSTOPERATIVE DIAGNOSIS: Ischemic intestine without
infarction.
SURGICAL PROCEDURE: Exploratory laparotomy.
ASSISTANT: [**Doctor First Name **] [**Doctor Last Name **], RES
ANESTHESIA: General.
INDICATIONS FOR SURGERY: This is a gentleman who has had a
complicated medical and surgical history with esophageal
cancer and colon cancer being diagnosed recently. He has had
a colectomy for colon cancer and is undergoing radiation and
chemotherapy for esophageal cancer. He presented with
abdominal pain and signs of infection with CT scan several
days ago showing portal venous gas and possible pneumatosis.
This was treated conservatively as it was thought this might
well be due to chemotherapy associated with enteritis. He has
improved clinically; however, his white blood cell count has
been persistently elevated and has gone up to over 30,000
without any other source.
A CT scan did not show any more pneumatosis but does show a
same loop of bowel with considerable edema and it was thought
most prudent to do an exploratory laparotomy to ensure that
there was not a small section of severely compromised
intestine which may be perforated.
PREPARATION: In the operating room, the patient was given
general endotracheal anesthetic. She previously had a Foley
catheter placed in the bladder. The abdomen was prepared with
Betadine solution and draped in the usual fashion.
INCISION: A midline incision was made through the old
limited laparoscopically-assisted upper midline incision
going down around the umbilicus.
FINDINGS: There was a mild to moderate amount of ascites,
slightly turbid. There was no evidence of perforation. The
small bowel appeared to be normal with the exception of a 1
to 1-1/2 foot segment somewhat distal to the jejunostomy site
which was edematous but was perfectly viable. The colon also
appeared to be normal.
PROCEDURES: The abdomen was opened and explored with the
above-mentioned findings. A few adhesions were encountered
which were light. The entire small bowel was run with the
above-mentioned findings. The anastomosis was inspected which
was normal. Some of the ascites was sent to microbiology for
culture and Gram stain. The area was irrigated copiously and
drained and sucked dry. The bowel was then placed back into
normal position. Hemostasis was achieved.
CLOSURE: The fascia was closed with a running suture of 0
PDS. The skin was closed with staples. A dry sterile dressing
was applied. The patient was then extubated and sent to the
recovery area in satisfactory condition having tolerated the
procedure well.
DRAINS: None.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
Date: [**2173-11-29**]
Signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18963**], RN on [**2173-11-29**] Affiliation: [**Hospital1 18**]
WOUND CARE
Follow up visit to evaluate heels.
Pt is now out of the ICU.
Pt's left heel is no longer red and is intact. It is mildly dry.
The pt's right heel remains with dark area approx 0.5 x 1 cm
with
intact skin. The redness seen previously has resolved.
The pt's right heel is in a waffle boot.
The FMS, flexiseal , remains in place.
The coccyx, gluteals are intact and without redness [**Name8 (MD) **] RN
caring
for pt.
Suggest:
Pressure relief measures per pressure ulcer guidelines
continue with waffle boots B/L
continue to use barrier cream perianal tissue as the flexiseal
can leak somewhat
Please call wound care with any questions or concerns re: pt or
flexiseal(can stay in for up to 29 days)
Brief Hospital Course:
Mr. [**Known lastname 11674**] was admitted to the surgical intensive care unit, an
abdominal CT scan confirmed portal venous gas with distended
loops of small bowel and mesenteric fluid, consistent with
ischemic bowel; no evidence of small or large bowel obstruction.
It was suspected that he had enteritis from his recent
chemotherapy, since there was no evidence of obstruction and it
was decided that an operation was not necessary unless his
clinical picture changed. His nasogastric tube and jejunostomy
tube continued to drain bilious fluid. His had leukocytosis with
WBC's 18.4k, he was placed on broad spectrum antibiotics
including: Levaquin, Flagyl, and Vancomycin. He was placed on
beta-blockade for his history of atrial fibrillation, Morphine
as needed for pain control, an Insulin sliding scale, and
received fluid resuscitation for low urine output and
tachycardia with good response. He was hemodynamically stable
with a hematocrit of 32.5. On HD 2, TPN was initiated, his
beta-blockade was increased for heart rates in the 120's, he
remained afebrile, and had adequate urine output. On HD 4 he had
an echocardiogram done which demonstrated a thrombus in the left
atrium (see pertinent results), a Heparin drip was initiated.
A hematology/oncology was placed with recommendations of
continuing current treatment but likelihood of 5FU enteritis was
small since the patient did not experience diarrhea prior to
admission, a repeat x-ray demonstrated persistent dilation of
small bowel. HD 5 his white blood cell count increased to 31k
despite being afebrile; all cultures up to date were negative
for bacteria. On HD 5 a repeat abdominal CT scan was done with
resolution or pneumatosis and new jejunal wall thickening; he
was taken to the operating room for an exploratory laparotomy
with no evidence of ischemia, 700cc of ascites was removed. He
had no intra-operative complications and post-operatively
returned to the surgical intensive care unit. On POD1/ HD 6 his
nasogastric tube was removed and his pain was well controlled
with a Morphine PCA. On POD 3 he was transferred to an
in-patient nursing unit, his Heparin drip continued with six
hour monitoring of his PTT and adjustments made as needed. On
POD 4 he was started on Coumadin therapy along with the Heparin
drip; his diet was advanced to liquids while continuing TPN. The
antibiotics were discontinued, he remained afebrile, and his
white blood cell count had decreased to 23.2k. He experienced
frequent episodes of loose stool, two C.Diff samples were sent
which were negative; Imodium was started. On POD 5 his foley
catheter was removed and he was voiding without difficulty, tube
feeds were started which he tolerated well. On POD 7 he was
tolerating tube feeds at goal, the TPN was discontinued, and he
received all medications through the jejunostomy tube.
On POD 7 he was hypertensive, a bladder scan demonstrated 900cc
of urine and the foley was replaced with a good response in his
blood pressure; he was started on Terazosin for a history of
BPH.
He received physical therapy throughout the hospitalization and
it was determined that he would benefit from short term
rehabilitation to increase his strength and functional mobility.
The patient was discharged on [**2173-12-4**] after removal of his CVL;
his INR was therapeutic at 2.4 and he was off the heparin drip.
Medications on Admission:
Toprol XL
Avodart
Senna
ASA
Discharge Medications:
1. Amlodipine 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily):
[**Month (only) 116**] give via J-tube.
2. Terazosin 1 mg Capsule [**Month (only) **]: Two (2) Capsule PO HS (at
bedtime): [**Month (only) 116**] give via J-tube.
3. Loperamide 1 mg/5 mL Liquid [**Month (only) **]: Two (2) mg PO BID (2 times a
day): Please add to tube feeds.
4. Insulin Regular Human 100 unit/mL Solution [**Month (only) **]: As directed
As directed Injection ASDIR (AS DIRECTED).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): [**Month (only) 116**] give via J-tube.
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Month (only) **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain: [**Month (only) 116**] give via
J-tube.
7. Metoprolol Tartrate 50 mg Tablet [**Month (only) **]: Two (2) Tablet PO TID
(3 times a day): [**Month (only) 116**] give via J-tube.
8. Albuterol Sulfate 0.083 % Solution [**Month (only) **]: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for wheeze.
9. Metoprolol 20 mg IV Q4H:PRN
hold for SBP < 100 HR < 60
10. Warfarin 5 mg Tablet [**Month (only) **]: One (1) Tablet PO HS x1: Please
monitor daily INR and adjust Coumadin dose appropriately.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House
Discharge Diagnosis:
Ischemic bowel without infarction
Esophageal Cancer
Colon Cancer
Discharge Condition:
Good
Discharge Instructions:
Please call/return to [**Hospital1 18**] if you have:
* Increasing pain or persistent pain that is not relieved by
pain medications
*Inability to urinate
* Fever (>101.5 F)
*Nausea or Vomiting that last longer than 24 hours
* Inability to pass gas or stool
*If J-tube is pulled out
*If incision becomes red or if there is drainage
* Other symptoms concerning to you
Please take all your medications as ordered. Please continue
your previous medications
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in ~1 week, call ([**Telephone/Fax (1) 1483**] for
an appointment.
Follow-up with Dr. [**Last Name (STitle) 32496**], call ([**Telephone/Fax (1) 32498**] for an
appointment.
|
[
"707.07",
"427.31",
"789.5",
"424.90",
"600.00",
"401.9",
"V10.03",
"557.9",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11",
"38.93",
"99.15",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
27144, 27200
|
22384, 25750
|
309, 366
|
27309, 27316
|
2024, 4575
|
27818, 28042
|
1668, 1811
|
25828, 27121
|
12222, 12364
|
27221, 27288
|
25776, 25805
|
27340, 27795
|
14843, 22361
|
1363, 1543
|
1826, 2005
|
233, 271
|
12393, 14817
|
394, 1191
|
1236, 1339
|
1559, 1652
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,654
| 180,734
|
49296
|
Discharge summary
|
report
|
Admission Date: [**2149-6-17**] Discharge Date: [**2149-6-22**]
Date of Birth: [**2068-8-29**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is comatose and intubated and there is no family
present;
so history limited to paperwork that was provided on transfer.
Mr. [**Known lastname 32416**] ([**Doctor Last Name **] Eu Critical) is an 80 y/o man with a PMH
significant for HTN, spinal stenosis and HLD who was transferred
from [**Hospital1 **] [**Location (un) 620**] with IPH and SDH. He flew in [**State 108**] today and
was noted to be confused by his friend upon arrival. Later this
evening, he was having dinner with his family, when he suddenly
slumped over and became unresponsive. He was also noted to have
R
sided weakness around 7pm. He was brought to the [**Location (un) 620**] Ed,
where he had a CT head, which showed a large frontotemporal IPH
and SDH with midline shift and uncal herniation. He received 20
grams of Mannitol at [**Location (un) 620**] and was transferred to [**Hospital1 18**]. Upon
arrival to [**Hospital1 18**], he was evaluated by neurosurgery, who said he
was not a surgical candidate given his age and extent of bleed.
ROS: unable to obtain as he is comatose and intubated
Past Medical History:
- Hypertension
- Hyperlipidemia
- cervical arthritis/stenosis
- h/o Basal cell and squamous cell CA
Social History:
unknown at time of admission
Family History:
unknown at time of admission
Physical Exam:
< ON ADMISSION: >
Vitals: P: 100 BP: 152/68 vent CPAP 5/5/40% R 21 SaO2: 99%
General: comatose, intubated
HEENT: ET tube in place
Pulmonary: anterior lung fields cta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, nondistended, +BS
Extremities: warm, well perfused
Neurologic: Examined off Propofol. He is comatose. No eye
opening
or commands. R pupil 5 mm and fixed. L pupil 7 mm and fixed. No
doll's eyes. Very weak corneal on right, corneal present on
left.
Cough and gag intact. No spontaneous movements of UE b/l; he has
spontaenous triple flexion of LE b/l. Decerebrate posturing to
noxious stimuli in UE b/l. Triple flexion to noxious stimuli in
LE b/l. Reflexes are 3+ and symmetric at [**Hospital1 **]/br/patellae.
Extensor
plantar response b/l.
<>
Pertinent Results:
[**2149-6-20**] 04:05AM BLOOD WBC-14.4* RBC-3.69* Hgb-11.1* Hct-33.1*
MCV-90 MCH-30.0 MCHC-33.4 RDW-15.4 Plt Ct-202
[**2149-6-19**] 03:56AM BLOOD WBC-13.2* RBC-3.75* Hgb-11.4* Hct-33.3*
MCV-89 MCH-30.4 MCHC-34.3 RDW-15.1 Plt Ct-214
[**2149-6-18**] 02:30AM BLOOD WBC-14.9* RBC-4.00* Hgb-12.1* Hct-34.4*
MCV-86 MCH-30.2 MCHC-35.2* RDW-15.3 Plt Ct-235
[**2149-6-17**] 09:55PM BLOOD WBC-16.6* RBC-4.03* Hgb-12.1* Hct-35.3*
MCV-88 MCH-30.1 MCHC-34.3 RDW-15.2 Plt Ct-229
[**2149-6-17**] 09:55PM BLOOD Neuts-93.9* Lymphs-3.6* Monos-2.0 Eos-0.3
Baso-0.2
[**2149-6-18**] 02:30AM BLOOD PT-12.5 PTT-23.5 INR(PT)-1.0
[**2149-6-17**] 09:55PM BLOOD PT-12.2 PTT-23.7 INR(PT)-1.0
[**2149-6-20**] 04:05AM BLOOD Glucose-151* UreaN-15 Creat-0.9 Na-147*
K-3.7 Cl-112* HCO3-28 AnGap-11
[**2149-6-19**] 03:56AM BLOOD Glucose-131* UreaN-15 Creat-1.0 Na-144
K-3.8 Cl-107 HCO3-28 AnGap-13
[**2149-6-18**] 02:26PM BLOOD Glucose-139* UreaN-13 Creat-0.9 Na-142
K-4.3 Cl-106 HCO3-28 AnGap-12
[**2149-6-18**] 09:11AM BLOOD Na-146* K-3.8 Cl-106
[**2149-6-18**] 02:30AM BLOOD Glucose-170* UreaN-16 Creat-0.8 Na-141
K-3.7 Cl-105 HCO3-28 AnGap-12
[**2149-6-17**] 09:55PM BLOOD Glucose-155* UreaN-18 Creat-0.9 Na-135
K-3.9 Cl-102 HCO3-23 AnGap-14
[**2149-6-20**] 04:05AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.9
[**2149-6-19**] 03:56AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9
[**2149-6-18**] 02:26PM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8
[**2149-6-18**] 02:30AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.8
[**2149-6-17**] 09:55PM BLOOD Calcium-8.2* Phos-2.8 Mg-1.7
[**2149-6-18**] 09:11AM BLOOD Osmolal-306
[**2149-6-18**] 02:30AM BLOOD Osmolal-303
[**2149-6-18**] 02:45PM BLOOD Type-ART pO2-178* pCO2-44 pH-7.44
calTCO2-31* Base XS-5
[**2149-6-17**] 10:03PM BLOOD Glucose-148* Lactate-1.2 Na-136 K-4.0
Cl-101 calHCO3-24
CXR [**6-18**]:
As compared to the previous radiograph, the patient has been
intubated. The tip of the endotracheal tube is relatively high
and projects more than 7 cm above the carina. The tube could be
advanced by approximately 2 cm. No evidence of complications, no
pneumothorax. The nasogastric tube is also new, the tube could
be advanced by approximately 5 cm.
[**2149-6-17**]
CT HEAD WITHOUT CONTRAST:
CLINICAL HISTORY: Change in mental status.
TECHNIQUE: Sequential axial images were acquired through
the head
without administration of intravenous contrast.
Multiplanar
reformations were performed.
COMPARISON: None.
FINDINGS:
There is multicompartmental hemorrhage including: a 6.6 x
4.0 cm left
frontoparietal intraparenchymal hemorrhage, left cerebral
convexity
subdural hemorrhage measuring up to 9 mm in maximal
thickness, and
scattered subarachnoid hemorrhage over the left cerebral
hemisphere.
There is marked associated mass effect with complete
effacement of the
suprasellar cistern, 1.7 cm of rightward shift of normally
midline
structures, compression of the left lateral ventricle, and
effacement
of left cortical sulci. The right lateral ventricle is
entrapped at
the level of the foramen of [**Doctor Last Name 23609**] and there is also
entrapment of the
temporal [**Doctor Last Name 534**] of the left lateral ventricle. There is both
downward
transtentorial and uncal herniation. Marked edema
surrounds the left
frontoparietal intraparenchymal hemorrhage, likely
vasogenic in
nature.
There are bilateral mucus-retention cysts in the maxillary
sinuses.
Mild mucosal thickening is seen throughout several
bilateral ethmoidal
air cells. The visualized portions of the paranasal
sinuses and
mastoid air cells are otherwise well-aerated. The imaged
osseous
structures are unremarkable. There is no evidence of a
subgaleal
hematoma.
IMPRESSION:
1. MULTICOMPARTMENTAL HEMORRHAGE INCLUDING LEFT
FRONTOPARIETAL IPH
AND LEFT HEMISPHERIC CONVEXITY SDH AND SAH. THERE IS
MARKED
ASSOCIATED EDEMA AND BOTH DOWNWARD TRANSTENTORIAL
HERNIATION AND
1.7 CM RIGHTWARD SHIFT OF THE NORMALLY MIDLINE
STRUCTURES.
GIVEN BOTH THE SIZE OF THE IPH AND THE PRESENCE OF
BLOOD IN
MULTIPLE COMPARTMENTS, AMYLOID ANGIOPATHY OR UNDERLYING
COAGULOPATHY
Brief Hospital Course:
Mr. [**Known lastname 32416**], a previously healthy 80 year-old man with spinal
stenosis, HTN, and HL, was transferred to our hosptial ED on
[**2149-6-17**] with a catastrophic intraparenchymal hemorrhage.
Neurosurgery were [**Name (NI) 653**], and decided that no surgical
intervention was indicated due to the poor prognosis portended
by the examination (including fixed, dilated pupils) and imaging
findings (including large-volume hemorrhage and uncal horizontal
transtentorial herniation). He was admitted to our Neurology
service, and brought to the ICU, still intubated. He was made
DNR status empirically due to futility of further intervention
with ICH score of 4 and a non-survivable brain injury. He was
breathing on CPAP with no ventilatory support and oxygenating
well. His alternate HCP was [**Name (NI) 653**] and he and the family (his
only son [**Name (NI) **] and his girlfriend [**Doctor Last Name 2048**] flew in from [**Name (NI) 108**]
and arrived in our ICU two days later. He was made formally [**Name (NI) 3225**]
(comfort-measures only). He was kept as comfortable as possible
using IV morphine gtt PRN and scopolamine patch and PRN
acetaminophen and hyoscyamine. He was transferred to the
Neurology floor ([**Hospital Ward Name 121**] 11) breathing on his own. He developed a
low-grade temp and then a fever, which was treated with
acetaminophen PR for comfort. His cultures, CXR, and UA (taken
before the family/HCP arrived, while he was not yet [**Name (NI) 3225**] status)
were not remarkable for any source of infection and no
antibiotics were started.
He stopped breathing in the late morning on Sunday [**2149-6-22**],
and Dr. [**Last Name (STitle) 54849**] was called to bedside a few minutes later. By
that time, he was still quite warm to the touch, but he
exhibited no spontaneous respirations or movements of any kind,
and no radial or carotid or femoral pulsations, and no heart
sounds. His pupils remained fixed and dilated as before, with no
VOR, but now the corneal reflexes were absent. Dr. [**Last Name (STitle) 54849**]
declared the time of death to be 11:40am. He called his son,
[**Name (NI) **], and his girlfriend, [**Name (NI) 2048**], to convey the news of his
death, and they agreed to visit the body within two hours. [**Doctor Last Name **]
refused autopsy. Dr. [**Last Name (STitle) 54849**] called and spoke with the Medical
Examiner's office, and Dr. [**Last Name (STitle) 54849**] is awaiting their call to
learn whether or not they would prefer to investigate the case
(there is the question of trauma, at least theoretically,
without the presence of the friend from dinner, given the
subdural hematoma on the head CT).
Medications on Admission:
-Finasteride 5 mg daily
-Gabapentin 300 mg tid
-Hydrocodone-Acetaminophen 7.5/650 q6h
-Ibuprofen 600 mg 1-2 tabs daily
-Lisinopril-HCTZ 20-12.5 mg daily
-Lovastatin 40 mg daily
-Oxycodone 10 mg q6h
-Flomax 0.4 mg XR daily
-ASA 162 mg daily
Discharge Medications:
n/a (patient died)
Discharge Disposition:
Expired
Discharge Diagnosis:
death from catastrophic intraparenchymal hemorrhage
Discharge Condition:
died
Discharge Instructions:
patient died
Followup Instructions:
n/a
Completed by:[**2149-6-22**]
|
[
"348.4",
"432.1",
"V66.7",
"780.60",
"272.4",
"431",
"780.01",
"723.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9720, 9729
|
6704, 9386
|
317, 323
|
9824, 9830
|
2461, 6681
|
9891, 9925
|
1620, 1650
|
9677, 9697
|
9750, 9803
|
9412, 9654
|
9854, 9868
|
1665, 1667
|
274, 279
|
351, 1435
|
1681, 2442
|
1457, 1558
|
1574, 1604
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
134
| 167,887
|
21746
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 57148**]
Admission Date: [**2127-1-14**]
Discharge Date: [**2127-1-24**]
Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is an 80-year-old male who
reports episodes of severe fatigue in [**2124**] that resolved
spontaneously. Diagnosed with cardiomyopathy and mitral
insufficiency. He also reports an episode of chest pressure
earlier in [**2126**] that resolved with rest, with a recent
increase in episodes of fatigue recently. Therefore,
referred for cardiac catheterization in [**2126-10-9**].
Cardiac catheterization revealed an ejection fraction of 56
percent, a 100 percent RCA occlusion, a 100 percent OM
occlusion, a 70 percent ramus occlusion, a 90 percent LAD
occlusion, an 80 percent first diagonal occlusion, with 2
plus mitral regurgitation; for which he was referred for
evaluation for coronary artery bypass grafting and mitral
valve repair or replacement.
PAST MEDICAL HISTORY: Peripheral vascular disease, abdominal
aortic aneurysm, silent myocardial infarction, transient
ischemic attacks, hypothyroidism, gastroesophageal reflux
disease, psoriasis, glaucoma, hypertension, left lower
extremity varicosities, and a sodium abnormality (on steroid
treatment).
PAST SURGICAL HISTORY: Includes a left carotid
endarterectomy in [**2125**] and bilateral cataract removal.
PREOPERATIVE MEDICATIONS: Hydrocortisone 10 mg in the
morning and 5 mg in the evening, aspirin 325 mg once daily,
lisinopril 5 mg once daily, Crestor 10 mg once daily, Lasix
40 mg every other day, testosterone 200-mg injection every
three to four weeks, Levoxyl (unknown dose), atenolol
(unknown dose), and Xalatan eye drops (unknown dose).
ALLERGIES: INTRAVENOUS DYE.
PHYSICAL EXAMINATION ON PRESENTATION: Height was 6 feet 2
inches tall, weight was 186 pounds, the heart rate was 44,
the blood pressure on the right was 143/68 and on the left
131/61. In general, a tall solid elderly male. Skin
revealed no obvious disease. HEENT examination revealed the
pupils were equal, round, and reactive to light and
accommodation. The extraocular movements were intact. The
eyes were anicteric. The neck revealed a healed left carotid
endarterectomy scar. Negative jugular venous distention. No
bruits appreciated. Chest was clear to auscultation. Right
crackles at the left base. Heart revealed a regular rate and
rhythm. S1 and S2. No appreciated murmur. The abdomen was
soft, nontender, and nondistended. There was positive bowel
sounds. Negative costovertebral angle tenderness. The
extremities were warm and well perfused. There was 1 plus
edema on the left leg. Varicosities were present in the left
lower extremity with venous stasis changes. Neurologically,
cranial nerves II through XII were grossly intact; nonfocal.
Good strength in all four extremities.
RADIOLOGIC STUDIES: Preoperative carotid ultrasound in
[**2126-2-7**] showed a 60 to 80 percent right internal
carotid artery stenosis with no noted left stenosis.
A chest x-ray with no acute cardiopulmonary disease.
PERTINENT LABORATORY DATA ON PRESENTATION: Pulmonary
function tests were also obtained in [**2126-10-9**]
showing an FEV1 of 93 percent of predicted and FEV1:FVC ratio
of 97 percent of predicted. White blood cell count was 7,
the hematocrit was 39.7, the platelets were 219. PT was
12.9, PTT was 30.9, and INR was 1. Urinalysis was negative.
Glucose was 91, BUN was 22, creatinine was 1.2, sodium was
136, potassium was 4.6, chloride was 101, and bicarbonate was
27. ALT was 15, AST was 26, alkaline phosphatase was 71, and
total bilirubin was 0.4. Albumin was 4.3. Hemoglobin A1C
was 5.5.
SUMMARY OF HOSPITAL COURSE: Mr. [**Name13 (STitle) 57149**] presented on his
operative day ([**2127-1-14**]) and proceeded to the
Operating Room for coronary artery bypass grafting times four
with a LIMA to the LAD, a saphenous vein graft to the OM, a
saphenous vein graft to the ramus, and a saphenous vein graft
to the PDA. He also had a mitral valve repair with a 28-mm
[**Doctor Last Name 405**] annuloplasty band. Total coronary artery bypass
time was 184 minutes with a cross-clamp time of 155 minutes.
He was transferred to the Cardiac Surgery Recovery Unit with
a mean arterial pressure of 66, a central venous pressure of
8, in a normal sinus rhythm at a rate 86 on a Neo-Synephrine
drip. Please see the Operative Report for full details. The
patient was successfully weaned and extubated on his
operative evening.
On postoperative day one, his intravenous drip medications
were discontinued, and physical therapy was initiated. On
postoperative day two, his chest tubes were discontinued.
Electrolytes were repleted as necessary, and he was
transferred to the inpatient floor for ongoing recovery and
rehabilitation. On postoperative day three continued
uneventfully with ongoing physical therapy. Cardiac pacing
wires were discontinued. Lopressor was increased to 25 mg
p.o. twice daily for heart rate and blood pressure control.
The patient began to be screened for rehabilitation.
Postoperative days five and six also progressed well with a
significant increase in physical therapy level. It was
decided that Mr. [**Name13 (STitle) 57149**] would not need physical therapy. We
consulted Mr. [**Last Name (Titles) 57150**] endocrinologist who recommended
hydrocortisone taper, which we initiated.
On postoperative day seven, Mr. [**Name13 (STitle) 57149**] of significant right
knee swallowing and pain, for which an Orthopaedics
consultation was obtained. Orthopaedics recommended
ambulation with range of motion of the knee. They stated
there was no evidence for infection. On postoperative day
eight, Mr. [**Name13 (STitle) 57149**] reported a significant decrease in pain
with improvement in stiffness with ambulation. An x-ray of
the knee showed chronic degenerative changes only.
On postoperative day nine, Mr. [**Name13 (STitle) 57149**] was cleared by
Physical Therapy and found to be safe for discharge home. He
also had a short burst of atrial fibrillation that
spontaneously converted to a sinus rhythm with no further
episodes of atrial fibrillation. He was kept in house
overnight to monitor his heart rate. On postoperative day
ten ([**2127-1-24**]), he was found to be medically ready
for discharge home.
DISCHARGE STATUS: Home with visiting nurse.
DISCHARGE DIAGNOSES:
1. Coronary artery disease and mitral regurgitation.
2. Status post coronary artery bypass grafting times four and
mitral valve repair.
3. Peripheral vascular disease.
4. Osteoarthritis.
5. Abdominal aortic aneurysm.
6. Panhypopituitary.
7. Gastroesophageal reflux disease.
8. Psoriasis.
9. Glaucoma.
10. Hypertension.
11. Status post left carotid endarterectomy.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice daily.
2. Percocet 5/325 one to two tablets p.o. q.4h. as needed
(for pain).
3. Lipitor 20 mg p.o. once daily.
4. Latanoprost 0.005 percent drops 1 drop both eyes at
bedtime.
5. Brimonidine tartrate 0.2 percent drops 1 drop both eyes
q.8h.
6. Aspirin 81 mg p.o. once daily.
7. Lasix 20 mg p.o. once daily (for seven days).
8. Potassium chloride 20 mEq p.o. once daily (for seven
days).
9. Hydrocortisone 20 mg in the morning and 10 mg in the
evening (until otherwise instructed by Dr. [**First Name (STitle) **].
10. Levoxyl 88 mcg p.o. once daily.
11. Crestor 10 mg p.o. once daily.
DI[**Last Name (STitle) 408**]E FOLLOW-UP PLANS:
1. The patient was to follow up with Dr. [**Last Name (STitle) 57151**] in one to
two weeks; with Dr. [**First Name (STitle) **] in one week; with Dr. [**Last Name (Prefixes) **]
in three to four weeks; and with Dr. [**Last Name (STitle) 27117**] in one to two
weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 5898**]
MEDQUIST36
D: [**2127-4-1**] 15:39:55
T: [**2127-4-1**] 16:41:29
Job#: [**Job Number 57152**]
|
[
"244.9",
"396.3",
"530.81",
"365.9",
"414.01",
"401.9",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.33",
"36.13",
"36.15",
"89.60"
] |
icd9pcs
|
[
[
[]
]
] |
6353, 6732
|
6758, 7429
|
1244, 1330
|
1357, 3633
|
3662, 6332
|
7446, 7982
|
153, 914
|
937, 1220
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,997
| 169,873
|
11926
|
Discharge summary
|
report
|
Admission Date: [**2144-11-16**] Discharge Date: [**2144-12-10**]
Date of Birth: [**2076-7-31**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 68 year old
male with a past medical history of chronic obstructive
pulmonary disease as well as Methicillin resistant
Staphylococcus aureus pneumonia, who was admitted to the
Emergency Room after being found unresponsive at his nursing
home at 10:15 on the morning of admission. He was found to
be lethargic. He was given [**Location (un) 2452**] juice and nebulizers,
without any improvement in his mental status. He was
transferred to the Emergency Room.
In the Emergency Room, the patient was given vancomycin and
ceftriaxone and intubated for decreased mental status as well
as hypercarbia with arterial blood gases of 7.2, 83, 44 on
four liters nasal cannula. He also received two and one-half
liters of fluid and was admitted to the Medical Intensive
Care Unit for further evaluation and treatment.
PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary
disease. 2. Coronary artery disease. 3. Congestive heart
failure. 4. Cerebrovascular accident. 5. Hypertension.
6. Noninsulin dependent diabetes mellitus. 7. Peripheral
vascular disease. 8. Bilateral below the knee amputations.
9. Methicillin resistant Staphylococcus aureus pneumonia.
10. Phantom limb pain. 11. Osteomyelitis. 12.
Parkinson's disease. 13. Gastroesophageal reflux disease.
MEDICATIONS ON ADMISSION: Simvastatin, Sinemet, zinc
sulfate, vitamin C, pantoprazole, digoxin, aspirin,
lisinopril, multivitamins, Glucotrol, MS Contin, Beclovent,
Combivent, Neurontin, Lopressor, regular insulin sliding
scale, Risperdal, Remeron, Klonopin, Percocet, Atrovent,
albuterol, Mylanta and Tylenol.
ALLERGIES: Penicillin.
SOCIAL HISTORY: The patient is a resident of a nursing
facility. His primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **].
PHYSICAL EXAMINATION: On physical examination on admission,
the patient had a temperature of 104.8, pulse 88, blood
pressure 76/64. General: Patient intubated, on pressure
support of 15, PEEP 5, FiO2 100%. Head, eyes, ears, nose and
throat: Pupils small and reactive to light, oropharynx
extremely dry. Neck: Supple, flat neck veins. Chest:
Rhonchi throughout, decreased breath sounds at both bases.
Cardiovascular: Regular rate and rhythm, III/VI systolic
ejection murmur. Abdomen: Soft, scaphoid, guaiac negative.
Extremities: Bilateral below the knee amputations, right 1.5
cm round shallow ulcer on right stump without any tracking
erythema or drainage.
LABORATORY DATA: Admission white blood cell count was 10.5,
hematocrit 46.3, platelet count 151, sodium 142, potassium
7.3, repeat 4.4, chloride 104, bicarbonate 31, BUN 47,
creatinine 1 and glucose 60. Urinalysis showed specific
gravity of 1.003, nitrite positive with moderate bacteria, 1
white blood cell, 1 red blood cell. Chest x-ray showed
parahilar prominence, bibasilar interstitial process
consistent with aspiration pneumonia as well as pulmonary
edema. Electrocardiogram showed sinus rhythm at 100 beats
per minute with a left axis deviation, no acute ST wave
changes; no old electrocardiogram available for comparison.
HOSPITAL COURSE: The patient was brought to the Medical
Intensive Care Unit intubated in respiratory failure with
underlying chronic obstructive pulmonary disease; also,
likely pneumonia. He eventually grew Methicillin resistant
Staphylococcus aureus out of his sputum and was treated with
a two week course of vancomycin. He also had a clotted right
PICC line at the time of admission, which was removed and
eventually grew out [**Female First Name (un) 564**]. He was treated with two weeks
of fluconazole.
The patient was also noted on chest x-ray to have evidence of
a right pneumothorax. Surgery was called to place a chest
tube, which drained transudative fluids for multiple days,
and was eventually removed. The patient also had his course
complicated by self-extubation with several days of
increasing respiratory distress. He was eventually
reintubated and underwent bronchoscopy.
The patient was also found to have a clot in his right
internal jugular, for which he was started on a heparin drip.
He also had a PICC line placed in the right arm. The patient
was doing better after a several week course. However, he
then began to spike multiple fevers again. He had a repeat
bronchoscopy which showed left lower lobe collapse. He then
grew Methicillin resistant Staphylococcus aureus out of his
sputum once again. He also had gram negative rods in his
sputum which turned out to be E. coli, sensitive to
ceftriaxone and ceftazidime. He was started on antibiotics
again.
The patient also grew Providencia stuartii in his urine and,
when his arterial line was removed on [**2144-12-8**], he
grew gram positive, likely Staphylococcus, from his blood.
The patient continued to do poorly despite aggressive
antibiotic therapy. His white blood cell count increased to
27. His urine output decreased. His pressures dropped into
the 40s systolic. He was started on Dopamine. His pressure
still did not respond and he required Levophed,
Neo-Synephrine and Vasopressin.
Despite all of these blood pressure medications, the patient
became increasingly lethargic, despite also being on
ceftazidime and gentamicin. His primary care physician was
called. Code status was changed to "Do Not Resuscitate".
The patient continued to do poorly. An electrocardiogram
showed no acute changes. A chest x-ray showed increasing
evidence of failure, likely the patient went back into acute
respiratory distress syndrome, became increasingly septic and
unresponsive. Eventually his code status was changed to
comfort measures only.
The patient was placed on a morphine drip and his pressure
support was discontinued. The patient expired at 9:35 a.m.
on [**2144-12-10**].
CONDITION AT DISCHARGE: Deceased.
DISCHARGE MEDICATIONS: None.
[**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) 37561**], M.D. [**MD Number(1) 37562**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2144-12-10**] 11:37
T: [**2144-12-14**] 09:24
JOB#: [**Job Number 37563**]
|
[
"996.62",
"112.5",
"518.82",
"512.8",
"453.8",
"507.0",
"496",
"250.00",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"96.04",
"34.04",
"38.91",
"31.1",
"33.24",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6044, 6324
|
1482, 1793
|
3316, 5994
|
2014, 3298
|
6009, 6020
|
158, 987
|
1010, 1455
|
1810, 1991
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,755
| 195,409
|
31765
|
Discharge summary
|
report
|
Admission Date: [**2182-8-18**] Discharge Date: [**2182-8-22**]
Date of Birth: [**2123-4-30**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Left MCA stroke; transferred from outside hospital following
TPA.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 16008**] is a 59yo F with HTN, Hyperlipidemia, DM2, Left CEA,
and history of R MCA infarct who had acute onset of global
aphasia and right sided weakness at 9:15am on [**8-18**]. She was
doing well at home fixing eggs in her kitchen when she suddenly
dropped her spatula and was unable to speak. She understood
simple commands, and went to lay down in bed. Shortly thereafter
when EMS arrived she was unable to get out of bed. Taken to
[**Hospital 8641**] Hospital in [**Location (un) 3844**] and given IV TPA at 11:50am for
NIHSS of 22 (-2 questions, -2 aphasia, -6 motor left arm and
leg, -8 motor right arm and leg, -2 sensory on the right side,
-2 dysarthria). Arrived at [**Hospital1 18**] via [**Location (un) **], monitored in the
Neuro ICU overnight and she is called out to the neurology
floor.
Prior to presentation the patient had a left MCA infarct in [**Month (only) 116**]
[**2181**] with similar presenting symptoms. She receieved speech and
physical therapy at home following the event. At baseline until
Sunday she has been ambulating without assistance with "normal"
speech- perhaps occasional word finding difficulty. She was not
on aspirin prior to her stroke in [**Month (only) 116**] due to history of GI
bleeding. She was started on aspirin in [**Month (only) 116**].
Upon evaluation on the neurology floor her strenth on the right
side had returned to [**Location 74587**]. She is able to answer "yes," and
understands simple commands, and becomes visibly frustrated by
her inability to communicate.
The patient was unable to offer a complete ROS, but denies pain
or discomfort.
Past Medical History:
DM2- normally on Glargine 90units daily, recently started new
type of insulin one week earlier.
Obesity
CAD- 70% RCA, 95% Circ
HTN
Hyperlipidemia
Asthma
GERD
Anemia
Low Back pain
Anemia- history of GI bleeding requiring transfusion
Depression
Social History:
She lives in [**Location (un) **] with her husband. history of tobacco
use. no current ETOH.
Family History:
unavailable
Physical Exam:
VS: T 98.9 BP 140/47 RR 17 Sat 96% on 4L
PE:
HEENT AT/NC, MMM no lesions
Neck Supple, no bruits
Chest difficult to clearly auscultate breath sounds due to
obesity.
CVS RRR, no m/r/g (but again, obesity limits quality of this)
ABD obese; protruding umbilicus with palpable hernia which is
full but not painful. there is no evidence of skin
discoloration.
EXT no C/C/E, some ecchymosis noted over the right flank.
NEUROLOGICAL
MS:
General: alert, appropriately interactive, normal affect;
patient gets visibly frustrated when asked questions by the
examiner, and she is unable to get the words out.
Orientation: unable to assess because the patient is aphasic
Attention: tracks to the examiner during the exam, but unable to
fully assess because the patient is aphasic
Speech/[**Doctor Last Name **]: expressive aphasia; she is limited to saying "yep"
and "no". she did make one attempt to say
"hydrochlorothiazide".
She follows 1 step command, but when she is faced with 2 steps,
she appears to be confused by the request. she was unable to
understand the command "stick out your tongue" or "lift your
left
hand"
CN:
II,III: pupils 4-->2 mm bilaterally to light, optics discs
sharp
and flat
III,IV,V: EOMI, no ptosis.
VII: there is a mild right sided facial droop with evidence of
flattening of the nasolabial fold on the right.
[**Doctor First Name 81**]: SCM/trapezeii could not be assessed well by the examiner
because she had difficulty understanding the task of shrugging
her shoulder.
XII: patient unable to understand the command of protruding her
tongue.
Motor: Normal bulk and tone; no tremor, rigidity, or
bradykinesia. Unable to sustain elevation of her right arm
[**Hospital1 **] Tri Grip IP Quad Hamst TibAnt [**Last Name (un) 938**]
C6 C7 C8/T1 L2 L3 L4-S1 L4 L5
L 5 5 5 4+ 4+ 4+ 4 4 5
R 3 3 3 3 3 3 2 2
Reflex:
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 2 Flexor
R 2+ 2+ 2+ 3 2 extensor
Sensation: unable to assess because the patient is aphasic
Coordination: Finger-nose-finger intact on the left; could not
perform on the right due to weakness
Gait: assessment deferred due to right hemiplegia and fall
risk due to TPA
DISCHARGE EXAMINATION
Pertinent Results:
TEE:
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 or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. 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. There are simple atheroma in the descending
thoracic aorta to 45cm. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: No cardiac source of embolism seen.
MR HEAD W/O CONTRAST [**2182-8-19**] 1:53 AM
FINDINGS: Diffusion and ADC map images show a large area of
acute infarction in the left middle cerebral artery territory,
mostly in the left temporal lobe, insula, and posterior left
frontal lobe. Two other separate foci of diffusion abnormality
are seen, one in the left parietal region, the other in the
right medial frontal lobe, adjacent to the cingulate gyrus.
These are confirmed by the ADC map to be acute; their
multiplicity and bilaterality also suggest an embolic
phenomenon.
MR angiography images demonstrate marked attenuation and lack of
flow in the distal left M1 segment, with lack of flow in several
portions of the M2, M3, and M4 segments. The right middle
cerebral artery, anterior cerebral artery, and vertebrobasilar
system appear patent, without aneurysm, significant stenosis, or
vascular malformation.
IMPRESSION: Acute infarction in both hemispheres, mostly in the
left MCA territory. Bilaterality and multiplicity suggests an
embolic phenomenon. Please note that this study is incomplete,
as the remainder of standard brain MRI images were not obtained
due to patient inability to tolerate the examination.
CT HEAD W/O CONTRAST [**2182-8-19**] 1:31 PM
IMPRESSION: Developing hypodensity in the left MCA territory as
well as a left parietal wedge-shaped density are seen, without
findings to suggest hemorrhagic transformation. Incidentally
noted are several punctate calcifications distributed throughout
the hemispheres in a pattern suggesting pial artery
calcifications. Otherwise, there is no significant interval
change
Brief Hospital Course:
Mrs. [**Known lastname 16008**] is a 59 year old woman with DM2, HTN,
Hyperlipidemia, L CEA, prior MCA infarct who presented with new
onset global aphasia and right sided weakness. She was
administered TPA at an outside hospital and transferred to [**Hospital1 18**]
for further care. On arrival she had resolving right sided
weakness and persistent global aphasia. Etiology of her prior
infarctions is unclear aside from multiple vascular risk factors
of likely an embolic source based on multifocal appearance of
neuroimaging.
1) MCA infarct
Her presenting symptoms likely represent a total MCA occlusion,
that appears to have recanulized partially preserving motor
function. She was started on Aspirin therapy following her first
stroke in [**2182-4-23**] despite history of GI bleeding requiring
transfusions. This second stroke (two prior infarcts were
radiographic findings only) represents a failure of aspirin
therapy. During this admission she was started on aggrenox [**Hospital1 **]
in combination with aspirin 81mg daily for secondary prevention.
TEE was performed to search for intracardiac shunt as route for
paradoxical emboli and no source was found. Carotid ultrasound
revealed less than 40% stenosis bilaterally. She will follow up
with Dr. [**Last Name (STitle) **] in the Vascular Neurology Center at [**Hospital1 18**].
2) Diabetes Mellitus Type 2-
Initially very difficult to treat diabetes with BG's in 400's.
She was given full doses of glagine 90units daily as well as
humalog sliding scale. Her glargine will need to be titrated
further for optimum BG control at rehab according to her sliding
scale requirements. Pre-prandial insuling may also be added once
clinically indicated.
3) Hypertension-
Her antihypertensive medications were intially held and she was
allowed to autoregulate in the setting of acute infarct.
Forty-eight hours post infarct her home dose of spironolactone
was re-initiated. She was also started on metoprolol 50mg [**Hospital1 **]
instead of atenolol for purposes of titration. She was on both
Lasix 40mg Daily and Isosorbide Mononitrate 60mg daily prior to
admission, these were held given her acute infarct and
fluctuating volume status. Daily weights and monitoring of
volume status should continue to determine appropriate timing or
need to add back these medications.
4) Hyperlipidemia-
She was continued atorvastatin 40mg (formulary equivalent from
lovastatin).
Medications on Admission:
Albuterol MDI q4h
Spironolactone 25mg daily
Lasix 40mg Daily
Isosorbide Mononitrate 60mg daily
Glargine 90units SC at noon
Lisinopril 10mg daily
atenolol 100mg daily
Nitroglycerin 0.3 SL daily
Humalog 15-30 SC QID
Glyburide 3mg
ASA 325mg daily
Diflucan 150mg
Sertraline 50mg daily
Lovastatin 40mg daily
Aciphex 20mg daily
Byetta 10mcg SC QAM, QPM (added ~1 week prior to admission)
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. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Humalog 100 unit/mL Cartridge Sig: Dose per sliding scale
units Subcutaneous QAC and HS.
8. Insulin Glargine 100 unit/mL Cartridge Sig: Ninety (90) units
Subcutaneous once a day.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Left Middle Cerebral Artery Stem Occlusion (infarct)
Discharge Condition:
Persistent nonfluent aphasia. Right sided arm and leg weakness
resolved completely since presentation.
Discharge Instructions:
You were admitted for a recurrent stroke affecting the right
side of your body and causing difficulty with your
interpretation of speech.
Please continue to take all medications as prescribed.
Call Dr. [**First Name (STitle) 449**] or 911 if you experience any worsening of your
speech, new weakness, numbness or tingling, chest pain,
shortness of breath or any other concerning symptoms.
Followup Instructions:
You have an appointment to see Dr. [**Last Name (STitle) **] (stroke neurology) at
[**Hospital1 18**] on Ocotober 2nd at 4pm. Please call [**Telephone/Fax (1) 2574**] prior to
your appointment to update your information with the department.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"250.02",
"278.00",
"434.11",
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icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
10898, 10968
|
7166, 9592
|
382, 389
|
11065, 11170
|
4731, 7143
|
11609, 11945
|
2442, 2455
|
10026, 10875
|
10989, 11044
|
9618, 10003
|
11194, 11586
|
2470, 4712
|
276, 344
|
417, 2048
|
2070, 2315
|
2331, 2426
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,239
| 157,443
|
782
|
Discharge summary
|
report
|
Admission Date: [**2105-11-10**] Discharge Date: [**2105-11-15**]
Date of Birth: [**2049-2-26**] Sex: M
Service: MEDICINE
Allergies:
Quinine / Vicodin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Sepsis/confusion
Major Surgical or Invasive Procedure:
R groin and L IJ central lines, R wrist and L groin arterial
lines
History of Present Illness:
56 yo m transferred from [**Hospital **] hospital w/ end stage liver dz
[**3-6**] hepatitis, sclerosing cholangitis, UC, on the transplant
list and normally followed at [**Hospital1 336**] (no beds available), who
presented from OSH septic on peripheral pressors. He had been in
rehab x 3 months, more recently had failure to thrive. Today
presents to [**Hospital1 **] ER with a BP 82/39, HR 45, WBC 18,
creatinine 4.4, Bili 24. Given daptomycin and imipenem at OSH.
.
In the ED, vitals were t 90, hr 50, bp 82/40, sat 98% ra. Noted
to have a lactate of 12.2 and an ABG 7.04/19/122. Patient given
daptomycin and imipenem for broad coverage. R IJ attempted but
failed. L femoral line placed. Was intubated for airway
protection, requiring minimal sedation given underlying
encephalopathy. Was started on levophed for BP support. On
placement of OGT noted to have ~500 cc bright red blood. Blood
was ordered and liver service notified with plan to evaluate
patient upon arrival to MICU. In the ED he received Vit K, FFP,
PRBCs and protonix.
.
When patient came to floor was continuing to have bright red
blood per OGT. Liver evaluated patient and felet that EGD would
not be useful at this time as his INR was too high to intervene.
Past Medical History:
- spinal osteomyelitis
- UC
- primary sclerosing cholangitis
- ESLD - hx of varices, s/p banding - followed by Dr. [**Last Name (STitle) 656**] at
[**Hospital1 336**], off the transplant list
- DM
Social History:
Unable to obtained
Family History:
Non-contributory
Physical Exam:
Vitals: t 93.7 rectally, bp 98/48 on levophed, hr 60, rr 24, sat
100%
Vent: AC RR TV 600 RR 20 PEEP 5 FiO2 100%
Gen: sedated, intubated
HEENT: + scleral edema
Resp: clear anteriorly
Cards: bradycardia, no murmurs appreciated
Abd: + bs, soft, non-distended
Ext: 1+ lower ext edema
Skin: + jaundice
Neuro: not responding to painful stimuli
Pertinent Results:
[**2105-11-9**] 09:40PM BLOOD WBC-14.1* RBC-2.20* Hgb-8.4* Hct-25.4*
MCV-116* MCH-38.3* MCHC-33.1 RDW-17.1* Plt Ct-118*
[**2105-11-10**] 06:05AM BLOOD WBC-17.3* RBC-2.74* Hgb-9.5* Hct-27.8*
MCV-102* MCH-34.7* MCHC-34.2 RDW-20.5* Plt Ct-84*
[**2105-11-10**] 11:46PM BLOOD WBC-10.3 RBC-2.42* Hgb-8.4* Hct-23.3*
MCV-96 MCH-34.7* MCHC-36.0* RDW-22.1* Plt Ct-35*
[**2105-11-11**] 11:47AM BLOOD WBC-11.3* RBC-2.44* Hgb-8.6* Hct-22.9*
MCV-96 MCH-35.4* MCHC-36.8* RDW-21.2* Plt Ct-39*
[**2105-11-12**] 03:52AM BLOOD WBC-13.7* RBC-2.39* Hgb-8.5* Hct-23.3*
MCV-98 MCH-35.7* MCHC-36.5* RDW-21.2* Plt Ct-28*
[**2105-11-10**] 03:37AM BLOOD Neuts-90.2* Bands-0 Lymphs-5.3* Monos-4.2
Eos-0.3 Baso-0.1
[**2105-11-11**] 11:47AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-2+ Polychr-1+ Ovalocy-1+ Target-1+ Burr-2+
Stipple-OCCASIONAL Acantho-1+
[**2105-11-9**] 09:40PM BLOOD PT-50.7* PTT-150* INR(PT)-6.0*
[**2105-11-10**] 11:46PM BLOOD PT-24.5* PTT-72.4* INR(PT)-2.5*
[**2105-11-12**] 03:52AM BLOOD PT-34.2* PTT-65.1* INR(PT)-3.7*
[**2105-11-10**] 09:23AM BLOOD Fibrino-78.3*
[**2105-11-11**] 03:11AM BLOOD Fibrino-113*
[**2105-11-9**] 09:40PM BLOOD Glucose-115* UreaN-97* Creat-3.3* Na-136
K-4.8 Cl-106 HCO3-5* AnGap-30*
[**2105-11-12**] 03:52AM BLOOD Glucose-106* UreaN-87* Creat-3.6* Na-137
K-4.0 Cl-101 HCO3-18* AnGap-22
[**2105-11-9**] 09:40PM BLOOD ALT-85* AST-503* CK(CPK)-45 AlkPhos-168*
Amylase-64 TotBili-16.4*
[**2105-11-10**] 06:05AM BLOOD ALT-262* AST-1864* LD(LDH)-1312*
AlkPhos-160* TotBili-16.4*
[**2105-11-10**] 11:24AM BLOOD ALT-639* AST-5061* LD(LDH)-3156*
CK(CPK)-94 AlkPhos-266* Amylase-74 TotBili-18.0*
[**2105-11-11**] 03:11AM BLOOD ALT-523* AST-4052* LD(LDH)-1661*
AlkPhos-326* Amylase-80 TotBili-20.3* DirBili-15.9* IndBili-4.4
[**2105-11-11**] 03:18PM BLOOD ALT-398* AST-3379* LD(LDH)-702*
AlkPhos-351* TotBili-22.6*
[**2105-11-12**] 03:52AM BLOOD ALT-294* AST-2406* LD(LDH)-436*
AlkPhos-337* TotBili-22.0*
[**2105-11-9**] 09:40PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2105-11-10**] 03:37AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2105-11-10**] 11:24AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2105-11-9**] 09:40PM BLOOD Calcium-7.7* Phos-6.9* Mg-3.1*
[**2105-11-12**] 03:52AM BLOOD Albumin-2.2* Calcium-9.4 Phos-5.3* Mg-2.3
[**2105-11-10**] 09:23AM BLOOD calTIBC-103* VitB12-GREATER TH
Folate-GREATER TH Hapto-<20* Ferritn-GREATER TH TRF-79*
[**2105-11-11**] 09:40PM BLOOD Ammonia-95*
[**2105-11-10**] 03:37AM BLOOD TSH-1.2
[**2105-11-10**] 06:05AM BLOOD Cortsol-16.8
[**2105-11-10**] 09:23AM BLOOD Cortsol-15.3
[**2105-11-12**] 05:10AM BLOOD Type-ART Temp-37.7 pO2-99 pCO2-30*
pH-7.43 calTCO2-21 Base XS--2 Comment-CPAP
[**2105-11-9**] 09:49PM BLOOD Lactate-12.2*
[**2105-11-11**] 03:30AM BLOOD Lactate-9.5* K-3.4*
[**2105-11-12**] 05:10AM BLOOD Lactate-6.9* K-3.9
[**2105-11-10**] 02:30AM BLOOD freeCa-0.99*
[**2105-11-10**] 04:12AM BLOOD freeCa-0.82*
[**2105-11-12**] 05:10AM BLOOD freeCa-1.14
CT ABDOMEN W/O CONTRAST [**2105-11-9**] 10:07 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: eval for abscess
Field of view: 38
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with sepsis, h/o liver ca. unclear source.
REASON FOR THIS EXAMINATION:
eval for abscess
CONTRAINDICATIONS for IV CONTRAST: None.
CT ABDOMEN AND PELVIS WITHOUT CONTRAST
INDICATION: 56-year-old man with sepsis, history of liver
carcinoma, evaluate for source of sepsis.
COMPARISON: Not available at this institution.
TECHNIQUE: MDCT axial images of abdomen and pelvis were obtained
without administration of oral contrast. Intravenous contrast
was administered due to poor renal function.
CT ABDOMEN WITHOUT CONTRAST: There are bilateral small
effusions, with adjacent consolidations, which may represent
atelectasis and/or pneumonia. There is a nodular component of
the right basilar consolidation.
The liver is shrunken and nodular, consistent with history of
cirrhosis. There is branching hyperdensity in the liver which
appears to follor the distribution of portal vein branches;
findings are concerning for portal vein thrombosis. This
abnormality does not extend into the main portal vein.
Evaluation of the abdomen is extremely limited by lack of
intravenous or oral contrast. Nasogastric tube terminates in the
stomach. There are no renal calculi. There is no hydronephrosis.
Spleen is non-enlarged. Multiple portosystemic collaterals are
present in the upper abdomen with recanalized umbilical vein
noted.
Pancreas, spleen, adrenal glands are unremarkable given lack of
contrast. There is a massive ascites. The definition of the
bowel is extremely poor though large bowel thickening is
suggested as is mesenteric congestion.
CT PELVIS WITHOUT CONTRAST: Urinary bladder is collapsed around
a Foley catheter. There is a rectal tube in place. A small
locule of gas is seen on image 74 of series 2 in the anterior
abdominal wall which may be related to medication injection.
There is no definite evidence for free intraperitoneal air. A
catheter is noted in the right femoral vein.
There is generalized body wall edema.
BONE WINDOWS: Demonstrate sclerosis and compression deformity of
T8 vertebral body, incompletely evaluated.
IMPRESSION: Limited study.
1. Hepatic cirrhosis with stigmata of portal hypertension.
2. Branching high-density material in the liver, concerning for
portal vein thrombosis.
3. Large volume of ascites, mesenteric congestion, large bowel
thickening.
4. Bilateral pleural effusions with lower lobe consolidations
which may represent pneumonia.
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOP ABD/PEL LIMITED
Reason: ? portal vein thrombosis, please use dopplers
[**Hospital 93**] MEDICAL CONDITION:
56 year old man h/o liver disease, ascites, GIB
REASON FOR THIS EXAMINATION:
? portal vein thrombosis, please use dopplers
INDICATION: 56-year-old man, history of liver disease, ascites,
GI bleed. Question portal vein thrombosis.
Comparison is made to a non-contrast abdomen CT performed
earlier today.
DUPLEX LIVER DOPPLER ULTRASOUND: There is a small right-sided
pleural effusion. A moderate amount of ascites is seen in the
right upper quadrant. There are large varices along the lesser
curvature. The liver is small and nodular consistent with
cirrhosis. There is marked gallbladder wall edema with a wall
thickness up to 12 mm, likely due to third spacing. The
gallbladder contains sludge but no stones. Within the liver
parenchyma, there are hyperechoic bands radiating in the
periphery following portal vein branches that correspond to
similar structures seen on the CT consistent with periductal
fibrosis in this patient with primary sclerosing cholangitis.
DOPPLER ULTRASOUND: The splenic vein and SMV as well as hepatic
veins and IVC are patent. There is an aneurysmal dilatation of
the confluence of the portal vein measuring up to 2.5 cm. Within
the right portal vein, there is a contracted non-occlusive
thrombus. Hepatopetal flow is demonstrated within the residual
lumen. The left portal vein is patent with outflow into a large
recanalized umbilical vein. Minimal slow flow is detected in the
right portal vein.
IMPRESSION:
1. Non-occlusive thrombus in the right portal vein with
maintained hepatopetal flow.
2. Patency of splenic vein, SMV, left portal vein with outflow
via large umbilical vein, hepatic veins, and IVC.
3. Minimal slow flow in the right portal vein.
4. Aneurysmal dilatation at the confluence of the portal vein
(2.5 cm).
5. Cirrhotic liver with periductal fibrosis consistent with the
history of PSC and stigmata of portal hypertension including
large varices at the lesser curvature and moderate ascites.
6. Sludge containing gallbladder with marked wall edema, likely
due to third spacing.
7. Small right pleural effusion.
TTE [**11-10**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size appears borderline
dilated. Right ventricular systolic function is normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2105-11-11**] 2:55 AM
CHEST (PORTABLE AP)
Reason: ? change
[**Hospital 93**] MEDICAL CONDITION:
56 year old man h/o liver disease, post-intubation
REASON FOR THIS EXAMINATION:
? change
INDICATION: 56-year-old man with history of liver disease,
post-intubation; evaluate for change.
COMPARISONS: Chest radiograph dated [**2105-11-10**].
FINDINGS: A single AP portable supine radiograph reveals an
endotracheal tube which terminates 6 cm above the carina. The
left internal jugular catheter and nasogastric tube are stable.
There is increased perihilar hazines and bilateral basilar
opacity. There is no pneumothorax. The cardiac silhouette is
stable.
IMPRESSION:
1. Increasing mild to moderate pulmonary edema and layering
bilateral pleural effusions.
Date 6 Specimen Tests Ordered By
All [**2105-11-9**] [**2105-11-10**] [**2105-11-11**] All BLOOD CULTURE
CATHETER TIP-IV MRSA SCREEN STOOL SWAB URINE All EMERGENCY
[**Hospital1 **] INPATIENT
[**2105-11-11**] CATHETER TIP-IV WOUND CULTURE-PENDING INPATIENT =
NGTD
[**2105-11-11**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT =Negative
[**2105-11-10**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2105-11-10**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-PENDING
INPATIENT
[**2105-11-10**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2105-11-10**] CATHETER TIP-IV WOUND CULTURE-PENDING EMERGENCY [**Hospital1 **]
=NGTD
[**2105-11-9**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING EMERGENCY [**Hospital1 **] =NGTD
[**2105-11-9**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING EMERGENCY [**Hospital1 **] =NGTD
[**2105-11-9**] URINE URINE CULTURE-FINAL EMERGENCY =Negative
Brief Hospital Course:
Mr. [**Known lastname **] was a 56 yo male with ESLD secondary primary
sclerosing cholangitis who was admitted with sepsis of [**First Name8 (NamePattern2) **] [**Last Name (un) 5487**]
source, with negative cultures but likely related to his
previously diagnosed vertebral osteomyelitis. He initially
required 2 vasopressor agents on arrival and was intubated for
airway protection and to assist in correcting his severe
acidosis. Upon insertion of the OGT, he started bleeding from
his oropharynx. He required multiple units of PRBCs and the
hepatology service did not desire to do an EGD as they felt they
would not be able to intervene on anything given his
coagulopathy (INR of 6) and his unstable hemodynamics.
Eventually the bleeding stopped and his hematocrit stabilized
with medical measure including a Protonix drip and an octreotide
drip. He was weened off his vasopressor medications. He was also
in acute renal failure and acute liver failure, both felt to be
due to his hypotension. His liver failure was slowly improving
but his renal failure continued to worsen. He had been taken off
the liver transplant list at [**Hospital1 336**] in [**Month (only) 205**] due to his vertebral
osteomyelitis and his long term prognosis was bleak. In
discussion with the family on HD 5, his code status was changed
to DNR and the family decided that hemodialysis would not be
acceptable to the patient given his living will.
On HD 7, the patient had some hypotension in the morning again
requiring one vasopressor medication. At approximately 7pm, he
began to spontaneously bleed from his mouth and blood was
suctioned out of his OGT in large amounts. He was initially
stabilized with IVF and increased vasopressor medications.
However, in discussion with his HCP it was decided that further
treatment would be in violation of his living will and the
decision was made to make him comfort measures only. The family
also decided that they did not want to be present for his death.
Supportive care was withdrawn and the patient was made
comfortable via a fentanyl drip. He passed peacefully on
[**2105-11-15**] at 8:20pm with doctors, nurses, and respiratory
technicians at his beadside
Medications on Admission:
vancomycin 750 mg daily
actigall 600 mg tid
pentasa [**Numeric Identifier 961**] mg tid
vit k
mvi
protonix 40 mg po daily
metformin 500 mg po bid
xanax 0.5 mg po q8hr prn anxiety
oxycodone 5 mg po q4hr prn pain
MOM
dulcolax prn
tyelnol 650 mg po q4hr prn pain
nadolol 40 mg qd
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Upper gastrointestinal bleed
Endstage liver disease
Ulcerative colitis and primary sclerosing cholangitis
Discharge Condition:
Deceased
Discharge Instructions:
none
Followup Instructions:
none
|
[
"576.1",
"572.3",
"571.5",
"511.9",
"789.59",
"155.2",
"458.9",
"276.2",
"572.2",
"V49.83",
"570",
"456.20",
"730.19",
"584.9",
"038.9",
"250.00",
"556.9",
"452",
"995.92",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14983, 14992
|
12437, 14626
|
297, 365
|
15143, 15153
|
2291, 5353
|
15206, 15213
|
1900, 1918
|
14954, 14960
|
10826, 10877
|
15013, 15122
|
14652, 14931
|
15177, 15183
|
1933, 2272
|
241, 259
|
10906, 12414
|
393, 1628
|
1650, 1848
|
1864, 1884
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,348
| 173,407
|
49955
|
Discharge summary
|
report
|
Admission Date: [**2165-9-5**] Discharge Date: [**2165-9-9**]
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89y/o F with type II DM, pulmonary nodules and hypothyroidism
presenting with gait unsteadiness.
She reports a 2 week history of not being able to walk and
buckling of her left knee. She states not being able to get up,
and states that her left foot "starts moving on its own" and "I
can't control it." She also endorses leg cramps. She was
otherwise feeling fine. She initially called her PCP and went
to ED. Notably, she had labs drawn a few weeks ago which showed
Na 131 and K of 5.0. She also received a flu shot two weeks
ago.
In the ED, initial vs were: T 98.9 P43 BP 200/83 R15 O2 sat
99%RA.
Her sodium was 123 and her potassium was 6.3. She was given
kayexalate and 1L NS, and her potassium decreased to 4.7. She
was given decadron 4mg IV X1. Her PCP was [**Name (NI) 653**] and he
denied her being on a course of steroids.
She denied dizzyness, vertigo, lightheadedness, fevers,
nightsweats, chills, chest pain, shortness of breath, cough,
abdominal pain, constipaiton, diarrhea, muscle aches.
Past Medical History:
Type 2 diabetes mellitus complicated by neuropathy (in left 1st
toe)
Hypertension
H/o cellulitis requiring hospital admission
TAH-BSO in 40's due to "hemorrhaging" and to prevent endometrial
cancer
S/p left SFA and tibial angioplasty on [**2165-2-15**]
H/o breast tumor removal many years ago, reportedly benign
S/p Left Hip ORIF
Hypothyroidism
Spinal stenosis status post laminectomy in [**2152**]
Bilateral total knee replacements in [**2147**]
Rectal and bladder prolapse
Status post cholecystectomy
Status post appendectomy
Left rotator cuff injury
Has not had a colonoscopy.
Last pap was before her hysterectomy.
Social History:
Lives alone in [**Location (un) **], although has hired nearly 24 hour
care. Husband died of prostate cancer 3 months ago, daughter
died of uterine cancer. Has son who lives in [**Name (NI) 760**], and
one in [**Location (un) 3844**] or [**Hospital3 **]. No smoking, present or past.
Denies alcohol or other drugs. Typically walks with a walker at
baseline.
Family History:
Daughter died of uterine cancer. Brother died of leukemia at age
16. Father died of leukemia in old age. Husband died of
prostate cancer. Mother died of "virus." Has two other children
that are healthy.
Physical Exam:
Vitals: BP 130/69 HR 79 RR 19 O2 Sat RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm with occasional ectopy, II/VI
systolic murmur heard at LLSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: WWP, no peripheral edema. Tender to palpation of left
heel.
Neuro: CN II-XII intact, downgoing Babinski. Sensation intact
in lower extremities. Intention tremor bilaterally, worse with
movement.
Pertinent Results:
[**2165-9-5**] 09:30PM GLUCOSE-226* UREA N-15 CREAT-0.7 SODIUM-125*
POTASSIUM-4.7 CHLORIDE-90* TOTAL CO2-27 ANION GAP-13
[**2165-9-5**] 09:05PM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2165-9-5**] 09:05PM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2165-9-5**] 01:25PM WBC-11.6* RBC-4.18* HGB-13.0 HCT-38.2 MCV-91
MCH-31.2 MCHC-34.1 RDW-14.7
[**2165-9-5**] 01:25PM PLT COUNT-372
[**Last Name (un) **] Stim Test Results: Cortisol level 10.5 before cosyntropin
injection, 37.5 after the injection
FSH: 5.4
LH: 1.8
Prolactin: 6.0
TSH: 3.2
Imaging:
[**2165-7-23**] (From prior hospitalization):
CT OF THE CHEST WITH IV CONTRAST:
The left lobe of the thyroid gland is well visualized and
appears normal. There is no evidence of any axillary or
mediastinal lymphadenopathy.
Multiple bilateral pulmonary nodules are seen suspicious for
metastatic disease (2:7, 2:35, 2:36, 2:39).
The visualized heart appears normal in size with evidence of
coronary, aortic valvular, and mitral anular calcification. The
pulmonary artery is slightly dilated suggestive for pulmonary
arterial hypertension measuring 3.8 cm at the proximal. A small
hiatal hernia is seen.
CT OF THE ABDOMEN WITH IV AND ENTERAL CONTRAST: The liver is
normal in size with evidence of a small area of hypodensity seen
in the segment V of the right lobe (2:66) which is
indeterminate. There is also evidence of some intrahepatic
biliary dilatation as well as extrahepatic biliary dilatation
which is within normal limits given patient's age and status
post cholecystectomy.Correlation with clinical history and LFTs
might be useful The spleen is normal with no evidence of any
granulomas, infarcts, or calcifications. The pancreas is normal
with no evidence of any surrounding fat stranding, hypodense
lesion, pseudocyst, or calcifications. The bilateral adrenal
glands are normal with no evidence of any nodule, thickening, or
masses. The bilateral kidneys show evidence of subcortical and
exophytic hypodense cysts which are too small to characterize.
The small and large bowel are normal without any evidence of
inflammatory changes, wall thickening, or distension. The small
bowel is seen approximating the anterior abdominal wall with
divarication of the recti without evidence of any herniation.
Focal thickening is noticed of the right ascending colon in the
cecal area. There are no surrounding stranding, lymph nodes, or
other changes which would suggest inflammatory or malignant
disease. This is most likely either due to under-distension.
There is no evidence of any abdominal free fluid or
lymphadenopathy.
CT OF THE PELVIS WITH IV AND ENTERAL CONTRAST:
The rectum and sigmoid colon appeared normal with no evidence of
any wall thickening, inflammatory changes, or distension. The
bladder shows evidence of a small bladder diverticulum
anteriorly (2:93). The patient is status post hysterectomy.
There is no evidence of any pelvic free fluid or
lymphadenopathy.
OSSEOUS STRUCTURES:
Patient is status post left hip fracture fixation and lumbar
laminectomy.
The head of the left humerus shows significant degenerative
disease which on multiple priors was seen before and is
suggestive for extensive osteoarthritis.
IMPRESSION:
1. No clear evidence of acute intraabdominal process.
2. Small hiatal hernia
.
EKG: sinus bradycardia rate 49
Brief Hospital Course:
89 year old female with history of T2DM, HTN, and multiple
pulmonary nodules who presented with weakness, sinus
bradycardia, hyponatremia, and hyperkalemia.
# Electrolyte abnormalities: She initially presented with
hyponatremia and hyperkalemia, as well as clinical weakness and
eosinophilia. There was initial concern for adrenal
insufficiency and she was given a single dose of dexamethasone
in the emergency room. She was also given IV fluids and
kayexelate and her hyperkalemia resolved. She had a cosyntropin
stimulation test which showed an appropriate bump in her
cortisol levels. Therefore, adrenal insufficiency was
considered less likely. She also may have had SIADH causing
hyponatremia due to possible lung malignancy as she has multiple
pulmonary nodules seen on previous CT scan. It was felt that
her glipizide may be causing hyponatremia, and it may be
multifactorial with SIADH as well. She had FSH and LH levels
that were low for her age, and so there was some concern for
primary adrenal insufficiency, although her degree of
hyperkalemia is not commonly seen in primary adrenal
insufficiency. At discharge, her potassium level was within
normal range, and her sodium level was lower than normal but
remained stable. Her glipizide dose was reduced to a previous
dose of 10mg qam and 5 mg qpm due to concern that this
medication was contributing to her hyponatremia.
# Weakness: She also presented with weakness and stated that her
left leg was not feeling stable prior to admission. She had
normal thyroid studies, as well as normal B12 and folate. She
has multiple lung nodules concerning for an underlying
malignancy, discovered during a recent hospitalization, and her
weakness may be related to underlying malignancy as well. She
had xrays of her left hip due to concern that her hardware may
be in an improper place. However, these films showed no
fracture and that her hardware is in the proper place. She
worked with physical therapy and by discharge, felt that she was
at her baseline.
# Bradycardia: She had sinus bradycardia on admission in setting
of hyperkalemia. She also had bradycardia to the 40's overnight
after her electrolytes had normalized. Therefore, her atenolol
dose was decreased from 25mg po bid to 25mg po daily. After
this change, her heart rate remained within normal limits.
#. Hypertension: She was initially hypertensive in the emergency
room in the setting of electrolyte abnormalities. This acute
hypertension resolved although she continued to be mildly
hypertensive throughout her stay.
#. Leukocytosis: She had a new leukocytosis after admission to
the hospital. As she had no localizing symptoms of infection,
it was felt to be related to receiving dexamethasone on
admssion.
#. Lung nodules: Prior CT scan demonstrated multiple lung
nodules concerning for metastatic disease. She has since had a
normal mammogram and the primary for this possible metastatic
disease is not known. Patient does not desire further workup
for these nodules.
#. Urinary incontinence: Upon admission to the MICU, a foley
catheter was placed to monitor urine output. Upon removal of
the catheter, she experienced multiple episodes of urinary
incontinence, but denied frequency, urgency, or dysuria. She
had two negative urinalysis on admission, and urinalysis after
removal of the foley showed moderate leukocytes, few bacteria,
negative nitrites, large amount of [**Month/Day/Year **], and glucose. As she
was asymptomatic and had recent foley placement, she was not
treated for a UTI. Her urine culture is pending at this time.
#. Diabetes: Her most recent HbA1c was 6.8 in [**7-28**]. Per the
patient, her glipizide dose had recently been increased and
there was concern that her glipizide was contributing to her
hyponatremia. Her dose was decreased on discharge. In the
hospital, an insulin sliding scale was added to help manage her
[**Date Range **] sugars.
#. Diabetic Neuropathy: She endorsed some neuropathy in left big
toe. Gabapentin was continued during this hospitalization.
#. Code Status: She was DNR/DNI during this hospitalization.
Medications on Admission:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Fifteen (15)
ML PO QHS (once a day (at bedtime)) as needed for constipation.
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours.
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
12. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
16. Glipizide 15mg po qam and 10mg po qpm (per patient, dose
recently increased to this)
17. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
once a day.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Psyllium Packet Sig: One (1) Packet PO once a day.
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for for pain.
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for for pain.
11. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please take 1 hour before or after eating and 1 hour
before or after other meds.
12. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
14. Glipizide 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
15. 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*
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
Disp:*1 tube* Refills:*0*
17. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) PO
once a day as needed for constipation.
18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
20. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO once a day.
21. Outpatient Lab Work
Please draw sodium and potassium on Wednesday, [**2165-9-11**] and fax
these to Dr.[**Name (NI) 2935**] office at [**Telephone/Fax (1) 7922**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Primary Diagnosis:
Hyponatremia/Hyperkalemia
Secondary Diagnosis:
Diabetes Mellitus
Hypertension
Discharge Condition:
Good, vital signs stable
Discharge Instructions:
You presented to the hospital because you were experincing
difficulty walking. You were found to have low sodium and high
potassium levels in your [**Last Name (LF) **], [**First Name3 (LF) **] there was a suspicion that
you had adrenal insufficiency. You were admitted to the MICU,
where you received Dexamethasone and IV fluids. You remained
stable so you were transferred to the floor, where your walking
improved. Your sodium has increased, but it still remains lower
than normal. We believe this is from your Glipizide, of which
you were taking a higher dose for the past few weeks. It is very
important that you follow up with your PCP [**Last Name (NamePattern4) **] [**1-23**] days to have
your sodium levels re-checked.
While you were here, we made the following changes to your
medications:
1. DECREASED atenolol to 25mg by mouth daily (instead of twice
daily)
2. DECREASED your Glipizide to 10 mg in the morning and 5 mg in
the evening.
3. Started you on Caltrate + Vitamin D for your bone health.
Please take all medications as prescribed.
Please keep all previously scheduled appointments.
Please return to the ED or your healthcare provider if you
experience shortness of breath, dizziness, chest pain,
increasing difficulty walking, fevers, chills, or any other
concerning symptoms.
It is important that you follow-up with your primary care doctor
in order to have your electrolytes checked. In addition, you
have a culture of your urine that is still pending. You will
need to follow-up the results of that test with your primary
care doctor.
Followup Instructions:
You have the following follow-up appointments scheduled:
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**]
Specialty: PCP
Date and time: [**2165-9-13**] 1:30pm
Location: [**Apartment Address(1) 2942**]
Phone number: [**Telephone/Fax (1) 2205**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"401.9",
"618.01",
"788.30",
"276.1",
"288.3",
"244.9",
"V15.51",
"357.2",
"250.60",
"E932.3",
"276.7",
"569.1",
"V43.65",
"235.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14298, 14384
|
6633, 10758
|
223, 229
|
14526, 14553
|
3189, 6610
|
16172, 16576
|
2304, 2508
|
12270, 14275
|
14405, 14405
|
10784, 12247
|
14577, 16149
|
2523, 3170
|
175, 185
|
257, 1270
|
14472, 14505
|
14424, 14451
|
1292, 1911
|
1927, 2288
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,650
| 138,141
|
5395
|
Discharge summary
|
report
|
Admission Date: [**2127-12-1**] Discharge Date: [**2127-12-4**]
Date of Birth: [**2072-9-3**] Sex: F
Service: MEDICINE
Allergies:
Red Dye / Gabapentin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Cough, Dyspnea, and Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 yo female with history of hypocomplimentemia (C3 and C4),
necrobiosis lipoidica with chronic leg ulcers on long term
immunosuppressant, multiple past admissions for pneumonia
presents with complaints of productive cough and dyspnea for
approximately 2 weeks, worse over the last 3-4 days. Patient
also reports feeling very tired and weak, with fever to [**Age over 90 **]
yesterday. Had one episode of hemoptysis last night, with a
small amount of blood on a towel. Denies abdominal pain,
vomiting, dysuria, or diarrhea. No [**Age over 90 **] contacts or recent
travel.
.
Of note, she has multiple episodes of PNA (4 in the last 5
years); was hospitalized in [**2124**] for pseudomonal sepsis and
pneumonia. Most recently admitted for PNA in [**2127-4-22**]. Pt also
has history of recurrent UTIs; most recent culture showed
pan-sensitive E.coli in [**2126-10-22**]. Pt had multiple UTIs in [**2125**]
included Enterococcus (resistant to tetracycline), Enterobacter,
and pseudomonas resistant to cipro and meropenem. Her leg wound
has been chronic and has required skin grafts; it was also
infected back in [**2124**] when pt was septic.
.
In the ED, initial vs were: 98.4, 95, 106/52, 20, 84% RA. She
triggered for hypoxia. Labs significant for WBC 15, CXR
concerning for multifocal PNA. Patient was given vancomycin and
zosyn. Also given 1 amp D50 for glucose 55, and 2L NS for SBP in
the 90's. She was given hydrocortisone due to chronic
prednisone use. Admitted to the MICU for continued lethargy.
Prior to transfer, vitals: afebrile, 87, 95/50, 24, satting 100%
on 3L.
.
On the floor, pt is very sleepy but arousable. Maintaining good
sats on 2L NC.
Past Medical History:
-Notable for cyclic neutropenia
-Raynaud's phenomenon
-hypothyroidism
-sicca keratitis
-MGUS
-chronic anemia/pancytopenia
-chronic right tibial wound, necrobiosis lipoidica
-connective tissue disease, not otherwise specified
-hypothyroidism.
-hypocomplimentemia (C3 and C4)
-Depression
Social History:
No smoking, drinking, drug use. Lives at home with husband and
son. [**Name (NI) 1403**] as pharmacy technician. Used to work as a florist.
Patient has consistently presented with signs of nutritional
deficiencies and malnourishment, but denies any type of eating
disorder.
Family History:
Patient denies any relevant family history. Mom had [**Name2 (NI) 21911**] of
glaucoma.
Physical Exam:
VS - Temp 98.5F, 115/72BP , 83HR , 20R , 98O2-sat % 2-l
GENERAL - cahcectic appearing female in NAD, comfortable
HEENT - NC/AT, temporal wasting. Pupils are poorly reactive to
light and persistent at 4mm. EOMI, sclerae anicteric, MMM, OP
clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - Coarse breath sounds B/L. Bronchial BS in upper lung
fields B/l. Insp crackles Left greater than Right in mid lung
fields. has expiratory wheezes worse at right bases than left.
HEART - RRR, 1/6 systolic mumur best heard near the apex, no
rubs or gallops, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - lower extremities with b/l indurated skin changes
on the shins. slightly erythematous/dusky appearing and shiny
skin. Hyperpigmented faint brown interrupted macules on anterior
upper thigh B/L.
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**3-25**] throughout, sensation grossly intact throughout
Pertinent Results:
[**2127-12-1**] 04:40PM BLOOD WBC-15.1*# RBC-4.62 Hgb-12.8 Hct-39.6
MCV-86 MCH-27.7 MCHC-32.3 RDW-15.3 Plt Ct-260#
[**2127-12-4**] 05:50AM BLOOD WBC-1.6* RBC-3.97* Hgb-11.1* Hct-33.6*
MCV-85 MCH-28.0 MCHC-33.1 RDW-15.2 Plt Ct-195
[**2127-12-1**] 04:40PM BLOOD Neuts-91.0* Bands-0 Lymphs-4.4* Monos-3.7
Eos-0.6 Baso-0.3
[**2127-12-4**] 05:50AM BLOOD Neuts-61.2 Lymphs-24.3 Monos-13.4*
Eos-0.6 Baso-0.5
[**2127-12-1**] 04:40PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2127-12-2**] 04:10AM BLOOD PT-17.4* PTT-30.6 INR(PT)-1.6*
[**2127-12-1**] 04:40PM BLOOD Glucose-57* UreaN-37* Creat-0.7 Na-140
K-4.1 Cl-97 HCO3-30 AnGap-17
[**2127-12-4**] 05:50AM BLOOD Glucose-94 UreaN-28* Creat-0.6 Na-138
K-3.2* Cl-102 HCO3-30 AnGap-9
[**2127-12-2**] 04:10AM BLOOD ALT-54* AST-64* LD(LDH)-116 AlkPhos-142*
TotBili-0.3
[**2127-12-4**] 05:50AM BLOOD ALT-51* AST-37 LD(LDH)-103 AlkPhos-91
TotBili-0.3
[**2127-12-1**] 04:40PM BLOOD cTropnT-<0.01 proBNP-1550*
[**2127-12-4**] 05:50AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0
[**2127-12-1**] 05:00PM BLOOD Glucose-55* Lactate-2.3* K-4.0
[**2127-12-1**] 09:24PM BLOOD Lactate-1.8
Microbiology
BCX- negative x2
Urine Culture- negative
.
Sputum Cutlure:
[**2127-12-2**] 1:21 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2127-12-6**]**
GRAM STAIN (Final [**2127-12-2**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2127-12-6**]):
CULTURE PROCESSED [**2127-12-2**] PER DR [**Last Name (STitle) **] (#[**Numeric Identifier 21912**]) .
MODERATE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. 2ND TYPE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S 2 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
CXR- [**2127-12-2**]
FINDINGS: As compared to the previous radiograph, there is mild
progression. The pre-existing extensive bilateral multifocal
areas of opacities, presumably reflecting multifocal pneumonia
show a rapid tendency to consolidations. As a consequence, the
lung bases have decreased in transparency and the number of
visible air bronchograms has increased. No evidence of newly
appeared focal parenchymal opacities. Unchanged size of the
cardiac silhouette. Presence of a minimal left pleural effusion
cannot be excluded.
Brief Hospital Course:
Pneumonia: Patient reported two week history of fevers, cough,
brief hemoptysis, and shortness of breath. Presented with
leukocytosis on admission and worsening bilateral infiltrates on
chest x-ray. Given history of multiple pneumonias in the past,
she was started empirically on vancomycin, zosyn and
levofloxacin. Sputum culture was obtained along with blood and
urine culture. In the ED she was hypoxic to 84% on room air and
admitted to the ICU for observation. She was started on
hydrocortisone 50 mg IV q6hrs with SBP's in the 90's given
concern for adrenal insufficeincy due to history of chronic
prednisone use. In the ICU, oxygen requirements were weaned to
room air, and leukocytosis improved. Patient was afebrile for
the remaining hospital stay. Based on history of recurrent
pneumonias, she was dischaged on levofloxacin to complete a
total of 10 day course of antibiotc therapy. Post discharge,
patient's sputum samples came back positive for two different
strains of Pseudomonas Aeuriginosa. Both starins were sensitive
to levofloxacin with a MAC of 0.25. Should follow up patient's
symptomatology in clinc, and consider Xray to assure no
advancement of radiographic consolidation.
Hemoptysis: has a history of hemoptysis. Had trace hemoptysis
prior to presentation, thought to be secondary to her
bronchiectasis. Hematocrit stayed stable and no further
episodes of hemoptysis occurred in house. Should check
hematocrit at follow up and assess for any further episodes of
hemoptysis post discharge.
Rheumatologic Disorders (Hypocomplementemia/Necrobiosis
Lipoidica/Cyclic Neutropenia): Has a very complicated detailed
history of rheumatologic disorders comprising complement
deficiency, skin disorder, and "cyclic neutropenia". White
counts continued to trend down by time of discharge, with her
pre discharge WBC count at 1.6. Continued on home prednisone
dose of 20 mg qday by time of discharge. Should check follow up
CBC at visit. Counseled on neutropenic precautions, avoiding
[**Month/Day/Year **] contacts, live animals, fresh flowers, consumption of fresh
fruits/vegetables, or raw/undercooked food. Should continue to
follow with outpatient rheumatologist and hematology physicians.
Pain control: on narcotics contract with PCP. [**Name10 (NameIs) **] held
home pain meds given altered mental status; gave morphine IV PRN
in the ICU. Received MS contin 30 mg TID while in house, and
patient reported being severely underdosed accompanied with
chronic lower extremity/ankle pain. Patient should be
reevaluated for appropriate pain management, as outpatient
regimen appears to be on extremely high doses of morphine,
taking MS Contin 60 mg TID and Morphine Immediate Release 30 mg
1-2 tablets TID, approaching daily values of morphine as high as
360mg per day. Alternatives to pain management should be
sought, including pain specialist consultation for possible
spinal injection. Additionally, would benefit from phyiscal
therapy and other pain relieving alternative such as gabapentin
given patient's neuropathic nature of her lower extremity pain.
Hypothyroidism: continued levothyroxine 50 mcg while in house.
Asthma: given nebulizers as needed for shortness of breath.
Pending Labs: None
Transitional Issues:
Pain Control-- per above. Patient is very heavily medicated and
on multpile sedating medications, including narcotics and
benzodiazepines. Initial presentation of lethargy and hypoxia
may have been directly related to overuse of prescribed
medications. Should strongly consider alternatives to pain
management in this patient, as she appears to be psychologically
and possibly physically addicted to her current regimen.
Eating Disorder NOS-- evidence of severe malnutrtion, including
lanugo on physical exam as well as albumin less than 2.5.
Patient frequently refused items from the hospital menu, saying
they were not palatable. Additionally, became very defensive
and agitated when not receiving her furosemide for her "lower
extremity swelling". Does have minor swelling on physical exam,
but given poor PO intake and nutritional deficits, may benefit
from decreased dosing of 20 mg instead of 40 mg, or PRN dosing
instead of daily. It is obvious the patient has an eating
disorder and is in denial about this disease. [**Month (only) 116**] benefit from
outpatient psychiatric consult for aid in handling this illness.
Medications on Admission:
albuterol 90 mcg 1-2 puffs q 3-6 hrs prn
diazepam 2.5 mg [**Hospital1 **] prn
fluticasone-salmeterol 250 mcg-50 mcg 1 puff [**Hospital1 **]
furosemide 40mg daily
gabapentin 100 mg qhs (unclear)
ipratropium inhalter 2 puffs [**Hospital1 **] or QID prn
levothyroxine 50 mcg qMonTuesWedThursFriSat, 100 mcg qSun
prednisone 20mg daily
calcium carbonate-vitamin D3 600 mg-400 unit daily
multivitamin 1 tab daily
senna 8.6 mg [**Hospital1 **] prn constipation
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: 1-2 puffs Inhalation q3-6hrs prn as needed for
cough.
2. diazepam 5 mg Tablet Sig: 0.5-1 Tablet PO BID PRN.
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
4. furosemide 20 mg Tablet Sig: 1-2 Tablets PO once a day: For
lower extremity swelling. .
5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation [**Hospital1 **] or qid prn as needed for shortness of
breath or wheezing.
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day.
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. senna 8.6 mg Capsule Sig: One (1) Capsule PO BID PRN as
needed for constipation: Laxative .
11. morphine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO three times a day as needed for pain: Hold
for sedation, slow breathing.
12. morphine 30 mg Tablet Sig: 1-2 Tablets PO TID PRN as needed
for pain: Hold for sedation, decreased respirations.
13. Zofran Oral
14. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
6 days: Please take all the medication in its entirity. .
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Community Acquired Pneumonia
.
Secondary:
Mixed Connective Tissue Disease
Cyclic Neutropenia
Raynaud's
Hypothyroidism
Necrobioiss Lipoidica
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 14218**],
It was a pleasure taking care of you. You were admitted to
the hospital with fevers, cough, and worsening shortness of
breath that was concerning for a pneumonia. Additionally, you
had an episode of decreased oxygenation while in the emergency
department. Given your presenting symptoms, you were initially
admitted to the intensive care unit for further monitroing. In
the ICU, you were started on broad spectrum antibiotics and
improved clinically. You were sent to the general medical
floors and continued to improve. You will be going home on a
course of an antibiotic known as levofloxacin (aka Levaquin),
which you should take in its entirity.
Additionally, while in the hospital you started developing a low
white blood cell count, known as "Leukopenia" or "Neutropenia".
This is a chronic issue for you, but needs to be followed up by
your primary care doctor. Your white blood cells are
responsible for defending your body from infection. While you
are neutropenic, it is important you avoid contact with people
who have a cold. You should wear a mask in public places,
especially in enclosed public places that may recycle breathing
air. You should avoid having fresh flowers in the home, as they
may carry microorganisms that could cause infection. Avoid
handling pets or live animals, or cleaning up after pets if you
have any. Do not eat fresh fruits or vegetables, and make sure
all food all food is THOROUGHLY cooked before eating. If you
develop any fevers, contact your physician IMMEDIATELY or go to
your nearest emergency room for further evaluation.
We have added an additional medication for you to take, an
antibiotic known as levofloxacin.
Please take: Levofloxacin 750 mg daily
Please continue to take the rest of your home medications as
prescribed.
Thank you for allowing us to partake in your care Ms. [**Known lastname 14218**].
Followup Instructions:
You have the following follow up appointments:
Department: [**Location (un) 2788**] INTERNAL MED.
When: MONDAY [**2127-12-15**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], MD [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
"493.90",
"279.8",
"710.9",
"486",
"244.9",
"443.0",
"709.3",
"311",
"288.02",
"307.50",
"261"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13147, 13153
|
6823, 10069
|
310, 316
|
13346, 13346
|
3748, 6800
|
15429, 15452
|
2626, 2716
|
11730, 13124
|
13174, 13325
|
11251, 11707
|
13497, 15406
|
2731, 3729
|
10091, 11225
|
240, 272
|
15477, 15828
|
344, 2009
|
13361, 13473
|
2031, 2318
|
2334, 2610
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,199
| 164,082
|
31019
|
Discharge summary
|
report
|
Admission Date: [**2164-5-23**] Discharge Date: [**2164-6-2**]
Date of Birth: [**2126-1-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Pneumonectomy for biopsy-proven non-small cell carcinoma of the
left upper lobe and base of the left hilum with ipsilateral
mediastinal lymph nodes and encroachment on the main pulmonary
artery.
Major Surgical or Invasive Procedure:
[**2164-5-23**] Bronchoscopy.
Left hemi-clamshell sternothoracotomy.
Left intrapericardial pneumonectomy with subaortic and
mediastinal lymph node dissection.
[**5-24**] & [**2164-5-25**] Fiberoptic bronchoscopy with aspiration
of purulent secretions.
History of Present Illness:
Ms. [**Known lastname **] is a 38-year-old ex-smoker with biopsy-proven
non-small cell carcinoma of the left upper lobe and base of the
left hilum with ipsilateral
mediastinal lymph nodes and encroachment on the main pulmonary
artery. This was clinically staged as T4N2 and she was treated
with induction chemoradiotherapy. She was referred from [**Location (un) 35240**]
for consideration of aggressive surgical therapy given a good
response to chemotherapy. There is greater than 50% reduction in
her tumor mass and more importantly no residual PET activity.
She appeared to have adequate cardiopulmonary reserve to
tolerate left
pneumonectomy.
Past Medical History:
Left non-squamous cell lung cancer s/p Chemo and XRT
Bronchitis
PNA
GERD (with XRT, improved)
Left ovarian CA, Cervical and endometrial CA
TAH [**2157**], Left oophorectomy
Social History:
Single with 2 children
Occupation: Cook
Tobacco: 22 year pack. quit 3 months ago
ETOH: no, Exposure no
Family History:
Mother: emphysema, lung CA
Siblings: Hypertension
Physical Exam:
General: 38 year-old female in NAD
HEENT: normocephalic, no LAD
Lungs: clear to bilateral auscultation
Cardiac: RRR, normal S1,S2 no murmur/gallop or rub, JVD flat
Abd: BS+ abdomen soft NT/ND
Extr: warm dry no edema
Skin: no rashes or lesions noted
Neuro: AA& O x 3, Moves all extremities
Pertinent Results:
Chest-X-ray; [**2164-5-30**]: No change in small right apical
pneumothorax with chest tube in place. Partial filling of
pneumonectomy space.
Labs:
RENAL UreaN Creat
[**2164-6-2**] 14 2.1
[**2164-6-1**] 14 2.2
[**2164-5-31**] 15 2.3*
[**2164-5-30**] 17 2.7*
[**2164-5-29**] 18 2.7*
[**2164-5-28**] 18 2.6*
[**2164-5-22**] 8 0.5
Brief Hospital Course:
Ms [**Known lastname **] was admitted on [**2164-5-23**] and taken to the operator
room for a left uncomplicated intrapericardial pneumonectomy. An
epidural was placed for pain control and the pt was followed
post operatively by the acute pain service. in the immed post op
period pt was placed on emperic vanco and zosyn pending pleural
fluid culture. Pleural fluid cuture grew out h.influenza
beta-lactamase positive. The vanco was d/c'd and she was
mainatained on zosyn. She remained afebrile and w/o
leukocytosis. She transferred to the surgical intensive care
unit intubated, right and left chest tubes in place. She was
hemodynamically stable. On post-operative day one she was
extubated but during the course of the day developed respiratory
distress. That evening she was re-intubated for pultiolet
including serial bronchoscopy for therapeutic aspiration. On
postoperative day 3 she did well and was successfully extubated.
She continue to do well and was transferred to the floor.
The left chest tube was d/c'd on POD #3
Daily cxr's were obtained and the left fluid level was followed
- at time of this summary it is just below the level of the
stump.Pleural fluid cuture grew out h.influenza beta-lactamase
positive. The vanco was d/c'd and she was mainatained on zosyn.
She remained afebrile and w/o leukocytosis.
On POD # 5 pt had a rise in her creat to 1.5 (from preop of .5).
Fena was .8. A renal consult was called and recommendations for
gentle hydration. Over the course of the next 3 days her creat
rose to a peak of 2.7 on POD# 7. On subsequent post op days her
creat began to drift down. At time of d/c her creat was 2.1.
At the time of d/c her pain was well controlled on fent patch
and po dilaudid. Her room air ambulatory sat was 95%. She was
[**Last Name (un) 1815**] a reg diet and had return of bowel function.
Medications on Admission:
Celexa 20 mg qDay
Hydrocodone [**12-13**] q4hrs
Fentanyl 100 mcg TD q48hrs
Stool softner PRN
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Hydromorphone 2 mg Tablet Sig: 2 - 2 1/2 Tablets PO Q3H
(every 3 hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonectomy Lung
Left non-squamous cell lung cancer status post Chemotherapy and
XRT
Bronchitis
Pneumonia
GERD (with XRT, improved)
Left ovarian cancer, cervical and endometrial cancer
Total abdominal historectomy with left oophorectomy
Discharge Condition:
Good
Discharge Instructions:
Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 73285**] and Dr.[**Doctor Last Name 4738**] office
[**Telephone/Fax (1) 170**] if you develop fever, chills, chest pian, shortness
of breath, pain swelling or redness at your incision site.
- You may shower on sunday. After showering, remove your chest
tube site dressings and cover the area with clean bandaid daily
until healed.
No tub bathing or swimming for 4 weeks.
Follow sternal precautions- no lifting greater than 10 pounds
for 6 weeks and no strenuous upper extremity exercises for 6
weeks.
The steri-strips on your incision will fall off in time.
- Do not drive while you are taking narcotic pain medicine
- take stool softeners every day you take pain medication:
colace, senna, dulcolax, and mild of magnesia are all good
options
- you should eat a regular diet
- you should continue to do your breathing exercises with the
incentive spirometry, coughing, and deep breathing
- you should remain as active as tolerated and gradually
increase your activity level on a daily basis.
Followup Instructions:
1. You have a follow up appointment with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**]
on [**6-21**] at 2:30pm in the [**Hospital Ward Name 23**] clinical center [**Location (un) **].
Please arrive 45 minutes prior to your to appointment and report
to [**Location (un) **] radiology.
2. You should schedule a follow up appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 60368**] for a cxr in one week and renal function
test. plaese fax the renal test results to Dr.[**Doctor Last Name 4738**] office
[**Telephone/Fax (1) 5793**].
3. Follow up with your primary care physician regarding your
resolving reanl failure
|
[
"162.3",
"V10.43",
"512.1",
"V10.41",
"584.9",
"V15.82",
"518.0",
"V10.42",
"486",
"196.1",
"997.3",
"530.81",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"96.71",
"32.5",
"33.24",
"96.04",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
5029, 5035
|
2521, 4366
|
516, 770
|
5317, 5323
|
2158, 2498
|
6460, 7148
|
1781, 1832
|
4510, 5006
|
5056, 5296
|
4392, 4487
|
5347, 6437
|
1847, 2139
|
281, 478
|
798, 1447
|
1469, 1644
|
1660, 1765
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,163
| 101,440
|
53134
|
Discharge summary
|
report
|
Admission Date: [**2110-7-11**] Discharge Date: [**2110-7-17**]
Service: MEDICINE
Allergies:
Plaquenil / Glyburide
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2110-7-11**] Cardiac catheterization
[**2110-7-12**] Pericardiocentesis with drain placement and L+R heart
cath
History of Present Illness:
[**Age over 90 **] yo F with h/o HTN, rheumatoid arthritis and gallstones (but
no cholecystitis) presents with 1 day history of chest pain.
Was in her USOH when yesterday afternoon ([**7-10**]) she began having
a "choking sensation"-like pain in her chest. This progressed
to include sharp pains up and down her left arm. Later in the
afternoon, she began to have a "burning" sensation from her
epigastrium up into her mouth/jaw. Pain was worse with lying
down, associated with some dizziness and diaphoresis, but no
shortness of breath, nausea, or palpitations. Also noticed
yesterday that her urine was darker than normal, but stool was
still normal color. Pain continued to get worse until she told
her sister at 2 AM "I feel like I'm having a heart attack", so
her sister rushed her to the [**Name (NI) **]. She had never had a pain like
this before, no history of reflux disease. At baseline walks
around her house and occasionally outside with a cane, but only
goes short distances because of gait instability.
In the ED, initial vitals: 97.6, 88, 118/58, 18, 100%. ECG
notable for SR @ 89 with ?ST-elevations and hyperacute T waves
in anterolateral leads with Q waves that are new compared to
last prior ECG in [**2107**]. Troponin was 0.04, MB (added on later)
was 5, hct was decreased to 29 from previous baseline 35.
Guaiac negative. LFTs revealed bili 4.4 (4.1 indirect), so RUQ
obtained and showed gallstones with no sign of obstruction. CXR
showed no acute abnormalities. Bedside US showed small
pericardial effusion but no evidence of aortic dissection (no
comment on WMAs). She was given aspirin 325, 1 SL NTG, after
which BP dropped to 60s but improved with 200cc bolus. Chest
pain resolved but then came back, responded well to morphine.
Started briefly on heparin gtt but then stopped prior to
admission to the floor.
On arrival to the floor, the patient was feeling comfortable
with no chest pain since receiving morphine in the ED. She
relayed the above story with no difficulty and with excellent
memory and attention to detail.
Shortly after her arrival, she began to have chest pain again,
same in quality as her previous chest pain. Also complained of
feeling very very weak.
REVIEW OF SYSTEMS:
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for:
+ chest pain, syncope and presyncope (most recently last week)
- dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations
Past Medical History:
- Hypertension
- Rhematoid arthritis
- Gallstones
- s/p hysterectomy
- s/p appendectomy
Social History:
Lives with her sister (also in her 90s) in [**Location (un) 1468**], MA.
Formerly worked in a school nursery, post office, and Navy ship
yards. She is still completely independent at home with all
ADLs, cooks her own food and cleans the home herself.
# Tobacco: never
# Alcohol: none
# Illicit: none
Family History:
Brother died of an MI in his 70s. Brother died of unknown causes
in his 60s. Sister died of AD at 91. Sister died at age 7 durng
tonsillectomy from ether use.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 98.3, BP 109/60, HR 91, RR 20, SpO2 95% RA
GENERAL: Elderly woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Slightly icteric sclera. PERRL, EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. Edentulous
NECK: Supple with JVP of [**11-6**] cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Systolic II/VI murmur heard at LLSB,
provoked/worsened with valsalva. 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.
EXTREMITIES: No c/c/e. No femoral bruits.
NEURO: CN II-XII tested and intact, strength 5/5 throughout,
sensation grossly normal. Gait not tested.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
LABS:
On admission:
[**2110-7-11**] 04:45AM BLOOD WBC-8.5# RBC-2.79*# Hgb-9.0*# Hct-29.3*
MCV-105*# MCH-32.4* MCHC-30.9* RDW-13.2 Plt Ct-515*
[**2110-7-11**] 04:45AM BLOOD Neuts-78.5* Lymphs-16.6* Monos-3.5
Eos-0.7 Baso-0.7
[**2110-7-11**] 01:55PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL
Spheroc-OCCASIONAL
[**2110-7-11**] 04:45AM BLOOD PT-12.1 PTT-25.7 INR(PT)-1.1
[**2110-7-11**] 04:45AM BLOOD Ret Aut-3.6*
[**2110-7-11**] 04:45AM BLOOD Glucose-125* UreaN-27* Creat-0.8 Na-129*
K-4.7 Cl-93* HCO3-26 AnGap-15
[**2110-7-11**] 04:45AM BLOOD ALT-13 AST-36 LD(LDH)-356* CK(CPK)-124
AlkPhos-69 TotBili-4.4* DirBili-0.3 IndBili-4.1
[**2110-7-11**] 04:45AM BLOOD Lipase-30
[**2110-7-11**] 04:45AM BLOOD CK-MB-5 cTropnT-0.04*
[**2110-7-11**] 04:45AM BLOOD Albumin-4.1
[**2110-7-11**] 11:53PM BLOOD Calcium-8.5 Phos-2.9 Mg-1.8
[**2110-7-11**] 04:45AM BLOOD Hapto-<5*
[**2110-7-11**] 07:10AM BLOOD Lactate-1.3
On discharge:
[**2110-7-17**] 06:15AM BLOOD WBC-8.8 RBC-3.49* Hgb-11.2* Hct-34.0*
MCV-97 MCH-32.0 MCHC-32.8 RDW-16.6* Plt Ct-361
[**2110-7-17**] 06:15AM BLOOD PT-11.9 INR(PT)-1.1
[**2110-7-17**] 06:15AM BLOOD Glucose-87 UreaN-31* Creat-1.0 Na-131*
K-4.4 Cl-99 HCO3-28 AnGap-8
[**2110-7-17**] 06:15AM BLOOD ALT-241* AST-113* AlkPhos-60 TotBili-0.5
[**2110-7-17**] 06:15AM BLOOD Calcium-7.7* Phos-2.0* Mg-2.0
MICRO:
[**2110-7-11**] Blood culture negative
[**2110-7-11**] Urine culture negative
[**2110-7-12**] Pericardial fluid:
GRAM STAIN (Final [**2110-7-12**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2110-7-15**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2110-7-14**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2110-7-12**] Urine culture negative
[**2110-7-12**] Blood culture negative
[**2110-7-13**] Blood culture negative
STUDIES/IMAGING:
[**2110-7-11**] Cardiac cath:
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated single vessel coronary artery disease. The LMCA
had distal
tapering into a 90% lesion at the origin of the LAD. The LAD
was
otherwise free of angiographically significant coronary artery
disease.
The LCX was free of angiographically apparant coronary artery
disease.
The RCA had an ostial 30% lesion and a 60% distal lesion.
2. Limited resting hemodynamics revealed normal systemic
arterial blood
pressure with a central aortic blood pressure of 109/49 mmHg.
3. Successful PTCA and stenting of distal LMCA into LAD origin
with
3.0x18mm Integrity bare metal stent with proximal stent segment
postdilated to 4.0mm. LCx jailed, however only minimal pinching
of
origin with TIMI 3 flow.
4. Successful closure of right femoral arteritomy with 6F
angioseal.
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease of the LAD.
2. Normal systemic arterial blood pressure.
3. Successful distal LMCA-LAD PCI with BMS
4. Successful RFA angioseal.
[**2110-7-11**] TTE:
There is mild (non-obstructive) focal hypertrophy of the basal
septum. There is severe regional left ventricular systolic
dysfunction with anterior, septal and apical akinesis. The
remaining segments contract normally (LVEF = 25-30%). The right
ventricular cavity is unusually small. The aortic valve leaflets
are mildly thickened (?#). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is a moderate
sized pericardial effusion. There is right ventricular diastolic
collapse, consistent with impaired fillling/tamponade
physiology.
IMPRESSION: Moderate pericardial effusion with evidence of early
tamponade physiology
[**2110-7-12**] TTE:
There is a small to moderate sized pericardial effusion. There
is right ventricular diastolic collapse, consistent with
impaired fillling/tamponade physiology. Compared with the
findings of the prior study (images reviewed) of [**2110-7-11**]
pericardial effusion is slightly larger.
[**2110-7-12**] Cardiac cath:
COMMENTS:
1. Selective coronary angiography of the left coronary artery
demonstrated a patent distal LMCA/proximal LAD stent. There was
no
contrast extravasation.
2. Right heart catheterization initially revealed low-normal
right sided
and minimally elevated left sided filling pressures. The mean
RA was
low-normal at 5 mmHg, and the RVEDP was low-normal at 6 mmHg.
The
pulmonary arterial pressure was normal at 30/12 mmHg with a mean
PA
pressure of 18 mmHg. The mean wedge was minimally elevated at
12 mmHg
with prominant x and y descents.
3. The cardiac output and index were normal at 5.5 L/min and 3.5
L/min/m2.
4. Systemic vascular resistance was normal at 814 dyne-sec/cm5,
and
pulmonary vascular resistance was normal at 86 dyne-sec/cm5.
5. There was a 9% step up in oxygen saturation between the RA
and PA,
but a significant amount of time had ellapsed between these two
measurements, and in the interim the patient's respiratory
status was
not stable.
6. Additional resting hemodynamics revealed a low-normal
systemic
arterial bloood pressure with a central aortic blood pressure of
96/40
mmHg.
FINAL DIAGNOSIS:
1. Patent LMCA/LAD stent with no signs of coronary artery
perforation or
contrast extravasation.
2. Low pressure cardiac tamponade.
[**2110-7-12**] TTE:
This study is a series of images during pericardiocentesis.
Initial images demonstrate a large pericardial effusion,
significantly expanded since the prior series of images two
hours earlier. The effusion appears echodense, most consistent
with blood. There is right ventricular diastolic collapse,
consistent with impaired fillling/tamponade physiology. After
completion of pericardiocentesis there is a small pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. The effusion appears
loculated. There are no longer echocardiographic signs of
tamponade. Compared with the findings of the prior study,
pericardial effusion has expanded. The final images confirm a
successful pericardiocentesis with echocardiographic evidence of
tamponade resolution.
[**2110-7-12**] TTE:
The left atrium is normal in size. There is mild
(non-obstructive) focal hypertrophy of the basal septum. There
is severe regional left ventricular systolic dysfunction with
anterior, septal and apical akinesis. No masses or thrombi are
seen in the left ventricle. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
moderately thickened. The study is inadequate to exclude
significant aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a very small echodense pericardial
effusion anterior to the right ventricle. There are no
echocardiographic signs of tamponade.
IMPRESSION: Very small echodense pericardial effusion. Severe
regional left ventricular systolic dysfunction.
Compared with the prior study (images reviewed) of [**2110-7-12**], no
major change.
Brief Hospital Course:
Ms. [**Name14 (STitle) 109444**] is a [**Age over 90 **] year old female with history of
hypertension (HTN), rheumatoid arthritis and gallstones (but no
cholecystitis) who presented with 1 day history of chest pain
and anemia, thought to be hemolytic. She was found to have a
large STEMI with placement of bare metal stent. Course
complicated by large pericardial effusion and subsequent cardiac
tamponade requiring pericardiocentesis and transfer to the CCU,
as well as hypotension requiring pressors and acute kidney
injury.
ACTIVE ISSUES BY PROBLEM:
# ST elevation myocardial infarction: Shortly after her arrival
to the floor, she began to have chest pain again. ECG showed
evolving/worsening ST-elevations in the anteroseptal leads.
Next cardiac enzymes rose, overall trend: trop 0.04-> 0.35->
1.36 -> 2.13 and MB 5-> 41-> 103. Bedside echo showed anterior
wall hypokinesis with depressed EF of 25% (from 75%) prompting
transfer to the cath lab. Patient had a right femoral artery
approach with mostly single vessel LAD disease with a 90%
proximal ostial LAD lesion, s/p BMS placement. During the cath,
she suffered a brief period of hypotension with systolics in the
high 60's mmHg associated with balloon inflation, otherwise
systolics maintained in the mid 100's mm Hg range. She was
started on full dose aspirin 325mg, atorvastatin 80, and plavix
75mg initially. After developing pericardial effusion (see
below), her aspirin dose was decreased to 162mg to avoid
bleeding complications, and her statin was stopped due to
transaminitis. Unable to tolerate beta blocker or ACEI given
hypotension. She will need to continue aspirin and plavix at
rehab, with possible re-initiation of statin when LFTs normalize
and beta blocker/ACEU when BPs will tolerate. Will follow up
with Dr.[**Name8 (MD) 5103**] NP in clinic on [**2110-8-19**], and she should have
a repeat echo in 1 month to determine if there has been any
recovery in cardiac function with improvement of EF.
# Cardiac tamponade: On the floor post-cath, started to have
episodes of hypotension, with blood pressures dropped from
121/58 to 58/38, after using bedpan for a bowel movement.
Patient's mental status also became more lethargic. Bolused
with 500 cc's NS x 2 with BP up to the 80's. Physical exam
concerning revealed elevated JVP and crackles on exam. She was
urgently transferred to the CCU (see CCU course above), where
she was started on dopamine. STAT bedside echo revealed large
pericardial effusion causing early tamponade. She was sent
urgently back to the cath lab, where 600 cc of frank blood was
drained from the pericardium, complicated by a small puncture of
the right ventricle. She briefly lost her pulse during the
procedure, but she had ROSC with 1 amp epinephrine (no CPR). She
had signficant bleeding so she was given a total of 4units PRBC.
She had some reaccumulation of pericardial fluid, so drain was
placed. The drain output was low over the next day, so this was
pulled the following day with no evidence of fluid
reaccumulation. Cause of her tamponade is not entirely clear--
no dye extravasation seen from coronary arteries on repeat cath
during pericardiocentesis, however she may have had a small
puncture that then clotted off.
# Acute kidney injury: She was noted to be oliguric on [**7-13**] and
her urine sediment showed muddy brown casts consistent with ATN
from the setting of hypotension. Baseline creatinine 0.6-0.8,
rose to maximum of 1.7. She was given 60mg iV lasix and diuresed
well and has return to normal urine output. Creatinine
downtrended to 1.0 on discharge. She should have her BUN/Cr
checked at next PCP visit to ensure full return to baseline.
# Anemia: no recent baseline, but hct was in 36-39 range in
11/[**2109**]. Has noted darkened urine in the past day and has
evidence of hemolysis on labs-- indirect bilirubinemia, elevated
LDH, low haptoglobin, high retic. No history of bleeding (no
blood in stool), guaiac negative in the ED. No new meds that may
have provoked G6PD deficiency related hemolysis, no exposures
suggestive of infectious cause. No known liver disease, no
hypersplenism on exam, no known hemoglobinopathy. Received 4
units packed RBCs due to bleeding post-pericardiocentesis (see
above) with improvement of hct to 30-36 range. Her hematocrit
then remained stable with no signs of hemolysis. Hct 34 on
discharge. Should have hct rechecked at next visit with PCP to
ensure it has remained stable.
# Ischemic cardiomyopathy: EF now 25% following anterior STEMI.
Appeared well-compensated without signs of congestive heart
failure during admission. On aspirin 162mg, however not on
b-blocker or ACEI due to low BPs and no statin due to
transaminitis. Should have a repeat echo as an outpatient in 1
month to see if she has any improvement in systolic function.
# Transaminitis: AST 100s, ALT 200s, tBili initially high from
hemolysis but trended down to normal, alk phos normal. Etiology
likely due to ischemic injury to the liver during hypotensive
episodes plus some degree of passive congestive from heart
failure. Atorvastatin was stopped, but could consider
restarting in the future once LFTs have normalized.
# Hyponatremia: Chronic ongoing hyponatremia, stable this
admission.
# Hyperbilirubinemia: Seems more likely related to hemolysis
(see above) than from hepatobiliary dysfunction. RUQ US normal
other than cholelithiases (non-obstructing), LFTs normal.
# Hypertension: Was taking diltiazem and lisinopril at home.
Due to hypotension, home medications were held. Could consider
starting beta clocker and ACEI one hypotension has resolved
# Rheumatoid arthritis: given tylenol PRN
TRANSITION OF CARE ISSUES:
- STEMI: s/p BMS to LAD ostium, now on aspirin 162mg and plavix
75mg. Will follow up with Dr. [**Last Name (STitle) 171**] and his NP [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**2110-8-19**] for follow up. She should have a repeat
echo at that time to see if EF has improved. Should start
metoprolol and ACEI/[**Last Name (un) **] once blood pressure allows and restart
statin once LFTs have normalized
- [**Last Name (un) **]: should have BUN/Cr checked at next PCP visit to ensure
renal function has remained normal
- Transaminitis: should recheck LFTs at next PCP [**Name Initial (PRE) **]. If
normalized, consider restarting low dose atorvastatin.
- Anemia: due to hemolysis (cause unknown) and acute blood loss,
should have hct checked at next PCP follow up
- FULL CODE (was DNR/DNI while in the CCU, however now wants "to
live a little longer")
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Ibuprofen 200 mg PO Q8H:PRN pain
Discharge Medications:
1. Aspirin 162 mg PO DAILY
RX *aspirin 81 mg once a day Disp #*60 Tablet Refills:*2
2. Clopidogrel 75 mg PO DAILY
for the recommended duration
RX *clopidogrel 75 mg once a day Disp #*30 Tablet Refills:*2
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - Elmhurst - [**Location (un) **]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
ST-elevation myocardial infarction
Acute kidney injury
Cardiac tamponade
Acute systolic heart failure
Cardiogenic shock
Hemolytica and acute blood loss anemia
SECONDARY DIAGNOSES:
Rheumatoid arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 90256**],
It was a pleasure taking care of you at [**Hospital1 **].
You were admitted to the hospital due to chest pain, and we
found that you had a large heart attack. You were taken for a
procedure called cardiac catheterization, where a large blockage
in your coronary artery was found and opened with a stent.
After the procedure you developed fluid around your heart that
needed to be drained, and you were sent to the intensive care
unit for close monitoring. Slowly but surely, you got better,
but we feel you should go to rehab to help get your strength
back before you go home.
Changes to your medications:
START aspirin 162mg daily
START plavix 75 mg daily
STOP diltiazem temporarily, until your blood pressure and kidney
function improves
STOP lisinopril, temporarily, until your blood pressure and
kidney function improves
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2110-8-19**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2110-8-4**] at 8:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**State **]When: FRIDAY [**2110-12-5**] at 8:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
|
[
[
[]
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19182, 19271
|
12092, 18694
|
240, 356
|
19536, 19536
|
4758, 4765
|
20701, 21744
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3620, 3780
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18953, 19159
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19292, 19471
|
18720, 18930
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10076, 12069
|
19721, 20340
|
3795, 3805
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19492, 19515
|
6532, 6631
|
6664, 7692
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3827, 4739
|
5738, 6446
|
20369, 20678
|
2623, 3172
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190, 202
|
384, 2604
|
4779, 5724
|
6482, 6496
|
19551, 19697
|
3194, 3283
|
3299, 3604
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,344
| 116,791
|
47649
|
Discharge summary
|
report
|
Admission Date: [**2198-2-13**] Discharge Date: [**2198-2-20**]
Date of Birth: [**2140-10-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Asymptomatic, positive stress test
Major Surgical or Invasive Procedure:
[**2198-2-15**] Three Vessel Coronary Artery Bypass Grafting(left
internal mammary to left anterior descending, vein grafts to
diagonal and obtuse marginal)
[**2198-2-13**] Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname 8430**] is a 57 yo Spanish speaking man with DM2, known CAD,
ESRD on HD who presents to [**Hospital1 18**] for elective catheterization
after a positive stress test. His stress test was notable for ST
depressions in the inferolateral leads while imaging showed
moderate reversible anterior and septal defects. He has never
experienced any cardiac symptoms.
Past Medical History:
Coronary artery disease - s/p PCI in [**2197-1-31**], History of
NSTEMI, ESRD - on hemodialysis and s/p AVF, Nephrotic Syndrome
with hypoalbuminemia, Diabetes mellitus, Hypertension,
Hypercholesterolemia, Retinopathy, Iron Deficiency Anemia, Bells
Palsy, History of Rhabdomyolysis, History of left [**Doctor Last Name **] lobe
pneumonia, s/p Hydrocele repair
Social History:
He is from El [**Country 19118**], and was a former sheet metal worker. He
now works as an electrician. He smoked previously, about 1
[**12-4**]-packs-per-day for 10 years, but quit about 15 years ago. He
stopped using alcohol on [**2195-12-3**]. Previously he drank
approximately 2 beers/week. He lives with his wife.
Family History:
Notable for diabetes in both his mother and father. His father
also had hypertension. There is no history of kidney disease in
his family.
Physical Exam:
T 96.8, BP 161/73, P 60, R 16, SAT 98% RA
Gen: NAD, pleasant, conversant
HEENT: NCAT, PERRL
Neck: could not assess JVD given lying flat post-cath
Cor: s1s2, rrr, no r/g/m
pulm: CTAB anteriorly (could not assess posterior given lying
flat post cath
ABD: soft, nt, nd, obese, +bs, R groin c/d/i, nt, no hematoma or
bruit
Ext: no c/c/e, 2+ PT pulses bilaterally
GU: foley catheter in place with no urine in bag.
Pertinent Results:
[**2198-2-20**] 07:10AM BLOOD Hct-29.3*
[**2198-2-18**] 09:10AM BLOOD WBC-7.3 RBC-3.19* Hgb-9.8* Hct-29.3*
MCV-92 MCH-30.6 MCHC-33.3 RDW-16.1* Plt Ct-104*
[**2198-2-20**] 07:10AM BLOOD UreaN-26* Creat-5.9* Na-141 K-4.4
[**2198-2-18**] 09:10AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0
[**2198-2-14**] 06:00AM BLOOD calTIBC-182* Ferritn-817* TRF-140*
[**2198-2-13**] 10:00AM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
Mr. [**Known lastname 8430**] was admitted and underwent cardiac catheterization.
Angiography showed a right dominant system revealed and two
vessel CAD. The LMCA had a 30% stenosis. The LAD had an 80% mid
lesion and a long 70% lesion on both ends of previosuly placed
stent. The first diagonal had an 80% ostial stenosis and second
diagonal had an 80% ostial stenosis. The LCX had a 70% distal
stenosis. The RCA was a dominant vessel with a 30% mid vessel
stenosis. Left ventriculography revealed a normal EF of 60%.
There was no transaortic gradient upon pullback of the catheter
from the LV to the aorta. Based on the above results, cardiac
surgery was consulted and further evaluation was performed.
Plavix was discontinued in anticipation of surgery. Preoperative
workup was essentially unremarkable and he was eventually
cleared for surgery. He remained pain free on medical therapy.
On [**2-15**], Dr. [**Last Name (STitle) **] performed three vessel coronary
artery bypass grafting. The operation was uneventful and he was
brought to the CSRU for invasive monitoring. Within 24 hours, he
awoke neurologically intact and was extubated. He was transfused
to maintain hematocrit near 30%. He successfully weaned from
inotropic support and transferred to the SDU on postoperative
day two. He remained on his regular dialysis schedule and
continued to be followed closely by the renal service. He
tolerated beta blockade and remained in a normal sinus rhythm
throughout his hospital stay. He experienced no atrial or
ventricular arrhythmias. Over several days, medical therapy was
optimized and he continued to make clinical improvements. His
hospital course was rather routine and he was cleared for
discharge to home on postoperative day five. At discharge, his
BP was 112/60 with a HR of 73. His oxygen sat was 96% on room
air. All surgical wounds were clean dry and intact. His
discharge chest x-ray was notable for bilateral pleural
effusions, left greater than right associated with bibasilar
atelectasis.
Medications on Admission:
ASA 325
renagel 800mg x 4 tabs TID
avandia 4mg po bid
atenolol 100mg po qday
norvasc 5mg po qday
plavix 75mg po qday
pravachol 20mg po qday
Discharge Medications:
1. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Caregroup
Discharge Diagnosis:
Coronary artery disease - s/p CABG, Post op Pleural Effusion,
ESRD - on hemodialysis, Nephrotic Syndrome, Diabetes mellitus,
Hypertension, Hypercholesterolemia, Retinopathy, Anemia, Bells
Palsy, s/p PCI, s/p AVF, s/p Hydrocele repair
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**3-7**] weeks - call for appt.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**1-5**] weeks - call for appt.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**1-5**] weeks - call for appt.
Completed by:[**2198-2-20**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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] |
5982, 6022
|
2717, 4735
|
357, 555
|
6300, 6307
|
2288, 2694
|
6625, 6932
|
1699, 1840
|
4926, 5959
|
6043, 6279
|
4761, 4903
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6331, 6602
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1855, 2269
|
283, 319
|
583, 963
|
985, 1345
|
1361, 1683
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,469
| 126,223
|
36066
|
Discharge summary
|
report
|
Admission Date: [**2118-1-4**] Discharge Date: [**2118-1-10**]
Date of Birth: [**2060-6-21**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Doxycycline
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
premalignant colonic lesions
Major Surgical or Invasive Procedure:
total abd colectomy with ileo-rectal anastomosis
History of Present Illness:
This is a 57yo female POD0 s/p total abd colectomy with
ileo-rectal anastomosis presenting with asymptomatic
hypotension.Mrs [**Last Name (STitle) 81833**] was admitted to the General Surgery
Service on [**2118-1-7**] to undergo an ileocolectomy for a large polyp
of the cecum.
ROS:
Positive abdominal pain 0-1/10
Negative fevers, chills, weight change, nausea, vomiting,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity edema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes.
Past Medical History:
#Ulcerative colitis => last flare greater than 8 years ago in
the past previously treated with prednisone and asacol
#elevated lipids.
PSHx:
tubal ligation
left knee surgery
goiter removal (non-cancerout 5 years ago)
breast lumpectomy (non-cancerous)
Social History:
patient smokes [**1-2**] pack of cigarettes per day for the last 40
years. Denies EtOH or illicit drug use. Patient currently lives
with her husband.
Family History:
Strong family history of UC and Crohn's
Physical Exam:
Vitals: T: 98.2 BP: 99/53, HR: 65 RR: 18 98% RA
GEN: Well-appearing, well-nourished, no acute distress, laying
supine in bed speaking in full sentences
HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: brady, reg rhythm, no M/G/R, normal S1 S2, radial pulses +2
PULM: anterior fields CTAB, no W/R/R, no accessory muscle use
ABD: Soft, midline incision: dressing in place with serosangious
staining; no hematoma; no rebound, no guarding
EXT: No C/C/E, no palpable cords
INC:abdominal midline incision with steri-strips
clean,dry,intact
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses
Pertinent Results:
[**2118-1-4**] 02:23PM BLOOD Hct-34.6*
[**2118-1-5**] 04:14AM BLOOD WBC-13.0* RBC-3.22* Hgb-10.3* Hct-29.6*
MCV-92 MCH-31.9 MCHC-34.7 RDW-12.7 Plt Ct-274
[**2118-1-5**] 08:32AM BLOOD Hct-30.0*
[**2118-1-5**] 03:24PM BLOOD WBC-11.9* RBC-3.36* Hgb-10.5* Hct-30.8*
MCV-92 MCH-31.2 MCHC-34.1 RDW-12.5 Plt Ct-295
[**2118-1-6**] 05:27AM BLOOD WBC-10.0 RBC-3.09* Hgb-9.9* Hct-28.3*
MCV-92 MCH-32.2* MCHC-35.1* RDW-12.7 Plt Ct-263
[**2118-1-5**] 04:14AM BLOOD PT-13.6* PTT-28.5 INR(PT)-1.2*
[**2118-1-5**] 04:14AM BLOOD Glucose-102* UreaN-13 Creat-0.7 Na-140
K-4.1 Cl-108 HCO3-23 AnGap-13
[**2118-1-5**] 03:24PM BLOOD Glucose-102* UreaN-15 Creat-0.7 Na-141
K-4.1 Cl-109* HCO3-25 AnGap-11
[**2118-1-6**] 05:27AM BLOOD Glucose-115* UreaN-14 Creat-0.7 Na-138
K-4.5 Cl-109* HCO3-24 AnGap-10
[**2118-1-4**] 09:57PM BLOOD Cortsol-2.0
[**2118-1-5**] 10:30AM BLOOD Cortsol-21.6*
[**2118-1-5**] 11:27AM BLOOD Cortsol-26.4*
[**2118-1-5**] 11:29AM BLOOD Lactate-2.1*
[**2118-1-5**] 08:31PM BLOOD Lactate-1.1
.
Micro:
Blood cultures: NGTD
.
ECG:
Bradycardia Sinus rhythm at rate of 45, normal axis, PR nl, nl
QRS, prolonged QT intervals, no ST or T-wave changes.
.
CXR:
HISTORY: Colectomy, to assess for pneumonia.
FINDINGS:
In comparison with study of [**2115-12-18**], there is a large amount of
free
intraperitoneal gas related to the recent colectomy.
Opacifications at both
bases are most likely consistent with atelectasis, though in the
appropriate
clinical setting, the possibility of supervening pneumonia
cannot be excluded.
Upper zones are clear and there is no evidence of vascular
congestion.
Brief Hospital Course:
On [**1-4**] patient underwent elective total abdominal colectomy
secondary to concern for premalignant lesions.
According to surgical documentation procedure was uncomplicated.
Regarding operative I/Os patient with 3L IVH/no documented
blood, urine output: 115 cc. In the PACU post-op patient
complained of [**10-10**] abdominal pain. Epidural placed and patient
started on buprivane/hydromorphone epidural with bolus of 5cc,
rate 10 cc/hr; Pain persisted: patient received additional 5cc
bolus as well as given 25mcg of IV Fentanyl. Patient received 10
cc/hr of bupivacaine/hydromorphone for 2hrs until epidural
stopped at 6:20p secondary to persistent systolic blood pressure
readings of 70-80, heart Rate 40s. Patient receive 1L + 500 cc
bolus x2 with urine output in the hour preceding transfer 188
cc. Random cortisol checked: 2; patient received 100 mg of IV
hydrocortisone for concern for adrenal insufficiency. A cortisol
stimulation test was done which was negative and was started on
prednisone on [**2118-1-5**]. Due to persistent SBP in 70s, mean
arterial pressure of 50s decision made to transfer patient to
the intensive care unit. On arrival to the intensive care unit,
hypotensive with blood pressure: 70/40 and heart rates in the
40s with abdominal pain 0-1/10. However was asymptomatic and was
mentating appropriately, she had no dizziness,lightheadedness or
confusion. She was fluid resuscitated with a 1L NS bolus on
arrival for a total of 6L of IVH with O2 sats 98% on 3L.
[**2118-1-6**] was transferred from the intensive care unit to the
surgical floor where she was relatively stable. She was
tolerating clear liquids, however had bouts of nausea and
migraines which progressively worsened after removal of the
epidural catheter. The diet was advanced to regular in the
evening. On [**2118-1-8**] s/p blood patch per acute care service and
had improved symptoms of spinal headache. She had return of
bowel function. On [**2118-1-9**] was started on Imodium for increased
bowel movemets. On [**2118-1-10**] is doing well,normotensive, has no
migraines, no nausea and is tolerating a regular diet. She has
been instructed to monitor bowel function closely and to titrate
Imodium and Psyllium wafer as needed. She will start her
prednisone taper tomorrow and will follow-up with Dr.
[**Last Name (STitle) **] in 1 month.
Medications on Admission:
Asacol 3.6 g', Fosamax, glucosamine chondroitin, fish oil,
Lutein, MVI
Discharge Medications:
1. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-2**]
Tablets PO Q4H (every 4 hours) as needed for headache.
2. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day) as needed for
indigestion.
3. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: Do not drink alcohol or
drive a car while taking this medication as it may cause
drowsiness.
Disp:*40 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
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. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
7. loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*150 Capsule(s)* Refills:*6*
8. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
Taper dose days: Take 5mg on [**12-8**], [**1-13**].Then take 2.5mg on
[**2-28**], [**1-16**] then discontinue. .
Disp:*5 Tablet(s)* Refills:*0*
9. psyllium wafer Sig: One (1) PO once a day as needed for
loose stool: Take [**1-2**] wafer and follow with a small amount of
water.
Disp:*3 * Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Ulcerative colitis with dysplasia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the General Surgery Unit after your total
abdominal colectomy with ileorectal anastomosis. You have
recovered from this procedure well and you are now ready to
return home.You have tolerated a regular diet, passing gas and
your pain is controlled with pain medications by mouth. You may
return home to finish your recovery.
Please monitor your bowel function closely. Initially expect to
have about [**3-4**] bowel movements a day. You can slow down the
bowel movements by taking Imodium. You may take up to 8 mg
Immodium a day. If needed you may also take Metamucil wafers,
chew a [**1-2**] wafer and follow with small amount of water. Some
loose stool and passing of small amounts of dark, old appearing
blood are expected however, if you notice that you are passing
bright red blood with bowel movments or having loose stool
without improvement please call the office or go to the
emergency room if the symptoms are severe. If you are taking
narcotic pain medications there is a risk that you will have
some constipation. Please take an over the counter stool
softener such as Colace, and if the symptoms does not improve
call the office. If you have any of the following symptoms
please call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonges loose stool, or constipation.
You have an abdominal incision please monitor the incision for
signs and symptoms of infection including: increasing redness at
the incision, opening of the incision, increased pain at the
incision line, draining of white/green/yellow/foul smelling
drainage, or if you develop a fever. Please call the office if
you develop these symptoms or go to the emergency room if the
symptoms are severe. You may shower, let the warm water run
over the incision line and pat the area dry with a towel, do not
rub.
Please continue to walk as tolerated. No heavy lifting for at
least 6 weeks after surgery unless instructed otherwise by your
surgeon. You may gradually increase your activity as tolerated
but no heavy exercising.
You will be prescribed a small amount of the pain medication
please take this medication exactly as prescribed. For mild
pain you may take Motrin/Tylenol. Do not take more than 4000 mg
of Tylenol daily. Please call and schedule a follow-up
appointment with Dr. [**Last Name (STitle) **] in 1 month.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 1 month [**Telephone/Fax (1) 9**].
Completed by:[**2118-1-10**]
|
[
"E938.9",
"346.90",
"728.85",
"556.6",
"338.18",
"349.0",
"211.3",
"305.1",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.95",
"45.82"
] |
icd9pcs
|
[
[
[]
]
] |
7759, 7765
|
4007, 6353
|
330, 380
|
7843, 7843
|
2393, 3984
|
10478, 10577
|
1505, 1546
|
6476, 7736
|
7786, 7822
|
6380, 6453
|
7994, 10455
|
1561, 2374
|
262, 292
|
408, 1045
|
7858, 7970
|
1067, 1321
|
1337, 1489
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,660
| 175,783
|
675
|
Discharge summary
|
report
|
Admission Date: [**2169-9-1**] Discharge Date: [**2169-9-2**]
Date of Birth: [**2119-6-16**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
none
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 50 year old right-handed man presenting
with a few weeks of progressively worsening headache. He rarely
has headaches (certainly no migraine or recurrent severe
headaches), but he started having a headache after sustaining a
head injury on [**2169-8-3**]. He was driving his car and was
broad-sided on the passenger side, causing him to hit the left
side of his head on the side window. He did not lose
consciousness and was not stunned, but actually was able to
drive
home (after the rather unpleasant other driver confronted him).
He had no external evidence of head trauma. He started having a
bitemporal, vertex, neck, and back achy that was predominantly
pulsatile, sometimes with a stabbing "needle-like" paroxysmal
pain in his eyes. The headache has been constant with no
temporal
relationship, but of concern it actually has awakened him from
sleep in the early morning hours. Getting up and walking around
has not helped; neither has the [**8-25**] Ibuprofen tablets he takes,
sometimes every day. The headache has been gradually worsening
over time, and he finds that he is becoming quite lethargic with
the headache, sleeping all day while he is usually a very active
person. He has had nausea with the headache and has started to
eat less, perhaps losing 5 lbs during this time due to the
nausea. Otherwise he had no weight loss before this. He does
think he has had some subjective (unmeasured) fevers. He denies
drenching night sweats but has felt slightly sweaty at times. He
thinks he may have had one of his usual "seizures" two days ago
(described as feeling lightheaded, then hot and sweaty, then he
lays down to prevent loss of consciousness, then has some [**Last Name (un) 5083**]
vu), but otherwise has had no apparent increased frequency above
his usual.
On neurologic review of systems, the patient endorses headache.
Denies lightheadedness, or confusion.
Denies difficulty with producing or comprehending speech.
Denies loss of vision, blurred vision, diplopia, vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies muscle weakness.
Denies loss of sensation.
Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient endorses subjective
fevers. Denies rigors, night sweats, or noticeable weight loss.
Denies chest pain, palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain.
Denies dysuria or hematuria.
Denies myalgias, arthralgias, or rash.
Past Medical History:
[] Neurologic - Possible/questionable seizures (lightheaded,
fatigue, [**Last Name (un) 5083**] vu, +/- LOC), Left hearing loss
[] Psychiatric - Anxiety, depression
[] Cardiovascular - Hyperlipidemia
Social History:
Works as a waiter. +Tobacco, 1ppd x 20 years. No
ETOH. No illicit drug use.
Family History:
Heart valve issue (mother). No seizures. No
malignancies.
Physical Exam:
VS T: 98.8 HR: 68 BP: 136/78 RR: 18 SaO2: 98% RA
General: NAD, lying in bed comfortably, tired appearing
middle-aged man. / Head: NC/AT, no conjunctival icterus, no
oropharyngeal lesions / Neck: Supple, no nuchal rigidity, no
meningismus, no bruits / Cardiovascular: RRR, no M/R/G /
Pulmonary: Equal air entry bilaterally, no crackles or wheezes /
Abdomen: Soft, NT, ND, +BS, no guarding / Extremities: Warm, no
edema, palpable radial/dorsalis pedis pulses / Skin: No rashes
or
lesions / Psychiatric: Appropriate and friendly affect congruent
with mood, pleasant, joking manner
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily attained and maintained. Concentration
maintained
when recalling months backwards. Recalls a coherent history.
Structure of speech demonstrates fluency with full sentences,
intact repetition, and intact verbal comprehension. Content of
speech demonstrates intact naming (high and low frequency) and
no
paraphasias. Normal prosody. No dysarthria. Verbal registration
and recall [**3-18**]. No apraxia. No evidence of hemineglect. No
left-right agnosia.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to number
counting. Funduscopy shows crisp disc margins, no papilledema.
[III, IV, VI] EOMI, 3-4 beats extreme end gaze nystagmus
bilaterally, fatigable. [V] V1-V3 without deficits to light
touch
bilaterally. [VII] Left lip downturned, but normal movement with
volitional smile; driver's license photograph reveals asymmetric
smile at baseline. [VIII] Hearing intact to finger rub
bilaterally. [IX, X] Palate elevation symmetric. [[**Doctor First Name 81**]]
SCM/Trapezius strength 5/5 bilaterally. [XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift. No
tremor
or asterixis. No myoclonus.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [C5] [R 5] [L 5]
Biceps [C5] [R 5] [L 5]
Triceps [C6/7] [R 5] [L 5]
Extensor Carpi Radialis [C6] [R 5] [L 5]
Extensor Digitorum [C7] [R 5] [L 5]
Flexor Digitorum [C8] [R 5] [L 5]
Interosseus [C8] [R 5] [L 5]
Abductor Digiti Minimi [C8] [R 5] [L 5]
Leg
Iliopsoas [L1/2] [R 5] [L 5]
Hip Adductors [L3] [R 5] [L 5]
Hip Abductors [S1] [R 5] [L 5]
Quadriceps [L3/4] [R 5] [L 5]
Hamstrings [L5/S1] [R 5] [L 5]
Tibialis Anterior [L4] [R 5] [L 5]
Gastrocnemius [S1] [R 5] [L 5]
Extensor Hallucis Longus [L5] [R 5] [L 5]
Extensor Digitorum Brevis [L5] [R 5] [L 5]
Flexor Digitorum Brevis [S1] [R 5] [L 5]
- Sensory - No deficits to light touch, pinprick, or
proprioception bilaterally.
- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway. No Romberg.
Pertinent Results:
Laboratory and Imaging Data:
NC Head CT: large area of right temporal parietal enhaning mass
with
vasogenic edema, possibly underlying soft tissue abnormality,
about 10mm midline shift to left, possible minor hemorrhage
component
MRI Head c/s contrast: (my impression) contrast-enhancing right
frontal lesion with significant vasogenic edema and midline
shift, also with necrotic core
WBC 12.7, Hgb 16.8, Plt 346, MCV 92, Na 139, K 4.2, Cl 104, HCO3
28, BUN 16, Cr 0.7, Glu 93
Brief Hospital Course:
Patient was admitted to Neurosurgery on [**2169-9-1**] for further
evaluation. He was started on dexamethasone 4mg Q6h for
cerebral edema. A CT Chest was obtained given his smoking
history which showed no apparent lung mass.
Surgical intervention was discussed. Patient wished to be
discharged and follow-up for surgery this week. Now DOD, patient
is afebrile, VSS, and neurologically stable.
Medications on Admission:
keppra 1500bid, sertaline 50qd
Discharge Medications:
1. Acetaminophen-Caff-Butalbital [**1-16**] TAB PO Q4H:PRN pain,
headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s)
by mouth every six (6) hours Disp #*40 Tablet Refills:*0
2. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 4 mg 1 tablet(s) by mouth Q6 hours Disp #*60
Tablet Refills:*0
3. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. LeVETiracetam 1500 mg PO BID
5. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch daily Disp #*30 Each
Refills:*0
6. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
right brain mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have been diagnosed with right temporal parietal brain mass.
You were started on dexamethasone 4mg Q6hours. You should
continue on this to keep the swelling in your head down.
You are on Keppra for seizures, you should continue on this.
You were started on pepcid, please continue this while on
dexamethasone
Followup Instructions:
Please call [**Telephone/Fax (1) 1669**] to schedulre your surgery with Dr.
[**Last Name (STitle) 739**] for this week.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2169-9-2**]
|
[
"311",
"239.6",
"300.00",
"272.4",
"348.5",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7836, 7842
|
6755, 7153
|
311, 318
|
7903, 7903
|
6251, 6283
|
8393, 8638
|
3198, 3258
|
7235, 7813
|
7863, 7882
|
7179, 7212
|
8054, 8370
|
3273, 3852
|
267, 273
|
346, 2864
|
6292, 6732
|
7918, 8030
|
3877, 6232
|
2886, 3088
|
3104, 3182
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,086
| 191,238
|
33646
|
Discharge summary
|
report
|
Admission Date: [**2103-5-10**] Discharge Date: [**2103-5-13**]
Date of Birth: [**2035-6-17**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 67 yom with hx of CAD s/p CABG x 4 in [**2098**], Diastolic
CHF with biventricular failure with NYHF Class III symptoms,
Moderate Pulmonary Hypertension, Afib on coumadin, DM2, CRI who
presents with worsening SOB for the past 3 days. Patient has
baseline SOB with minimal walking but currently is SOB at rest.
At baseline, she sleeps with 3 pillows but for the past few
nights has been sleeping in a chair. She has noted mild increase
in her pedal edema and also reports a 10 pound weight gain in
the past 2 weeks. She did not notify her doctor about this
weight increase. She denies dietary indiscretion or medication
non-compliance. She denies any recent chest pain, palpitations,
N/V, fevers, chills, diarrhea, abdominal pain, BRBPR, melena,
dysuria or back pain. +cough for the past few weeks. Of note,
she was treated two weeks ago at an OSH for Pneumonia. She
reports a fall during her hospital stay which accounts for
several bruises on her torso and arms.
In the ED: Temp 98.9, BP 114/38, HR 44, RR 22 100% 3L. She was
given Kayex 30g, Lasix 40mg IV x 1, ASA 325mg PO x 1. She was
admitted for CHF exacerbation.
Past Medical History:
- Afib on coumadin
- CAD s/p CABG x4 [**2098**], ACS s/p cath in [**3-11**]
- Diastolic CHF with biventricular failure - NYHA Class III
symptoms-->Moderate to severe pulmonary htn on ECHO in [**2-12**]:
LVEF 70%, mod pulm HTN, sig RV dysfunction
- Seizure d/o
- S/p left carotid endarterectomy
- IDDM
- Ventral hernia
- Skin cancer of left nose 15 yrs ago
- CRI (Cr 2.1-2.5)
- S/p appy
- GERD
- OSA - (intolerant of BIPAP, does not use at home)
Social History:
Widower. Lives with daughter [**Name (NI) **], who is her only child.
Family History:
Mother died of ESRD, father died of pneumonia.
Physical Exam:
V/S: T 97.2 BP 110/62 HR 50 RR 20 98%2L
General - Mild distress, able to complete sentences
HEENT - Sclera anicteric, dry MM, oropharynx clear
Neck - Supple, JVP diffcult to assess given obesity but seems to
be at the angle of the jaw, no LAD
Pulm - Decreased breath sound midway up right posterior lung
field, +egophany, +crackles mid to lower left and right lung
fields, decreased breath
CV - normal S1/S2; II/VI SEM LUSB, +bradycardia, irregular
rhythm
Abdomen - Normoactive bowel sounds; soft, non-tender,
non-distended, +epigastric hernia which is reducible, no TTP of
hernia
Back - +ecchymoses over right flank
Ext - +2 bilateral pedal edema, DP pulses 2+; no clubbing,
cyanosis
Pertinent Results:
ADMISSION LABS:
CBC:
[**2103-5-10**] 04:00PM BLOOD WBC-9.8 RBC-3.05* Hgb-8.7* Hct-27.2*
MCV-89 MCH-28.5 MCHC-32.0 RDW-16.6* Plt Ct-119*
[**2103-5-10**] 04:00PM BLOOD Neuts-85.7* Lymphs-7.7* Monos-4.7 Eos-1.5
Baso-0.4
COAGS:
[**2103-5-10**] 04:00PM BLOOD PT-33.4* PTT-32.6 INR(PT)-3.5*
[**2103-5-10**] 04:00PM BLOOD Glucose-249* UreaN-94* Creat-3.5*# Na-139
K-5.5* Cl-101 HCO3-26 AnGap-18
CARDIAC ENZYMES:
[**2103-5-10**] 04:00PM BLOOD CK-MB-NotDone cTropnT-0.01 proBNP-7833*
[**2103-5-11**] 12:32AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2103-5-11**] 03:00AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2103-5-11**] 12:35PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2103-5-11**] 04:42PM BLOOD CK-MB-NotDone cTropnT-0.02* proBNP-8278*
[**2103-5-10**] 04:00PM BLOOD CK(CPK)-47
[**2103-5-11**] 12:32AM BLOOD LD(LDH)-248 CK(CPK)-40 TotBili-0.4
[**2103-5-11**] 03:00AM BLOOD CK(CPK)-35
[**2103-5-11**] 12:35PM BLOOD CK(CPK)-37
[**2103-5-11**] 04:42PM BLOOD CK(CPK)-37
LFTs:
[**2103-5-12**] 02:51AM BLOOD ALT-36 AST-17 LD(LDH)-249 AlkPhos-135*
TotBili-0.5
===================
MICROBIOLOGY:
Urine Cx negative [**2103-5-10**] and [**2103-5-11**]
===================
ECG [**2103-5-10**]:
Atrial fibrillation with a slow ventricular response.
Non-specific
intraventricular conduction delay. Non-specific ST-T wave
changes.
In the setting of the non-specific intraventricular conduction
delay
the Q-T interval is probably prolonged. Compared to the previous
tracing
the rate is slower.
IMAGING STUDIES:
CXR [**2103-5-10**]:
There has been prior median sternotomy and coronary artery
bypass
surgery. Pulmonary vascularity appears increased in caliber but
there is no evidence of acute pulmonary edema. Small-to-moderate
right pleural effusion has slightly increased in size from the
prior study, and is accompanied by adjacent right basilar
parenchymal opacity, likely atelectasis.
CT CHEST [**2103-5-10**]:
1. Increasing right pleural effusion with no evidence of
pneumothorax.
2. Increasing anterior chest wall hernia, which contains part of
the
transverse colon.
3. Unchanged sternal widening after sternotomy and CABG with no
evidence of
osteomyelitis.
4. Multiple new ground glass pulmonary nodules. Given very small
individual
and overall size, likely not of significant clinical
consequence. Correlate
clinically.
CXR [**2103-5-11**]:
Since yesterday, right pleural effusion significantly increased,
now moderate to severe, could be hemothorax given the clinical
information of
supratherapeutic INR. Right middle lobe and right lower lobe
collapse
increased. The cardiomediastinal silhouette and hilar contours
are otherwise unchanged. Sternotomy wires are intact. The left
lung is essentially clear. There are no signs of volume
overload.
CXR [**2103-5-12**]:
As compared to the previous radiograph, there is improvement
with
reduction of the pre-existing right-sided pleural effusion. The
remaining
effusion is mild-to-moderate in extent. There is no evidence of
newly
occurred focal parenchymal opacities suggesting pneumonia. The
retrocardiac
lung areas, however, are less well-aerated than on the previous
film. The
size of the cardiac silhouette appears unchanged.
CXR [**2103-5-13**]:
As compared to the previous examination, the extent of the
pre-existing right pleural effusion has markedly decreased.
Although dorsal portions of the effusion might not be
visualized, the chest radiograph now displays the entire right
hemidiaphragm. Substantial portions of lateral pleural effusion
are no longer present. Unchanged cardiomegaly. Dense right
hilum. Minimal signs indicative of overhydration. Focal
parenchymal opacities suggestive of pneumonia have not newly
occurred.
Brief Hospital Course:
Mrs. [**Known lastname 77911**] is a 67 year old female with a history of
diastolic heart failure, pulmonary hypertension and atrial
fibrillation who presented with worsening dyspnea over the
course of one week both with exertion and at rest. She was felt
to be having an acute exacerbation of her diastolic heart
failure given clinical signs of volume overload including
increased right sided pleural effusion, crackles on lung exam,
elevated jugular venous pressure, and lower extremity edema. On
the floor she was diuresed with intravenous lasix but continued
to be hypoxic despite increasing her oxygen and even delivering
oxygen via face mask. Her course on the floor was further
complicated by epistaxis, likely related to digital trauma in
the setting of a supratherapeutic INR. She was seen by ENT who
placed absorbable packing which stopped the epistaxis. Reversal
of INR initiated with Vitamin K 2 mg PO x 1.
Patient ultimately, required transfer to the ICU given her
persistent hypoxia. She had a CXR prior to transfer that showed
increased right pleural effusion volume that was particularly
concerning given she was actually diuresing quite well. In the
MICU diuresis with lasix boluses was continued. Given
improvement in right sided pleural effusion thoracentesis was
not attempted.
Patient was called back out to the floor today, [**5-13**]. On morning
rounds she appeared closer to euvolemia and CXR confirmed that
right sided pleural effusion markedly decreased. Patient's sats
in high 90's on [**2-5**].5 L which is what she uses at baseline.
Later in am patient began to have intermittent epistaxis managed
with pressure. Per nursing hemostasis was achieved with this
manuever.
A code blue was called at around 1115 at shortly prior to which
patient witnessed to become acutely apneic while sitting on the
side of her bed, with pallor changing to blue. Attending
confirmed DNR/DNI with patient's daughter who was at her
bedside. 12 lead ECG demonstrated PEA. Patient was confirmed
deceased at 1135. Initially her daughter declined an autopsy,
but later on with further discussion she requested autopsy given
uncertainty as to cause of death. It is possible that patient
aspirated on blood and became hypoxic leading to PEA. Pulmonary
embolus also possible though seems less likely given she had
therapeutic INR. Morning electrolytes did not indicate any
abnormalities that could have been attributed.
Medications on Admission:
Citalopram 40mg daily
Furosemide 80mg daily
Humalong Mix 75/25 60u qAM, 20u qPM
Isosorbide Mononitrate SR 60mg daily
Metoprolol Tartrate 25mg [**Hospital1 **]
Omeprazole 20mg daily
Trileptal 300mg qAM, 600mg qPM
Simvastatin 40mg daily
Diovan 80mg daily
Warfarin (unknown dosage)
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: PEA Arrest, Acute on chronic heart failure
exacerbation, Acute on chronic renal failure
Secondary: Coronary Artery Disease, Pulmonary Hypertension
Discharge Condition:
expired
Discharge Instructions:
Admitted to the hospital with progressive dyspnea over the past
week. Appeared to be having an acute congestive heart failure
exacerbation. She required short stay in the MICU due to
episodes of hypoxia on the medicine floor. She was diuresed with
IV lasix with good effect, given O2 requirement returned to
baseline and right sided pleural effusion improved. Patient
called back out to the medicine floor on [**2103-5-13**] and had sudden
PEA arrest. Patient was DNR/DNI.
Followup Instructions:
N/A
Completed by:[**2103-5-13**]
|
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"345.90",
"428.33",
"799.1",
"428.0",
"416.8",
"311",
"403.90",
"E934.2",
"285.9",
"784.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"21.01"
] |
icd9pcs
|
[
[
[]
]
] |
9280, 9289
|
6494, 8922
|
288, 295
|
9489, 9499
|
2797, 2797
|
10020, 10055
|
2028, 2076
|
9252, 9257
|
9310, 9468
|
8948, 9229
|
9523, 9997
|
2091, 2778
|
3205, 4262
|
241, 250
|
323, 1456
|
2814, 3188
|
1478, 1925
|
1941, 2012
|
4280, 6471
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,165
| 191,360
|
1271
|
Discharge summary
|
report
|
Admission Date: [**2172-3-26**] Discharge Date: [**2172-4-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain.
Major Surgical or Invasive Procedure:
Left-heart cardiac catheterization.
History of Present Illness:
This is a 83 Y/o M with h/o CAD s/p CABG [**2157**] (LIMA to LAD, SVG
to OM, SVG to D1, SVG to PDA) recently admitted in [**Month (only) 958**] for
NSTEMI and underwent POBA of LMCA and LCx, presented again from
home with recurrent chest discomfort. He recently saw his
cardiologist where he reported occasional exertional and rest
chest discomfort but was felt to be poor candidate for
revascularization. Patient was found by home health aide to have
increasing shortness of breath and worsening chest discomfort at
rest. Patient apparently had shortness of breath since previous
night, but noted acute worsening this AM. He denies any
increased salt intake or non-adherence to diuretic regimen. Home
health felt he looked unwell, and called EMS. Patient says the
pain resembeled his typical anginal symptoms, substernal
radiating to left arm and is similar but less intense than pain
experienced during previous hospitalzation.
.
ECG done by EMS showed ST-depressions and TWI in V2-V5, similar
to ECG changes on previous admission. He was also hypoxic with
saturation fo 85%. He was given 3 sublingual nitroglycerin's by
EMS with incomplete resolution of symptoms. Patient was started
on heparin gtt, nitroglycerin gtt and given 40mg IV furosemide
in the ED. He was then evaluated by cardiology and taken for
catheterization.
.
In the Cath lab, patient was found to have the following:
LMCA with 80% diffuse disease (known to have severe diffuse
disease with moderate calcification on previous catheterization)
LAD occluded with patent LIMA->LAD and good distal flow
LCx with 90% proximal lesion
RCA not injected
.
Unable to cross LCx lesion with balloon, therefore, rotawire of
LMCA and LCx was attempted, with resultant LCx dissection. Final
angiography demonstrated subtotal occlusion of LCx with
extensive midvessel dissection with localized contained
intromyocardial perforation. Patient was then admitted to CCU
for monitoring due to concerns for hemopericardium and
tamponade.
Past Medical History:
CAD, MI [**2154**] and [**4-26**] s/p CABG ([**2157**]) LIMA to LAD, SVG to OM,
SVG to D1, SVG to PDA)
Diabetes Type 2
gout
arthritis
CABG
RT leg bypass - NOS
CHF
hypertension
hypercholesterolemia
chronic renal insufficiency
peripheral vascular disease
Psoriasis
Social History:
The patient currently lives at home with services for assistance
with ADLs. He was an accountant in [**Country 532**]. He denied smoking,
alcohol or illicit drugs. He does not recall any family history
of premature coronary artery disease of sudden death.
Family History:
No history of premature CAD
Physical Exam:
VS: T 98.0 Bp 130/58 HR:65 RR:19 84% on RA -> 94% on NRB
General: the patient was well developed, well nourished and well
groomed. The patient was oriented to person, place and time.
HEENT: no xanthalesma. conjuctiva pink. dry oral mucose. Neck
supple.
there was no thyromegaly. JVD - lying flat ~ 7cm
Chest: No chest wall deformities, scolisosis or kyphosis.
Lungs: + crackles bilaterally anteriorly.
Cardiac: PMI non-displaced. RRR.
Abdominal: The abdominal aorta was not enlarged by palpation.
There was no hepatosplenomegaly or tenderness. The abdomen was
soft nontender and nondistended.
Extremities: No pallor, no cyanosis. There were no abdominal,
femoral or carotid bruits.
Skin: = psoriatic plaques over extensor surface forearms
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal unable to asses DP 1+ PT
1+
Left: Carotid 2+ Femoral 2+ Popliteal unable to assess DP 1+ PT
1+
Pertinent Results:
ADMIT LABS: [**2172-3-26**]
CHEMISTRIES:
Glucose-318* UreaN-45* Creat-1.9* Na-138 K-4.4 Cl-103 HCO3-25
AnGap-14
CBC:
BLOOD WBC-9.4 RBC-3.08* Hgb-8.7* Hct-26.1* MCV-85 MCH-28.2
MCHC-33.3 RDW-14.6 Plt Ct-198
CARDIAC ENZYMES:
[**2172-3-26**] 01:40PM BLOOD cTropnT-0.04*
[**2172-3-26**] 07:22PM BLOOD CK-MB-6
[**2172-3-27**] 05:20AM BLOOD CK-MB-13* MB Indx-8.0*
[**2172-3-28**] 05:55AM BLOOD CK-MB-8 cTropnT-0.93*
CARDIAC CATH ([**2172-3-26**]):
1. Three vessel coronary artery disease.
2. Unsuccessful rotational atherectomy of the proximal
circumflex
complicated by mid vessel dissection with contained perforation.
ECHO ([**2172-3-27**]):
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe regional
left ventricular systolic dysfunction. Right ventricular chamber
size is normal. There is mild global right ventricular free wall
hypokinesis. The aortic valve leaflets are mildly thickened. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mitral regurgitation is present but cannot be
quantified (?mild-moderate). There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2172-3-3**], the
severity of mitral regurgitation has increased, left ventricular
systolic function is more depressed (septum less vigorous), and
right ventricular free wall dysfunction is now identified. No
pericardial effusion is again seen.
CXR ([**2172-3-27**]):
Interval worsening of now moderate-to-severe pulmonary edema
Brief Hospital Course:
1. Coronary artery disease/NSTEMI:
Patient with substantial history of coronary disease and ST
changes on EKG, positive cardiac enzymes. Therefore, he
underwent cardiac catheterization with rotawire to LM and LCx
and subsequent dissection of LCx. No stents placed.
Echocardiography x 2 did not demonstrate significant effusion.
Held heparin and integrilin given dissection. Continued
aspirin/Plavix. Continued beta-blocker, given CHF. Started
Ezetemibe as patient was supposed to begin on this as
outpatient. Continued with atorvastatin. Increased Imdur to
120mg daily. Restarted Ranexa. ACEI was added as blood
pressure tolerated.
2. Congestive heart failure:
Patient was very volume overloaded on admission and initially
saturating 90% on non-rebreather. Diuresed >9 Liters with
improvement in oxygen requirement (initially used IV lasix,
later changed to PO, then finally back to home regimen of
Torsemide 20mg daily). An echo showed an EF of 40%. Restarted
ACE inhibitor when blood pressure was able to tolerate it. At
the time of discharge, he was saturating in the mid-90s on room
air with a weight of 65kg (143lbs).
3. Rhythm:
Experienced a brief paroxysm of atrial fibrillation with RVR
during hospitalziation that converted spontaneously to sinus
rhythm. Will use aspirin/Plavix for now, but can consider
starting long-term anticoagulation as outpatient if this recurs.
4. Hypertension:
As above, treated with beta-blocker and ACE inhibitor
5. Hyperlipidemia:
Continued high dose statin with ezetemibde.
6. Chronic renal insufficiency:
Baseline SCr of ~1.6; slightly elevated on admission, but
improved, even with diuresis. After ACEI was restarted, SCr
back up mildy. Plan was for outpatient lytes/BUN/Cr within a
week of discharge to ensure stability.
7. Anemia:
Baseline hematocrit is low 30's, but patient appeared to have
hematocrit drop post procedure. Was transfused 1 unit PRBC
given symptomatic coronary disease and hematocrit < 30. His
hematocrit was checked daily and remained in the high 20s during
most of his hospitalization.
8. DM/Hyperglycemia:
Elevated blood sugar on admission. Initially was started on
prior home regimen of NPH. [**Last Name (un) **] was consulted and noted that
his NPH had been increased recently; he was therefore changed to
this new/increased regimenw with a HISS. He was discharged on
this regimen with plan for [**Last Name (un) **] follow-up.
9. Depression:
Continued Celexa as per outpatient regimen.
Communication: HCP [**Name (NI) **] (Son) [**Telephone/Fax (1) 7908**]
DNR/DNI
Medications on Admission:
Aspirin 325 mg qd
Renexa 500mg qd
Atorvastatin 80 mg qd
Celexa 10 mg qd
Clopidogrel 75 mg qd
NPH 14 units each morning and 6 units each evening
Toprol XL 50 mg qd
Torsemide 20 mg qd
Colace 100 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **] prn
Zetia 10mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO daily ().
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: As
directed Subcutaneous As directed.: 24 units in the morning; 15
units at bedtime.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Isosorbide Mononitrate 120 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Outpatient Lab Work
Chem 7; please have the results sent to PCP ([**First Name9 (NamePattern2) 7910**] [**Doctor Last Name 1603**])
fax # [**Telephone/Fax (1) 716**]
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as directed.
Disp:*30 tabs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary:
1. Non ST-elevation myocardial infarction
2. Congestive heart failure
Secondary:
1. Diabetes mellitus, type II, uncontrolled
2. Hypertension
3. Hyperlipidemia
4. Chronic kidney disease
5. Anemia
Discharge Condition:
Hemodynamically stable; euvolemic with a weight of 65kg
(143lbs). Saturating well on room air.
Discharge Instructions:
You were admitted after having a heart attack and heart failure.
It will be very important for you to continue taking all your
medications as prescribed. You should also be sure to follow-up
with your PCP and cardiologist (as below).
If you experience chest pains or problems breathing or have any
concerns, please be sure to call your primary care doctor.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs
(your dry/current weight is 65kg/143lbs). Adhere to 2 gm sodium
diet.
Please note the following medication changes:
1. IMDUR (isosorbide mononitrate): This medication helps to
control anginal pains (chest pains). It should be taken once
daily.
2. LISINOPRIL: This is a blood pressure medication that also
protects the heart. It should be taken once daily.
Followup Instructions:
You have the following appointment scheduled:
1. [**2172-4-8**] 11:00 - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC Phone:[**Telephone/Fax (1) 719**]
2. [**2172-4-15**] 9:30 - [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7909**], MD Phone:[**Telephone/Fax (1) 719**]
3. [**2172-4-30**] 7:30 - OR/EYE LIST OR EYE SURGERY
Phone:[**Telephone/Fax (1) 253**]
You should also have blood work checked next week given that you
were started on lisinopril.
|
[
"V45.81",
"403.90",
"410.71",
"427.31",
"696.1",
"998.2",
"414.01",
"428.0",
"585.9",
"285.21",
"250.02",
"274.9",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.41",
"00.66",
"37.22",
"99.04",
"99.20",
"88.55",
"88.52"
] |
icd9pcs
|
[
[
[]
]
] |
9738, 9813
|
5408, 7969
|
272, 309
|
10062, 10160
|
3851, 4061
|
11012, 11513
|
2903, 2934
|
8281, 9715
|
9834, 10041
|
7995, 8258
|
10184, 10722
|
2949, 3832
|
4078, 5385
|
10743, 10989
|
221, 234
|
337, 2326
|
2348, 2612
|
2628, 2887
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,386
| 133,276
|
10147+56106
|
Discharge summary
|
report+addendum
|
Admission Date: [**2136-9-16**] Discharge Date: [**2136-9-26**]
Date of Birth: [**2072-5-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Thoracentesis
.
Hemodialysis
.
CT T-spine, L-spine ([**9-19**]):
IMPRESSION: Unchanged osteomyelitis at T7-8 thoracic vertebra
with
retropulsed fragment at T7-8 that causes severe spinal stenosis
and is unchanged. The paraspinal abscess is also unchanged.
.
CT Chest ([**9-18**]):
IMPRESSION: Interval increase in size in bilateral pleural
effusions. We do not know the significance of the negative
measurements of the pleural fluid (?fat content) Interval
progression of the osteomyelitis centered at the T7/T8 levels
with increased destruction of the vertebral body of T8 involving
posterior margin with spinal canal and with apparent fragment
extending into into spinal canal with bony fragments going to
the spinal canal. This could be better evaluated by MR exam of
the spine. Cholelithiasis.
.
MR spine ([**9-18**])
IMPRESSION:
1. Spinal canal stenosis at the level of L4/L5, appears to be
slightly more severe than the prior study secondary to increase
in disc bulge. It is probably causing compression of the cauda
equina at this level.
2. Increased signal in the disc of L4/L5 is unchanged when
compared to prior studies and is likely degenerative since there
is no involvement of the endplates and is stable.
.
RUQ Ultrasound ([**9-17**])
IMPRESSION:
1. Cholelithiasis without evidence of cholecystitis.
2. No evidence of biliary ductal obstruction.
.
History of Present Illness:
64 female with h/o mental retardation, DM, renal failure on TIW
HD, recent hospitalization with epidural abscess s/p laminectomy
and drainage of T11-S1, I&D of foot, drainage of sphenoid
sinues, who was readmitted from [**Hospital3 7**] with
intermittent fevers and back pain. She is unable to give a good
history, but according to her caregiver and the staff at
[**Name (NI) **], she has been complaining of increasing back pain for
the past two days. She has not had fevers in the past week, but
since her last discharge ([**2136-9-1**]) and last week, she has been
having intermittent fevers. She was discharged on oxacillin (for
abscess), levaquin (for UTI), and flagyl (for presumed c.dif).
.
She has also been noted to be intermittently hallucinating and
paranoid since her last admission. She continues to have
diarrhea. Her urination has been improving, and she is still
dialyzed q MWF at [**Hospital1 **]. She complains also of intermittent
abdominal pain. She has not been coughing, denies N/V.
.
ED COURSE: She was febrile to 103, tachy, and requiring
supplemental oxygen. She was given 2L NS, ceftriaxone, and
vancomycin. She got an abdominal / pelvic CT scan which showed
worsening bone destruction at T7,8 retropulsing into the
thoracic canal concerning for osteomyelitis.
.
Past Medical History:
COPD
Mental retardation
DVT [**1-/2130**]
NIDDM
Obesity
Sciatica
Hypertension
Hypercholesterolemia
Anxiety
Psoriasis
Paroxysmal
A fib
.
Social History:
Lives in apartment with 24 hour caregiver; has a long term
boyfriend. [**Name (NI) 1403**] part time. Guardian is [**Name (NI) 402**] [**Name (NI) 33801**]
[**Telephone/Fax (1) 33802**]
.
Family History:
Pt unable to provide
.
Physical Exam:
PHYSICAL EXAM
VS- 99.6 120/61 121 25 99% 3L
GEN- Pale, anxious female with stigmata of mental retardation,
non-toxic, NAD
HEENT- MMdry, anicteric, poor dentition, PERRLA, EOMI, no sinus
tenderness
NECK- supple, no LAD, thick neck
CV- Reg rhythm, tachy, no murmur appreciated, nl S1, S2
CHEST- Diminished breath sounds bilaterally, no wheezes.
ABD- obese, slightly distended, ttp epigastric and LLQ, no
guarding or rebound, pos BS.
EXT- 1+ tense pitting edema, no clubbing, pale nail beds
NEURO- oriented to self only, MAEW, 2+ DTR upper extremity, 3+
DTR lower extremity
SKIN- echymotic over lower abdomen, superficial breakdown right
buttock, dry feet
MSK- TTP mid thoracic spine
.
Pertinent Results:
[**2136-9-16**] 11:00PM GLUCOSE-104 UREA N-24* CREAT-3.1* SODIUM-138
POTASSIUM-3.2* CHLORIDE-102 TOTAL CO2-21* ANION GAP-18
[**2136-9-16**] 11:00PM CK-MB-1 cTropnT-0.07*
[**2136-9-16**] 11:00PM CALCIUM-6.8* PHOSPHATE-2.4* MAGNESIUM-1.4*
[**2136-9-16**] 11:00PM WBC-9.7 RBC-2.70* HGB-8.4* HCT-25.5* MCV-95
MCH-31.2 MCHC-33.0 RDW-20.6*
[**2136-9-16**] 11:00PM NEUTS-76.6* LYMPHS-15.6* MONOS-4.6 EOS-2.6
BASOS-0.6
[**2136-9-16**] 11:00PM ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+
[**2136-9-16**] 11:00PM PLT COUNT-420
[**2136-9-16**] 11:00PM PT-15.6* PTT-30.7 INR(PT)-1.4*
[**2136-9-16**] 03:56PM LACTATE-1.2 K+-3.2*
[**2136-9-16**] 01:30PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.007
[**2136-9-16**] 01:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2136-9-16**] 01:30PM URINE RBC-[**6-30**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0-2 RENAL EPI-0-2
[**2136-9-16**] 12:33PM LACTATE-1.5 K+-3.3*
[**2136-9-16**] 12:33PM HGB-10.0* calcHCT-30
[**2136-9-16**] 12:30PM GLUCOSE-129* UREA N-23* CREAT-3.0* SODIUM-137
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-22 ANION GAP-19
[**2136-9-16**] 12:30PM ALT(SGPT)-11 AST(SGOT)-13 CK(CPK)-14* ALK
PHOS-146* AMYLASE-15 TOT BILI-0.5
[**2136-9-16**] 12:30PM LIPASE-12
[**2136-9-16**] 12:30PM cTropnT-0.06*
[**2136-9-16**] 12:30PM ALBUMIN-1.9* CALCIUM-7.2* PHOSPHATE-2.1*#
MAGNESIUM-1.4*
[**2136-9-16**] 12:30PM OSMOLAL-296
[**2136-9-16**] 12:30PM WBC-8.9 RBC-2.79* HGB-9.2* HCT-26.3* MCV-94
MCH-33.0*# MCHC-35.1* RDW-20.6*
[**2136-9-16**] 12:30PM NEUTS-77.5* LYMPHS-15.0* MONOS-5.1 EOS-2.3
BASOS-0.1
[**2136-9-16**] 12:30PM ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+
[**2136-9-16**] 12:30PM PLT COUNT-398
[**2136-9-16**] 12:30PM PT-14.9* PTT-33.3 INR(PT)-1.3*
.
Brief Hospital Course:
Impression/Plan:
64 female with MMP, recently admitted with MSSA epidural abscess
s/p drainage of paraspinal abscess and laminectomy of T12-L1,
now presents with fever, tachycardia, and increasing back pain,
concerning for improperly treated paraspinal abscess
.
MICU Course:
In the MICU, pt was continued on Vancomycin, CTX was changed to
cefepime. She was on flagyl at the time secondary to diarrhea.
Her urine returned positive for enterobacter which was sensitive
to cefepime. MRI obtained on [**9-18**] showed worsening of
osteomyelitis with new compression deformity of T7 causing mass
effect on the spinal cord at this level. Ortho was consulted
regarding another surgical exploration to obtain more tissue and
determine whether the osteomyelitis has been adequately treated.
Ortho recommended a CT of T/L spine to further evaluate extent
of progression of osteo/abscess, which showed soft tissue mass
at T7 c/w abscess, unchanged from prior CT. ID consulted and
recommend CT guided aspiration and Cx of T7 paraspinal abscess
to determine if she still needs IV Nafcillin. CT radiology
declined to do procedure because of level of abscess. Due to
patient stability, she was called out to the floor.
.
Hospital Course:
1. Fever: Concerning for untreated paraspinal abscess given that
the patient was on IV Nafcillin for an extended course. Both
orthopoedics and infectious disease following through hospital
course. Radiology uncomfortable with performing CT guided
aspiration of abscess given the level. There was a consensus
that the patient should not be put through any further invasive
procedures (such as an open aspiration) to further speciate
source of abscess. She did get a thoracentesis with the
anticipation that her pleural effusions were communicating with
her abscess, but the pleural fluid was transudative in nature
and did not subsequently grow out any bacteria. She was
continued on Vancomycin secondary to fevers on Nafcillin, and
this was dosed for a level of 15-20. When she came in, she
initially had an Enterobacter UTI, and was treated with Cefepime
for this, with a course ending on [**2136-9-26**]. A subsequent UA
showed Vancomycin resistant Enterococcus, and she was started on
Linezolid on [**9-25**]. This should continue for a total of one week
(to end on [**2136-10-2**]). After that course is done, she should
continue on Nafcillin 2g IV q6h for a total of three weeks (to
end on [**10-23**]). She has outpatient follow-up with Dr. [**Last Name (STitle) 3394**]
of infectious disease.
.
2. Paraspinal abscess: Orthopoedics following through hospital
course. Repeat CT scan showed stable abscess. She was to
continue TLSO brace when out of bed. She is to get an
outpatient MRI and she has an appointment to follow up with Dr.
[**Last Name (STitle) **] on [**10-2**].
.
3. Mouth lesions: Thrush, on Nystatin swish and swallow.
.
4. Renal failure: Secondary to ATN from sepsis in [**8-26**].
Creatinine baseline of 1.5. Pt with good UOP. Continued MWF
hemodialysis. Renal following throughout hospital course. She
received hemodialysis with her contrast studies. She did have
decreased UOP after a contrast CT which resolved.
.
5. Diarrhea: The patient has persistent diarrhea, and her C
diff negative times 3
Flagyl was discontinued with third negative result.
.
6. Abdominal pain: During prior hospitalization imaging revealed
no etiology. Likely chronic in nature. Unsure if reliable
exam. Did not have any further problems with abdominal pain
during her hospitalization.
.
7. AFib: She has a history of Afib with RVR. During the
hospitalization, she remained in NSR. She was not
anticoagulated due to recent SDH.
.
8. DM2: She was maintained on an RISS with good glucose control
as well as a diabetic diet.
.
9. Anemia: Appears to be anemia of inflammation / ACD. Baseline
Hct ~ 25. She did receive multiple transfusions for Hct <22.
.
#. Anxiety: Very anxious on exam. Continued psych meds at outpt
dose.
.
#. FEN: Replete lytes prn. Regular, renal, diabetic diet.
.
#. PPX: SC heparin, boots, PPI, lotion and repositioning for
decub skin breakdown.
.
#. ACCESS: Left PICC, PIV, dialysis line
.
#. CODE: Full, confirmed with HCP
.
#. COMMUNICATION: [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **], guardian, [**Telephone/Fax (1) 33802**]
.
Medications on Admission:
-Metronidazole 500 mg PO BID
-Lamotrigine 100 mg PO BID
-Paroxetine HCl 40 daily
-Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
-Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H
-Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q2-3H prn
-Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q6H
-Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID
-Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
-B Complex-Vitamin C-Folic Acid 1 mg Capsule qd
-Insulin Regular Human 100 unit/mL SS
-Promethazine 25 mg Tablet q6h prn
-Pantoprazole 40 mg q24h
-Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
-Fentanyl 75 mcg/hr Patch 72HR
-Metoprolol Tartrate 12.5 mg [**Hospital1 **]
-Senna 8.6 mg [**Hospital1 **] prn
-Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams
Intravenous Q4H Continue until pt reevaluated
by ID on [**2136-9-13**].
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
MSSA epidural abscess/osteomyelitis
ARF on HD MWF
Anemia of renal failure
Enterobacter UTI
VRE UTI
Discharge Condition:
Stable
Discharge Instructions:
Please follow up with your doctor as below.
Please take medications as below. Please complete your
antibiotic course as specified below.
If develops fever, chills, low blood pressure, or any other
symptoms, please contact the Infectious Disease specialist or
proceed to the nearest ER.
Always wear your TLSO brace when not in bed.
Followup Instructions:
Infectious Disease follow up:
Provider: [**First Name8 (NamePattern2) 7618**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2136-10-23**]
11:00
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17007**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2136-10-10**] 1:00
.
You have an MRI scheduled: RADIOLOGY MRI Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2136-10-30**] 1:45. This is at [**Hospital Ward Name 23**] on the [**Location (un) **].
.
She will need weekly CBC, LFTs, ESR, CRP, BUN/Cr, please fax
results to ([**Telephone/Fax (1) 1353**] with attention to Dr. [**Last Name (STitle) 3394**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Name: [**Known lastname 5916**],[**Known firstname **] Unit No: [**Numeric Identifier 5917**]
Admission Date: [**2136-9-16**] Discharge Date: [**2136-9-26**]
Date of Birth: [**2072-5-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 391**]
Addendum:
.
Chief Complaint:
.
Major Surgical or Invasive Procedure:
.
History of Present Illness:
.
Past Medical History:
.
Social History:
.
Family History:
.
Physical Exam:
.
Pertinent Results:
.
Brief Hospital Course:
.
Medications on Admission:
.
Discharge Medications:
1. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*qs * Refills:*2*
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
Disp:*qs nebulizer* Refills:*0*
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
Disp:*120 nebulizer* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*qs Tablet(s)* Refills:*0*
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
Disp:*qs * Refills:*0*
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
Disp:*qs units* Refills:*2*
9. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*qs Patch 72HR(s)* Refills:*0*
10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
11. Nafcillin 2 g Piggyback Sig: Two (2) grams Intravenous
every six (6) hours for 3 weeks: Start after complete 1 week
course of Linezolid. Start [**2136-10-2**] until [**2136-10-23**]. .
Disp:*qs grams* Refills:*0*
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*qs Tablet(s)* Refills:*0*
14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*qs Cap(s)* Refills:*2*
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*qs Tablet, Delayed Release (E.C.)(s)* Refills:*2*
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
Disp:*qs ML(s)* Refills:*0*
17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush for 1 weeks.
Disp:*qs ML(s)* Refills:*0*
18. Insulin Regular Human 100 unit/mL Solution Sig: As per
standard insulin sliding scale units Injection ASDIR (AS
DIRECTED).
Disp:*qs units* Refills:*2*
19. Hydromorphone 2 mg/mL Syringe Sig: 0.5-1 mg Injection Q4H
(every 4 hours) as needed for pain.
Disp:*qs mg* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
Discharge Diagnosis:
.
Discharge Instructions:
.
Followup Instructions:
.
[**Name6 (MD) 116**] [**Name8 (MD) 117**] MD [**MD Number(1) 392**]
Completed by:[**2136-9-26**]
|
[
"041.85",
"041.04",
"730.08",
"250.00",
"324.1",
"112.0",
"787.91",
"285.21",
"276.52",
"511.9",
"599.0",
"319",
"427.31",
"585.6",
"496",
"336.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
15765, 15846
|
13204, 13207
|
13044, 13047
|
11492, 11501
|
13178, 13181
|
15920, 16049
|
13138, 13141
|
13259, 15742
|
15867, 15870
|
13233, 13236
|
7147, 10251
|
15894, 15897
|
13156, 13159
|
11914, 12986
|
13003, 13006
|
13075, 13078
|
11370, 11471
|
13100, 13103
|
13119, 13122
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,290
| 132,627
|
43579
|
Discharge summary
|
report
|
Admission Date: [**2104-4-2**] Discharge Date: [**2104-4-8**]
Date of Birth: [**2043-1-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Simvastatin / Codeine / Latex
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
asymptomatic LLL nodule found on CT scan after MVC
Major Surgical or Invasive Procedure:
[**2104-4-2**]
Left exploratory thoracoscopy, left thoracotomy,
and left lower lobectomy, mediastinal lymph node dissection,
intercostal muscle flap buttress.
History of Present Illness:
The patient is a 61-year-old
woman with a biopsy-proven stage IIIA lung cancer. She
underwent induction chemotherapy and radiation and had a good
response. She presents for resection.
Past Medical History:
-Diabetes Mellitus, BS poorly controlled ranging from 120 - 400
-Hypercholesterolemia, hypertriglyceridemia
-CAD, MI x 3, most recently in [**2088**] w/ PCI at that time
-Peripheral vascular disease s/p b/l iliac stenting
-Acute pancreatitis x 3 thought to be secondary to
-hypertriglyceridemia
-Adrenal mass (Bx negative for cancer)
Social History:
She lives alone. She has one son, [**Name (NI) 2855**].
She previously smoked for approximately 45
years, starting with three packs per day. In the last 10 years,
she has smoked one pack per day. She denies alcohol use
currently, but previously drank socially. Her last alcoholic
beverage was 17 years ago. She works as an insurance salesman.
Family History:
Father with heart disease and prostate cancer at
the age of 78. Mother with diabetes. She has three siblings
without a history of cancer.
Physical Exam:
BP: 108/63. Heart Rate: 77. Weight: 142.4. Height: 63.25. BMI:
25.0. Temperature: 97. Resp. Rate: 16. Pain Score: 0. O2
Saturation%: 98.
Gen: A&O, NAD
CV: RRR, no M/R/G
Pulm: CTAB. TTP over left lower ribs anteriorly.
Abd: S/NT/ND
Ext: w/d, no edema
Pertinent Results:
[**2104-4-2**] 10:52AM HGB-9.6* calcHCT-29 O2 SAT-99
[**2104-4-2**] 10:52AM GLUCOSE-173* LACTATE-1.7 NA+-137 K+-4.3
CL--106
[**2104-4-2**] 03:08PM WBC-8.8# RBC-2.99* HGB-10.1* HCT-27.6* MCV-92
MCH-33.9* MCHC-36.7* RDW-14.4
[**2104-4-2**] 03:08PM GLUCOSE-249* UREA N-27* CREAT-0.7 SODIUM-135
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-24 ANION GAP-11
[**2104-4-5**] CXR:
Interval removal of left chest tube. Tiny left-sided
pneumothorax present, decreased compared with [**2104-4-4**].
Otherwise, no
significant interval change.
Brief Hospital Course:
Ms. [**Known lastname 93746**] was admitted to the hospital and taken to the
Operating Room where she underwent a Left VATS converted to open
thoracotomy (See formal op note for details). She tolerated the
procedure well and returned to the PACU in stable condition. Her
pain was initially controlled with an epidural catheter and she
maintained stable hemodynamics.
Following transfer to the Surgical Floor she continued to make
good progress. Her oxygen was gradually weaned off and her room
air saturations were 96%. She was able to use her incentive
spirometer effectively. Following removal of her chest tube and
epidural catheter her pain was not controlled on oral
medications and she requires a Dilaudid PCA which was effective
along with some Toradol. She was eventually placed on oral
Dilaudid and schedule Ultram and Tylenol and was then able to
get up and walk independently and continue use of the Incentive
spirometer. Constipation was a problem which was treated with
Dulcolax and Mirilax effectively.
Her blood sugars were initially in the mid 200 range post op but
decreased after her home Lantus and sliding scale coverage was
resumed. She was tolerating a diabetic diet without difficulty.
Her left thoracotomy incision was healing well. After a
relatively uneventful recovery she was discharged to home on
[**2104-4-8**] and will return to the Thoracic Clinic in 2 weeks.
Medications on Admission:
atenolol 25', plavix 75', gemfibrozil 600", lantus 64 qAM,
lispro SSI TID, lisinopril 10', lorazepam 0.5-1 q4h, ranitidine
150", crestor 20', ASA325, omega 3, MVI
Discharge Medications:
1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
4. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
8. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on for
12 hours, off for 12 hours.
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*2*
11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. insulin glargine 100 unit/mL Solution Sig: Sixty Four (64)
units Subcutaneous once a day.
13. insulin lispro 100 unit/mL Solution Sig: per sliding scale
coverage units Subcutaneous three times a day: before meals.
14. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
15. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
16. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
17. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Left lower lobe lung cancer.
Acute blood loss anemia
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 for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 1000 mg every 8 hours in between your narcotic.
If your doctor allows you may also take Ibuprofen to help
relieve the pain.
* Check your blood sugars 3 times a day and follow your sliding
scal that you have at home.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2104-4-15**] at 9:00 AM
With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: EAST Best Parking: [**Street Address(1) 592**] Garage
Please report 30 minutes prior to your appointment to the
Raadiology Department on the th floor of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2104-8-20**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2104-4-8**]
|
[
"285.1",
"530.81",
"272.1",
"162.5",
"443.9",
"V64.42",
"272.4",
"357.2",
"412",
"362.01",
"250.60",
"V15.82",
"V58.67",
"401.9",
"250.50",
"414.01",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"32.49",
"03.90",
"83.82"
] |
icd9pcs
|
[
[
[]
]
] |
5638, 5644
|
2444, 3846
|
345, 506
|
5741, 5741
|
1888, 2421
|
7355, 8193
|
1460, 1602
|
4060, 5615
|
5665, 5720
|
3872, 4037
|
5892, 7332
|
1617, 1869
|
255, 307
|
534, 721
|
5756, 5868
|
743, 1078
|
1094, 1444
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,414
| 118,336
|
46562
|
Discharge summary
|
report
|
Admission Date: [**2135-2-10**] Discharge Date: [**2135-2-15**]
Date of Birth: [**2066-12-25**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine / Darvon
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
AMS/ ? benzodiazepine overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 68 yo M with past medical history of HTN, HIV, hep C
s/p interferon (per patient) who was brought in by EMS with
altered mental status after an apparent vicodin overdose.
.
The patient is not an appropriate historian, however, he says
that he took all of his vicodin today in addition to drinking
gin. He denies any suicidal gestures but cannot explain why he
took all of his medication. When asked who called EMS, the
patient reports his building manager, though he not clear as to
how he was found or what the initial concern was.
.
Per report, the patient was recently given a prescription for
110 hydrocone pills for back pain. The patient initially
reported that he had taken all the pills. On arrival to the ED,
he was found to be altered with slurred speech.
.
In the ED, initial vs were: T 98.4 P 78 BP 164/91 R 18 O2 sat
96% on RA. Patient was given narcan 0.4 mg x1 with minimal
response and 3L of NS. He was transferred to the ICU for close
observation and management.
.
On the floor, the patient is sleep but easily arousable. He can
answer questions appropriately though is not clear on details.
He reports he is unable to recount his home medications but has
them all filled at CVS in [**Location (un) 5069**]. In addition, when asked
if he has any relatives or friends that could be [**Name (NI) 653**], he
states that they do not get along. He is able to protect his
airway at this time. His only complaint is of back and leg pain
which is chronic.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria.
Past Medical History:
HIV - reports he is on HAART but per pharmacy not on medications
for this
Hep C - states he was on interferon and cleared his infection
HTN - not on medication
Lumbar stenosis
Ant/post lumbar fusion in [**2131**]
Depression
Social History:
Lives alone. Denies tobacco. Reports occasional marijuana use,
states he only drinks socially (usually gin)
Family History:
N/C
Physical Exam:
On arrival:
Vitals: T:97.4 BP:182/88 P: 78 R: 18 O2: 98% on 3L NC
General: Somnolent but arousable, oriented to place and date but
not year, NAD
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally though poor inspiratory
effort, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Multiple eccymoses on abdomen and on L anterior chest near
shoulder, also area of excoriation on R hip without evidence of
infection
Pertinent Results:
Admission labs:
[**2135-2-10**] 03:00PM BLOOD WBC-7.6 RBC-4.30*# Hgb-13.6*# Hct-39.0*#
MCV-91 MCH-31.6 MCHC-34.8 RDW-14.3 Plt Ct-219
[**2135-2-10**] 03:00PM BLOOD Neuts-59.4 Lymphs-34.3 Monos-4.8 Eos-0.8
Baso-0.6
[**2135-2-10**] 03:00PM BLOOD PT-13.9* PTT-19.8* INR(PT)-1.2*
[**2135-2-10**] 03:00PM BLOOD Plt Ct-219
[**2135-2-10**] 03:00PM BLOOD Glucose-78 UreaN-13 Creat-0.8 Na-146*
K-3.7 Cl-105 HCO3-22 AnGap-23*
[**2135-2-10**] 03:00PM BLOOD ALT-71* AST-105* LD(LDH)-497*
CK(CPK)-3115* AlkPhos-92 TotBili-0.4
[**2135-2-10**] 03:00PM BLOOD cTropnT-0.03*
[**2135-2-10**] 03:00PM BLOOD CK-MB-72* MB Indx-2.3
[**2135-2-10**] 03:00PM BLOOD Calcium-9.3 Phos-2.8 Mg-1.8
[**2135-2-10**] 03:00PM BLOOD Ammonia-26
[**2135-2-10**] 03:00PM BLOOD Osmolal-330*
[**2135-2-10**] 03:00PM BLOOD ASA-NEG Ethanol-121* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
.
[**2135-2-10**] CT Head: IMPRESSION:
1. No acute intracranial process.
2. Mild sinus mucosal disease.
.
[**2135-2-10**] CXR:
IMPRESSION: No acute cardiopulmonary abnormality.
.
[**2135-2-11**] TTE: The left atrium is mildly dilated. No thrombus/mass
is seen in the body of the left atrium. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
Discharge labs:
[**2135-2-14**] 05:40AM BLOOD WBC-4.1 RBC-3.26* Hgb-10.5* Hct-29.5*
MCV-91 MCH-32.1* MCHC-35.5* RDW-14.5 Plt Ct-198
[**2135-2-14**] 05:40AM BLOOD Plt Ct-198
[**2135-2-14**] 05:40AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-143
K-3.5 Cl-105 HCO3-31 AnGap-11
[**2135-2-14**] 05:40AM BLOOD Calcium-8.8 Phos-4.3# Mg-1.6
Brief Hospital Course:
This is a 68 yo M with history of HTN, depression, chronic back
pain and HIV/hep C who is admitted with AMS following a possible
vicodin ingestion.
.
# Altered mental status: Likely secondary to ingestion per
report. The patient reportedly told EMS that he had taken an
entire bottle of hydrocodone/acetaminophen. Urine and serum tox
screens positive for opiates, benzos and etoh. Head CT negative
and no evidence of infiltrate on CXR. No leukocytosis or other
evidence of current infection that might be contributing. Of
note, patient reports vicodin overdose, but has a negative
acetaminophen screen. Pt was monitored overnight in the ICU
then transferred to the floors where he was initially somnolent
but began to wake up with time. He remained oriented x3 while on
the floor.
Psych was consulted and agreed with d/c of all sedating
medications. The exception to this is that the pt was put on a
CIWA scale for possible EtOH withdrawl during his first 48 hr on
the floor. Prior to discharge, they evaluated the pt and
recommended he have an inpt psychiatric stay. Social work was
also consulted.
.
# Hypernatremia: Likely from volume depletion/decreased free
water intake as patient had not likely been able to drink while
intoxicated. Also, appears to have been down for some time
leading to elevated CK as below. Na quickly normalized with
IVF.
.
# Rhabdomyalysis: CK elevated to 3000 with normal renal function
on admission in the setting of intoxication, immobilization.
Consistent with this diagnosis, initialy UA had large blood but
no RBCS. Pt was hydrated with IVF initially and Cr was trended
and remained stable at 0.8.
.
# Depression: Followed by psych at [**Hospital1 18**] prior to [**2123**] for
recurrent major depression and etoh abuse. There is some
question of whether this was a suicidal gesture according to
signout from EMS. He is followed by Dr. [**Last Name (STitle) **] (?sp) as an
outpatient. Psychiatric meds were held initially in house with
concern for oversedation. Psych evaluated pt in house and he is
being discharged to inpatient psych bed.
.
# ECG changes: Last available ECG is from [**2124**]. RBBB this
admission appears to be new as is TWI in III, avF. Also had
elevated CK with mildly incr. trop. No complaints of chest pain
or SOB. CE were repeated and pt was ruled out for MI. Echo was
done and results are as above.
.
# Prophylaxis: Subcutaneous heparin, bowel regimen, no
indication for ppi
.
# Communication: Patient. No contact information available for
family members. [**Name (NI) **] contact PCP in am for further information
about patient, current medication regimen and chronic disease
status.
Medications on Admission:
Vicodin 7.5-500 100 pills filled on [**1-25**] pills filled [**1-17**]
Ambien 10 mg daily
Methylphenidate SA 20 mg
Finasteride 5 mg
Paxil CR 37.5 mg
HCTZ 12.5 - last filled on [**10-22**]
Diazepam - last filled [**10-22**]
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis:
Alcohol intoxication and opiate overdose
Altered Mental Status
Secondary diagnoses:
HIV
Depression
Hypernatremia
Rhabdomyalysis
Discharge Condition:
Good. VSS. No O2 requirement. Hct stable
Discharge Instructions:
You were admitted with intoxication and medication overdose.
While you were here, we monitored you for signs of toxic side
effects of this overdose. Other than sleepiness, you did not
have any of these side effects. You were also evaluated by
psychiatry while you were here who determined you need to have
an inpatient psychiatric stay before going home.
.
Please continue your medications as prescribed.
.
Please follow up with your PCP at [**Name9 (PRE) 778**] within 1-2 weeks.
.
Please call your doctor or return to the ED if you have fever,
chest pain, shortness of breath, thoughts of wanting to hurt
yourself, headaches, lightheadedness, sleepiness or any other
concerning symptoms.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 6164**] within [**11-26**] wks after
discharge from the hospital. The office number is [**Telephone/Fax (1) 98861**].
Completed by:[**2135-2-15**]
|
[
"965.09",
"780.97",
"276.2",
"401.9",
"V08",
"276.0",
"311",
"724.2",
"E980.0",
"303.00",
"728.88",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8972, 8987
|
5423, 5583
|
322, 328
|
9178, 9221
|
3355, 3355
|
9959, 10196
|
2588, 2593
|
8350, 8949
|
9008, 9008
|
8102, 8327
|
9245, 9936
|
5084, 5400
|
2608, 3336
|
9111, 9157
|
252, 284
|
1851, 2199
|
356, 1833
|
4232, 5068
|
3372, 4223
|
9027, 9090
|
5598, 8076
|
2221, 2447
|
2463, 2572
|
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